The tumor microenvironment consists of multiple cells types, including endothelial cells that line the tumor vasculature. Tumor vasculature is often abnormal and results in development of tissue ischemia, another contributing factor to the tumor microenvironment. Previous studies have demonstrated that ischemia influences epigenetic programming, but the mechanisms remained unclear and required further investigation. First, we profiled DNA methyltransferase (DNMT) expression and activity in human colorectal cancer cells (HCT116) under hypoxia or hypoglycaemia (mimicking ischemia). We found that DNMT1 and DNMT3b were significantly downregulated by hypoxia and hypoglycaemia, and DNMT3a was downregulated by hypoglycaemia. However, DNMT1 downregulation was p53-dependent. To examine if the changes in DNMT expression and activity translated to changes in DNA methylation patterns, we used bisulfite sequencing and examined the promoter region of p16. Hypoglycaemia significantly demethylated this region in both p53 wild-type and p53-null cells. Next, we used a genome-wide approach to discover what additional genes are hypomethylated by ischemia. Methylated DNA was immunoprecipitated and analysed with an Affymetrix promoter array, in parallel with an expression array. Ingenuity pathway analysis software revealed that a significant proportion of genes which were hypomethylated and upregulated were involved in cellular movement, including PLAUR and CYR61. We believe that hypoxia and hypoglycaemia may be driving changes in DNA methylation through dysregulation of DNMTs, resulting in cells acquiring a more mobile phenotype in ischemic regions. DNMT and histone deacetylase inhibitors are commonly used in research and some cancer therapies. Modifying epigenetic patterning with these inhibitors has been widely studied in cancer cells, but only briefly explored in the tumor’s vascular endothelium. We profiled the effect of these inhibitors on endothelial cell (EC) behaviour, and tested if combining them with a targeted anti-angiogenic therapy would augment the inhibition of angiogenesis. When the DNMT inhibitor 5-aza-2’-deoxycytidine was combined with sunitinib, inhibition of EC proliferation was enhanced compared to treatment with sunitinib alone. EC migration was also inhibited by the combination of these two inhibitors, but not in an additive manner. These studies have improved our understanding of how altering epigenetic patterning with ischemia and therapeutic inhibitors can influence colorectal cancer and endothelial cell behaviour. / Canadian Cancer Society Research Institute. The Cancer Research Society.

<p>Pathophysiologic lactate accumulation is characteristic of solid tumors and has been associated with metastases and poor overall survival in cancer patients. In recent years, there has been a resurgence of interest in tumor lactate metabolism. In the past, our group has shown that lactate can be used as a fuel in some cancer cell lines; however, survival responses to exogenous lactate alone are not well-described. We hypothesized that lactate utilization and cellular responses to exogenous lactate were varied and dynamic, dependent upon factors such as lactate concentration, duration of lactate exposure, and of expression of the lactate transporter, monocarboxylate transporter 1 (MCT1). We hypothesized that pharmacological inhibition of MCT1 with a small molecule, competitive MCT1 inhibitor, &#945;-cyano-4-hydroxycinnamic acid (CHC), could elicit cancer cell death in high lactate conditions typical of that seen in breast cancer. </p><p>My work focused on defining: 1. Lactate levels in locally advanced breast cancer (LABC); 2. Lactate uptake and catabolism in a variety of cancer cell lines; 3. The effect of exogenous lactate on cancer cell survival; 4. Whether the lactate-transporters, MCT1 and MCT4 can be used as markers of cycling hypoxia. </p><p>Lactate levels in LABC biopsies were assessed ex vivo by bioluminescence. NMR techniques were employed extensively to determine metabolites generated from 13C-labeled lactate. Cell viability in response to extracellular lactate ( ± glucose and ± CHC) was measured with Annexin V / 7-AAD staining to assess acute survival responses and clonogenic assays to evaluate long-term colony forming ability after lactate treatment. MCT1 and MCT4 protein expression was evaluated in cancer cell lines with Western blots after exposure to chronic or cycling hypoxia. Immunofluorescence was employed to assess MCT1 and MCT4 expression in head and neck cancer biopsies, and the expression patterns of the transporters were correlated to areas of hypoxia, as indicated by hypoxia marker EF5. </p><p>Lactate concentrations in LABC biopsied ranged from 0 - 12.3 µmol/g of tissue. The LABC dataset was too small to derive statistical power to test if lactate accumulation in LABC biopsies was associated with poor patient outcome or other clinical parameters of known prognostic significance. All cell lines tested (normal and cancer) showed uptake and metabolism of labeled lactate, with dominant generation of alanine and glutamate; however, relative rates and the diversity of metabolites generated was different among cell lines. MCF7 cells showed greater overall lactate uptake (mean = 18mM) over five days than MDA-MB-231 cells (mean = 5.5mM). CHC treatment effectively prevented lactate uptake in cancer cells when lactate concentrations were &#8804;20mM. </p><p>Cell survival was dependent upon lactate concentration and glucose availability. Acute responses to exogenous lactate did not reflect the long-term consequences of lactate exposure. Acutely, HMEC and R3230Ac cells were tolerant of all lactate concentrations tested (0-40mM) regardless of presence or absence of glucose. MCF7 and MDA-MB-231 cells were tolerant of lactate within the concentration ranges seen in biopsies. Cytotoxicity was seen after 24 hr incubation with 40mM lactate (-glucose), but this concentration is three times higher than any measurement made in human biopsies of LABC. Similarly, HMEC and MCF7 cells showed significantly decreased colony formation in response to 40mM exogenous lactate (+ glucose) while R3230Ac and MDA-MB-231 cells showed no impairment in colony-forming abilities with any lactate concentration (+ glucose). 5mM CHC significantly increased cell death responses independent of lactate treatment, indicating off-target effects at high concentrations. </p><p>MCT1 was found to be expressed in a majority of the cell lines tested, except for MDA-MB-231 cells. Cancer cells exposed to exogenous lactate showed upregulation of MCT1 but not MCT4. Chronic hypoxia resulted in an increase in protein expression of MCT4 but a decrease in MCT1 expression in cancer cell lines. The time course of regulation of protein levels of each transporter suggested the possibility of expression of both transporters during cycling hypoxia. When cancer cells were exposed to cycling hypoxia, both transporters showed upregulation. In head and neck tumor biopsies, MCT1 expression was significantly positively correlated to aerobic tumor regions and inversely correlated to hypoxic tumor regions. </p><p>Cancer cell responses to exogenous lactate were not uniform. Some cell lines demonstrated a lactate-tolerant and/or a lactate-consuming phenotype while other cell lines demonstrated lactate-intolerant and/or non-lactate-consuming phenotype. My work indicates that exogenous lactate was well-tolerated at clinically relevant concentrations , especially in the presence of glucose. Evidence of glutamate metabolism from lactate indicated that exogenous lactate partially progresses through the TCA cycle, suggesting that lactate may be utilized for fuel. The cell death elicited from 5mM CHC treatment was not dependent upon presence of lactate, indicating that manipulation of lactate metabolism may not be the best option for targeting cancer metabolism. When attempting to manipulate lactate metabolism in tumors, microenvironmental factors, such as hypoxia and glucose, must be taken into account in order to ensure a predictable and favorable outcome. Together, these results illustrate the importance of characterizing tumor metabolism before therapeutic intervention.</p> / Dissertation

No description available.

Adenoviral CD40L gene therapy (AdCD40L) is a strong inducer of anti-tumor immune responses via its activation of dendritic cells (DCs). Activated DCs can in turn activate T cells, which are key players in an efficient anti-tumor response. This thesis includes three papers that focus on different aspects of AdCD40L gene therapy. In the first paper, the infiltration of suppressive CD11b+Gr-1+ cells in orthotopic MB49 bladder tumors was investigated and found to be significantly reduced while activated T cells were increased when the tumors had been treated with local AdCD40L gene therapy. Further, AdCD40L could tilt the cells in the tumor microenvironment in favor of an efficient anti-tumor immunity (M1 macrophages and activated T cells) instead of an immunosuppressive environment (CD11b+Gr-1int/low myeloid cells and M2 macrophages). Immunotherapy combined with chemotherapy has shown promising results, and the second paper investigates the combination of AdCD40L gene therapy together with the chemotherapeutic drug 5-Fluorouracil (5-FU). A synergistic effect of the combination treatment on orthotopic MB49 bladder tumors could be demonstrated. The combination therapy resulted in decreased tumor growth, increased survival and systemic MB49-specific immunity, whereas AdCD40L or 5-FU therapy alone had a poor effect on tumor growth. Efficient AdCD40L therapy is dependent on high transduction efficiency in both cancer cells and cells present in the tumor microenvironment. In an attempt to enhance the transduction efficiency, and thereby the therapeutic efficacy, a modified adenovirus was developed for paper three. This modified Ad5PTDf35(mCD40L) could, in comparison with the unmodified Ad5(mCD40L), demonstrate increased transduction capacity of a variety of murine cells. Further, the ability of antigen presenting cells (APCs) to present antigens to T cells was improved after transduction with Ad5PTDf35(mCD40L).

Glioblastoma multiforme (GBM) is one of the most common and aggressive primary brain tumours, with a median patient survival time of 6-12 months in adults. It has been recently suggested that a typically small sub-population of brain tumour cells, in possession of certain defining properties of stem cells, is responsible for initiating and maintaining the tumour. More recent experiments have studied the interactions between this subpopulation of brain cancer cells and tumour microenvironmental factors such as hypoxia and high acidity. In this thesis a computational approach (based on Gillespie’s algorithm and cellular automata) is proposed to investigate the tumour heterogeneities that develop when exposed to various microenvironmental conditions of the cancerous tissue. The results suggest that microenvironmental conditions highly affect the characterization of cancer cells, including the self-renewal, differentiation and dedifferentiation properties of cancer cells.

Τα stem κύτταρα αποτελούν ένα υποσύνολο κυττάρων με τις εξής χαρακτηριστικές ιδιότητες: την ικανότητα για αυτο-ανανέωση και την δυναμική για διαφοροποίηση προς πολλαπλούς κυτταρικούς τύπους (πολυδυναμία) [4]. Είναι σπάνια κύτταρα, εντούτοις ο ρόλος τους στην ομοιόσταση του οργανισμού είναι πολύ σημαντικός. Η διαντίδραση με το μικροπεριβάλλον (φωλεά) ρυθμίζει σε μεγάλο βαθμό τη συμπεριφορά τους [5]. Πράγματι, στοιχεία του μικροπεριβάλλοντος, είτε με φυσική επαφή, είτε με έκκριση διάφορων μορίων, είναι σε διαρκή διαντίδραση επαφή και διαντίδραση με τα stem κύτταρα και πολύ πιθανόν με τους άμεσους απογόνους τους (θυγατρικά κύτταρα). / --

<p>In order to propagate a solid tumor, cancer cells must adapt to and survive under various tumor microenvironment (TME) stresses, such as hypoxia or lactic acidosis. Additionally, cancer cells exposed to these stresses are more resistant to therapies, more likely to metastasize and often are worse for patient prognosis. While the presence of these stresses is generally negative for cancer patients, since these stresses are mostly unique to the TME, they also offer an opportunity to develop more selective therapeutics. If we achieve a better understanding of the adaptive mechanisms cancer cells employ to survive the TME stresses, then hopefully we, as a scientific community, can devise more effective cancer therapeutics specifically targeting cancer cells under stress. To systematically identify genes that modulate cancer cell survival under stresses, we performed shRNA screens under hypoxia or lactic acidosis. From these screens, we discovered that genetic depletion of acetyl-CoA carboxylase alpha (ACACA or ACC1) or ATP citrate lyase (ACLY) protected cancer cells from hypoxia-induced apoptosis. Furthermore, the loss of ACLY or ACC1 reduced the levels and activities of the oncogenic transcription factor ETV4. Silencing ETV4 also protected cells from hypoxia-induced apoptosis and led to remarkably similar transcriptional responses as with silenced ACLY or ACC1, including an anti-apoptotic program. Metabolomic analysis found that while α-ketoglutarate levels decrease under hypoxia in control cells, α-ketoglutarate was paradoxically increased under hypoxia when ACC1 or ACLY were depleted. Supplementation with α-ketoglutarate rescued the hypoxia-induced apoptosis and recapitulated the decreased expression and activity of ETV4, likely via an epigenetic mechanism. Therefore, ACC1 and ACLY regulated the levels of ETV4 under hypoxia via increased α-ketoglutarate. These results reveal that the ACC1/ACLY-α-ketoglutarate-ETV4 axis is a novel means by which metabolic states regulate transcriptional output for life vs. death decisions under hypoxia. Since many lipogenic inhibitors are under investigation as cancer therapeutics, our findings suggest that the use of these inhibitors will need to be carefully considered with respect to oncogenic drivers, tumor hypoxia, progression and dormancy. More broadly, our screen provides a framework for studying additional tumor cell stress-adaption mechanisms in the future.</p> / Dissertation

O carcinoma espinocelular é responsável por 90% das lesões malignas na cavidade bucal, sendo o oitavo tipo de câncer em todo o mundo e apresenta uma taxa de sobrevida de apenas 50% em 5 anos. Os carcinomas podem se desenvolver diretamente de células epiteliais normais ou a partir das desordens potencialmente malignas, as quais envolvem as hiperplasias e as displasias. Para que estas lesões se desenvolvam é necessário que nutrientes e oxigênio sejam disponibilizados, o que ocorre a partir da formação de uma nova vasculatura. Este processo, denominado angiogênese, é complexo e envolve a regulação de diferentes fatores indutores, como as moléculas Angiopoetina 1 (ANG1) e Trombospondina 1 (TSP1), cuja ação pode ser influenciada tanto pelas células de origem epitelial quanto pelos componentes do microambiente da lesão. O objetivo deste projeto foi descrever o perfil de expressão das moléculas angiopoetina 1 e trombospondina 1 em biópsias de desordens potencialmente malignas e em carcinoma espinocelular oral. A amostra foi composta por biópsias de pacientes que apresentaram diagnóstico de hiperplasia (n=6), displasia epitelial leve (n=7), displasia epitelial severa (n=15), carcinoma espinocelular oral grau 1 e 2 (n= 13) e 3 e 4 (n=13). As lâminas histológicas foram submetidas à reação de imunoistoquímica para ANG1 e TSP1, das quais foi realizada uma análise descritiva quanto ao perfil de marcação tanto em epitélio quanto em tecido conjuntivo subjacente à lesão. Angiopoetina apresentou uma marcação concentrada principalmente nas células endoteliais e com leve marcação nas células da camada basal do epitélio, sendo observada uma redução da intensidade de marcação de acordo com o grau de severidade da desordem epitelial, porém com um aumento de marcação em células do microambiente tumoral. Trombospondina apresentou marcação heterogênea tanto em tecido epitelial, endotelial e conjuntivo, com um aumento da marcação em macrófagos e fibroblastos de acordo com a severidade da lesão. Este perfil diferenciado de expressão destes marcadores do processo de angiogênese, tanto por células epiteliais modificadas quanto por células do microambiente celular, evidencia a necessidade de mais estudos que explorem a diversidade celular das lesões neoplásicas, com o objetivo de aprimorar as terapias anti-angiogênicas vigentes para o tratamento de desordens potencialmente malignas. / Oral squamous cell carcinoma is the eight most common cancer and it accounts for 90% of malignant lesions in the oral cavity, presenting a survival rate of only 50% after 5 years. Carcinomas may develop directly from normal epithelial cells or from the potentially malignant disorders, such as hyperplasia and dysplasia. During the carcinogenesis process, it is necessary an increase on nutrients and oxygen supply, which occurs through the formation of new vasculature. This process, known as angiogenesis, is complex and involves the regulation of various inducing factors such as angiopoietin molecules 1 (ANG1) and Thrombospondin 1 (TSP1), whose action can be influenced both by epithelial cells or cells from the lesion microenvironment . The objective of this project was to describe the expression profile of molecules angiopoietin 1 and thrombospondin 1 in biopsies of potentially malignant disorders and oral squamous cell carcinoma. The sample consisted of biopsies from patients who were diagnosed with hyperplasia (n = 6), mild dysplasia (n=7), severe dysplasia (n=15), squamous cell carcinoma grade 1 and 2 (n=13) and 3 and 4 (n=13). The histological slides were submitted to immunohistochemical reaction to ANG1 and TSP1, which underwent a descriptive analysis of the staining profile in both epithelium and in the underlying connective tissue to injury. Angiopoietin showed staining mainly in endothelial cells and a subtle staining on cells at the basal layer of the epithelium, and it was observed a reduction in the intensity of the staining in accordance with the severity of epithelial disorder, but with an increase of staining of cells from the microenvironment. Thrombospondin presented a heterogeneous staining among epithelial, endothelial, and connective tissue, with an increase in the staining on macrophages and fibroblasts according to the severity of injury. This differential expression profile of these markers of angiogenesis process, which was observed in both epithelial cells and cells from the microenvironment, highlights the need for more studies exploring the cellular diversity of neoplastic lesions, in order to improve the existing anti-angiogenic therapies for the treatment of malignant disorders.

INTRODUÇÃO: O carcinoma espinocelular de origem bucal (CEC) apresenta uma alta taxa de mortalidade devido à invasividade das células tumorais. A migração celular, principal evento da invasão e metástase, pode ser regulada tanto por fatores intrínsecos, como adesão e contratilidade celular, quanto extrínsecos, como composição, densidade e remodelagem da matriz extracelular (MEC). OBJETIVO: Avaliar o papel de elementos intrínsecos e extrínsecos sobre o processo invasivo do carcinoma espinocelular de origem bucal. MÉTODOS: Foi realizada imuno-histoquímica para as proteínas: Miosina II (isoformas A, B e C), metaloproteinases de matriz (1, 2, 9 e 14); imunofluorescência as proteínas: e-caderina, n-caderina, FAK, paxilina, vinculina e fibronectina em amostras de CEC oral. Foi realizado ensaio de migração nas seguintes condições: 1 – matriz 2D com o substrato de fibronectina, ou laminina ou matrigel; 2 – matriz 3D com colágeno na presença ou não de fibronectina ou laminina; 3 – matriz 3D com diferentes concentrações de colágeno (0,6; 1,2 e 1,8 mg/ml) + fibronectina na presença ou não de um inibidor de MMP. Foi realizado análise de adesão celular utilizando-se o microscópio TIRF e o microscópio confocal, tanto em matrizes 2D quanto 3D. Foram realizados esferoides celulares para avaliar a contratilidade celular, através do plaqueamento das células em gel de agarose e a utilização de drogas que inibem ou que induzem a contratilidade, bem como a partir de células transfectadas com versões fosfomiméticas para a cadeia leve de miosina. Foi realizado ainda western blotting para proteínas: e-caderina, FAK, vinculina, paxilina, N-caderina, integrinas e as isoformas de miosina II, bem como foi avaliado os níveis de ativação das proteínas da família RhoGTPase, as quais estão envolvidas no controle da migração celular. RESULTADOS: A expressão das MMPs analisadas e das isoformas de miosinas foi maior nas zonas de invasão tumoral, sendo que o CEC oral também apresenta uma maior expressão de proteínas associadas à adesão com a MEC. A migração celular foi afetada pela densidade e a composição da MEC, bem como pela atividade das MMPs. Adicionalmente, a modulação das proteínas de adesão célula-matriz altera a velocidade de migração, a direcionalidade dessa migração e também a forma de migração, mudando de uma migração coletiva para uma migração individual. O aumento na contratilidade células resulta numa dispersão celular enquanto que a diminuição da contratilidade resulta numa melhor adesão célula – célula. CONCLUSÕES: O comportamento das células tumorais pode ser modulado através de fatores extrínsecos como, por exemplo, a alteração no microambiente tumoral, seja ela por mudança no substrato ou na densidade da matriz, e também dos fatores intrínsecos como a alteração nos níveis de miosina. / INTRODUCTION: Oral squamous cell carcinoma (OSCC) presents high mortality index due to the invasive phenotype of tumor cells. Cell migration is the main event in cell invasion and metastasis and it can be regulated by intrinsic factor, such as adhesion and cell contractility, and extrinsic factors, such as density and extracellular matrix (EMC) remodeling. OBJECTIVE: Analyze the role of intrinsic and extrinsic factor during the invasive process of oral squamous cell carcinoma. METHODS: We performed immunostaining in OSCC samples for the following proteins: myosin II (isoforms A, B and C), matrix metalloproteinase (1, 2, 9 and 14) e-cadherin, n-cadherin, FAK, paxillin, vinculin and fibronectin. We also performed migration assays with OSCC cell line in the following conditions 1 – 2D matrix with fibronectin or laminin or matrigel; 2 – 3D matrix with collagen in the presence or not of fibronectin or laminin; 3 – 3D matrix with different collagen concentration (0,6; 1,2 e 1,8 mg/ml) with fibronectin in the presence or not of the MMP inhibitor. In order to analyze cell adhesion, it was performed Total Internal Reflectance Fluorescence and Confocal microscopy, in 2D and 3D matrix. To analyze cell contractility, cells were plated in agarose gel in order to produce spheroids, which were treated with drugs that inhibit or induce cell contractility or cells were previously transfected with Myosin Light Chain phosphomimetics mutants. It was also performed western blotting to: e-cadherin, n-cadherin, FAK, paxillin, vinculin and myosin II isoforms, as well as it was analyze the levels in RhoGTPase family, which are involved in cell migration control. RESULTS: The expression to MMPs and myosin II isoforms were higher at invasion zone of the tumor, and the OSCC presented higher expression of proteins associated to adhesion to ECM. Cell migration was affected by the EMC composition and density and by MMP activity. Also, the modulation of cell-matrix adhesion proteins altered migration speed, cell directionality as well as influenced the switch between collective and single cell migration. The increase in cell contractility resulted in cell dispersion while the decrease in cell contractility resulted in a better cell-cell adhesion. CONCLUSIONS: The behavior of cell tumor can be modulate by extrinsic factors, for example, the change in tumor microenvironment, by the change in the EMC substrate or density and by intrinsic factors such as the alteration in myosin levels.

La sénescence cellulaire est un mécanisme de suppression cellulaire caractérisé par un arrêt irréversible du cycle cellulaire. Les cellules sénescentes ont également un secrétome spécifique qui influe sur les cellules voisines, pouvant induire leur entrée prématurée en sénescence, l'apoptose, la prolifération cellulaire et le développement tumoral. Dans ce contexte, l'objectif de ma thèse était d'identifier une nouvelle protéine sécrétée par les fibroblastes sénescents et de caractériser ses fonctions dans les cellules sénescentes et dans les cellules tumorales. Nous avons mis en évidence la protéine WNT16B. Elle est surexprimée dans plusieurs modèles de sénescence cellulaire obtenus à partir de fibroblastes pulmonaires. Dans un modèle de souris transgénique, WNT16B est également associée avec l'accumulation de cellules sénescentes dans les lésions précancéreuses pulmonaires. WNT16B est impliqué dans le mécanisme de sénescence cellulaire. En effet, l'inhibition de WNT16B prévient l'entrée en sénescence, en empêchant l'activation de p53 et l'expression de p21/WAF1, et donc l'arrêt du cycle cellulaire.Nous avons finalement associé l'expression de WNT16B avec la présence de cellules sénescentes dans des tumeurs prélevées chez des patients atteints de carcinomes pulmonaires non à petites cellules. Cette expression est corrélée avec une meilleure survie pour les patients ayant reçu un traitement chimiothérapeutique. Ce dernier résultat fait donc le lien entre traitement, sénescence cellulaire et survie, et illustre le rôle potentiel des marqueurs des cellules sénescentes pour le suivi des patients. Globalement, ces travaux ont donc non seulement permis d'identifier WNT16B comme nouveau marqueur des cellules sénescentes, mais ils ont également ouvert des perspectives d'utilisation de ce marqueur pour l'identification, le traitement et le suivi des patients atteints d'un cancer. / Cellular senescence is a tumor suppression mechanism consisting of an irreversible cell cycle arrest. Senescent cells also express a specific secretome that plays a role in the microenvironment. It may induce premature senescence, apoptosis, cellular proliferation or tumor development in the neighboring cells. In this context, my thesis aimed to identify and characterize a new senescence-associated secreted protein, before highlighting its role in tumorigenesis. We identified the WNT16B protein. It was overexpressed in various cellular senescence models obtained from lung fetal fibroblasts. Moreover, WNT16B expression was associated with the accumulation of senescent cells in precancerous lesions in a transgenic mice model. WNT16B is also involved in the senescence machinery. Indeed, WNT16B inhibition prevented the senescence onset through inactivation of the p53/p21 pathway, thus stopping the cell cycle progression. Finally, we observed a correlation between the WNT16B expression and the occurrence of senescent tumoral cells in NSCLC samples. This expression was also correlated with a better patient outcome after chemotherapeutical treatment. Thus, this last result linked the treatment efficiency, the occurrence of senescence and the patient survival. Overall, my thesis established elevated WNT16B levels as a novel biomarker for senescence that might be useful for the identification, the treatment follow-up and the prognosis of patient outcome.