Malignant Mesothelioma Epidemiology and molecular biology

Transcription

1 Malignant Mesothelioma Epidemiology and molecular biology Oluf Dimitri Røe, MD, PhD Assoc Prof. Levanger Hospital Department of Cancer Research and Molecular Medicine Norwegian University of Science and Technology (NTNU) Trondheim Norway Aalborg University Hospital, Denmark

2 No disclosures

3 Short CV My name: Oluf Dimitri Røe Trondheim, Norway/ Mykonos, Greece 10 years GP 15 years Oncology PhD on mesothelioma Now: Consultant oncologist Postdoc NTNU Ass. Prof at Aalborg University, Aalborg, Denmark Hospital 3

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5 Department of Cancer Research and Molecular Medicine Faculty of Medicine Norwegian University of Science and Technology Trondheim,Norway A day at the lab center

6 Overview Asbestos Mesothelioma Epidemiology Mesothelioma Molecular Biology Biomarkers, Early Biomarkers Cancer-Biomarker HUNT - Where are we? 6

7 One of our patients with Pleural mesothelioma A woman 42 years old The reason? She worked as a hair-dresser And used an Asbestos containing hair dryer For 10 years

8 History of Asbestos Asbestos (Greek, inextinguishable) a family of naturally occuring minerals that readily separate into thin fibers and are found in many parts of the world. Amiantus (Greek, untaintable, currently used in modern Greek for asbestos) was used by Pliny the Elder (23-79 AD) described that this was mined in the Montains of Arcadia, could be spun and woven to material and was resistant to fire [1]. The Greek geographer Strabo (63/64 BC-ca.24 AD) described similar use of the socalled Karystian stone from the ancient quarry in Evvia island of Greece Dioscorides (ca AD) described in his Materia Medica the use of this stone for for weaving napkins that could be cleaned and whitened by fire [1].

9 History of Asbestos In Finland, asbestos was used in pottery 4500 years ago In Norway, bucket-shaped pottery tempered with crushed asbestos was used for storing and making food in the Late Roman and Migration periods (c AD) [2]. Marco Polo ( AD) also described asbestos mining in China [3]. 1. Dilek Y, Newcomb S, Geological Society of America. Meeting (2003) Geological Society of America. xii, 504 p. p. 2. Engevik A (2008) Oxford: Archaeopress. xiv, 240 p. p. 3. Rapp GR (2009) Archaeomineralogy. Berlin ; London: Springer. xv, 348 p. p. 9

10 Bucket-shaped pottery contains 20-25% clay and 65-80% asbestos Norway, AD

11 Mesothelioma etiology: asbestos inhalation WHO and the IARC monograph (2012) all types of asbestos: class I carcinogens Crocidolite Amosite Anthrophyllite Chrysotile

12 History of Asbestos Massive production and use started in the 20th century, due to its properties as insulation against heat, fire, corrosion and its tensile strenght. Asbestos was widely used for insulation of water- and combustion pipes, materials used for house construction and shipbuilding, car brakes and gaskets, even toys, jewellery, and cigarette filters, At its peak, 3000 products were registered 12

13 Norway Denmark Sweden AC Trends of asbestos consumption in metric tons based on Worldwide Asbestos Supply and Consumption Trends from 1900 through 2003 by Robert L. Virta

14 World Europe Former Soviet Union USA AC Trends of asbestos consumption in metric tons based on Worldwide Asbestos Supply and Consumption Trends from 1900 through 2003 by Robert L. Virta

15 mill tonn asbestos mined in countries. Russia 50% China 20% Brazil 12% Kazakhstan 10% Canada stopped 2013

16 A meso epidemic is coming in the 3 rd World...

17 Asbestos consumption in Denmark Metric tons År 17

18 Mesothelioma incidens i North Jutland: 5/ fold incrase in 4 decades ( ) and increasing MM tilfælde År Panou V, Meristoudis C, Røe OD. 26 th European Pathology Congress, London

19 Asbestos exposure in North Jutland Types of asbestos exposure for females with MM 20% 20% 46% DOMESTIC ENVIRONMENTAL OCCUPATIONAL UNCERTAIN 14% Panou V, Omland Ø, Langhoff MD, Meristoudis C, Weinreich UM, Røe OD. 12 th International Mesothelioma Conference, Cape Town

20 Overrepresentation of Peritoneal Mesothelioma in Women Females with MM MM in pleura MM in peritoneum 20% Males with MM 9% MM in pleura MM in peritoneum 80% 91% Panou V, Omland Ø, Vyberg M, Røe OD. 12 th International Mesothelioma Conference, Cape Town

21 Type of asbestos exposure and location of mesothelioma in women MPM and types of asbestos exposure MAM and types of asbestos exposure 15% primary 29% primary 85% secondary 71% secondary Panou V, Omland Ø, Meristoudis C, Hoffmann L, Røe OD. Abstract submitted to the 16 th World Conference on Lung Cancer, Denver

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23 Asbestos and Malignant Mesothelioma Mainly by asbestos inhalation first documented by Dr. Wagner, South Africa, 1960 Both pleural and peritoneal mesothelioma is induced by asbestos inhalation Risk of mesothelioma is dependent on dose and duration of asbestos inhalation, but there is no lower limitone fiber can be enough Occupational exposure heavily exposed- max 10% got mesothelioma Several occupations with low exposure but still risk (plumber, carpenter, car mechanic.) 23

24 Asbestos and Malignant Mesothelioma Non-occupational exposures with known risk Second-hand exposure- Wife cleaning dusty clothes of husband or son, children indirectly exposed Langhoff et al Dan Med J Neighborhood exposure- living by an asbestos plant In Italy in Casale Monferrato (Eternit) and Bari (Fibronit) Risk- OR 10 and 5.25 (<500m from factory) respectively Barbieri et al Ann Occup Hyg 2012 Environmental exposure- asbestos or similar minerals in the soil Greece, Turkey, China, USA, Italy 24

25 Denmark Aalborg Eternit factory used asbestos from Cyprus The Danish Company bought and drifted the Amiantos mine in Cyprus In Aalborg Path.Dept. 436 mesotheliomas from In Cyprus unknown number of mesotheliomas

26 Environmental exposure 50% of the mortality was of mesothelioma In the Karain village Genetical tendency? One village was moved! Cappadocia in Turkey, Erionit and Asbestos on the earth surface

27 Other possible causes Confirmed: The contrast medium Thorotrast- alpha- emitter (not in use any more) Secondary cancer many years after thorax-peritoneal irradiation for lymphoma, testicular cancer and breast cancer. Hypothetical: SV40 virus- contaminated poliovaccine? 27

28 Future challenges: Carbon nanotubes are already widely used have recently shown carcinogenic properties in vitro and in vivo The regulatory framework is not restrictive enough before letting these compounds into production The asbestos of the future? Stella, Biointerphases 2011

29 Incidence There are no reliable world-wide statistics on mesothelioma 0-6 cases / ,000-20,000 deaths / year, very unreliable figures, lack of registries USA 4000 / year UK 2200 / year Denmark 120 / year Western Australia had the highest incidence but North-Jutland in Denmark among highest in the world (5/ ) In Aalborg cases yearly Our first report linking asbestos with mesothelioma with asbestos from mainland China is now in press Zhibin Gao, Kenzo Hiroshima, Oluf D. Røe, Xing Zhang, Kenji Morinaga Asbestos textile production linked to malignant peritoneal and pleural mesothelioma in women: Analysis of 28 cases in Southeast China American Journal of Industrial Medicine, May

30 Malignant Mesothelioma Facts Latency from asbestos exposure cancer median 40 years Diagnosis is often challenging and Patients are rarely diagnosed in an early stage Pleural Mesothelioma has 12 months median survival with pemetrexed/platinum chemotherapy 5-years overall survival 0-5% 30

31 Schematic presentation of mesothelioma, the parietal and visceral pleura. Representative histology showing the most abundant cell types. Parietal pleura (Mesothelial cells stain dark brown) Mesothelium Vascular endothelium Stroma with Fibrocytes, fibroblasts and collagen Fat cells Alveolar cells Mesothelioma with >80% tumour cells (brown) Visceral pleura

32 Pleural plaque and mesothelioma start in the parietal pleura Parietal and visceral pleura serve different functions

33 Mesothelioma pathophysiology Asbestos inhalation Asbestos fibers ----->Lung---->Pleura /Peritoneum ----->Cytotoxicity ----->DNA-damage--->Chronic inflammation----->mesothelioma (Latency yrs, median 40 yrs) multiple deletions eg. p16 (CDKN2A), NF2-Merlin Inactivation of p53 and prb but rarely mutation Differential gene (mrna) expression Differential DNA methylation Differential microrna expression 33

34 Asbestos effects on mesothelium Clastogenic and cytotoxic in vitro Abnormal segregation at mitosis Deletions in 1p, 3p21, 6q, 9p21, 15q11-15, 22q Promoter hypermethylation at tumor suppressor loci

35 Known molecular changes in mesothelioma AP-1 transcriptional activity and NF-kB signaling pathway have been linked to mesothelial cell transformation and tumor progression. HGF and c-met are highly expressed PI3K, AKT and the downstream mtor are involved in cell growth and survival and are often found to be activated p16ink4a and p14arf are frequently inactivated and approximately 50% contain NF2 mutation

36 Crocidolite fiber inhibits microvilli formation in the mesothelial cell Chrysotile fibers entangle In lung cancer cell division Lung cancer from asbestos exposed patient with distinct gain of 2p21(B) and loss of 2p16 (C)

37 mrna expression of mesothelioma

38 Early Microarray studies-classifiers Lopez-Rios, Cancer Res 2006

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40 Partial least square analysis (PLS) Every spot is the sum of gene expression i a biological sample related to the other samples. PV PP T

41 DNA repair pathways are differentially expressed DNA repair systems Repairs HR (homologous recombination) Double-strand break (DSB) NHEJ (non-homologous end joining) Single and DSB (error-prone) MMR (mismatch repair) BER (base excision repair) NER (nucleotide excision repair) Base mismatches Wrong/defect bases Wrong/defect nucleotides 41

42 CHEMOTHERAPY IRRADIATION TELOMERE MAINTENANCE DAMAGE RESPONSE CHEK1 DNA RAD50 ICL DSB RAD50 SURVIVAL VARIOUS INHIBITORS TOP2A UHRF1 S/G2 CELL CYCLE ARREST RAD21 RAD18 CURCUMIN RAD50 RAD51AP1 RAD54L EME1 BCCIP BRCA2/FANCD1 FANCA FANCF HR FANCI FANCD2 UBE2V2 SHFM1 NHEJ XRCC4 CIB1/DNA-PK NATURAL VANILIN RAD50 RAD18 BORTEZOMIB MMR BER/SP BER/LP NER PCNA PCNA PCNA MSH6 CCNO/Ung2 FEN1 GTF2H2/p44 13 PROTEASOME GENES

43 Searching for molecular resistance mechanisms in the individual patient

44 One of our cases of Pleural mesothelioma A woman 42 years old 3 rd line Alimta Carbo 39 courses Biopsy before and after resistance >5 years later Genome-wide mrna expression

45 Gene expression- average signal Genes changed m ore than 2 -fold after resistance Change down Change up Expression before Expression after SPARCL1 SPARCL1 I GFBP7 I TM2 A SEPP1 FSTL1 SRPX SOX1 8 CXCL1 2 DCN CRTAP OSR1 CLDN 1 CCL1 5 OGN SNAI 2 CMBL PCOLCE2 ZFP3 6 L2 ADD3 C4 orf1 8 CAV2 I L3 3 BCHE GPR1 7 7 PMP2 2 ECM2 LOC Gene sym bols KRT7 EEF1 A2 PI TX1 COMP MYOM2 SDC1 DAPL1 SYNPO2 L COL1 0 A1 MMP3 GUCY1 B2 HFE2 0

46 Tumour before resistance (above) and at acquired resistance (below) CHEK1 TYMS NQO1 CK7 TYMP SPARCL1

47 Cell cycle changes in tumour versus normal and in acquired resistance.

48 Next-generation sequencing

49 Transcriptome/second generation sequencing of mesothelioma 15 new mutations were discovered in 4 mesothelioma patients All had a different mutational profile Sugarbaker et al PNAS 2007 Bueno et al PlosOne 2010 Significant aneuploidy and numerous translocations Novel, large-scale, inter- and intra-chromosomal deletions, inversions, and translocations. Nearly all candidate point mutations appeared to be previously unknown SNPs. Thirty tumor-specific fusions/translocations were independently validated with PCR and Sanger sequencing Take home message: the deeper you search the more complex and individual changes you find

50 Methylation and micrornas EPIGENETICS OF MESOTHELIOMA

51 DNA methylation distinguishes mesothelioma, adenocarcinoma and normal lung and pleura Christensen et al Cancer Res 2009

52 microrna expression of mesothelioma

53 microrna origins from non-coding or junk-dna

54 microrna facts >1800 have been discovered One microrna can regulate several hundred genes One gene can be regulated by many microrna Can act as tumor suppressors and oncogenes Can classify tumors Can show cancer risk Diagnostic/prognostic/predictive markers potential microrna are stable in body fluids and tumors and easy to measure by PCR 54

55 Detection and analysis of cancer-specific microrna expression patterns

56 microrna in tumour can be used for differential diagnosis of mesothelioma versus other carcinomas Benjamin et al, J Mol Diagn November; 12(6):

57 microrna in serum for diagnosing mesothelioma Increased circulating mir-625-3p was found to be a potential biomarker for patients with malignant pleural mesothelioma. Kirschner et al, J Thorac Oncol Jul;7(7):

58 microrna can be a prognostic marker of mesothelioma in serum Elevated hsa-mir-29c* was associated with a significantly longer TTP and survival time. Pass H I et al. Cancer Res 2010;70: by American Association for Cancer Research

59 Genetic mesothelioma syndrome BAP1(BRCA1 associated protein 1) BAP1 is a tumor supressor gene located in the 3p21 BAP1 mutations cause a new cancer syndrome characterized by mesothelioma, uveal melanoma and melanocytic tumors BAP1 is also related to other cancers like renal cancer BAP1 provides researchers with a novel target for prevention and early detection. Carbone et al Nat Rev Cancer. 2013

60 BAP1 mutation families and cancer In these two families (n=28): Mesothelioma (12) Uveal Melanoma (1) Skin cancer (2) Pancreatic cancer (1) Prostate cancer (2) Testa et al Nat Genetics 2011

61 BAP1 cancer syndrome melanocytic BAP1-mutated atypical intradermal tumors (MBAITs) or epitheloid atypical Spitz tumors Carbone et al J Transl Med 2012

62 MOLECULAR BIOMARKERS

63 Clinical Prognostic factors Epithelial vs non-epithelial types (biphasic and sarcomatous) Sex, female better prognosis Age, younger better prognosis But still we talk about differences in months 63

64 WHAT are Molecular Biomarkers? a molecule detected in body fluids or tissues that are associated with a special process (normal or abnormal), a condition or disease ( Single molecules or signatures of DNA, RNA, microrna, proteins, metabolites that may diagnose and subtype a disease prognose the natural disease path predict effect of certain treatments for this disease Ideally sensitivity and specificity higher than 80% 64

65 Why are diagnostic biomarkers problematic? Tumor types and subtypes are heterogenous Clinically Histology-Morphology Molecular Genes Epigenetic 65

66 Biomarkers for early diagnosis Most cancers have a better prognosis by early detection Non-invasive methods based on blood analysis is an ideal method Non-invasive methods with SINGLE markers have repeatedly failed (CEA, CA125, CYFRA 19-9, mesothelin, osteopontin etc etc) 66 BUT THERE IS HOPE

67 Currently the only approved blood biomarker for diagnosing and monitoring mesothelioma is mesothelin (SMRP or N-ERC) 44 Mesothelioma Patients 228 Controls 67 Robinson et al. The Lancet 2005

68 68 Studies of biomarkers in blood samples of Mesothelioma (Panou et al, Cancer Treatment Reviews May 2015)

69 Current Status There are no clinically validated, non-invasive proven diagnostic markers for mesothelioma with high sensitivity and specificity Translational research urgently needed!! 69

70 Studies of microrna in pre-diagnostic blood samples of Mesothelioma ZERO studies Studies only reached phase 2 of biomarker discovery and validation 70

71 Our project Cancer-Biomarkers in HUNT: Biomarker discovery for early diagnosis of human mesothelioma and lung cancer. 間 皮 瘤 & 肺 癌 microrna regulates mrna post-translationally. Cartoon from the Illumina homepage. 71

72 72 HUNT Research Centre HUNT Biobank Levanger, Norway

73 What is HUNT HUNT is the abbreviation of Helse-Undersøkelsen i Nord- Trøndelag (Health Survey of Nord-Trøndelag County) HUNT is a prospective Population-based biobank participants (70% of the population) Serum/ DNA collected 1998 and 2007 >400 clinical parameters registered pr. patient >500 lung cancer and 30 mesothelioma cases with blood samples 1-15 years PRIOR to clinical disease 73

74 New biomarkers urgently needed Early diagnostic markers can save many lives world-wide Existing markers are not good enough or not validated for early diagnosis MicroRNA sequencing, metabolomics and proteomics of serum has not been combined and may identify unknown new markers Golden opportunity- we have the precious pre-clinical samples in the prospective HUNT biobank We identify those who got lung cancer or mesothelioma through linking to the cancer registry and identify matched samples (sex, age, smoke history, no cancer 74

75 75 What is Cancer-Biomarker-HUNT

76 Mesothelioma Cancer-Biomarker HUNT: From clinical samples to biomarkers Clinical data collection Clinical history Biomarkers Physical exams Results collection Exams results Combined Clinical information and Validation Biological sample collection Serum/blood sample Tissue sample Nucleic acid extraction RNA DNA microrna/ mrna Epigenetics DNA Methylation Bioinformatics analyses Serum&samples&collected&and&accumulated&Mesothelioma& cases , ,000 25,000 20,000 15,000 10,000 5,000 0

77 Techniques used in this study Next Generation Sequencing (NGS) -can detect 2000 micrornas Magnetic Resonance Spectrometry (MRS) -can detect 40 metabolites MS Metabolomics -can detect 1500 metabolites 77 MS Proteomics -can detect 1000 proteins

78 Is this study different? Probably the first study with up-to-date, comprehensive high-throughput analysis of different classes of molecules in the same pre-diagnostic samples Relations between microrna, proteins AND metabolites has been little studied, especially in SERUM 78

79 Next-Generation sequencing (NGS) of serum microrna (Illumina) Small RNA sequencing is a powerful application, enabling the discovery and profiling of micrornas and other non-coding RNA, without prior genome annotation Using low RNA inputs, one can profile the differential expression of known micrornas, as well as detect novel microrna targets and wide-ranging sequence variation or "isomirs" mirbase accessions Illumina's small RNA sequencing methods enable accurate detection and quantification of rare small RNA sequences 79

80 RNA isolation and library preparation RNA was isolated from 100 ul serum MicroRNA sequencing libraries were generated using the Illumina TruSeq small RNA Sample prep kit. Marker Small RNAs Ribosomal RNAs 80

81 MR based serum metabolomics Use 100microl serum Avance III 600MHz for proton Equipped with a QCI cryoprobe (for increased sensitivity) and a Bruker SampleJet (for automation) > 40 small molecular metabolites can be quantified (Chenomx) MR Core Facility, NTNU:

82 82 Orbitrap - MS proteomics and metabolomics

83 Proteomic approach Tryptic digestion of proteins, lyophilization and reconstitution for LC-MSMS Serum depletion using Mars Hu-14 (Agilent) for removal of the 14 most abundant proteins in Serum Metabolomic approach Protein precipitation using cold methanol and centrifugation Lyophilization and reconstitution for LC-MSMS Mass spectrometry for ID and/or (metabolomics) relative quantitation at PROMEC, NTNU

84 84 We correlate serum micrornas with proteomics and metabolomics

85 How to analyze huge amounts of data from 3-4 datasets? Comprehensive data analysis by a group of dedicated bioinformaticians (University of Crete, Prof. Tsamardinos) Using novel bioinformatics methods mine data for diagnostic signatures pathways and combinations Search for biological meaning Chemosensitivity Prediction of Tumours Based on Expression, mirna, and Proteomics Data I. Tsamardinos 1, 2, G. Bor boudakis 1, 2, E. G. Christodoulou 3, O. D. Røe 4, 5 1 Bioinformatics Laboratory, ICS-FORTH, Heraklion, Crete, Greece 2 Computer Science Department, University of Crete, Heraklion, Crete, Greece 3 Cellular Networks Group, BIOTEC TU Dresden, Dresden, Germany 4 Cancer Clinic, Levanger Hospital, Nord-Trøndelag Health Trust, Levanger, Norw ay 5 Department of Cancer Research and Molecular Medicine Norwegian University of Science and Technology (NTNU), Trondheim, Norway 85

86 Conclusions I Asbestos (Greek, inextinguishable) is the term of a family of naturally occurring minerals 1960 J. C. Wagner, C. A. Sleggs and P. Marchand from South Africa linked mesothelioma to asbestos All types of asbestos are class-i carcinogens according to the WHO. Asbestos-related mesothelioma has a median lag-time from exposure to cancer of 40 years. Other etiological factors are environmental exposition to erionite, ionizing radiation and SV40 virus as a putative cofactor. Pleural mesothelioma has increasing incidence worldwide. Most mesotheliomas are of epithelial type, while the sarcomatous and biphasic types are less common. 86

87 Conclusions II early and combined markers There were no pre-clinical sample studies for mesothelioma. The complexity of tumor biology probably calls for COMBINATION MARKERS for early diagnosis including global microrna and other non-coding RNAs metabolomics proteomics Immune markers Urgent need for large-scale, multicenter studies for mirna profiling in pre-diagnostic and general population samples and cross-validation in different populations in order to determine valid mirna signatures for timely cancer diagnosis. 87

88 Conclusions III - where are we? With a limited sample size we showed that our study design can identify potential early diagnosis biomarkers for lung cancer and mesothelioma ca 3 years prior to diagnosis. Probably detect subgroups as well Differential expression in metabolites and proteins and validation studies are ongoing. 88

89 European Respiratory Journal ERR 2015

90 PUBLICATIONS ON MESOTHELIOMA 34. Zhibin Gao, Kenzo Hiroshima, Oluf D. Røe, Xing Zhang, Kenji Morinaga Asbestos textile production linked to malignant peritoneal and pleural mesothelioma in women: Analysis of 28 cases in Southeast China American Journal of Industrial Medicine, May V Panou, M Vyberg, U M Weinreich, C Meristoudis, U Falkmer, O D Røe The established and future biomarkers of malignant pleural mesothelioma Cancer Treatment Reviews, Online 8 th May Oluf D. Røe, Giulia M. Stella, Malignant pleural mesothelioma- history, controversy, and future of a man-made epidemic; review. Eur Respir Rev Mar 13. Xiao-feng Chen, Guo-qiang Ping,, Oluf Dimitri Røe, Yong-qian Shu, Ren-hua Guo, Case report: Recombinant human endostatin (endostar) decreased recurrent ascites, pleural fluid and ascitic VEGF in a case of advanced mesothelioma, J Chemother Aug 12. Oluf Dimitri Røe, Adam Szulkin, Helmut Sandeck, Endre Anderssen, Tore Amundsen, Sten Even Erlandsen, Katalin Dobra, Stein Harald Sundstrøm, Molecular Resistance Fingerprint of Pemetrexed and Platinum in a Long-Term Survivor of Mesothelioma. PLoS One Sandeck HP, Røe OD, Kjærheim K, Willén H, Larsson E. Re-evaluation of histological diagnoses of malignant mesothelioma by immunohistochemistry. Diagn Pathol Jul 4. Røe OD, Anderssen E, Sandeck H, Christensen T, Larsson E, Lundgren S. Malignant pleural mesothelioma: Genome-wide expression patterns reflecting general resistance mechanisms and a proposal of novel targets. Lung Cancer Jan 3. Oluf D. Røe, Endre Anderssen, Eli Helge, Caroline Hild Hakvaag Pettersen, Karina Standahl Olsen, Helmut Sandeck, Rune Haaverstad, Steinar Lundgren, Erik Larsson, Genome-wide profile of pleural mesothelioma versus parietal and visceral pleura: The emerging gene portrait of the mesothelioma phenotype. PLoS One Aug 2. Røe OD, Creaney J, Lundgren S, Larsson E, Sandeck H, Boffetta P, Nilsen TI, Robinson B, Kjaerheim K. Mesothelin-related predictive and prognostic factors in malignant mesothelioma: A nested case-control study. Lung Cancer Aug 1. Kjaerheim K, Røe OD, Waterboer T, Sehr P, Rizk R, Dai HY, Sandeck H, Larsson E, Anderssen A, Boffetta P, Pawlita M. Absence of SV40 antibodies or DNA fragments in prediagnostic mesothelioma serum samples. Int J Cancer Jun

91 Acknowledgements/Collaborators Norwegian University of Science and Technology (NTNU), Norway The HUNT research center Head Prof. Kristian Hveem Dept of Cancer Research and Molecular Medicine, Prof. Hans Krokan Prof Frank Skorpen Robin Mjelle, PhD student Lars Hagen, PhD Animesh Sharma, MD PhD Charalampis Giannadakis, MD Dept of Computers and Information Science Prof Pål Sætrom MRI-Cancer Group Prof Tone F Bathen Trygve Andeassen PhD Riyas Vettukatil, PhD University of Crete (UOC), Greece Dept of Computer Science Prof. Ioannis Tsamardinos Ass.Prof. Vincenzo Lagani Kostas Kerkentzes, PhD student Nanjing Medical University (NMU), China Prof Jianwei Zhou Wu Chen/Xiaofei Zhi PhD stud Aalborg University Hospital (AUH), Denmark Prof Ursula Falkmer Prof Hans E Johnsen Prof Mogens Vyberg Prof Øyvind Omland Overlege Christos Meristoudis Vasiliki Panou MD PhD stud/ Nikolaj A Jensen MD PhD stud Uppsala University (UU), Sweden Prof Erik Larsson

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93 Takk og god sommer