Disseminated Tumor Cells and Dormancy in Breast Cancer Progression

Advances in the study of biomarkers related to bone metastasis in breast cancer

Breast cancer is by far the most common malignancy in females. And bone is the most common site of distant metastasis in breast cancer, accounting for about 65 to 75% of all metastatic breast cancer patients.1,2Bone metastasis is an important factor affecting the prognosis of breast cancer. When patients have early-stage breast cancer without metastasis, their 5-year survival rate is as high as 90%, and once metastasis occurs, their 5-year survival rate will drop to 10%.3 Bone radionuclide imaging (ECT), X-ray, CT scan, MRI and other imaging tests to diagnose breast cancer bone metastasis are commonly used in clinical, It is currently believed that breast cancer bone metastasis is a multistep process: first, breast cancer cells need to acquire invasive and metastatic properties; breast cancer cells enter the blood circulation and migrate from blood breast cancer cells enter the blood circulation and migrate from blood vessels to bone tissue in a targeted manner; breast cancer cells adhere and remain in bone tissue and colonise it; and finally, it leads to bone destruction.4 Several key molecules are involved in breast cancer bone metastasis, and serum biomarkers are generally able to detect pathological changes earlier Several key molecules are involved in breast cancer bone metastasis, and serum biomarkers are generally able to detect pathological changes earlier than imaging.5 This review describes the progress of serum biomarkers for breast cancer bone metastasis.

The genomic regulation of metastatic dormancy

The genomics and pathways governing metastatic dormancy are critically important drivers of long-term patient survival given the considerable portion of cancers that recur aggressively months to years after initial treatments. Our understanding of dormancy has expanded greatly in the last two decades, with studies elucidating that the dormant state is regulated by multiple genes, microenvironmental (ME) interactions, and immune components. These forces are exerted through mechanisms that are intrinsic to the tumor cell, manifested through cross-talk between tumor and ME cells including those from the immune system, and regulated by angiogenic processes in the nascent micrometastatic niche. The development of new in vivo and 3D ME models, as well as enhancements to decades-old tumor cell pedigree models that span the development of metastatic dormancy to aggressive growth, has helped fuel what arguably is one of the least understood areas of cancer biology that nonetheless contributes immensely to patient mortality. The current review focuses on the genes and molecular pathways that regulate dormancy via tumor-intrinsic and ME cells, and how groups have envisioned harnessing these therapeutically to benefit patient survival.

In vivo metabolic imaging identifies lipid vulnerability in a preclinical model of Her2+/Neu breast cancer residual disease and recurrence

Recurrent cancer cells that evade therapy is a leading cause of death in breast cancer patients. This risk is high for women showing an overexpression of human epidermal growth factor receptor 2 (Her2). Cells that persist can rely on different substrates for energy production relative to their primary tumor counterpart. Here, we characterize metabolic reprogramming related to tumor dormancy and recurrence in a doxycycline-induced Her2+/Neu model of breast cancer with varying times to recurrence using longitudinal fluorescence microscopy. Glucose uptake (2-NBDG) and mitochondrial membrane potential (TMRE) imaging metabolically phenotype mammary tumors as they transition to regression, dormancy, and recurrence. “Fast-recurrence” tumors (time to recurrence ~55 days), transition from glycolysis to mitochondrial metabolism during regression and this persists upon recurrence. “Slow-recurrence” tumors (time to recurrence ~100 days) rely on both glycolysis and mitochondrial metabolism during recurrence. The increase in mitochondrial activity in fast-recurrence tumors is attributed to a switch from glucose to fatty acids as the primary energy source for mitochondrial metabolism. Consequently, when fast-recurrence tumors receive treatment with a fatty acid inhibitor, Etomoxir, tumors report an increase in glucose uptake and lipid synthesis during regression. Treatment with Etomoxir ultimately prolongs survival. We show that metabolic reprogramming reports on tumor recurrence characteristics, particularly at time points that are essential for actionable targets. The temporal characteristics of metabolic reprogramming will be critical in determining the use of an appropriate timing for potential therapies; namely, the notion that metabolic-targeted inhibition during regression reports long-term therapeutic benefit.

Does the Presence of Circulating Tumor Cells in High-Risk Early Breast Cancer Patients Predict the Site of First Metastasis—Results from the Adjuvant SUCCESS A Trial

Simple Summary

Due to recent advances in breast cancer detection and treatment strategies, the number of breast cancer survivors has increased over the past decades. However, breast cancer follow-up guidelines have not changed for years. The presence of CTCs detected during follow-up has been shown to indicate poor prognosis in high-risk breast cancer patients. Here, we evaluated if the presence of CTCs also indicates the site of metastatic disease by analyzing CTC status and metastatic location in 206 patients with distant recurrence from the large adjuvant breast cancer trial SUCCESS A. Patients who were CTC-positive both before and after chemotherapy were more likely to show bone-only first distant disease (37.5% vs. 21.0%) and first distant disease at multiple sites (31.3% vs. 12.6%) than patients without CTCs. These data indicate that CTCs might serve as a liquid biopsy surveillance-marker enabling risk-stratification for deciding on further adjuvant add-on-treatment.

Abstract

The prognostic relevance of circulating tumor cells (CTCs) in breast cancer is well established. However, little is known about the association of CTCs and site of first metastasis. In the SUCCESS A trial, 373 out of 3754 randomized high-risk breast cancer patients developed metastatic disease. CTC status was assessed by the FDA-approved CellSearch^®-System (Menarini Silicon Biosystems, Bologna, Italy) in 206 of these patients before chemotherapy and additionally in 159 patients after chemotherapy. CTCs were detected in 70 (34.0%) of 206 patients before (median 2 CTCs, 1–827) and in 44 (27.7%) of 159 patients after chemotherapy (median 1 CTC, 1–124); 16 (10.1%) of 159 patients were CTC-positive at both timepoints. The site of first distant disease was bone-only, visceral-only, and other-site-only in 44 (21.4%), 60 (29.1%), and 74 (35.9%) patients, respectively, while 28 (13.6%) patients had multiple sites of first metastatic disease. Patients with CTCs at both timepoints more often showed bone-only first distant disease (37.5% vs. 21.0%) and first distant disease at multiple sites (31.3% vs. 12.6%) than patients without CTCs before and/or after chemotherapy (p = 0.027). In conclusion, the presence of CTCs before and after chemotherapy is associated with multiple-site or bone-only first-distant disease and may trigger intensified follow-up and perhaps further treatment.

IFN-I signaling in cancer: the connection with dysregulated Insulin/IGF axis

Type I interferons (IFN-Is) are prototypical inflammatory cytokines produced in response to stress. IFN-Is have a critical role in antitumor immunity by driving the activation of leukocytes and favoring the elimination of malignant cells. However, IFN-I signaling in cancer, specifically in the tumor microenvironment (TME), can have opposing roles. Sustained IFN-I stimulation can promote immune exhaustion or enable tumor cell-intrinsic malignant features. Herein, we discuss the potential impact of the insulin/insulin-like growth factor system (I/IGFs) and of metabolic disorders in aberrant IFN-I signaling in cancer. We consider the possibility that targeting I/IGFs, especially in patients with cancer affected by metabolic disorders, contributes to an effective strategy to inhibit deleterious IFN-I signaling, thereby restoring sensitivity to various cancer therapies, including immunotherapy.

Prognostic value of disseminated tumor cells in unresectable pancreatic ductal adenocarcinoma: a prospective observational study

BACKGROUND

Although pancreatic ductal adenocarcinoma (PDAC) rarely metastasizes to the skeleton, disseminated tumor cells have been detected in bone marrow samples from patients with this disease. The prognostic value of such findings is currently unclear. Thus, the current study aimed to clarify the prognostic information associated with disseminated tumor cell detection in samples from patients with PDAC.

METHODS

Bone marrow aspirates were obtained from 48 patients with locally advanced (n = 11) or metastatic (n = 37) PDAC, before and after 2 months of chemotherapy. Disseminated tumor cells were detected with an mRNA panel and quantitative reverse transcription PCR. We used the highest levels measured in healthy bone marrow (n = 30) as a threshold to define the positive detection of disseminated tumor cells. Progression-free and overall survival were analyzed with Kaplan-Meier and Cox proportional hazards regression analyses.

RESULTS

Disseminated tumor cells were detected in 15/48 (31%) bone marrow samples obtained before starting chemotherapy and in 8/25 (32%) samples obtained during chemotherapy. Patients with disseminated tumor cells detected before therapy had significantly shorter progression-free (p = 0.03; HR = 2.0) and overall survival (p = 0.03; HR = 2.0), compared to those without disseminated tumor cells in the bone marrow. When restricting disseminated tumor cell detection to keratins KRT7 and KRT8, the prognostic information was substantially stronger (p = 1 × 10-6; HR = 22, and p = 2 × 10-5; HR = 7.7, respectively). The multivariable Cox regression analysis demonstrated that disseminated tumor cell detection prior to treatment had independent prognostic value. In contrast, disseminated tumor cells detected during treatment did not have prognostic value.

CONCLUSIONS

Disseminated tumor cells detected before commencing chemotherapy had prognostic value in patients with inoperable PDAC.

Exploiting Mouse Models to Recapitulate Clinical Tumor Dormancy and Recurrence in Breast Cancer

Breast cancer recurrence and metastasis from activated dormant tumors remain the leading causes in disease morbidity. Estrogen receptor positive breast cancer that accounts for nearly 80% of all cases face a life-long risk of relapse after initial treatment. The biology of dormant tumors and dormant cancer cells that give rise to recurrent disease and metastasis remain to be understood for us to overcome the clinical challenges that they bring. The selection and optimization of pre-clinical models to recapitulate dormancy and recurrence in patients is critical for studying the underlying cellular and environmental factors. Here, we provide a brief review of studies that utilize mouse models to dissect the mechanisms of dormancy and therapeutic strategies to avert recurrence. This review specifically accentuates the versatility and benefits of immunocompetent transgenic mouse models that can be manipulated to recapitulate primary dormancy, metastatic dormancy, and post-therapy dormancy.

Role of Neural (N)-Cadherin in Breast Cancer Cell Stemness and Dormancy in the Bone Microenvironment

Breast cancer cells that interact with spindle-shaped N-Cadherin+ Osteoblasts (SNOs) are recognised to become dormant through a Notch2-dependent mechanism. We found that Notch2High human BrCa MDA-MB231 (MDA) cells also expressed high level of N-Cadherin. This prompted us to hypothesize that N-Cadherin could have a role in MDA-SNO interaction. Of note, the expression of N-Cadherin in MDA cells reduced tumour incidence and bone osteolysis in BrCa mouse model. Moreover, similarly to Notch2High MDA cells, the N-CadherinHigh MDA cells revealed a high expression of the canonical Haematopoietic Stem cell (HSC) markers, suggesting an HSC mimicry, associated with higher ability to form mammospheres. Interestingly, N-CadherinHigh MDA cells showed greater capacity to adhere to SNOs, while the inhibition of SNO-mediating MDA cell proliferation was unremarkable. To investigate whether these features were shared by mouse BrCa, we used the 4T1 cell line in which N-Cadherin expression was abolished and then rescued. At variance with MDA cells, 4T1 cells expressing N-Cadherin revealed that the latter was associated with a lower expression of the HSC marker, Cxcr4, along with a lower capacity to form mammospheres. Furthermore, the rescue of N-Cadherin expression increased cell-cell adhesion and reduced proliferation of 4T1 cells when they were co-plated with SNOs. In conclusion, we demonstrated that: (i) N-CadherinHigh and Notch2High MDA cells showed similar HSC mimicry and dormancy features; (ii) N-Cadherin mediated BrCa-SNO adhesion; (iii) N-Cadherin had a positive Notch2-dependent role on SNO-induced dormancy and HSC mimicry in MDA cells, and a negative role in 4T1 cell stemness and HSC mimicry.

Enigmatic role of exosomes in breast cancer progression and therapy

Breast cancer (BC) is reported to be the leading cause of mortality in females worldwide. At the beginning of the year 2021, about 7.8 million women were diagnosed with BC in past 5 years. High prevalence and poor neoadjuvant chemotherapeutic efficacy has motivated the scientists around the globe to investigate alternative management strategies. In recent years, there has been an exponential rise in the scientific studies reporting the role of tumor derived exosomes (TDEs) in the BC pathophysiology and management. TDEs play an important role in the intercellular communication and transportation of biomolecules. This manuscript reviews the role of exosomes in the BC pathophysiology, diagnosis, and therapy. Role of TDEs in the mechanistic pathways of BC metastasis, immunosuppression, migration, dormancy and chemo-resistance is extensively reviewed. We have also highlighted the epigenetic modulations orchestrated by exosomal miRNAs and long noncoding RNAs (lnc RNAs) in the BC environment. Liquid biopsies analyzing blood circulating exosomes for early and accurate detection of the BC have been discussed. Characterization of exosomes, strategies to use them in BC chemotherapy, BC immunotherapy and potential challenges that will present themselves in translating exosomes based technologies to market are discussed.

Atorvastatin facilitates chemotherapy effects in metastatic triple-negative breast cancer

BACKGROUND

Metastatic triple-negative breast cancer (mTNBC) is treated mainly with chemotherapy. However, resistance frequently occurs as tumours enter dormancy. Statins have been suggested as effective against cancer but as they prolong and promote dormancy, it is an open question of whether the concomitant use would interfere with chemotherapy in primary and mTNBC. We examined this question in animal models and clinical correlations.

METHODS

We used a xenograft model of spontaneous metastasis to the liver from an ectopic tumour employing a mTNBC cell line. Atorvastatin was provided to sensitise metastatic cells, followed by chemotherapy. The effects of statin usage on outcomes in women with metastatic breast cancer was assessed respectively by querying a database of those diagnosed from 1999 to 2019.

RESULTS

Atorvastatin had limited influence on tumour growth or chemotherapy effects in ectopic primary tumours. Interestingly, atorvastatin was additive with doxorubicin (but not paclitaxel) when targeting liver metastases. E-cadherin-expressing, dormant, breast cancer cells were resistant to the use of either statins or chemotherapy as compared to wild-type cells; however, the combination of both did lead to increased cell death. Although prospective randomised studies are needed for validation, our retrospective clinical analysis suggested that patients on statin treatment could experience prolonged dormancy and overall survival; still once the tumour recurred progression was not affected by statin use.

CONCLUSION

Atorvastatin could be used during adjuvant chemotherapy and also in conjunction with metastatic chemotherapy to reduce mTNBC cancer progression. These preclinical data establish a rationale for the development of randomised studies.

Clinical management and biology of tumor dormancy in breast cancer

Clinical tumor dormancy is specified as an extended latency period between removal of the primary tumor and subsequent relapse in a cancer patient who has been clinically disease-free. In particular, patients with estrogen receptor-positive breast cancer can undergo extended periods of more than five years before they relapse with overt metastatic disease. Recent studies have shown that minimal residual disease in breast cancer patients can be monitored by different liquid biopsy approaches like analysis of circulating tumor cells or cell-free tumor DNA. Even though the biological principles underlying tumor dormancy in breast cancer patients remain largely unknown, clinical observations and experimental studies have identified emerging mechanisms that control the state of tumor dormancy. In this review, we illustrate the latest discoveries on different molecular aspects that contribute to the control of tumor dormancy and distant metastatic relapse, then discuss current treatments affecting minimal residual disease and dormant cancer cells, and finally highlight how novel liquid biopsy based diagnostic methodologies can be integrated into the detection and molecular characterization of minimal residual disease.

Palbociclib with adjuvant endocrine therapy in early breast cancer (PALLAS): interim analysis of a multicentre, open-label, randomised, phase 3 study

BACKGROUND

Palbociclib added to endocrine therapy improves progression-free survival in hormone-receptor-positive, HER2-negative, metastatic breast cancer. The PALLAS trial aimed to investigate whether the addition of 2 years of palbociclib to adjuvant endocrine therapy improves invasive disease-free survival over endocrine therapy alone in patients with hormone-receptor-positive, HER2-negative, early-stage breast cancer.

METHODS

PALLAS is an ongoing multicentre, open-label, randomised, phase 3 study that enrolled patients at 406 cancer centres in 21 countries worldwide with stage II-III histologically confirmed hormone-receptor-positive, HER2-negative breast cancer, within 12 months of initial diagnosis. Eligible patients were aged 18 years or older with an Eastern Cooperative Oncology Group performance score of 0 or 1. Patients were randomly assigned (1:1) in permuted blocks of random size (4 or 6), stratified by anatomic stage, previous chemotherapy, age, and geographical region, by use of central telephone-based and web-based interactive response technology, to receive either 2 years of palbociclib (125 mg orally once daily on days 1-21 of a 28-day cycle) with ongoing standard provider or patient-choice adjuvant endocrine therapy (tamoxifen or aromatase inhibitor, with or without concurrent luteinising hormone-releasing hormone agonist), or endocrine therapy alone, without masking. The primary endpoint of the study was invasive disease-free survival in the intention-to-treat population. Safety was assessed in all randomly assigned patients who started palbociclib or endocrine therapy. This report presents results from the second pre-planned interim analysis triggered on Jan 9, 2020, when 67% of the total number of expected invasive disease-free survival events had been observed. The trial is registered with ClinicalTrials.gov (NCT02513394) and EudraCT (2014-005181-30).

FINDINGS

Between Sept 1, 2015, and Nov 30, 2018, 5760 patients were randomly assigned to receive palbociclib plus endocrine therapy (n=2883) or endocrine therapy alone (n=2877). At the time of the planned second interim analysis, at a median follow-up of 23·7 months (IQR 16·9-29·2), 170 of 2883 patients assigned to palbociclib plus endocrine therapy and 181 of 2877 assigned to endocrine therapy alone had invasive disease-free survival events. 3-year invasive disease-free survival was 88·2% (95% CI 85·2-90·6) for palbociclib plus endocrine therapy and 88·5% (85·8-90·7) for endocrine therapy alone (hazard ratio 0·93 [95% CI 0·76-1·15]; log-rank p=0·51). As the test statistic comparing invasive disease-free survival between groups crossed the prespecified futility boundary, the independent data monitoring committee recommended discontinuation of palbociclib in patients still receiving palbociclib and endocrine therapy. The most common grade 3-4 adverse events were neutropenia (1742 [61·3%] of 2840 patients on palbociclib and endocrine therapy vs 11 [0·3%] of 2903 on endocrine therapy alone), leucopenia (857 [30·2%] vs three [0·1%]), and fatigue (60 [2·1%] vs ten [0·3%]). Serious adverse events occurred in 351 (12·4%) of 2840 patients on palbociclib plus endocrine therapy versus 220 (7·6%) of 2903 patients on endocrine therapy alone. There were no treatment-related deaths.

INTERPRETATION

At the planned second interim analysis, addition of 2 years of adjuvant palbociclib to adjuvant endocrine therapy did not improve invasive disease-free survival compared with adjuvant endocrine therapy alone. On the basis of these findings, this regimen cannot be recommended in the adjuvant setting. Long-term follow-up of the PALLAS population and correlative studies are ongoing.

FUNDING

Pfizer.

Delayed breast reconstruction with tram-flap and various modifications after radical mastectomy

This study describes the experience of radical mastectomies with simultaneous breast reconstruction using TRAM flap in patients with inflammatory breast cancer. The study aimed to evaluate the effectiveness of primary breast reconstruction using the TRAM-flap procedure in patients with an inflammatory form of breast cancer. Our work is associated with some deviation from generally accepted standards: delayed breast reconstruction after radical mastectomy for inflammatory breast cancer. We describe the experience of radical mastectomies with the simultaneous reconstruction of the breast using a TRAM flap in patients with inflammatory breast cancer. This study included 12 patients diagnosed with breast cancer stages IIIB and IIIC. Almost all patients (eleven out of twelve patients) underwent radical mastectomy with one-stage reconstruction using a TRAM flap after chemotherapy. Two years later, one patient (8.3%) showed disease progression in the form of distant metastases in the bones of the spine. One patient (8.3%) had a regional relapse in the displaced flap near the postoperative scar. The rest of the patients (83.4%) showed no signs of continuing the disease. Patients with one-stage breast reconstruction improved socially, and their subjective well-being was better than those who underwent radical mastectomy without reconstruction. Experience in performing one-stage reconstructions in the surgical treatment of patients with inflammatory breast cancer is a reason for restrained optimism regarding the possibility and feasibility of these operations.

Late recurrence of gastric carcinoma 15 years after surgery

A 70-year-old man who had undergone total gastrectomy 15 years ago for mucinous gastric carcinoma on the lesser curvature of the cardia, visited our hospital complaining of cough. Chest X-ray showed a right hilar shadow and an infiltrative shadow in the left middle lung field, which was not seen in the previous year. Whole-body positron emission tomography-computed tomography (CT) revealed abnormal uptake in the irregular consolidation of the left lung, enlarged right hilar lymph nodes, and a mass lesion on the right adrenal gland. Advanced primary lung adenocarcinoma with multi-organ metastasis was suspected and a CT-guided percutaneous lung biopsy was performed. Histopathological examination showed immunostaining patterns in complete accordance with those of the resected specimen of stomach, and the diagnosis of late recurrence of gastric carcinoma was confirmed. Pulmonary metastasis might have occurred as a direct hematogenous metastasis rather than through the liver. He achieved 31 months survival after the diagnosis receiving some sequences of chemotherapy. Late recurrence over 10 years after gastrectomy is extremely rare and significant predictive factors of late recurrence are not known. We hope that this case will help in detecting significant factors predictive of late recurrence after gastrectomy for gastric carcinoma.