As solid tumor types, breast and prostate cancer are rivalled only by lung cancer in their propensity to metastasize to bone in the later stages of disease. At advanced stages of disease, approximately 80% of breast and 90% of prostate cancer patients will present with bone metastases. Bone metastases are often a painful conclusion to the lives of these patients, resulting in bone pain, hypercalcemia, pathological fractures and spinal cord compression. The culmination of these comorbidities considerably reduces a patient’s quality of life and prolonged survival. Hormone depletion is used as a first line of treatment in the majority of cases, negatively regulating bone health due to increased bone resorption by osteoclasts and decreased bone formation by osteoblasts. Not only is bone integrity undermined, but this action of increased bone turnover is beneficial for the colonization of metastasizing cells which co-opt and enhance the same mechanisms to establish and maintain their own growth. This is termed ‘the vicious cycle’ of osteolytic bone metastasis. Current research approaches aim to identify bone-targeted therapies which not only inhibit tumor growth but concurrently protect bone. In this study, Dickkopf-1 (DKK-1), mechanistic target of rapamycin (mTOR) and p38 mitogen-activated kinases (p38 MAPK) are presented as novel targets. Pro-tumor roles have been described for all and clinical trials are currently investigating their efficacy in different cancer types. In normal bone biology DKK-1 is an inhibitor of the canonical Wnt signaling pathway which promotes osteoblastogenesis while mTOR signaling is a promoter of osteoclastogenesis. P38 MAPK inhibitors have been shown to regulate DKK-1 expression and bone destruction in preclinical models of multiple myeloma. The aims of this current study were to 1) investigate the role of DKK-1 in the biology of osteotropic breast cancer, 2) to assess the potential bone protective effects of mTOR inhibition by everolimus in the context of osteotropic cancers and 3) to test the hypothesis that p38 MAPK is a regulator of DKK-1 expression in prostate cancer, potentially supporting an osteolytic phenotype by impairing osteoblastogenesis. In aim 1, analysis of a breast cancer tissue microarray demonstrated that DKK-1 expression was elevated in advanced and invasive tumor stages. Strikingly, positive DKK-1 expression correlated with a significantly reduced survival rate only in estrogen receptor-negative (ER-) breast cancer patients compared to patients with tumors which were negative for DKK-1 expression. In MDA-MB-231 breast cancer xenograft models, neutralization of secreted DKK-1 by treating mice with the monoclonal DKK-1 antibody BHQ880 or knocking out the expression of DKK-1 in MDA-MB-231 cells using CRISPR-Cas9 mediated gene editing, resulted in reduced tumor growth and burden by ≥ 50% (p < 0.05). In aim 2, the mTOR inhibitor everolimus is presented as an anti-tumor and bone-protective agent. The anti-tumor effects of everolimus were confirmed in two subcutaneous tumor models and a model of breast cancer bone metastasis, were tumor burden in the bone was reduced by 45.4% (p < 0.01). Bone loss induced by a hormone-deprived environment in ovariectomized mice was prevented with everolimus treatment as was bone destruction in the metastasis model. In more detail, it could be shown that everolimus maintained osteoblast function while specifically inhibiting osteoclast function. In aim 3, p38 MAPK is presented as a regulator of DKK-1 in prostate cancer. While the activation of p38 MAPK upregulated DKK-1, inhibition of p38 MAPK using small molecule inhibitors and siRNAs inhibited DKK-1 expression. Furthermore, assessment of different p38 MAPK isoforms revealed MAPK11 as the most effective regulator of DKK-1 and inhibition of DKK-1 by interfering with p38 MAPK signaling was sufficient to prevent the inhibitory effects of prostate cancer-derived DKK-1 on osteoblastogenesis in vitro. This study has assessed multiple targets and their concurrent roles in cancer and bone cell biology. Specifically, DKK-1 has been proven to be a tumor promoter in ER- breast cancer and can be targeted therapeutically to inhibit tumor growth. MTOR inhibition by everolimus has been shown to be an effective mono-therapy in ER- breast cancer, inhibiting the growth of subcutaneous tumor and bone metastases and preventing bone loss induced by estrogen ablation. This further supports its use in postmenopausal women with breast cancer who are predisposed to developing osteoporosis and bone metastases. It also supports the use of everolimus in hormone receptor-negative or triple receptor-negative breast cancer, for which it has not yet been approved. A clear link has been made between p38 MAPK signaling and DKK-1 expression in prostate cancer and its consequent regulation of osteoblastogenesis. A future focus on the inhibition of a specific MAPK isoform, MAPK11 in particular, may help in translating these encouraging in vitro results into promising pre-clinical trials in vivo. As a whole, these investigations provide a foundation for further research and could be valuable for the design of future clinical trials, leading to improvements in the treatment and prognosis of osteolytic bone metastases.

Les métastases osseuses sont une complication majeure des cancers du sein. Les bisphosphonates (BPs) bloquent la progression des lyses osseuses. Des effets anti-tumoraux ont été mis en évidence mais à des doses importantes incompatibles avec un usage clinique. La forte affinité des BPs pour le minéral osseux limite leur biodisponibilité et amoindrit donc leur potentiel antitumoral in vivo. Mon travail de thèse s'est inscrit dans le cadre de la potentialisation des effets anti-tumoraux des BPs. Les BPs ont été combinés avec des ultrasons de faible intensité (LIUS) dont le rôle est d'induire une stimulation mécanique et une augmentation modérée de la température du milieu insonifié sans effet de cavitation. Les LIUS favorisent la pénétration des BPs dans des cellules tumorales en augmentant le phénomène d'endocytose. In vivo, un traitement répété aux LIUS associé à une dose clinique de BPs entraine une diminution des lyses osseuses ainsi que de la masse tumorale. L'accumulation d'un marqueur, retrouvé dans les moelles des souris traitées aux LIUS, suggère que la pénétration des BPs a été favorisée sous l'effet des LIUS. L'effet de l'association BPs avec les LIUS a ensuite été évalué sur un modèle de tumeur sous-cutanée mammaire. Un ralentissement de la croissance tumorale lors des premiers jours de traitements a été mis en évidence. Une étude menée avec de la doxorubicine et des BPs a permis d'élargir le champ d'application des LIUS pour le traitement du cancer du sein. En conclusion, ces travaux montrent que les LIUS apparaissent comme une solution d'intérêt pour augmenter la pénétration de drogues dans des tumeurs osseuses et mammaires et augmenter leur potentiel antitumoral / Bone metastases are common complications of advanced breast cancer. They increase morbidity of patients and alter their quality of life. Bisphosphonates (BPs) stop the progression of osteolysis. However, BPs do not affect the tumor burden located inside the bone marrow cavity. Antitumoral effects have been shown but with high doses incompatibles with a clinical use. BPs bind also avidly to bone mineral which limits their bioavailability and reduce their antitumoral potential in vivo. This work is incorporated within the framework of the enhancement of antitumoral effects of BPs. BPs were combined with low intensity ultrasound (LIUS), which are known to induce a mechanical stimulation and a slight increase of temperature without involving cavitationnal effect. Initially, LIUS were found to increase the penetration of BPs inside several mammary tumor cell lines without affecting their viability by increasing endocytosis. In vivo, a daily repeated treatment of LIUS associated with a single and clinical dose of BPs lead to a decrease in osteolysis as well as tumor burden. The accumulation of unprenylated Rap1A form was found in bone marrow of mice suggesting that LIUS promote BPs penetration inside cells of the bone cavity. The effect of BPs and LIUS was evaluated in a subcutaneous mammary tumor xenograft. Tumor growth was slowed during the first days of LIUS treatment. A study was performed using doxorubicin and BPs leading to a better penetration of both compounds when LIUS were used. This last result allows increasing the field of application of LIUS for breast cancer treatment. In conclusion, this work showed that LIUS are an interesting method to enhance the penetration of drugs inside bone and mammary tumors leading to an increase of their antitumoral activity

Chez les patients atteints d’un cancer du sein ou de la prostate, le tissu osseux est souvent le siège de métastases qui présentent un phénotype essentiellement lytique dans le cas des métastases dérivant du cancer du sein, ou mixte (combinaison de lyse et de formation osseuse) dans le cas d’un cancer de la prostate. Le récepteur ERRalpha est impliqué dans la physiologie osseuse et il est considéré comme un facteur de mauvais pronostic dans ces deux types de cancers. Nous avons donc émis l’hypothèse qu'il pourrait être impliqué dans la formation des métastases osseuses associées à ces deux cancers. Nous avons observé que, dans les deux cas, ERRalpha stimule la progression tumorale au site primaire via la stimulation de l'angiogenèse et de l'expression du VEGF. Concernant les métastases osseuses dérivant du cancer du sein, ERRalpha inhibe les lésions ostéolytiques via la modulation de l'ostéoclastogenèse et de l'expression de son inhibiteur, l’OPG. A l'inverse, l'expression de ERRalpha stimule la formation de lésions lytiques induites par les cellules de cancer de la prostate en induisant l'expression du TGF-beta, de MCP-1 et de la cathépsine K, tout en induisant des zones de formation osseuse via la régulation de l'expression de l'OPG, de l’endothéline-1 et de membres de la famille Wnt. Ces résultats confirment la valeur de facteur de mauvais pronostic de ERRalpha dans la tumeur primaire. De plus, ils révèlent, pour la première fois, son implication dans le développement des métastases osseuses et suggèrent une dualité fonctionnelle de ERRalpha, comme inhibiteur et stimulateur du développement des métastases osseuses du cancer du sein et de la prostate, respectivement. Ces résultats suggèrent des mécanismes d'action différents pouvant dépendre des cellules tumorales mais aussi du microenvironnement et du statut hormonal / Breast cancer and prostate cancer patients, often developed bone metastases. As ERRalpha, an orphan nuclear receptor, is involved in bone physiology and is considered as a bad prognosis factor in breast and prostate cancer, we hypothesize that it can be implicated in bone metastasis development that derived from breast and prostate cancers. While we found that, in both cases, ERRalpha stimulates the development of the primary tumor through regulation of angiogenesis and VEGF expression, we show that ERRalpha inhibits osteolytic lesions from breast cancer cells via the regulation of osteoclastogenesis and OPG expression. On the other side ERRalpha stimulates osteolytic lesions from prostate cancer through regulation of TGFbeta, MCP-1 and cathepsin K expression while inducing new bone formation combine with OPG, endothelin-1, and Wnts regulation. All together, our results confirmed ERRalpha as a bad prognosis factor in breast and prostate primary tumors. They also show a dual function of ERRalpha in bone metastasis development as an inhibitor and a stimulator of bone metastasis derived from breast and prostate cancer respectively which suggest different ERRalpha mechanisms that may depend of cancer cells but also of the microenvironment and hormonal status

As solid tumor types, breast and prostate cancer are rivalled only by lung cancer in their propensity to metastasize to bone in the later stages of disease. At advanced stages of disease, approximately 80% of breast and 90% of prostate cancer patients will present with bone metastases. Bone metastases are often a painful conclusion to the lives of these patients, resulting in bone pain, hypercalcemia, pathological fractures and spinal cord compression. The culmination of these comorbidities considerably reduces a patient’s quality of life and prolonged survival. Hormone depletion is used as a first line of treatment in the majority of cases, negatively regulating bone health due to increased bone resorption by osteoclasts and decreased bone formation by osteoblasts. Not only is bone integrity undermined, but this action of increased bone turnover is beneficial for the colonization of metastasizing cells which co-opt and enhance the same mechanisms to establish and maintain their own growth. This is termed ‘the vicious cycle’ of osteolytic bone metastasis. Current research approaches aim to identify bone-targeted therapies which not only inhibit tumor growth but concurrently protect bone. In this study, Dickkopf-1 (DKK-1), mechanistic target of rapamycin (mTOR) and p38 mitogen-activated kinases (p38 MAPK) are presented as novel targets. Pro-tumor roles have been described for all and clinical trials are currently investigating their efficacy in different cancer types. In normal bone biology DKK-1 is an inhibitor of the canonical Wnt signaling pathway which promotes osteoblastogenesis while mTOR signaling is a promoter of osteoclastogenesis. P38 MAPK inhibitors have been shown to regulate DKK-1 expression and bone destruction in preclinical models of multiple myeloma. The aims of this current study were to 1) investigate the role of DKK-1 in the biology of osteotropic breast cancer, 2) to assess the potential bone protective effects of mTOR inhibition by everolimus in the context of osteotropic cancers and 3) to test the hypothesis that p38 MAPK is a regulator of DKK-1 expression in prostate cancer, potentially supporting an osteolytic phenotype by impairing osteoblastogenesis. In aim 1, analysis of a breast cancer tissue microarray demonstrated that DKK-1 expression was elevated in advanced and invasive tumor stages. Strikingly, positive DKK-1 expression correlated with a significantly reduced survival rate only in estrogen receptor-negative (ER-) breast cancer patients compared to patients with tumors which were negative for DKK-1 expression. In MDA-MB-231 breast cancer xenograft models, neutralization of secreted DKK-1 by treating mice with the monoclonal DKK-1 antibody BHQ880 or knocking out the expression of DKK-1 in MDA-MB-231 cells using CRISPR-Cas9 mediated gene editing, resulted in reduced tumor growth and burden by ≥ 50% (p < 0.05). In aim 2, the mTOR inhibitor everolimus is presented as an anti-tumor and bone-protective agent. The anti-tumor effects of everolimus were confirmed in two subcutaneous tumor models and a model of breast cancer bone metastasis, were tumor burden in the bone was reduced by 45.4% (p < 0.01). Bone loss induced by a hormone-deprived environment in ovariectomized mice was prevented with everolimus treatment as was bone destruction in the metastasis model. In more detail, it could be shown that everolimus maintained osteoblast function while specifically inhibiting osteoclast function. In aim 3, p38 MAPK is presented as a regulator of DKK-1 in prostate cancer. While the activation of p38 MAPK upregulated DKK-1, inhibition of p38 MAPK using small molecule inhibitors and siRNAs inhibited DKK-1 expression. Furthermore, assessment of different p38 MAPK isoforms revealed MAPK11 as the most effective regulator of DKK-1 and inhibition of DKK-1 by interfering with p38 MAPK signaling was sufficient to prevent the inhibitory effects of prostate cancer-derived DKK-1 on osteoblastogenesis in vitro. This study has assessed multiple targets and their concurrent roles in cancer and bone cell biology. Specifically, DKK-1 has been proven to be a tumor promoter in ER- breast cancer and can be targeted therapeutically to inhibit tumor growth. MTOR inhibition by everolimus has been shown to be an effective mono-therapy in ER- breast cancer, inhibiting the growth of subcutaneous tumor and bone metastases and preventing bone loss induced by estrogen ablation. This further supports its use in postmenopausal women with breast cancer who are predisposed to developing osteoporosis and bone metastases. It also supports the use of everolimus in hormone receptor-negative or triple receptor-negative breast cancer, for which it has not yet been approved. A clear link has been made between p38 MAPK signaling and DKK-1 expression in prostate cancer and its consequent regulation of osteoblastogenesis. A future focus on the inhibition of a specific MAPK isoform, MAPK11 in particular, may help in translating these encouraging in vitro results into promising pre-clinical trials in vivo. As a whole, these investigations provide a foundation for further research and could be valuable for the design of future clinical trials, leading to improvements in the treatment and prognosis of osteolytic bone metastases.

Background: Individuals with metastatic bone disease (MBD) and multiple myeloma (MM) are commonly excluded from exercise oncology research due to safety concerns regarding potential skeletal complications including the incidence of pain, impaired mobility, pathological fracture, and spinal cord compression. However, over the past decade research has demonstrated that exercise is not only safe for this population but may offer other therapeutic benefits. To our knowledge, the specific perspectives and needs of individuals with MBD related to physical activity and exercise have not yet been explored. The objective of this study was to identify the attitudes towards and needs related to physical activity and exercise among individuals with MBD and MM. Methods: A phenomenological qualitative study utilizing a pragmatic approach to thematic analysis within a patient-oriented research framework was utilized. Semi-structured interview questions and various questionnaires were utilized to gather this descriptive information. Thematic analysis was completed using the 7-stage Framework Method, including transcription, familiarization, coding, analytical framework, and interpreting the data. Results: Of the 20 volunteer participants (90% male), four were living with MM (20%), and 16 had MBD diagnosed within 2-66 months of the study. Half of the participants did not report feeling any bone pain, with none experiencing severe bone pain, and eight (40%) experienced pain specifically with movement. Most participants engaged in a variety of physical activities and at various intensities, although 25% were found to be sedentary/insufficiently active. Five major themes emerged from the interviews including “meaning of physical activity”, “cancer care ‘exercise is medicine’ support (or lack thereof)”, “motivators to engage in physical activity”, “barriers causing a reduction in physical activity post diagnosis”, and “physical activity program preferences”. These themes encompassed a total of 32 categories and 44 subcategories, creating the overall thematic framework. Discussion: Individuals with MBD and MM do engage in regular physical activity, although differences in the frequency and intensity of exercise exist. Exercise has a recognized and valued role in their lives and health, including bone health. These patients are genuinely interested in some form of exercise program as part of their cancer care. Movement or activity modifications may be required for some based on bony lesions and fracture prevention. Differences may also be related to comorbidities, preferences, and/or abilities. While there is no “one size fits all” approach to oncology-based exercise prescription and implementation among this population, the findings of this study demonstrate that there is a strong patient-identified need to support those living with MBD and MM to engage in regular exercise in order to obtain its physical and psychological benefits. / Graduate / 2023-03-03

The objective of this work is to develop an on-line planning and delivery technique for palliative radiotherapy of spinal metastases using a linear accelerator capable of cone-beam CT (CBCT) imaging. This technique integrates all preparation and delivery steps into a single session equivalent to an initial treatment session. The key technical challenges pertaining to the development and implementation of this novel treatment technique are related to CBCT image performance, efficient system integration, development of on-line planning tools and design of novel quality assurance (QA) phantoms and processes. Hardware and software image corrections were first implemented to make CBCT images suitable for target definition and planning. These corrections reduced CBCT non-uniformity and improved CBCT-number accuracy. The on-line treatment technique workflow and the integration of all the subsystems involved in the process were assessed on a customized spine phantom constructed for the study. The challenges related to the routine QA of the highly integrated on-line treatment technique were addressed with the construction and validation of an integral test phantom. This phantom, which contains point detectors (diodes) allows for real-time QA of the entire image guidance, planning and treatment process in terms of dose delivery accuracy. The integral test phantom was also effective for the QA of high-dose, high-precision spinal radiosurgery. Simulation of the on-line treatment technique on patient data showed that the planning step was the one of the most time consuming tasks due predominantly to manual target definition. A semi-automatic method for detection and identification of vertebrae on CBCT images was developed and validated to streamline vertebra segmentation and improve the on-line treatment efficiency. With a single patient setup at the treatment unit, patient motion during the on-line process represents the main source of geometric uncertainty for dose delivery. Spine intra-fraction motion was assessed on CBCT for a group of 49 patients treated with a palliative intent. The use of surface marker tracking as a surrogate for spine motion was also evaluated. Finally, the complete on-line planning and delivery technique was implemented in a research ethics board (REB) approved clinical study at the Princess Margaret Hospital and 7 patients have been successfully treated at the time of this report with this novel treatment approach.

Les métastases osseuses sont des complications fréquentes de nombreuses tumeurs solides et sontresponsables, sur le plan clinique, de fractures osseuses, d’hypercalcémie et de douleurs. A l’heure actuelle,il n’existe aucun traitement curatif ; la compréhension des mécanismes impliqués dans la formation et ledéveloppement des métastases osseuses est donc nécessaire afin d’envisager de nouvelles approchesthérapeutiques.Une analyse transcriptomique comparative entre une lignée humaine de cancer du sein, les MDA-MB-231, et leur sous-population ostéotropique, les B02, a montré une surexpression de composants de la voie designalisation Slit/Robo.Les récepteurs Robo et leurs ligands Slits, initialement identifiés comme facteurs clés du guidage axonal lorsdu développement, sont également impliqués dans la migration des cellules cancéreuses.Afin d’étudier le rôle de ces récepteurs Robo1 et 4 dans la dissémination métastatique à l’os, nousavons inhibé l’expression de ces gènes dans les cellules B02. Des expériences in vitro et in vivo montrentalors un rôle antagoniste de Robo1/4. En effet, l’inhibition de Robo1 augmente la croissance des tumeursprimaires, tandis que celle de Robo4 la diminue. Ces récepteurs régulent également différemment laformation de lésions ostéolytiques ainsi que la croissance tumorale de ces métastases. In vitro, l’absence deRobo1 augmente l’invasion, tandis que celle de Robo4 la diminue. Nous avons également montré quel’inhibition de Robo4 ralentit la colonisation de la moelle osseuse par les cellules B02 à des temps précoces.Enfin, l’étude d’une cohorte de patientes atteintes d’un cancer du sein montre une corrélation entrel’expression de Robo4 et la rechute métastatique osseuse.Cette étude montre l’implication de la voie Slit/Robo dans la dissémination métastatique à l’os, etsemble par conséquent constituer une approche thérapeutique judicieuse pour traiter ces métastases. / Bone metastases are a common complication of many solid tumors and are clinically responsible ofbone fractures, hypercalcemia, and pain. Currently, there is no curative treatment; understanding themechanisms involved in the formation and development of bone metastases is therefore necessary toconsider new therapeutic approaches.A comparative transcriptomic analysis between the human breast cancer cell line MDA-MB-231, andits osteotropic subpopulation, B02, has shown an up-regulation of Slit/Robo signaling pathway.Robo receptors and their ligands Slits were initially identified as key factors in axon guidance duringdevelopment. However, these proteins are also involved in the migration of cancer cells.To investigate the role of these receptors Robo1 and 4 in breast cancer bone metastasis, theexpression of these genes was inhibited in B02 cells. In vitro and in vivo experiments point out antagonisticrole of Robo1/4. Indeed, inhibition of Robo1 expression increases primary tumors growth, while Robo4invalidation reduces it. These receptors also differently regulate the formation of osteolytic lesions and extentof skeletal tumor burden. In vitro, Robo1 depletion induces an increased invasion, whereas Robo4 depletiondecreases it. We also showed that inhibition of Robo4 reduces survival and growth of B02 cells in the bonemarrow at early times of invasion. Finally, a cohort study of breast cancer patients shows a strong correlationbetween Robo4 expression and metastatic relapse in bone.This study shows the involvement of the Slit/Robo pathway in bone metastasis, and therefore seemsto be a judicious therapeutic approach to treat these metastases.

No description available.

Background: The first-line treatment for patients with advanced prostate cancer (PC) is androgen deprivation therapy. This therapy is initially effective, but after some time tumors relapse, predominantly within the bone, and are then termed castration-resistant prostate cancer (CRPC). The majority of CRPC tumors show androgen receptor (AR) activity despite castrate levels of circulating testosterone. AR activity could be caused by several mechanisms including; intratumoral androgen synthesis, AR amplification, AR mutations and expression of AR splice variants. The mechanisms controlling CRPC growth in the clinically most relevant metastatic site, the bone, are not fully identified. The purpose of this thesis was therefore to explore AR expression and possible mechanisms behind CRPC growth in PC bone metastases in order to find mechanisms that could be targeted for treatment and/or predict response to certain therapies. Materials and Methods: We have examined hormone-naïve and CRPC bone metastases samples obtained from patients at metastasis surgery, non-malignant and malignant prostate samples obtained from patients at radical prostatectomy, and PC cell lines cultured in vitro. Analysis has been performed using RT-PCR, whole-genome expression arrays, immunohistochemistry, western blotting, FISH, copy number assays and gene ontology analysis. Functional studies have been made by protein overexpression and knock-down in PC cells in vitro and effects studied by evaluation of cell viability, migration, and invasion. Results: We found that high nuclear AR immunostaining (presumed to reflect high AR activity) in bone metastases from CRPC patients was associated with a particularly poor prognosis, while no difference in AR staining was observed between hormone-naïve and CRPC metastases. Further, expression of AR splice variants (AR-V7, AR-V567es) was associated with a high nuclear AR immunostaining score and shown to be increased in CRPC compared to hormone-naïve bone metastases. High levels (levels in the upper quartile) of AR splice variants in CRPC bone metastases was related to disturbed cell cycle regulation and short patients survival. No differences in steroidogenic enzyme levels were detected between CRPC and hormone-naïve bone metastases. Higher levels of enzymes involved in late steps of androgen synthesis (adrenal gland steroid conversion) were observed in bone metastases than in non-malignant and/or malignant prostate tissue, while the enzyme levels in earlier steps (de novo steroidogenesis) were lower in bone metastases. A subgroup of metastases expressed very high levels of AKR1C3, indicating that this group may have an induced capacity of converting adrenal-gland derived steroids into more potent androgens. This was not associated to CRPC but merely with the advanced stage of metastasis. High protein levels of AR splice variants were found in bone metastases with low AKR1C3 levels, while metastases with high AKR1C3 levels primarily contained low AR variant levels. Furthermore, about half of the CRPC bone metastases showed androgen receptor gene amplification which was associated with co-amplification of YIPF6, and a gene expression pattern that pointed at decreased osteoclast activity, and consequently decreased bone resorption. Conclusions: The majority of CRPC bone metastases show high nuclear AR immunostaining that seems to be associated with a particularly unfavorable outcome after metastasis surgery. Subgroups of CRPC bone metastases could be identified according to presence of AR amplification and expression levels of AKR1C3 or AR splice variants, which might have clinical relevance for treatment of PC patients. / <p>Författaren är även publicerad med efternamnet Hörnberg.</p>

The objective of this work is to develop an on-line planning and delivery technique for palliative radiotherapy of spinal metastases using a linear accelerator capable of cone-beam CT (CBCT) imaging. This technique integrates all preparation and delivery steps into a single session equivalent to an initial treatment session. The key technical challenges pertaining to the development and implementation of this novel treatment technique are related to CBCT image performance, efficient system integration, development of on-line planning tools and design of novel quality assurance (QA) phantoms and processes. Hardware and software image corrections were first implemented to make CBCT images suitable for target definition and planning. These corrections reduced CBCT non-uniformity and improved CBCT-number accuracy. The on-line treatment technique workflow and the integration of all the subsystems involved in the process were assessed on a customized spine phantom constructed for the study. The challenges related to the routine QA of the highly integrated on-line treatment technique were addressed with the construction and validation of an integral test phantom. This phantom, which contains point detectors (diodes) allows for real-time QA of the entire image guidance, planning and treatment process in terms of dose delivery accuracy. The integral test phantom was also effective for the QA of high-dose, high-precision spinal radiosurgery. Simulation of the on-line treatment technique on patient data showed that the planning step was the one of the most time consuming tasks due predominantly to manual target definition. A semi-automatic method for detection and identification of vertebrae on CBCT images was developed and validated to streamline vertebra segmentation and improve the on-line treatment efficiency. With a single patient setup at the treatment unit, patient motion during the on-line process represents the main source of geometric uncertainty for dose delivery. Spine intra-fraction motion was assessed on CBCT for a group of 49 patients treated with a palliative intent. The use of surface marker tracking as a surrogate for spine motion was also evaluated. Finally, the complete on-line planning and delivery technique was implemented in a research ethics board (REB) approved clinical study at the Princess Margaret Hospital and 7 patients have been successfully treated at the time of this report with this novel treatment approach.