The tumor dormant state

Role of myeloid-derived suppressor cells in tumor recurrence

The establishment of primary tumor cells in distant organs, termed metastasis, is the principal cause of cancer mortality and is a crucial therapeutic target in oncology. Thus, it is critical to establish a better understanding of metastatic progression for the future development of improved therapeutic approaches. Indeed, such development requires insight into the timing of tumor cell dissemination and seeding of distant organs resulting in occult lesions. Following dissemination of tumor cells from the primary tumor, they can reside in niches in distant organs for years or decades, following which they can emerge as an overt metastasis. This timeline of metastatic dormancy is regulated by interactions between the tumor, its microenvironment, angiogenesis, and tumor antigen-specific T-cell responses. An improved understanding of the mechanisms and interactions responsible for immune evasion and tumor cell release from dormancy would help identify and aid in the development of novel targeted therapeutics. One such mediator of dormancy is myeloid derived suppressor cells (MDSC), whose number in the peripheral blood (PB) or infiltrating tumors has been associated with cancer stage, grade, patient survival, and metastasis in a broad range of tumor pathologies. Thus, extensive studies have revealed a role for MDSCs in tumor escape from adoptive and innate immune responses, facilitating tumor progression and metastasis; however, few studies have considered their role in dormancy. We have posited that MDSCs may regulate disseminated tumor cells resulting in resurgence of senescent tumor cells. In this review, we discuss clinical studies that address mechanisms of tumor recurrence including from dormancy, the role of MDSCs in their escape from dormancy during recurrence, the development of occult metastases, and the potential for MDSC inhibition as an approach to prolong the survival of patients with advanced malignancies. We stress that assessing the impact of therapies on MDSCs versus other cellular targets is challenging within the multimodality interventions required clinically.

Modeling Androgen Deprivation Therapy-Induced Prostate Cancer Dormancy and Its Clinical Implications

Treatment-induced tumor dormancy is a state in cancer progression where residual disease is present but remains asymptomatic. Dormant cancer cells are treatment-resistant and responsible for cancer recurrence and metastasis. Prostate cancer treated with androgen-deprivation therapy (ADT) often enters a dormant state. ADT-induced prostate cancer dormancy remains poorly understood due to the challenge in acquiring clinical dormant prostate cancer cells and the lack of representative models. In this study, we aimed to develop clinically relevant models for studying ADT-induced prostate cancer dormancy. Dormant prostate cancer models were established by castrating mice bearing patient-derived xenografts (PDX) of hormonal naïve or sensitive prostate cancer. Dormancy status and tumor relapse were monitored and evaluated. Paired pre- and postcastration (dormant) PDX tissues were subjected to morphologic and transcriptome profiling analyses. As a result, we established eleven ADT-induced dormant prostate cancer models that closely mimicked the clinical courses of ADT-treated prostate cancer. We identified two ADT-induced dormancy subtypes that differed in morphology, gene expression, and relapse rates. We discovered transcriptomic differences in precastration PDXs that predisposed the dormancy response to ADT. We further developed a dormancy subtype-based, predisposed gene signature that was significantly associated with ADT response in hormonal naïve prostate cancer and clinical outcome in castration-resistant prostate cancer treated with ADT or androgen-receptor pathway inhibitors.

IMPLICATIONS

We have established highly clinically relevant PDXs of ADT-induced dormant prostate cancer and identified two dormancy subtypes, leading to the development of a novel predicative gene signature that allows robust risk stratification of patients with prostate cancer to ADT or androgen-receptor pathway inhibitors.

The Evolutionary Ecology of Dormancy in Nature and in Cancer

Dormancy is an inactive period of an organism’s life cycle that permits it to survive through phases of unfavorable conditions in highly variable environments. Dormancy is not binary. There is a continuum of dormancy phenotypes that represent some degree of reduced metabolic activity (hypometabolism), reduced feeding, and reduced reproduction or proliferation. Similarly, normal cells and cancer cells exhibit a range of states from quiescence to long-term dormancy that permit survival in adverse environmental conditions. In contrast to organismal dormancy, which entails a reduction in metabolism, dormancy in cells (both normal and cancer) is primarily characterized by lack of cell division. “Cancer dormancy” also describes a state characterized by growth stagnation, which could arise from cells that are not necessarily hypometabolic or non-proliferative. This inconsistent terminology leads to confusion and imprecision that impedes progress in interdisciplinary research between ecologists and cancer biologists. In this paper, we draw parallels and contrasts between dormancy in cancer and other ecosystems in nature, and discuss the potential for studies in cancer to provide novel insights into the evolutionary ecology of dormancy.

Myeloid derived suppressor cells and the release of micro-metastases from dormancy

Metastasis is the primary cause of cancer mortality and an improved understanding of its pathology is critical to the development of novel therapeutic approaches. Mechanism-based therapeutic strategies require insight into the timing of tumor cell dissemination, seeding of distant organs, formation of occult lesions and critically, their release from dormancy. Due to imaging limitations, primary tumors can only be detected when they reach a relatively large size (e.g. > 1 cm³), which, based on our understanding of tumor evolution, occurs approximately 10 years and about 30 doubling times following tumor initiation. Genomic profiling of paired primary tumors and metastases has suggested that tumor seeding at secondary sites occurs early during tumor progression and frequently, years prior to clinical diagnosis. Following seeding, tumor cells may enter into and remain in a dormant state, and if they survive and are released from dormancy, they can proliferate into an overt lesion. The timeline of tumor initiation and metastatic dormancy is regulated by tumor interactions with its microenvironment, angiogenesis, and tumor-specific cytotoxic T-lymphocyte (CTL) responses. Therefore, a better understanding of the cellular interactions responsible for immune evasion and/or tumor cell release from dormancy would facilitate the development of therapeutics targeted against this critical part of tumor progression. The immunosuppressive mechanisms mediated by myeloid-derived suppressor cells (MDSCs) contribute to tumor progression and, we posit, promote tumor cell escape from CTL-associated dormancy. Thus, while clinical and translational research has demonstrated a role for MDSCs in facilitating tumor progression and metastasis through tumor escape from adoptive and innate immune responses (T-, natural killer and B-cell responses), few studies have considered the role of MDSCs in tumor release from dormancy. In this review, we discuss MDSC expansion, driven by tumor burden associated growth factor secretion and their role in tumor cell escape from dormancy, resulting in manifest metastases. Thus, the therapeutic strategies to inhibit MDSC expansion and function may provide an approach to delay metastatic relapse and prolong the survival of patients with advanced malignancies.

Stability analysis of a fractional-order cancer model with chaotic dynamics

In this paper, we develop a three-dimensional fractional-order cancer model. The proposed model involves the interaction among tumor cells, healthy tissue cells and activated effector cells. The detailed analysis of the equilibrium points is studied. Also, the existence and uniqueness of the solution are investigated. The fractional derivative is considered in the Caputo sense. Numerical simulations are performed to illustrate the effectiveness of the obtained theoretical results. The outcome of the study reveals that the order of the fractional derivative has a significant effect on the dynamic process. Further, the calculated Lyapunov exponents give the existence of chaotic behavior of the proposed model. Also, it is observed from the obtained results that decrease in fractional-order [Formula: see text] increases the chaotic behavior of the model.

Role of myeloid-derived suppressor cells in metastasis

The spread of primary tumor cells to distant organs, termed metastasis, is the principal cause of cancer mortality and is a critical therapeutic target in oncology. Thus, a better understanding of metastatic progression is critical for improved therapeutic approaches requiring insight into the timing of tumor cell dissemination and seeding of distant organs, which can lead to the formation of occult lesions. However, due to limitations in imaging techniques, primary tumors can only be detected when they reach a relatively large size (e.g., > 1 cm³), which, based on our understanding of tumor evolution, is 10 to 20 years (30 doubling times) following tumor initiation. Recent insights into the timing of metastasis are based on the genomic profiling of paired primary tumors and metastases, suggesting that tumor cell seeding of secondary sites occurs early during tumor progression and years prior to diagnosis. Following seeding, tumor cells may remain in a dormant state as single cells or micrometastases before emerging as overt lesions. This timeline and the role of metastatic dormancy are regulated by interactions between the tumor, its microenvironment, and tumor-specific T cell responses. An improved understanding of the mechanisms and interactions responsible for immune evasion and tumor cell release from dormancy would support the development of novel targeted therapeutics. We posit herein that the immunosuppressive mechanisms mediated by myeloid-derived suppressor cells (MDSCs) are a major contributor to tumor progression, and that these mechanisms promote tumor cell escape from dormancy. Thus, while extensive studies have demonstrated a role for MDSCs in the escape from adoptive and innate immune responses (T-, natural killer (NK)-, and B cell responses), facilitating tumor progression and metastasis, few studies have considered their role in dormancy. In this review, we discuss the role of MDSC expansion, driven by tumor burden, and its role in escape from dormancy, resulting in occult metastases, and the potential for MDSC inhibition as an approach to prolong the survival of patients with advanced malignancies.

Mitotic quiescence in hepatic cancer stem cells: An incognito mode

Hepatocellular carcinoma represents one of the most aggressive cancers with high recurrence rates. The high recurrence is a major problem in the management of this disease. Cancer stem cells (CSCs) are often regarded as the basis of cancer recurrence. The anti-proliferative therapy kills the proliferating cells but induces mitotic quiescence in CSCs which remain as residual dormant CSCs. Later on, withdrawal of treatment reactivates the residual CSCs from dormancy to produce new cancer cells. The proliferation of these newly formed cancer cells initiates new tumor formation in the liver leading to tumor recurrence. HCC cells evade the immune surveillance via modulating the key immune cells by alpha feto-protein (AFP) secreted from CSCs or hepatic progenitor cells. This AFP mediated immune evasion assists in establishing new tumors by cancer cells in the liver. In this review, we will summarise the CSC mechanisms of recurrence, mitotic quiescence, dormancy and reactivation of CSCs, metastasis and immune evasion of hepatocellular carcinoma.

The influence of time delay in a chaotic cancer model

The tumor-immune interactive dynamics is an evergreen subject that continues to draw attention from applied mathematicians and oncologists, especially so due to the unpredictable growth of tumor cells. In this respect, mathematical modeling promises insights that might help us to better understand this harmful aspect of our biology. With this goal, we here present and study a mathematical model that describes how tumor cells evolve and survive the brief encounter with the immune system, mediated by effector cells and host cells. We focus on the distribution of eigenvalues of the resulting ordinary differential equations, the local stability of the biologically feasible singular points, and the existence of Hopf bifurcations, whereby the time lag is used as the bifurcation parameter. We estimate analytically the length of the time delay to preserve the stability of the period-1 limit cycle, which arises at the Hopf bifurcation point. We also perform numerical simulations, which reveal the rich dynamics of the studied system. We show that the delayed model exhibits periodic oscillations as well as chaotic behavior, which are often indicators of long-term tumor relapse.

Mathematical Model Application to the Kinetic Study of Tumor Markers

In order to overcome the inefficient cutoff criterion in the management of neoplastic patients after therapy, in follow-up, in recurrence and in monitoring treatment, we have analysed some mathematical models to evaluate serial determinations of tumor markers, with the aim to ascertain the radicality of surgery or the presence of recurrences.

Since a tracer study of the biological system of tumor markers is impossible, some information, such as rate factor and half-life, is obtained by determination of the marker after radical treatment.

In steady state with two or more samples in time it is possible with adequate statistical models to establish a significant increase in the marker.

In recurrence, if it is true that the secretion rate of the marker by a tumor is proportional to tumor mass, then increasing concentrations of the tumor marker would be a phenotypic expression of tumor growth.

Therefore some mathematical models are proposed to evaluate the kinetics of tumor growth.

The acidic microenvironment as a possible niche of dormant tumor cells

Although surgical excision, chemo-, and radio-therapy are clearly advanced, tumors may relapse due to cells of the so-called "minimal residual disease". Indeed, small clusters of tumor cells persist in host tissues after treatment of the primary tumor elaborating strategies to survive and escape from immunological attacks before their relapse: this variable period of remission is known as "cancer dormancy". Therefore, it is crucial to understand and consider the major concepts addressing dormancy, to identify new targets and disclose potential clinical strategies. Here, we have particularly focused the relationships between tumor microenvironment and cancer dormancy, looking at a re-appreciated aspect of this compartment that is the low extracellular pH. Accumulating evidences indicate that acidity of tumor microenvironment is associated with a poor prognosis of tumor-bearing patients, stimulates a chemo- and radio-therapy resistant phenotype, and suppresses the tumoricidal activity of cytotoxic lymphocytes and natural killer cells, and all these aspects are useful for dormancy. Therefore, this review discusses the possibility that acidity of tumor microenvironment may provide a new, not previously suggested, adequate milieu for "dormancy" of tumor cells.

Cancer nanoimmunotherapy using advanced pharmaceutical nanotechnology

Immunotherapy is a promising option for cancer treatment that might cure cancer with fewer side effects by primarily activating the host's immune system. However, the effect of traditional immunotherapy is modest, frequently due to tumor escape and resistance of multiple mechanisms. Pharmaceutical nanotechnology, which is also called cancer nanotechnology or nanomedicine, has provided a practical solution to solve the limitations of traditional immunotherapy. This article reviews the latest developments in immunotherapy and nanomedicine, and illustrates how nanocarriers (including micelles, liposomes, polymer-drug conjugates, solid lipid nanoparticles and biodegradable nanoparticles) could be used for the cellular transfer of immune effectors for active and passive nanoimmunotherapy. The fine engineering of nanocarriers based on the unique features of the tumor microenvironment and extra-/intra-cellular conditions of tumor cells can greatly tip the triangle immunobalance among host, tumor and nanoparticulates in favor of antitumor responses, which shows a promising prospect for nanoimmunotherapy.

Choroidal metastases 34 years after remission of breast cancer

PURPOSE

To report a case of choroidal metastases from breast carcinoma occurring after a remission period of 34 years.

METHODS

Case report and literature review.

RESULTS

A 77-year-old woman who presented with blurry vision was found to have choroidal metastatic lesions in both her eyes. She had a remote history of breast cancer (status post mastectomy) 34 years ago. A metastatic workup was performed that revealed the presence of widespread metastatic lesions in the lungs, liver, and bones.

CONCLUSION

Although the median time period for the detection of choroidal metastases is 3 years after the diagnosis of the primary malignancy, choroidal metastases can present till 34 years later as in our case (the longest time interval reported in the literature).

Tumour antigens recognized by T lymphocytes: at the core of cancer immunotherapy

In this Timeline, we describe the characteristics of tumour antigens that are recognized by spontaneous T cell responses in cancer patients and the paths that led to their identification. We explain on what genetic basis most, but not all, of these antigens are tumour specific: that is, present on tumour cells but not on normal cells. We also discuss how strategies that target these tumour-specific antigens can lead either to tumour-specific or to crossreactive T cell responses, which is an issue that has important safety implications in immunotherapy. These safety issues are even more of a concern for strategies targeting antigens that are not known to induce spontaneous T cell responses in patients.

The host support niche as a control point for tumor dormancy: implications for tumor development and beyond

An increasingly appreciated focus of carcinogenesis research is on mechanisms governing tumor growth after the fact of cancer cell creation. Of particular interest are dynamical interactions between tumor and host cell populations that can themselves strongly impact the fate of established cancer lesions. Regardless of tumor type, all cancers face the common problem of having to breach the barrier of angiogenic competency in order to advance from a microscopic lesion to symptomatic disease. If pre-angiogenic tumor cells are held in dormancy due to cell cycle arrest, this will postpone the need to traverse this higher-level barrier. On the other hand, the barrier itself may prove limiting to a tumor at its diffusion-limited size, creating a population-level dormancy characterized by balanced proliferation and cell death. In both cases of dormancy, the "angiogenic switch" has not yet occurred. We here describe and mathematically quantify an underappreciated third dormancy state defined by an angiogenic balance following the angiogenic switch. In this state we term "post-vascular dormancy," a tumor has attained angiogenic competency, but again demonstrates balanced proliferation and cell death because ambient pro- and anti-angiogenic influences are offsetting. Interestingly, autopsies have shown virtually all of us carry latent tumors in pre- or post-vascular states, many of which lie under the threshold of routine clinical detection. We show how, in the post-vascular case, tumor latency can arise from an elaborate mechanism of self-controlled growth, mediated through the tumor-vascular interaction. Underlying this observation is the finding that a tumor produces both angiogenesis stimulators and inhibitors, with the latter having greater influence, both locally and systemically, as the tumor grows-a mechanism we hypothesize is an aberrant co-option of normal organogenic regulation. That a tumor can limit its own growth raises the prospect that chronic therapies aimed at suppressing this tumor-host dynamic may compare favorably to current strategies which often yield favorable short-term responses but fail to deliver long-term tumor suppression.

Cancer immunoediting in malignant glioma

Significant work from many laboratories over the last decade in the study of cancer immunology has resulted in the development of the cancer immunoediting hypothesis. This contemporary framework of the naturally arising immune system-tumor interaction is thought to comprise 3 phases: elimination, wherein immunity subserves an extrinsic tumor suppressor function and destroys nascent tumor cells; equilibrium, wherein tumor cells are constrained in a period of latency under immune control; and escape, wherein tumor cells outpace immunity and progress clinically. In this review, we address in detail the relevance of the cancer immunoediting concept to neurosurgeons and neuro-oncologists treating and studying malignant glioma by exploring the de novo immune response to these tumors, how these tumors may persist in vivo, the mechanisms by which these cells may escape/attenuate immunity, and ultimately how this concept may influence our immunotherapeutic approaches.

Neurofibromatosis-1 heterozygosity increases microglia in a spatially and temporally restricted pattern relevant to mouse optic glioma formation and growth

Whereas carcinogenesis requires the acquisition of driver mutations in progenitor cells, tumor growth and progression are heavily influenced by the local microenvironment. Previous studies from our laboratory have used Neurofibromatosis-1 (NF1) genetically engineered mice to characterize the role of stromal cells and signals to optic glioma formation and growth. Previously, we have shown that Nf1+/- microglia in the tumor microenvironment are critical cellular determinants of optic glioma proliferation. To define the role of microglia in tumor formation and maintenance further, we used CD11b-TK mice, in which resident brain microglia (CD11b+, CD68+, Iba1+, CD45low cells) can be ablated at specific times after ganciclovir administration. Ganciclovir-mediated microglia reduction reduced Nf1 optic glioma proliferation during both tumor maintenance and tumor development. We identified the developmental window during which microglia are increased in the Nf1+/- optic nerve and demonstrated that this accumulation reflected delayed microglia dispersion. The increase in microglia in the Nf1+/- optic nerve was associated with reduced expression of the chemokine receptor, CX3CR1, such that reduced Cx3cr1 expression in Cx3cr1-GFP heterozygous knockout mice led to a similar increase in optic nerve microglia. These results establish a critical role for microglia in the development and maintenance of Nf1 optic glioma.

Influence of Viable Cells on the Resuscitation of Dormant Cells in Micrococcus luteus Cultures Held in an Extended Stationary Phase: the Population Effect

A high proportion of Micrococcus luteus cells in cultures which had been starved for 3 to 6 months lost the ability to grow and form colonies on agar plates but could be resuscitated from their dormancy by incubation in an appropriate liquid medium (A. S. Kaprelyants and D. B. Kell, Appl. Environ. Microbiol. 59:3187-3196, 1993). In the present work, such cultures were studied by both flow cytometry and conventional microbiological methods and were found to contain various numbers of viable cells. Pretreatment of such cultures with penicillin G, and subsequent dilution, was used to vary this number. When the initial number of colony-forming cells per 30-ml flask was approximately nine (+/-five) or more, resuscitation of 10 to 40% of the cells, and thus culture growth, was observed. The lag period before the appearance of a population of cells showing significant accumulation of the fluorescent dye rhodamine 123 (i.e., of cells with measurable membrane energization) decreased from 70 to 27 h when the number of viable cells was increased from 30 to 10 per flask, while the lag period before an observable increase in the number of colony-forming cells occurred was almost constant (at some 20 h). Provided there were more than nine (+/-five) initially viable cells per flask, the number of initially viable cells did not affect the final percentage of resuscitable cells in the culture. The lag period could be ascribed in part to the time taken to restore the membrane permeability barrier of starved cells during resuscitation, as revealed by flow cytometric assessment of the uptake of the normally membrane-impermeant fluorescent DNA stain PO-PRO-3 {4-[3-methyl-2, 3-dihydro-(benzo-1, 3-oxazole)-2-methylidene]-1-(3'-trimethylammonium propyl)-pyridinium diiodide}. Although cell populations which contained fewer than nine +/-five viable cells per flask failed to grow, 4 to 20% of the cells (of 1.2 X 10) were able to accumulate rhodamine 123 after 80 to 100 h of incubation, showing the ability of a significant number of the cells in the population at least to display "metabolic resuscitation." Resuscitation and cell growth under such conditions were favored by the use of a 1:1 mixture of fresh lactate medium and supernatant from late-logarithmic-phase M. luteus cultures as the resuscitation medium. We conclude that the presence of a small fraction of viable cells at the onset of resuscitation facilitates the recovery of the majority of the remaining (dormant) cells. The cell density dependence of the kinetics, or population effect, suggests that this recovery is due to the excretion of some factor(s) which promoted the transition of cells from a state in which they are incapable of growth and division to one in which they are capable of colony formation.

Interferons, immunity and cancer immunoediting

A clear picture of the dynamic relationship between the host immune system and cancer is emerging as the cells and molecules that participate in naturally occurring antitumour immune responses are being identified. The interferons (IFNs) - that is, the type I IFNs (IFNalpha and IFNbeta) and type II IFN (IFNgamma) - have emerged as central coordinators of tumour-immune-system interactions. Indeed, the decade-old finding that IFNgamma has a pivotal role in promoting antitumour responses became the focus for a renewed interest in the largely abandoned concept of cancer immunosurveillance. More recently, type I IFNs have been found to have distinct functions in this process. In this Review, we discuss the roles of the IFNs, not only in cancer immunosurveillance but also in the broader process of cancer immunoediting.

Interferon-gamma and cancer immunoediting

Over the last 12 yr, we have shown that interferon-gamma and lymphocytes collaborate to regulate tumor development in mice. Specifically, we found that the immune system not only prevents the growth of primary (carcinogen-induced and spontaneous) and transplanted tumors but also sculpts the immunogenicity of tumors that form. These observations led us to refine the old and controversial "cancer immunosurveillance" hypothesis of Burnet and Thomas into one that we termed cancer immunoediting that better emphasizes the paradoxical host-protective and tumor-sculpting roles of immunity on developing tumors. Our current work focuses on defining the molecular mechanisms that underlie cancer immunoediting and exploring the implications of this process for cancer immunotherapy.

Cancer Immunosurveillance and Immunoediting: The Roles of Immunity in Suppressing Tumor Development and Shaping Tumor Immunogenicity

Cellular transformation and tumor development result from an accumulation of mutational and epigenetic changes that alter normal cell growth and survival pathways. For the last 100 years, there has been a vigorous debate as to whether the unmanipulated immune system can detect and eliminate such altered host derived cells despite the fact that cancer cells frequently express either abnormal proteins or abnormal levels of normal cellular proteins that function as tumor antigens. In this review, we discuss the current state of this argument and point out some of the recent key experiments demonstrating that immunity not only protects the host from cancer development (i.e., provides a cancer immunosurveillance function) but also can promote tumor growth, sometimes by generating more aggressive tumors. The terminology "cancer immunoediting" has been used to describe this dual host protective and tumor promoting action of immunity, and herein we summarize the ever-increasing experimental and clinical data that support the validity of this concept.

The immunobiology of cancer immunosurveillance and immunoediting

The last fifteen years have seen a reemergence of interest in cancer immunosurveillance and a broadening of this concept into one termed cancer immunoediting. The latter, supported by strong experimental data derived from murine tumor models and provocative correlative data obtained by studying human cancer, holds that the immune system not only protects the host against development of primary nonviral cancers but also sculpts tumor immunogenicity. Cancer immunoediting is a process consisting of three phases: elimination (i.e., cancer immunosurveillance), equilibrium, and escape. Herein, we summarize the data supporting the existence of each of the three cancer immunoediting phases. The full understanding of the immunobiology of cancer immunosurveillance and immunoediting will hopefully stimulate development of more effective immunotherapeutic approaches to control and/or eliminate human cancers.

Behaviour of metastasis in relation to vascular index in patients with node-positive breast cancer treated with adjuvant tamoxifen

Some experimental studies suggested that one possible oestrogen-receptor-unrelated mechanism of action of tamoxifen involves inhibition of angiogenesis. We evaluated the correlation of the degree of vascularisation of the primary tumour and we assessed it by using the panendothelial marker anti-CD31 and immunohistochemistry with microvessels count, performed at the vascular 'hot spot' of each single cancer, with the risk of recurrence in time. A cohort of 176 consecutive patients with node-positive invasive breast cancer treated with adjuvant tamoxifen (30 mg/daily for 3 years) and a median follow-up of 72 months was studied. Sixty-two patients developed metastasis (30 visceral, 18 skeletal and 14 in soft tissues) during the time of observation. The study of the hazard function for metastasis was performed by a generalized linear modelling approach with a binomial error according to Efron. The risk of first recurrence was strictly associated with vascular index, having the patients with the highest microvessel counts the highest risk of metastasis during all the period of observation. We did not find an interaction of vascularity with oestrogen receptor (ER) status. However, in the subgroup of patients with ER-positive tumours the hazard of metastasis was almost constant in time, while in that with ER-negative tumours it increased rapidly up to 20 months and, thereafter, decreased sharply. The results of our study are an indirect evidence that the patients with highly vascularized breast cancers may gain poor benefit of adjuvant tamoxifen and, therefore. that this antioestrogen is unlikely to retain a clinically relevant antiangiogenic activity in human breast cancer. Our data need confirmation by a prospective randomized clinical trial.

Angiogenesis sustains tumor dormancy in patients with breast cancer treated with adjuvant chemotherapy

Experimental studies performed in Folkman laboratories suggest that angiogenesis is involved in the biology of tumor dormancy. We determined the vascular index in a series of 190 women operated of node-positive invasive breast cancer treated with adjuvant chemotherapy (CMF schedule) and we studied the relationship between vascularity of primary tumors with the behaviour in time of metastasis. The study of the hazard function of recurrence (in any site) was performed resorting to a generalized linear modelling approach with a binominal error according to Efron. A total of 80 cases developed recurrences during the period of observation. We found that the hazard function of metastasis in time presented two peaks of incidence at 20 and 60 months, respectively. We also plotted the curves of the hazard function by considering three values of microvessel counts corresponding to the quartiles of their distribution. The risk of first recurrence was associated with vascular index, and the patients of the third quartile of distribution of microvessels had the highest risk. In the final full model for the risk of recurrence at 5 years vascular index provided the highest prognostic contribution followed by the number of involved axillary lymph nodes. The observation that the patients with highly angiogenic tumors are at high risk of recurrence coupled with the identification of the second peak of incidence after 5 years which was also mainly sustained by angiogenic tumors suggest that a fraction of breast cancers promote metastasis after a period of tumor dormancy. The clinical and therapeutic implications of our results are discussed.

Perspective: tumour spread--the problems of latency

Tumour latency, or dormancy, is a well-recognized clinical phenomenon and induction or maintenance of this state would appear to offer a novel therapeutic approach to limiting the effects of neoplastic disease. Current interest has focused on the role that neovascularization plays in this process and the consequences of shifts in the balance between angiogenic and anti-angiogenic peptides. Targeting tumour vasculature by the administration or induction of such anti-angiogenic peptides is close to clinical evaluation.

Multistep nature of metastatic inefficiency: dormancy of solitary cells after successful extravasation and limited survival of early micrometastases

In cancer metastasis, only a small percentage of cells released from a primary tumor successfully form distant lesions, but it is uncertain at which steps in the process cells are lost. Our goal was to determine what proportions of B16F1 melanoma cells injected intraportally to target mouse liver 1) survive and extravasate, 2) form micrometastases (4 to 16 cells) by day 3, 3) develop into macroscopic tumors by day 13, and 4) remain as solitary dormant cells. Using in vivo videomicroscopy, a novel cell accounting assay, and immunohistochemical markers for proliferation (Ki-67) and apoptosis (TUNEL), we found that 1) 80% of injected cells survived in the liver microcirculation and extravasated by day 3, 2) only a small subset of extravasated cells began to grow, with 1 in 40 forming micrometastases by day 3, 3) only a small subset of micrometastases continued to grow, with 1 in 100 progressing to form macroscopic tumors by day 13 (in fact, most micrometastases disappeared), and 4) 36% of injected cells remained by day 13 as solitary cancer cells, most of which were dormant (proliferation, 2%; apoptosis, 3%; in contrast to cells within macroscopic tumors: proliferation, 91%; apoptosis/necrosis, 6%). Thus, in this model, metastatic inefficiency is principally determined by two distinct aspects of cell growth after extravasation: failure of solitary cells to initiate growth and failure of early micrometastases to continue growth into macroscopic tumors.

Detection and characterization of carcinoma cells in the blood

A highly sensitive assay combining immunomagnetic enrichment with multiparameter flow cytometric and immunocytochemical analysis has been developed to detect, enumerate, and characterize carcinoma cells in the blood. The assay can detect one epithelial cell or less in 1 ml of blood. Peripheral blood (10-20 ml) from 30 patients with carcinoma of the breast, from 3 patients with prostate cancer, and from 13 controls was examined by flow cytometry for the presence of circulating epithelial cells defined as nucleic acid+, CD45(-), and cytokeratin+. Highly significant differences in the number of circulating epithelial cells were found between normal controls and patients with cancer including 17 with organ-confined disease. To determine whether the circulating epithelial cells in the cancer patients were neoplastic cells, cytospin preparations were made after immunomagnetic enrichment and were analyzed. Epithelial cells from patients with breast cancer generally stained with mAbs against cytokeratin and 3 of 5 for mucin-1. In contrast, no cells that stained for these antigens were observed in the blood from normal controls. The morphology of the stained cells was consistent with that of neoplastic cells. Of 8 patients with breast cancer followed for 1-10 months, there was a good correlation between changes in the level of tumor cells in the blood with both treatment with chemotherapy and clinical status. The present assay may be helpful in early detection, in monitoring disease, and in prognostication.

Tumor Dormancy and Cell Signaling. V. Regrowth of the BCL1 Tumor After Dormancy Is Established

The majority of BALB/c mice immunized with the BCL1 lymphoma-derived idiotype (Id+) IgM and subsequently challenged with BCL1 tumor cells develop a state of tumor dormancy. The vast majority of dormant lymphoma cells are in cell cycle arrest, but there are also residual replicating cells. In the present studies, we attempted to define features of both the dormant lymphoma cells and the host that lead to escape from dormancy. Escape from dormancy occurs at a steady rate over a 2-year period, suggesting that it is a stochastic process. We found that, in the majority of mice, escape was due to the emergence of genetic variants that were no longer susceptible to the anti-Id–mediated induction of dormancy. Ten percent of these variants were Id−; the remainder were Id+ but could grow in the presence of anti-Id antibodies, suggesting that there were mutations in molecules involved in one or more mIg-mediated negative-signaling pathways. In two of five such escapees, alterations in either Syk, HS1, and/or Lyn were observed. In a small percentage of mice, a low titer of circulating anti-Id antibody before tumor challenge correlated with a subsequent, more rapid loss of dormancy.

Circulating clonotypic B cells in the biology of multiple myeloma: speculations on the origin of myeloma

The population of circulating B cells in myeloma patients includes an apparently large but variable subset with the IgH VDJ rearrangement diagnostic for the malignant clone of plasma cells in individual myeloma patients. Although the biological significance is at present unknown, it is likely that they include both malignant and non-malignant clonal relatives of the myeloma plasma cells. This article presents speculations on the significance of these cells in the origin of myeloma and the relationship between monoclonal gammopathy of undetermined significance (MGUS) and frank myeloma. MGUS appears to represent the establishment of clonal dominance probably by a chronically antigen-stimulated B cell clone. It seems likely that malignant transformation event(s) occurring in a clonal daughter cell give rise to myeloma. If correct, this implies that in a myeloma patient, non-malignant antigen-responsive B cells expressing the patient-specific IgH rearrangement coexist in the circulation and probably all lymphoid tissues, with their malignant antigen-independent relatives. However, the significance one attributes to the clonotypic B cells detected in the blood of myeloma patients depends in part on the view one takes of the progression from MGUS to myeloma. An alternative perspective is that MGUS represents a dormant state of malignancy held in check by controlled apoptosis, arrested cell cycling, and/or by immunoregulatory networks. Although lacking in experimental support, if this interpretation were correct, myeloma would occur when the regulatory mechanisms fail, allowing uncontrolled malignant cell renewal. This alternative view would imply that the majority of circulating clonotypic B cells might be malignant. Thus, an analysis of the biology of these clonotypic circulating B cells, with an emphasis on measures of malignancy, is likely to shed considerable light on the events underlying myeloma genesis, progression and spread.

Somatic microsatellite mutations as molecular tumor clocks

Microsatellite (MS) mutations can potentially unravel the past of mutator phenotype tumors, with greater genetic diversity expected in older regions. Rapid clonal expansions of xenografts were characterized by relatively homogenous MS alleles, whereas greater diversity was observed in a colorectal cancer with the greatest variation in its adjacent adenoma. A subcutaneous lung cancer metastasis demonstrated diversity consistent with its one-month clinical duration and evidence of active mitosis during dormancy. The genetic legacy inherent to multistep tumorigenesis provides direct estimates of tumor ages, with up to thousands of cell divisions and high death rates necessary to yield the observed diversities. MS molecular tumor clocks have the unique potential to systematically reconstruct the early and occult evolution of individual human mutator phenotype tumors.

Dormancy of micrometastases: balanced proliferation and apoptosis in the presence of angiogenesis suppression

In cancer patients, dormant micrometastases are often asymptomatic and clinically undetectable, for months or years, until relapse. We have studied dormant lung metastases under angiogenesis suppression in mice. The metastases exhibited rapid growth when the inhibition of angiogenesis was removed. Tumour cell proliferation, as measured by bromodeoxyuridine incorporation and immunohistochemical staining proliferating cell nuclear antigen, was not significantly different in dormant and growing metastases. However, tumour cells of dormant metastases exhibited a more than threefold higher incidence of apoptosis. These data show that metastases remain dormant when tumour cell proliferation is balanced by an equivalent rate of cell death and suggest that angiogenesis inhibitors control metastatic growth by indirectly increasing apoptosis in tumour cells.

The influence of angiogenesis research on management of patients with breast cancer

The diagnosis and treatment of patients with breast cancer is beginning to be influenced by new ideas and discoveries emerging from the field of angiogenesis research. This field, pursued in the laboratory for more than 20 years, has in the past 5 years generated clinical applications. Some of these applications have begun to change current thinking about cancer patients and especially about those with breast cancer. I here discuss how an understanding of the process of angiogenesis may contribute to improved management of patients with breast cancer.

Activation of dormant cancer cells in the prostates and seminal vesicles of Lobund-Wistar rats

Lobund-Wistar (L-W) rats are unique in their susceptibility to spontaneous and induced metastasizing adenocarcinomas in the prostate-seminal vesicle (P-SV) complex. Tumors were induced in 70-100% of rats by a combination of i.v. inoculated methylnitrosourea (MNU) followed by a series of subcutaneous slow-release implants of testosterone propionate (TP). Adenocarcinoma cells initiated by MNU in 3-month-old L-W rats were activated significantly by implants of the promoter, TP, after intervening periods of 3, 6 and 12 months following their exposures to MNU. The longer the time between MNU and TP, the shorter the subsequent latent period. Control rats inoculated with MNU (without TP) did not develop tumors during the observation period of 12 months, and their dormant tumor cells were activated by a single implant of TP, thereby eliciting P-SV tumors.

Nonlinear dynamics of immunogenic tumors: parameter estimation and global bifurcation analysis

We present a mathematical model of the cytotoxic T lymphocyte response to the growth of an immunogenic tumor. The model exhibits a number of phenomena that are seen in vivo, including immunostimulation of tumor growth, "sneaking through" of the tumor, and formation of a tumor "dormant state". The model is used to describe the kinetics of growth and regression of the B-lymphoma BCL1 in the spleen of mice. By comparing the model with experimental data, numerical estimates of parameters describing processes that cannot be measured in vivo are derived. Local and global bifurcations are calculated for realistic values of the parameters. For a large set of parameters we predict that the course of tumor growth and its clinical manifestation have a recurrent profile with a 3- to 4-month cycle, similar to patterns seen in certain leukemias.

Induction of B cell tumor dormancy by anti-idiotypic antibodies

Long-term dormancy of murine B-cell lymphomas can be experimentally induced by immunizing the host with the idiotype expressed on the tumor. Interaction of the cells with anti-idiotype antibodies is sufficient to induce and maintain the dormant state. The growth of lymphoma cells interacting with anti-idiotype antibodies is arrested and they undergo dramatic changes in their morphology, cell-cycle status and oncogene expression. Regrowth of a tumor after long-term dormancy results from the emergence of a tumor cell variant that no longer responds to the antibodies with growth inhibition. These data demonstrate the feasibility of reversing a malignant phenotype of cells by specific growth arrest signals and suggest new approaches for therapeutic intervention in cancer.

A sequential cell kinetic study of meningioma cells in primary explant culture using bromodeoxyuridine

The present study was undertaken to evaluate the sequential BrdU-LI at weekly intervals upto four weeks in 18 primary explant cultures of meningiomas. This revealed three distinct patterns of growth which could be arbitrarily defined as 'degenerating' (group I), 'proliferating' (group II) and 'adaptive' (group III) types. Interestingly two cases of malignant and two of recurrent meningiomas fell into the 'degenerating' group I pattern. The possible explanations for the observed relatively higher in vitro LI values compared to lower in vivo values as reported in the literature and the theoretical implications of the three distinct patterns of sequential LI values are discussed.

Immunotherapy of B lymphoma by anti-idiotype antibodies: characterization of variant tumour cells appearing a long time after the initial tumour inoculation

Immunotherapy of a murine B-cell lymphoma by antibodies to idiotypic determinants of its IgM, resulted in surviving tumour-free mice. Several of these mice, however, did develop tumours a long time after the initial inoculation of the tumour cells, or upon rechallenge of the survivors with B-lymphoma cells. The presence of tumour cells during this long latent period may have been due to the development in the host of an anti-idiotype immune response. These late-developing tumours were detected by a radioimmunoassay and characterized by immunofluorescent staining and sodium dodecyl sulphate/polyacrylamide gel electrophoresis. Cells of some late-developing tumours lost the idiotype recognized by the antibodies used for the immunotherapy. Several of these tumours expressed IgM on the cell surface, while others did not, because of the absence of light chains. They were identical in the structure of their rearranged mu chain genes proving their derivation from the original inoculation. Cell lines obtained from the late-developing tumours differed in their tumorigenicity. The appearance of idiotype-negative tumour cells as a result of anti-idiotype immunotherapy has a great impact in our efforts to cure lymphoma by this modality.

Idiotypic vaccination against B-cell lymphoma leads to dormant tumour

Idiotypic immunoglobulin, which can be considered to bear tumour-associated antigens in the context of B-cell lymphoma, has been obtained from the splenic A31 tumour, purified, and used to immunise syngeneic mice. On subsequent exposure to a lethal challenge of lymphoma cells, the mice showed no overt tumour development over an observation period of 6 months, whereas mice immunised with an unrelated idiotypic immunoglobulin succumbed to lymphoma after about 20 days. Anti-idiotypic immunity persisted in protected mice, since a second exposure to a lethal tumour dose 4 months after the first challenge also failed to induce lymphoma. Anti-idiotypic antibody appeared to have a major role in protection when analysed by passive transfer experiments, with no contribution from transferred cells. Protected mice were investigated for the presence of lymphoma cells 4-8 months following exposure to tumour, but the spleens, which were of normal weight and appearance, contained few or no tumour cells by phenotypic analysis. However, passage of cells dispersed from these spleens led, in 60% of cases, to tumour development in unimmunised recipients. The emergent tumours were indistinguishable from the original A31 lymphoma, with no evidence for variants, indicating that the cells were unable to grow in the immune mice, but that this dormant state could be disrupted by transfer.

Dormancy and breast cancer

A case is presented in which multiple nodules of recurrent cancer appeared about the scar 25 years after radical mastectomy. They were accompanied by an inflammatory reaction. Breast cancers may recur as long as 50 years after surgery. Such late recurrence is accomplished by the cancer cell entering a "dormant" state in which little or no de novo DNA transcription occurs and only enough RNA is translated into proteins to maintain the vegetative functions that sustain cell viability. Features favoring the evolvement of dormancy are discussed as well as the nature of the cocoon-like shell which affords such cancer cells protection from the host's cellular and serological defenses. Speculation, promoted by the new cellular biology, as to the cause of secondary inflammatory cancers, is presented. A possible mechanism for the reactivation of these quiescent cells is suggested. The altered immune reactions of host and cancer cells provide an explanation for the controversies plaguing surgeons regarding the treatment and prognosis of breast cancer.

Delayed cutaneous metastasis of gastric carcinoma

This paper describes a case of skin cancer resembling carcinoma en cuirasse associated with multiple bone lesions, which were both judged to be due to metastasis of poorly differentiated carcinoma of the stomach, the primary lesion excised ten years previously. Overt bone involvement had been observed for more than two years and a half. Histologic examination of a skin biopsy specimen showed that carcinoma cells had infiltrated into the middle and lower dermis, forming clusters and strands in an abundance of fibrous stromata. No primary lesion was detected in the remnant stomach at autopsy.

Prospects for the treatment of B cell tumors using idiotypic vaccination

Manipulation of the immune system in order specifically to attack autologous tumor cell has been a distant goal, largely due to the poor definition of tumor-associated antigens. By focussing on B cell lymphomas which express a molecularly defined clonal marker, the idiotypic immunoglobulin, it has been possible to generate autologous anti-idiotypic responses which suppress individual tumors. Studies of the components of these responses are providing insight into host effector mechanisms which can be activated against tumors, and also into the many strategies adopted by the target cells in order to avoid such attack. Promising results in various animal models where tumor bearers can be treated by idiotypic immunization have led to the point where application of this approach to the treatment of certain categories of human B cell lymphoma can be considered.