(2021) 21:454Tanaka et al. Cancer Cell r Cell InternationalOpen AccessREVIEWThe current issues and future perspectiveof artificial intelligence for developing newtreatment strategy in non‑small cell lung cancer:harmonization of molecular cancer biologyand artificial intelligenceIchidai Tanaka1* , Taiki Furukawa2 and Masahiro Morise1AbstractComprehensive analysis of omics data, such as genome, transcriptome, proteome, metabolome, and interactome,is a crucial technique for elucidating the complex mechanism of cancer onset and progression. Recently, a varietyof new findings have been reported based on multi-omics analysis in combination with various clinical information. However, integrated analysis of multi-omics data is extremely labor intensive, making the development of newanalysis technology indispensable. Artificial intelligence (AI), which has been under development in recent years, isquickly becoming an effective approach to reduce the labor involved in analyzing large amounts of complex dataand to obtain valuable information that is often overlooked in manual analysis and experiments. The use of AI, suchas machine learning approaches and deep learning systems, allows for the efficient analysis of massive omics datacombined with accurate clinical information and can lead to comprehensive predictive models that will be desirablefor further developing individual treatment strategies of immunotherapy and molecular target therapy. Here, we aimto review the potential of AI in the integrated analysis of omics data and clinical information with a special focus onrecent advances in the discovery of new biomarkers and the future direction of personalized medicine in non-smalllung cancer.Keywords: Artificial intelligence, NSCLCIntroductionTo improve prognosis of cancer patients, there is a growing trend to analyze numerous types of omics data, suchas DNA, RNA, microRNA, protein, and metabolites [1,2]. Many researchers have been aiming to develop identified markers for clinical application of early cancer detection, prognosis prediction, and evaluation of treatment*Correspondence: firstname.lastname@example.orgDepartment of Respiratory Medicine, Nagoya University GraduateSchool of Medicine, 65 Tsurumai‑cho, Showa‑ku, Nagoya 466‑8550, JapanFull list of author information is available at the end of the articleefficacy. The recent advent of next generation sequencing(NGS) has permitted the generation of comprehensiveprofiles of somatic mutations in various cancer types andhas contributed to the rapid advancements made in thefield of cancer research. Genome sequence-based studies of large numbers of clinical samples, such as thoseavailable through The Cancer Genome Atlas (TCGA)and International Cancer Genome Consortium (ICGA),have led to the identification of a variety of driver genemutations and oncogenic signaling pathways that givecancer cells a fundamental growth advantage duringtheir neoplastic transformation [3–7]. These studies have The Author(s) 2021. Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, whichpermits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to theoriginal author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images orother third party material in this article are included in the article’s Creative Commons licence, unless indicated otherwise in a credit lineto the material. If material is not included in the article’s Creative Commons licence and your intended use is not permitted by statutoryregulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of thislicence, visit http:// creat iveco mmons. org/ licen ses/ by/4. 0/. The Creative Commons Public Domain Dedication waiver (http:// creat iveco mmons. org/ publi cdoma in/ zero/1. 0/) applies to the data made available in this article, unless otherwise stated in a credit line to the data.
Tanaka et al. Cancer Cell Int(2021) 21:454revealed significant genomic heterogeneity, not only indifferent regions of the same patient, but also within asingle tumor, and are contributing to the elucidation ofthe essential qualities of cancer development and progression . Furthermore, numerous biological networksof genetic mutations affecting DNA copy number, methylation, the proteome, and the transcriptome have beendramatically demonstrated in cancer systems [9–12]. Inaddition, the recent advanced omics-technologies allowus to conduct single cell multi-omics sequencing, whichcan characterize the unique genotype and phenotypeof each individual cell. This approach can provide newinsights into tumor heterogeneity and deep characterization of the tumor microenvironment at a single-cell resolution . Therefore, integration of these diverse omicsdata with highly accurate clinical information should leadto new clinical developments regarding the preventionof cancer onset and new treatment strategies based onintratumoral heterogeneity.In parallel with the development of omics data analysis, recent exploitation of artificial intelligence (AI)based technology has progressed rapidly. The theory ofAI itself has existed since around the time of World WarII, but several endeavors at developing AI failed due toproblems associated with the lack of computing power.However, the application of AI in molecular biology hasbecome more common with the advancements in computer technology. In accordance with the developmentof AI technology, trained deep learning has graduallyevolved and currently plays an important role in clinical applications, especially in analyzing radiographs[14–16] and pathological images [17–19]. Meanwhile, themachine learning approach remains to be used mainly foromics data analysis due to the features of small samplesizes and large dimension data . Multiple omics databases, such as TCGA and ICGA, have been dramaticallyexpanded. Additionally, recent new multilayer omicsanalyses, such as single-cell sequencing, have been generating an extremely huge amount of data, resulting in therapid evaluation of these massive amounts of data beingbeyond the capabilities of manual analysis. To reducethe level of labor involved in analyzing huge amounts ofcomplex omics data, successful collaborations betweenbiologists and computer scientists are required. Ultimately, machine learning approaches will play a centralrole in the creation of efficient strategies for promotingpositive cancer research outcomes.Among the numerous types of cancer, lung cancercan be a pervasive disease that is commonly diagnosedat advanced stages, with non-small-cell lung cancer(NSCLC) being the most prevalent form of lung cancer. In recent decades, two innovative treatment strategies have been established to achieve long-term survivalPage 2 of 14of patients with advanced NSCLC. The first one wasbased on the discovery of druggable oncogenic drivermutations or fusions. The second was the developmentof immune oncology, which is especially represented byimmune checkpoint inhibitors (ICIs). Pivotal clinical trials have led to the establishment of a variety of first-linetherapies as standard treatment strategies for subgroupsof patients with NSCLC based on oncogenic driver mutation status and programmed death-ligand 1 (PD-L1)tumor proportion scores [22–25]. Furthermore, variousclinical trials investigating new compounds or combination therapies with existing antineoplastic agents havebeen performed or are ongoing for each subgroup ofNSCLC. Unfortunately, primary and acquired resistanceagainst new strategies are a relevant issue and a primaryconcern as resistance complicates the decision of choosing the best therapeutic strategy among the numeroustreatment options available. Therefore, establishmentof AI-based comprehensive predictive models for efficacy and toxicity of each treatment is particularly desirable in terms of further developing individual treatmentstrategies. In this review, we summarize recent medicalapplications of AI for the analysis of omics data in combination with clinical information for NSCLC and discussfuture application of this magnificent and powerful technology to clinical fields.AI in medicine—concepts and utilizationClassification of AIAccording to the algorithm used, AI is categorized as“rule-based,” which is called AI in a broad sense, and“non-rule-based,” which is referred to as machine learning. For rule-based algorithms, a person provides conditional branches and rules to solve for an optimal answer.For example, if a person defines the AI algorithm withthe condition that "when study number of two databasesare the same, they are regarded as duplicates and shouldbe integrated," the algorithm will be fully faithful to thecommand and integrate the numbers. A rule-based algorithm is effective in limited situations in which there arelimited choices. However, it is difficult to create a rulebased algorithm under complicated situations.In contrast, machine learning automatically generatesrules from known training data and applies them to themachine-learning algorithm using statistical analysis.Therefore, machine learning is focused on reading patterns from a large amount of data in a short amount oftime and can semi-automatically obtain more accurateresults than that of manual human evaluations. Machinelearning is classified into three types, supervised learning, unsupervised learning, and reinforcement learning [26, 27]. Supervised learning is a technique in whichthe learner parameter is updated in order to get closer
Tanaka et al. Cancer Cell Int(2021) 21:454to the correct output. In other words, training data areprovided to the algorithm, the correct answer label islearned, and a learning algorithm is generated in whichthe output is the correct answer label. Next, it is verifiedwhether a value close to the "correct label" is obtainedwhen unknown data is applied to the generated model.This type of machine learning is usually used for classification tasks or regression tasks in image recognition.For example, when a whole slide image of lung cancer isprovided as an input and the output is labeled as “normallung”, the learner will be updated by the teacher that thecorrect answer is “lung cancer” . Supervised learningrequires an extensive amount of training data and the following labeled data, which are often difficult to obtain inmedical and biological fields. Meanwhile, unsupervisedlearning is another machine learning technique in whichthe learner is updated using only inputs without “correctanswer” data. Reinforcement learning is the final machinelearning technique, and updates the learner through trialand error in order to determine the best course of actionto suit the current situation.Deep learning is a machine-learning technique inspiredby the human brain that uses large mathematical functions with millions of parameters based on a neuralnetwork structure that combines multiple layers of artificial nerve cells . Using a deep-learning system,great power can be exerted for the recognition and classification of various medical images and is applicable topathological diagnosis and cancer detection using computed tomography (CT) images [15, 29–31]. While mostof deep-learning algorithms to date have been appliedusing supervised-learning methods to learn a specialist’sthought or technique, some deep-learning algorithmshave been recently created using unsupervised-learning methods. For instance, Yamamoto et al. developeda deep-learning algorithm that enables an automatedacquisition of explainable features from diagnostic annotation-free histopathology images of prostate cancer andidentified a new feature that improves the accuracy ofdiagnosis of prostate cancer recurrence . Essentially,they created a deep-learning algorithm that uses histopathological images of prostate cancer as inputs, whichthen automatically outputs feature maps of the histopathological images.Application of AI for analysis of omics data and clinicalinformationThe application of AI in medicine is currently of greatinterest, especially in the diagnostic and predictiveassessment of medical images . Among AI algorithms, machine learning is able to learn health trajectorypatterns from vast numbers of patients (Fig. 1). This canhelp physicians anticipate future events at an expert levelPage 3 of 14and draw curves from extensive amounts of clinical information, providing insight well beyond the experiencefrom an individual physician’s practice. Development ofan algorithm for medical diagnosis or prediction typicallyrequires a huge dataset, often referred to as “big data,”especially an algorithm in which supervised learningof deep neural networks are used. Accurate algorithmsrequire high quality datasets; however, these big datasets need to be collected in various ways from multipleheterogeneous sources . When the algorithm diagnosis outputs in the training phase differ from the actualdiagnosis, the calculated parameter weights are updatedin order for the output to approach the correct diseaselabel. This process is then repeated many times. Duringthe updating process, deep learning generally requires anextremely large number of samples to approach the correct answer as the algorithm parameter may exceed onehundred million.Although the samples available for omics data analysis have been usually limited, deep-structured learningusually requires an extremely large number of samples.Therefore, machine-learning models have been commonly utilized to create quicker and more accurate algorithms under current situations for the analysis of omicsdata (Fig. 1). Because the inclusion of too much featuresmay lead to overfitting and increases calculation costs,each analysis initially starts with biomarker selection andknowledge of omics data, as well as selection of statisticalmethods that increase the stability of the feature selection process. In biomedical analysis, the term “features”indicates measured characteristics used as learning input,such as age, gender, or X genes.After feature selection, machine learning can be usedto achieve various ends, such as disease type or severity classification or mortality prediction. To analyzeomics data using machine learning, feature selectionis one of the most important procedures because of itslarge dimension. Interestingly, machine-learning techniques have sometimes been used in the feature selection procedure itself . Best et al. selected specificspliced-RNA biomarker panels using likelihood ratioanalysis of variance (ANOVA) statistics and then comparing healthy individuals to patients with cancer basedon analysis of differential expression of spliced junctions. Logistic regression analysis, ANOVA statistics, andan ensemble approach with random sub-sampling havebeen widely used to select important features [37–39].Another way to reduce the dimension of potential features is using unsupervised-machine learning, such asleast absolute shrinkage and selection operator (LASSO)regression or principal component analysis (PCA) .LASSO regression, one approach of regression analysis,has the feature of part of the coefficient being set to zero,
Tanaka et al. Cancer Cell Int(2021) 21:454Clinical dataPage 4 of 14Integration of multi-omics dataImaging dataLimited to hundreds featuresPhenomicsLong dataA large number of patientswith a hundred features,such as age and gender.A few to dozens of patientsHundreds to thousands patientsMetabolomics Proteomics TranscriptomicsEpigenomicsGenomicsHuge amount of information per one patientWide dataSupervised or unsupervised learningRecurrent Neural NetworkConvolutional Neural NetworkHandling of Time-Series DataSupport Vector MachinePrincipal Component AnalysisHandling of Image DataRandom ForestDeep learningMachine learningand moreand moreA better groupA worse group Mortality rate: XX %ClassificationPredictionFig. 1 Application image of artificial intelligence use for analysis of omics data and clinical informationreducing that dimension of the feature. Lu et al. obtained2139 genetic mutations for consideration in their initialmodel to predict long‑term clinical benefit, which wasthen reduced using the LASSO model to 161 geneticmutations without a reduction in the clinical predictionaccuracy . Meanwhile, PCA weighs and integratesmany features to create a relatively small number of newfeatures that represent the overall variability. Guan et al.
Tanaka et al. Cancer Cell Int(2021) 21:454performed PCA to distinguish patients with inflammatory bowel disease (IBD) from control subjects using55 lipid species . They defined two new features ofprincipal component 1(PC1) and principal component2 (PC2), which were able to distinguish between patientswith IBD and the control subjects. These filtering stepsimprove data normalization, which is a critical step inbiological data analysis.Generally, supervised and/or unsupervised learning models, including LASSO, support vector machine(SVM), random forest, and gradient boosting, have beenused after feature selection to perform the classification task, such as identifying patients with significantlyworse mortality rates. SVM is an algorithm that minimizes the distance of prediction error and is one of themost frequently used systems of supervised machinelearning in omics data analysis. The advantage of SVMcompared to that of other algorithms is its good accuracy and use of fewer parameters to be optimized, evenif the data dimension is large. However, the disadvantagesof the SVM algorithm are the large calculation costs asthe amount of training data increases; therefore, featurestandardization will be needed.Identification of early detection biomarkersin NSCLC using omics data and AIThe application of AI in imaging diagnostics for NSCLCscreeningMost patients with NSCLC have advanced stage disease with distant metastasis at the initial diagnosis. Thefive-year survival rate of patients diagnosed at stage IVNSCLC is only 6.0% for patients that receive historiccytotoxic chemotherapy regimens, while the five-yearsurvival rate dramatically rise to around 70–90% forpatients diagnosed with stage I NSCLC . Therefore, early detection of NSCLC is extremely effectivetoward improving the survival rate of patients. In 2011,the National Lung Screening Trial (NLST) showed thatlow-dose CT (LD-CT) screening for lung cancer reducedthe relative mortality by 20% . The all-cause mortality rate was 6.7% lower in the LD-CT group compared tothat in the X-ray group. The US Preventive Services TaskForce recommends an annual LD-CT screening test forhigh-risk populations, which comprises patients with asmoking history of at least 30 pack-years and an age of55 to 80 years. However, the inclusion criteria excludedyoung subjects and never-smoker or light-smoker populations. Furthermore, LD-CT screening is costly withhigh false positive rates because of the detection ofbenign pulmonary nodules .To detect ever-smaller lung tumors and to improvethe accuracy of CT screening, the development of AIbased screening methods for all populations is rapidlyPage 5 of 14progressing. Currently, complex algorithms and varioustypes of software devices have been utilized to developAI-based screening methods, and these are mainly categorized into two systems, namely, computer-aideddetection (CADe) system and computer-aided diagnosis(CADx) system . The CADe system, which highlightsthe detection of small nodules, has been engineered toimprove radiologist sensitivity in identifying nodules.The CADx platforms can support diagnosis of pre-identified lesions when clinicians evaluate malignancy risk orconduct clinical decision-making. The development ofboth the systems is indeed important for improving diagnosis correctness, early diagnosis, and reducing diagnostic variation owing to clinician’s subjectivity. However,most of the recent studies involve small sample sizes orno validated models, and therefore, AI-based screeningmethods are not enough for clinical application at thispoint of time.To surmount the current difficulties, several frameworks of academia–industry collaboration have beengradually established worldwide. Optellum Ltd., a company that specializes in image analysis of lung cancerdiagnosis, developed a machine leaning algorithm calledthe lung cancer prediction convolutional neural network (LCP-CNN), which was initially trained using theNLST data under guidance from experienced thoracicradiologists at Oxford University Hospitals [27, 45]. Subsequently, to compare the performance of LCP-CNNwith that of the Brock University model, recommendedby United Kingdom (UK) guidelines, Baldwin et al. conducted a validation study by retrospectively collectingdata from 5–15 mm lung nodules, which consisted of1187 patients with 1397 nodules from three hospitalsin the UK . In this study, the area under the curve(AUC) for LCP-CNN was 89.6% compared with 86.8%for the Brock model (p 0.005), resulting in a better discrimination ability of LCP-CNN with over 99.5% sensitivity compared with that of the Brock model. As anothermodel of academia–industry collaboration, Ardila et al.used the TensorFlow platform of Google Inc., to developa deep-learning model trained using 42,290 CT scanimages from 14,851 patients, which is able to determine the malignancy of lung nodules without the needfor human intervention . The AI-equipped systemdetected minute malignant lung nodules in 6716 testcases with an accuracy of 94%. The model performed better than six radiologists who made the diagnosis in theabsence of previous CT images . The approach wasundertaken in a collaboration between Google, Northwestern University, and other institutions, and is one ofthe systems moving toward clinical adoption. Both thesestudies showed successful academia–industry collaboration on radiomics and AI-based screening, which can
Tanaka et al. Cancer Cell Int(2021) 21:454make the detection of early lung cancer more precise andaccessible for all the population.The application of omics data and AI for identificationof early detection biomarkersFor the purpose of supplementing the false positivityof LD-CT screening or earlier detection of lung cancerthan that achieved using CT, a variety of new technologies have been investigated over the past decade for thediscovery of biomarkers from various biomolecules. Forexample, because of dramatic advances in the accuracy ofmass determination and characterization of target proteins, mass spectrometry (MS) has been developed toanalyze a diverse range of proteins, lipids, and metabolites. Currently, it is possible to detect extremely smallamounts of protein from tiny cancers using the advancedMS technology. In addition, Taguchi et al. performedproteomics analysis using blood samples obtained fromvarious cancer mouse models and found levels of theN-terminal pro-peptide of surfactant protein B (proSFTPB) are characteristically increased in the bloodof mice with lung cancer . Diagnostic blood tests,including for pro-SFTPB, may be able to identify peoplewith lung cancer up to 2 years earlier with about twicethe sensitivity of the current LD-CT criteria [48–50].This indicates the combination of LD-CT screening anddetection of protein-based biomarkers will be truly effective for the accurate and early detection of lung cancer.The use of machine-learning approaches and theaccumulation of omics data in recent years have led tomore sensitive and accurate detection of biomarkers.For instance, Noreldeen et al. described a non-targetedlipidomic approach based on ultra-high-performanceliquid chromatography coupled with quadrupole timeof-flight MS in combination with two machine learningapproaches (genetic algorithm and binary logistic regression) to screen candidate discriminating lipids and todefine a combinational lipid biomarker in serum samples for distinguishing female patients with NSCLC .They showed that fatty acid (FA) (20:4), FA (22:0), andlysophosphatidylethanolamine (20:4) can serve as a combinational biomarker for distinguishing female patientswith early-stage NSCLC from healthy controls with goodsensitivity and specificity and the AUC reaching 0.99.In a study using machine learning to parse omics dataother than protein-based data, Best et al. analyzed RNAbiomarker panels from platelet-derived RNA-sequencing libraries using particle-swarm optimization (PSO)enhanced algorithms . Their results showed accuratetumor-educated blood platelets (TEP)-based detectionof early-stage NSCLC (AUC, 0.89). Because the characteristics AI are from a completely different perspectivesthan that of earlier reports, the AI studies may lead toPage 6 of 14the elucidation of molecular biological mechanisms oflung cancer progression, as well as the identification ofbiomarkers for its early detection. It is expected that AIin the future will be able to integrate diagnostic imagingwith new biomarkers using the comprehensive analysis ofomics data.Development of immune checkpoint inhibitors(ICIs) treatment of NSCLC based on AI analysisof OMICS dataCurrent issues in the standard treatment strategy of NSCLCand further development of immune therapyPivotal phase III clinical trials have led to the worldwideapproval of ICIs, such as programmed cell death 1 (PD1)/programmed death-ligand 1 (PD-L1) inhibitors andcytotoxic T-lymphocyte-associated protein 4 (CTLA-4)inhibitors, especially for non-squamous NSCLC withoutsensitizing Epidermal Growth Factor Receptor (EGFR)mutation or anaplastic lymphoma kinase (ALK) fusion,and squamous cell lung carcinoma [53–58]. Multipletreatment regimens, including PD-1/PD-L1 inhibitorswith CTLA-4 inhibitors and PD-1/PD-L1 inhibitors withor without CTLA-4 plus platinum-based chemotherapy,are currently standard treatment options (Fig. 2). However, the optimal regimen for individual patients remainsunclear as these new treatment regimens were comparedto traditional platinum-based chemotherapy as the control-arm in all the phase III studies. Furthermore, comparative clinical trials of these new regimens have notbeen conducted and “round robin” clinical trials comparing these regimens may be unrealistic. However, novelimmune therapeutic agents other than PD-1/PD-L1inhibitors and CTLA-4 inhibitors are currently beinginvestigated in several clinical trial settings , suggesting multiple combination therapies of immune targeting drugs may be approved before long as additionalstandard treatment options. Accordingly, the development of patient selection strategies for individualizedimmunotherapy is an important issue. In recent decades,comprehensive analyses of tumor specimens combinedwith detailed clinical information have been performedin various clinical trials . Although these large profiling datasets have the potential to benefit the discovery of novel prediction methods of immune therapeuticactivity for individual patients, translational and reversetranslational research has not been adequately conducted. Under these circumstances, machine-learningapproaches are some of the most promising technologiesfor identifying new biomarkers from various omics datathat can be used to drive individualized immunotherapy.The evaluation of PD-L1 expression and tumor mutation burden (TMB) using immunohistochemistry havebeen widely adopted as markers for ICI treatment [61,
Tanaka et al. Cancer Cell Int(2021) 21:454Page 7 of 14Recommended treatment options according to oncogene driver status and PD-L1 expressionin non-small-cell lung cancerNon-Small Cell Lung CancerNon-targetable alterationsTargetable driver inib RAMErlotinib ntrectinibBRAFDabrafenib RKEntrectinibLarotrectinibPD-L1 1%PD-L11-49%PD-L1 50%Non-squamous cell carcinomaCBDCA / CDDP PEM PembroCBDCA / CDDP PEM AtezoCBDCA PTX BEV AtezoCBDCA nab-PTX AtezoCBDCA / CDDP PEM NIVO IPISquamous cell carcinomaCBDCA PTX / nab-PTX PembroCBDCA PTX NIVO IPINIVO IPI†PembroAtezo † †Platinum-based chemotherapyCBDCA PTX BEV AtezoPlatinum-based chemotherapyDTXRAM / PEM / nab-PTXDTXRAM / PEM / nab-PTXFig. 2 Recommended treatment options according to oncogene driver status and PD-L1 expression in non-small-cell lung cancer. Next generationtyrosine kinase inhibitors for each driver oncogenic aberrations are approved one after another, and novel immune check point inhibitorscombination with or without platinum-based chemotherapy are established as standard treatment options for non-small cell lung cancer withoutdruggable alterations. †Nivolumab plus ipilimumab is an option for patients with PD-L1 tumor proportion score 1% in addition to those withPD-L1 tumor proportion score 1%. ††High PD-L1 expression is defined as 50% of tumor cells or 10% of tumor-infiltrating immune cellsby SP142 assay. CBDCA: Carboplatin; CDDP: Cisplatin; PTX: Paclitaxel; DTX: Docetaxel; PEM: Pemetrexed; nab-PTX: nanoparticle albumin boundPaclitaxel; BEV: bevacizumab; RAM: Ramucirumab; NIVO: Nivolumab; IPI: ipilimumab; Atezo: atezolizumab; Pembro: pembrolizumab62]. However, the predictive ability is insufficient toadequately stratify patients for proper treatments compared to that of targeted oncogenic driver aberrations.These limitations are associated with immune responsesbeing affected by tumor-cell specific features of NSCLC,immune-cell specific features, and the tumor microenvironment . Using AI to establish a comprehensiveprediction model for immunoblockade strategies willresult in relevant advantages compared to that of traditional biomarker analysis. Once AI technology is able toidentify populatio
harmonization of molecular cancer biology and articial intelligence Ichidai Tanaka 1*, Taiki Furukawa 2 and Masahiro Morise1 Abstract Comprehensive analysis of omics data, such as genome, transcriptome, proteome, metabolome, and interactome, is a crucial technique for elucidating the complex mechanism of cancer onset and progression.
May 02, 2018 · D. Program Evaluation ͟The organization has provided a description of the framework for how each program will be evaluated. The framework should include all the elements below: ͟The evaluation methods are cost-effective for the organization ͟Quantitative and qualitative data is being collected (at Basics tier, data collection must have begun)
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Le genou de Lucy. Odile Jacob. 1999. Coppens Y. Pré-textes. L’homme préhistorique en morceaux. Eds Odile Jacob. 2011. Costentin J., Delaveau P. Café, thé, chocolat, les bons effets sur le cerveau et pour le corps. Editions Odile Jacob. 2010. Crawford M., Marsh D. The driving force : food in human evolution and the future.
Le genou de Lucy. Odile Jacob. 1999. Coppens Y. Pré-textes. L’homme préhistorique en morceaux. Eds Odile Jacob. 2011. Costentin J., Delaveau P. Café, thé, chocolat, les bons effets sur le cerveau et pour le corps. Editions Odile Jacob. 2010. 3 Crawford M., Marsh D. The driving force : food in human evolution and the future.
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