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Epithelial and Stromal Characteristics of Primary Tumors Predict the Bone Metastatic Subtype of Prostate Cancer and Patient Survival after Androgen-Deprivation Therapy. Cancers (Basel) 2022; 14:cancers14215195. [PMID: 36358614 PMCID: PMC9659192 DOI: 10.3390/cancers14215195] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2022] [Revised: 10/17/2022] [Accepted: 10/20/2022] [Indexed: 12/02/2022] Open
Abstract
Simple Summary Metastatic prostate cancer is a lethal disease and metastasis-specific treatments need to be developed. Mechanisms driving metastases and primary tumor growth could be different, but this is largely unexplored. We previously discovered that bone metastases can be separated into transcriptomic-based subtypes, showing different responses to standard androgen-deprivation therapy for metastatic prostate cancer. One subtype, named MetB, is particularly aggressive and has the worst prognosis. Here, we describe similarities and differences between primary tumors and their metastases, and specifically examine if the development of specific subtype of bone metastases can be predicted by analyzing the primary tumor. Results show that many aspects of prostate cancer bone metastases morphology are related to those in the primary tumor, while others are not. Importantly, men with primary tumors with high cell proliferation and low cellular PSA expression tend to develop metastases enriched for the MetB subtype, have poor prognosis, and need complementary treatment to standard hormone treatment. Abstract Prostate cancer (PC) bone metastases can be divided into transcriptomic subtypes, by us termed MetA-C. The MetB subtype, constituting about 20% of the cases, is characterized by high cell cycle activity, low androgen receptor (AR) activity, and a limited response to standard androgen deprivation therapy (ADT). Complementary treatments should preferably be introduced early on if the risk of developing metastases of the MetB subtype is predicted to behigh. In this study, we therefore examined if the bone metastatic subtype and patient outcome after ADT could be predicted by immunohistochemical analysis of epithelial and stromal cell markers in primary tumor biopsies obtained at diagnosis (n = 98). In this advanced patient group, primary tumor International Society of Urological Pathology (ISUP) grade was not associated with outcome or metastasis subtype. In contrast, high tumor cell Ki67 labeling (proliferation) in combination with low tumor cell immunoreactivity for PSA, and a low fraction of AR positive stroma cells in the primary tumors were prognostic for poor survival after ADT. Accordingly, the same tissue markers were associated with developing metastases enriched for the aggressive MetB subtype. The development of the contrasting MetA subtype, showing the best response to ADT, could be predicted by the opposite staining pattern. We conclude that outcome after ADT and metastasis subtype can, at least to some extent, be predicted by analysis of primary tumor characteristics, such as tumor cell proliferation and PSA expression, and AR expression in stromal cells.
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Halin Bergström S, Lundholm M, Nordstrand A, Bergh A. Rat prostate tumors induce DNA synthesis in remote organs. Sci Rep 2022; 12:7908. [PMID: 35551231 PMCID: PMC9098422 DOI: 10.1038/s41598-022-12131-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2021] [Accepted: 05/05/2022] [Indexed: 11/09/2022] Open
Abstract
Advanced cancers induce systemic responses. However, if such systemic changes occur already when aggressive tumors are small, have not been thoroughly characterized. Here, we examined how localized prostate cancers of different sizes and metastatic potential affected DNA synthesis in the rest of the prostate and in various remote organs. Non-metastatic Dunning R-3327 G (G) tumor cells, metastatic MatLyLu (MLL) tumor cells, or vehicle were injected into the prostate of immunocompetent rats. All animals received daily injections of Bromodeoxyuridine (BrdU), to label cells/daughter cells with active DNA synthesis. Equal sized G- and MLL-tumors, similarly increased BrdU-labeling in the prostate, lymph nodes and liver compared to tumor-free controls. Prior to metastasis, MLL-tumors also increased BrdU-labeling in bone marrow and lungs compared to animals with G-tumors or controls. In animals with MLL-tumors, BrdU-labeling in prostate, lungs, brown adipose tissue and skeletal muscles increased in a tumor-size-dependent way. Furthermore, MLL-tumors induced increased signs of DNA damage (γH2AX staining) and accumulation of CD68 + macrophages in the lungs. In conclusion, small localized prostate cancers increased DNA synthesis in several remote tissues in a tumor type- and size-dependent way. This may suggest the possibility for early diagnosis of aggressive prostate cancer by examining tumor-induced effects in other tissues.
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Affiliation(s)
- Sofia Halin Bergström
- Department of Medical Biosciences, Pathology, Umeå University, Building 6M, second floor, 901 87, Umeå, Sweden.
| | - Marie Lundholm
- Department of Medical Biosciences, Pathology, Umeå University, Building 6M, second floor, 901 87, Umeå, Sweden
| | - Annika Nordstrand
- Department of Medical Biosciences, Pathology, Umeå University, Building 6M, second floor, 901 87, Umeå, Sweden
| | - Anders Bergh
- Department of Medical Biosciences, Pathology, Umeå University, Building 6M, second floor, 901 87, Umeå, Sweden
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Thysell E, Köhn L, Semenas J, Järemo H, Freyhult E, Lundholm M, Thellenberg Karlsson C, Damber J, Widmark A, Crnalic S, Josefsson A, Welén K, Nilsson RJA, Bergh A, Wikström P. Clinical and biological relevance of the transcriptomic-based prostate cancer metastasis subtypes MetA-C. Mol Oncol 2022; 16:846-859. [PMID: 34889043 PMCID: PMC8847984 DOI: 10.1002/1878-0261.13158] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2021] [Revised: 10/10/2021] [Accepted: 12/09/2021] [Indexed: 11/11/2022] Open
Abstract
To improve treatment of metastatic prostate cancer, the biology of metastases needs to be understood. We recently described three subtypes of prostate cancer bone metastases (MetA-C), based on differential gene expression. The aim of this study was to verify the clinical relevance of these subtypes and to explore their biology and relations to genetic drivers. Freshly-frozen metastasis samples were obtained as hormone-naive (n = 17), short-term castrated (n = 21), or castration-resistant (n = 65) from a total of 67 patients. Previously published sequencing data from 573 metastasis samples were also analyzed. Through transcriptome profiling and sample classification based on a set of predefined MetA-C-differentiating genes, we found that most metastases were heterogeneous for the MetA-C subtypes. Overall, MetA was the most common subtype, while MetB was significantly enriched in castration-resistant samples and in liver metastases, and consistently associated with poor prognosis. By gene set enrichment analysis, the phenotype of MetA was described by high androgen response, protein secretion and adipogenesis, MetB by high cell cycle activity and DNA repair, and MetC by epithelial-to-mesenchymal transition and inflammation. The MetB subtype demonstrated single nucleotide variants of RB transcriptional corepressor 1 (RB1) and loss of 21 genes at chromosome 13, including RB1, but provided independent prognostic value to those genetic aberrations. In conclusion, a distinct set of gene transcripts can be used to classify prostate cancer metastases into the subtypes MetA-C. The MetA-C subtypes show diverse biology, organ tropism, and prognosis. The MetA-C classification may be used independently, or in combination with genetic markers, primarily to identify MetB patients in need of complementary therapy to conventional androgen receptor-targeting treatments.
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Affiliation(s)
- Elin Thysell
- Department of Medical Biosciences, PathologyUmeå UniversitySweden
| | - Linda Köhn
- Department of Radiation Sciences, OncologyUmeå UniversitySweden
| | - Julius Semenas
- Department of Medical Biosciences, PathologyUmeå UniversitySweden
| | - Helena Järemo
- Department of Medical Biosciences, PathologyUmeå UniversitySweden
| | - Eva Freyhult
- Department of Cell and Molecular BiologyNational Bioinformatics Infrastructure SwedenScience for Life LaboratoryUppsala UniversitySweden
| | - Marie Lundholm
- Department of Medical Biosciences, PathologyUmeå UniversitySweden
| | | | - Jan‐Erik Damber
- Department of UrologySahlgrenska Center for Cancer ResearchInstitute of Clinical SciencesSahlgrenska AcademyUniversity of GothenburgSweden
| | - Anders Widmark
- Department of Radiation Sciences, OncologyUmeå UniversitySweden
| | - Sead Crnalic
- Department of Surgery and Perioperative Sciences, OrthopedicsUmeå UniversitySweden
| | - Andreas Josefsson
- Department of UrologySahlgrenska Center for Cancer ResearchInstitute of Clinical SciencesSahlgrenska AcademyUniversity of GothenburgSweden
- Department of Surgery and Perioperative Sciences, Urology & AndrologyUmeå UniversitySweden
- Wallenberg Center for Molecular MedicineUmeå UniversitySweden
| | - Karin Welén
- Department of UrologySahlgrenska Center for Cancer ResearchInstitute of Clinical SciencesSahlgrenska AcademyUniversity of GothenburgSweden
| | | | - Anders Bergh
- Department of Medical Biosciences, PathologyUmeå UniversitySweden
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Akinduro OO, De Biase G, Goyal A, Meyer JH, Sandhu SJS, Kowalchuk RO, Trifiletti DM, Sheehan J, Merrell KW, Vora SA, Broderick DF, Clarke MJ, Bydon M, McClendon J, Kalani MA, Quiñones-Hinojosa A, Abode-Iyamah K. Focused versus conventional radiotherapy in spinal oncology: is there any difference in fusion rates and pseudoarthrosis? J Neurooncol 2022; 156:329-339. [PMID: 34993721 DOI: 10.1007/s11060-021-03915-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2021] [Accepted: 11/26/2021] [Indexed: 10/19/2022]
Abstract
INTRODUCTION Radiotherapy is considered standard of care for adjuvant peri-operative treatment of many spinal tumors, including those with instrumented fusion. Unfortunately, radiation treatment has been linked to increased risk of pseudoarthrosis. Newer focused radiotherapy strategies with enhanced conformality could offer improved fusion rates for these patients, but this has not been confirmed. METHODS We performed a retrospective analysis of patients at three tertiary care academic institutions with primary and secondary spinal malignancies that underwent resection, instrumented fusion, and peri-operative radiotherapy. Two board certified neuro-radiologists used the Lenke fusion score to grade fusion status at 6 and 12-months after surgery. Secondary outcomes included clinical pseudoarthrosis, wound complications, the effect of radiation timing and radiobiological dose delivered, the use of photons versus protons, tumor type, tumor location, and use of autograft on fusion outcomes. RESULTS After review of 1252 spinal tumor patients, there were 60 patients with at least 6 months follow-up that were included in our analyses. Twenty-five of these patients received focused radiotherapy, 20 patients received conventional radiotherapy, and 15 patients were treated with protons. There was no significant difference between the groups for covariates such as smoking status, obesity, diabetes, intraoperative use of autograft, and use of peri-operative chemotherapy. There was a significantly higher rate of fusion for patients treated with focused radiotherapy compared to those treated with conventional radiotherapy at 6-months (64.0% versus 30.0%, Odds ratio: 4.15, p = 0.036) and 12-months (80.0% versus 42.1%, OR: 5.50, p = 0.022). There was a significantly higher rate of clinical pseudoarthrosis in the conventional radiotherapy cohort compared to patients in the focused radiotherapy cohort (19.1% versus 0%, p = 0.037). There was no difference in fusion outcomes for any of the secondary outcomes except for use of autograft. The use of intra-operative autograft was associated with an improved fusion at 12-months (66.7% versus 37.5%, OR: 3.33, p = 0.043). CONCLUSION Focused radiotherapy may be associated with an improved rate of fusion and clinical pseudoarthrosis when compared to conventional radiation delivery strategies in patients with spinal tumors. Use of autograft at the time of surgery may be associated with improved 12-month fusion rates. Further large-scale prospective and randomized controlled studies are needed to better stratify the effects of radiation delivery modality in these patients.
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Affiliation(s)
| | - Gaetano De Biase
- Department of Neurosurgery, Mayo Clinic, Jacksonville, FL, 32224, USA
| | - Anshit Goyal
- Department of Neurosurgery, Mayo Clinic, Jacksonville, FL, 32224, USA
| | - Jenna H Meyer
- Department of Neurosurgery, Mayo Clinic, Phoenix, AZ, USA
| | | | | | | | - Jason Sheehan
- Department of Neurosurgery, University of Virginia, Charlottesville, VA, USA
| | | | - Sujay A Vora
- Department of Radiation Oncology, Mayo Clinic, Phoenix, AZ, USA
| | | | | | - Mohamad Bydon
- Department of Neurosurgery, Mayo Clinic, Rochester, MN, USA
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Leach DA, Fernandes RC, Bevan CL. Cellular specificity of androgen receptor, coregulators, and pioneer factors in prostate cancer. ENDOCRINE ONCOLOGY (BRISTOL, ENGLAND) 2022; 2:R112-R131. [PMID: 37435460 PMCID: PMC10259329 DOI: 10.1530/eo-22-0065] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 08/26/2022] [Accepted: 09/08/2022] [Indexed: 07/13/2023]
Abstract
Androgen signalling, through the transcription factor androgen receptor (AR), is vital to all stages of prostate development and most prostate cancer progression. AR signalling controls differentiation, morphogenesis, and function of the prostate. It also drives proliferation and survival in prostate cancer cells as the tumour progresses; given this importance, it is the main therapeutic target for disseminated disease. AR is also essential in the surrounding stroma, for the embryonic development of the prostate and controlling epithelial glandular development. Stromal AR is also important in cancer initiation, regulating paracrine factors that excite cancer cell proliferation, but lower stromal AR expression correlates with shorter time to progression/worse outcomes. The profile of AR target genes is different between benign and cancerous epithelial cells, between castrate-resistant prostate cancer cells and treatment-naïve cancer cells, between metastatic and primary cancer cells, and between epithelial cells and fibroblasts. This is also true of AR DNA-binding profiles. Potentially regulating the cellular specificity of AR binding and action are pioneer factors and coregulators, which control and influence the ability of AR to bind to chromatin and regulate gene expression. The expression of these factors differs between benign and cancerous cells, as well as throughout disease progression. The expression profile is also different between fibroblast and mesenchymal cell types. The functional importance of coregulators and pioneer factors in androgen signalling makes them attractive therapeutic targets, but given the contextual expression of these factors, it is essential to understand their roles in different cancerous and cell-lineage states.
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Affiliation(s)
- Damien A Leach
- Division of Cancer, Imperial Centre for Translational & Experimental Medicine, Imperial College London, Hammersmith Hospital Campus, London, UK
| | - Rayzel C Fernandes
- Division of Cancer, Imperial Centre for Translational & Experimental Medicine, Imperial College London, Hammersmith Hospital Campus, London, UK
| | - Charlotte L Bevan
- Division of Cancer, Imperial Centre for Translational & Experimental Medicine, Imperial College London, Hammersmith Hospital Campus, London, UK
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Thysell E, Vidman L, Ylitalo EB, Jernberg E, Crnalic S, Iglesias-Gato D, Flores-Morales A, Stattin P, Egevad L, Widmark A, Rydén P, Bergh A, Wikström P. Gene expression profiles define molecular subtypes of prostate cancer bone metastases with different outcomes and morphology traceable back to the primary tumor. Mol Oncol 2019; 13:1763-1777. [PMID: 31162796 PMCID: PMC6670017 DOI: 10.1002/1878-0261.12526] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2019] [Revised: 04/25/2019] [Accepted: 06/23/2019] [Indexed: 12/13/2022] Open
Abstract
Bone metastasis is the lethal end-stage of prostate cancer (PC), but the biology of bone metastases is poorly understood. The overall aim of this study was therefore to explore molecular variability in PC bone metastases of potential importance for therapy. Specifically, genome-wide expression profiles of bone metastases from untreated patients (n = 12) and patients treated with androgen-deprivation therapy (ADT, n = 60) were analyzed in relation to patient outcome and to morphological characteristics in metastases and paired primary tumors. Principal component analysis and unsupervised classification were used to identify sample clusters based on mRNA profiles. Clusters were characterized by gene set enrichment analysis and related to histological and clinical parameters using univariate and multivariate statistics. Selected proteins were analyzed by immunohistochemistry in metastases and matched primary tumors (n = 52) and in transurethral resected prostate (TUR-P) tissue of a separate cohort (n = 59). Three molecular subtypes of bone metastases (MetA-C) characterized by differences in gene expression pattern, morphology, and clinical behavior were identified. MetA (71% of the cases) showed increased expression of androgen receptor-regulated genes, including prostate-specific antigen (PSA), and glandular structures indicating a luminal cell phenotype. MetB (17%) showed expression profiles related to cell cycle activity and DNA damage, and a pronounced cellular atypia. MetC (12%) exhibited enriched stroma-epithelial cell interactions. MetB patients had the lowest serum PSA levels and the poorest prognosis after ADT. Combined analysis of PSA and Ki67 immunoreactivity (proliferation) in bone metastases, paired primary tumors, and TUR-P samples was able to differentiate MetA-like (high PSA, low Ki67) from MetB-like (low PSA, high Ki67) tumors and demonstrate their different prognosis. In conclusion, bone metastases from PC patients are separated based on gene expression profiles into molecular subtypes with different morphology, biology, and clinical outcome. These findings deserve further exploration with the purpose of improving treatment of metastatic PC.
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Affiliation(s)
- Elin Thysell
- Department of Medical Biosciences, Pathology, Umeå University, Sweden
| | - Linda Vidman
- Department of Mathematics and Mathematical Statistics, Umeå University, Sweden
| | | | - Emma Jernberg
- Department of Medical Biosciences, Pathology, Umeå University, Sweden
| | - Sead Crnalic
- Department of Surgical and Perioperative Sciences, Orthopaedics, Umeå University, Sweden
| | - Diego Iglesias-Gato
- Department of Drug Design and Pharmacology, Faculty of Health and Medical Sciences, University of Copenhagen, Denmark
| | - Amilcar Flores-Morales
- Department of Drug Design and Pharmacology, Faculty of Health and Medical Sciences, University of Copenhagen, Denmark
| | - Pär Stattin
- Department of Surgical Sciences, Uppsala University, Sweden
| | - Lars Egevad
- Department of Pathology and Cytology, Karolinska University Hospital, Stockholm, Sweden
| | - Anders Widmark
- Department of Radiation Sciences, Oncology, Umeå University, Sweden
| | - Patrik Rydén
- Department of Mathematics and Mathematical Statistics, Umeå University, Sweden
| | - Anders Bergh
- Department of Medical Biosciences, Pathology, Umeå University, Sweden
| | - Pernilla Wikström
- Department of Medical Biosciences, Pathology, Umeå University, Sweden
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Iglesias-Gato D, Thysell E, Tyanova S, Crnalic S, Santos A, Lima TS, Geiger T, Cox J, Widmark A, Bergh A, Mann M, Flores-Morales A, Wikström P. The Proteome of Prostate Cancer Bone Metastasis Reveals Heterogeneity with Prognostic Implications. Clin Cancer Res 2018; 24:5433-5444. [DOI: 10.1158/1078-0432.ccr-18-1229] [Citation(s) in RCA: 54] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2018] [Revised: 06/13/2018] [Accepted: 07/18/2018] [Indexed: 11/16/2022]
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Jernberg E, Bergh A, Wikström P. Clinical relevance of androgen receptor alterations in prostate cancer. Endocr Connect 2017; 6:R146-R161. [PMID: 29030409 PMCID: PMC5640574 DOI: 10.1530/ec-17-0118] [Citation(s) in RCA: 81] [Impact Index Per Article: 11.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/21/2017] [Accepted: 09/19/2017] [Indexed: 12/20/2022]
Abstract
Prostate cancer (PC) remains a leading cause of cancer-related deaths among men worldwide, despite continuously improved treatment strategies. Patients with metastatic disease are treated by androgen deprivation therapy (ADT) that with time results in the development of castration-resistant prostate cancer (CRPC) usually established as metastases within bone tissue. The androgen receptor (AR) transcription factor is the main driver of CRPC development and of acquired resistance to drugs given for treatment of CRPC, while a minority of patients have CRPC that is non-AR driven. Molecular mechanisms behind epithelial AR reactivation in CRPC include AR gene amplification and overexpression, AR mutations, expression of constitutively active AR variants, intra-tumoural and adrenal androgen synthesis and promiscuous AR activation by other factors. This review will summarize AR alterations of clinical relevance for patients with CRPC, with focus on constitutively active AR variants, their possible association with AR amplification and structural rearrangements as well as their ability to predict patient resistance to AR targeting drugs. The review will also discuss AR signalling in the tumour microenvironment and its possible relevance for metastatic growth and therapy.
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Affiliation(s)
- Emma Jernberg
- Department of Medical biosciencesUmeå University, Umeå, Sweden
| | - Anders Bergh
- Department of Medical biosciencesUmeå University, Umeå, Sweden
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Nordstrand A, Bergström SH, Thysell E, Bovinder-Ylitalo E, Lerner UH, Widmark A, Bergh A, Wikström P. Inhibition of the insulin-like growth factor-1 receptor potentiates acute effects of castration in a rat model for prostate cancer growth in bone. Clin Exp Metastasis 2017; 34:261-271. [PMID: 28447314 PMCID: PMC5442252 DOI: 10.1007/s10585-017-9848-8] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2016] [Accepted: 04/19/2017] [Indexed: 12/30/2022]
Abstract
Prostate cancer (PCa) patients with bone metastases are primarily treated with androgen deprivation therapy (ADT). Less pronounced ADT effects are seen in metastases than in primary tumors. To test if acute effects of ADT was enhanced by concurrent inhibition of pro-survival insulin-like growth factor 1 (IGF-1), rats were inoculated with Dunning R3327-G tumor cells into the tibial bone marrow cavity and established tumors were treated with castration in combination with IGF-1 receptor (IGF-1R) inhibitor NVP-AEW541, or by each treatment alone. Dunning R3327-G cells were stimulated by androgens and IGF-1 in vitro. In rat tibia, Dunning R3327-G cells induced bone remodeling, identified through increased immunoreactivity of osteoblast and osteoclast markers. Tumor cells occasionally grew outside the tibia, and proliferation and apoptotic rates a few days after treatment were evaluated by scoring BrdU- and caspase-3-positive tumor cells inside and outside the bone marrow cavity, separately. Apoptosis was significantly induced outside, but unaffected inside, the tibial bone by either castration or NVP-AEW541, and the maximum increase (2.7-fold) was obtained by the combined treatment. Proliferation was significantly reduced by NVP-AEW541, independently of growth site, although the maximum decrease (24%) was observed when NVP-AEW541 was combined with castration. Tumor cell IGF-1R immunoreactivity was evaluated in clinical PCa bone metastases (n = 61), and positive staining was observed in most cases (74%). In conclusion, IGF-1R inhibition may be evaluated in combination with ADT in patients with metastatic PCa, or in combination with therapies for the subsequent development of castration-resistant disease, although diverse responses could be anticipated depending on metastasis site.
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Affiliation(s)
- Annika Nordstrand
- Department of Radiation Sciences, Oncology, Umeå University, Umeå, Sweden
| | | | - Elin Thysell
- Department of Medical Biosciences, Pathology, Umeå University, Umeå, Sweden
| | | | - Ulf H Lerner
- Department of Molecular Periodontology, Umeå University, Umeå, Sweden.,Centre for Bone and Arthritis Research, Department of Internal Medicine and Clinical Nutrition at Institute for Medicine, Sahlgrenska Academy at University of Gothenburg, Gothenburg, Sweden
| | - Anders Widmark
- Department of Radiation Sciences, Oncology, Umeå University, Umeå, Sweden
| | - Anders Bergh
- Department of Medical Biosciences, Pathology, Umeå University, Umeå, Sweden
| | - Pernilla Wikström
- Department of Medical Biosciences, Pathology, Umeå University, Umeå, Sweden.
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