WO2014116833A2

WO2014116833A2 - Compositions and methods for detecting neoplasia

Info

Publication number: WO2014116833A2
Application number: PCT/US2014/012758
Authority: WO
Inventors: Soumen Kanti MANNA; Kristopher W. Krausz; Frank J. Gonzalez
Original assignee: US Department of Health and Human Services
Current assignee: US Department of Health and Human Services
Priority date: 2013-01-23
Filing date: 2014-01-23
Publication date: 2014-07-31
Anticipated expiration: 2015-07-23
Also published as: US10487363B2; EP2948775A2; EP2948775B1; WO2014116833A3; US20150344969A1

Abstract

Compositions and methods for the diagnosis, treatment, and prevention of neoplasia (e.g., colorectal cancer).

Description

The Application claims priority to U.S. Provisional Application No. 63/755,89] , filed on January 23, 2013, the entire contents of which are incorporated by reference in its entirety herein.

This work was supported by the National Cancer Institute Intramural Research Program, National Institutes of Health. The Government has certain rights in this invention,

BACKGROUND OF THE INVENTION

Colorectal cancer is the second leading cause of cancer mortality in United States and fourth worldwide. Although colorectal cancer has good therapeutic response at early stages, advanced stages are frequently associated with metastasis and poor prognosis. Therefore, regular screening and early diagnosis of the disease is pivotal to therapeutic success.

Currently used diagnostic procedures such as endoscopy and biopsy are invasive and time- consuming. The sensitivity and specificity of serum-based carcinoembryoiiic antigen test has also been found to be poor for early diagnosis. Lack of high-throughput noninvasive markers continues to contribute to avoidable healthcare burden and mortality.

Metabolomics has the potential to be a useful tool for identification of changes in biochemical signature associated with pathogenesis. However, tissue metabolomics, which requires biopsy samples, is also invasive. Moreover, there has been a general lack of studies investigating the mechanistic link between these biomarkers and changes in cancer tissue. Accordingly, high-throughput noninvasive methods for detecting neoplasia are urgently required.

SUMMARY OF THE INVENTION

As described below, the present invention features compositions and methods for the diagnosis, treatment, and prevention of neoplasia (e.g., colorectal cancer, small intestine cancer, duodenal cancer, gastric cancer, pancreatic cancer, liver cancer, esophageal cancer, ovarian cancer, prostate cancer, uterine cancer, breast cancer, thyroid cancer, and melanoma).

In one aspect, the invention generally features a method for identifying a subject as having or having a propensity to develop neoplasia, the method involving identifying an increased level of a combination of two or more biomarkers in a biological sample derived from the subject relative to the level present in a reference, where a first biomarker is selected from a first group and at least one additional marker is selected from a different group, where the groups are selected from among the following: biomarkers related to methy!ation;

biomarkers related to nucleic acid metabolism; biomarkers related to urea cycle and polyamine metabolism; and biomarkers related to amino acid metabolism, where an increase in the levels of two or more biomarkers identifies a subject as having or having a propensity to develop neoplasia.

in another aspect, the invention generally features a method for identifying a subject as having or having a propensity to develop neoplasia, the method involving identifying an increased level of a combination of two or more biomarkers in a biological sample derived from the subject relative to the level present in a reference, where a first biomarker is selected from a first group and at least one additional marker is selected from a different group, where the groups are selected from among the following:

biomarkers related to methylation including asymmetric-dimethylarginine, symmetrtc-dimethylarginine, carnitine, methionine, dimethy!giycine, and betaine;

biomarkers related to nucleic acid metabolism including xanthosine, inosine, deoxyuridine, thymidine, deoxycytidine, cytosine, hypoxanthine, xanthine, uracil, guanosine, and adenosine;

biomarkers related to urea cycle and polyamine metabolism including N t - acetylspermidine, NS-acety!spermidine, spermine, arginine ornithine, and citrulline;

biomarkers related to amino acid metabolism including proline, g!utamine, glutamic acid, threonine, and Na-aeetyiSysine; and

M264 (β-D-Ribofuranosylcreatine), where an increase in the levels of two or more biomarkers identifies a subject as having or having a propensit to develop neoplasia.

In one embodiment, the the groups are selected from the following:

biomarkers related to methylation comprising asymmetric-dimethylarginine and symmetric-dimethyiarginine; biomarkers related to nucleic acid metabolism comprising xanthosine, inosine, deoxyuridirie, and thymidine;

biomarkers related to poiyamine metabolism comprising Nl -acetylspermidine, N8- acetyispermidine, and spermine; and

biomarkers related to amino acid metabolism comprising proline, glutamine, and ^'Να- acetyilysine.

In another aspect, the invention features a method for determining the prognosis of neoplasia in a subject, the method involving identifying an increased level of a combination of two or more biomarkers in a biological sample derived from the subject relative to the level present in a reference, where a first biomarker is selected from a first group and at least one additional marker is selected from a different group, where the groups are selected from among the following: biomarkers related to methylation; biomarkers related to nucleic acid metabolism; biomarkers related to urea cycle and poiyamine metabolism; and biomarkers related to amino acid metabolism, thereby determining the prognosis of neoplasia in the subject.

in another aspect, the invention features a method for determining the prognosis of neoplasia in a subject, the method involving identifying an increased level of a combination of two or more biomarkers in a biological sample derived from the subject relative to the level present in a reference, where a first biomarker is selected from a first group and at least one additional marker is selected from a different group, where the groups are selected from among the following:

biomarkers related to methylation including asymmetric-dimethylarginine, symmetric-dimethylarginine, carnitine, methionine, dimethySglycine, and betaine;

biomarkers related to nucleic acid metabolism including xanthosine, inosine, deoxyuridirie, thymidine, deoxycytidine, cytosine, hypoxanthine, xanthine, uracil, guanosine, and adenosine;

biomarkers related to urea cycle and poiyamine metabolism including Nl - acetylspermidine, NS-aeetylspermidine, spermine, arginine ornithine, and citruf line;

biomarkers related to amino acid metabolism including proline, glutamine, glutamic acid, threonine, and Na-acetyllysine; and

M264 (β-D-Ribofuranosylcreatine), thereby determining the prognosis of neoplasia in the subject.

In one embodiment, the groups are selected from the following: biomarkers related to methylation comprising asymmetric-dimethylarginine and symmetric-dimethylarginine;

biomarkers related to nucleic acid metabolism comprising xanthosine, inosine, deoxyuridine, and thymidine;

biomarkers related to poiyamine metabolism comprising N l -acetylspermidine, N8- acetylspermidine, and spermine; and

biomarkers related to amino acid metabolism comprising proline, glutamine, and Na- acetyilysine.

In one embodiment, an increase in the level of asymmetric-dimethylarginine, symmetric-dimethylarginine, carnitine, methionine, dimethylglycine or betaine relative to the reference identifies the subject as having a reduced chance of survival, in a further embodiment, an increase in the level of asymmetric-dimethylarginine and symmetric- dimethylarginine relative to the reference identifies the subject as having a reduced chance of survival.

In another embodiment, a decrease in the level of asymmetric-dimethylarginine, symmetric-dimethylarginine, carnitine, methionine, dimethylglycine or betaine relative to the reference identifies the subject as having an increased chance of survival, In a further embodiment, a decrease in the level of asymmetric-dimethylarginine and symmetric- dimethylarginine relative to the reference identifies the subject as having an increased chance of survival.

In another aspect, the invention features a method for monitoring response to neoplasia therapy in a subject, the method involving identifying an increased level of a combination of two or more biomarkers in a biological sample derived from the subject relative to the level present in a reference, where a first biomarker is selected from a first group and at least one additional marker is selected from a different group, where the groups are selected from among the following: biomarkers related to methylation; biomarkers related to nucleic acid metabolism; biomarkers related to urea cycle and poiyamine metabolism; biomarkers related to amino acid metabolism; thereby monitoring neoplasia therapy in the subject.

In another aspect, the invention features a method for monitoring response to neoplasia therapy in a subject, the method involving identifying an increased level of a combination of two or more biomarkers in a biological sample derived from the subject relative to the level present in a reference, where a first biomarker is selected from a first group and at least one additional marker is selected from a different group, where the groups are selected from among the following;

biomarkers related to methylation including asymmetric-dimethylarginine, symmetric-dimethylarginine, carnitine, methionine, dimethylglycine, and betairse;

biomarkers related to urea cycle and polyamine metabolism including N l - acetylspermidine, N8-acetylspermidine, spermine, arginine ornithine, and eitruliine;

biomarkers related to amino acid metabolism including proline, glutam ine, glutamic acid, threonine, and Na-acetyllysine; and

M264 (β-D-RibofuranosyJcreatine), thereby monitoring neoplasia therapy in the subject.

In one embodiment, the groups are selected from the following:

biomarkers related to methylation comprising asymmetric-dimethylarginine and sy m m et ri c-d i methy largi ni e;

biomarkers related to polyamine metabolism comprising Nl -acetylspermidine, N8~ acetylspermidine, and spermine; and

biomarkers related to amino acid metabolism comprising proline, glutamine, and Na- acetyllysine,

In one embodiment, a therapy that reduces the level of asymmetric-dimethylarginine, symmetric-dimethylarginine, carnitine, methionine, dimethylglycine, or betaine is identified as effective, in another particular embodiment, a therapy that reduces the level of asymmetric-dimethylarginine and symmetric-dimethylarginine is identified as effective. in another embodiment, the reference is a sample obtained from the subject prior to therapy or at an earlier time point during therapy,

in one aspect, the invention features a method for characterizing the aggressiveness of a neoplasia in a subject, the method involving identifying an increased level of a combination of two or more biomarkers in a biological sample derived from the subject relative to the level present in a reference, where a first biomarker is selected from a first group and at least one additional marker is selected from a different group, where the groups are selected from among the following: biomarkers related to methylation; biomarkers related to nucleic acid metabolism; biomarkers related to urea cycle and polyamine metabolism; and biomarkers related to amino acid metabolism, where an increased level of a biomarker related to methylation identifies the neoplasia as aggressive, and a decreased level of a biomarker related to methylation identifies the neoplasia as less aggressive.

In another aspect, the invention features a method for characterizing the

aggressiveness of a neoplasia in a subject, the method involving identifying an increased level of a combination of two or more biomarkers in a biological sample derived from the subject relative to the level present in a reference, where a first biomarker is selected from a first group and at least one additional marker is selected from a different group, where the groups are selected from among the following;

biomarkers related to methylation including asymmetric-dimethylarginine, symmetric-dimethylarginine, carnitine, methionine, dimethyiglycine, and betaine;

biomarkers related to urea cycle and polyamine metabolism including N l - acetylspermidine, N8-acetylspermidine, spermine, arginine ornithine, and citrulline; d

biomarkers related to amino acid metabolism including proline, glutatnine, glutamic acid, threonine, and Na-acetyllysine; and

M264 (β-D-Ribofuranosylcreatine), where an increased le vel of asymmetric- dimethylarginine and symmetric-dimethylarginine identifies the neoplasia as aggressive, and a decreased level of asymmetric-dimethylarginine and symmetric-dimethylarginine identifies the neoplasia as less aggressive.

In one embodiment, the groups are selected from the following:

biomarkers related to methylation comprising asymmetric-dimethylarginine and symmetric-dimethylarginine;

biomarkers related to polyamine metabolism comprising Nl -acetylspermidine, N8- acety!spermidine, and spermine; and

biomarkers related to amino acid metabolism comprising proline, glutamine, and Na- acetyllysine. In one aspect, the invention features a method for identifying a subject as having or having a propensity to develop colorectal cancer, the method involving identifying an increased levei of a combination of two or more biomarkers in a biological sample derived from the subject relative to the level present in a reference, where at least one biomarker is selected from the group of biomarkers reiated to methylation; and at least one additional marker is selected from a group from among the following: biomarkers related to nucleic acid metabolism; biomarkers related to urea cycle and polyamine metabolism; and biomarkers related to amino acid metabolism, where an increase in the levels of two or more biomarkers identifies a subject as having or having a propensity to develop neoplasia,

In another aspect, the invention features a method for identifying a subject as having or having a propensity to develop colorectal cancer, the method involving identifying an increased level of a combination of two or more biomarkers in a biological sample derived from the subject reiative to the level present in a reference, where at least one biomarker is selected from the group of biomarkers related to methylation including asymmetric- dimethylarginine, symmetric-dimethylarginine, carnitine, methionine, dimeihylglycine and betaine; and at least one additional marker is selected from a group from among the following:

biomarkers related to nucleic acid metabolism including xanthosine, tnosine, deoxyuridine, thymidine, deoxycytidine, cytosine, hypoxanthine, xanthine, uracil, guanosine, and adenosine;

biomarkers reiated to urea cycle and polyamine metabolism including N 1 - acetylspermidine, NS-acetylspermidine, spermine, arginine ornithine, and citrulline;

biomarkers related to amino acid metabolism including proline, glutamine, glutamic acid, threonine, and Να-acetyllysine, and

M264 (β-D-Ribofuranosylcreatine), where an increase in the levels of two or more biomarkers identifies a subject as having or having a propensity to develop neoplasia,

in one embodiment, the groups are selected from the following:

biomarkers related to methylation comprising asymmetric-dimethylarginine and symmetric-dimethyiarginine;

biomarkers related to polyamine metabolism comprising Nl -acetylspermidine, NS- acetylspermidine, and spermine; and biomarkers related to amino acid metabolism comprising proline, glutamine, and Na- acetyl lysine.

in one aspect, the invention features a method for identifying a subject as having or having a propensity to develop neoplasia, the method involving measuring the level of a combination of two or more biomarkers in a biological sample deri ved from the subject relative to the level present in a reference, where a first biomarker is selected from a first group and at least one additional marker is selected from a different group, where the groups are selected from among the following: biomarkers related to methylation; biomarkers related to nucleic acid metabolism; biomarkers related to urea cycle and polyamine metabolism; and biomarkers related to amino acid metabolism, and correlating the measurements of the level of the measured biomarkers with the subject having neoplasia or the subject having a propensity to develop neoplasia.

In one embodiment, the subject is identified as having or having a propensity to develop neoplasia when the level of a biomarker related to methylation is increased relative to a reference.

In yet another aspect, the invention features a method for identifying a subject as having or having a propensity to develop neoplasia, the method involving measuring the level of a combination of two or more biomarkers in a biological sample derived from the subject relative to the level present in a reference, where a first biomarker is selected from a first group and at least one additional marker is selected from a different group, where the groups are selected from among the following:

biomarkers related to methylation including asymmetnc-dimethyiarginine, symmetric-dimethylarginine, carnitine, methionine, dimethylglycine, and betaine;

biomarkers related to nucleic acid metabolism including xanthosine, inosine, deoxyundine, thymidine, deoxycytidine, cytosine, hvpoxanthine, xanthine, uracii, guanossrse, and adenosine;

biomarkers related to urea cycle and polyamine metabolism including Nl - acetylspermidine, N8-acetylspermidine, spermine, arginine ornithine, and citruiline;

M264 (β-D-Ribofuranosylcreatine), and correlating the measurements of the level of the measured biomarkers with the subject having neoplasia or the subject having a propensity to develop neoplasia, In one embodiment, the groups are selected from the following:

biomarkers related to methylation comprising asymmetric-dimethy!arginine arsd symmetric-d imethy largi nine;

biomarkers related to polyamine metabolism comprising Nl-acetylspermidine, N8- acetylspermidine, and spermine; and

biomarkers related to amino acid metabolism comprising proline, glutamine, and Nct- acetyllysine.

In one embodiment, the subject is identified as having or having a propensity to develop neoplasia when the level of asymmetric-dimethylargimne, symmetric- dimethylarginine, carnitine, methionine, dimethyiglycine, or betaine is increased relative to a reference.

In another embodiment, the subject is identified as having or having a propensity to develop neopiasia when the level of asymmetric-dimethylarginine and symmetric- dimethylarginine is increased relative to a reference.

In one aspect, the invention features a method for determining the prognosis of neoplasia in a subject, the method involving measuring the level of a combination of two or more biomarkers in a biological sample derived from the subject relative to the level present in a reference, where a first biomarker is selected from a first group and at least one additional marker is selected from a different group, where the groups are selected from among the following: biomarkers related to methylation; biomarkers related to nucleic acid metabolism; biomarkers related to urea cycle and polyamine metabolism; and biomarkers related to amino acid metabolism, and correlating the measurements of the level of the measured biomarkers with the prognosis of neoplasia in the subject,

In one embodiment, the subject is identified as having a reduced chance of survival when the level of a biomarker related to methylation is increased relative to a reference. In another embodiment, the subject is identi fied as having an increased chance of survival when the level of a biomarker related to methylation is decreased relative to a reference.

In another aspect, the invention features a method for determining the prognosis of neoplasia in a subject, the method involving measuring the level of a combination of two or more biomarkers in a biological sample derived from the subject relative to the ievel present in a reference, where a first biomarker is selected from a first group and at least one additional marker is selected from a different group, where the groups are selected from among the following:

biomarkers related to methy!ation including asymmetric-dimethylarginine, symmetrie-dimethylarginine, carnitine, methionine, dimethylglycine, and betaine;

biomarkers related to urea cycle and polyamine metabolism including N l - acetylspermidine, N8-acety!spermidine, spermine, arginine ornithine, and citrulline;

biomarkers related to amino acid metabolism including proline, glutamine, glutamic acid, threonine, and N -acetyllysine, and

M264 (p-D-Ribofuranosylcreatine), and correlating the measurements of the level of the measured biomarkers with the prognosis of neoplasia in the subject.

In one embodiment, the groups are selected from the following:

biomarkers related to methylation comprising asymmetric-dimethylarginine and symmetrie-dimethylarginine;

biomarkers related to polyamine metabolism comprising Nl -acetylspermidine, N8- acetylspermidine, and spermine; and

biomarkers related to amino acid metabolism comprising proline, glutamine, and Na- acetyllysine.

In one embodiment, the subject is identified as having a reduced chance of survival when the level of asymmetric-dimethylarginine, symmetrie-dimethylarginine, carnitine, methionine, dimethylglycine, or betaine is increased relative to a reference. In another embodiment, the subject is identified as having an increased chance of survival when the level of asymmetric-dimethylarginine, symmetrie-dimethylarginine, carnitine, methionine, dimethylglycine, or betaine is decreased relative to a reference.

In one embodiment, the subject is identified as having a reduced chance of survival when the level of asymmetric-dimethylarginine and symmetrie-dimethylarginine is increased relative to a reference. In another embodiment, the subject is identified as having an increased chance of survival when the level of asymmetric-dimethylarginine and symmetrie- dimethylarginine is decreased relative to a reference. in one aspect, the Invention features a method for monitoring neoplasia therapy in a subject, the method involving measuring the level of a combination of two or more biomarkers in a biological sample derived from the subject relative to the level present in a reference, where a first biomarker is selected from a first group and at least one additional marker is selected from a different group, where the groups are selected from among the following: biomarkers related to methylation; biomarkers related to nucleic acid metabolism; biomarkers related to urea cycle and polyamine metabolism; and biomarkers related to amino acid metabolism, and correlating the measurements of the level of the measured biomarkers to thereby monitor neoplasia therapy in the subject.

In another aspect, the invention features a method for monitoring neoplasia therapy in a subject, the method involving measuring the level of a combination of two or more biomarkers in a biological sample derived from the subject relative to the level present in a reference, where a first biomarker is selected from a first group and at least one additional marker is selected from a different group, where the groups are selected from among the following:

biomarkers related to nucleic acid metabolism including xanthosine, inosine, deoxvuridine, thymidine, deoxycytidine, cvtosine, hypoxanthine, xanthine, uracil, guanosine, and adenosine;

biomarkers related to urea cycle and polyamine metabolism including Nl - acetyispermidine, N8-acetyIspermidine, spermine, arginine ornithine, and citruf line;

biomarkers related to amino acid metabolism including proline, glutamine, glutamic acid, threonine, and N -acetyllysine; and

M264 (β-D-Ribofuranosylcreatine), and correlating the measurements of the level of the measured biomarkers to thereby monitor neoplasia therapy in the subject.

In one embodiment, the groups are selected from the following:

biomarkers relaied to methylation comprising asymmetric-dimethylarginine and symmetric-dimethylarginine;

biomarkers related to nucleic acid metabolism comprising xanthosine, inosine, deoxvuridine. and thymidine;

biomarkers related to polyamine metabolism comprising Nl -acetyispermidine, N8- aeetylspermidine, and spermine: and biomarkers related to amino acid metabolism comprising proline, glutamine, and Na- aceiyllysine.

in one embodiment, a therapy that reduces the level of asyrnmetric-dimethylarginine, symmetric-dimethylarginine, carnitine, methionine, dimethy [glycine, or betaine is identified as effective.

In another embodiment, a therapy thai reduces the level of asymmetric- dimethylarginine and symmetric-dimethylarginine relative to a reference is identified as effective.

In one aspect, the invention features a method for characterizing the aggressiveness of a neoplasia in a subject, the method involving measuring the level of a combination of two or more biomarkers in a biological sample derived from the subject relative to the level present in a reference, where a first biomarker is selected from a first group and at least one additional marker is selected from a different group, where the groups are selected from among the following: biomarkers related to methylation; biomarkers related to nucleic acid metabolism; biomarkers related to urea cycle and poiyamine metabolism; and biomarkers related to amino acid metabolism, and correlating the measurements of the level of the measured biomarkers to thereby characterize the aggressiveness of the neoplasia in the subject, where an increased level of a biomarker related to methylation relative to a reference, identifies the neoplasia as aggressive, and a decreased level of a biomarker related to methylation relative to a reference identifies the neoplasia as less aggressive.

In another aspect, the invention features a method for characterizing the

aggressiveness of a neoplasia in a subject, the method involving measuring the level of a combination of two or more biomarkers in a biological sample derived from the subject relative to the level present in a reference, where a first biomarker is selected from a first group and at least one additional marker is selected from a different group, where the groups are selected from among the following:

biomarkers related to methylation including asymmetric-dimethylarginine, symmetric-dimethylarginine, carnitine, methionine, dimethylglycine, and betaine;

biomarkers related to urea cycle and poiyamine metabolism including N l - acety [spermidine, N8-acetylspermidine, spermine, arginine ornithine, and citrulline; biomarkers related to amino acid metabolism including proline, glutamine, glutamic acid, threonine, and Na-acetyllystne; and

M264 (β-D-Ribofuranosylcreatirte), and correlating the measurements of the level of the measured biomarkers to thereby characterize the aggressiveness of the neoplasia in the subject, where an increased level of asymmetric-dimethylarginine and symmetric- dimethylarginine relative to a reference, identifies the neopiasia as aggressive, and a decreased level of asymmetric-dimethylarginine and symmetric-dimethylarginine relative to a reference identifies the neoplasia as less aggressive,

In one embodiment, an increased level of asymmetric-dimethylarginine, symmetric- dimethylarginine, carnitine, methionine, dimethylglycine, and betaine relative to a reference, identifies the neoplasia as aggressive, and a decreased level of asymmetric-dimethylarginine, symmetric-dimethylarginine, carnitine, methionine, dimethylglycine, and betaine relative to a reference identifies the neoplasia as less aggressive.

In one embodiment, the groups are selected from the following:

biomarkers related to amino acid metabolism comprising proline, glutamine, and Not- acetyliysine.

in one aspect, the invention features a method for identifying a subject as having or having a propensity to develop colorectal cancer, the method involving measuring the level of a combination of two or more biomarkers in a biological sample deri ved from the subject relative to the level present in a reference, where at least one biomarker is selected from the group of biomarkers related to methylation and at least one additional marker is selected from a group from among the following; biomarkers related to nucleic acid metabolism;

biomarkers related to urea cycle and polyamine metabolism; and biomarkers related to amino acid metabolism, and correlating the measurements of the level of the measured biomarkers with the subject having neoplasia or the subject having a propensity to develop neoplasia, where the subject is identified as having or having a propensity to develop neoplasia when the level of a biomarker related to methylation is increased relative to a reference. In another aspect, the invention features a method for identifying a subject as having or having a propensity to develop colorectal cancer, the method involving measuring the level of a combination of two or more bioniarkers in a biological sample derived from the subject relative to the level present in a reference, where at least one biornarker is selected from the group of bioniarkers related to methylation including asymmetric-dimethylarginine, symmetric-dimethy!arginine, carnitine, methionine, dimethylglycine, and betaine and at least one additional marker is selected from a group from among the following:

biomarkers related to urea cycle and polyamine metabolism including N l - acety!spermidine, N8-acetylspermidine, spermine, arginine ornithine, and citrul!ine;

biomarkers related to amino acid metabolism including proline, giutamine, glutamic acid, threonine, and Na-acetyilysine; and

M264 (β-D-Ribofuranosylcreatine), and correlating the measurements of the level of the measured biomarkers with the subject having neoplasia or the subject having a propensity to develop neoplasia, where the subject is identified as having or having a propensity to develop neoplasia when the level of asymmetric-dimethylarginine and symmetric- dimethylargi ine is increased relative to a reference.

In one embodiment, the groups are selected from the following:

biomarkers related to polyamine metabolism comprising N l -acetyispermidine, N8- acetyispermidine, and spermine; and

biomarkers related to amino acid metabolism comprising proline, giutamine. and Net- acetyl lysine.

In one embodiment of any one of the above aspects, the methods feature measuring the level of M264 ( ?-D-ribofuranosylcreatine). In another embodiment of any one of the above aspects, the methods feature measuring the level of M264 (?-D-ribofiiranosylcreatine) in addition to any one or more of the c laimed biomarkers. In one aspect, the invention features a kit for aiding the diagnosis of neoplasia or colorectal cancer, the kit including at least one reagent capable of detecting, binding, or capturing a first biomarker selected from a first group and at least one reagent capable of detecting, binding, or capturing at least one additional marker selected from a different group, where the groups are selected from among the following; biomarkers related to methylation; biomarkers related to nucleic acid metabolism; biomarkers related to urea cycle and poiyamine metabolism; and biomarkers related to amino acid metabolism.

In another aspect, the invention features a kit for aiding the diagnosis of neoplasia or colorectal cancer, the kit including at least one reagent capable of detecting, binding, or capturing a first biomarker selected from a first group and at least one reagent capable of detecting, binding, or capturing at least one additional marker selected from a different group or M264, where the groups are selected from among the following:

biomarkers related to methylation including asymmetric-dimethylarginine, symmetric-dimethyiarginine, carnitine, methionine, dirnethyiglycine, and betaine;

biomarkers related to urea cycle and poiyamine metabolism including N l - acetylspermidine, N8-acetylspermidine, spermine, arginine ornithine, and citrulline;

biomarkers related to amino acid metabolism including proline, glutamine, glutamic acid, threonine, and Να-acetyilysine; and

M264 (β-D-Ribofuranosylcreatine).

In one embodiment, the groups are selected from the following:

biomarkers related to amino acid metabolism comprising proline, glutamine, and Na- acety!lysine.

In one aspect, the invention features a kit for aiding the diagnosis of neoplasia or colorectal cancer, the kit including at least one reagent capable of detecting, binding, or capturing at least one biomarker selected from the group of biomarkers related to methyiation and at ieast one reagent capable of detecting, binding, or capturing at least one additional marker selected from a group from among the following: biomarkers related to nucleic acid metabolism; biomarkers related to urea cycle and polyamine metabolism; biomarkers related to amino acid metabolism,

In another aspect, the invention features a kit for aiding the diagnosis of neoplasia or colorectal cancer, the kit including at least one reagent capable of detecting, binding, or capturing at !east one biomarker selected from the group of biomarkers related to methyiation including asymmetric-dimethylarginine, symmetric-dimethylarginine, carnitine, methionine, dimethylglycine, and betaine and at ieast one reagent capable of detecting, binding, or capturing at least one additional marker selected from a group from among the following: biomarkers related to nucleic acid metabolism including xanthosine, inosine, deoxyuridine, thymidine, deoxycytidine, cytosine, hypoxanthine, xanthine, uracil, guanosine, and adenosine;

biomarkers related to urea cycle and polyamine metabolism including Nl - acetyispermidine, N8-acetyIspermidine, spermine, arginine ornithine, and eitruHine;

M264 (β-D-Ribofuranosylcreatine).

In one embodiment, the groups are selected from the following:

biomarkers related to methyiation comprising asymmetric-dimethylarginine and symmetric-dimethylarginine;

biomarkers related to polyamine metabolism comprising N l -acety!spermidine, N8- acetylspermidine, and spermine; and

In another aspect, the invention features a kit for aiding the diagnosis of neoplasia or colorectal cancer, the kit containing at ieast one reagent capable of detecting, binding, or capturing asymmetric-dimethylarginine and at ieast one reagent capable of detecting, binding, or capturing symmetric-dimethylarginine. In another embodiment, the kit further contains at least one reagent capable of detecting, binding or capturing carnitine, methionine, dimethylglycine, and betaine.

in another embodiment, the kit further contains at least one reagent capable of detecting the M264 biomarker.

In one embodiment, the kit further contains at least one reagent capable of detecting, binding, or capturing proline, glutamine, glutamic acid, threonine, Na-acetyllysine, xanthosine, inosine, deoxyuridine, thymidine, deoxycytidine, cytosine, hypoxanthine, xanthine, uracil, guanosine, adenosine, N l -acetylspermidine, N8-acetylspermidine, spermine, arginine ornithine, ciirulline, and M264 (β-D-Ribofuranosylcreatine), or a combination of reagents thereof.

In another embodiment, the kit further contains directions for using the reagent to analyze the level of asymmetric-dimethylarginine, symmetric-dimethylarginine, carnitine, methionine, dimethylglycine, betaine, xanthosine, inosine, deoxyuridine, thymidine, deoxycytidine, cytosine, hypoxanthine, xanthine, uracil, guanosine, adenosine, l - acetyispermidine, N8-acetylspermidine, spermine, arginine ornithine, ciirulline, proline, glutamine, glutamic acid, threonine, and Na-aceiyl lysine, M264 (β-D-Ribofuranosyicreatine), or a combination thereof,

In another embodiment, the kit further contains directions for contacting a test sample with the reagent and detecting asymmetric-dimethylarginine, symmetric-dimethylarginine, carnitine, methionine, dimethylglycine, betaine, xanthosine, inosine, deoxyuridine, thymidine, deoxycytidine, cytosine, hypoxanthine, xanthine, uracil, guanosine, adenosine, Nl -acetylspermidine, NS-acetylspe niidine, spermine, arginine ornithine, citru!line, proline, glutamine, glutamic acid, threonine, and Να-acetyllysine, M264 (p-D-Rtbofuranosylcreatme), or a combination thereof retained by the reagent.

in another aspect, the invention features a panel for aiding the diagnosis of neoplasia or colorectal cancer, the panel including at least one reagent capable of detecting, binding, or capturing at least one biomarker selected from the group of biornarkers related to

methylation; biornarkers related to nucleic acid metabolism; biornarkers related to urea cycle and poiyamine metabolism; and biornarkers related to amino acid metabolism.

In yet another aspect, the invention provides a panel for aiding the diagnosis of neoplasia or colorectal cancer, the panel containing at least one reagent capable of detecting, binding, or capturing a first biomarker selected from a first group and at least one reagent capable of detecting, binding, or capturing at least one additional marker selected from a different group, where the groups are selected from among the following:

bioniarkers related to methylation including asymmetric-dimethylarginine, symmetric-dimethylarginine, carnitine, methionine, dimethylglycine, and betaine;

bioniarkers related to nucleic acid metabolism including xanthosine, inosine, deoxyuridine, thymidine, deoxycyiidine, cytosine, hypoxanthine, xanthine, uracil, guanosine, and adenosine;

bioniarkers related to urea cycle and poiyamine metabolism including Nl ~ acetyispermidine, N8-acetylspermidine₅ spermine, arginine ornithine, and citrulline;

bioniarkers related to amino acid metabolism including proline, g!utamine, glutamic acid, threonine, and Na-acetyllysine; and

M264 (β-D-Ribofuranosylcreatine).

In one embodiment, the groups are selected from the following:

bioniarkers related to nucleic acid metabolism comprising xanthosine, inosine, deoxyuridine, and thymidine;

bioniarkers related to poiyamine metabolism comprising Nl -acetyispermidine, N8- acetylspermidine, and spermine; and

biomarkers related to amino acid metabolism comprising proline, giutamine, and Na- acetyllysine.

In another aspect, the invention features a panel for aiding the diagnosis of neoplasia or colorectal cancer, the panel including at least one reagent capable of detecting, binding, or capturing at least one biomarker selected from the group of biomarkers related to methylation including asymmetric-dimethyiarginine, symmetric-dimethylarginine, carnitine, methionine, dimethylglycine, and betairse and at least one reagent capable of detecting, binding, or capturing at least one additional marker selected from a group from among the following: biomarkers related to nucleic acid metabolism including xanthosine, inosine, deoxyuridine, thymidine, deoxycyiidine, cytosine, hypoxanthine, xanthine, uracil, guanosine, and adenosine;

biomarkers related to urea cycle and poiyamine metabolism including N l - aceiy!spermidine, N8-acetylspermidine, spermine, arginine ornithine, and citrulline; biomarkers related to amino acid metabolism including proline, g!utamine, glutamic acid, threonine, and Na-acetyllysine; and

M264 (β-D-Ribofuranosylcreatine).

in one embodiment, the groups are selected from the following:

biomarkers related to methy!ation comprising asymmetric-dimethylarginine and symmetric-dimethylarginine;

biomarkers related to polyamine metabolism comprising N l -acetyispermidme, N8- acetylspermidine, and spermine; and

biomarkers related to amino acid metabolism comprising proline, g!utamine, and Na- acetyllysine.

In another aspect, the invention features a pane! for aiding the diagnosis of neoplasia or colorectal cancer, the panel including at least one reagent capable of detecting, binding, or capturing asymmetric-dimethylarginine and at least one reagent capable of detecting or capturing symmetric-dimethylarginine. in one embodiment, the reagent is one or more of an organic molecule, peptide, peptide mimetic, polypeptide, nucleic acid ligand, aptamer, or antibody.

in another embodiment, the panel further contains at least one reagent capable of detecting, capturing, or binding carnitine, methionine, di ethylgiycine, betaine, xanthosine, inosine, deoxyuridine, thymidine, deoxycytidine, cytosine, hypoxanthine, xanthine, uracil, guanosine, and adenosine, N l -acetylspermidine, N8-acetylspermidine, spermine, arginine ornithine, and citruliine, proline, glutamine, glutamic acid, threonine. Na-acetyllysine and M264 (β-D-Ribofuranosylcreatine), or a combination of reagents thereof.

In various embodiments of any of the above aspects or any other aspect of the in vention delineated herein, the invention further provides measuring the level of biomarkers in one or more groups including one or more of biomarkers related to methylation;

biomarkers related to polyamine metabolism; and biomarkers related to amino acid metabolism. In various embodiments of the above aspects, an increase in the level of biomarkers in one or more of the groups identities a subjeci as having or having a propensity to develop neoplasia; identifies a subject as having a reduced chance of survival; or identifies a neoplasia as aggressive. In other embodiments, a decrease in the level of biomarkers in one or more of the groups identifies a subject as having an increased chance of survival; identifies a therapy as effective; or identifies a neoplasia as less aggressive. In other embodiments, the biological sample is a bioiogicai fluid (e.g., urine, blood, blood serum, plasma, bile, fecal aspirate, intestinal aspirate, cerebrospinal fluid and saliva) or tissue sample. In various embodiments of the above aspects, the method further involves measuring the level of carnitine in the bioiogicai sample. In other embodiments a decrease in the level of carnitine in a biological sample that is a biological fluid identifies a subject as having or having a propensity to develop neoplasia; identifies a subject as having a reduced chance of survival; or identifies a neoplasia as aggressive. In still other embodiments, an increase in the level of carnitine in a biological sample that is a biological fluid identifies a subject as having an increased chance of survival; identifies a therapy as effective; or identifies a neoplasia as less aggressive.

in other embodiments, an increase in the level of carnitine in a bioiogicai sample that is a tissue sample identifies a subject as having or having a propensity to develop neoplasia; identifies a subject as having a reduced chance of survival; or identifies a neoplasia as aggressive. In still other embodiments, a decrease in the level of carnitine in a biological sample that is a tissue sample identifies a subject as having an increased chance of survival; identifies a therapy as effective; or identifies a neoplasia as less aggressive.

In various embodiments of the above aspects, the neoplasia is colorectal cancer, small intestine cancer, duodenal cancer, gastric cancer, pancreatic cancer, liver cancer, esophageal cancer, ovarian cancer, prostate cancer, uterine cancer, breast cancer, thyroid cancer or melanoma. In other embodiments, the neoplasia contains a mutation in APC or a Wnt signaling pathway protein. In still other embodiments of the above aspects, the method further involves detecting a mutation in APC or a Wnt signaling pathway protein. In other embodiments, the level of the biomarker is increased 1 .5, 2, 2,5, 3, 3.5, 4, 5, 6, 7, 8, 9, 10, 1 1 , 12, 13, 14, 15-fold or more relative to the reference. In still other embodiments, the reference is a control or a corresponding biological sample derived from a healthy subject. In still other embodiments, the level of the biomarker is normalized to the level of creatinine in the sample, absolute concentration, 24-hr excretion, or with respect to specific gravity. in still other embodiments, the subject is human, In still other embodiments, the level is detected by chromatography, mass spectrometry, spectroscopy, immunoassay, ultra performance liquid chromatography (IJPLC). In other embodiments, the mass spectrometry is electrosprav ionization quadruple time-of-flight mass spectrometry (ESI-QTF-MS). In other

embodiments, spectroscopy is NMR spectroscopy, in other embodiments, the immunoassay is ELISA, In still other embodiments, the method further involves measuring the level of biomarkers in one or more groups from among biomarkers related to methyiation; biomarkers related to polyamine metabolism; and biomarkers related to amino acid metabol ism, in other embod iments, an increase in the level of biomarkers in one or more of the groups identifies a subject as having or having a propensity to develop neoplasia; identifies a subject as having a reduced chance of survival; or identifies a neoplasia as aggressive. In sti l l other

embodiments, an increase in the level of biomarkers in one or more of the groups identifies a subject as having an increased chance of survival; identifies a therapy as effective; or identifies a neoplasia as less aggressive,

The invention provides compositions and methods for diagnosing, treating or preventing neoplasia (e.g., colorectal cancer). Other features and advantages of the invention wi l l be apparent from the detai led description, and from the claims.

Definitions

Unless defined otherwise, all technical and scientific terms used herein have the meaning commonly understood by a person skilled in the art to which this invention belongs. The following references provide one of skill with a general definition of many of the terms used in this in vention: Singleton et al., Dictionary of Microbiology and Molecular B iology (2nd ed. 1994); The Cambridge Dictionary of Science and Technology (Walker ed., 1 988); The Glossary of Genetics, 5th Ed., R. Rieger et al, (eds.), Springer Verlag ( 1991 ); and Hale & arham, The Harper Coll ins Dictionary of Biology ( 1991 ), As used herein, the following terms have the meanings ascribed to them below, unless specified otherwise.

As used herein, the term "biomarker" generally refers to a molecule that is differentially present in a sample (e.g., biopsy, biological or physiological fluid) taken from a subject of one pbenotypic status (e.g., having a disease) as compared with another phenotypic status (e.g., not having the disease), A biomarker is differentially present between different phenotypic statuses i f the mean or median level of the biomarker in a first phenotypic status relative to a second phenotypic status is calculated to represent statistically significant differences. Common tests for statistical significance include, among others, t-test, ANOVA, Kruskal-Wa! Iis, Wi lcoxon, Mann- Whitney and odds ratio, Biomarkers, alone or in combination, provide measures of relative likelihood that a subject belongs to a phenotypic status of interest. As such, biomarkers can find use as markers for, for example, disease (diagnostics), therapeutic effectiveness of a drug (theranostics), and of drug toxicity.

^ i As used herein, the term "biomarker related to methyiation" refers to metabolic intermediates and products related to increased methyiation (e.g., protein methyiation, DNA methyiation) in a subject or a tissue or a cell of the subject (e.g., a neoplastic tissue or ceil). In various embodiments, the biomarker related to methyiation is a small molecule compound. In various embodiments, the biomarker related to methyiation is present n a sample derived from the subject (e.g., a biological or physiological fluid). In particular embodiments, an alteration in the levels of one or more biomarkers related to methyiation, relative to a reference, indicates a tissue or ceil is neoplastic. In specific embodiments, an alteration in the levels of one or more biomarkers related lo methyiation, relative to a reference, indicates a subject has or is at risk of having neoplasia. Exemplary biomarkers related to methyiation include without limitation: asymmetric-dimethylarginine; symmetric-dimethylarginine; carnitine; N-monomethylargmine (CAS: 17035-90-4); N(6)-methyllysine (CAS: 1 188-07-4); N6,N6 dirneihyllysine (CAS: 2259-86-1 , C1D: 4478779, InCh! ey: XXEWFEBMSGLYBY- UHFFFAOYSA-N); N6, N6, N6 trimethyllysine (CAS: 19253-88-4); Sarcosine (CAS: 107- 97- 1 ); Betaine (CAS: 107-43-7); Dimethylglycine (CAS: 1 1 18-68-9); l -methylhistidine (CAS: 332-80-9); 3-methylhistidine (CAS: 368-16-1 ); Trigonelline (CAS: 535-83- 1 ); N- methylnicotinamide (CAS: 1 14-33-0): l -methylnicotinamide (CAS: 31 06-60-3); 6- methylnicotinamide (CAS: 6960-22-1 ): Methionine (CAS; 63-68-3); homocysteine (CAS: 454-29-5); S-adenosylhomocysteine (CAS: 979-92-0): S-adenosylmethionine (CAS: 29908- 03-0); Trimethylammonioacetate (InChlKey: WIUHFFTVRNATP-UHFFFAOYSA-O); Trimethylamine (CAS: 75-50-3); Trimethylamine N-oxide (CAS: 1 ] 84-78-7);

Dimethylamine (CAS: 124-40-3); N-Formyl-L-methionine (CAS: 4289-98-9); Folic acid (CAS: 59-30-3); Tetrahydrofolic acid (CAS: 135- 36-0); choline (CAS: 62-49-7);

phosphory!choime (CAS; 3616-04-4); g!ycerophosphocholine (CAS: 283 1 -77-9);

acetylcarnitine (CAS: 3040-38-8); propionylcamitine (CAS: 37298-37-2); butyrylcarnitine (CAS: 25576-40-3); and isobutyryicarnitine (CAS: 25518-49-4); including pharmaceutically acceptable salts, solvates, hydrates, geometrical isomers, tautomers, optical isomers, ssotopic derivatives, polymorphs, prodrugs, and N-oxides thereof. In certain exemplary embodiments, biomarkers related to methyiation include asymmetric-dimethylarginine, symmetric- dimethylarginine, carnitine, methionine, dimethylglycine, and betaine.

As used herein, the term "biomarker related to nucleic acid metabolism" refers to metabolic intermediates and products related to increased nucleic acid metabolism in a subject or a tissue or a cell of the subject (e.g., a neoplastic tissue or ceil). In various embodiments, the biomarker related to nucleic acid metabolism is a small molecule compound. In various embodiments, the biomarker related to nucleic acid metabolism is present in a sample derived from the subject (e.g., a biological or physiological fluid). In particular embodiments, an alteration in the levels of one or more biomarkers related to nucleic acid metabolism, relative to a reference, indicates a tissue or cell is neoplastic. n specific embodiments, an alteration in the levels of one or more biomarkers related to nucleic acid metabolism, relative to a reference, indicates a subject has or is at risk of having neoplasia. Exemplary biomarkers related to nucleic acid metabolism include without limitation: xanthosine (CAS: 146-80-5); inosine (CAS: 58-63-9); deoxyuridine (CAS: 951 - 78-0); thymidine (CAS: 50-89-5); Uric acid (CAS: 69-93-2); S-allantoin (CAS: 97-59-6); Xanthine (CAS: 69-89-6); Hypoxanthine (CAS: 68-94-0); Guanine (CAS: 73-40-5);

Guanosine (CAS: 1 18-00-3); Deoxyguanosine (CAS: 961 -07-9); Adenine (CAS: 73-24-5); Adenosine (CAS: 58-6 1 -7); Deoxyadenosine (CAS: 958-09-8); FAPy-adenine (CAS: 5122- 36-1 ); l -Methyladenme (CAS; 5142-22-3); Deoxyonosine (CAS: 890-38-0); uracil (CAS: 66-22-8); uridine (CAS: 58-96-8): dihydrouracil (CAS: 504-07-4); dihydrouridine (CAS: 5627-05-4); Orotic acid (CAS: 65-86-3); Thymine (CAS: 65-71 -4); dihydrothymine (CAS: 696-04-8); Ureidopropionic acid (CAS: 462-88-4); beta -Alanine (CAS: 107-95-9);

Ureidoisobutyric acid (CAS: 2905-86-4); 4,5-Dihydroorotic acid (CAS: 155-54-4); 5- ethylcytidine (CAS: 2140-61 -6); 5-Methyldeoxycytidine (CAS: 838-07-3);

Carbamoylphosphate (CAS: 590-55-6); and 5-Hydroxymethyluracil (CAS: 4433-40-3); including pharmaceutically acceptable salts, solvates, hydrates, geometrical isomers, tautomers, optical isomers, isotopic derivatives, polymorphs, prodrugs, and N-oxides thereof. In certain exemplary embodiments, biomarkers related to nucleic acid metabolism include xanthosine, inosine, deoxyuridine, thymidine, deoxycytidine, cytosine, hypoxanthine, xanthine, uracil, guanosine, and adenosine.

As used herein, the term "biomarker related to urea cycle and polyamine metabolism" refers to metabolic intermediates and products related to increased polyamine metabolism in a subject or a tissue or a cell of the subject (e.g., a neoplastic tissue or ceil), in various embodiments, the biomarker related to polyamine metabolism is a small molecule compound. In various embodiments, the biomarker related to polyamine metabolism is present in a sample derived from the subject (e.g., a biological or physiological fluid). In particular embodiments, an alteration in the levels of one or more biomarkers related to polyamine metabolism, relative to a reference, indicates a tissue or cell is neoplastic. In specific embodiments, an alteration in the levels of one or more biomarkers related to polyamine metabolism, relative to a reference, indicates a subject has or is at risk of having neoplasia. Exemplary biomarkers related to urea cycle and polyamine metabolism include without limitation: Nl -acetyl spermidine (CAS: 14278-49-0); N8-acetylsperrnidine (CAS: 34450-15- 2); spermine (CAS: 71-44-3); Putrescine (CAS: 1 10-60-1); spermidine (CAS: 124-20-9); ornithine (CAS: 70-26-8); Citrulline (CAS: 372-75-8); L-arginine (CAS: 74-79-3); N- acetylputrescine (CAS: 124-20-9); Nl -acetylspermine (CAS: 25593-72-0); and L- argininosuccinic acid (CAS: 2387-71 -5) including pharmaceutically acceptable salts, solvates, hydrates, geometrical isomers, tautomers, optical isomers, isotopic

derivatives, polymorphs, prodrugs, and N-oxides thereof. In certain exemplary embodiments, biomarkers relaed to polyamine metabolism include biomarkers related to urea cycle and polyamine metabolism including Nl -acetylspermidine, N8-acetylspermidine₅ spermine, arginine ornithine, and citrulline.

As used herein, the term "biomarker related to amino acid metabolism" refers to metabolic intermediates and products related to increased amino acid metabolism in a subject or a tissue or a cell of the subject (e.g., a neoplastic tissue or cell). n various embodiments, the biomarker related to amino acid metabolism is a small molecule compound. In various embodiments, the biomarker related to amino acid metabolism is present in a sample derived from the subject (e.g., a biological or physiological fluid), in particular embodiments, an alteration in the levels of one or more biomarkers related to amino acid metabolism, relative to a reference, indicates a tissue or cell is neoplastic, In specific embodiments, an alteration in the levels of one or more biomarkers related to amino acid metabolism, relative to a reference, indicates a subject has or is at risk of having neoplasia. Exemplary biomarkers related to amino acid metabolism include without limitation: proline (CAS; 609-36-9 or 147- 85-3); glutamine (CAS: 56-85-9);Na-acetyllysine (CAS: 1946-82-3); Serine (CAS: 56-45-1 ); Threonine (CAS: 72-19-5); glycine (CAS: 56-40-6); asparagine (CAS: 70-47-3); aspartic acid (CAS: 56-84-8); glutamic acid (CAS: 56-86-0); 4-hydroxyproline (CAS: 30724-02-8); 2- ketog!utaric acid (CAS: 1 8465- 19-5); 2-hydroxyglutaric acid (CAS: 2889-31 -8); Oxaloacetic acid (CAS: 328-42-7); Fumaric acid (CAS: 1 10-17-8); Lysine (CAS: 923-27-3); Creatine (CAS: 57-00- 1 ); Creatinine (CAS: 60-27-5); Phoshocreatine (CAS: 67-07-2);

Guanidinoacctic acid (CAS: 352-97-6); and N(6)-Methyllysine (CAS: 1 1 88-07-4); including pharmaceutically acceptable salts, solvates, hydrates, geometrical isomers, tautomers, optical isomers, isotopic derivatives, polymorphs, prodrugs, and N-oxides thereof. In certain exemplary embodiments, biomarkers related to amino acid metabolism include proline, gliitamine, glutamic acid, threonine, and N -acetyllysine.

As used herein, the term "asymmetric-dimethylarginine (ADMA)" refers to a compound having the CAS number 102783-24-4, including a pharmaceutically acceptable salt, solvate, hydrate, geometrical isomer, tautomer, optical isomer, isotopic

derivative, polymorph, prodrug, or N-oxide thereof, An increase in asymmetric- dimethylarginine in a biological sample is related to an increase in methy!ation (e.g. protein methylation, DNA methyiation) in a subject or a tissue or a cell of the subject (e.g., a neoplastic tissue or cell).

As used herein, the term "symmetric-dimethylarginine (SDMA)" refers to a compound having the CAS number 30344-00-4, including a pharmaceutically acceptable salt, solvate, hydrate, geometrical isomer, tautomer, optica! isomer, isotopic

derivative, poiymorph, prodrug, or Λ^'-oxide thereof. An increase in symmetric- dimethylarginine in a biological sample is related to an increase in methylation (e.g. protein methylation, DNA methylation) in a subject or a tissue or a ceil of the subject (e.g., a neoplastic tissue or cell).

As used herein, the term "carnitine" refers to a compound having the CAS number 541 -1 5-1 , including a pharmaceutically acceptable salt, solvate, hydrate, geometrical isomer, tautomer, optical isomer, isotopic derivative, poiymorph, prodrug, or N-oxide thereof. A decrease in carnitine in a biological fluid sample is related to an increase in methylation (e.g. protein methy lation, DNA methylation) in a subject or a tissue or a ceil of the subject (e.g., a neoplastic tissue or ceil). A decrease in carnitine in a biological tissue sample is related to an increase in methylation in a subject or a tissue or a ceil of the subject (e.g., a neoplastic tissue or cell).

As used herein, the term "methio ine" refers to a compound having the CAS number

63-68-3, including a pharmaceutically acceptable salt, solvate, hydrate, geometrical isomer, tautomer, optical isomer, isotopic derivative, poiymorph, prodrug, or .N-oxide thereof. An increase in methionine in a biological sample is related to an increase in nucleic acid metabolism in a subject or a tissue or a cell of the subject (e.g., a neoplastic tissue or cell).

As used herein, the term "dimethylglycine'' refers to a compound having the CAS number ! 1 1 8-68-9, including a pharmaceutically acceptable salt, solvate, hydrate, geometrical isomer, tautomer, optical isomer, isotopic derivative, polymorph, prodrug, or N- oxide thereof. An increase in dimethylglycine in a biological sample is related to an increase in nucleic acid metabolism in a subject or a tissue or a eel! of the subject (e.g., a neoplastic tissue or cell).

As used herein, the term "betaine' refers to a compound having the CAS number 107- 43-7, including a pharmaceutically acceptable salt, solvate, hydrate, geometrical isomer, tautomer, optical isomer, isoiopic derivative, polymorph, prodrug, or N-oxide thereof. An increase in betaine in a biological sample is related to an increase in nucleic acid metabolism in a subject or a tissue or a celi of the subject (e.g., a neoplastic tissue or ceil).

As used herein, the term "xanthosine'' refers to a compound having the CAS number 146-80-5, including a pharmaceutically acceptable salt, solvate, hydrate, geometrical isomer, tautomer, optical isomer, isotopie derivative, polymorph, prodrug, or N-oxide thereof. An increase in xanthosine in a biological sample is related to an increase in nucleic acid metabolism in a subject or a tissue or a celi of the subject (e.g., a neoplastic tissue or cell).

As used herein, the term "inosine" refers to a compound having the CAS number 58- 63-9, including a pharmaceutically acceptable salt, solvate, hydrate, geometrical isomer, tautomer, optical isomer, isotopie derivative, polymorph, prodrug, or N-oxide thereof. An increase in inosine in a biological sample is related to an increase in nucleic acid metabolism in a subject or a tissue or a ceil of the subject (e.g., a neoplastic tissue or ceil).

As used herein, the term "deoxyuridine" refers to a compound having the CAS number 951 -78-0, including a pharmaceutically acceptable salt, solvate, hydrate, geometrical isomer, tautomer, optical isomer, isotopie derivative, polymorph, prodrug, or N-oxide thereof. An increase in deoxyuridine in a biological sample is related to an increase in nucleic acid metabolism in a subject or a tissue or a ceil of the subject (e.g., a rseoplastic tissue or cell).

As used herein, the term "thym idine" refers to a compound having the CAS number 50-89-5, including a pharmaceutically acceptable salt, solvate, hydrate, geometrical isomer, tautomer, optical isomer, isotopie derivative, polymorph, prodrug, or N-oxide thereof. An increase in thymidine in a biological sample is related to an increase in nucleic acid metabolism in a subject or a tissue or a cell of the subject (e.g., a neoplastic tissue or cell).

As used herein, the term "deoxycytidine" refers to a compound having the CAS number 951 -77-9, including a pharmaceutically acceptable salt, solvate, hydrate, geometrical isomer, tautomer, optical isomer, isotopie derivative, polymorph, prodrug, or N-oxide thereof. An increase in deoxycytidine in a biological sample is related to an increase in nucleic acid metabolism in a subject or a tissue or a cell of the subject (e.g., a neoplastic tissue or ceil). As used herein, the term "cytosine" refers to a compound having the CAS number 71 - 30-7, including a pharmaceutically acceptabie salt, solvate, hydrate, geometrical isomer, tautomer, optical isomer, isotopic derivative, polymorph, prodrug, or N-oxide thereof. An increase in cytosine in a biological sample is related to an increase in nucleic acid metabolisin in a subject or a tissue or a cell of the subject (e.g., a neoplastic tissue or cell).

As used herein, the term "hypoxanthine" refers to a compound having the CAS number CAS: 68-94-0, including a pharmaceutically acceptable salt, solvate, hydrate, geometrical isomer, tautomer, optica! isomer, isotopic derivative, polymorph, prodrug, or N- oxide thereof. An increase in hypoxanthine in a biological sample is related to an increase in nucleic acid metabolism in a subject or a tissue or a cell of the subject (e.g., a neoplastic tissue or cell).

As used herein, the term "xanthine" refers to a compound having the CAS number CAS: 69-89-6, including a pharmaceutically acceptabie salt, solvate, hydrate, geometrical isomer, tautomer, optical isomer, isotopic. derivative, polymorph, prodrug, or N-oxide thereof. An increase in dxanthine in a biologicai sample is related to an increase in nucleic acid metabolism in a subject or a tissue or a cell of the subject (e.g., a neoplastic tissue or cell).

As used herein, the term "uracil" refers to a compound having the CAS number CAS;

66-22-8, including a pharmaceutically acceptable salt, solvate, hydrate, geometrical isomer, tautomer, optical isomer, isotopic derivative, polymorph, prodrug, or N-oxide thereof. An increase in uracil in a biological sample is related to an increase in nucleic acid metabolism in a subject or a tissue or a ceil of the subject (e.g., a neoplastic tissue or ceil).

As used herein, the term "guanosine" refers to a compound having the CAS number

CAS: 1 18-00-3, including a pharmaceutically acceptabie salt, solvate, hydrate, geometrical isomer, tautomer, optical isomer, isotopic derivative, polymorph, prodrug, or N-oxide thereof. An increase in guanosine in a biological sample is related to an increase in nucleic acid metabolism in a subject or a tissue or a cell of the subject (e.g., a neoplastic tissue or cell).

As used herein, the term "adenosine" refers to a compound having the CAS number CAS: 58-61 -7, including a pharmaceutically acceptable salt, solvate, hydrate, geometrical isomer, tautomer, optical isomer, isotopic derivative, polymorph, prodrug, or N-oxide thereof. An increase in adenosine in a biological sample is related to an increase in nucleic acid metabolism in a subject or a tissue or a cell of the subject (e.g., a neoplastic tissue or cell).

As used herein, the term "N l -acetyispermidine" refers to a compound having the CAS number 14278-49-0, including a pharmaceutically acceptable salt, solvate, hydrate, geometrical isomer, tautomer, optical isomer, isotopic derivative, polymorph, prodrug, or N- oxide thereof. An increase in N l -acetylspermidine in a biological sample is related to an increase in polyamine metabolism in a subject or a tissue or a eel! of the subject (e.g., a neoplastic tissue or ceil).

As used herein, the term "N8-acetylspermidine" refers to a compound having the CAS number 34450- 15-2, including a pharmaceutically acceptable salt, solvate, hydrate, geometrical isomer, tautomer, optica! isomer, isotopic derivative, polymorph, prodrug, or N- oxide thereof. An increase in N8-acetylspermidine in a biological sample is related to an increase in polyamine metabolism in a subject or a tissue or a ceil of the subject (e.g., a neoplastic tissue or cell).

As used herein, the term "spermine'^'' refers to a compound having the CAS number

71 -44-3, including a pharmaceutically acceptable salt, solvate, hydrate, geometrical isomer, tautomer, optical isomer, isotopic derivative, polymorph, prodrug, or N-oxide thereof. An increase in spermine in a biological sample is related to an increase in polyamine metabolism in a subject or a tissue or a cell of the subject (e.g., a neoplastic tissue or ceil).

As used herein, the term "arginine" refers to a compound having the CAS number

CAS: 74-79-3, including a pharmaceutically acceptable salt, solvate, hydrate, geometrical isomer, tautomer, optical isomer, isotopic derivative, polymorph, prodrug, or N-oxide thereof. An increase in arginine in a biological sample is related to an increase in polyamine metabolism in a subject or a tissue or a cell of the subject (e.g., a neoplastic tissue or cell).

As used herein, the term "ornithine" refers to a compound having the CAS number

CAS: 70-26-8, including a pharmaceutically acceptable salt, solvate, hydrate, geometrical isomer, tautomer, optical isomer, isotopic derivative, polymorph, prodrug, or N-oxide thereof. An increase in ornithine in a biological sample is related to an increase in polyamine metabolism in a subject or a tissue or a cell of the subject (e.g., a neoplastic tissue or cell), As used herein, the term "citru!line" refers to a compound having the CAS number

CAS: 372-75-8, including a pharmaceutically acceptable salt, solvate, hydrate, geometrical isomer, tautomer, optical isomer, isotopic derivative, polymorph, prodrug, or N-oxide thereof. An increase in citruiline in a biological sample is related to an increase in polyamine metabolism in a subject or a tissue or a cell of the subject (e.g., a neoplastic tissue or cell).

As used herein, the term "proline" refers to a compound having the CAS number 609- 36-9 or 147-85-3 (L-proline), including pharmaceutically acceptable, salts, solvates, hydrates, geometrical isomers, tautomers, optical isomers, isotopic derivatives, polymorphs, prodrugs, or N-oxides thereof. An increase in proline in a biological sample is related to an increase in amino acid metabolism in a subject or a tissue or a cell of the subject (e.g., a neoplastic tissue or cell).

As used herein, the term "glutamine" refers to a compound having the CAS number 56-85-9, including pharmaceutically acceptable salts, solvates, hydrates, geometrical isomers, tautomers, optical isomers, isotopic derivatives, polymorphs, prodrugs, or N-oxides thereof. An increase in glutamine in a biological sample is related to an increase in amino acid metabolism in a subject or a tissue or a cell of the subject (e.g., a neoplastic tissue or cell).

As used herein, the term "N -acetyliysine" refers to a compound having the CAS number 1946-82-3, including pharmaceutically acceptable salts, solvates, hydrates, geometrical isomers, tautomers, optical isomers, isotopic derivatives, polymorphs, prodrugs, or N-oxides thereof. An increase in Na-acetyilysine in a biological sample is related to an increase in amino acid metabolism in a subject or a tissue or a ceil of th subject (e.g., a neoplastic tissue or cell).

As used herein, the term "glutamic acid" refers to a compound having the CAS number CAS: 56-86-0, including pharmaceutically acceptable salts, solvates, hydrates, geometrical isomers, tautomers, optical isomers, isotopic derivatives, polymorphs, prodrugs, or N-oxides thereof. An increase in glutamic acid in a biological sample is related to an increase in amino acid metabolism in a subject or a tissue or a cell of the subjeci (e.g., a neoplastic tissue or cell).

As used herein, the term "threonine" refers to a compound having the CAS number CAS: 72-19-5, including pharmaceutically acceptable salts, solvates, hydrates, geometrical isomers, tautomers, optical isomers, isotopic derivatives, polymorphs, prodrugs, or N-oxides thereof. An increase in threonine in a biological sample is related to an increase in amino acid metabolism in a subject or a tissue or a cell of the subject (e.g., a neoplastic tissue or cell).

As used herein, the term "M264" refers to a novel metabolite that was identified as a biomarker for colorectal cancer in human urine samples. The metabolite has a molecular formulae C9H 17N3O6 and gives rise to a protonated ion with m/z = 264. 12 in the ESI positive mode. The ion gives rise to fragments 132 and 90, characteristic fragments of creatine, in the ESI-MS/MS mode. The structure contains a creatine moiety with a ribofuranosyl ring attached to one ogf the guanidirse nitrogens through C 3 of the sugar. The IUPAC name of the compound is 2-{2-[(2R₎3R,4S,5R)-3,4-dihydroxy-5-(hydroxymethyI)-oxolan-2-yl ]- l - methylcarbam imidamido} acetic acid and the common name β-D-Ribofuranosyicreatine. The biosynthesis of the compound is expected to invoive arginine metabolism, rnethvlation and pentose phosphate pathway, which is also involved in nucleic acid biosynthesis.

By "agent" is meant any small molecule chemical compound, antibody, nucleic acid molecule, or polypeptide, or fragments thereof.

By "alteration" is meant an increase or decrease. An alteration may be by as little as 1 %, 2%, 3%, 4%, 5%, 10%. 20%, 30%, or by 40%, 50%, 60%, or even by as much as 75%, 80%, 90%, or 1 00%.

As used herein, the term "antibody" means not only intact antibody molecules, but also fragments of antibody molecules that retain immunogen-binding ability. Such fragments are also well known in the art and are regularly employed both in vitro and in vivo.

Accordingly, as used herein, the term "antibody" means not only intact immunoglobulin molecules but also the well-known active fragments F(ab')2, and Fab. F(ab')2, and Fab fragments that lack the Fc fragment of intact antibody, clear more rapidly from the circulation, and may have less non-specific tissue binding of an intact antibody (Wahl et a!., J. uci. Med. 24:3 1 6-325 ( 1983). The antibodies of the invention comprise whole native antibodies, bispecific antibodies; chimeric antibodies; Fab. Fab', single chain V region fragments (scFv), fusion polypeptides, and unconventional antibodies.

By "biologic sample" is meant any tissue, cell, fluid, or other material derived from an organism.

By "clinical aggressiveness" is meant the severity of ihe neoplasia. Aggressive neoplasias are more likely to metastasize than less aggressive neoplasias. While conservative methods of treatment are appropriate for less aggressive neoplasias, more aggressive neoplasias require more aggressive therapeutic regimens.

As used herein, the terms "determining", "assessing", "assaying", "measuring" and

"detecting" refer to both quantitative and qualitative determinations, and as such, the term

"determining" is used interchangeably herein with "assaying," "measuring," and the like.

Where a quantitative determination is intended, the phrase "determining an amount" of an analyte and the like is used, Where a qualitative and/or quantitative determination is intended, the phrase "determining a level" of an analyte or "detecting" an anaiyte is used.

The terms "isolated." "purified," or "biologically pure" refer to material that is free to varying degrees from components which normally accompany it as found in its native state. "Isolate" denotes a degree of separation from original source or surroundings. "Purify" denotes a degree of separation that is higher than isolation. A "purified" or "biologically pure" protein is sufficiently free of other materials such that any impurities do not materially affect the biological properties of the protein or cause other adverse consequences. That is, a nucleic acid or peptide of this invention is purified if it is substantially free of cellular material, viral material, or culture medium when produced by recombinant DNA techniques, or chemical precursors or other chemicals when chemically synthesized. Purity and homogeneity are typicaily determined using analytical chemistry techniques, for example, polyacrylamide gel electrophoresis or high performance liquid chromatography. The term "purified" can denote that a nucleic acid or protein gives rise to essentially one band in an electrophoretic gel For a protein that can be subjected to modifications, for example, phosphorylation or glycosylation, different modifications may give rise to different isolated proteins, which can be separately purified.

The term "microarray" or "array" is meant to include a collection or panel of capture reagents arranged on a solid support (for example, a chip, plate, or bead).

By "neoplasia" is meant any disease that is caused by or results in inappropriately high levels of ceil division, inappropriately low levels of apoptosis, or both. For example, cancer is an example of a neoplasia. Examples of cancers include, without limitation, prostate cancer, leukemias (e.g., acute leukemia, acute lymphocytic leukemia, acute myelocytic leukemia, acute myeloblastic leukemia, acute promyelocyte leukemia, acute myeiomonoeytic leukemia, acute monocytic leukemia, acute erythroleukemia, chronic leukemia, chronic myelocytic leukemia, chronic lymphocytic leukemia), polycythemia vera, lymphoma (Hodgkin's disease, non-Hodgkin's disease), Waldenstrom's macroglobulinemia, heavy chain disease, and solid tumors such as sarcomas and carcinomas (e.g., fibrosarcoma, myxosarcoma, iiposarcoma, chondrosarcoma, osteogenic sarcoma, chordoma, angiosarcoma, endothe!iosarcoma, iymphangiosarcoma, lymphangioendotheliosarcoma, synovioma, mesothelioma, Ewing's tumor, leiomyosarcoma, rhabdomyosarcoma, colon carcinoma, pancreatic cancer, breast cancer, ovarian cancer, squamous cell carcinoma, basal cell carcinoma, adenocarcinoma, sweat gland carcinoma, sebaceous gland carcinoma, papillary carcinoma, papillary adenocarcinomas, cystadenocarcinoma, medullary carcinoma, bronchogenic carcinoma, renal cell carcinoma, hepatoma, nile duet carcinoma,

choriocarcinoma, seminoma, embryona l carcinoma, Wiim's tumor, cervical cancer, uterine cancer, testicular cancer, lung carcinoma, smal l cell lung carcinoma, bladder carcinoma, epithelial carcinoma, glioma, astrocytoma, medu iloblastoma, craniopharyngioma, ependymoma, pinealoma, hemangiobiastoma, acoustic neuroma, oligodenroglioma, schwannoma, meningioma, melanoma, neuroblastoma, and retinoblastoma),

Lymphopro!iferaiive disorders are also considered to be proliferative diseases.

By "reference" is meant a standard of comparison. For example, the level of one or more of asymmetric-dimethylarginine, symmetric-dimethylarginine, proline, giutamine, a- acetyllysine, xanthosine, inosine, deoxyuridine, thym idine, N l -acetyispermidine, N8- acetyfspermidine, spermine, or carnitine present in a patient sample may be compared to the level of the compound(s) in a corresponding healthy cell or tissue or in a diseased cell or tissue (e.g. , a cell or tissue derived from a subject having neoplasia). In quantitating the level of a compound of interest in a sample, the levels of the compound may be normalized to those of another compound whose levels are not related to a disease and/or are not expected to change (e.g., creatinine).

By "periodic" is meant at regular intervals. Periodic patient monitoring includes, for example, a schedule of tests that are administered daily, bi-weekly, bi-monthly, monthly, bi- annually, or annually.

By "severity of neoplasia" is meant the degree of pathology. The severity of a neoplasia increases, for example, as the stage or grade of the neoplasia increases.

By "Marker profi le" is meant, a characterization of the level of two or more compounds, analytes, or metabolites. For example, Marker profi les of the fol lowing groups of biomarkers are useful in characterizing neoplasia in the methods of the invention:

asymmetric-dimethylarginine and symmetric-dimethylarginine, and optionally carnitine (methylation); proline, giutam ine, Net-acetyliysine (am ino acid metabolism); xanthosine, inosine, deoxyuridine, thymidine (nucleic acid metabol ism); and (po!yamine metabolism); or a combination thereof

The term "subject" or "patient" refers to an animal which is the object of treatment, observation, or experiment. By way of example only, a subject includes, but is not limited to, a mammal, including, but not limited to, a human or a non-human mammal, such as a non- human primate, murine, bovine, equine, canine, ovine, or feline. By "specifically binds" is meant an affinity agent (e.g., an antibody) that recognizes and binds a compound or agent of interest (e.g., a biomarker), but which does not substantially recognize and bind other molecules in a sample, for example, a biological sample,

As used herein, the terms "prevent," "preventing," "prevention," "prophylactic treatment," and the like, refer to reducing the probability of developing a disease or condition in a subject, who does not have, but is at risk of or susceptible to developing a disease or condition, e.g., neoplasia.

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

As used herein, the terms "comprises," "comprising," "containing," "having" and the like can have the meaning ascribed to them in U.S. Patent law and can mean "includes," "including," and the like. The term "including" is used herein to mean, and is used interchangeably with, the phrase "including but not limited to." The terms "consisting essentially of or "consists essentially" likewise has the meaning ascribed in U.S. Patent, law and the term is open-ended, allowing for the presence of more than that which is recited so long as basic or novel characteristics of that which is recited is not changed by the presence of more than that which is recited, but excludes prior art embodiments.

As used herein, the singular forms "a", "an", and "the" include plural forms unless the context clearly dictates otherwise. Thus, for example, reference to "a biomarker" includes reference to more than one biomarker.

Unless specifically stated or obvious from context, as used herein, the term "about" is understood as within a range of normal tolerance in the art, for example within 2 standard deviations of the mean. About can be understood as within 10%, 9%, 8%, 7%, 6%, 5%, 4%, 3%, 2%, 1%, 0.5%, 0.1 %, 0.05%, or 0.01% of the stated value. Unless otherwise clear from context, all numerical values provided herein are modified by the term about.

The recitation of a listing of chemical groups in any definition of a variable herein includes definitions of that variable as any single group or combination of listed groups. The reci tation of an embodiment for a variable or aspect herein includes that embodiment as any single embodiment or in combination with any other embodiments or portions thereof. Unless specifically stated or obvious from context as used herein, the term "or" is understood to be inclusive. Any compounds, compositions, or methods provided herein can be combined with one or more of any of the other compositions and methods provided herein. DESCRIPTION OF THE DRAWINGS

Figures 1A-1C depict the characterization of APC^{M,n r} and wild-type mice. Figure 1 A shows a representative picture of longitudinally opened intestine of APC^M,n/+ and wild-type mice. Red arrows indicate tumor and polyps in the mutant. Figure I B is a graph of absolute body weight profile of wild-type (dotted line) and APC^M"^V÷ (solid line) mice during the study. There was no significant difference in body weight of wild-type and APC ^in/+ mice. All values presented as mean ± SEM, Figure 1 C is a graph of box plots for alanine

aminotransferase (ALT) and aspartate aminotransferase (AST) levels in wild-type and

APC^{Min +} serum.

Figures 2A-2F depict the effect of tumorigenesis on global metabolomic signature and amino acid metabolism. Figure 2A is a scores scatter plot for principal components analysis (PCA) of total ion count (TlC)-normaiized data obtained from UPLC-HiLIC-ESI-MS analysis urine samples at five months in negative ionization mode. Figure 2B is a scores scatter plot for principal components analysis (PCA) of creatinine-normalized data obtained from UPLC-H1LIC-ESI-MS analysis urine samples at five months in negative ionization mode. Figure 2C is a graph showing the longitudinal variation in the creatinine-normalized urinary excretion of glutamine in wild-type and APC^M""^÷ mice is shown by dotted and solid lines, respectively. Figure 2D is a graph showing the longitudinal variation in the creatinine- normalized urinary excretion of proline in wild-type and APC^Ml"'⁺ mice is shown by dotted and solid lines, respectively. Figure 2E is a graph showing the longitudinal variation in the creatinine-normalized urinary excretion of Na-acetyllysme in wild-type and APC^M""'⁺ mice is shown by dotted and solid lines, respectively, Figure 2F is a graph showing the longitudinal variation in the creatinine-normalized urinary excretion of carnitine in wild-type and

APC^Min/+ mice is shown by dotted and solid lines, respectively. The statistical significance of the difference in metabolite concentrations were calculated by two-tailed Mann- Whitney test with 95% confidence interval. P values < 0.05, < 0,01 and < 0.005 are indicated by ' * ', and respectively. All values are presented as mean ± SEM.

Figures 3A-3D depict analysis of creatinine-normalized metabolomic signature using reverse-phase separation. Figure 3A is a scores scatter plot for unsupervised principal components analysis (PCA) of creatinine-normalized UPLC-RP-ESIMS positive ionization mode data (0, 1 - 1 ,3 mins) obtained from urine samples collected at six months, Figure 3B is a scores scatter plot for orthogonal projections to latent structures (OPLS) analysis of creatinine-normalized data obtained from UPLC-HSLSC-ESIMS analysis of urine samples col lected at five months in negative ionization mode. Figure 3C is a scores scatter plot for orthogonal projections to latent structures (OPLS) analysis of creatinine-normalized obtained from UPLC-RP-ESIMS analysis of urine samples collected at six months in positive ionization mode. Figure 3D is a loadings S-plot of the ions from OPLS analysis of creatinine-normalized data obtained from UPLC-HILIC-ESIMS analysis of urine samples collected at f ve months in negative ionization mode. Distance from the origin along the Y- axis is commensurate with the contribution of the ion to separation of wild-type and mutant animals and that along the X-axis is commensurate with the abundance of the ion in the chromatogram. Ions in the upper right quadrant (shown in red box) represent ions elevated in APC^M'^n,+ urine and those in the bottom left quadrant (shown in green box) represent ions reduced in APC ^in/+ compared to their wild-type.

Figures 4A-4F depict the effect of tumorigenesis on urinary excretion of metabolites related to arginine and polyamine metabolism. Figure 4A is a graph showing the longitudinal variation in the creatinine-normalized urinar excretion of symmetric-dimethyiarginine in wild-type and APC^{Miri "} mice is shown by dotted and solid lines, respectively. Figure 4B is a graph showing the longitudinal variation in the creatinine-normalized urinary excretion of asymmetric-dimethylarginine in wild-type and APC^Mia'⁺ mice is shown by dotted and solid lines, respectively. Figure 4C is a graph showing the longitudinal variation in the creatinine- normalized urinary excretion of citruliine in wild-type and APC ^{m "} mice is shown by dotted and solid lines, respectively. Figure 4D is a graph showing the longitudinal variation in the creatinine-normalized urinary excretion of spermine in wild-type and APC^{M l"}"'⁺ mice is shown by dotted and solid lines, respectively. Figure 4E is a graph showing the longitudinal variation in the creatinine-normalized urinary excretion of Nl -acetylspermidine in wild-type and APC ^{in +} mice is shown by dotted and solid lines, respectively. Figure 4F is a graph showing the longitudinal variation in the creatinine-normalized urinary excretion of 8- acetyispermidine in wild-type and APC^Min'^'1" mice is shown by dotted and solid lines, respectively. The statistical significance of the difference in metabolite concentrations were calculated by two-tailed Mann-Whitney test with 95% confidence interval. P values < 0.05, < 0.01 and < 0.005 are indicated by ' * ', ⁴ * * ' and '*** ', respectively. A3! values are presented as mean ± SEM.

Figures 5 A and 5B depict the effect of tumorigenesis on urinary excretion of metabolites related to urea cycle and polyamine metabolism, Figure 5A is a graph showing longitudinal variation in the creatinine-normalized excretion of ornithine in the wild-type and A ^M,n/" mice in discovery set is shown by dotted and solid lines, respectively. All values shown as mean ± SEM and ' ** ' indicate P value < 0.01. Figure 5B is a graph of box plots for urinary excretion of N-acetyllysine. citrulline, thymidine, deoxyuridine, cytidine and xanthine in validation cohort. AH statistical significances were calculated by two-tailed Mann-Whitney test with 95% confidence interval,

Figures 6A-6F depict the effect of tumorigenesis on urinary excretion of metabolites related to nucleic acid metabolism. Figure 6A is a is a graph showing longitudinal variation in the creatinine-normalized urinary excretion of xanthosine in wild-type and APC^Min'⁺ mice is shown by dotted and solid lines, respectively. Figure 6B is a is a graph showing longitudinal variation in the creatinine-normalized urinary excretion of inosine in wild-type and APC ^{lti 4} mice is shown by doited and solid lines, respectively. Figure 6C is a is a graph showing longitudinal variation in the creatinine-normalized urinary excretion of xanthine in wild-type and APC^M"^{v i} mice is shown by dotted and solid lines, respectively. Figure 6D is a is a graph showing longitudinal variation in the creatinine-normalized urinary excretion of cytidine in wild-type and APC ^{,n +'} mice is shown by dotted and solid lines, respectively.

Figure 6E is a is a graph showing longitudinal variation in the creatinine-normalized urinary excretion of deoxyuridine in wild-type and APC ^m/+ mice is shown by dotted and solid lines, respectively, Figure 6F is a is a graph showing longitudinal variation in the creatinine- normalized urinary excretion of thymidine in wild-type and APC ⁱⁿ'^" mice is shown by dotted and solid lines, respectively. The statistical significance of the difference in metabolite concentrations were calculated by two-tailed Mann-Whitney test with 95% confidence interval. P values < 0,05, 0.0.1 and < 0.005 are indicated by ' *', ' ** ' and ' ** *^*, respectively. All values are presented as mean ± SEM.

Figures 7A-7E depict validation of metaboiomic biomarkers and evaluation of diagnostic power. Figure 7A is a graph of box plots for creatinine-normalized concentrations of carnitine, glutamine, N 1 ~acetylspermidine, N8-acetylspermidine, proline, asymmetric- dimethyiarginine, symmetric-dimethyiarginine, spermine, xanthosine and inosine in age- matched (six month old) non-littermate healthy control (wild-type) and tumor-bearing (APC^{Mm !} ) animals. Figure 7B is a graph of the receiver operating characteristic (ROC) curve for tumor diagnosis using biomarkers related to amino acid metabohsm (proline, glutamine and Na-acetyiiysine), Figure 7C is a graph of the receiver operating characteristic (ROC) curve for tumor diagnosis using biomarkers related to polyamine metabolism (N 1 ~ aeeiylspermidine, N8-acety!spermidine and spermine). Figure 7D is a graph of the receiver operating characteristic (ROC) curve for tumor diagnosis using biomarkers related to nucleic acid metabolism (xanthosine, inosine, deoxvuridine and thymidine). Figure 7E is a graph of the receiver operating characteristic (ROC) curve for tumor diagnosis using biomarkers related to methy!ation (symmeiric-dimethyiarginine, asymmetric-dimethylarginine and carnitine). Area under the ROC curve (AUCROC) and accuracy is shown for each plot.

Figures 8A-8D are graphs of Box plots for comparison of ranges of creatinine- normalized urinary excretion of individual metabolites in discovery, validation and combined cohorts at six months. Figure 8A depicts graphs of metabo!ites related to amino acid metabolism. Figure 8B depicts graphs of metabolites related to polyamine metabolism. Figure 8C depicts graphs of metabolites related to nucleic acid metabolismn. Figure 8D depicts graphs of metabolites related to methylation.

Figures 9A-9D depict analysis of individual metabolic urinary biomarkers. Figure 9A depicts ROC curves for individual metabolites related to amino acid metabolism. Figure 9B depicts ROC curves for individual metabolites related to polyamine metabolism. Figure 9C depicts ROC curves for individual metabolites related to nucleic acid metabolism, Figure 9D depicts ROC curves for individual metabolites related to methylation, The area under the curve (AUCROC) and accuracy for each metabolite is mentioned. See Table 1 for details on their diagnostic capability.

Figures 10A and 10B depict accuracy of tumor diagnosis using a panel of metabolic urinary biomarkers, Figure 10A is a heat-map showing distinct metabo!omic trait associated with APC ^iil,÷ mice compared to wild-type. Figure 10B shows that hierarchical clustering using the metabolite panel shows correct classification of ail except one wild-type and one mutant mouse.

Figures ! IA and 1 I B depict the ability of the biomarker panels to distinguish wiid- type and mutant animals at 5 months. Figure 1 1 A depicts ROC curves for individual biomarker panels for detection of subjects prone to tumorigenesis (mutants) at five months in the longitudinal discovery cohort. Figure I I B depicts ROC curves for a combination of biomarker panels for detection of subjects prone to tumorigenesis (mutants) at five months in the longitudinal discovery cohort. The area under the curve (AUCROC) and accuracy for each metabolic panel is mentioned. Carnitine had to be removed from the methylation panel as it perfectly identified mutants with a cut off value of 42.56 μηιοΐ/rnmol creatinine,

Figures 12A and 12B depict the ability of the biomarker panels to distinguish wild- type and mutant animals at 4 months. Figure 12A depicts ROC curves for individual biomarker panels for detection of subjects prone to tumorigenesis (mutants) at four months in the longitudinal discovery cohort. Figure 12B depicts ROC curves for a combination of biomarker panels for detection of subjects prone to tumorigenesis (mutants) at four months in the longitudinal discovery cohort. The area under the curve (AUCROC) and accuracy for each metabolic panel is mentioned.

Figures 13A and 13B depict the ability of the biomarker panels to distinguish wild- type and mutant animals at 3 months. Figure 13A depicts ROC curves for individual biomarker panels for detection of subjects prone to tumorigenesis (mutants) at three months in the longitudinal discovery cohort. Figure 13B depicts ROC curves for a combination of biomarker panels for detection of subjects prone to tumorigenesis (mutants) at three months in the longitudinal discovery cohort. The area under the curve (AUCROC) and accuracy for each metabolic panel is mentioned.

Figures S4A and 14B depict the ability of the biomarker panels to distinguish wild- type and mutant animals at 2 months. Figure 14A depicts ROC curves for individual biomarker panels for detection of subjects prone to tumorigenesis (mutants) at two months in the longitudinal discovery cohort. Figure MB depicts ROC curves for a combination of biomarker panels for detection of subjects prone to tumorigenesis (mutants) at two months in the longitudinal discovery cohort, The area under the curve (AUCROC) and accuracy for each metabolic panel is mentioned.

Figures 15A-15D depict the effect of colorectal tumorigenesis on tissue metabolome.

Figure 15.A depicts graphs of box plots showing relative abundance of metabolites related to amino acid metabolism in normal colon mucosa (wild type) and colon tumor (APC^Mm/+) tissue, Figure 15B depicts graphs of box plots showing relative abundance of metabolites related to polyamme metabolism in normal colon mucosa (wild type) and colon tumor (APC^{Min +}) tissue. Figure 15C depicts graphs of box plots showing relative abundance of metabolites related to nucleic acid metabolism in normal colon mucosa (wild type) and colon tumor (APC ^{m +}) tissue. Figure 15D depicts graphs of box plots showing relative abundance of metabolites related to methylation in normal colon mucosa (wild type) and colon tumor (APC^{Mli, +}) tissue. The abundance of proline, glutamine, glutamic acid, threonine, arginine, citrulline, ornithine. N 1 -acetyl spermidine, thymidine, ATP, dimethylarginine and carnitine were elevated while those of xanthine and inosine were reduced. All values presented as fold-change with respect to the abundance of the metabolite in the normal colon epithelium. Statistical significance was calculated by two-tailed Mann- Whitney test with 95% confidence interval

Figures I 6A- 16E depict the effect of colorectal tumorigenesis on tissue transcriptome. Figure 16A is a graph of the expression of genes involved in am ino acid biosynthesis are- shown as fold change with respect gene expression in normal colon mucosa. Figure 16B is a graph of the expression of genes involved in purine metabolism are shown as fold change with respect gene expression in normal colon mucosa. Figure 16C is a graph of the expression of genes involved in pyrimidine metabolism are shown as fold change with respect gene expression in normal colon mucosa. Figure 36D is a graph of the expression of genes involved in po!yamine metabolism are shown as fold change with respect gene expression in normal colon mucosa. Figure 16E is a graph of the expression of genes involved in methylation are shown as fold change with respect gene expression in normal colon mucosa. Statistical significance was calculated by two-tailed Mann-Whitney test with 95% confidence interval with '#'„ '$' and indicating P values < 0.05, < 0,01 and < 0.005, respectively.

Figure 37 A-E are a seried of graphs that show changes in urinary metabolic profile associated with AOM-induced colorectal carci ogenesis in mice. Dot-scatter plots {presented as mean with 95% confidence interval) showing creatinine-normalized urinary excretion of metabolites related to Figure 17A shows amino acid metabolism (glutamine, glutamic acid, proline, threonine, and N -acetyllysine), Figure 17B shows urea cycle and poiyamins metabolism (NS-acetylspermidine, l -acetylspermidine, citrulline, arginine, and ornithine), Figure 17C shows pyrimidine metabolism (deoxycytidine, cytosine, deoxyuridine, uracil, and thymidine), Figure 17D purine metabolism (xanthine, xanthosine, and guanosine), and Figure 17E methylation (symmetric-dimethylarginine, asymmetrtc-dimethylarginine, methionine, carnitine, and betaine) in saline-treated healthy (control, N^:;;: 6) or tumor-bearing mice (AOM, N - 6) five months after AOM -treatment. All statistical significances were calculated by two- tailed Mann-Whitney test with 95% confidence interval.

Figure 18 is a series of graphs that show the effect of colorectal tumorigenesis on the metaboiome of human epithelial tissue. Arrow plots showing changes in metabolite abundance between paired colon tumor and adjacent non-tumor tissue. All cases (ΊΝ = 23) with tumors found in rectum and sigrnoidal, descending or transeverse colon are presented. P values were calculated by two-tailed paired t-test with 95% confidence intervals.

Figure 19 is a series of graphs thai shows the effect of colorectal tumorigenesis on the metabolome of human epithel ial tissue. Arrow plots showing changes in metabolite abundance between paired colon tumor and adjacent non-tumor tissue. All tumors (N ^~ 39) are presented irrespective of location and histology. Statistical significance was calculated by two-tailed paired t-test with 95% confidence intervals.

Figure 20 shows identification of a novel metabolite (M264) as a urinary biomarker of human colorectal cancer. Figure 20A shows the molecular formula, IUPAC name and structure of the compound that would be commonly referred to as β-D-Ribofuranosylcreatine. Figure 20B shows the creatin tne-normal ized relative abundance of the metabolite in control (N = 10) and patient (N = 10) urine samples. Statistical significance was calculated by two- tailed Mann- Whitney test with 95% confidence interval. Figure 20C shows the ROC curve for detection of colorectal cancer using the metabolite.

Figures 21A and 21B depict the coordinate deregulation and reprogramming of metabolic network in APC mutation-mediated colorectal tumorigenesis. Coordinate reprogramming of metabolic machinery in colorectal tumorigenesis. Figure 2 IA shows metabolic pathways captured by metabo!omic and transcriptomic analysis in this study with metabolite names in red, black or blue indicating increase, no change or decrease, respectively, in abundance in Apc^{Miri r} tumor tissue, ' *' indicates that the metabolite was significantly elevated in human tumor tissues. Solid red, black or blue boxes indicate that creatinine-normaiized excretion of the metabolite was elevated, unchanged or depleted, respectively, in urine of the Apc^M"'^H mice. Doited box indicates that the metabolite was either not detected or monitored in Apc^frlin/+ urine. FA, Ac-CoA, Να-Ac Lysine, OAA, a-KG, PRRP, SAH, SAM, MTA, SAMA, ADMA, SOMA, NMMA, N l -AcS and N8~AcS represent, fatty acid, acetyl coenzyme A, No. acetyliysine, oxaloacetic acid, a-ketogiutarie acid, 5- phosphoribosyl 3 -pyrophosphate, S-adenosyihomocysteine, S-adenosylmethionine, S-methyl- 5-thioadenosine, S-adenosylmethioninamine, aswime/n^'e-dimelhylarginine, symmetric- dimethylarginine, N^m-monomethyiarginine, Nl-aeetyispermidine and NS-acetylspermidine, respectively. Arrows indicate pathways of conversion of metabolites with solid and dotted lines indicating the involvement of single and multiple reactions, respectively. Red, black or blue colors indicate upregulation, no change or downregulation of expression of genes encoding enzymes involved in these pathways in Apc^Mm/r tumor tissue compared to normal colon mucosa, respectively. Dash-dotted arrows indicate pathways for biosynthesis of essential amino acids (such as threonine and lysine) that are unannotated in human and mouse. Figure 21B shows the origin and utility of biomarkers of metabolic reprogramming in early noninvasive diagnosis.

DETAILED DESCRIPTION OF THE INVENTION

The invention features compositions and methods that are useful for the diagnosis, treatment and prevention of neoplasia, including colorectal cancer, as well as to determine subject prognosis and aid in treatment selection.

As detailed herein, metabolomic and transcriptomic analysis revealed changes in amino acid, nucleic acid, polyamine metabolism and methylation (e.g. protein methyiation,

DNA methylation) in tumor tissue. This invention is based, at least in part, on the discovery that the following groups or panels of bion trkers are useful and effective for identifying a subject as having or having a propensity to develop neoplasia (e.g., colorectal cancer, small intestine cancer, duodenal cancer, gastric cancer, pancreatic cancer, liver cancer, esophageal cancer, ovarian cancer, prostate cancer, uterine cancer, breast cancer, thyroid cancer and melanoma): biomarkers related to methylation; biomarkers related to nucleic acid metabolism; biomarkers related to urea cycle and polyamine metabolism; and biomarkers related to amino acid metabolism.

in particular, the biomarkers related to methyiation include asymmetric- dimethylargmine, symmetric-dimethylarginine, carnitine, methionine, dimethylglycine, and betaine; the biomarkers related to nucleic acid metabolism include xanthosine, inosine, deoxyuridine, thymidine, deoxycytidine, cytosine, hypoxanthine, xanthine, uracil, guanosine, and adenosine; the biomarkers related to urea cycle and polyamine metabolism include N l - acetylspermidine, N8-acetylspermidine, spermine, arginine ornithine, and citrulline; and the biomarkers related to amino acid metabolism include proline, gSutamine, glutamic acid, threonine, and Na-acetyl lysine.

Also contemplated by the present invention is the biomarker M26 as useful and effective for identifying a subject as having or having a propensity to develop neoplasia.

Changes in the urinary rnetabo!ome were found to be in concert with these metabolomic and transcriptomic changes in tumor tissue and. consequently, helped to correctly distinguish healthy and tumor-bearing animals. The consistency of longitudinal trait of simultaneous deregulation of these pathways during tumorigenesis resulted in highly accurate and early prediction of subjects at risk of developing colorectal cancer in this mouse model.

The results described herein revealed a concerted deregulation of epigenetic, transcriptional, post-translational and metabolic events associated with tumorigenesis in APC^Min/r mice. Coordinate reprogramming of cellular metabolism during tumongeneis is reflected in the urine ietabolome. In particular, progressive elevation of symmetric- and asymmetrie-dimethylarginine in urine of animals as a reflection of hyperactive methylation machinery is a novel observation in the context of colorectal cancer. The ability of urinary metabolites to prospectively identify animals that would eventually develop tumor, indicate a combined panel of urinary biomarkers representing synchronized deregulation of amino acid, nucleic acid, polyamine metabolism and methylation may provide a powerful high- throughput noninvasive method for screening as well as early diagnosis of colorectal cancer.

Accordingly, the invention provides for methods and kits that are useful in the diagnosis, treatment, and prevention of neoplasia, as well as for characterizing neoplasia to determine subject prognosis and aid in treatment selection. The invention further provides methods and kits for monitoring a patient identified as having neoplasia.

Diagnostics and Diagnostic Assays

The present invention features diagnostic assays for the detection of neoplasia, including colorectal cancer. In embodiments, the level of a biomarker(s) is measured in a subject sample and used to characterize neoplasia or the propensity to develop neoplasia. In particular embodiments, the levels of a group of methylation biomarkers are measured including at least asymmetric-dimethylarginirje and symmetric-dirnethylarginine, and optionally carnitine, in additional or alternative embodiments, the levels of biomarkers are measured from one or more of the following groups: biomarkers related to methylation; biomarkers related to nucleic acid metabolism; biomarkers related to urea cycle and polyamine metabolism; and biomarkers related to amino acid metabolism.

in particular, the biomarkers related to methylation include asymmetric- dimethylarginine, symmetric-dimethylarginine, carnitine, methionine, dimethylglycine, and betaine; the biomarkers related to nucleic acid metabolism include xanthosine, inosine, deoxyuridine, thymidine, deoxycytidine, cytosine, hypoxanthtne, xanthine, uracil, guanosine, and adenosine; the biomarkers related to urea cycle and polyamine metabolism include Nl - acetylspermidine, N8-acetyispermidine, spermine, arginine ornithine, and citruiline; and the biomarkers related to amino acid metabolism include proline, giutamine, glutamic acid, threonine, and Να-aeetyi!ysine. M264 (β-D-Ribofiiranosylcreatine) biomarker is also contremplated in the diagnostic assays described herein.

Bioiogica! samples include tissue samples (e.g., cell samples, biopsy samples, and the like) and bodily fluids, including, but not limited to, urine, blood, blood serum, plasma, bile, fecal aspirate, intestinal aspirate, cerebrospinal fluid and saliva. Samples can optionally be treated to enrich for the biomarker(s) using enrichment and separation methods well known in the art,

Elevated levels of the biomarker(s) are considered a positive indicator of neoplasia.

In general, an increase in the levels of one or more of biomarkers related to methylation; biomarkers related to nucleic acid metabolism; biomarkers related to urea cycle and poiyamine metabolism; biomarkers related to amino acid metabolism and M264 is indicative of neoplasia or the propensity to develop neoplasia.

In particular, an increase in the levels of one or more biomarkers related to methylation including asymmetric-dimethyiarginine, symmetric-dimethyiarginine, carnitine, methionine, dimethylglycine, and betaine; the biomarkers related to nucleic acid metabolism including xanthosine, inosine, deoxyuridine, thymidine, deoxycytidine, cytosine, hypoxanthine, xanthine, uracil, guanosine, and adenosine; the biomarkers related to urea cycle and poiyamine metabolism including Nl -acetylspermidine, N8-acety!spermidine, spermine, arginine ornithine, and citruiline; and the biomarkers related to amino acid metabolism including proline, giutamine, glutamic acid, threonine, Na-acetyllysine and M264 is indicative of neoplasia or the propensity to develop neoplasia.,

Elevated levels of the biomarker carnitine in tissue samples and reduced levels of the biomarker carnitine in biological fluid (e.g. urine) is indicative of neoplasia or the propensity to develop neoplasia. The increase or decrease in biomarker levels may be by at least about 10%, 25%, 50%, 75%, 90% or more. The increase or decrease in biomarker levels may be by at least about 1.5, 2, 2.5. 3, 3.5, 4, 4.5, 5, 5.5, 6, 6.5, 7, 7.5, 8, 8.5, 9, 9.5, 10, 10.5, 1 1 , 1 1 .5, 12, 12.5, 13, 13.5, 14, 14.5, 15, 16, 17, 1 8, 19, 20, 25, 30, 35, 40, 45, 50, 55, 60, 65, 70, 75, 80, 85, 90, 95-fold or more.

In embodiments, multiple biomarkers are measured (e.g., asymmetric- dimethyiarginine, symmetric-dimethyiarginine, carnitine, methionine, dimethylglycine, and betaine (methylation); proline, giutamine, glutamic acid, threonine, and Na-acety! lysine (amino acid metabolism); xanthosine, inosine, deoxyuridine, thymidine, deoxycytidine, cytosine, hypoxanthine, xanthine, uracil, guanosine, and adenosine (nucleic acid

metabolism); N l -acetylspermidine, N8-acetylspermidine, spermine, arginine ornithine, and citrul!ine (urea cycle and polyamine metabolism), Additionally, one or more additional neoplasia biomarkers that are known in the art, (e.g., an APC variant associated with colon cancer),

in a particular embodiment, levels of the M264 biomarker are measured.

The use of multiple biomarkers increases the predictive value of the test and provides greater utility in diagnosis, toxicology, patient stratification and patient monitoring. The process called "Pattern recognition" detects the patterns formed by multiple biomarkers greatly improves the sensitivity and specificity of the diagnostic assay for predictive medicine. Subtle variations in data from clinical samples indicate that certain patterns of biomarkers can predict phenotypes such as the presence or absence of a certain disease, a particular stage of disease-progression, or a positive or adverse response to drug treatments.

Detection of an alteration relative to a reference sample (e.g., normal sample) can be used as a diagnostic indicator of neoplasia or colorectal cancer. In embodiments, the invention provides methods for identifying a subject as having or having a propensity to develop neoplasia or colorectal cancer, in related embodiments, the methods involve detecting the levels of one or more groups or panels of biomarkers as follows; asymmetric- dimethylarginine, symmetric-dimethylarginine, carnitine, methionine, dimeth !glycine, and beta^'me (methylation); proline, glutamine, glutamic acid, threonine, and Na-acetyllysine (amino acid metabolism); xanthosine, inosine, deoxyuridine, thymidine, deoxycytidine, cytosine, hypoxanthine, xanthine, uracil, guanosine, and adenosine (nucleic acid

metabolism); N l -acetylspermidine, N8-acetyispermidine, spermine, arginine ornithine, and citrui !ine (urea cycle and polyamine metabolism);, or a combination thereof as specified herein, in a sample obtained from the subject, in embodiments, the methods involve comparing the level of the biomarker to a reference. In embodiments, the methods involve identifying the subject as having or having a propensity to develop neoplasia or colorectal cancer when the level of the biomarker is increased relative to the reference.

in embodiments, the invention provides methods for identifying neoplasia or colorectal cancer in a subject, in related embodiments, the methods involve detecting the levels of one or more groups or panels of biomarkers as follows: asymmetric- dimethylarginine, symmetrie-dimethyiarginine, carnitine, methionine, dimethyiglycine, and betaine (tnethylation); proline, glutamine, glutamic acid, threonine, and Na-acetyliysine (amino acid metabolism); xanthosine, inosine, deoxyuridine, thymidine, deoxycytidine, cytosine, hypoxanthine, xanthine, uracil, guanosine, and adenosine (nucleic acid metabolism); Nl -acetyispermidine, N8-acetylsperrnidine, spermine, arginine ornithine, and citruiline (urea cycle and polyamine metabolism); or a combination thereof as specified herein, in a sample obtained from the subject. In embodiments, the methods involve comparing the level of the biomarker to a reference. In embodiments, the methods involve identifying neoplasia or colorectal cancer in the subject when the ievel of the biomarker is increased relative to the reference.

In embodiments, the invention provides methods for characterizing the stage of neoplasia in a subject. In related embodiments, the methods involve detecting the levels of one or more groups or panels of biomarkers as follows: asymmetric-dimethylarginine, symmetric-dimethylarginine, carnitine, methionine, dimethylglycine, and betaine

(methyiation); proline, glutamine, glutamic acid, threonine, and Na-acetyliysine (amino acid metabolism); xanthosine, inosine, deoxyuridine, thymidine, deoxycytidine, cytosine, hypoxanthine, xanthine, uracil, guanosine. and adenosine (nucleic acid metabolism); N l - acetylspermidine, NS-acetylspermidine, spermine, arginine ornithine, and citruiline (urea cycle and polyamine metabolism); or a combination thereof as specified herein, in a sample obtained from the subject. In embodiments, the methods involve comparing the ievel of the biomarker to a reference. In embodiments, the methods involve identifying the subject as having a later stage of neoplasia when there is an increase in the level of the biomarker relative to the reference.

In embodiments, the invention provides methods for determining the prognosis of neoplasia in a subject. In related embodiments, the methods involve detecting the levels of one or more groups or panels of biomarkers as follows: a symmetric-dimethylarginine, symmetric-dimethylarginine, carnitine, methionine, dimethylglycine, and betaine

(methyiation); proline, glutamine, glutamic acid, threonine, and a-acctyl lysine (amino acid metabolism); xanthosine, inosine, deoxyuridine, thymidine, deoxycytidine, cytosine, hypoxanthine, xanthine, uracil, guanosine, and adenosine (nucleic acid metabolism): Nl- acetylspermidine, NS-acetylspermidine, spermine, arginine ornithine, and citruiline (urea cycle and polyamine metabolism); or a combination thereof as specified herein in a sample obtained from the subject, In embodiments, the methods involve comparing the level of the biomarker to a reference. In embodiments, the methods involve identifying the subject as having a poor prognosis when there is an increase in the ieve! of the biomarker relative to the reference.

In embodiments, the invention provides methods for characterizing the degree of lipid accumulation during the early stage of neoplasia in a subject. In related embodiments, the methods involve detecting the level s of one or more groups or panels of biomarkers as follows: asymmetric-dimethylarginine, symmetric-dimethylarginine, carnitine, methionine, dimethylgiycine, and betaine (methylation); proline, glutamine, glutamic acid, threonine, and Na-acetyl lysine (amino acid metabolism); xanthosine, inosine, deoxyuridine, thymidine, deoxycytidine, cytosine, hypoxanthine, xanthine, uracil, guanosine, and adenosine (nucleic acid metabolism); N l -acetyispermidine, N8^«acety [spermidine, spermine, arginsne ornithine, and citruUine (urea cycle and po!yamine metabolism);, or a combination thereof as specified herein in a sample obtained from the subject. In embodiments, the methods involve comparing the level of the biomarker to a reference. In embodiments, the methods involve identifying the subject as having a higher level of lipid accumulation during the early stage of neoplasia when there is an increase in the level of the biomarker relative to the reference.

In embodiments, the invention provides methods for monitoring neoplasia therapy in a subject. In related embodiments, the methods involve detecting the levels of one or mor groups or panels of biomarkers as follows: asymmetric-dimethylarginine, symmetric- dimethylarginine, carnitine, methionine, dimethylgiycine, and betaine (methylation); proline, glutamine, glutamic acid, threonine, and Na-acetyllysine (amino acid metabolism);

xanthosine, inosine, deoxyuridine, thymidine, deoxycytidine, cytosine, hypoxanthine, xanthine, uracil, guanosine, and adenosine (nucleic acid metabolism); Nl -acetylspermidine, NS-acetylspermidine, spermine, arginine ornithine, and citrulline (urea cycle and poiyamine metabolism); or a combination thereof as specified herein in a sample obtained from the subject. In embodiments, the methods involve comparing the level of the biomarker to a reference. In embodiments, the methods involve identifying the therapy as effective when there is a decrease in the level of the biomarker relative to the reference.

In embodiments, the invention provides methods for detecting an agent's therapeutic efficacy i a subject having neoplasia, in related embodiments, the methods involve detecting an alteration in the levels of one or more groups or panels of biomarkers as follows; asymmetric-dimethylarginine, symmetric-dimethylarginine, carnitine, methionine, dimethylgiycine, and betaine (methylation); proline, glutamine, glutamic acid, threonine, and

Na-acetyl lysine (amino acid metabolism); xanthosine, inosine, deoxyuridine, thymidine, deoxycytidine, cytosine, hypoxanthine, xanthine, uracil, guanosine, and adenosine (nucleic acid metabolism); N l -acety [spermidine, 8-acetylsperrnidine, sperm ine, arginine ornithine, and eitruSSine (urea cycle and poiyamine metabolism); or a combination thereof as specified herein, in a sample obtained from the subject, in embodiments, the methods involve comparing the level of the biomarker to a reference (e.g., a patient sample taken at an earlier time point or prior to treatment). In embodiments, the methods involve identifying the agent as having therapeutic efficacy in the subject when there is a decrease in the level, In embodiments, the methods involve identifying the agent as lacking therapeutic efficacy in the subject when there maintenance or increase in the level.

in embodiments, the level of the btomarker(s) is measured on at least two different occasions and an alteration in the levels as compared to normal reference levels over time is used as an indicator of neoplasia, including colorectal cancer. The level of the biomarker(s) in a sample from a subject (e.g., bodily fluids such as blood, blood serum, plasma, bile, fecal aspirate, intestinal aspirate, cerebrospinal fluid, saliva, and urine) of a subject having neoplasia or the propensity to develop such a condition may be altered by as little as 10%, 20%, 30%, or 40%, or by as much as 50%, 60%, 70%, 80%, or 90% or more relative to the level of such biomarker(s) in a normal control, in embodiments, a subject sample is collected prior to the onset of symptoms of neoplasia. In embodiments, a subject sample is collected after the onset of symptoms of neoplasia. In embodiments, a subject sample is collected while the subject is undergoing treatment for neoplasia

The diagnostic methods described herein can be used individually or in combination with any other diagnostic method described herein or well known in the art for a more accurate diagnosis of the presence or severity of neoplasia. The diagnostic methods described herein can also be used to monitor and manage neoplasia, including colorectal cancer.

As indicated above, the invention provides methods for aiding an neoplasia diagnosis using one or more groups or panels of biomarkers as follows: asymmetric-dimethy!arginine, symmetric-dimethylarginitie, carnitine, methionine, dimethyiglycine, and betaine

(methvlalion); proline, giutamine, glutamic acid, threonine, and Nu-acetyllysine (amino acid metabolism); xanthosine, inosine, deox uridine, thymidine, deoxycytidine, cytosine, hypoxanthine, xanthine, uracil, guanosine, and adenosine (nucleic acid metabolism); N i- acetylspermidine, NS-acetylspermidine, sperm ine, arginine ornithine, and citrulline (urea cycle and poiyamine metabolism); or any combination of the recited biomarkers. These biomarker(s) can be used alone, in combination with other biomarkers in any set, or with entirely different markers in aiding neoplasia diagnosis. The markers are differentially present in samples of a neoplasia patient and a normal subject in whom neoplasia is undetectable. Therefore, detection of one or more of these biomarkers in a person would provide useful information regarding the probability that the person may have neoplasia or regarding the stage of neoplasia progression.

The detection of the biomarker(s) is then correlated with a probable diagnosis of neoplasia. In embodiments, the detection of the mere presence of a biomarker, without quantifying the amount thereof, is useful and can be correlated with a probable diagnosis of neoplasia. The measurement of biomarkers may also involve quantify ing the markers to correlate the detection of markers with a probable diagnosis of neoplasia. Thus, if the amount of the biomarkers detected in a subject being tested is different compared to a control amount (e.g., higher than the control), then the subject being tested has a higher probability of having neoplasia.

The correlation may take into account the amount of the biomarker(s) in the sample compared to a control amount of biomarker(s) (e.g., in normal subjects or in non-neoplasia subjects such as where neoplasia is undetectable). A control can be, e.g., the average or median amount of the biomarker(s) present in comparable samples of normal subjects in normal subjects or in non-neoplasia subjects such as where neoplasia is undetectable. The control amount is measured under the same or substantially similar experimental conditions as in measuring the test amount. As a result, the control can be employed as a reference standard, where the normal (non-neoplasia) phenotype is known, and each result can be compared to that standard (e.g., a standardized curve for use), rather than re-running a control.

in some embodiments, the control is derived from the patient and provides a reference level of the patient prior to, during, or after treatment for neoplasia.

Accordingly, a biomarker profi le may be obtained from a subject sample and compared to a reference biomarker profi le obtained from a reference population, so that it is possible to classify the subject as belonging to or not belonging to the reference population. The correlation may take into account the presence or absence of the biomarkers in a test sample and the frequency of detection of the same biomarkers in a control . The correlation may take into account both of such factors to facilitate determ ination of neoplasia status. In certain embodiments of the methods of qualifying neoplasia status, the methods further comprise managing subject treatment based on the status. The invention also provides for such methods where the biomarker(s) are measured again after subject management. In these cases, the methods are used to monitor the status of neoplasia, e.g. , response to neoplasia treatment, including improvement, maintenance, or progression of the disease,

A biomarker, individually, can be useful in aiding in the determination of neoplasia status, First, the selected biomarker is detected in a subject sample using well known methods, including, but not limited to, the methods described herein. Then, the result is compared with a control that distinguishes neoplasia status from non-neoplasia status. As is well understood in the art, the techniques can be adjusted to increase sensitivity or specificity of the diagnostic assay depending on the preference of the diagnostician.

While an individual biomarker is a useful diagnostic marker, in some instances, a combination of biomarkers provides greater predictive value than single markers alone. The detection of a pluralit of biomarkers (or absence thereof, as the case may be) in a sample can increase the percentage of true positive and true negative diagnoses and decrease the percentage of false positive or false negative diagnoses. Thus, in embodiments, methods of the present invention comprise the measurement of more than one biomarker.

Colorectal Cancer

Colorectal cancer is the second leading cause of cancer mortality in United States and fourth worldwide. Although colorectal cancer has good therapeutic response at early stages, advanced stages are frequently associated with metastasis and poor prognosis. Regular screening and early diagnosis of the disease is pivotal to therapeutic success.

More than 80% of colorectal cancers arise from adenomatous polyps making this cancer amenable to screening. Diagnosis of cases of colorectal cancer through screening tends to occur 2-3 years before diagnosis of cases with symptoms. Screening has the potential to reduce colorectal cancer deaths by 60%.

Colorectal Cancer Staging

The most commonly used staging system for colorectal cancer is that of the American Joint Committee on Cancer (AJCC), or the TNM system. Older staging systems for colorectal cancer, such as the Dukes and Astier-Coller systems, are mentioned for comparison. The TNM system describes 3 key pieces of information: "T" describes how far the main (primary) tumor has grown into the wall of the intestine and whether it has grown into nearby areas; "N" describes the extent of spread to nearby (regional) lymph nodes, Lymph nodes are small bean-shaped collections of immune system cells that are important in fighting infections, "M" indicates whether the cancer has spread (metastasized) to other organs of the body. (Colorectal cancer can spread almost anywhere in the body, but the most common sites of spread are the liver and lungs.). Numbers appearing after T, N, and M (0-4) indicate increasing severity.

T categories of colorectal cancer describe the extent of spread through the layers that form the wall of the colon and rectum. Tx: No description of the tumors extent is possible because of incomplete information, Tis: The cancer is in the earliest stage (in situ); involves only the mucosa; and/or has not grown beyond the muscularis mucosa (inner muscle layer), Tl : The cancer has grown through the muscularis mucosa and extends into the submucosa. T2: The cancer has grown through the submucosa and extends into the muscularis propria (thick outer muscle layer). T3: The cancer has grown through the muscularis propria and into the outermost layers of the colon or rectum but not through them, It has not reached any nearby organs or tissues, T4a: The cancer has grown through the serosa (also known as the visceral peritoneum), the outermost lining of the intestines. T4b: The cancer has grown through the wall of the colon or rectum and is attached to or invades into nearby tissues or organs,

N categories indicate whether or not the cancer has spread to nearby lymph nodes and, if so, how many lymph nodes are involved. Nx: No description of !ymph node involvement is possible because of incomplete information, NO: No cancer in nearby lymph nodes. N l : Cancer cells are found in or near 1 to 3 nearby lymph nodes; small deposits of cancer cells are found in areas of fat near lymph nodes, but not in the lymph nodes themselves, N2: Cancer cells are found in 4 or more nearby lymph nodes

M categories indicate whether or not the cancer has spread (metastasized) to distant organs, such as the liver, lungs, or distant lymph nodes. MO: No distant spread is seen. M i a: The cancer has spread to 1 distant organ or set of distant lymph nodes, Ml b: The cancer has spread to more than 1 distant organ or set of distant lymph nodes, or it has spread to distant parts of the peritoneum (the lining of the abdominal cavity).

Information from T, N, and M categories is combined in a process called stage grouping. ^'The stage is expressed in Roman numerals from stage I (the least advanced) to stage IV (the most advanced). Stage 0 - Tis, NO, MO: The cancer is in the earliest stage; the cancer has not grown beyond the inner layer (mucosa) of the colon or rectum (carcinoma in situ or intramucosal carcinoma), Stage I - T1 -T2, NO, MO: The cancer has grown through the muscularis mucosa into the submucosa (Tl ) or it may also have grown into the muscularis propria (T2); the cancer has not spread to nearby lymph nodes or distant sites. Stage UA - T3, NO, MO: The cancer has grown into the outermost layers of the colon or rectum but has not gone through them (T3). The cancer has not reached nearby organs. The cancer has not yet spread to the nearby lymph nodes or distant sites. Stage I IB - T4a, NO, MO: The cancer has grown through the wall of the colon or rectum but has not grown into other nearby tissues or organs (T4a), The cancer has not yet spread to the nearby lymph nodes or distant sites. Stage IIC - T4b, NO, MO: The cancer has grown through the wall of the colon or rectum and is attached to or has grown into other nearby tissues or organs (T4b). The cancer has not yet spread to the nearby lymph nodes or distant sites, Stage ΙΠΑ - One of the following applies. ΤΊ -Τ2, N l , MO: The cancer has grown through the mucosa into the submucosa (Tl ) and it may also have grown into the muscularis propria (T2). The cancer has spread to 1 to 3 nearby lymph nodes (N l a Ni b) or into areas of fat near the lymph nodes but not the nodes themselves (Nl c). It has not spread to distant sites. Tl , N2a, MO: The cancer has grown through the mucosa into the submucosa (Tl). It has spread to 4 to 6 nearby lymph nodes (N2a), The cancer has not spread to distant sites, Stage ΪΙΙΒ - One of the following applies. T3-T4a, Nl , MO: The cancer has grown into the outermost layers of the colon or rectum (T3) or through the visceral peritoneum (T4a) but has not reached nearby organs, The cancer has spread to 1 to 3 nearby lymph nodes (Nl a/N 1 b) or into areas of fat near the lymph nodes but not the nodes themselves (N l c). It has not spread to distant sites. T2-T3, N2a, MO: The cancer has grown into the muscularis propria (T2) or into the outermost layers of the colon or rectum (T3). The cancer has spread to 4 to 6 nearby lymph nodes (N2a). It has not spread to distant sites. T1-T2, N2b, MO: The cancer has grown through the mucosa into the submucosa (Tl) or it may also have grown into the muscularis propria (T2). The cancer has spread to 7 or more nearby lymph nodes (N2b). The cancer has not spread to distant sites. Stage IIIC - One of the following applies. T4a, N2a, MO: The cancer has grown through the wall of the colon or rectum (including the visceral peritoneum) but has not reached nearby organs (T4a). The cancer has spread to 4 to 6 nearby lymph nodes (N2a). The cancer has not spread to distant sites. T3-T4a, N2b, MO: The cancer has grown into the outermost layers of the colon or rectum (T3) or through the visceral peritoneum (T4a) but has not reached nearby organs. The cancer has spread to 7 or more nearby lymph nodes (N2b). The cancer has not spread to distant sites. T4b, N1 -N2, MO: The cancer has grown through the wall of the colon or rectum and is attached to or has grown into other nearby tissues or organs (T4b). The cancer has spread to at least one nearby lymph node or into areas of fat near the lymph nodes (N 3 or N2). The cancer has not spread to distant sites. Stage IV A - Any T, Any N, Mia: The cancer may or may not have grown through the wall of the colon or rectum, and it may or may not have spread to nearby lymph nodes. The cancer has spread to 1 distant organ (such as the liver or lung) or set of lymph nodes (M i a). Stage IVB - Any T, Any , M l b; The cancer may or may not have grown through the wall of the colon or rectum, and it may or may not have spread to nearby lymph nodes. The cancer has spread to more than 1 distant organ (such as the liver or lung) or set of lymph nodes, or it has spread to distant parts of the peritoneum (the lining of the abdominal cavity) (M l b).

Colorectal Cancer Grading

The grade of the cancer is another factor that can affect the outlook for survival. Grade is a description of how closely the cancer looks like normal colorectal tissue when seen under a microscope. The scale used for grading colorectal cancers goes from Gl (where the cancer looks much like normal colorectal tissue) to G4 (where the cancer looks very abnormal). The grades G2 and G3 fall somewhere in between. The grade is often simplified as either "low grade" (G l or G2) or "high grade" (G3 or G4). Low-grade cancers tend to grow and spread more slowly than high-grade cancers. Most of the time, the outlook is better for low-grade cancers than it is for high-grade cancers of the same stage. Doctors sometimes use this distinction to help decide treatment selection (e.g., additional (adjuvant) treatment with chemotherapy after surgery).

Diagnosis of colorectal cancer is via tumor biopsy typically done during

sigmoidoscopy or colonoscopy. The extent of the disease is then usually determined by a CT scan of the chest, abdomen and pelvis. There are other potential imaging test such as PET and MRI which may be used in certain cases. The three main screening tests are fecal occult blood testing, flexible sigmoidoscopy and colonoscopy. Of the three, only sigmoidoscopy can not screen the right side of the colon where 42% of malignancies are found. Virtual colonoscopy via a CT scan can detect cancers and large adenomas but is expensive, associated with radiation exposure, and can not remove any detected abnormal growths like standard colonoscopy can.

Fecal occult blood testing of the stool is typically recommended every two years and can be either guaiac based orimmunochemica! . Medical societies recommend screening

-Di- between the age of 50 and 75 years with .sigmoidoscopy every 5 years and colonoscopy every 10 years. For those at high risk, screenings usually begin at around 40. For people with average risk who have had a high-quality colonoscopy with normal results, the American Gastroenterological Association does not recommend any type of screening in the 10 years following the colonoscopy. For people over 75 or those with a life expectancy of less than 10 years, screening is not recommended.

Metabolomics has the potential to be a useful tool for identification of changes in biochemical signature associated with pathogenesis. However, tissue metabolomics requires biops samples and is invasive. Urine metabolomics has been shown to be a powerful approach to identify noninvasive biomarkers for diagnosis. A number of meiaboiomic studies have actually shown that metabolite composition of the tissue as well as biofluids from colorectal cancer patients are different from that of healthy controls thus raising the hope for an alternative noninvasive method for screening, diagnosis and therapeutic monitoring. On the other hand, sensitivity of the metaboiome to factors such as genetic composition, food and environment, warrants exploration of the mechanistic link between biofluid biomarkers and molecular signatures of tumor tissue to identify robust biomarkers of pathogenesis and high- fidelity target pathways. Moreover, there has been a general lack of studies investigating the mechanistic Sink between these biomarkers and changes in cancer tissue.

Longitudinal changes in population at risk (due to genetic or environmental predisposition) vis-a-vis healthy controls to find out consistent and progressive changes during tumorigenesis, which may also yield early biomarkers, Animal models have long provided a reasonably sound fundamental and translationai bypass on human biology. In fact, a large volume of the molecular events associated with colorectal carcinogenesis has been derived from research on animal models such as APC^, "ⁿ' ^" mice. These animals harbor a mutation in an allele of the Adenomatous Polyposis Coli (A PC) gene that causes familial adenomatous polyposis-associated colorectal cancer in humans. Mutations in the APC gene, which is involved in the Wnt-signaling pathway, are also frequently associated with sporadic colorectal cancer. The results herein describe, for the first time, a longitudinal trace of evolution in urinary meiaboiomic signature during colorectal carcinogenesis and detail a potential mechanistic Sink with transcriptomic and metabolomic changes in tumor tissue to identify potential high-throughput noninvasive biomarkers using APC ^""⁺ mouse model.

Adenomatous polyposis coli (APC) The most commonly mutated gene in all colorectal cancer is the APC gene, which produces the APC protein. The APC protein, which is a tumor suppressor gene, inhibits the accumuialion of β-catenin protein. Without APC, β-catenin accumulates to high levels and translocates (moves) into the nucleus, binds to DNA, and activates the transcription of genes that are normally important for stem cell renewal and differentiation but when inappropriately expressed at high levels can cause cancer. While APC is mutated in most colon cancers, some cancers have mutations in other Wnt signaling pathway proteins. For example, such situations where Wnt signaling pathway proteins are mutated other than APC include mutations in β-catenin (CTNNB 1) that block its degradation, resulting in increased β-catenin levels, or mutation(s) in other genes with function analogous to APC such as AXIN1 , ΑΧΓΝ2, TCF7L2, or NKD1 . Like colorectal cancer, APC and Wnt signaling pathway proteins may be mutated in other cancers including small intestine cancer, duodenal cancer, gastric cancer, pancreatic cancer, liver cancer, esophageai cancer, ovarian cancer, prostate cancer, uterine cancer, breast cancer, thyroid cancer or melanoma (Giles et al„ Biochim. Biophys. Acta. 2003; 1653: 1 -24).

The amino acid sequence of an exemplary human APC sequence (isoform B) is provided at GenBank Accession No. NP_000Q29, which is reproduced below;

1 maaasydqll kqvealkmen siilrqel dn srihl klete asnmkevlkq lqgsiedearo 61 asjigqidlle rlkelnldss nl^'pgvkirsk mslrsygsre gsvs;sr;>q8c spvp-ngsf r 121 rgfvngsres tgyleeleke rsllladldk eekekdwyya qlqnltfcrid slpltenfsi 181 qtdratrrqle yearqirvam eeqlgtcqdm ekraqrriar iqqiskdil irqllqsqat 2 1 eaerseqnkh etgshdaerq negqgvgein tnatsgngqgs ttrmdhetas vlssssthsa 301 prrltshlgb kvemvyslls mlgthdkddm srtllamsss qdeciemrqs gclpliiqll 3S1 hgndkasvll gnsrgskear arasaal nl ihaqpddkrg rreirvlhll eqiraycetc 421 wewqeahepg mdqdknpinpa pvehqicpav cvlmkiafde e r amnelg glqaiaellq 431 vdcemygltn dhysi ^;:I r. ?:y agmaltiilfcf gdvankatlc smkgcoiral v aqlks¾sedl 541 qqviasvlrn Iswradvnek ktlr vgsvk altnecalevk kestlksvls alw-ilsahct. 601 enkadicavd gala lvgt^'i tyrsqtncla iiesgggilr nvssiiatne dhrqilrenix 661 ciq llqhlk shsltivsna cgtlwnlsar npkdqeaXwd mgavemlknl ihskhkmiam 721 gsaaalrnl™ axirpakykda rail msj ssi slhvrkqkai eaeldaq ls etfdrxidiiIs; 781 pkas rskqr hkqslygdyv fdtnrhddnr sdnfntgtunt vlspylnttv ipsssssrgs 841 ldssrsekdr slerergigl gnyhpatenp gtsskrglqi sttaaqiakv raeevsaihts 301 qedrssgstt elhcvtderii a irrssaahfc ksntyxiftks ens^p.rtcsmp yakleykrss 961 rtdslnsvsss dgygkrgqmk psiesysedd eskfcsygqy padlabkihs anhmddndge 1021 Xdtpiriyslk yedeqlxissgr qspsqner a rpkhlledei kqseqrqsm qsttypvyte 1081 sfcddk lkfq phfgqgecvs pyrsrgarigs etnrvgsnhg inqnvsqslc qeddyeddkp 1X41 cnyser see eqheeeerpc nysikyneek rhvdqpidye lkyatdipss qkqsfsfsks 1201 ssgqsskteh sissssen s!: pssriakrqnq I pssaqsrs gqpqkaatck vssiisqetiq 1261 tycvedtpic fsrcsslssi ssaedeigcr. qttqeade n tlqiaeikek igtrsaedpv 1321 sevpavsqhp rtkssrlqgs slssesar k avefesgaks psksgaqtpk sppehyvqet 1361 pXmfsrctsv eeldsfesrs iassvqsepc sgravsgiisp sdlpdspgqt mppsrskcpp 1441 pppqtaqtkr evpkiikapta ekresgpkqa avnaavqrvq vlpdadtllh fates pdgf 1501 scssslsa.Is Idepfiqkdv elrlenppvqe ndngnetese qpkesneriqe keaektidss 1561 kdllddsddd dieileecii samptkssrk akkpaqtask Ipppvarkps qlpvykl ips 1621 qnrlqpqkhv a:: tpgddmpr vycvegtpin f^'statsisdi tiesppnela agegvrggaq 1681 sgefekrdci ptegrstdea qggktssvti pelddnkaee gdi laecins ampk.gksh.kp 1741 frvkkimdqv qqasasssap nknqldgkkk kptspvkpip quteyrtrvr knadsknnln .1801 aervtsdnkd skkqnlknns kvfndklpnn edrvrgefaf dsphhytpie gfcpycfsmd 1S¾1 sissldfddd dvdlsrekae Irkakenkes eakvts el tsnggsarxkr, q iakqpinx- 1921 gqpkpiiqkq str^'pqsskdi pdrgaatdek Iqnfaientp vcfshnssls slsdidgenn 1931 nkenepiket eppdsqgeps kpqasgyapk. sfhvedtpvc fsrnsslssl sldseddllq 2041 ecissampkk kkpsrlkgdn ekhspramgg ilgedltldi kdiqrpdseh g.Ispdsjenfd 2101 kaiqsgans ivsslhqaaa aacle qass dsdsilslks gislgspfhl tpdqeek f t 2161 sakgpriikp gekstletkk isseskgikg gkkvyksl ί gk rsnseis gqmkqpiqaxi 2221 mpsisrgrtm i. .l.pgvrnss sstspvskkg pplktpasks psegqtatts prgakpsvks 2281 elspvarqts qiggsskape regsrdstps rpaqqplsrp iqspgrnsis pgrng Lsppn 2341 klsqlprtss pstasfckssg sgkrosy spg rqroeqqtiltk qtgl.3knass iprsesaskg 2401 Inqmrmgnga rtkkvelsrras stkssgsesd rserpvlvrq stfikeapsp tlrrkleesa 2461 sfeslspssr pasptrsqaq tpvlspslpd mslsthssvq agg rklppra Isptleyndg 2621 rpakrhdiar s sespsrlp inrsgtwk e hskhssslpr vsnwrrtgss ssiisasses 2681 s¾kaksedek hvnsisgtkq skenqvsakg twrkikenef sp nstsqtv ssgatngaes 2641 ktliyqmapa vsktedvwvr iedc inripr sgrsptgntp pvidsvseka npsiikdskdrx 2701 qakqnvgngs vpmrtvglen rlnef iqvda pdqkgteikp gqnnpypvse tnessai ert 2761 pfsessssk sspsgcvaar vtpfnyxipsp rkssadscssa rpsqiptpvn nntkkrdskt 2321 dstessgtqs pkr sgeylv tsv

APC is a 2843-arrnno acid polypeptide. The nucleotide sequence of human APC corresponds to nucleotides 86-8617 of die human APC mRNA transcript (variant 3) provided at GenBank Accession No. NM 000038,5, which is reproduced below:

1 gtattggtgc agcccgccaa ggtgtcactg gagacagaat ggaggtgctg ccggactcgg 61 aaatggggtc caagggtagc caaggatggc tgcagcttca tatgatoagt tg taaagca 121 agttgaggca ctgaagatgg agaactcaaa tcttcgacaa gagctagaag ataattccaa 131 tcatcttaca aaactggaaa ctgaggcatc aatacgaag gaagtactta aacaac aca 241 aggaagtatt gaagacgaag ctatggcctc ttctggacag attgattcat tagagcgtct

301 taaagagctt aacttagata gcagtaaur.;; ccctggagta aaactgeggt caaaaatgtc 361 cct.cc.gttc·: tatggaagcc gggaaggatc tgtatcaagc: cgttcfcggag agtgcag ee

421 ugtt.cct.atg ggttcatttc caagaagagg gtttgtaaat ggaagcagag aaagtactgg SI aeafcfctagaa gaacttgaga aagagaggtc attgcttctt gctgatcttg a aaagaaga 541 aaaggaaaaa gactggtac acgctcaact tcagaatcto actaaaagaa tagatagtek 601 tcctttaact gaaaatttt ccttac&aac agatatgacc aqaaggcaat togaatatga 661 agcaaggcaa atcagagttg cgatggaaga acaaetaggt acctgccagg ata kggaaaa 721 acgagcacag cgaagaatag ccagaatt.es. gcaaatcgaa aaggacatac ttcgtatacg 781 acagctfctta cagtcccaag caacagaagc agagaggtca tctcagaaca agcatgaaac 841 cggcccacat gatgetgage ggcagaa ga aggtcaagga gtgggagaa tcaacatggc 901 aacttctggt aa ggtcagg gttcaactac acgaatggac catgaaacag ccagtgtttt 961 gagttctagt agcacacact. ctgca tcg aaggctgaca agtcatctgg gaaccaaggt

1021 ggaaa ggtg tactcattgt tgtcaatget tggtaetcat gataaggatg atatgtcgcg 1081 aactttgeta gotatgtcta gctcccaaga cageCg tat tccatgcgac agtctggatg 1141 tctt.cct.ctc ctcatccagc ttttacaegg caatgacaaa gactctgtat tgttgggaaa 120.1 ttcccggggc agtaaagagg ctcgggccag ggccagtgca gcactccaca acatcattca 1261 ctcacagcct qatqacaaga gaggcaggcg taaaatccga gtccttcatc ttttggaaca

~S5- ^' 1321 gatacgcgct tactgtgaaa cctgttggga gfcggcaggaa gctcatgaac caggcatgga 1381 ccaggacaaa aatccaatgc cagctcc gt cgaacatcag atctgccctg ctgtgtgtgt 1441 tctaatgaaa otfcfccatttg atgaagagca tagacatgca atgaacgaac tagggggact 1501 acaggccatt gcagaattat tgcaagcgga tgtgaaatg tatgggctta c aatgacca 1561 ctacagtatt acactaagac gatacgccgg aatggctttg acaaacttga ct ttggaga

1621 tgcagccaac aaggctacgc ta gc;: c;:;<t gaaaggctgc acgagagcac ttgtggccca 1681 actaaaatct gaaagtgaag aattacagca ggttattgeg agtgfctttga ggaatttgtc 1741 ttggcgagca gatgtaaata gbaaaaagac gttgcgagaa gctggaagtg t aaagcatt 1801 gaiggaatgt gctttagaag ttaaaaagga accaaccctc aaaagcgta cgagtgcctt 1861 atggaatttg tcagcacatt gcactgagaa taaagctgat atatgtgccg tagatggtgc

1321 acttgcattt ttggttggca ctcttactca ccggagccag acaaacactt tagccattat 1981 tgaaagtgga ggtgggatat taeggaatgt gtccagcttg atagctacaa atgaggacca 2041 caggeaaato ctaagagaga acaactgtct acaaacttta ttacaa act taaaatctca 2101 tagtttgaca ataqtcag a atgcatqtgg aactttvtgg aatctctcag caacaaatcc 2161 caaagaccag gaagcattat gggaca ggg ggcagttagc atgctcaaga acctcactca 2221 ;:;:caaageac aaaatga tg ctatgggaag tgctgcagcc ttaaggaatc tcatggcaaa 2231 tagg ctgcg aagtacaagg atgccaatat tatgtctccc ggctcaagct tgac&tctct 23-41 catgttagg aaacaaaaag ccctagaagc agaattagat gctcag act tatcagaaac 2401 ttttgacaat atagacaatt taagtcccaa ggca ctcat cgtagcaagc agagacacaa 2461 gcaaagtctc. cacggtgatt atgttcttga caccaatcga catgatgata ataggtcaga

2521 caafcccaat actggcaaca tgaocgccct ttcaceatat ttgaa^;:ac a cagtgttacc 2581 cagcncccct tcatcaagag gaaget aga tagttctcgt tctgaa.aaag atagaagttt 2541 ggaga.gagaa cgcggaattg gtctaggcaa ctaccatcca gcaacagaaa atccaggaac 2701 ttcfctcaaag cgaggtttgc agatetccac cactgcagcc cagattgeca aagtcatgga 2761 agaagtgtca gecattcata ectctcagga agacagaagt tctgggtcta coaccgaatt

2321 acattgtgtg acagacgaga gaaatgeact tagaagaagc tctg tgccc atacacattc 2381 aaaca ttac aatttcacta agtcggaaaa ttcaaatagg acatgttcta tgcct atgc 294.1 caaattagaa fcacaagagat cttcaaatga cagtttaaat agtgtcagta gcagtgatgg 3001 ttatggtaaa agaggtcaaa tgaaaccctc gattqaatcc tattctgaag atgatgaaag 3061 taagcfcttgc agttatggte aatacccagc cgacctsgcc cataaaatac atagtgcaaa

3121 tca?:a;;ggai; gataatgatg gagaaetaga tacac aata aattacagtc ftaaatattc 3181 agacgagcaq ttgaactctg gaaggeaa.aq tcc tca ag aatgaaagat gggcaagacc 3241 caaacacata atagaagatg aaataaaaca aagtgagcaa agacaatcaa ggaatcaaag 3301 tacaacttat cctgtttata ccgsgagcac tgatgataaa cacctcaagt tccaaccaoa 3361 ttttggacag caggaatgtg tttctccata caggtcaegg ggagccaatg gttcagaaac

3421 aaat gagtg ggttctaatc atggaattaa teaaaacgea agecagtett tgtg caaga 3481 agatga ta gaagatgata agcctaccaa tbatagtgaa cgttactctg aagaagaaca 3541 gcatgaaga gaagagagac caacaaatta tagcataaaa tataatgaag agaaaegtea 3601 gtggatcag cctattga t atagectaaa atatgecaca gata ccct catcacagaa 366 acagecattt tcattctcaa agagcucatc: tggacaaagc agtaaaaccg aacatatgtc

3721 tteaagcagt gagaataege ccacaccttc ctaatgcc aagaggcaga atcageteca 3781 tccaagttct gcacagagxa gaagtggtca gect aaaag gctgccactt gcaasgtttc 3841 tt ta taac caagaaacaa tacagactta fcgtgtagaa gatactccaa ta gtttttc 3901 aagatgtagt tcattatcat ctttgtcatc agctgaagat gaaataggat gtaatcagac 3961 gacacaggaa gcagattctg ctaa accct gcaaaCagca gaaataaaag aaaagattgg

4021 aactaggeca gctgaagatc ctgtgagcga agttccagca gtgteaeagc accctagaac 4081 caaatccagc agactgeagg gttctagttt atcttcagaa tcagccaggc acaaagctgt 4141 tgaattttct teaggagega aatctccctc caaaagtggt gctcagacac ccaaaagt.ee 4201 acctgaacac tatgttcagg agaccccact catgtttage agatgfcactt ctgtcagttc 42G1 acttgatagt tttgagagtc gttcgattgc cagotccgct cagagtgaac catgcagtgg

4321 aatggtaagt ggcattacaa gccccagtga tcttccagac agccctggac aaaecatgoc 4381 accaagcaga agtaaaacac ctccaccaoc ccctcaaaca gctcaaacca agegagaagt 4441 acctaaaaat aaagcaccta ctgctgaaaa gagagagagt ggacctaagc aagctgcagt 4501 aaatgctgca gttcagaggg tccaggttcn. cccagatgct gacacfcttat tacattttgc 4561 cacggaaagc acccoagatg gattttcctg tca ccagc ctgagtgctc tgagcc cga 4621 tgagccattc acacagaaag atgtggaatt aagaataatg cctccagttc aggaaaacga 4681 caatgggaa gaaacagaat cagagcagcc taaagaatca aatgaaaacc aagagaaaga 4741 ggcagaaaaa ac attgat etgaaaagga cctattagac gattcagatg atgatgatat 4801 tgaaatacta gaagaatgta ttatttctgc catgccaaca aagtcatcac gtaaagcaaa 4861 aaagccagcc cagactgctc caaaattacc cccaco.tgtg gcaaggaaae caagtcagct 4921 gcctgtgtac aaacttctac catca aaaa caggttgcaa ccccaaaagc atr ttagttt 4981 tacaccgggg gatgatatgc cacgggtg a ttgtgttgaa gggacaccta taaacttttc 5041 cacagctaca tctccaagtg atc aacaat cgaatcccct coaaatgagfc tagctgotgg 5101 agaaggag t agaggagggg cacagtcagg tgaatttgaa aaacgagata ccattcctac 5161 agaaggcaga agtacagatg aggctcaagg aggaaaaacc fccatctgtaa ccatacctga 5221 attggatgac aataaagcag aggaaggtga tattcttgca gaatgcatta atcccgctat 5281 gcccaaaggg aaaagtcaca agectttccg tgtgaaaaag ataatggaoc aggcccagca 53 1 agcatctgcg tcttcttctg cacccaacaa aaatcag ta gatggtaaga aaaagaaacc 5401 aacttcacca gtaaaaccta taccacaaaa tactgaata aggacacgtg taagaaaaaa 54S1 tgcagactca aaaaataatt taaatgctga gagag ttc tcagaoaaoa aagattcaaa 5521 gaaacagaat ttgaaaaata attccaaggr. cttcaatgat aagctcccaa ataatgaag 5581 tagagtcaga ggaagttttg cttttgattc acctcatcat tacacgccta ttgaaggaac 5641 tccttactgc ttttcacgaa acgattcttt gagttctcta gas tttgatg atgatgatgt 5701 cgacctttcc agggaaaagg c gaattaag aaaggcaaaa gaaaataagg aat agaggc 5761 caaagttacc agccacacag aactaacctc caaecaacaa tcagctaata agacacaagc 5821 tattgcaaag eagccaataa atcgaggtca gcctaaaccc atact caga aacaatccac 5881 tttccccag tcatccaaag acataccaga cagaggggca gcaactga .g aaaagttaca 5941 gaattttgct a fcgaaaata ctccggtttg ctcctctcat aattcctctc tgagttctct 6001 cagtgaca i: gaocaagaaa acaacaataa agaaaatgaa ccta caaag agactgagcc 6061 ccctgactca eagggagaae caagtaaacc tcaagcatca ggctatgcto taaatcaui; 6121 tcai:gttga≤ gatac cag tttgnttotc aagaaacagt cctctcagtt ctcttagtat 6181 tgactctgaa gatgacctgt cgcaggaatg tataagctcc gcaatgccaa aaaagaaaaa 6241 gccttcaaga ctcaaggg g afca tgaaaa acatagtccc agaaata gg gtggcatatt •1301 aggtgaagat ctgacacttg atttgaaaga tatacagaga ccagattcag aacatggtot 6361 tcccctgat tcagaaaat ttgattggaa agctat cag gaaggtgc a a .toc .tag t 6421 aagtagttta catcaagc g ctgctgctgc atgttt tot agacaagct cgtctgattc 6481 agattcca c ctttccctga aatcaggaat ctctctggga tcaccatttc accttacacc 6541 tgatcaagaa. gaaaaaccct ttacaagtaa caaaggccca cgaattctaa. aaccagggga 6601 gaaaagtaca t ggaaacta aaaagataga atctgaaagt aaaggaatca aaggaggaaa 6661 aaaagfcfcfcat aaaagtttga ttaotggaaa agttcgatct aattcagaaa tttcaggcca 6721 aatgaaacag ccccttcaag caaacatgcc ttcaatctct cgaggcagga caatgattca 6781 tattccagga gttcgaaata gctcctcaag tacaagtcct gtttctaaaa aaggcccacc 6841 cct aagact ccagcctcea aaagccctag tgaaggfceaa acagccacca ccccfccctag 6901 aggagccaag ccatctgtga aatcagaatt aagccotgtt gccaggcaga cateccaaat 6961 aggtgggtca agtaaagcac cttctagatc aggatctaga gattcgaccc cttcaagacc 7021 tgcccagcaa ccattaagta gacctata. a g ctcctggc cgaaactcaa tttcccctgg 7081 tagaaa.tgga a aagtcctc c aacaaatt atctcaactt ccaaggacat catcccctag 7141 tactgcttca actaagtcet caggfctctgg aaaaatgtca tatacatctc caggtagaca 7201 gatgagccaa cagaacctta ccaaacaaac aggtttatcc aagaatgcca gtagtafctcc 7261 aagaagtgag tctgccccca aaggactaaa tcagatgaa aatggtaatg gagccaataa 7321 aaaggtagaa ctttctagaa tgtcttcaac taaatcaagt ggaagtgaa ctgatagatc 7381 agaaagacct g attagtac gccagteaac fcfctcatcaaa gaagctccaa gcccaacctt 7441 aagaagaaaa. ttggaggaat ctgcttcatt tgaatctc t. tctccatcat ctagaccagc 7501 ttctcceact aggfccccagg caeaaaetcc agttttaagt cctto ettc ctgatatgtc 7561 cctafcccaca cattcgtctg ttcaggctgg tggatggcga aaactccca ctaatctcag 7S21 tcccactata gagtataacg atggaagacc agcaaagcgc catgatattg cacggtccca 7681 ttctgaaagt ccttctagac tcccaatcaa taggt agga acctggaaac gtgagcaeag 7741 caaacalica tcatcccttc ctcgagtaag cacttggaga agaactggaa gt ea o tc 7301 aattctt ct gcttcatcag aatccagtga aaaagcaaaa agtgaggatg aaaaacatgt 7861 gaactctatt tcaggaacca aacaaagtaa agaaaaccaa gtatccgcaa aaggaacatg 7921 gagaaaaata aaagaaaatg aattttctco cac aatagt acttctcaga ccgtttcctc

7331 aggtgct ca aatggsgc g aatcaaagac tcfcaatttat caaatggcac ctgctgtttc 8041 taaaacagag gatgtttggg tgagaaccg ggactgtccc a"c"aacaatc ct.aga.c gg 8101 aagatctccc acaggtaata ctcccccggt gattgacagt gccucagaaa aggcaaa cc 8161 aaacattaaa gattcaaaacr caafccaqgc aaaacaaaa gtgggtaata gcaortaeecc 8221 cacgcgtacc gtgggtfctgg aaaatcgcrct gaactcctcc a tcaggtgg atgcccctga

62S1 ecaaaaagga ctgagacaa aaccaggaca aaataa ocr. gtccctgtat cagagactaa 8341 tgaaagttct atagtggaac gtaccccatt cagttctagc agctcaagca aacacagttc 8401 acctagtggg actgtt.gctg ccagagtgac tocLtttaat tacaacccaa gccctaggaa 8461 aagcagcgca gatagcactt cagctcggcc accfccaga c: ccaaccccag tgaataacaa 8521 cacaaagaag cgagattcca aaac gacag cacagaat.cc agtggaaccc aaagt ctaa

858.1. gcgccatLct gggtct acc ttgtgacafcc g aaaag agaggaagaa tgaaactaag 8641 aaaattcbat qttaattaca actgctatat agacattttg tttcaaatga aactttaaaa 8701 gaetgaaaaa ttttgtaaae aggtttgatt cttgttagag ggtttttgtt. ctggaagcca 8761 tatttgatag tatactttgt cttcactggt etcat;:>:.tgg gaggcactct tgatggttag 8821 gaaaaaaata gtaaagccaa gtatgtttgt aoagtaxgtt ttacatgtat ttaaagtagc

3881 atcccatccc aactcccttt aattatcgcfc tgtcttaaaa taatgaacac tacagataga 8941 aaatatgata tattgctgtt atcaatcacc tctagattat aaactgac a aacttacatc 9001 agggaaaaa tggtatttat gcaaaaaaaa atgtttttgt cctfcgtgagt ecatctaaca 9061 tcataatcaa toatgtggct gxgaaattca cagtaatatg gt ;;i:c:c:gatg aacaag tta 9121 cccageetge tttgcttta tgcatgaatg aaactgatgg ttcaatttca gaagtaatga

9:1 S ucaacagtta tgtggtcaca tgacgtgcat agagatagct acagtgtaat aatttacact 92,41 accttgtgct ccaaacaaaa caaaaatctg tgtaaetgta aaacattgaa tgaaacta. t 9301 ttacctgaac tagatt^■: t:a t: ctgaaagtag gtagaatttt tgctatgctg caatttgttg 9381 tatattctgg ca tgaggt gagatggctg ctcfcttfcatt aatgagacat gaattgtgtc 9421 tcaacagaaa etaaatgaac atttcagaat aaatbattgc tgta gtaaa ctgttactga

9481 aattggtatt tgt tgaagg gtcttgfcttc acatttgtat taataaccgt ttaaaatgcc 9541 t tcttaaaa gcttatataa attttcctct tcagcttcta tgcattaaga gtaaaattcc 9601 tcttactgta ataaaaacaa ttgaagaaga ctg g cac taaccattc catgcgttgg 9661 cacttatcta ttcctgaaat ctcttttatg tgattagcte a;:ct;i:gattt ttaatatttc 9721 tccacttaaa cttttttt c ttactccact ggagc cagt aaaagtaaat tcatgcaafca

9781 qcaatgcaag cagccfcagca cagactaagc attgagcata ataggcccac ataat ttoot 3341 ctttcttaat attatagaat tctgtacttg aaattgattc ttagacattg cagtctcttc 9901 gaggctccac agtgtaaact gtcttgcccc Ltcatcttct tgttgcaacC gggtctgaca 9961 tgaaeacttt ttatcaccct gtatgttagg gcaagatctc agcagtgaag tataatcagc 10021 actttgccat gctcagaaaa cccaaatcac atggaacttt agaggtagat ttaatacgat

10081 teagatattc agaagtatat tttagaatcc ctgcctgtta aggaaacttt atttgtggta 10141 ggtacagttc tgggg acat gttaagtgtc cccttacaca gtggagggaa gtcttcc tc 10201 ctgaaggaaa ataaae gao acttattaac taagataat t tacttaatat aLcttccctg 10261 atttgtttta aaagatcaga gggtgactga gatacatgc atacatattt gt tgaataaa 10321 tgaaaattta. cttttagtga taagattcat acactctgta tttggggagg gaaaacctt

10381 ttaagcatgg cggggcactc aga aggagt gaatacacct a c ggtgco ttgaaaa ca 10441 caccaagtag ttaattatct accccttacc tgtgtttata acttccaggt aatgagaatg 10501 teettfcfcta aagctaaaat gccagtaaat aaaagtgcta tgacttgagc taagatattt 10561 gactccaatg cctgtactgfc g ctactgca ccactttgta aacac caa tfccactatct 10621 ttgaaatgat tgacctttaa atttttgcca aacgctatct gaaattgtct atgaatacca

10681 tctacttctg ccgfctttccc aggcttccat aaaoaatgga gatacacgca aaaaaaaaaa Familial adenomatous polyposis (FAP) is caused by mutations in the APC gene, More than 800 mutations in the APC gene have been identified in families with classic and attenuated types of familial adenomatous polyposis. Most of these mutations cause the production of an APC protein that is abnormal ly short and nonfunctional. This short protein cannot suppress the cellular overgrowth that leads to the formation of polyps, which can become cancerous. The most common mutation in familial adenomatous polyposis is a deletion of five bases in the APC gene. This mutation changes the sequence of amino acids in the resulting APC protein beginning at position 1 309.

Another mutation is carried by approximately 6 percent of people of Ashkenazi (eastern and central European) Jewish heritage. This mutation results in the substitution of the amino acid lysine for isoleucine at position 1307 in the APC protein (also written as Π 307Κ. or i!e l 307Lys). This change was initially thought to be harmless, but has recently been shown to be associated with a 1 to 20 percent increased risk of colon cancer. Detection of Biomarkers

Any suitable method can be used to detect the biomarker(s). Successful practice of the invention can be achieved with one or a combination of methods that can detect and, in embodiments, quantify the biomarker(s). Detection of the biomarkers of the invention (e.g. symmetric-dimethylarginine, symmetric-dimethylarginine, carnitine, methionine, dimethylglycine, betaine, proline, giutarnine, glutamic acid, threonine, and Na-acetylSysine, xanthosine, inosine, deoxyuridine, thymidine, deoxycytidine, eytosine, hypoxanthine, xanthine, uracil, guanosine, adenosine, N l -acetylsperm idine, N8-acetyispermidine, spermine, arginine ornithine, citruiline and M264 can be detected using one or more methods well known in the art, including, without limitation, mass spectrometry, chromatography, spectroscopy (e.g., NMR), elemental analysis, conventional chemical methods,

immunoassays, and the like,

Detection of the biomarkers can be conducted in the same or d ifferent samples, the same or separate assays, and may be conducted in the same or different reaction m ixtures. Where the biomarkers are assayed in different samples, the samples are usually obtained from the subject during the same procedure (e.g.. urine collection, blood draw, tissue extraction, and the like) or with only a relative short time intervening so as to avoid an incorrect result due to passage of time. Where the biomarkers are detected in separate assays, the samples assayed are can be derived from the same or different samples obtained from the subject to be tested.

In embodiments, the biomarker(s) are detected using mass spectrometry. Mass spectrometry-based methods exploit the differences in mass of biomarkers to facilitate detection. Mass spectrometry can be combined with other assays, e.g., resolving the analyte in a sample by one or two passes through liquid or gas chromatography followed by mass spectrometry analysis. Methods for preparing a biological sample for analysis by mass spectrometry are well known in the art. Suitable mass spectrometers for use include, without limit, electrospray ionization mass spectrometry (ESI-MS), ESIMS MS, ESi-MS/(MS)n (n is an integer greater than zero), matrix-assisted laser desorption ionization time-of-fiight mass spectrometry (MALDI-TOF-MS), electron impact ionization mass spectrometry (El-MS), chemical ionization mass spectrometry (CI-MS), surface-enhanced laser desorption ionization time-of-flight mass spectrometry (SELDI-TOF-MS), desorption/ionization on silicon (DIGS), secondary ion mass spectrometry (SIMS), quadrupo!e timeof-flight (Q-TOF), atmospheric pressure chemical ionization mass spectrometry (APCI-MS), APCi-MS/MS, APCi(MS)! 1 , atmospheric pressure photoionization mass spectrometry (APPS-MS), APPI- MS/MS, APPI-(MS), quadrupole, fourier transform mass spectrometry (FTMS), ion trap, and hybrids of these methods, e.g. , electrospray ionization quadrupole time-of-f!ight mass spectrometry (UPLC-ESI-QTOFMS) and two-dimensional gas chromatography electron impact ionization mass spectrometry (GCxGC-EI-MS).

The methods may be performed in an automated (Villanueva, et ai. Nature Protocols (2006) 1 (2):880-891) or semi -automated format. This can be accomplished, for example with MS operabiy linked to a liquid chromatography device (LC-MS/MS or LC-MS) or gas chromatography device (GC-MS or GC-MS/MS). Methods for performing MS are known in the field and have been disclosed, for example, in US Patent Application Publication Nos: 20050023454 and 20050035286; US Patent No. 5,800,979; and the references disclosed therein.

Samples are collected on a collection layer. They may then be analyzed by a spectroscopic method based on matrix-assisted laser desorption/ionization (MALDI), electrospray ionization (ESI), and the like.

Other techniques for improving the mass accuracy and sensitivity of the MALDi-TOF MS can be used to analyze the anaiytes obtained on the collection membrane. These include the use of delayed ion extraction, energy reflectors and ion-trap modules. In addition, post source decay and MS—MS analysis are useful to provide further structural analysis. With ESI, the sample is in the liquid phase and the analysis can be by ion-trap, TOP, single quadrupole or multi-quadrupole mass spectrometers. The use of such devices (other than a single quadrupole) allows MS— MS or MS'¹ analysis to be performed, Tandem mass spectrometry allows multiple reactions to be monitored at the same time,

Capillary infusion may be employed to introduce the marker to a desired MS implementation, for instance, because it can efficiently introduce small quantities of a sample into a mass spectrometer without destroying the vacuum. Capillary columns are routinely used to interface the ionization source of a MS with other separation techniques including gas chromatography (GC) and liquid chromatography (LC), GC and LC can serve to separate a solution into its different components prior to mass analysis. Such techniques are readily combined with MS, for instance. One variation of the technique is that high performance liquid chromatography (HPLC) can now be directly coupled to mass spectrometer for integrated sample separation/and mass spectrometer analysis.

Quadrupole mass analyzers may also be employed as needed to practice the invention.

Fourier-transform ion cyclotron resonance (FTMS) can also be used for some invention embodiments, It offers high resolution and the ability of tandem MS experiments. FTMS is based on the principle of a charged particle orbiting in the presence of a magnetic field.

Coupled to ESI and MALDI, FTMS offers high accuracy with errors as low as 0.001%.

In embodiments, the diagnostic methods of the invention may further comprise identifying significant peaks from combined spectra. The methods may also further comprise searching for outlier spectra. In other embodiments, the methods of the invention further comprise determining distant dependent -nearest neighbors.

In embodiments, an ion mobility spectrometer can be used to detect and characterize the biomarker(s). The principle of ion mobility spectrometry is based on different mobility of ions. Specifically, ions of a sample produced by ionization move at different rates, due to their difference in, e.g., mass, charge, or shape, through a tube under the influence of an electric field. The ions (typically in the form of a current) are registered at the detector which can then be used to identify a biomarker or other substances in a sample. One advantage of ion mobility spectrometry is that it can operate at atmospheric pressure.

In embodiments, the procedure is electrospray ionization quadrupole mass spectrometry with time of flight (TOF) analysis, known as UPLC-ESI-QTOFMS. UPLC- ESI-QTOFMS is well known in the art (see, e.g., Manna et ah, J. Proteome Res. 9:4176-88 (2010)) and methods for using UPLC-ES1-QTOFMS are described in detail herein.

In embodiments, detection of the biomarker(s) involves chemical methods well known in the art. in embodiments, the chemical method is chemical extraction. In embodiments, the chemical method is chemical derivitization.

In embodiments, detection of the biomarker(s) involves use of chromatography methods that are well known in the art. Such chromatography methods include, without limit, column chromatography, ion exchange chromatography, hydrophobic (reverse phase) liquid chromatography, normal phase chromatography, hydrophiiic interaction liquid chromatography, or other chromatography, such as thin!ayer, gas, or liquid chromatography (e.g. , high-performance or ultraperformance !iquid chromatography), or any combination thereof.

3n embodiments, detection of the biomarker(s) involves use of spectroscopy methods that are well known in the art. Such chromatography methods include, without limitation, NMR, IR, and the like.

In embodiments, detection of the biomarker(s) involves elemental analysis methods that are well known in the art. Such elemental analysis methods include, without limitation, combustion analysis, gravimetry, atomic spectroscopy, and the like.

In embodiments, detection of the biomarker(s) involves use of immunoassays. In embodiments, the immunoassays involve the use of antibodies. Suitable immunoassays include, without limition, ELISA, flow chamber adhesion, colorimetric assays (e.g., antibody based colorimetric assays), biochip (e.g., antibody based biochip), and the like.

Analytes (e.g., biomarkers) can be detected by a variety of detection methods.

Detection methods may include use of a biochip array. Biochip arrays useful in the invention include protein and polynucleotide arrays. One or more markers are captured on the biochip array and subjected to analysis to detect the level of the markers in a sample.

Markers may be captured with capture reagents immobilized to a solid support, such as a biochip, a multivvei! microtiter plate, a resin, or a nitrocellulose membrane that is subsequently probed for the presence or level of a marker. Capture can be on a

chromatographic surface or a biospecific surface. For example, a sample containing the markers, such as serum, may be used to contact the active surface of a bsochip for a sufficient time to allow binding. Unbound molecules are washed from the surface using a suitable eiuani, such as phosphate buffered saline. In general, the more stringent the eluant, the more tightly the proteins must be bound to be retained after the wash.

Upon capture on a biochip, anaiytes can be detected by a variety of detection methods selected from, for example, a gas phase ion spectrometry method, an optical method, an electrochemical method, atomic force microscopy and a radio frequency method, in one embodiment, mass spectrometry, and in particular, SELDl, is used. Optical methods include, for example, detection of fluorescence. luminescence, chemi luminescence, absorbance, reflectance, transmittance, birefringence or refractive index (e.g., surface plasmon resonance, ellipsometry, a resonant mirror method, a grating coupler waveguide method or

interferometry). Optical methods include microscopy (both confocai and non-confoeal), imaging methods and non-imaging methods. Immunoassays in various formats (e.g., ELISA) are popular methods for detection of anaiytes captured on a solid phase. Electrochemical methods include vo!tametry and amperometry methods. Radio frequency methods include multipolar resonance spectroscopy.

Other variations of the assays described herein to provide for different assa formats for detection of the biomarker(s) will be readily apparent to the one of ordinary skill in the art upon reading the present disclosure.

Types of Biological Samples

The level of symmetric-dimethylarginine, symmetric-dimethylargimrie, carnitine, methionine, dimethyig!ycine, betaine. proline, giutamine, glutamic acid, threonine, and Na- acetyllysine, xanthosine, inosine, deoxyuridine, thymidine, deoxycytidine, cytosine, hypoxanthine, xanthine, uracil, guanosine, adenosine, N l -acetylspermidine, N8- acety!spermidine, spermine, arginine ornithine, citrulline and M26 , or a combination thereof, is measured in different types of samples. In embodiment, the level of the biomarker(s) is measured in a biologic sample. Suitable biologic samples include, without limit, a tissue sample (e.g., from a biopsy) and biological or physiological fluids (e.g., urine, blood, blood serum, plasma, fecal aspirate, intestinal aspirate, bile, saliva, cerebrospinal fluid or any other biological fluid useful in the methods of the invention). In embodiments, the sample is a urine sample derived from the patient, In particular embodiments, the collection of a biological fluid is noninvasive (e.g., urine). Subject Monitoring

The disease state or treatment of a subject having neoplasia (including colorectal cancer), or a propensity to develop such a condition can he monitored using the methods and biomarkers of the invention. In embodiments, methods and biomarkers of the invention are used by a clinician to identify subjects as having or not having neoplasia. For example, a general practitioner may use the methods delineated herein to screen patients for the presence of neoplasia. In embodiments, the level of biomarker(s) present in a patient sample, e.g., bod i ly fluid such as urine, blood, blood serum, plasma, fecal aspirate, bi le, intestinal aspirate, or saliva, is monitored. Such monitoring may be useful, for example, in assessing disease progression or in assessing the efficacy of a particular drug in a subject. An increase in the level of a biomarker of the invention (e.g., symmetric-dimethyiarginine, symmetric- dimethyiarginine, carnitine, methionine, dimethyiglycine, betaine, proline, glutamine, glutamic acid, threonine, and Na-acetyliysine, xanthosine, inosine, deoxyuridine, thymidine, deoxycytidine, eytosine, hypoxanthine, xanthine, uracil, guanostne, adenosine, N l- acetylsperrnidine, NS-acetylspermid ine, sperm ine, arginine ornithine, citrulline and M264, or a combination thereof as speci fied herein) may indicate cancer onset or relapse. A decrease in the level of a biomarker of the invention (e.g. , symmetric-dimethyiarginine, symmetric- dimethyiarginine, carnitine, methionine, dimethyiglycine, betaine, proline, glutamine, glutamic acid, threonine, and Na-acetyliysine, xanthosine, inosine, deoxyuridine, thym idine, deoxycytidine, eytosine, hypoxanthine, xanthine, uracil, guanostne, adenosine, Nl - acetylsperm idine, N8-acetylspermidine, spermine, arginine ornithine, citrulline and M264, or a combination thereof as specified herein) may indicate cancer remission or the effectiveness of a therapy. Therapeutics that decrease the level of a biomarker of the invention (e.g., symmetric-dimethyiarginine, symmetric-dimethyiarginine, carnitine, methionine, dimethyiglycine, betaine, proline, glutam ine, glutamic acid, threonine, and Na-acetyllysine, xanthosine, inosine, deoxyuridine, thymidine, deoxycytidine, eytosine, hypoxanthine, xanthine, uracil, guanosine, adenosine, N l -acetylsperrn idine, N8-acety [spermidine, spermine, arginine ornithine, citrulline and M264, or a combination thereof as specified herein) are taken as particularly useful in the invention,

In embodiments, the biomarker(s) are monitored prior to administering therapy.

These results provide a baseline that describes the level of the biomarker(s) prior to treatment. In embodiments, the biomarker(s) are monitored periodically. In embodiments, the biomarker(s) are monitored periodically throughout treatment. A therapy is identified as efficacious when a diagnostic assay of the invention detects a decrease in marker leve!s relative to the baseline level of marker prior to treatment.

Selection of a treatment method

After a subject is diagnosed as having colorectal cancer, a method of treatment is selected, In colorectal cancer, for example, a number of standard treatment regimens are available. The marker profile of the neoplasia is used in selecting a treatment method, increased levels of symmetrie-dimethylargmine, syminetric-dimethyiarginine, carnitine, methionine, dimethyiglycine, or betaine (metbylatiort) correlate with a poor prognosis and an increased risk of death. Additionally, the levels of the methylation biomarkers may be used alone or in combination with the levels of biomarkers from one or more of the following groups: biomarkers related to nucleic acid metabolism including xanthosine, inosine, deoxyuridine, thymidine, deoxycytidine, cytosine, hypoxanthine, xanthine, uracil, guanosine, and adenosine; biomarkers related to urea cycle and polyamine metabolism including N 1 - acetylspermidine, N8-aceiylspermidine, spermine, arginine ornithine, and citruliine; and biomarkers related to amino acid metabolism including proline, glutamine, glutamic acid, threonine, and Na-acetyilysine, and M264 or a combination thereof, increased levels of amino acid metabolism, nucleic acid metabolism, and/or polyamine metabolism biomarkers correlate with a poor prognosis and an increased risk of death. Such neoplasias are identified as aggressive neoplasias. Marker profiles that correlate with good clinical outcomes (e.g., decreased or basal levels of asymmetric-dimethylarginine and symmetric-dimethylarginine) ar identified as less aggressive neoplasias.

Less aggressive neoplasias are likely to be susceptible to conservative treatment methods. Conservative treatment methods include, for example, cancer surveillance, which involves periodic patient monitoring using diagnostic assays of the invention, Cancer surveillance is selected when diagnostic assays indicate that the adverse effects of treatment (e.g., impotence, urinary, and bowel disorders) are likely to outweigh therapeutic benefits.

More aggressive neoplasias are less susceptible to conservative treatment methods. When methods of the invention indicate that a neoplasia is very aggressive, an aggressive method of treatment should be selected. Aggressive therapeutic regimens typical ly include one or more of the following therapies: radical surgery, radiation therapy (e.g., external beam and brachytherapy), and chemotherapy. Therapy may he provided wherever cancer therapy is performed: at home, the doctor's office, a clinic, a hospital's outpatient department, or a hospital, Treatment generally begins at a hospital so that the doctor can observe the therapy's effects closely and make any adjustments that are needed. The duration of the therapy depends on the kind of cancer being treated, the age and condition of the patient, the stage and type of the patient's disease, and how the patient's body responds to the treatment. Drug administration may be performed at different intervals (e.g., daily, weekly, or monthly). Therapy may be given in on-and-off cycles that include rest periods so that the patient's body has a chance to build healthy new cells and regain its strength.

Depending on the type of cancer and its stage of development, the therapy can be used to slow the spreading of the cancer, to slow the cancer's growth, to kill or arrest cancer cells that may have spread to other parts of the body from the original tumor, to relieve symptoms caused by the cancer, or to prevent cancer in the first place. As used herein, the term

"colorectal cancer" is meant a collection of colon, rectum, large intestine, or appendix cells multiplying in an abnormal manner. Cancer growth is uncontrolled and progressive, and occurs under conditions that would not elicit, or would cause cessation of, multiplication of normal cells.

Patient monitoring

The diagnostic methods of the invention are also useful for monitoring the course of a colon cancer in a patient or for assessing the efficacy of a therapeutic regimen. In one embodiment, the diagnostic methods of the invention are used periodically to monitor the levels of biomarkers in one or more of the following groups: biomarkers related to methyiation including asymmetric-dimethyiarginine, symmetric-dimethylarginine, carnitine, methionine, dimethy!glycine, and betaine; biomarkers related to nucleic acid metabolism including xanthosine, inosine, deoxyuridine, thymidine, deoxycytidsne, cytosine, hypoxanthine, xanthine, uracil, guanosine, and adenosine; the biomarker related to urea cycle and polyamine metabolism including Nl -acetyispermidine, N8-acetylspermidine, spermine, arginine ornithine, and citruiline; and biomarkers related to amino acid metabolism including proline, glutamine, glutamic acid, threonine, and Να-acetyiiysine, and M264 or a

combination thereof, in one example, the neoplasia is characterized using a diagnostic assay of the invention prior to administering therapy. This assay provides a baseline that describes the level of one or more markers of the neoplasia prior to treatment. Additional diagnostic assays are administered during the course of therapy to monitor the efficacy of a selected therapeutic regimen. A therapy is identified as efficacious when a diagnostic assay of the invention detects a decrease in marker levels relative to the baseline level of marker prior to treatment.

The invention provides diagnostic arrays or microarrays for measuring the levels of a metabolic biomarker in accordance with the invention. Capture reagents, including organic molecules, peptides, peptide mimetics, polypeptides, nucleic acid ligands, aptamers, and antibodies are useful array elements in the microarray. The array elements are organized in an ordered fashion such that each element is present at a specified location on the substrate. Useful substrate materials include membranes, composed of paper, nylon or other materials, filters, chips, glass slides, and other solid supports. The ordered arrangement of the array elements allows hybridization patterns and intensities to be interpreted as expression levels of particular genes or proteins. Methods for making nucleic acid mscroarrays are known to the skilled artisan and are described, for example, in U.S. Pat. No. 5,837,832, Lockhart, et ai. (Nat. Biotech, 14: 1675-1680, 1996), and Schena, et ai . (Proc. Natl. Acad. Sci. 93: 10614- 10619, 1996), herein incorporated by reference. Methods for making polypeptide

microarrays are described, for example, by Ge (Nucleic Acids Res. 28:e3.i-e3.vii, 2000), MacBeath et ai„ (Science 289: 1760-1763, 2000), Zhu et ai. (Nature Genet. 26:283-289), and in U.S. Pat. No. 6,436,665, hereby incorporated by reference.

To produce a nucleic acid microarray oligonucleotides may be synthesized or bound to the surface of a substrate using a chemical coupling procedure and an ink jet application apparatus, as described in PCT application W095/251 1 16 (Baldeschweiler et a!.), incorporated herein by reference. Alternatively, a gridded array may be used to arrange and link cDNA fragments or oligonucleotides to the surface of a substrate using a vacuum system, thermal, UV, mechanical or chemical bonding procedure.

Metabolic biomarkers, such as those described herein, may also be analyzed using protein microarrays. Such arrays are useful in high-throughput low-cost screens to identify peptide or candidate compounds that bind a polypeptide of the invention, or fragment thereof. Typically, protein microarrays feature a protein, or fragment thereof, bound to a solid support. Suitable solid supports include membranes (e.g., membranes composed of nitrocellulose, paper, or other material), polymer-based films (e.g., polystyrene), beads, or glass slides. For some applications, proteins are spotted on a substrate using any convenient method known to the skilled artisan (e.g., by hand or by Inkjet printer), Preferably, such methods retain the biological activity or function of the protein bound to the substrate (Ge et a!., supra; Zhu et al., supra).

The microarray is hybridized with a detectable probe. Such probes can be small molecules, polypeptides, or nucleic acids. For some applications, small molecule probes are derived from a biological sample taken from a patient, such as a bodily fluid (e.g., urine, blood, blood serum, plasma, bile, fecal aspirate, intestinal aspirate, cerebrospinal fluid, and saliva); a homogenized tissue sample (e.g. a tissue sample obtained by biopsy); or cultured cells (e.g., colorectal cancer cells). Binding or capture conditions (e.g., temperature, pH, protein concentration, and ionic strength) are optimized to promote specific interactions. Such conditions are known to the skilled artisan and are described, for example, in l iarlow, E. and Lane, D._> Using Antibodies: A Laboratory Manual. 1998, New York: Cold Spring Harbor Laboratories. After removal of non-specific probes (e.g., by washing), specifically bound probes are detected, for example, by fluorescence, enzyme activity (e.g., an enzyme- linked calorimetric assay), direct immunoassay, radiometric assay, or any other suitable detectable method known to the skilled artisan. A detection system may be used to measure the absence, presence, and amount of binding or capture for ail of the biomarkers simultaneously (e.g., Heller et ai., Proc. Natl. Acad. Sci, 94:2150-2155, 1997). Preferably, a scanner is used to determine the levels and patterns of fluorescence.

Diagnostic Kits

The invention provides kits for diagnosing or monitoring neoplasia (e.g., colorectal cancer), or for selecting a treatment for neoplasia, in embodiments, the kits include one or more reagents capable of detecting and/or capturing one or more of the following groups of biomarkers: biomarkers related to methylation including asymmetric-dimethyiarginine, symmetric-dimethy!arginine, carnitine, methionine, dimethylgiycine, and betaine; biomarkers related to nucleic acid metabolism including xanthosine, inosine, deoxyuridine, thymidine, deoxycytidine, cytosine, hypoxanthine, xanthine, uracil, guanosine, and adenosine;

biomarkers related to urea cycle and polyamine metabolism including N l -acetylspermidine,

N8-acetylspermidine, sperm ine, arginine ornithine, and eiirulline; and biomarkers related to amino acid metabolism including proline, glutamine, glutamic acid, threonine, and Na- acetyllysine and M264 or a combination thereof. In certain embodiments, the reagent is an antibody or a mass spectrometry probe. The kit may include a collection of detection/capture reagents in the form of an array or pane! which can be used for high throughput screening and/or profiling of samples.

in various embodiments, the kits include an affinity agent or adsorbent that retains one or more of the biomarkers, or a combination thereof. In related embodiments, the kit further contains directions for contacting a test sample with the affinity agent or adsorbent and detecting one or more of the biomarkers, or a combination thereof retained by the affinity agent or adsorbent. In various embodiments, the reagents and/or affinity agents are provided on a solid support (e.g. , chip, microliter plate, bead, resin, and the like). In embodiments, the kits include washing solution(s) or instructions for making a washing solution, in which the combination of the reagent/adsorbent and the washing solution allows capture of the biomarkers on the reagent/adsorbent.

In various embodiments, the kits include the biomarkers, which can be used as standard(s) for cal ibration as may be desired.

in various embodiments, the kit contains a container(s) that houses the components of the kit (e.g., reagent, adsorbant, solid support, and the like). Such containers can be boxes, ampoules, bottles, vials, tubes, bags, pouches, blister-packs, or other suitable container forms known in the art. Such containers can be made of plastic, glass, laminated paper, metal foi l, and the like.

In various embodiments, the kits further contain directions for using the kit in any of the methods described herein (e.g., diagnosing neoplasia, monitoring neoplasia,

characterizing neoplasia, selecting a treatment for neoplasia, and the like). In various embodiments, the instructions include at least one of the following: description of the reagents, supports, and/or affinity agents: warnings; indications; counter-indications; animal study data; clinical study data; and/or references. The instructions may be printed directly on the container (when present), or as a label applied to the container, or as a separate sheet, pamphlet, card, or folder suppl ied in or with the container.

The practice of the present invention employs, unless otherwise indicated, conventional techniques of molecular biology (including recombinant techniques), microbiology, cell biology, biochemistry and immunology, which are well within the purvie of the skil led artisan. Such techniques are explained fully in the literature, such as,

"Molecu lar Cloning: A Laboratory Manual", second edition (Sambrook, 1989);

'Oligonucleotide Synthesis" (Gait, 1984); "Animal Cell Culture" (Freshney, 1 87): "Methods in Enzymo!ogy" "Handbook of Experimental Immunology" (Weir, 1996); "Gene Transfer Vectors for Mammalian Ceils" (Miller and Ca!os, 1987); "Current Protocols in Molecular Biology" (Ausubel, 1987); "PGR: The Polymerase Chain Reaction", (Muilis, 1994); "Current Protocols in Immunology" (Coligan, 1991 ). These techniques are applicable to the production of the polynucleotides and polypeptides of the invention, and, as such, may be considered in making and practicing the invention. Particularly useful techniques for particular embodiments will be discussed in the sections that follow,

The following examples are put forth so as to provide those of ordinary skill in the art with a complete disclosure and description of how to make and use the assay, screening, and therapeutic methods of the invention, and are not intended to limit the scope of what the inventors regard as their invention.

EXAMPLES

Example 1. Distinct metabolic traits correlated with colorectal tumor development is APC^{Mta +}mice.

Al l APC^iVl!n mice studied developed colorectal tumors along with multiple intestinal polyps compared to wild-type mice, which were tumor-free at six months of age (Figure 1A). The unsupervised principal components analysis of the total ion count-normalized urinary metaboiomics data were acquired with hydrophilic interaction chromatography-based separation of the metabolites (Figure 2A), Analysis of the urinary metaboiomics data did not show segregation of APC ^in/+ and wild-type metabolomes. However, creatinine-normalized data (Figure 2B) showed clear separation of the wild-type and APC^{M!!, +} animals along the first component in the principal components analysis (PCA), although none of the mice were visibly sick and there was no significant drop in body weight (Figure I B) or change in liver enzyme levels in serum (Figure 1 C) even at six months of age, Similarly, analysis of the creatinine-normalized metabolomic signature using reverse-phase separation also showed that while wild-type animals tended to cluster together, APC^M,n'⁺ animals separated from the cluster along first component in PCA (Figure 3A). These observations indicated that tumorigenesis in APC^M,a'⁺ mice was associated with development of a distinct metabolic trait.

In order to identify the ions contributing to segregation of the metabolomic signature of naive and tumor bearing mice, supervised orthogonal projection to latent structure analysis was performed (see Figure 3B and 3C). A significant number of ions were modulated as a result of tumorigenesis (Figure 3D). The identities of these ions were confirmed and concentrations measured with authentic standards. The creatinine-normalized excretion of glutamine, proline, citruliine, N -aeetyl!ysine, spermine, l -acetylspermidine, N8- aceiy!spermidine, spermine, xanthosine, inosine, xanthine, deoxyuridine, cytidine, and thymidine were progressively eievated whereas those of ornithine and carnitine were reduced in tumor-bearing animals, A detai led description of quantitative ranges and statistical significances (P value and odds ratio) of these urinary biomarkers is provided at Table 1 , The urinary excretion of glutamic acid, aspartic acid, lysine, arginine, hypoxanthine, creatine, Νω-monomethylarginine, and uridine were found to be unaffected during tumorigenesis.

Longitudinal variation in excretion of amino acid metabolites.

The excretion of glutamine (Figure 2C) was found to be progressively elevated in APC^M'^""⁺ mice and was 7,2-fold and 6.1 -fold higher than that in wild-type mice at five and six months, respectively. The excretion of proline was also were found to increase by 3.0-fold in tumor-bearing mice at six months (Figure 2D). However, Να-acety!lysine was elevated in urine of tumor bearing mice by 1 .3-fold at both five and six months (Figure 2E).

Longitudinal variation in excretion of hypermethylated metabolites.

Urinary excretion of carnitine, a permethyiated metabolite of lysine, was reduced by 1.9- and 2.1 -fold at five and six months, respectively (Figure 2F). However, the urinary excretion of hypermethylated arginine metabolite syrnmetric-dimethylarginine was elevated by 1.7-fold and 1.6-fold at five and six months (Figure 4 A), while that of asymmetric- dimethyiarginine (Figure 4B) was also elevated by 1 ,7-fold and 2-fold at four and six months, respectively.

Longitudinal variation in urea cycle and poiyamine metabolites in urine.

The creatinine-normalized urinary excretion of citruliine (Figure 4C) was 2.7-fold and 1.4-fold higher at four and five months, respectively, while that of ornithine (Figure 5A) was found to be lower by 1.4-fold at six months. Spermine excretion was progressively eievated in urine of tumor bearing animals and was found to be i .8-fold higher at both five and six months (Figure 4D). Acetylated poiyamine metabolite Nl -acetylspermidine (Figure 4E) was elevated by 4.3-fold and 6.0-fold at four and six months, respectively, whereas N8- acetylspermidine (Figure 4F) was elevated by 1 .6-fold at four months.

Longitudinal variation in excretion of purine and pyrimidine metabolites.

The urinary excretion of xanthosine (Figure 6A) was elevated 2.0- and 2,8-fold at five and six months, respectively, whereas inosine (Figure 6B) and xanthine (Figure 6C) were elevated by 3,5- and 4.2-f !d, respectively, at six months. The urinary excretion of cytidine (Figure 6D) was elevated 28.7- and 6,8-fold at five and six months, respectively whereas that of deoxyuridine (Figure 6E) and thymidine (Figure 6F) were elevated by 5,0- and 7.4-fo!d, respectively, at five months.

Example 2, Validation ami predictive power of urinary excreted metabolic cancer biomarkers.

The robustness of the biomarkers was tested in an independent cohort. Similar to that in the discovery cohort, the creatinine-normalized urinary excretions (Figure 7 A) of carnitine (3.6-fold) was reduced whereas those of glutamine (1 , 8-fold), Nl -acetylspermidine (4.8- fold), N8-acety!spermidine (2, 1 -fold), proiine (2.9-foid), asymmetric-dimethylarginine (2- fo!d), symmetric-dirnethyiarginine (1.6-fold), spermine (1.9-fold), xanthosine (1 , 9-fold),

inosine (3.2-fold), and -acetyllysine (1 ,4-fo!d; Figure 5B) were elevated in the urine of tumor-bearing animals. Although not statistically significant, urinary excretion of thymidine (6.6-fold, P ^:;= 0.054) and deoxyuridine (3.1 -fold, P = 0.065), showed a trend toward elevation as observed in the discovery cohort (Figure 5B).

Thirteen biomarkers, related to amino acid metabolism (proline, gluta iine and Na- acetyllysine), nucleic acid metabolism (Xanthosine, inosine, deoxyuridine and thymidine) and polyamine metabolism (N l -acetylspermidine, NS-acety!spermidine and spermine) as well as methylation (asymmetric-dimethylarginine, symmetric-dimethyiarginine and carnitine), were selected on the basis of their consistent and significant derangement in both cohorts (see Figures 8A-8D for comparison) for evaluation of predictive power using ROC analysis. Individual biomarkers (Figures 9A-9D) showed moderate to high (75-99%) accuracy of prediction. However, combining the biomarkers according to metabolic pathway as mentioned above showed significant improvement in (see Table I ) sensitivity as well as specificity. Consequently, biomarker parsels comprising amino acid metabolites (Figure 7B, AUCROC = 0.92, sensitivity - 83%, specificity = 91 %), polyamine metabolites (Figure 9C, AUCROC = 0.99, sensitivity = 92%, specificity ^::; ! 00%), nucleic acid metabolites (Figure 4D, AUCROC ^· 1 .0, sensitivity = 100%, speci ficity - 100%) and methylation metabolites (Figure 9B, AUCROC - 1 .0, sensitivity = 100%, specificity = 100%) showed 88%, 96%, 100% and 100% accuracy of tumor diagnosis, respectively, in combined cohort at six months, The hierarchical clustering analysis (Figure 10B) of the modulation of metabolomie signature (heatmap shown in Figure 10A) also correctiy ciassified all except one naive and one tumor- bearing animal.

Subsequently, the ability of the biomarker panels to distinguish wild-type and mutant animals during earlier stages (5 months, Figures 1 1A and 1 IB; 4 months, Figures 12A and 12B; 3 months, Figures 13A and 13B; and 2 months, Figures 14A and 14B) of tumorigenesis were evaluated using ROC analysis. The results showed that although individual metabolites or pathways, especially, amino acid metabolism, performed poorly, any combination of biomarkers related to nucleic acid metabolism, polyamine metabolism and methylation, predicted mutant mice at risk of developing colorectal tumors with 100% sensitivity and specific ity even at two months of age, when only few animals start developing tiny polyps.

Example 3. Analysis of tissu metabolome. In order to examine whether changes in the urinary biomarkers correlate with changes in the tissue metabolome, the abundance of these and related metabolites were examined in colon tumor and normal colon epithelial tissue. Targeted analysis showed thai the abundance of amino acids (Figure 15A) such as proline (5.2-fold), glutamine (3.0-fold), glutamic acid (2,4-fold), and threonine (4,2-fold) were elevated in colon tumors. Metabolites related to urea cycle and po!yamine metabolism (Figure 15B) such as arginine (2.4-foid), citrulline (2.5-foid), ornithine (3.5-foid) and Nl -acetyispermidine (10.3-fold) were also elevated. While metabolites related to nucleic acid metabolism (Figure 15C) such as thymidine (2.7- fo!d) was elevated, the abundance of both xanthine (10.0-fold) and inosine (3,4-fold) were reduced in tumors. ATP, which is related to nucleic acid and energy metabolism, was elevated (2.9-fold) in colon tumor. Hypermethyiaied metabolites, dimethylarginine (3.2-fold) and carnitine (4.2-foSd) were also elevated in tumor tissue.

Example 4. Analysis of gene expression.

The expression of key genes (see Table 2) related to these metabolic pathways were analyzed in order to elucidate the transcriptomic changes that contributed to changes in metabolic flux and precipitated observed segregation of metabolomic traits. Messenger RNA encoding enzymes involved in de novo amino acid biosynthesis (Figure 36A), such as GLUD1 ( 1 .5-fold), GOT2 (2. 3 -fold), ASS 1 (3.1 -fold), ASL (2-fold), PYCR 1 (6.7-fold), PYCR2 (2,2-fold), ALDH4A I ( 1.3-fold) and AHCYL1 (2.3-fold) were all elevated in colon tumor. Genes involved in de novo purine biosynthesis such as GART(2.9-foid), ATIC l (3.3- fold), IMPDH1 (2.2-fold) and metabolism such as ADA (3.7-fold), PNP (2.9-fold), HPRT i (1 ,9-fold) were also elevated in tumor tissue along with genes involved in de novo pyrimidine biosynthesis such as CAD (2.9-fold), IJMPS ( 1.8-fold), LIMPK (2.5-fold), TYMS (2.1 -fold), TX RDl (2.7-fold), TXNRD2 ( 1 ,6-fold) and TXNRD3 (2.3-foid). Messenger RNA encoding enzymes involved in urea cycle and polyamine metabolism such as ARG 1 (78.5-fold), ARG2 (2-fold), NOS2 (7,8-fold), NOS3 (4.6-fold), ODC (2.1 -fold), SRM (5- fo!d), SMS (2.9-fold), SMOX (6.7-fold), and SAT1 (2.5-fold) were elevated whereas OTC (8.2-fold) was reduced. A whole host of mRNAs related to posMrans!ational and epigenetic methylation machinery such as DNMT1 (3.3-fold), DNMT3A (2-fold), PRMT1 (2.7-fold), PRMT3 (2.5-foid), CARM 1 (2.1 -fold), PRMT5 (2.8-fold), PRMT6 ( 1.6-fold), PRMT7 (3.5- fold), PRMT8 (2.6-fold), AMD1 (2.4-fold), MAT2A ( 1.4-fold), MTAP1 ( 18.2-foid), DHFR

(1.9-fold), MTHFR (1.5-fold), MTHFS (1.3-fold) and SHMT 1 (1 .6-fold) were also elevated,

Example 5, Changes in ammo aeid, nucleic acid, and polyamine metabolism and met ylatioe hi tumor tissue accompany neoplasia.

Metabolomic and transcriptomic analysis revealed changes in amino acid, nucleic acid, polyamine metabolism and methyiation in tumor tissue. Changes in the urinary metabolome were found to be in concert with these changes and, consequently, helped to correctly distinguish healthy and tumor-hearing animals. The consistency of longitudinal trait of simultaneous deregulation of these pathways during tumors genesis resulted in highly accurate and early prediction of subjects at risk of developing colorectal cancer in this mouse model.

Growth and proliferation are hallmarks of cancer cells. Loss-of- function APC mutation leads to activation of Wnt-signaling target genes such as c-Myc, which is a master regulator of genes involved in these processes, Growth demands building blocks for macromolecu!es and energy, which come from nutrients. It was shown that cancer cells develop an ability to increase nutrient (glucose, glutamine and fatty acid) uptake. In fact, the accumulation of essential amino acids such as threonine in colon tumors of APC ^lll'⁺ mice indicated development of a similar capability. In order to extract energy from nutrients cancer cells resort to a variety of metabolic reprogramming ranging from increased glycolysis (Warburg effect), Krebs cycle to fatty acid oxidation. The present results showed that urinary carnitine excretion was lower whereas tumor tissue carnitine concentrations were higher. Without being bound to a particular theory, this indicates an active retention of carnitine in tumors, presumably to shuttle fatty acids into mitochondrial for β-oxidation to produce energy. It was shown that Wnt-signaling promotes mitochondrial biogenesis via c-Myc, which increases acetyl-CoA production. Therefore, elevated acetylated urinary biomarkers (Ν -acety!Sysine and acetylspermidines) may be a reflection of c-Myc activation in tumor tissue. Acetyl-CoA can either enter the Krebs cycle or de novo fatty acid synthesis, which is required for cell growth and has been shown to be upregulated in cancer. Mitochondrial Krebs cycle plays an important role in energy production and de novo synthesis of amino acids. Reducing equivalents produced via fatty acid oxidation or Krebs cycle can either be used in fatty acid biosynthesis or to produce ATP via mitochondrial oxidative

phosphorylation, c-Myc activation was shown to increase oxidative phosphorylation. The concentration of ATP was indeed found to be higher in tumors. The gene (GOT2) encoding the mitochondrial anapierotic enzyme involved in transamination of aspartate and giutamate (1 ) was found to be overexpressed in tumors. Aspartate is involved in ATP-dependent biosynthesis and regeneration of arginine through urea cycle. The genes involved in this process such as ASS 1 and ASL (6) were elevated in tumors. Consequently, arginine concentration in tumors was found to he higher than norma! colon. The transamination of oxaloacetate to aspartate requires giutamate with concomitant production of ct-ketoglutarate, which can contribute to the biosynthesis of non-essential amino acids via the Krebs cycle. Giutamate can be produced from glutamine, which was significantly elevated in tumor tissue, by giutaminase. c-Myc was shown to increase the production of giutamate without any change in giutaminase expression via suppression of miR-23. Giutamate can also be converted to a-ketog!utarate by GLUD 1 , which was found to he upregulated in tumors. Giutamate is a precursor to the biosynthesis of proline and the genes involved in this pathway such ALDH4A l and PYCRI, PYCR2 were overexpressed in tumors. Consequently, both tissue abundance and urinary excretion of proline was elevated tumor-bearing mice. The transcriptomic and metabolomic enrichment of these pathways, which might be the result of c-Myc activation, reflect hyperactive central carbon

metabolism, energy metabolism and de novo amino acid biosynthesis to support growth of colon cancer cells in APC^Mltl'⁺ mice.

Cell proliferation, on the other hand, requires the synthesis of genetic material. It was shown that glutamine plays a central role in c-Myc driven proliferation. Apart from glutamine and ATP, de novo nucleotide synthesis also requires 5-phosphoribosyl 1 - pyrophosphate (PRRP), which is synthesized via pentose phosphate pathway (PPP) with concomitant production of NADPH. c-Myc was shown to increase flux through PPP. The present study showed that the expression of genes involved in funnel ing increased carbamoyl phosphate and PPP flux into purine biosynthesis, such as GART znd ATIC, were elevated in colon tumors. In addition, the expression of genes involved in purine interconversion and metabolism such as IMPDHl, ADA, PNP, and HPRTl , were also elevated in tumors.

IMPDH1 was shown to be a direct c-Myc target and inhibition of this gene was found to inhibit proliferation. These resulted in the elevation of inosine, xanthosine and xanthine in urine. However, inosine and xanthine were reduced in the tissue, presumably due to the interconversion and/or excretion through urine.

The expression of CAD, another direct target of c-Myc, that encodes a protein with triplet enzymatic activity required for biosynthesis of pyrimidines from glutamine, aspartate and ATP, was elevated in tumors. In addition, the expression of UMPS and UMPK, genes involved in converting PRRP and orotic acid into uridine triphosphate, were aiso elevated. Uridine triphosphate is the precursor of other pyrimidine nucleotides required for RNA and DNA synthesis, in Sine with the elevated de novo synthesis flux of pyrimidine nucleotides, excretion of eytidine was found to be elevated in urine, in addition, ail three isoforms of thioredoxin reductase, the enzymes involved in synthesis of deoxyribonucieotides, were overexpressed along with TYMS, the gene involved in the synthesis of DNA-specific thymidine nucleotide. As a result, tissue distribution of thymidine as well as urinary excretion of thymidine and deoxyuridine was significantly elevated in tumor-bearing animals. These observations reflect a hyperactivation of RNA and DNA biosynthesis, an essence of proliferative capacity, via synchronized redistribution of centra! metabolic flux towards PPP and amino acid biosynthesis.

A significant amount of central metabolic flux was also directed towards urea cycle via aspartic acid mediated arginine biosynthesis. However, the arginases were also highly expressed in tumor tissue along with nitric oxide synthases NOS2 and NOS3 that produce citruliine and nitric oxide. Consequently citruliine was found to be elevated in both tumor tissue and urine. Arginase, which produces ornithine, was already shown to be increased in human colorectal cancer tissue. Ornithine can be converted to either citruliine by Ornithine transcarbamyiase (OTC) to re-enter the urea cycle or putrescine byornithine decarboxiyase (ODC), The ODC expression was upreguiated in tumor with concomitant downregulation of OTC expression that would result in funne!ing of ornithine into biosynthesis of putrescine. This indicates that the arginine pool is channelized in bifurcated fashion into both urea cycle (via NOS) and polyamine biosynthesis (via ODC). The next step in polyamine biosynthesis involves successive addition of propylamine groups from S-adenosylmethioninamine (SAMA) by SRM to produce spermidine and then, by SRM or SMS to produce spermine.

The expression of both enzymes was elevated in tumors that also showed elevated expression of SMOX that reverts spermine to spermidine with concomitant production of H₂Q₂. This should lead to a build-up of spermidine in tumors, instead, a marked increase in N8- acetylspermidine in urine and N l -acetyl spermidine in tumor and urine was observed in APC^Mii \ This could be rationalized by the elevated production of aeetyl-CoA and increase in expression of SAT! in tumors. Both of these metabolites were earlier shown to be elevated in the urine of colorectal cancer patients. Polyamines are known to epigenetical ly modulate gene expression and promote proliferation. ODC, the key enzyme involved in determining the flux into po!yamine biosynthesis, was shown to be a direct c-Mye target, interestingly, p!oyamines were also shown to induce c-Myc overexpression by perturbing chromatin structure. Thus, these results suggest that activation of Wnt-signaling can direct central carbon flux is directed towards po!yamine biosynthesis and epigenetica!ly promote pro!iferation. It was interesting to note that the expression of MTAP that converts S-methy!- 5'-thioadenosine (MTA), the product propylamine transfer from SAMA, into adenine was also increased in tumors. This might, in turn, contribute to the observed increase in purine metabolites in tissue and urine,

Epigenetic modulation of gene expression, particularly, downregulation of tumor suppressor genes, plays an important role in tumorigenesis. These mechanisms involve methylation of DNA as well as methyiation and acety!ation of arginine and lysine residues of histone. c-Myc has also been shown to influence DNA methylation. An increase in the expression of DNA methyltransferases (DNMTl, DNMT3A) was observed in colon tumors in APC^{Mm +} mice. These enzymes transfer methyl group from S-adenosyimethionme (SAM) to eytosine of CpG islands upstream of the target gene. SAM is converted to S~

adenosylhomocysteine in the process, which eventually gets reconverted to SAM via homocysteine and methionine. Genes involved in the process, AHCYL1 and MAT2A were upregulated in tumors. This process requires ATP as well as 5-methyltetrahydrofolate that is derived from folic acid, Another folic acid metabolite, 5, 10-meth lenetetrahydrofoiate, is also involved in thymidine synthesis by TYMS, which was significantly elevated. Purine biosynthetic enzyme GART, which was elevated in tumors, also requires 10- formyltetrahydrofolate. These results indicate funneiing of carbon flux into folate-mediaied one-carbon transfer machinery. Folic acid fortification has been shown promote colorectal cancer. c-Myc has earlier been shown to increase central carbon flux into one carbon pool and induce genes involved in folate metabolism. Genes involved in folate metabolism such as DHFR, MTHFR, MTHFS (A P -dependent), and SHMT] were, indeed, overexpressed in tumors. SHMTt also participates in biosynthesis of serine, in addition, the gene AMD ! involved in conversion of SAM to SAMA, which drives poiyamine biosynthesis, was also elevated in colon tumors. These observations indicate to hyperactive methylation machinery in colon tumors,

In addition to DNA methylation, post-iranslational modification of protein lysine and arginine residues also plays an important role in the epigenetic regulation of gene expression and modulation of protein activity. Carnitine is produced as a result of trimethylation of protein lysine residues. It was recently shown that trimethyiation of lysine residues are involved in regulation of expression of Wnt-signaling target genes. The increase in abimdance of carnitine indicates that increase in SAM-dependent lysine methy!ation might contribute to aberrant gene expression patterns in APC^{Min +} colon tumors. In addition, the expression and activity of protein arginine methyltransferases (PRMTs) were also elevated. PRMTs transfers methyl groups from SAM to arginine side chains of histones and, thereby, modulate their nuc!eosome binding affinity to regulate gene expression. While type-ϊ PRMTs typical ly activates gene expression, type-Ii PRMTs repress them and they act on different sites. PRMTs can regulate the transcriptional activity of a number of genes, including P53, NF-κΒ and E2F1 that p!ay important role in tumorigenesis by regulation of downstream signaling for ceil survival and proliferation. In addition, arginine methylation also post-translationally modulates the activity of a host of other proteins involved in processes like RNA processing, signal transduction and DNA repair. Arginine residues are methylated either symmetrically (by type-I PRMTs such as PRMT l , PR.MT3, CARM1, PRMT6) or asymmetrically (by type-II PRMTs such as PRMTS, PRMT7) to produce symmetric or asymmetric dimethylarginine. The expression of all of these genes was upregulated along with PrmtS, which was recently shown to interact with hnRNPs and RNA- helicases, in the tumor tissue. Consequently, the abundance of dtmethylarginines in tumor tissue as well as their excretion in the urine was significantly elevated. Wnt-signaling has been shown to cause arginine methylation of G3BP1 that acts as a molecular switch for β- catenin activity. Thus, increased arginine methylation due to activation of Wnt-signaling may compound the activation of the proliferative signal and viciously accelerate

tumorigenesis.

The results described herein revealed a concerted deregulation of epigenetic, transcriptional, post-translational and metabolic events associated with tumorigenesis in

APC^{Min +} mice. The existing literature suggests that e-Myc can directly contribute to many of these events. However, it remains unclear why all cells harboring APC mutation do not turn into cancer cells, it was proposed that colorectal carcinogenesis is a multi-step process where inflammation and mutagenesis plays the role of a promoter following mutation (genetic or somatic) in a tumor suppressor (such a APC) gene, increase in production of reducing equivalents (via fatty acid oxidation, TCA cycle and PPP) and oxidative phosphorylation by c-Myc can significantly increase reactive oxygen species (ROS) production, in addition, the activities of ROS-generating metabolic processes, such as oxidation of spermine to spermidine or hypoxanthine to xanthine, were elevated in tumor tissue. Chronic elevation of ROS production can increase inflammation, DNA damage and mutation which keeps accumulating stochastically in cells in a time-dependent manner, ROS production can also induce antioxidant response in cancer cells and prevent apoptosis as well as accelerate ageing-autophagy in tumor microenvironment that helps to feed cancer cells. These may augment the activation of Wnt-signaling due to the APC mutation and promote t morigenesis in a time-dependent, yet stochastic manner. Taken together, these observations suggest that c-Myc can simultaneously drive inflammation as well as genetic and epigenetic aberrations to precipitate redistribution of metabolic flux towards de novo biosynthesis of amino acids, nucleic acids, polyamines and energy production to promote growth and proliferation,

Without being bound to a particular theory, the results described herein indicate that a coordinate reprogramming of cellular metabolism during imorigeneis is reflected in the urine metabolome. In particular, progressive elevation of symmetric- and asymmetric- dimethylarginine in urine of animals as a reflection of hyperactive methylation machinery is a novel observation in the context of colorectal cancer. The ability of urinary metabolites to prospectively identify subjects that would eventually develop tumor, indicate combined panel of urinary biomarkers representing synchronized deregulation of amino acid, nucleic acid, polyamine metabolism and methylation has the potential to provide a powerful high- throughput noninvasive method for screening as well as early diagnosis of colorectal cancer.

Example 6. Validation of urinary metabolic signatures in mouse model of sporadic colorectal cancer.

The following examples further demonstrate the utility of metabolic biomarkers belonging to methylation, urea cycle and polyamine metabolism, nucleic acid metabolism and amino acid metabolism in early noninvasive screening and diagnosis of colorectal cancer.

In order to examine whether the noninvasive signatures associated with colorectal tumorigenesis identified in hereditary colorectal cancer mouse model (Apc^M,n/+) is, in general, etiology-independent biomarkers of colorectal cancer, these metabolites were measured in the urine of mouse model of AGM-induced sporadic colorectal carcinogenesis,

Similar to that observed Apc "^v~i mice, AOM-treated mice also show (Figure 17) elevated excretion of glutamine, proline, Να-acetyUysine, N8-acetylsperm idine, citrulline, deoxyuridine, thymidine, symmetric-dimethylarginine, and asymmetric-dimethylarginine (Figure 1 7). Although not statistically significant, xanthine (P = ,065), xanthosirte (P = , 132) ii- and N l -acety!spermidine (P = .132) showed a trend of elevation (Supplementary Figure 19). In addition, it also showed elevation of glutamic acid, threonine, deoxycytidine, cytosine, guanosine,betaine, methionine (Figure 17). However, unlike Apc^{M h} mice it showed an increase in excretion of ornithine and carnitine. Nevertheless, the overall metabolic signature indicated a concerted dysregulation of the aforementioned metabolic pathways similar to Apc^Mm* mice. This indicated that such derangements may be a common feature of colorectal carcinogenesis irrespective of etiological heterogeneity as found in human subjects. The fact that even the genetic background of AOM-treated mice ( 129P3/J) and Apc^Min/' mice

(C57/BL6J) were different strongly indicates to the robustness of association of these signatures with colorectal carcinogenesis.

Accordingly, based on the foregoing results, it can be concluded that derangement of urinary excretion of metabolites related to methylation, urea cycle and po!yamirte metabolism, nucleic acid metabolism and amino acid metabolism is a general phenomenon associated with hereditary as well as sporadic colorectal cancer.

Example 7, Validation of metabolic reprogrammmg associated with colorectal tsimorigessesis in Isimian colorectal tumor samples.

in order to examine whether the metabolic reprogramming observed in colon tumors from Apc^M, "⁺ mice were also associated with human colorectal tumorigenesis, the metabolic profile of human colorectal tumors and adjacent non-tumor tissues from the same patient were analyzed. To compare with the observation made in Apc^u,r"⁺ mice where colon tumors are found only in lower two-third of the colon, human colon tumors found in rectum and sigmoida!, descending or transeverse colon were analyzed together. Similar to that observed in Apc^M>n,+ mice, amino acid metabolites were elevated in human colorectal tumors (Figure 1 8), Metabolites connecting amino acid metabolism to urea cycle and polyamine metabolism, such as arginine and N l -acetylspermidine were also elevated. Nucleic acid metabolites such as uracil, hypoxanthine and xanthine were elevated. Similar to Apc^Mm' mice, human tumors showed elevation of hypermethylated metabolites such as carnitine, symmetrie- dimethylarginine, asymmetric-dimethylarginine, dimethylgiycine and betaine along with S- adenosvlmethsonine and S-adenosylhomocysteine. Even in the overall cohort, which included tumors from ascending colon, aspartic acid, glutamic acid, proline, threonine, lysine, arginine, uracil, xanthine, hypxanthine, S-adenosylhomocysteine, S-adenosylmethionine, carnitine, symmetric-dimethylarginine, asymmetric-dimethylarginine, beiaine and dimethylgiycine were significantly elevated (Figure 19).

Accordingly, based on the foregoing results, it can be concluded that coordinate metabolic reprogramming of metabolic machinery involved in methylation, urea cycle and polyamine metabolism, nucleic acid metabolism and amino acid metabolism is also associated with human colorectal tumorsgenesis. Similar to that observed in two independent mouse models, metabolites belonging to these pathways may act as noninvasive biomarkers of colorectal cancer in human subjects.

Example 8, Validation of urinary biomarkers of colorectal cancer in human samples.

In order to examine whether derangement of urinar metabolic profiles are indeed associated with human colorectal carcinogenesis, a preliminary set urine samples from colorectal cancer patients (N = 10) and healthy controls (N =10) were analyzed.

Metabolic profiling showed significant derangement in excretion of metabolites related to amino acid metabolism (glutamine, proline and N-acetyllysine), urea cycle and polyamine metabolism (N-acetylspermidine, arginine, and ornithine), nucleic acid metabolism (deoxycyiidine, cytosine, inosine, adenosine, xanthosine and hypoxanthine) and methylation (symmetric-dimethylarginine, beiaine. carnitine and methionine). This included ten metabolites that were found to be elevated in the human colorectal tumor samples. In general, metabolites related to methylation and nucleic acid metabolism showed the most consistent trend. A summary of concentration ranges and statistical analysis is presented in Table 3, below.

Table 3. Preliminary changes in urinary metabolic profiles of colorectal cancer patients

Deoxycy.idine Nucleic acid metabolism .006 (.004-.008) .0i04(.00g-. l3) ^' :6T .84

Cyios ie Nucleic acid metabolism 1,28 (.94-1.61) 2.35 (1.83-2.31) .0005 .93 mositw Nucleic acid metabolism .055 (.032-, 078) .29 (.071 -.51) ^'" ;οδδ; .96

H oxanthine Nucleic acid metabolism 14,5 (9,41-19.5) 36.4(17.6-55.9) . 1 .84

Xanthosine Nucleic acid metabolism \ (.48-1.33) 4,74 ( 73-8.75) <.ooo; " .96

Adenosine Nucleic acid metabolism .00014 (0001-.0004) ,115 (.05-. IS < ,00! 1

N 1 -Ace!ysspenradine Urea cycle and po!ya:ii;nc 21.2 (Ϊ 8.14-24.2) 27.65 (20.54-348) ,052 ' .76

N8-Acety:spemsidine Urea cycle and po!yamine ,86 (.61-1.1) 1.79 (.92-2.66) < .02 83

Af gin hie Urea cycle and polyamine 908 (5.79-12.4) 16.Π (9,95-22.3) .03 I

Ornithine Urea cycle and polyamine 15,0 (10.6-19.4) 8.84(6.58-11.1) < .004 .87

Giutamine Amino ;ji;ic metabolism 2.6: (Ί.Ϊ3-2.89} 70.46 (25.72-! 15.2) " -'..0001 1

Pro!me Amino acid metabolism 4.29(2:97-56) Ϊ.25 (.49-2.2) < .004 .87

Na-acetyllys'.iie Amino acid metabolism 4.32 (2.89-5.75) 8.82 (6,03- I Ϊ .6) 02 ^'"S3 ^d All values are in the units of umol/mmo! creatinine; P values were calculated by Mann- Whitney test. in order to further validate and extend the utility of these biomarkers in colorectal cancer screening, and diagnosis, urine samples will be collected from subjects undergoing colonoscopy to compare the metabolic signature of colorectal cancer patients with those having benign polyps as well as other non-cancerous pathologies or normal colon, In this case, the patients serve as their own control. These subjects will be monitored longitudinally to evaluate the utility of noninvasive metabolomic biomarkers in screening, prognosis and prediction of therapeutic response. A repository of urine samples from other GS malignancies will also be examines in order to examine the utility of metabolic biomarkers to other GI malignancies and/to identity signatures specific to GI sites.

Accordingly, based on the foregoing results, biomarkers reflecting metabolic

reprogramming of methylation, urea cycle and polyamine metabolism, nucleic acid

metabolism and amino acid metabolism can be useful in noninvasive screening and early diagnosis of colorectal cancer.

Example 9, identification of M264 bi marker in urine f colorectal cancer patients, Another novel ion (M264) has been identified as a biomarker: 2- {2-[(2R,3R,4S,5R)- 3,4-dihydroxy-5-(hydroxymeihyj)-oxo!an~2^ acid (aka, beta-D-Ribofuranosylcreatine). Figure 20A shows the structure of the metaboliie which has a molecular formula C9H17 3O6. M264 has been found to be significantly (p < .0001) elevated only in the urine samples of CRC patients. Figure 20B shows the creatinine-normalized relative abundance of this metabolite in control ( = 10) and patient (N = 10) urine samples, ROC analysis (Figure 20C) showed that this metabolite can identif colorectal cancer patients with high accuracy (AUCROC = 0.98).

Production of this metabolite may be a result of simultaneous upregulation of pentose phosphate pathway (which also contributes to nucleic acid biosynthesis) as well as dysreguiation of urea cycle and methylation machinery both of which are involved in creatine biosynthesis.

The results reported herein were obtained using the following methods and materials. A nimal studies

Wild-type and mutant (APC^M'^""' ¹) mice were purchased from Jackson laboratories (Bar Harbor, ME). Six age-matched wild-type and six APC^{Mm +} iittermates were cohabited one week after weaning in two cages containing equal numbers of wild-type and six APC^Min,'^" . Mice were fed with normal chow and water ad libitum and used as discovery cohorts for longitudinal metabolomtc studies. Twenty four-hour urine samples were colieeted monthly starting from two months up to six months of age by placing mice in metabolic cages. Urine samples were also collected from an independent set of age-matched (six wild-type and six APC^Mm/ ) non-1 ittermat.es at six months of age, which were used as a validation cohort.

Serum samples were collected by retro-orbital bleeding before euthanasia. Animals were killed through CO₂ asphyxiation at the end of the study, intestine flushed with normal saline, longitudinally opened, tumor counted under light microscope, tissue samples harvested and all samples were stored at -8Q°C.

Biochemistry

Serum ALT and AST levels were measured by using VetSpec kits (Catachem inc., Bridgeport, CT) following the manufacturer's instructions.

Meiabolomics

Deproteinated urine and tissue samples were analyzed in Xevo G2 ESiQToFMS coupled with Acquity UPLC BEH amide column (Waters Corp. Miiford, MA) for HILIC analysis. Reverse-phase analysis of urine samples were performed using SY APT HDMS ESIQToFMS coupled with Acquity UPLC BEH C_{j S} column. The data was deconvolved and annotated using MassLynx software (Waters) and analyzed using SIMCA-P12+ (Umet ics, Umea, Sweden) software. The quantitaion of the urinary metabolites were performed on a Xevo triple-quadruple ESIQToF platform coupled with an amide column through multiple reaction monitoring and all data were presented as normalized with respect to creatinine concentrations. Changes in relative abundance of the metabolites in tissue were calculated from internal standard-normalized area under extracted chromatograms. See Supplementary methods for detail,

Gem Expression

RNA was isolated using RNAeasy mini kit (Qiagen, Valencia, CA) and qPCR was performed using SYBR® GreenER™ Reagent System (Invitrogen, Carlsbad, CA) in a 7900 HT Fast Real-Time PGR system (Applied Biosystems, Carlsbad, CA). Relative change in gene expressions were calculated by the AAC. method with normalization to ] 8S rRNA. See Table 2 for primers used in qPCR.

Chemicals

HPLC grade water, acetonitrile and methanol were purchased from Fisher Scientific (Hampton, NH), Difluoromethylornithine, a-aminopimelic acid, creatinine, glutamine, glutamic acid, creatine, aspartic acid, lysine, citrul!ine, ornithine, proline, threonine, uracil, uridine, deoxyuridine, thymidine, deoxycytidine, cytidine, adenosine, guanosine, xanthine, xanthosine, hypoxanthine, inosine, uridine monophosphate, deoxyuridine monophosphate, cytidine monophosphate, adenosinetriphosphate, acetyl CoA, Na-acetyl lysine, N- acetylglutamic acid, spermine, N l -acetylspermidine, N8-acetyispermidine, arginine, No monomethylarginine, s m-dimethylarginine, and a y/w-dimethylarginme, dimethylglycine, S- adenosylhomocysteine, S-adenosylmethionine, methionine, and betaine were purchased from Sigma-Aldrich (St. Louis, MO).

Global urinary metaholomic analysis and biomarker identification.

Urine samples were deproteinated using 50% or 70% acetonitrile containing 5 μΜ eh!oropropam ide or a-aminopimelic acid as internal standards for reverse-phase (RP) or hydrophilic interaction liquid chromatography (H1LIC), respectively. Supernatants were transferred into 96-well sample plates, All pipetting and dilution were performed using a

MICROLAB STAR^LET automated liquid handler (Hamilton Robotics, Reno, NV). For HTLIC analysis, 5 μί. aliquot of samples were injected in a randomized fashion into a 2, 1 x 50 mm Acquity UPLC BEH amide column (1 .7 μΜ) connected to a XEVO G2 ES!QTOF mass spectrometer (Waters Corporation, Mi!ford, MA). Chromatographic separation was achieved by using a mixture of (A) J OmM ammonium acetate in 90% acetonitrile (pH = 8.9) and (B) ! OmM ammonium acetate in 10% acetonitrile (pH ^;;; 8.9) as mobile phase. The gradient elution was performed over 10 min using: 1-60% B in 4 min (0,4 ml/min), 60-80% B at 8 min (0.4 ml/min), holding at 80% B up to 8.5 min (0.3 ml/min). bringing back to 1 % B at 8.8 min and holding at 1% until end (0.3 ml/min). Column temperature was maintained at 40°C. Column was re-equilibrated with 99% A at the end of each run prior to injection of next sample. For reverse-phase analysis, 5 μΕ aliquot of samples were injected into a 2.1 x50 mm Acquity UPLC BEH C, ₈ column (1 .7 μΜ) connected to a SYNAPT HDMS ESIQTOF mass spectrometer (Waters Corporation). Chromatographic separation was achieved by using a mixture of (A) water containing 1 % formic acid and (B) acetonitrile containing 1 % formic acid as mobile phase. The gradient elution was performed over 6min at a flow rate of 0.3 mL using: 1-99% B in 4 min, holding at 99% B up to 5.0 min, bringing back to 1% at 5.5 min and holding at 1 % until end. Column temperature was maintained at 40°C, Column was re- equilibrated with 98%s A at the end of each run prior to injection of next sample. Mass spectrometric analysis was performed in both positive and negative ionization modes. Sulfadimethoxine was used as the lock mass (m/z 31 1.08 14^÷) for accurate mass calibration in real time. MassLynx software (Waters Corporation) was used to acquire mass chromatograms and mass spectral data in centroid format.

Chromatograms were manually inspected for chromatogram quality and retention time reproducibility across the run. MarkerLynx software (Waters Corporation) was used to deconvolve chromatograms, bin the data according to mass- retention time pairs and integrate the area under the peak. The intensity of each ion was normalized with respect to the either total ion count (TIC) or creatinine (m/z 1 14.067, RT = 0.3 min or 0,8 min in RP or H1LIC mode) count to generate a data matrix consisting of m/z value, retention time, and the normal ized peak area. The multivariate data matrix was analyzed by SIMCA-P+12 software (Umetrics, innelon, NJ), Data quality inspection as well as distribution and unsupervised segregation of wild-type and mutants on global metabolomic space were checked by principal components analysis (PCA) of the Pareto-scaled data. The supervised orthogonal projection to latent structures (OPLS) model was used identify ions contributing to discrimination

(indicated by their distance from origin along Y-axes) of metabolic traits. Consistency of longitudinal trend of ions in contributing to difference of wild-type and mutant metabolome was examined to select potential biomarker candidates, Candidate metabolites for these ions were identified on the basis of accurate mass measurement using metabolomic databases such as METL1N (http://meilin.scripps.edu ) or HMDB (http://www.hmdb.ca/) and MS/MS fragmentation pattern. Finally, identities of biomarker were confirmed by comparison of retention time and fragmentation pattern with authentic standards.

Targeted urinary metabolite quantitation.

Metabolites in the deproteinated urine samples were quantified in multiple reactions monitoring mode on a XEVO triple quadruple mass spectrometer (Water Corporation), - Aminopimelic acid (5μΜ) was used as internal standard. The following metabolites were quantified by monitoring characteristic fragmentation reactions (in bracket); -aminopimelic acid (176-» 1 12, ESI+), creatinine (1 14-» 86, ESI+), aspartic acid (132-» 88, ESI-), glutamine ( 147-» 84, ESI+), glutamic acid ( 148-» 84, Ε8Ϊ+), creatine (132-» 90, ESI+), lysine (347-» 130, ESI+), citrulline ( 176~» 159, ESI+), ornithine ( 133-» 70, ESB-), arginine (1 75-» 60, ESi-i-). Νω-monomethylarginine (1 89~» 84, ES1+), jym-dimethylarginine (203 -» 172, ESI+), and osryw-dimethylarginine (203 -» 46, ES1+), proline ( 1 16-» 70, ES1+), threonine (120-» 74, ESI+), uridine (245 -» 1 13, ESI+), deoxyuridine (229-» 1 17, ESI+), thymidine (243 - 151 , ESI-), cytidine (244-» 1 12, ESI+), xanthine ( 151» 108, ESI-), xanthosine, (285-» 153, ESI+), hypoxanthine ( 137-> 1 19, ESJ+), inosine (269-» 153, ESI+), Na-acetyllysine (1 89--» 129, ESI+), l -acetylspermidine ( 188-» 72, ES1+), N8- acetylspermidine (188-» 1 14, ESI+), betaine (1 18-» 59, ESI+), deoxycytidine (228-» 1 1 1 , ES1+), adenosine (268-» 136, ES1+), methionine ( 150~> 56, ESI+), guanosine (284-» 122, ESS+) and M264 (264-» 132, ESI+). Spermine was measured by single ion monitoring (203, ESI+) and relative abundance was measured by area under the peak. Chromatographic separation was achieved on a 2.1 x 50 mm Acquity UPLC BEH arnide column using the mobile phase as mentioned above. The gradient e!ution was performed over 10 min at a flow rate of 0.5 ml/min using: 1 -40% B in 6 min, 40-60% B at 8 min, 60-80% at 8.2 min, bringing back to 1 % B at 9 min and holding at 1 % until end. All data were processed using TargetLvnx software (Waters Corporation). Internal standard-normalized area under the peak (response) from serially diluted authentic standard solution was used to build calibration curve for each metabolite. The concentration of metabolite was determined from the calibration curve and divided by creatinine concentration to determine creatinine-normaiized excretion of the metabolite in 24-hour urine. Mouse tissue metabolite measurements.

Tumor (n = 6) and normal colon mucosal tissue (n = 5) samples were weighed and homogenized using a Precellys 24 homogenizes (Bertin technologies, France) and extracted using modified Bligh-Dyer method to separate the polar and non-polar metabolites, cx- Aminopimelic acid ( 10 μΜ) was added to each sample before extraction to normalize differences in metabolite extraction efficiency. Aqueous layer was vacuum-dried and reconstituted in acetonitrile/water/methanoi (65:30:5) mixture containing 5 μΜ difuoromethylornithine. Samples were analyzed on a XEVO G2 ESi-QTOF instrument connected to a 2. 1x50 mm Acquity UPLC BEH amide column (1.7 μΜ) with mobile phase as mentioned earlier. The gradient elution was performed over 10 min using: 1 -40% B in 6 min (0.4 mi/min), 40-80% B at 8 min (0.4 ml/miii), holding at 80% B up to 8.5 min (0.3 mi/min), bringing back to 1% B at 8.8 min and holding at 1 % until the end of the run (0.3 mi/min). Ail samples were run in a randomized fashion along with authentic standards, Raw chromatograms were extracted with masses for target compounds and peaks at characteristic retention times (as that of the authentic standard) were integrated to get area under the peak using TargetLynx software. The area under the peak for each metabolite was normalized step-by-step for initial tissue weight, extraction efficiency (a-aminopime!ic acid) and instrument response (difluromethylornithine). The fold change in abundance of metabolites in tumor tissue samples were calculated by dividing the normalized response for the metabolite from tumor samples by the average normalized response from normal mucosal tissue samples. Colon scrapes from tamoxifen-treated Cre+ (n= 3) and Cre~ (n=3) mice were extracted as mentioned above. Metabolite composition was quantitated using MRM and normalized as mentioned above. In addition to aforementioned MRMs, the following MRMs were also monitored for respective metabolites; adenosine (268~> 136, ESK), UMP (325-^ 97, ES1-), dUMP (309-» 81 , ESI+), CMP (324-» 1 12, ESI+), ATP (508- 136, ESI+), N- acetylglutamic acid ( 190-» 84, ES1+), acetyl CoA (810-> 303, ESI+), uracil (1 1 1 - 42, ESI- ), dimethylglycine ( 10 ~> 58, E8I+), S-adenosylhomocysteine (385-> 334, EST+), and S- adenosylmethionine (399~> 250, ESI+). The fold change in abundance of metabolites in Cre+ colon epithelium were calculated by dividing the normalized response for the metabolite from tumor samples by the average normalized response from Cre- colon epithelium.

Human tissue metabolite measurements.

Matched tumor (N= 39) and adjacent normal tissues were extracted following the same protocol as that described above for mouse tissues. Targeted measurement of metabolite abundances in the reconstituted aqueous extract were performed by MRM reaction monitoring coupled with hydrophilic interaction liquid chromatography as mentioned above for analysis of urine samples, The area under the peak for each metabolite was normalized step-by-step for initial tissue weight, extraction efficiency (a-aminopimelic acid) and instrument response (difluromethylornithine) and presented as normalized response.

Statistics

Statistical significance of changes in metabolite abundance and gene expression were calculated by two-tailed Mann-Whitney test with 95% confidence interval using Graphpad Prism (San Diego, California) unless mentioned otherwise. The creatinine-norma!ized urinary excretion of metabolites was used to test the predictive power of individual metabolites or metabolite panels by ROC analysis using STATA software (StataCorp, College Station, TX). The statistical significance of the change in metabolite abundances in matched human samples were calculated using two-tailed paired 't'-test with 95% confidence interval. P value < 0.05 was considered statistically significant.

Other Embodiments

From the foregoing description, it will be apparent that variations and modifications may be made to the invention described herein to adopt it to various usages and conditions. Such embodiments are also w ithin the scope of the following claims.

The recitation of a listing of elements in any definition of a variable herein includes definitions of that variable as any single element or combination (or subcombination) of listed elements. The recitation of an embodiment herein includes that embodiment as an single embodiment or in combination with any other embodiments or portions thereof,

All patents, publications, and CAS numbers mentioned in this specification are herein incorporated by reference to the same extent as if each independent patent and publication was specifically and individually indicated to be incorporated by reference.

Claims

What is claimed is:

! . A method for identifying a subject as having or having a propensity to develop neoplasia, th method comprising:

identifying an increased !eve! of a combination of two or more biomarkers in a biological sample derived from the subject relative to the level present in a reference, wherein a first biomarker is selected from a first group and at least one additional marker is selected from a different group, wherein the groups are selected from among the following;

biomarkers related to methylation comprising asymmetric-dimethylarginine, symmetric-dimethylarginine, carnitine, methionine, dimethylglycine, and betaine;

biomarkers reiated to nucleic acid metabolism comprising xanthosine, inosine, deoxyuridine, thymidine, deoxycytidine, cytosine, hypoxanthine, xanthine, uracil, guanosine, and adenosine;

biomarkers related to urea cycle and poiyamine metabolism comprising M l - acetylspermidine, N8-aeetylspermidine, spermine, arginine ornithine, and citrulline;

biomarkers related to amino acid metabolism comprising proline, glutamine, glutamic acid, threonine, and Na-acetyllysine; and

M264 (β-D-Ribofuranosylcreatine),

wherein an increase in said levels of two or more biomarkers identifies a subject as having or having a propensity to develop neoplasia.

2. The method of claim I , wherein the groups are selected from the following;

biomarkers reiated to methylation comprising asymmetric-dimethylarginine and symmetric-dimethylarginine;

biomarkers related to poiyamine metabolism comprising Nl -acetylspermidine, N8- acetylsperniidine, and spermine; and

biomarkers related to amino acid metabolism comprising proline, glutamine, and Na- acetyliysine.

3, A method for determining the prognosis of neoplasia in a subject, the method comprising: identifying an increased level of a combination of two or more biomarkers in a biological sample derived from the subject relative to the level present in a reference, wherein a first biomarker is selected from a first group and at least one additional marker is selected from a different group, wherein the groups are selected from among the following:

biomarkers related to methylation comprising asymmetric-dimethyiarginine, symmetric-dimethylarginine, carnitine, methionine, dimethylglycine, and betaine;

biomarkers related to nucleic acid metabolism comprising xanthosine, inosine, deoxyuridine, thymidine, deoxycytidine, cytosine, hypoxanthine, xanthine, uracil, guanosine, and adenosine;

biomarkers related to urea cycle and poiyamine metabolism comprising N l - acetyispermidine, N8-acetylspermidine, spermine, arginine ornithine, and citmiline;

biomarkers related to amino acid metabolism comprising proline, giutamine, glutamic acid, threonine, and Ma-acetyllysine; and

M264 (pVD-Ribofuranosylcreatine),

thereby determining the prognosis of neoplasia in the subject.

4. The method of claim 3, wherein the groups are selected from the following:

biomarkers related to methylation comprising asymmetric-dimethyiarginine and symmetric-dimethylarginine;

biomarkers related to poiyamine metabolism comprising Nl -acet {spermidine, N8- aeetylspermidine, and spermine; and

5. A method for identifying a subject as having or having a propensity to develop neoplasia, or for determining the prognosis of neoplasia in a subject, the method comprising: identifying an increased level of a combination of two or more biomarkers in a biological sample derived from the subject relative to the level present in a reference, wherein a first biomarker is selected from a first group and at least one additional marker is selected from a different group, wherein the groups are selected from among the following:

biomarkers related to methylation; biomarkers related to nucleic acid metabolism;

biomarkers related to urea cycle and po!yamine metabolism; and

biomarkers related to amino acid metabolism:

wherein an increase in said levels of two or more biomarkers identifies a subject as having or having a propensity to develop neoplasia or determines the prognosis of neoplasia in a subject.

6. The method of any one of claims 1 -5, wherein an increase in the level of a biomarker related to methylation identifies the subject as having a reduced chance of survival and a decrease in the level of a biomarker related to methylation relative to the reference identifies the subject as having an increased chance of survival.

7. A method for monitoring response to neoplasia therapy in a subject, the method comprising:

identifying an increased level of a combination of two or more biomarkers in a biological sample derived from the subject relative to the level present in a reference, wherein a first biomarker is selected from a first group and at least one additional marker is selected from a different group, wherein the groups are selected from among the following:

biomarkers related to nucleic acid metabolism comprising xanthosine, inosine, deoxvuridine, thymidine, deoxycytidine, cytosine, hypoxanthine, xanthine, uracil, guanosine, and adenosine:

biomarkers related to urea cycle and polyamtne metabolism comprising N l- acetylspermidine, N8-acety!spermidine, spermine, arginine ornithine, and citruiiine;

biomarkers related to amino acid metabolism comprising proline, giutamine, glutamic acid, threonine, and N -acetyl lysine: and

M264 (β-D-Ribofuranosylcreatine).

thereby monitoring neoplasia therapy in the subject.

8. The method of claim 7, wherein the groups are selected from the following:

biomarkers related to methylation comprising asymmetric-dimethylarginine and symmetric-dimethylarginine; biomarkers related to nucleic acid metabolism comprising xanthosine, inosine, deoxyuridine, and thymidine;

biomarkers related to amino acid metabolism comprising proline, glutamine, and N - acetyliysine.

9, The method of claim 7, wherein a therapy that reduces the level of a biomarker related to methylation is identified as effective.

10, The method of claim 7, wherein the reference is a sample obtained from the subject prior to therapy or at an earlier time point during therapy.

1 1 , A method for characterizing the aggressiveness of a neoplasia in a subject, the method comprising:

biomarkers related to methylation comprising asymmetric-diiTiethylarginine, symmetric-dimethyiarginine, carnitine, methionine, dimethylglycine, and betaine;

biomarkers related to urea cycle and polyamine metabolism comprising N l- acetylspermidine, N8-acety]spermidine, spermine, arginine ornithine, and citmlline;

M264 (β-D-Ribofuranosylcreatine),

wherein an increased level of a biomarker related to methylation identifies the neoplasia as aggressive, and a decreased level of a biomarker related to methylation identifies the neoplasia as less aggressive.

12. The method of claim 1 1 , vvherein the groups are selected from the following:

biomarkers related to polyamine metabolism comprising M l -acetylspermidine, N8- acetylspermidine, and spermine; and

biomarkers related to amino acid metabolism comprising proline, giutamme, and Na- acetyilysine.

13. The method of any one of claims 1 - 12, further comprising measuring the level of biomarkers in one or more groups consisting of: biomarkers related to methylation, biomarkers related to polyamine metabolism, and biomarkers related to amino acid metabolism.

14. The method of any one of claims 1-12, further comprising measuring the level of M264 (β-D-Ribofuranosylcreatine).

15. The method of any one of claims 1 - 14, -vvherein an increase or decrease in the level of biomarkers in one or more of the groups identifies a subject as having or having a propensity to develop neoplasia; identifies a subject as having a reduced or increased chance of survival; identifies a therapy as effective; or identifies a neoplasia as more or less aggressive.

16. The method of any one of claims 1 -15, vvherein the biological sample is a biological fluid or tissue sample.

17. The method of claim 16, vvherein the biological fluid is selected from the group consisting of urine, blood, blood serum, plasma, bile, fecal aspirate, intestinal aspirate, cerebrospinal fluid and saliva.

] 8. The method of any one of claims 1 -17, further comprising measuring the level of carnitine in the biological sample.

19. The method of any one of claims 1-18, wherein a decrease in the level of carnitine in a biological sample that is a biological fluid identifies a subjeci as having or having a propensity to develop neoplasia; identifies a subjeci as having a reduced chance of survival; or identifies a neoplasia as aggressive.

20. The method of any one of claims 1 -18, wherein an increase in the levei of carnitine in a biological sample that is a biological fluid identifies a subject as having an increased chance of survival; identifies a therapy as effective; or identifies a neoplasia as less aggressive.

21 , The method of any one of claims 1 -18, wherein an increase in the level of carnitine in a biological sample that is a tissue sample identifies a subject as having or having a propensity to develop neoplasia identifies a subject as having a reduced chance of survival; or identifies a neoplasia as aggressive.

22. The method of any one of claims 1 -38, wherein a decrease in the level of carnitine in a biological sample that is a tissue sample identifies a subject as having an increased chance of survival; identifies a therapy as effective; or identifies a neoplasia as less aggressive.

23. The method of any one of claims 1 -22, wherein the neoplasia is colorectal cancer, small intestine cancer, duodenal cancer, gastric cancer, pancreatic cancer, liver cancer, esophageal cancer, ovarian cancer, prostate cancer, uterine cancer, breast cancer, thyroid cancer or melanoma.

24. A method for identifying a subject as having or having a propensity to develop colorectal cancer, the method comprising:

identifying an increased level of a combination of two or more biomarkers in a biological sample derived from the subject relative to the level present in a reference, wherein at least one btomarker is selected from the group of biomarkers related to methylation comprising asymmetric-dimethylarginine, symmetric-dirnelhylarginine, carnitine, methionine, dimethylgiycine, and betaine and at least one additional marker is selected from a group from among the following: biomarkers related to nucleic acid metabol ism comprising xanthosine, inosine, deoxyuridme, thymid ine, deoxycytidine, cytosine, hypoxanthine, xanthine, uracil, guanosine, and adenosine;

biomarkers related to urea cycle and polyamine metabol ism comprising N l - acetylspermidine, N8-acetylsperm idine, spermine, arginine ornithine, and citrullsne;

biomarkers related to amino acid metabolism comprising proline, giuiamine, glutamic acid, threonine, and Na-aeetyl lysine; and

M264 (p-D-Ribofuranosylcreatine),

wherein an increase in said levels of two or more biomarkers identities a subject aa having or having a propensity to develop neoplasia.

25. The method of claim 24, wherein the groups are selected from the following:

biomarkers related to nucleic acid metabol ism comprising xanthosine, inosine, deoxyuridine, and thymidine;

biomarkers related to polyamine metabolism comprising N 1 -acetylspermidine, N8- acetylspermidine, and spermine; and

biomarkers related to amino acid metabolism comprising proline, giuiamine, and a- acetyllysine.

26. The method of any one of claims 1 -25, wherein the neoplasia comprises a mutation in APC or a Wnt signaling pathway protein.

27. The method of any one of claims 1 -26, further comprising detecting a mutation in APC or a Wnt signal ing pathway protein,

28, The method of any one of claims 1 -27, wherein the level of the biomarker is increased 1 .5, 2, 2.5, 3, 3.5, 4, 5, 6, 7, 8, 9, 10, 1 1 , 12, 13, 14, 1 5-fold or more relative to the reference.

29. The method of any one of claims 1 -28, wherein the reference is a control or a corresponding biological sample derived from a healthy subject.

30, The method of any one of claims 1 -29, wherein the the ieve! of the biornarker is normalised to the level of creatinine in the sample, absolute concentration, 24-hr excretion, or with respect to specifi gravity.

31 . The method of claim 24, comprising measuring the level of the M264 biornarker.

32, The method of any one of claims 1 -31 , wherein the biornarker level is detected by chromatography, mass spectrometry, spectroscopy, or immunoassay.

33. The method of claim 32, wherein the chromatography is ultra performance liquid chromatography (UPLC).

34. The method of claim 32, wherein the mass spectrometry is e!ectrospray ionization quadruple time-of-fitght mass spectrometry (ESi-QTF- S).

35. The method of claim 32, wherein the spectroscopy is NMR spectroscopy.

36. The method of claim 32, wherein the immunoassay is ELiSA.

37. A method for identifying a subject as having or having a propensity to develop neoplasia, the method comprising:

(a) measuring the level of a combination of two or more biomarkers in a biological sample derived from the subject relative to the level present in a reference, wherein a first biornarker is selected from a first group and at least one additional marker is selected from a different group, wherein the groups are selected from among the following:

biomarkers related to nucleic acid metabolism comprising xanthosine, inosine, deoxvuridine, thymidine, deoxycytidine, cytosine, hypoxanthine, xanthine, uracil, guanosine, and adenosine;

biomarkers related to urea cycle and polyamine metabolism comprising N l - acetylspermidine, NS-acety!spermidine, spermine, arginine ornithine, and citrulline; biomarkers related to amino acid metabolism comprising proline, glutamine, glutamic acid, threonine, and Na-acetyliysine; and

M264 (β-D-Ribofuranosyicreatine), and

(b) correlating the measurements of the level of the measured biomarkers with the subject having neoplasia or the subject having a propensity to develop neoplasia.

38. The method of claim 37, wherein the groups are selected from the following:

biomarkers related to methylation comprising asymmetric-dimethylarginine and symmetnc-dimethylarginine;

biomarkers related to polyamine metabolism comprising N l -acetylspermidine, N8- acetylspermidine, and spermine; and

39. The method of c!aim 37 or 38, wherein the subject is identified as having or having a propensity to develop neoplasia when the level of a biomarker related to methylation is increased relative to a reference.

40. A method for determining the prognosis of neoplasia in a subject, the method comprising:

(a) measuring the level of a combination of two or more biomarkers in a biological sample derived from the subject relative to the level present in a reference, wherein a first biomarker is selected from a first group and at least one additional marker is selected from a different group, wherein the groups are selected from among the following:

biomarkers related to urea cycle and polyamine metabolism comprising N l- acetylspermidine, N8-acetylspermidine, spermine, arginine ornithine, and ciirui!ine;

-l ot - biomarksrs related to amino acid metabolism comprising proline, g!utamine, glutamic acid, threonine, and N -acetyiiysine; and

M264 (β-D-Rihofuranosylcreatine), and

(b) correlating the measurements of the level of the measured biomarksrs with the prognosis of neoplasia in the subject.

41 , The method of claim 40, wherein the groups are selected from the following;

biomarkers related to poiyamine metabolism comprising N l -acetylspermidine, 8- acetylspermidine, and spermine; and

biomarkers related to amino acid metabolism comprising proline, giutam ine, and Ncx- acetyllysine.

42. The method of claim 40 or 41, wherein the subject is identified as having a reduced chance of survival when the level of a biomarker related to methyiation is increased relative to a reference.

43. The method of claim 42, wherein the subject is identified as having an increased chance of survival when the level of a biomarker related to methyiation is decreased relative to a reference.

44, A method for monitoring neoplasia therapy in a subject, the method comprising:

biomarkers related to methyiation comprising asymmetric-dimethylarginine, symmetric-dimethylarginine, carnitine, methionine, dimethylglycine, and betaine; biomarkers related to nucleic acid metabolism comprising xanthosine, inosine, deoxyuridine, thymidine, deoxycytidine, cytosine, hypoxanthine, xanthine, uracil, guanosine, and adenosine;

biomarkers related to urea cycle and polyamine metabolism comprising l- acetylspermidine, N8~acetylspermidtne, spermine, arginine ornithine, and citrulline;

biomarkers related to amino acid metabolism comprising proline, glutamine, glutamic acid, threonine, and c -acetyllysine; and

M264 (β-D-Ribofuranosylcreatine), and

(b) correlating the measurements of the level of the measured biomarkers to thereby monitor neoplasia therapy in the subject,

45, The method of claim 44, wherein the groups are selected from the following;

biomarkers related to polyamine metabolism comprising N l -acetylspermidine, N8- acetyispermidine, and spermine: and

46, The method of claim 44 or 45, wherein a therapy that reduces the level of asymmetric-dimethylarginine and symmetric-dimethylarginine relative to a reference is identified as effective.

47, A method for characterizing the aggressiveness of a neoplasia in a subject, the method comprising:

biomarkers related to methylation comprising asymmetric-dimethylarginine, symmetric-dimethylarginine, carnitine, methionine, dimethylglycine, and betaine; biomarkers related to nucleic acid metabolism comprising xanthosine, inosine, deoxyuridine, thymidine, deoxvcytidine, cytosine, hypoxanthine, xanthine, uracil, guanosirte, and adenosine;

biomarkers related to urea cycle and polyamine metabolism comprising Nl - acetyispermidine, N8-acetylspermidine, spermine, arginine ornithine, and citrulline;

biomarkers related to amino acid metabolism comprising proline, giutamine, glutamic acid, threonine, and N -acetyllysine; and

M264 (β-D-Ribofuranosylcreatine), and

(b) correlating the measuremen ts of the level of the measured biomarkers to thereby characterize the aggressiveness of the neoplasia in the subject,

wherein an increased level of a biomarker related to methylation relative to a reference, identifies the neoplasia as aggressive, and a decreased level of a biomarker related to methylation relative to a reference identifies the neoplasia as less aggressive,

48. The method of claim 47, wherein the groups are selected from the following;

biomarkers related to methylation comprising asy nmetric-dimethy!arginine and symmetric-dimethyiarginine;

biomarkers related to polyamine metabolism comprising N l -acetyispermidine, N8- acetylspermidine, and spermine; and

biomarkers related to amino acid metabolism comprising proline, giutamine, and Na- acetyllysine,

49. The method of any one of claims 37-48, further comprising measuring the level of biomarkers in one or more groups consisting of: biomarkers related to methylation, biomarkers related to polyamine metabolism, and biomarkers related to amino acid metabolism.

50. The method of any one of claims 37-48, further comprising measuring the level of M264 (β-D-Ribofuranosylcreatme).

51 . The method of claims 37-50, wherein an increase or decrease in the ievel of biomarkers in one or more of the groups identifies a subject as having or having a propensity to develop neoplasia; identifies a subject as having an increased or reduced chance of survival; or identifies a neoplasia as more or less aggressive,

52. The method of any one of claims 37-51 , wherein the biological sample is a biological fluid or tissue sample.

53. The method of claim 52, wherein the biological fluid is selected from the group consisting of urine, blood, blood serum, plasma, bile, fecal aspirate, intestinal aspirate, cerebrospinal fluid, and saliva.

54. The method of claims 37-53, further comprising measuring the level of carnitine in the biological sample.

55. The method of claims 37-54, wherein a decrease in the level of carnitine in a biological sample that is a biological fluid identifies a subject as having or having a propensity to develop neoplasia; identifies a subject as having a reduced chance of survival; or identifies a neoplasia as aggressive.

56. The method of claims 37-54, wherein an increase in the level of carnitine in a biological sample that is a biological fluid identifies a subject as having an increased chance of survival; identifies a therapy as effective; or identifies a neoplasia as less aggressive.

57. The method of c laims 37-54, wherein an increase in the level of carnitine in a biological sample that is a tissue sample identifies a subject as having or having a propensity to develop neoplasia; identifies a subject as having a reduced chance of survival; or identifies a neoplasia as aggressive.

58. The method of claims 37-54, wherein a decrease in the level of carnitine in a biological sample that is a tissue sample identifies a subject as having an increased chance of survival; identifies a therapy as effective; or identifies a neoplasia as less aggressive.

59. The method of any one of ciaims 37-58, wherein the neoplasia is colorectal cancer, small intestine cancer, duodenal cancer, gastric cancer, pancreatic cancer, liver cancer, esophageal cancer, ovarian cancer, prostate cancer, uterine cancer, breast cancer, thyroid cancer or melanoma.

60. A method for identifying a subject as having or having a propensity to develop colorectal cancer, the method comprising:

(a) measuring the level of a combination of two or more biomarkers in a biological sample derived from the subject relative to the level present in a reference, wherein at least one biomarker is selected from the group of biomarkers related to methylation comprising asymmetric-dimethyiarginine, symmetric-dimethylarginine, carnitine, methionine, dimeihylglycine, and betaine. and at least one additional marker is selected from a group from among the fol lowing:

biomarkers related to urea cycle and polyamine metabolism comprising N l - acetylspermidine, N8-acetylspermidine, spermine, arginine ornithine, and citrulline;

biomarkers related to amino acid metabolism comprising proline, glutamine, glutamic acid, threonine, and Nct-acetyilysine; and

M264 (β-D-Ribofuranosylcreatine), and

(b) correlating the measurements of the le vel of the measured biomarkers with the subject having neoplasia or the subject having a propensity to develop neoplasia,

wherein the subject is identified as having or having a propensity to develop neoplasia when the level of a biomarker related to methylation comprising asymmetric- dimethyiarginine, symmetric-dimethylarginine, carnitine, methionine, dimeihylglycine, and betaine is increased relative to a reference.

61 . The method of claim 60, wherein the groups are selected from the following:

biomarkers related to nucleic acid metabolism comprising xanthosine, inosine, deoxyuridine, and thymidine; biomarkers related to polyamine metabolism comprising Nl -acetylspermidine, N8- acetylspermidine, and spermine; and

62. The method of any one of claims 37-61 , wherein the neoplasia comprises a mutation in APC or a Wnt signaling pathway protein,

63. The method of any one of claims 37-62, further comprising detecting a mutation in APC or a Wnt signaling pathway protein,

64. The method of any one of claims 37-63, wherein the level of the biomarker is increased 1.5, 2, 2,5, 3, 3.5, 4, 5, 6, 7, 8, 9, 10, 1 1. 12, 13, 14, 15-fold or more relative to the reference.

65. The method of any one of claims 37-64, wherein the reference is a controi or a corresponding biological sample derived from a healthy subject.

66. The method of any one of claims 37-65, wherein the the level of the biomarker is normalized to the level of creatinine in the sample, absolute concentration, 24-hr excretion, or with respect to specific gravity.

67. The method of any one of claims 37-66, wherein the subject is human.

68. The method of any one of claims 37-67, wherein the level is detected by

chromatography, mass spectrometry, spectroscopy, or immunoassay.

69. The method of claim 68, wherein the chromatography is ultra performance liquid chromatography (UPLC).

70. The method of claim 68, wherein the mass spectrometry is electrospray ionization quadruple time-of-flight mass spectrometry (ESI-QTF-MS).

71 . The method of claim 68, wherein the spec troscopy is NMR spectroscopy.

72. The method of claim 68, wherein the immunoassay is ELISA,

73. A kit for aiding the diagnosis of neoplasia or colorectal cancer, the kit comprising at least one reagent capable of detecting, binding, or capturing a first biomarker selected from a first group and at least one reagent capable of detecting, binding, or capturing at least one additional marker selected from a different group, wherein the groups are selected from among the following:

biomarkers related to methyiation comprising asymmetric-dimethy!arginine, symmetric-dimethylarginine, carnitine, methionine, dimethylglycine, and betaine;

biomarkers related to urea cycle and polyamine metabolism comprising Nl - acetylspermidine, N8-acetylspermidine, spermine, arginine ornithine, and citriiHine;

biomarkers related to amino acid metabolism comprising proline, glutamine, glutamic acid, threonine, and Να-acety!lysine; and

M264 (β-D-Rtbofuranosyicreatine).

74. The kit of claim 73, wherein the groups are selected from the following:

biomarkers related to po!yamine metabolism comprising N l -acetylspermidine, N8- acetylspermidine, and spermine; and

biomarkers related to amino acid metabolism comprising proline, glutamine, and Net- acetyilysine.

75. A kit for aiding the diagnosis of neoplasia or colorectal cancer, the kit comprising at least one reagent capable of detecting, binding, or capturing at least one biomarker selected from the group of

biomarkers related to methvlation comprising asymmetric-dimethy!arginine, symmetric-dimethylargirtine, carnitine, inethionine, dimethylg!ycine, and beiaine; and

at least one reagent capable of detecting, binding, or capturing at least one additional marker selected from a group from among the following:

biomarkers related to urea cycle and poiyamine metabolism comprising l - acetylspermidine, N8-acetylspermidine, spermine, arginine ornithine, and citruliine;

biomarkers related to amino acid metabolism comprising proline, glutamine, glutamic acid, threonine, and -acetyllysine; and

M264 (β-D-Ribofuranosylcreatine).

76. The kit of claim 75, wherein the groups are selected from the following;

biomarkers related to methvlation comprising asyrnmetric-diniethylarginine and symmetric-dimethy!arginine;

biomarkers related to poiyamine metabolism comprising M l -acetylspermidine, N8- acetylspermidine, and spermine; and

77. A kit for aiding the diagnosis of neoplasia or colorectal cancer, the kit comprising at least one reagent capable of detecting, binding, or capturing asymmetric-dimetbyiarginine and at least one reagent capable of detecting, binding, or capturing symmetric- dimethylarginine.

78. The kit of any one of claims 73-77, further comprising at least one reagent capable of detecting, binding, or capturing proline, glutamine, Na-acely)lysine, xanthosine, inosine, deoxyuridine, thymidine, Nl -acetylspermidine, N8-acetyispermidtne, spermine, carnitine, or a combination of reagents thereof,

79. The kit of any one of claims 73-78, wherein the kit further comprises directions for using the reagent to analyze the level of asymmetric-dimethylarginine, symmetric- dimethyiarginine, carnitine, proline, glutamine, Na-acetyllysine, xanthosine, inosine, deoxyiiridine, thymidine, l -acetylspermidine, N8-aeeiylsperniidine, spermine, and M264 (β-D-Riboftiranosylcreatine), or a combination thereof.

80. The kit of any one of claims 73-79, wherein the kit comprises directions for contacting a test sample with the reagent and detecting the M264 biomarker,

81 . A panel for aiding the diagnosis of neoplasia or colorectal cancer, the panel comprising at least one reagent capable of detecting, binding, or capturing a first biomarker selected from a first group and at least one reagent capable of detecting, binding, or capturing at least one additional marker selected from a different group, wherein the groups are selected from among the following;

biornarkers related to methylation comprising asymmetric-dimethylarginine, symmetric-dimethylarginine, carnitine, methionine, dimeihylgiycine, and betaine;

biornarkers related to nucleic acid metabolism comprising xanthosine, inosine, deoxyuridine, thymidine, deoxycytidine, cytosine, hypoxanthine, xanthine, uracil, guanosine, and adenosine;

biornarkers related to urea cycle and polyamine metabolism comprising N l - acetyispermidine, N8-acetylspermidine, spermine, arginine ornithine, and citru!iine;

biornarkers related to amino acid metabolism comprising proline, glutamine, glutamic acid, threonine, and Na-acetyl lysine; and

M264 (β-D-RibofuranosyIcreatine).

82. The panel of claim 81 , wherein the groups are selected from the following:

biornarkers related to methylation comprising asymmetric-dimethylarginine and symmetric-dimethylarginine;

biornarkers related to nucleic acid metabolism comprising xanthosine, inosine, deoxyuridine, and thymidine; biomarkers related to polyamine metabolism comprising M l -acetylspermidine, N8- acetylspermidine, and spermine; and

biomarkers related to amino acid metabolism comprising proline, giutamine, and Να- acetyllysine.

83. A panel for aiding the diagnosis of neoplasia or colorectal cancer, the panel comprising at least one reagent capable of detecting, binding, or capturing at least one biomarker seiected from the group of biomarkers related to metbylation comprising asymmetric-dimethylargmine, symmetrie-dimethylarginine, carnitine, methionine, dimethy!glyeine, and betaine;

and at least one reagent capable of detecting, binding, or capturing at least one additional marker selected from a group from among the following:

biomarkers related to nucleic acid metabolism comprising xanthosine, inosine, deoxyuridine, thymidine, deoxycvtidine, cytosine, hypoxan thine, xanthine, uracil, guanosine, and adenosine;

biomarkers related to urea cycle and polyamine metabolism comprising Nl - acety!spermidine, N8-acetylspermidine, spermine, arginine ornithine, and citruiline;

biomarkers related to amino acid metabolism comprising proline, giutamine, glutamic acid, threonine, and Nu-acetyilysine; and

M264 (β-D-Ribofuranosylcreatine).

84. The panel of claim 83, wherein the groups are selected from the following;

biomarkers related to methyiation comprising asymmetric-dimethylarginine and symmetrie-dimethylarginine;

biomarkers related to amino acid metabolism comprising proline, giutamine, and Na- acetyliysine.

-I l l-

85. A panel for aiding the diagnosis of neoplasia or colorectal cancer, the panel comprising at least one reagent capable of detecting, binding, or capturing asymmetric- dimethylargmine and at least one reagent capable of detecting or capturing symmetric- dirnethy!arginine.

86. The panel of any one of claims 81 -85, wherein the reagent is one or more of an organic molecule, peptide, peptide mimetic, polypeptide, nucleic acid Hgand, aptamer, or antibody.

87. The panel of any oe of claims 81 -85, comprising at least one reagent capable of binding or capturing M264 (p-D-Ribofuranosyicreatine).