Níveis séricos de CSF-1 e Ang-2: parceiros no prognóstico e diagnóstico de Cancro do Pulmão de Células Não-Pequenas

2017/2018 Ana Luísa Pequeno Coelho Ní eis sé icos de CSF-1 e Angiopoie ina-2: pa cei os no p ognós ico e diagnós ico do Canc o do Pulmão de Células Não-Pequenas CSF-1 and Ang-2 se um le els: p ognos ic and diagnos ic pa ne s in Non-Small Cell Lung Cance . ma ço, 2018 Mes ado In eg ado em Medicina Á ea: Ciências Médicas e da Saúde Tipologia: Disse ação T abalho e e uado sob a O ien ação de: P o esso Dou o Rui Manuel de Medei os Melo Sil a E sob a Coo ien ação de: P o esso Dou o An ónio Manuel Fe ei a A aújo T abalho o ganizado de aco do com as no mas da e is a: ESMO Open Ana Luísa Pequeno Coelho Ní eis sé icos de CSF-1 e Angiopoie ina-2: pa cei os no p ognós ico e diagnós ico do Canc o do Pulmão de Células Não-Pequenas CSF-1 and Ang-2 se um le els: p ognos ic and diagnos ic pa ne s in Non-Small Cell Lung Cance . ma ço, 2018 FÜR Tü P oje o de Opção do 6o ano - DTcLARAçÃo DE INTEGRTDADE F| nUF FÂC ,LÕaOÈ O l ËDlc i*À !, ii: !'i q 5 ì iÌ.À ì | i ì ) ji:),á1 {,. Eu, Ana Luísa Pequeno Coelho, abaixo assinado, no mecanog á ico 1995oL4g4,es udan e do 6o ano do Ciclo de Es udos In eg ado em Medicina, na Faculdade de Medicina da Uni e sidade do po o, decla o e a uado com absolu a in eg idade na elabo ação des e p oje o de opção. Nes e sen ido, con i mo que nÃo inco i em plágio (a o pelo qual um indi íduo, mesmo po omissão, assume a au o ia de um de e minado abalho in elec ual, ou pa es dele). Mais decla o que odas as ases que e i ei de abalhos an e io es pe encen es a ou os au o es, o am e e enciadas, ou edigidas com no as pala as, endo colocado, nes e caso, a ci ação da on e bibliog á ica. Faculdade de Medicina da Uni e sidade do po o, POR Ü FÁ{uL É B hiE.Ésc.4&À i.. s '".S *s iì Á l[ Jó,4] l?Ì :] P ojec o de Opção do 60 ano - DecumçÃo oe ReenoouçÃo NOME Ana Luísa Pequeno Coelho NUMERO DE ESTUDANTE E-MAIL 199s01484 pequenocoelho@ ho mai Lcom DESIGNAçAO DA AREA DO PROJECTO Ciências médicas e da saúde > Medicina básica Í ulo o ssen ndo/+qeNo€RAFI ( isca o que não in e essa) Ní eis sé icos de CSF-1 e Angiopoie ina-2: pa cei os no p ognós ico e diagnós ico do Canc o do Pulmão de Celulas Não-Pequenas. ORIENTADOR Rui Manuel de Medei os Melo Sil a ASSTNALE ApENAS UMA DAs opÇÕ s: Faculdade de Medicina da Uni e sidade do po o, COORIENTADOR (se aplicá el) Manuel Fe ei a A aújo E AUTORIZADA a RepnoouçÃo INTEGML DEs E TRABALHo ApENAs nARA EFE os oe u snce$o, MEDIANTE DECLAMçÃO ESCRITA DO INTERESSADO, QUE A TAL SE COMPROMETE. ! E AUToRTzADA R nenRoouçÃo pARc AL DEs E TMBA qÁx Flo oE pÁGIl, RS, -us nnçÕ s, Gú lcos, Eïc,) ApENAs pAM EFE os DE INVESTIGACÃo, u o n u e o cunn$o EScR A Do TNTERESSADo, euE A TAL sE coMpRoMETE. DE AcoRDo coM A LEGISLAçÃo e IGoR, (INDICAR, cASo AL s :n l cessÁR o, No wÁx lo oE pÁc uRs, lus RRçÕ s, GúF cos, c.; uÃo E nERMITIDA n n enoouSo DE QUALQUER nARTE DEs E TRABALH9. T Assina u a con o me ca ão de ìden i icacão: Dedica ed o hose who ne e ga e up on me… 1 CSF-1 and Ang-2 se um le els: p ognos ic and diagnos ic pa ne s in Non-Small Cell Lung Cance – A hospi al-based s udy. Ana Luísa Coelho1,2,3,4, Mónica Pa ícia Gomes1,3,4, Raquel Jo ge Ca a ino1,4, Ch is ian Rol o5,6, Rui Manuel Medei os1,2,3, An ónio Manuel A aújo4,7,8* 1 – Molecula Oncology & Vi al Pa hology G oup, IPO-Po o Resea ch Cen e (CI- IPOP) 2 – Facul y o Medicine – Uni e si y o Po o, Po o, Po ugal. 3 – LPCC Resea ch Depa men -Po uguese League Agains Cance (NRNo e) Po o, Po ugal 4 – UMIB – Uni o Mul idisciplina y Resea ch in Biomedicine 5 – Phase I, Ea ly Clinical T ials Uni , An we p Uni e si y Hospi al, Edegem, Belgium 6 – Cen e o Oncological Resea ch (CORE), An we p Uni e si y, Edegem, Belgium 7 – Medical Oncology Se ice o Cen o Hospi ala do Po o, Po o (CHP); 8 – ICBAS-UP - Ins i u o de Ciências Biomédicas Abel Salaza -Uni e si y o Po o Co espondence o: P o esso An ónio A aújo; [email p o ec ed] 2 Abs ac Backg ound: Lung cance is he mos inciden and le hal o m o cance , wi h la e diagnosis as a majo de e minan o i s bad p ognosis. Immuno he apies a ge ing immune checkpoin s imp o e su i al, bu posi i e esul s encompass only 30-40% o he pa ien s, possibly due o al e na i e pa hways o immunosupp ession, including umo associa ed mac ophages (TAM). CSF-1 is implica ed in TAM di e en ia ion and ec ui men o umo s and in umo angiogenesis, h ough a special se ing o Tie-2- exp essing mac ophages, which espond o Angiopoie in-2 (Ang-2). We e alua ed he ole o se um le els o CSF-1 in NSCLC p ognosis and whe he hese could se e as bioma ke s o NSCLC de ec ion, along wi h Ang-2. Pa icipan s and me hods: We p ospec i ely s udied an unselec ed coho o 145 NSCLC pa ien s and a g oup o 30 con ol indi iduals. Se um le els o Ang -2 and CSF- 1 we e measu ed by ELISA p io o ea men . Resul s: Se um le els o CSF-1 and Ang-2 a e posi i ely co ela ed (p<0.000001). Indi iduals wi h high se um le els o CSF-1 p esen a se en een- old isk o NSCLC de elopmen and pa ien s wi h combined High Ang-2/CSF-1 se um le els p esen a 5- old inc eased isk o de eloping NSCLC. High Ang-2/CSF-1 pheno ype is also associa ed wi h wo s p ognosis in NSCLC. Conclusions: Combined exp ession o CSF-1 and Ang-2 seems o con ibu e o wo s p ognosis in NSCLC and i is wo hy o unde s and he basis o his unexplo ed pa ne ship. Mo eo e , we hink CSF-1 could be included as a bioma ke in NSCLC sc eening p o ocols ha can imp o e he posi i e p edic i e alue o he cu en sc eening modali ies, inc ease o e all cos e ec i eness, and po en ially imp o e lung cance su i al. 3 In oduc ion Lung cance is he mos common inciden o m o cance wo ldwide, wi h an es ima ed 1.8 million new cases in 2012, ep esen ing 12.9% o all new cance cases. The numbe o lung cance ela ed dea hs exceed hose om any o he ype o malignancy, accoun ing o nea ly one in i e dea hs (1.6 million dea hs in o al)1. App oxima ely 85% o hose cases a e cu en ly classi ied as non-small-cell lung cance s (NSCLCs), wi h wo p edominan his ological pheno ypes, adenoca cinoma (ADC; ~50%) and squamous cell ca cinoma (SCC; ~40%)2. Un o una ely, no sc eening p og am is p o en consis en o ea ly s age NSCLC de ec ion, when cu a i e su ge y is s ill an op ion3, and mos pa ien s wi h NSCLC p esen s a an ad anced s age o disease, when cu a i e ea men is no longe a possibili y, esul ing in a dismal p ognosis and low o e all su i al4 5. In he las decade, howe e , NSCLC ea men has e ol ed in an o e whelming ashion, mainly due o a ge ed app oaches, which ha e led o g ea imp o emen in ou comes o his disease6 7. Undoub edly, new agen s a ge ing immune checkpoin s (immune checkpoin inhibi o s), namely an ibodies ha block he p og ammed dea h-1 ecep o (PD-1) and i s ligand 1 (PD-L1) pa hway, a e among he mos powe ul he apeu ic s a egies app o ed in ecen yea s o ea ad anced NSCLC8. Despi e i s g ea impac in lung cance ea men , wi h du able esponses now obse ed in pa ien s wi h p e iously un ea able umo s9, objec i e esponse a es a e somewha disappoin ing and comple e esponses a e s ill a e6. This limi ed clinical success can be explained by he ac ha inhibi ion o T cell unc ions by PD-1 o e exp ession is jus one o he a ious mechanisms ha umou s use o sup ess he hos immune esponses and e ade elimina ion by he immune sys em6 10. Tumo -associa ed mac ophages (TAM), a majo componen o he s oma o solid umo s, (and he mos abundan cell popula ion in many cases), dese e ca e ul a en ion as main playe s in his con ex , owing o i s capaci y o supp ess T-cell esponses, inducing egula o y T cells and elici ing immune ole ance11-13. The ecognized impo ance o TAM in umo mic oen i onmen boos ed esea ch in he immuno he apy ield, aiming o s a egies o hal TAM ec ui men , di e en ia ion and unc ions14. TAM de i e om ci cula ing monocy es, which a e ec ui ed om he bloods eam in o umo s and, as hey ex a asa e ac oss he umo ascula u e, begin o di e en ia e in o ully ma u e mac ophages depending upon mic oen i onmen s imuli13 15. Colony s imula ing ac o ‑1 (CSF-1), also known as mac ophage colony-s imula ing 4 ac o (M-CSF), is he chemokine ha s ands ou mos , o i s p incipal ole in TAM biology9 14. I ’s a key egula o o monocy e ac i a ion, mig a ion and i s in lux o umo s16-18 and i is he mas e signal ha enhances mac ophages su i al and pola iza ion, d i ing TAM di e en ia ion owa ds an immunosupp essi e, umou - p omo ing pheno ype13 15. Apa om p omo ing umo escape om immune su eillance, CSF-1-educa ed TAM ha e a cen al ole in p omo ing angiogenesis11-14 19. A e y elegan s udy conduc ed by M. Fo ge and co-wo ke s showed ha CSF-1 is also in ol ed in he di e en ia ion o a subpopula ion o mac ophages which exp ess endo helial cell y osine kinase ecep o (Tie-2) (TEMs)20, ha di ec ly espond o angiopoie in-2 (Ang-2) and a e commi ed o in insic p oangiogenic ac i i y21 22. They es ablished a no el ole o CSF-1 in egula ing Tie2 ecep o exp ession on mac ophages in i o and in i o in a model o mu ine b eas cance and ha hese cells a e mo e esponsi e o Ang-2 s imula ion upon CSF-1 exposu e, esul ing in inc eased cell mig a ion and p o-angiogenic po en ial20. Se e al s udies ha e demons a ed ha solid umo s, including lung cance cells, o e exp ess CSF-1 and ha hese co ela e wi h g ea TAM in il a e and poo e p ognosis23. The aim o ou s udy was o e alua e he ole o se um le els o CSF-1 in NSCLC p ognosis and whe he hese could se e as bioma ke s o NSCLC de ec ion, using he same coho o pa ien s. We p e iously showed ha Ang-2 se um le els a e associa ed wi h NSCLC p ognosis and wi h he p obabili y o indi iduals p esen ing NSCLC24. A ending o he es ablished ole o CSF-1 in TEM di e en ia ion and o Ang- 2 in i s ec ui men o umo s, we also wande ed i Ang-2 and CSF-1 migh ha e linked se um exp ession in NSCLC pa ien s, since he e is no in o ma ion on his p obable pa ne ship in li e a u e, and which, i any, in luences i migh ha e in he ou come o his disease. To he bes o ou knowledge, his is he i s s udy o ocus on he simul aneous exp ession o CSF-1 and Ang-2 in NSCLC. Me hods Pa icipan s We p ospec i ely ec ui ed a g oup o 145 Caucasian indi iduals, admi ed o he Po uguese Ins i u e o Oncology o Po o (IPO-Po o), Po ugal, be ween 2006 and 2009, wi h cy ological o his ological newly diagnosed and un ea ed NSCLC, wi h an Eas e n 11 he da a. AC and RM coo dina ed he s udy. AC, AA, RC pa icipa ed in he d a o he manusc ip . All au ho s ead and app o ed he inal manusc ip . Con lic o in e es The au ho s decla e no con lic s o in e es . E hical app o al The s udy was app o ed by he local e hics commi ee a he Ins i u o Po uguês de Oncologia – Po o (Po ugal) and he na ional esea ch commi ee. Re e ences 1. Fe lay J, Soe joma a am I, Dikshi R, e al. Cance incidence and mo ali y wo ldwide: sou ces, me hods and majo pa e ns in GLOBOCAN 2012. In J Cance 2015;136(5):E359-86. doi: 10.1002/ijc.29210 2. Chen Z, Fillmo e CM, Hamme man PS, e al. Non-small-cell lung cance s: a he e ogeneous se o diseases. Na Re Cance 2014;14(8):535-46. doi: 10.1038/n c3775 3. Blanco-P ie o S, De Chia a L, Rod iguez-Gi ondo M, e al. Highly Sensi i e Ma ke Panel o Guidance in Lung Cance Rapid Diagnos ic Uni s. Sci Rep 2017;7:41151. doi: 10.1038/s ep41151 4. Da idson MR, Gazda AF, Cla ke BE. The pi o al ole o pa hology in he managemen o lung cance . J Tho ac Dis 2013;5 Suppl 5:S463-78. doi: 10.3978/j.issn.2072-1439.2013.08.43 5. E inge DS, Ake ley W, Bo ghaei H, e al. Non-small cell lung cance , e sion 2.2013. J Na l Comp Canc Ne w 2013;11(6):645-53; quiz 53. 6. Assi HI, Kampho s AO, Moukalled NM, e al. Immune checkpoin inhibi o s in ad anced non-small cell lung cance . Cance 2018;124(2):248-61. doi: 10.1002/cnc .31105 7. Be gsma DP, Salama JK, Singh DP, e al. Radio he apy o Oligome as a ic Lung Cance . F on Oncol 2017;7:210. doi: 10.3389/ onc.2017.00210 8. Rol o C, Cagle ic C, San a pia M, e al. Immuno he apy in NSCLC: A P omising and Re olu iona y Weapon. Ad Exp Med Biol 2017;995:97-125. doi: 10.1007/978- 3-319-53156-4_5 9. Ellio LA, Dohe y GA, Sheahan K, e al. Human Tumo -In il a ing Myeloid Cells: Pheno ypic and Func ional Di e si y. F on Immunol 2017;8:86. doi: 10.3389/ immu.2017.00086 10. Ae s JG, Hegmans JP. Tumo -speci ic cy o oxic T cells a e c ucial o e icacy o immunomodula o y an ibodies in pa ien s wi h lung cance . Cance Res 2013;73(8):2381-8. doi: 10.1158/0008-5472.CAN-12-3932 12 11. Alla ena P, Man o ani A. Immunology in he clinic e iew se ies; ocus on cance : umou -associa ed mac ophages: undispu ed s a s o he in lamma o y umou mic oen i onmen . Clin Exp Immunol 2012;167(2):195-205. doi: 10.1111/j.1365- 2249.2011.04515.x 12. Chanmee T, On ong P, Konno K, e al. Tumo -associa ed mac ophages as majo playe s in he umo mic oen i onmen . Cance s (Basel) 2014;6(3):1670-90. doi: 10.3390/cance s6031670 13. Lewis CE, Polla d JW. Dis inc ole o mac ophages in di e en umo mic oen i onmen s. Cance Res 2006;66(2):605-12. doi: 10.1158/0008- 5472.CAN-05-4005 14. Man o ani A, Ma chesi F, Malesci A, e al. Tumou -associa ed mac ophages as ea men a ge s in oncology. Na Re Clin Oncol 2017;14(7):399-416. doi: 10.1038/n clinonc.2016.217 15. Lewis CE, De Palma M, Naldini L. Tie2-exp essing monocy es and umo angiogenesis: egula ion by hypoxia and angiopoie in-2. Cance Res 2007;67(18):8429-32. doi: 10.1158/0008-5472.CAN-07-1684 16. Ugel S, De Sanc is F, Mand uzza o S, e al. Tumo -induced myeloid de ia ion: when myeloid-de i ed supp esso cells mee umo -associa ed mac ophages. J Clin In es 2015;125(9):3365-76. doi: 10.1172/JCI80006 17. Geissmann F, Manz MG, Jung S, e al. De elopmen o monocy es, mac ophages, and dend i ic cells. Science 2010;327(5966):656-61. doi: 10.1126/science.1178331 18. Van O e mei e E, S ijlemans B, Heymann F, e al. M-CSF and GM-CSF Recep o Signaling Di e en ially Regula e Monocy e Ma u a ion and Mac ophage Pola iza ion in he Tumo Mic oen i onmen . Cance Res 2016;76(1):35-42. doi: 10.1158/0008-5472.CAN-15-0869 19. Bingle L, B own NJ, Lewis CE. The ole o umou -associa ed mac ophages in umou p og ession: implica ions o new an icance he apies. J Pa hol 2002;196(3):254-65. doi: 10.1002/pa h.1027 20. Fo ge MA, Voo hees JL, Cole SL, e al. Mac ophage colony-s imula ing ac o augmen s Tie2-exp essing monocy e di e en ia ion, angiogenic unc ion, and ec ui men in a mouse model o b eas cance . PLoS One 2014;9(6):e98623. doi: 10.1371/jou nal.pone.0098623 21. De Palma M, Venne i MA, Galli R, e al. Tie2 iden i ies a hema opoie ic lineage o p oangiogenic monocy es equi ed o umo essel o ma ion and a mesenchymal popula ion o pe icy e p ogeni o s. Cance Cell 2005;8(3):211-26. doi: 10.1016/j.cc .2005.08.002 22. Mu doch C, Tazzyman S, Webs e S, e al. Exp ession o Tie-2 by human monocy es and hei esponses o angiopoie in-2. J Immunol 2007;178(11):7405-11. 23. Achko a D, Mahe J. Role o he colony-s imula ing ac o (CSF)/CSF-1 ecep o axis in cance . Biochem Soc T ans 2016;44(2):333-41. doi: 10.1042/BST20150245 24. Coelho AL, A aujo AM, Gomes MP, e al. Combined Ang-2 and VEGF se um le els: holding hands as a new in eg al bioma ke in non-small-cell lung cance s. Fu u e Oncol 2015;11(24):3233-42. doi: 10.2217/ on.15.207 25. S anley ER, Be g KL, Eins ein DB, e al. Biology and ac ion o colony--s imula ing ac o -1. Mol Rep od De 1997;46(1):4-10. doi: 10.1002/(SICI)1098- 2795(199701)46:1<4::AID-MRD2>3.0.CO;2-V 26. Dwye AR, G eenland EL, Pixley FJ. P omo ion o Tumo In asion by Tumo - Associa ed Mac ophages: The Role o CSF-1-Ac i a ed Phospha idylinosi ol 3 13 Kinase and S c Family Kinase Mo ili y Signaling. Cance s (Basel) 2017;9(6) doi: 10.3390/cance s9060068 27. De Palma M, Lewis CE. Mac ophage egula ion o umo esponses o an icance he apies. Cance Cell 2013;23(3):277-86. doi: 10.1016/j.cc .2013.02.013 28. Qian BZ, Polla d JW. Mac ophage di e si y enhances umo p og ession and me as asis. Cell 2010;141(1):39-51. doi: 10.1016/j.cell.2010.03.014 29. Ru ell B, A a a NI, Coussens LM. Di e en ial mac ophage p og amming in he umo mic oen i onmen . T ends Immunol 2012;33(3):119-26. doi: 10.1016/j.i .2011.12.001 30. Kubo a Y, Takubo K, Shimizu T, e al. M-CSF inhibi ion selec i ely a ge s pa hological angiogenesis and lymphangiogenesis. J Exp Med 2009;206(5):1089- 102. doi: 10.1084/jem.20081605 31. Kaminska J, Kowalska M, Ko owicz B, e al. P e ea men se um le els o cy okines and cy okine ecep o s in pa ien s wi h non-small cell lung cance , and co ela ions wi h clinicopa hological ea u es and p ognosis. M-CSF - an independen p ognos ic ac o . Oncology 2006;70(2):115-25. doi: 10.1159/000093002 32. Ka suma a N, Eguchi K, Fukuda M, e al. Se um le els o cy okines in pa ien s wi h un ea ed p ima y lung cance . Clin Cance Res 1996;2(3):553-9. 33. P iceman SJ, Sung JL, Shaposhnik Z, e al. Ta ge ing dis inc umo -in il a ing myeloid cells by inhibi ing CSF-1 ecep o : comba ing umo e asion o an iangiogenic he apy. Blood 2010;115(7):1461-71. doi: 10.1182/blood-2009- 08-237412 34. Wooda d GA, Jones KD, Jablons DM. Lung Cance S aging and P ognosis. Cance T ea Res 2016;170:47-75. doi: 10.1007/978-3-319-40389-2_3 35. Bach PB, Mi kin JN, Oli e TK, e al. Bene i s and ha ms o CT sc eening o lung cance : a sys ema ic e iew. JAMA 2012;307(22):2418-29. doi: 10.1001/jama.2012.5521 36. Gyoba J, Shan S, Roa W, e al. Diagnosing Lung Cance s h ough Examina ion o Mic o-RNA Bioma ke s in Blood, Plasma, Se um and Spu um: A Re iew and Summa y o Cu en Li e a u e. In J Mol Sci 2016;17(4):494. doi: 10.3390/ijms17040494 14 Tables Table 1 – Mul i a ia e logis ic eg ession analysis o se um high exp ession o Ang-2, CSF-1 and bo h combined ega ding he suscep ibili y o de elop NSCLC aOR 95%CI *P High Ang-2 2.59 1.13-5.93 0.025 High CSF-1 18.23 6.20-53.54 <0.000001 High Ang-2 and CSF-1(n=109) 5.12 2.12-12.35 0.0003 *aOR, 95% CI and P using logis ic eg ession analysis, adjus ed by age, smoking s a us and gende . Table 2 – Mul i a ia e Cox eg ession model adjus ed o p edic able de e minan s o poo ou come in NSCLC aHR 95%CI *P High Ang-2 1.88 1.23-2.88 0.003 High CSF-1 0.879 0.330-2.34 0.797 High Ang-2/CSF-1 1.61 1.06-2.42 0.026 *P, aOR and 95% CI using Cox eg ession analysis, adjus ed by umo s age, age, gende , his ological ype and smoking s a us. 15 Figu es Figu e 1 - Associa ion o se um le els o CSF-1 o e all su i al in NSCLC by Kaplan- Meie cu es. 16 Figu e 2 - Associa ion o combined se um le els o CSF-1 and Ang-2 wi h o e all su i al in NSCLC by Kaplan-Meie cu es. Acknowledgmen s This hesis p ecludes a e y long jou ney, ha begun way be o e I knew I would e e be able o pe o m i … A lo o playe s helped me o su pass his di icul le el o he game we call li e and o all o hem, I would like o exp ess my p o ound g a i ude. To P o esso Rui Medei os, I would like o hank he a ailabili y he showed each ime I needed him, o so many di e en easons… Despi e his busy schedule, he ne e said no o a mee ing, wi h o wi hou a cup o ea! Also, eassu e him ha Science will always make pa o my li e! To Núcleo Regional do No e da Liga Po uguesa con a o Canc o, in he pe son o Doc o Ví o Veloso, o he g an conceded o execu e his wo k. To he old iends and he new iends ha came ac oss my way… My g a i ude goes o all o hem, o making me smile in some poin o my li e! To my dea , dea , iend Mónica Gomes, o all he ime she spen helping me wi h he expe iences o simply lis ening o my complain s, like a eal iend does! She was my igh and le a ms in he lab and ou o i , and I am no su e wha I would ha e done wi hou he … To Raquel Ca a ino, whom I easu e like a sis e , which has he igh amoun o pa ience and madness o ake ca e o me and pu me back in game when I am abou o qui , I hank om he bo om o my hea o ne e , e e , le ing me down! You know how much I lo e you! To my amily… well, how can I e e hank hem enough? My suppo i e, lo e and ca ing pa en s, my ou o his wo ld b o he , my nephews, my sis e in law… You all had a e y special pa in his ou e I made, hand in hand wi h me… I will y o ake ca e o you like you did wi h me! To my husband… I ha e a lo o hings o hank him o , om he i s momen I encoun e ed him un il oday… I hank him o showing me how being a Medical Doc o is such a special hing, ha we can ne e gi e up on ou d eam o being one! I hank him o encou aging me and helping me o accomplish his s age, o unde s anding I am an agog pe son, p o iding me he eedom o deal wi h my doub s and inne de ils. Bu mos o all, I hank him o he g ea es achie emen o my li e, ou lo ely son... His shinning smile is he eason I keep playing, ne e gi ing up, o make su e he lea ns ha wi h ha d wo k and he w igh skills, he can do wha e e he pleases wi h his u u e li e and is able o deal wi h he inc easing le els o di icul y his game will b ing him! Annexes I – ESMO Open Ins uc ions o Au ho s Annex I – ESMO Open Ins uc ions o Au ho s Ins uc ions o au ho s ESMO Open is a new online-only, pee - e iewed, Open Access oncology jou nal published by BMJ on behal o he Eu opean Socie y o Medical Oncology (ESMO). The jou nal aims o ope a e a as submission and e iew p ocess wi h con inuous publica ion online, o ensu e ha imely, up- o-da e esea ch is a ailable wo ldwide. The jou nal adhe es o a igo ous and anspa en pee e iew p ocess. Submissions should be made h ough he ESMO Open Submission Si e. All submissions a e subjec o ex e nal pee e iew. Submission o he jou nal implies ha he wo k desc ibed has no been accep ed o publica ion elsewhe e, ha i is no unde conside a ion o publica ion elsewhe e and does no duplica e ma e ial al eady published. Au ho s e ain copy igh o hei wo k and a icles a e published unde a C ea i e Commons licence. Publishing in ESMO Open enables you o ul il he open access equi emen s o unde s such as he Wellcome T us and Resea ch Councils UK, including using hei p e e ed CC-BY licence. MANUSCRIPT TRANSFERS You can op o ha e you a icle ans e ed o ESMO Open i ejec ed om Annals o Oncology o ano he BMJ jou nal. Once au ho s ag ee o hei manusc ip o be ans e ed o ESMO Open, he e will be no need o esubmission and any e iewe commen s will also be sha ed, esul ing in a educed ime o decision. Manusc ip s will be e alua ed sepa a ely by ESMO Open’s edi o ial eam, wi h di e en c i e ia o accep ance. T ans e o ESMO Open does no gua an ee accep ance. Please no e ha ESMO Open cha ges an a icle publishing cha ge (APC) – see A icle Publishing Cha ge below o mo e in o ma ion. SUBMISSION GUIDELINES Fo guidelines on submission and edi o ial policies o ESMO Open please e e o he BMJ Au ho Hub. He e you will ind in o ma ion on planning you esea ch h ough o submi ing and p omo ing you esea ch. Be o e you submi W i ing and o ma ing Policies A e submi ing P omo ing you pape Open Access Re iewing manusc ip s ARTICLE TYPES Please e iew he below speci ica ions o each a icle ype and he equi ed a icle leng hs, illus a ions and able limi s, and e e ences coun s. The wo d coun excludes he i le page, abs ac , ables, acknowledgemen s and con ibu ions, and e e ences. Manusc ip s should be as succinc as possible. O iginal esea ch P o ocols Re iews Edi o ials Co espondence News Images in oncology O iginal Resea ch Full pape s should ollow he basic s uc u e o abs ac , in oduc ion, me hods, esul s, discussion, e e ences, and ables and igu es as app op ia e. The e is an online da a