Article

Isolation of blood-borne epithelium-derived c-erbB-2 oncoprotein-positive clustered cells from the peripheral blood of breast cancer patients

Authors:
  • Sana Klinikum Offenbach GmbH
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Abstract

Clinical studies including thousands of breast cancer patients have shown that c-erbB-2 is amplified and overexpressed in 20–30% of invasive human breast cancers and that it is associated with distant metastasis in specified patient subgroups. To isolate and characterize hematogeneously spreading c-erbB-2-positive epithelium-derived cells from the peripheral blood of breast cancer patients, a combined buoyant density gradient and immuno-magnetic separation method has been used. The method utilizes a biotinylated anti-cytokeratin monoclonal antibody (MAb) for capturing the epithelium-derived cells. The expression of c-erbB-2 by the captured cells was detected using an anti-c-erbB-2 rabbit antibody (21N) coupled to an anti-rabbit gold-labeled antibody, whereby immunoenzymatic cytokeratin staining was performed using a silver-enhanced immunogold double staining protocol. In total, 29 of the 46 patients tested had either cytokeratin (24/29) or cytokeratin/c-erbB-2 (19/29) positive clustered cells in their peripheral blood. We thus report here the presence and the frequency of clone-specifically stained clustered cells in the peripheral blood of breast cancer patients. The frequency of cytokeratin/c-erbB-2 double-positive clustered cells in the peripheral blood was on average 10 times higher than that of double-positive single cells. The numbers of cytokeratin/c-erbB-2 double-positive clustered cells were positively correlated with the stage of tumors. Results of in vitro motility experiments using single and clustered cells from primary breast cancer tissue strongly support the assumption that cytokeratin/c-erbB-2 double-positive clustered cells have a high potential for locomotion. We suggest that blood-borne epithelium-derived c-erbB-2-positive clustered cells are the possible precursor cells responsible for the formation of distant metastases and bone marrow micrometastases. Int. J. Cancer 76:824–828, 1998.© 1998 Wiley-Liss, Inc.

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... DTCs and CTCs may express the HER2 oncoprotein in 60-70% early stage patients with breast cancer [14][15][16][17], and often present HER2 gene amplification and aneusomy [18,19]. Interestingly, HER2 expression on DTCs/CTCs is independent of its expression on primary tumor cells [16][17][18][19][20][21][22]. ...
... DTCs and CTCs may express the HER2 oncoprotein in 60-70% early stage patients with breast cancer [14][15][16][17], and often present HER2 gene amplification and aneusomy [18,19]. Interestingly, HER2 expression on DTCs/CTCs is independent of its expression on primary tumor cells [16][17][18][19][20][21][22]. A shift of breast cancer patients' CTCs from HER2(-) to HER2(+) status [23] has been attributed to acquired HER2 gene amplification during cancer progression [24]. ...
... A shift of breast cancer patients' CTCs from HER2(-) to HER2(+) status [23] has been attributed to acquired HER2 gene amplification during cancer progression [24]. The detection of HER2 oncoprotein on DTCs and CTCs has been associated with an increased risk of death [16][17][18][19][20][21][22]and decreased disease-free interval [22]; moreover, HER2 mRNA-positive CTCs have independent prognostic value for worse disease-free and overall survival [25,26]. ...
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... Cancer cell lines have been shown to overexpress the HRG receptor protein at levels up to 100 times those of normal cells [23]. This is also seen in patient samples where 20%-30% of invasive breast cancers exhibit amplification of this receptor gene, and the presence of such overexpression is associated with distant metastases [24]. ...
... Overexpression of erbB2 is thought to occur in 25%-30% of patients, and this correlates with a poor prognosis [24][25][26]. It is thought that adjuvant immunotherapy may assist those patients found to be erbB-positive. ...
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... Finally, it has been demonstrated that the presence of HER2-positive CTCs in early BC patients and showed that this positivity is an independent factor from HER2-status in the primary tumour [69][70][71][72]. In an interesting study [44], it was demonstrated that patients with HER2-negative tumours but positive CTCs treated with trastuzumab showed reduced probability of relapse and improved disease-free interval. ...
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... In most cases, the isolation procedures based on immunological methods. Paramagnetic beads conjugated with monoclonal antibodies were used to capture disseminated (epithelial ) cells (Brandt et al, 1998; Soria et al, 1999 ). Major limitations of immunomagnetic isolation protocols are altered or masked antigenic epitopes and down-regulation of antigen expression.Figure 5 Actuarial relapse-free survival curves for breast cancer patients stratified by genomic imbalances (14 parameters; seeFigure 4) detected in isolated MRCC of the blood derived from nodal-negative (A; n = 146) and nodal-positive (B; n = 161) patients. ...
Article
The prognostic value of disseminated tumour cells derived from 353 breast cancer patients was evaluated. Disseminated tumour cells were purified from blood using a newly established method and nucleic acids were subsequently isolated. We investigated genomic imbalances (GI) such as mutation, amplification and loss of heterozygosity of 13 tumour suppressor genes and 2 proto-oncogenes using DNA from isolated minimal residual cancer cells. Significant correlations were found between genomic alterations of the DCC - and c-erbB-2 genes in disseminated breast cancer cells and actuarial relapse-free survival. Furthermore, increasing numbers of genomic imbalances measured in disseminated tumour cells were significantly associated with worse prognosis of recurrent disease. Logistic regression and Cox multivariate analysis led to the identification of genomic imbalances as an independent prognostic factor. Determination of disseminated tumour cells by genotyping of oncogenes and tumour suppressor genes seems not only to be a useful adjunct in follow up of carcinoma patients but provides also valuable additional individualized prognostic and predictive information in breast cancer patients beyond the TNM system.
... In a comparative investigation the purification efficiencies of a commonly used immunological purification system (anti-EGP on magnetic beads) (18)(19)(20) and the novel DISCcell system were evaluated. MRCCs from breast cancer patients were isolated using the immunological approach (n = 260) and the novel approach (n = 347). ...
Article
Clinical relevance, purification techniques and molecular characterization of minimal residual cancer cells (MRCC) is a controversial topic in the literature. An analytical concept including a novel isolation procedure and a panel of tests for DNA and RNA typing of MRCCs is described and clinically evaluated in this paper. The purification procedure exploiting the physical characteristics of MRCCs shows superior performance leading to > 50% pure and viable tumor cells. Proof of the presence and purity of MRCCs in an isolated sample is given by multiparametric DNA typing (amplifications, mutations, losses of heterozygosity). On the basis of the proven presence of MRCCs tumor-relevant mRNAs can be adequately analyzed by normalized quantitative real-time RT-PCR. The molecular characterization of MRCCs isolated from blood of breast cancer patients could have a strong clinical impact on prognostication, drug targeting and therapy monitoring.
... Thus, in a nude mouse model, cells expressing both c-erbB-2 and EGFR most frequently enhanced tumor formation and developed higher tumor masses than did cells expressing any other combination of the erbB receptors (18). As a consequence of the frequent detection of c-erbB-2-positive staining cell clusters in the peripheral blood of breast cancer patients (19), we established an in vitro model for the capillary wall by growing human umbilical vein endothelial cells (HUVECs) on porous membranes coated with basement membrane extracellular matrix and thereby demonstrated that c-erbB-2-expressing cell subpopulations within an individual primary breast cancer are of high transendothelial invasiveness (20). ...
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Separate mechanisms for oncogenesis and metastasis have been postulated. We show here that prolonged and invasive cell migration, a key mechanism in cancer metastasis, is linked to c-erbB-2 signaling. Cell lines with c-erbB-2 and EGFR expression and transphosphorylation activity display a high transendothelial invasiveness in an endothelial-extracellular matrix model mimicking a capillary vessel wall in vitro. Tyrosine-phosphorylated c-erbB-2 receptors and EGFR are localized predominantly in areas of the cell with high membrane extension activity. On the molecular level, there is a subtle cross talk between the transmembrane signaling molecule c-erbB-2 and the actin cytoskeleton at multiple levels, including the generation of the second messenger PIP2 and the mobilization of the actin-regulatory protein gelsolin. Our data strongly suggest that c-erbB-2, especially in a heterodimer with EGFR, is closely involved in signaling pathways, inducing alterations in cell morphology that are required for a human breast cancer cell to become motile and conceivably metastatic.
... All breast carcinoma patients analyzed who had distant metastases (stage M 1 ) had p185 erbB2 on CK-positive cells compared with about 50% of the patients who had regional disease (stage M 0 ; TNM classification system). More recently, Brandt et al. (144) suggested that blood-borne c-erbB2-positive CK-positive clustered cells are the possible precursors of distant metastases. These findings might explain why antibody therapy directed against erbB2-expressing cancer cells appears to be successful in patients with metastatic breast cancer who are receiving additional chemotherapy (145,146). ...
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Metastatic relapse in patients with solid tumors is caused by systemic preoperative or perioperative dissemination of tumor cells. The presence of individual tumor cells in bone marrow and in peripheral blood can be detected by immunologic or molecular methods and is being regarded increasingly as a clinically relevant prognostic factor. Because the goal of adjuvant therapy is the eradication of occult micrometastatic tumor cells before metastatic disease becomes clinically evident, the early detection of micrometastases could identify the patients who are most (and least) likely to benefit from adjuvant therapy. In addition, more sensitive methods for detecting such cells should increase knowledge about the biologic mechanisms of metastasis and improve the diagnosis and treatment of micrometastatic disease. In contrast to solid metastatic tumors, micrometastatic tumor cells are appropriate targets for intravenously applied agents because macromolecules and immunocompetent effector cells should have access to the tumor cells. Because the majority of micrometastatic tumor cells may be nonproliferative (G0 phase), standard cytotoxic chemotherapies aimed at proliferating cells may be less effective, which might explain, in part, the failure of chemotherapy. Thus, adjuvant therapies that are aimed at dividing and quiescent cells, such as antibody-based therapies, are of considerable interest. From a literature search that used the databases MEDLINE(R), CANCERLIT(R), Biosis(R), Embase(R), and SciSearch(R), we discuss the current state of research on minimal residual cancer in patients with epithelial tumors and the diagnostic and clinical implications of these findings.
... These studies have shown that most DTC and CTC do not express the proliferation antigen Ki-67, which could explain the partial resistance to chemotherapy (60). Furthermore, the presence or absence of the HER2 proto-oncogene appears to characterize an aggressive subpopulation with regard to invasive capabilities as well as impaired prognosis (73,74). Also the presence of DTC that express the urokinase-type plasminogen activator receptor (uPAR) has been correlated with an unfavourable prognosis (75). ...
Article
Many epithelial cancers carry a poor prognosis even after curative resection of early stage tumours. Tumour progression in these cancer patients has been attributed to the existence and persistence of disseminated tumour cells (DTC) in various body compartments as a sign of minimal residual disease. Bone marrow (BM) has been shown to be a common homing organ and reservoir for DTC. A significant correlation between the presence of DTC in BM and metastatic relapse has been reported in various tumour types. However, only a portion of patients with DTC in BM at primary surgery relapse. Thus far, little is known about the conditions required for the persistence of dormancy or the escape from the dormant phase into the active phase of metastasis formation. Thereby, this peculiar stage of conceivably balanced tumour cell division and death may last for decades in cancer patients. Most likely, the ability of a dormant DTC to "be activated" is a complex process involving (i) somatic aberrations in the tumour cells, (ii) the interaction of the DTC with the new microenvironment at the secondary site, and (iii) hereditary components of the host (i.e., cancer patient). In this review, we will summarize the key findings of research on micrometastatic cancer cells and discuss these findings in the context of the concept of tumour dormancy.
... Thus, a striking potential of CTC could be to re-evaluate therapeutic targets on these cells, which might enable a more individual and optimized antimetastatic therapy in patients with cancer. For example, it has been shown that CTC in the blood and disseminated tumor cell in the bone marrow are more frequently HER2-positive than the corresponding primary tumor (12)(13)(14). ...
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This study was aimed at detecting and characterizing circulating tumor cells (CTC) before and after neoadjuvant therapy (NT) in the peripheral blood of patients with breast cancer. The clinical trial GeparQuattro incorporated NT approaches (epirubicin/cyclophosphamide prior to randomization to docetaxel alone, docetaxel in combination with capecitabine, or docetaxel followed by capecitabine) and additional trastuzumab treatment for patients with HER2-positive tumors. We used the Food and Drug Administration-approved CellSearch system for CTC detection and evaluation of HER2 expression and developed HER2 immunoscoring for CTC. We detected > or =1 CTC/7.5 mL in 46 of 213 patients (21.6%) before NT and in 22 of 207 patients (10.6%) after NT (P = 0.002). Twenty (15.0%) initially CTC-positive cases were CTC-negative after NT, whereas 11 (8.3%) cases were CTC-positive after NT, although no CTC could be found before NT. CTC detection did not correlate with primary tumor characteristics. Furthermore, there was no association between tumor response to NT and CTC detection. HER2-overexpressing CTC were observed in 14 of 58 CTC-positive patients (24.1%), including 8 patients with HER2-negative primary tumors and 3 patients after trastuzumab treatment. CTC scored HER2-negative or weakly HER2-positive before or after NT were present in 11 of 21 patients with HER2-positive primary tumors. HER2 overexpression on CTC was restricted to ductal carcinomas and associated with high tumor stage (P = 0.002). CTC number was low in patients with primary breast cancer. The decrease in CTC incidence during treatment was not correlated with standard clinical characteristics and primary tumor response. Information on the HER2 status of CTC might be helpful for stratification and monitoring of HER2-directed therapies.
... Almost a century later some studies emerged acknowledging the role of CTC clusters in metastasis [28,29]. It was in the 90´s that first studies isolated CTC clusters from the blood of patients with certain types of cancer, such as prostate, colorectal, breast, lung and clear cell renal cell and hepatocellular carcinoma [30][31][32][33][34][35][36]. According to cancer animal models, the proportion of CTC clusters in the blood increases during cancer progression [37]. ...
Article
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The crosstalk between cancer cells and the tumor microenvironment (TME) is a key determinant of cancer metastasis. Cancer-associated fibroblasts (CAFs), one of the main cellular components of TME, promote cancer cell invasion and dissemination through mechanisms including cell-cell interactions and the paracrine secretion of growth factors, cytokines and chemokines. During metastasis, circulating tumor cells (CTCs) are shed from the primary tumor to the bloodstream, where they can be detected as single cells or clusters. The current knowledge about the biology of CTC clusters positions them as key actors in metastasis formation. It also indicates that CTCs do not act alone and that they may be aided by stromal and immune cells, which seem to shape their metastatic potential. Among these cells, CAFs are found associated with CTCs in heterotypic CTC clusters, and their presence seems to increase their metastatic efficiency. In this review, we summarize the current knowledge on the role that CAFs play on metastasis and we discuss their implication on the biogenesis, metastasis-initiating capacity of CTC clusters, and clinical implications. Moreover, we speculate about possible therapeutic strategies aimed to limit the metastatic potential of CTC clusters involving the targeting of CAFs as well as their difficulties and limitations.
... The finding of CTC clusters in human blood samples might be limited by the technologies used for their isolation, most of which use harsh batch purification approaches likely to disrupt such cellular aggregates. Early studies in advanced prostate, breast, and colorectal cancers relied on gradient centrifugation in combination with magnetic bead selection (Brandt et al., 1996Brandt et al., , 1998 Wang et al., 2000; Molnar et al., 2001). Our own recent study identifiedFigure 3. CTC clusters captured from lung cancer patients' blood using an anti-EpCAM– coated HB-chip. ...
Article
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Circulating tumor cells (CTCs) shed from primary and metastatic cancers are admixed with blood components and are thus rare, making their isolation and characterization a major technological challenge. CTCs hold the key to understanding the biology of metastasis and provide a biomarker to noninvasively measure the evolution of tumor genotypes during treatment and disease progression. Improvements in technologies to yield purer CTC populations amenable to better cellular and molecular characterization will enable a broad range of clinical applications, including early detection of disease and the discovery of biomarkers to predict treatment responses and disease progression.
... 15 Direct and indirect methods have been proposed to detect CTCs, but their results show large variability in specificity, sensitivity, and cost. 10,[16][17][18][19][20][21][22][23][24][25][26] Among the direct methods, cytopathologic detection of CTCs, after substantial enrichment according to their size (isolation by size of epithelial tumor cells [ISET]), seems to be a very attractive procedure providing good specificity and sensitivity in addition to its simplicity, rapidity, and low cost. 26 However, although cytopathologic analysis is predictably more specific than antigen-mediated CTC capture based on antibodies lacking specificity for tumor cells, it still has to be shown that CTCs can be recognized using the cytopathologic criteria of malignancy already used in conventional cytology (ie, in exfoliative and in fine-needle aspiration [FNA] cytopathology). ...
Article
Detection of circulating tumor cells (CTCs) morphologically may be a promising new approach in clinical oncology. We tested the reliability of a cytomorphologic approach to identify CTCs: 808 blood samples from patients with benign and malignant diseases and healthy volunteers were examined using the isolation by size of epithelial tumor cell (ISET) method. Cells having nonhematologic features (so-called circulating nonhematologic cells [CNHCs]) were classified into 3 categories: CNHCs with malignant features, CNHCs with uncertain malignant features, and CNHCs with benign features. CNHCs were found in 11.1% and 48.9% of patients with nonmalignant and malignant pathologies, respectively (P < .001). CNHCs with malignant features were observed in 5.3% and in 43.1% of patients with nonmalignant and malignant pathologies, respectively. Cytopathologic identification of CTCs using the ISET method represents a promising field for cytopathologists. The possibility of false-positive diagnosis stresses the need for using ancillary methods to improve this approach.
... A possible explanation for these changes could be the high potential for locomotion and extravasation of cytokeratin/HER-2 double-positive clustered circulating breast cancer cells. Blood-borne epithelium-derived HER-2/neu positive clustered cells with a high survival advantage could be the precursor cells responsible for the formation of distant metastases (34,35). ...
Article
Background HER-2/neu positivity is required for the selection of stage IV breast cancer patients for trastuzumab therapy. We compared the results of the recommended immunohistochemistry (IHC) evaluation with the automated ACIS ™ IHC system and with fluorescence in situ hybridization (FISH). These HER-2/neu tissue results were correlated with the serum HER-2/neu (sHER-2/neu) levels at the time of metastatic spread. Patients and Methods A total of 61 IHC slides from 30 patients were stained using the HercepTest ™ . HER-2/neu gene amplification was determined using the Ventana ™ FISH assay. sHER-2/neu levels were measured with the Oncogene Science” ELISA kit. The concordance of HER-2/neu results was determined using the concordance index Kappa (κ). Results The best concordance between any IHC and FISH was found for the automated ACIS system (88.5%, κ=0.68, category “good”). The comparison between the manual interpretations and the automated IHC was categorized as “very good” (95.1%, κ=0.85). The median sHER-2/neu level of FISH positive patients was significantly higher (67 ng/mL) than that of FISH negative patients (17 ng/mL, p=0.018). The increase in HER-2/neu positivity comparing tissue to stage IV serum was statistically significant (p=0.001). Conclusions The concordance between conventional IHC and computerized analysis was very good. The number of patients with stage IV breast cancer with an elevated sHER-2/neu level was much higher than HER-2/neu positivity in tissue. This discrepancy is only partially explained by the influence of tumor load. Patients with an elevated sHER-2/neu level and no tissue overexpression should be considered for retesting of tissue or a new biopsy.
... The frequency of CK + HER-2/neu + clustered cells was on average 10 times higher than that of CK + HER-2/neu + single cells. The numbers of clustered cells were positively correlated with tumor stage; data on the correlation with clinical relapse, however, were not included [164]. ...
Article
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The confounding problem in treatment of breast cancer is the metastasis of breast tumour. Reverse transcriptase polymerase chain reaction (RT-PCR) has been recently used in the detection of circulating breast cancer cells. This review reports on the development of this assay as well as its advantages and disadvantages. We feel that cytokeratin 20 and beta -human chorionic gonadotropin (hCG) mRNA are the best markers for the detection of circulating breast cancer cells. We suggest that the multiple RNA marker RT-PCR assay can help to increase both sensitivity and specificity of detection, and that quantitative RT-PCR assay is more effective than the qualitative assay in the detection of circulating breast cancer cells.
Chapter
Metastasis is the major cause of mortality in patients with breast cancer; however, the mechanisms of tumor cell dissemination and metastasis formation are not well established yet. The study of circulating tumour cells (CTCs), the metastatic precursors of distant disease, may help in this search. CTCs can be found in the blood of cancer patients as single cells or as tumor cell aggregates, known as CTC clusters. CTC clusters have differential biological features such as an enhanced survival and metastatic potential, and they hold great promises for the evaluation of prognosis, diagnosis and therapy of the metastatic cancer. The analysis of CTC clusters offers new insights into the mechanism of metastasis and can guide towards the development of new diagnostic and therapeutic strategies to suppress cancer metastasis. This has become possible thanks to the development of improved technologies for detection of CTCs and CTC clusters. However, more efficient methods are needed in order to address important questions regarding the metastatic potential of CTC and future clinical applications. In this chapter, we explore the current knowledge on the role of CTC clusters in breast cancer metastasis, their origin, metastatic advantages and clinical importance.
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This study was performed to test the validity of different methods for determining the status of the erbB-2/HER-2 oncogene in breast cancer tissues for diagnostic use. Forty formalin-fixed, paraffin-embedded breast carcinomas were investigated by fluorescence in situ and comparative genomic hybridization (FISH, CGH) as well as by immunohistochemistry (IHC) using Dako-HercepTest and CB11 antibody (Ventana). Additionally, competitive-differential polymerase chain reaction (cdPCR) was performed on frozen samples to estimate gene dosage alterations of erbB-2/HER-2. Amplification was detected in 12-23% and protein overexpression in 16-68% of the cases, depending on the methodology and/or the reagent used. Perfect concordance (100%) was found between the results of cdPCR and CB11-IHC, and a 97% concordance between FISH and CB11-IHC. The concordance between Dako-HercepTest and CB11-IHC was 78%: seven of eight 2+ carcinomas with the Dako-HercepTest were classified as nonamplified using FISH. Our results indicate that high-level expression as well as normal erbB-2/HER-2 status of breast carcinomas can be detected reliably both by IHC and gene dosage assessment in paraffin material for diagnostic use. However, borderline results, especially those with 2 + immunopositivity, should be interpreted with caution and increased emphasis should be given to other clinical and prognostic information available.
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The aim of laboratory diagnostics in oncology is to improve the clinical outcome of cancer by allowing earlier detection. Molecular knowledge of cancer should increase the number of risk and prognostic factors and will allow development of methods for detection and elimination of even very small tumors. Thus, the race for the specific tumor antigen in peripheral blood and the race for the blood-borne cancer cell happened simultaneously. The direct detection of the cells which have the highest probability to harbor all the properties mandatory to be life-threatening, conceivably metastatic, would be the most promising way to find the target structure of malignancy. Methods applying enrichment techniques based on density, morphology, tissue specific protein and tumor-associated protein detection enabled multi-parametric analysis of those blood-borne cancer cells. In exemplary studies it was demonstrated that the count of cell clusters positive for the tissue-specific proteins cytokeratin and prostate-specific antigen (PSA) from the peripheral blood of prostate cancer patients and a combination of a tissue-specific protein, a oncogenic receptor protein cytokeratin and p185(c-erbB-2) from the peripheral blood of breast cancer patients is related to the stage of the diseases. Breast cancer patients who presented with cytokeratin/p185(c-erbB-2) positive cell clusters showed a decrease of those cells under adriamycin adjuvant therapy. Nevertheless, additional molecular markers are required to characterize the functional properties of blood-borne cancer cells. Therefore, the genome of the cells can be investigated using a procedure for indirectly detecting aberrations of defined gene locations, i.e. multiplex microsatellite polymerase chain reaction. Up to now, the methods applied to the separation of blood-borne cancer cells are time-consuming and rather expensive. They consist of an initial enrichment step of density gradient centrifugation or buffy coat preparation followed by a specific isolation step using superparamagnetic microbeads coupled to antibodies, filter techniques or multi-parametric flow cytometry. Novel technologies have to be applied using miniaturization, integration and parallel-processing techniques based on those used in the computer industry to overcome the drawbacks.
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Although there have been many reports on the immunocytochemical detection of bone marrow micrometastases in breast cancer patients, peripheral blood micrometastases (PBM) have rarely been studied by immunocytochemistry (ICC). PBM in operable and metastatic breast cancer patients were studied using immunomagnetic separation of tumor cells followed by immunocytochemistry (IMS-ICC). PBM were not detected in any peripheral blood samples from 21 healthy women, six patients with benign disease, or in a 21 patients with primary operable breast cancer, of which there were 7 stage I (n=7), 9 stage II, 2 stage III, and 3 inflammatory tumors. On the other hand, PBM were detected in 8 of 29 patients with metastatic breast cancers (27.6%). The number of tumor cells per patient varied from 2 to 90 cancer cells (median: 8 cells). Positivity of PBM was not significantly associated with the first site of recurrence, number of involved organs, tumor marker status, performance status, or disease-free interval, but it was significantly (p<0.01) associated with progesterone receptor negativity. PBM are very rare in primary operable breast cancer patients but can be observed in a considerable number of metastatic breast cancer patients. The clinical significance of PBM still remains to be established.
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Circulating tumor cells (CTCs) escape from primary or metastatic lesions and enter into circulation, carrying significant information of cancer progression and metastasis. Capture of CTCs from the bloodstream and the characterization of these cells hold great significance for the detection, characterization, and monitoring of cancer. Despite the urgent need from clinics, it remains a major challenge to capture and retain these rare cells from human blood with high specificity and yield. Recent exciting advances in micro/nanotechnology, microfluidics, and materials science have enable versatile, robust, and efficient cell isolation and processing through the development of new micro/nanoengineered devices and biomaterials. This review provides a summary of recent progress along this direction, with a focus on emerging methods for CTC capture and processing, and their application in cancer research. Furthermore, classical as well as emerging cellular characterization methods are reviewed to reveal the role of CTCs in cancer progression and metastasis, and hypotheses are proposed in regard to the potential emerging research directions most desired in CTC-related cancer research. © 2015 WILEY-VCH Verlag GmbH & Co. KGaA, Weinheim.
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To evaluate whether HER2 mRNA could be used as a marker of circulating tumor cells (CTCs) in women with operable breast cancer. A nested RT-PCR assay was developed and used for the detection of HER2 mRNA-positive CTCs. Blood from 216 women with early breast cancer obtained before adjuvant treatment was tested for HER2 mRNA-positive cells to assess their prognostic value. Nested RT-PCR for HER2 mRNA showed high sensitivity whereas no HER2 mRNA-positive cells could be identified in the blood of healthy donors. HER2 mRNA-positive CTCs were detected in 53 (24.5%) of 216 patients and HER2 mRNA detection was associated with reduced disease-free survival (DFS; P P = 0.004). In multivariate analysis, detection of HER2 mRNA-positive CTCs emerged as independent prognostic factor for DFS (P = 0.0001) and OS (P = 0.003). HER2 mRNA could be a valuable prognostic marker for the detection of CTCs in early breast cancer patients.
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The detection of circulating tumor cells (CTC) aids in diagnosis of disease, prognosis, disease recurrence, and therapeutic response. The molecular aspects of metastasis are reviewed including its relevance in the identification and characterization of putative markers that may be useful in the detection thereof. Also discussed are methods for CTC enrichment using molecular strategies. The clinical application of CTC in the metastatic disease process is also summarized.
Chapter
The presence of disseminated tumor cells (DTCs) in the bone marrow has been shown to predict poor clinical outcome in early stage breast cancer. However, peripheral blood is easier to obtain and allows for real time monitoring of minimal residual disease (MRD). Towards this end, circulating tumor cells (CTCs) in the blood are detected using either direct methods, mainly antibody-based assays (immunocytochemistry, immunofluorescence, flow cytometry), or indirect methods, mainly nucleic acid-based assays (detection of mRNA transcripts by reverse transcriptase polymerase chain reaction, RT-PCR). The detection of CTCs using RT-PCR for CK19 was shown to be an independent prognostic factor in women with early breast cancer. Furthermore, there has been considerable progress in genotyping, phenotyping and profiling micrometastatic cells. The challenge now is to integrate minimal residual disease as a prognostic and predictive tool in the management of breast cancer. This requires the standardization of micrometastatic cell detection and characterization which will allow the incorporation of CTCs into prospective clinical trials testing their clinical utility. KeywordsBreast cancer-Circulating tumor cells-CK19mRNA-Disseminated tumor cells-Immunocytochemistry-Micrometastatic cells-Prediction-Prognosis-RT-PCR
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Distant metastases are the main cause of cancer-related death. The onset of the metastatic process can now be assessed in cancer patients by the use of sensitive immunocytochemical and molecular methods which allow the identification of single disseminated carcinoma cells or small tumor cell clusters in regional lymph nodes, peripheral blood, or distant organs.Among the distant organs, bone marrow is a common homing organ for disseminated cancer cells derived from various primary sites, and the presence of these cells predicts the occurrence of overt metastases in bone and other organs. The bone marrow is, therefore, a very useful indicator organ for the presence of disseminated cancer cells. The current assays for detection of micrometastatic tumor cells may be used to improve tumor staging with potential consequences for adjuvant therapy. Another promising clinical application is monitoring the response to adjuvant therapies, which, at present, can only be assessed retrospectively after an extended period of clinical follow-up. Moreover, tools recently established in several laboratories allow further insights into the phenotype and genotype of micrometastases.The available data indicate that micrometastatic cells represent a selected population of cancer cells that express a considerable degree of heterogeneity with regard to chromosomal aberrations and phenotypic properties.Identification of the molecular determinants of micrometastatic cells may help to design new strategies to detect and eliminate minimal residual cancer. The present review summarizes the current state of research on micrometastatic disease in patients with solid tumors.
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High-dose therapy with subsequent allogeneic or autologous transplantation of haemopoietic progenitor cells has proved to be an important therapy for patients with haematological malignancies, certain non-haematological cancers and several nonmalignant disorders such as severe aplastic anaemia. Allogeneic and autologous transplantation are associated with specific complications. One major problem after allotransplantation is the graft versus host disease with jaundice, diarrhoea and erythema. The major problem of autologous stem cell transplantation is a potential reinfusion of contaminating tumor cells. Allogeneic transplantation has been refined, and an approach to modulate graft versus host disease is a partial or complete lymphocyte depletion. Especially in the allogeneic setting, the field of cell therapy for modulation of graft versus host disease and treatment of transplant-related complications is expanding. For autologous transplantation different techniques to purge autografts from malignant contaminants have been developed. These cell selection techniques consist of immunological, biological, cultural, chemotherapeutical and physical techniques. This article reviews techniques currently used for graft engineering in bone marrow and blood stem cell transplantation.
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In order to investigate the prognostic value of circulating tumor cells (CTCs) in patients with metastatic breast cancer (MBC), the blood cells from 98 MBC patients and 60 controls were evaluated by RT-PCR to detect the presence of markers EpCAM, CK19, and hMAM. Peripheral blood was obtained from all patients with MBC before any systemic therapy. Immunofluorescence staining experiment was conducted on CTCs samples from 10 patients to investigate the coexpression of EpCAM, CK19, and hMAM. In addition, analyses were carried out for their correlation with patients' clinicopathologic features. EpCAM+, CK19+, and hMAM+ cells were detected in 50 (51.0 %), 43 (43.9 %), and 68 (69.4 %) of the 98 patients, respectively. Triple-marker-positive CTCs were detected in 86 of 98 (87.8 %) patients with a significantly higher rate than the control group. Among the 98 patients, 12 (12.2 %) patients were negative for three genes, 34 (34.7 %) positive for one gene, 29 (29.6 %) positive for any two genes, and 23 (23.5 %) positive for all three genes. Compared to single-marker detection, the triple combined marker detection exhibited significantly higher rate. Furthermore, the specificity of triple combined markers of serial test was 100 %. The expression of three genes was significantly correlated with lymph node metastasis, high histological grade, and high levels of serum CA153 and CEA. Double-immunofluorescence labeling confirmed the presence of following CTCs phenotypes: CK19+/hMAM+, CK19+/hMAM-, CK19-/hMAM+, CK19+/EpCAM+, CK19-/EpCAM+, CK19+/EpCAM-, hMAM+/EpCAM+, and hMAM+/EpCAM-. After 2 years of follow-up, the presence of CTCs with triple-marker positive in peripheral blood was an independent risk factor for reduced progression-free survival (PFS) and overall survival (OS), and the presence of CTCs before any chemotherapy predicts poor OS and PFS in patients with MBC.
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Anti-idiotype (anti-Id) antibody can induce tumor dormancy in a mu rine B lymphoma, BCL,, by its ability to induce cell cycle arrest and apoptosis (negative signaling). In human B lymphoma, there is accumu lating evidence that the antitumor effect of anti-Id or several other B cell-reactive antibodies relates to their ability to act as agonists rather than conventional effector antibodies. In this study, we sought to elucidate the role of cyclins, cyclin-dependent kinases (CDKs), and their inhibitors in anti-IgM-induced cell cycle arrest to better understand the mechanisms underlying cancer dormancy. To accomplish this, we have performed in vitro studies with a human lymphoma cell line (Daudi) because its re sponse to anti-Id (or anti-IgM) is similar to that of a BCL, cell line, more reagents are available, and the results would be particularly pertinent to therapy of human B cell lymphomas. Our results show that cross-linking of membrane IgM on Daudi cells induces an arrest late in G, and prevents pRb from becoming phosphorylated. The G, arrest is correlated with an induction of the CDK inhibitor p21 and reduced CDK2 activity, although the level of CDK2 protein was not changed. Coprecipitation of CDK2 with p21 in anti-IgM-treated cells and the unchanged level of cyclin E suggest that p21 is responsible for the reduction of CDK2 activity and therefore blockade of the cell cycle. The induction of p21 was not accompanied by changes in p53 levels. As a result of the G, block, cyclin A levels sharply declined by 24 h after anti-IgM treatment. There was no evidence for involvement of CDK4 or CDK6 in the blockade. These results provide evidence that membrane IgM cross-linking on Daudi cells induces expression of p21 and a subsequent inhibition of the cyclin E-CDK2 kinase complex resulting in a block to pRb phosphoryla- tion and cell cycle arrest late in (.,.
Chapter
The early and clinically occult spread of viable tumour cells to the organism is becoming acknowledged as a hallmark in cancer progression, since abundant clinical and experimental data suggest that these cells are precursors of subsequent distant relapse. Prospective clinical studies have shown that the presence of such immunostained cells in bone marrow is prognostically relevant with regard to relapse-free and overall survival of breast cancer patients. As current treatment strategies have not resulted in a substantial improvement of breast cancer mortality rates so far, it is noteworthy to consider the intriguing options of immunocytochemical screening of bone marrow aspirates for occult metastatic cells. Besides improved tumour staging, such screening offers opportunities for guiding patient stratification for adjuvant therapy trials, monitoring response to adjuvant therapies, which, at present, can only be assessed retrospectively after an extended period of clinical follow-up, or for specifically targeting tumour-biological therapies against disseminated tumour cells.
Chapter
Early tumor cell dissemination can be detected in patients with breast cancer using immunocytochemical and molecular assays based on the use of monoclonal antibodies or PCR. Studies involving more than 4,000 breast cancer patients have demonstrated now that the presence of disseminated tumor cells (DTC) in bone marrow (BM) identified with immuncytochemical assays at primary diagnosis is a strong prognostic factor. The published studies for the detection of disseminated tumor cells in bone marrow fulfill the highest level of evidence as prognostic markers in primary breast cancer. In addition, various assays for the detection of circulating tumor cells in the peripheral blood have been recently developed and some studies suggest a potential clinical relevance of this parameter as prognostic and predictive factor. Advanced methods for molecular characterization of single tumor cells have been developed lately and this approach allows new insights into the metastatic cascade and characterization of targets for therapeutic approaches. These findings provide the basis for the implementation of DTC in BM or blood as markers for stratification and assessment of therapies in prospective clinical trials. The valuable information derived from these trials should help to improve future treatment of breast cancer patients.
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We have developed a new assay, ISET (isolation by size of epithelial tumor cells), which allows the counting and the immunomorphological and molecular characterization of circulating tumor cells in patients with carcinoma, using peripheral blood sample volumes as small as 1 ml. Using this assay, epithelial tumor cells can be isolated individually by filtration because of their larger size when compared to peripheral blood leukocytes. ISET parameters were defined using peripheral blood spiked with tumor cell lines (HepG2, Hep3B, MCF-7, HeLa, and LNCaP). ISET can detect a single, micropipetted tumor cell, added to 1 ml of blood. We also demonstrate that fluorescence in situ hybridization can be used to perform chromosomal analyses on tumor cells collected using ISET. Polymerase chain reaction-based genetic analyses can be applied to ISET-isolated cells, and, as an example, we demonstrate homozygous p53 deletion in single Hep3B cells after filtration and laser microdissection. Finally, we provide evidence for the in vivo feasibility of ISET in patients with hepatocellular carcinoma undergoing tumor resection. ISET, but not reverse transcriptase-polymerase chain reaction, allowed analysis of cell morphology, counting of tumor cells, and demonstration of tumor microemboli spread into peripheral blood during surgery. Overall, ISET constitutes a novel approach that should open new perpectives in molecular medicine.
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The enumeration of circulating tumor cells has long been regarded as an attractive diagnostic tool, as circulating tumor cells are thought to reflect aggressiveness of the tumor and may assist in therapeutic decisions in patients with solid malignancies. However, implementation of this assay into clinical routine has been cumbersome, as a validated test was not available until recently. Circulating tumor cells are rare events which can be detected specifically only by using a combination of surface and intracellular markers, and only recently a number of technical advances have made their reliable detection possible. Most of these new techniques rely on a combination of an enrichment and a detection step. This review addresses the assays that have been described so far in the literature, including the enrichment and detection steps and the markers used in these assays. We have focused on breast cancer as most clinical studies on CTC detection so far have been done in these patients.
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A need exists for a breast cancer risk identification paradigm that utilizes relevant demographic, clinical, and other readily obtainable patient-specific data in order to provide individualized cancer risk assessment, direct screening efforts, and detect breast cancer at an early disease stage in historically underserved populations, such as younger women (under age 40) and minority populations, who represent a disproportionate number of military beneficiaries. Recognizing this unique need for military beneficiaries, a consensus panel was convened by the USA TATRC to review available evidence for individualized breast cancer risk assessment and screening in young (< 40), ethnically diverse women with an overall goal of improving care for military beneficiaries. In the process of review and discussion, it was determined to publish our findings as the panel believes that our recommendations have the potential to reduce health disparities in risk assessment, health promotion, disease prevention, and early cancer detection within and in other underserved populations outside of the military. This paper aims to provide clinicians with an overview of the clinical factors, evidence and recommendations that are being used to advance risk assessment and screening for breast cancer in the military.
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The prognostic significance of circulating tumor cells (CTCs) in patients with breast cancer is controversial. We performed a meta-analysis of published literature to assess whether the detection of CTCs in patients diagnosed with primary breast cancer can be used as a prognostic factor. We searched Medline, Science Citation Index, and Embase databases as well as reference lists of relevant articles (including review articles) for studies that assessed the prognostic relevance of tumor cell detection in the peripheral blood (PB). A total of 24 eligible studies with 4,013 cases and 1,333 controls were included. Meta-analyses were performed using a random-effects model, using the hazard ratio (HR) and 95% confidence intervals (95% CIs) as effect measures. The positive detection of CTCs in patients was significantly associated with poor overall survival (OS) (HR = 3.00 [95% CI 2.29-3.94], n = 17, P < 0.0001) and recurrence-free survival (RFS) (HR = 2.67 [95% CI 2.09-3.42], n = 22, P < 0.0001). CTC-positive breast cancers were significantly associated with high histological grade (HR = 1.21 [95% CI 1.09-1.35], n = 34, P < 0.0001), tumor size (>2 cm) (HR = 1.12 [95% CI 1.02-1.22], n = 31, P = 0.01). and nodal status (≥1) (HR = 1.10 [95% CI 1.00-1.21], n = 32, P = 0.037), but cytokeratin-19 (CK-19) mRNA-positive CTCs were not associated with these clinicopathological parameters of breast cancer. Furthermore, the presence of CTCs was not associated with estrogen receptor (ER) negativity, progesterone receptor (PR) negativity, or human epidermal growth factor receptor type 2 (HER2) positivity. Detection of CTCs in the PB indicates poor prognosis in patients with primary breast cancer. Larger clinical studies are required to further evaluate the role of these markers in clinical practice.
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Unlabelled: Circulating tumor cells (CTCs) are an independent prognostic factor for patients with metastatic breast cancer (MBC). However, the role of CTCs in early breast cancer management is not yet clearly defined. The aim of this study was to assess the CTC-positivity rate in patients undergoing chemotherapy depending on breast cancer stage in the adjuvant and neoadjuvant setting. We evaluated the ability to confirm therapy response by CTC analysis. Patients and methods: CTCs isolated from blood by means of immunomagnetic separation were further characterized by means of reverse transcriptase - polymerase chain reaction (RT-PCR) for epithelial cell adhesion molecule (EPCAM), mucin 1 (MUC1) and v-erb-b2 avian erythroblastic leukemia viral oncogene homolog 2 (HER2) transcripts with the AdnaTest™. This prospective study included 179 patients; altogether 419 blood samples were evaluated. Patients with primary tumors were divided into neoadjuvant (n=38), and adjuvant (n=100) groups. Forty-one patients with MBC were evaluated under palliative treatment. Results: CTC positivity was described in 35% of patients with early breast cancer without detected metastases before neoadjuvant chemotherapy; similarly, a 26% positivity rate was found in the adjuvant group. In patients with MBC, we detected CTCs in 43% of them. After completing the therapy, the CTC positivity rate decreased to 5% in the neoadjuvant group, to 13% in the adjuvant group and to 12% in the MBC group. CTC positivity after the therapy may classify a subgroup of patients at high risk of developing metastatic disease. This was even true when a patient was evaluated as being CTC-negative before chemotherapy. The multivariate analysis evaluating the correlation of CTC positivity with clinicopathological characteristics such as tumor size, nodal involvement, hormone receptor status, HER2 expression and number of metastatic sites revealed no statistically significant relationships. Conclusion: CTC status may have a significant impact on early BC management.
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Breast cancer is a leading cause of death in women, occurring in one of eight during their lifetime. A comparable cancer in men, prostate cancer, claims the lives of just under 30,000 men in the United States each year with a prevalence of one in six (1). These tumors, along with carcinomas of the lung, thyroid, and kidney have a high propensity to metastasize to bone, which constitutes one of their most serious complications, creates a great challenge for treatment, and often carries a poor prognosis. Metastases are the most frequent bone tumors and cause significant morbidity due to pain, osteolysis, pathological fractures, hypercalcemia, and anemia (2). Established bone metastases are resistant to treatment and current therapeutic approaches such as endocrine therapy, radiation therapy, and chemotherapy are often ineffective (3). This chapter has been written on the premise that a better understanding of the pathophysiology of bone metastasis may provide insight into the design of diagnostic techniques that would help to identify bone metastasis formation at its earliest stages. This may provide an opportunity for early treatment and alleviate the necessity to treat them at a late stage.
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Diese Arbeit beschäftigt sich mit der prognostischen und prädiktiven Bedeutung der Serummessung des shed antigens des Onkoproteins HER-2/neu (s-HER-2/neu) für Mammakarzinompatientinnen in unterschiedlichen Erkrankungsstadien sowie unter verschiedenen Formen der Systemtherapie inklusive der Behandlung mit dem monoklonalen Antikörper Herceptin. Hierbei wurde der Stellenwert von s-HER-2/neu mit weiteren biochemischen Serummarkern (s-EGFR, s-uPA, CA 27.29) und etablierten Prognosefaktoren des Mammakarzinoms verglichen. Da HER-2/neu zu verschiedenen Zeitpunkten der Erkrankung mit verschiedenen Methoden an unterschiedlichen Materialien bestimmt werden kann, mußte schwerpunktmäßig auch die differentielle Wertigkeit von s-HER-2/neu im Vergleich zu Methoden der HER-2/neu-Bestimmung am Tumormaterial untersucht werden. Hierbei wurde insbesondere hinterfragt, ob die verschiedenen Methoden der HER-2/neu-Diagnostik stets zum gleichen Ergebnis führen, welche biologischen und technischen Ursachen möglichen Diskordanzen zugrunde liegen, und welche Konsequenzen diese Diskordanzen für die Therapiewahl (vor allem mit Herceptin beim metastasierten Mammakarzinom) mit sich bringen. Es wurden folgende Ergebnisse erzielt: - Grenzwerte: s-HER-2/neu: 50 ng/ml mit großer Wahrscheinlichkeit auch eine HER-2/neu-Überexpression am Tumorgewebe aufweisen. - Insgesamt 70% der Patientinnen mit HER-2/neu-negativen Tumoren hatten bei der späteren Fernmetastasierung einen erhöhten s-HER-2/neu-Spiegel. Diese Zunahme des Nachweises der HER-2/neu-Positivität zwischen Gewebenachweis am Primärtumor und dem Serumnachweis im Stadium IV ist nicht zufällig (p=0,001) und allenfalls teilweise durch den Einfluß der Tumormasse erklärbar. Klonale Veränderungen müssen in Erwägung gezogen werden.
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Overexpression of the c-erbB-2 gene-encoded p185c-erbB-2 is correlated with early onset of metastasis in breast cancer patients. Furthermore, the detection of blood-borne epithelium-derived clustered cells expressing p185c-erbB-2 was related to advanced stages in breast cancer. To further elucidate the receptor’s function in the metastatic process of human breast cancers, we analyzed disaggregated cells and cell clusters from freshly dissected breast cancer tissues. We studied whether their capability of extravasation is correlated with their expression of c-erbB-2. A model for the venular wall was constructed by growing human umbilical vein endothelial cells (HUVECs) on porous membranes coated with basement membrane extracellular matrix. In four control breast cancer cell lines (SK-BR-3, MCF-7, MDA-MB-468, and MDA-MB-468, the latter transfected with a full-length c-erbB-2 cDNA vector) producing different levels of the c-erbB-2 receptor, the expression level correlated positively with the invasiveness of the cells. The invasive, predominantly clustered cells from 14 of 23 tumors were positively stained for p185c-erbB-2 by immunocytochemistry. Furthermore, we show that the invasive cell populations express the metastasis-associated proteins matrix metalloproteinase MMP-2, CD44, and integrins αvβ3 and α6. In this first study on the behavior of cells and cell clusters from disaggregated operated cancers in an extravasation model, we could demonstrate the presence of c-erbB-2-expressing cell subpopulations within the individual breast cancers that are presumably of high metastatic potential.
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Breast cancers shed cancer cells into the blood soon after they become invasive. We developed an assay for removing these circulating cancer cells. In this study, we wanted to determine the percentage of early stage and metastatic patients with circulating breast cancer cells. Twenty milliliters of blood were drawn from patients with breast cancer. Epithelial cells were removed by immunomagnetic selection and analyzed by flow cytometry, cytomorphology, and immunocystochemistry. Early stage patients averaged 16 epithelial cells per 20 cc blood whereas metastatic patients averaged 122 tumor cells. Cytomorphology and immunostains confirmed that these were cancer cells. Control blood samples had 1.7 squamous epithelial cells per 20 cc blood. This assay can identify and characterize circulating breast cancer cells. Metastatic patients had more circulating cells than early stage patients. This assay could screen high-risk patients, determine the need for and monitor response to adjuvant therapy, and detect early recurrence of breast cancer.
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c-erbB2/neu is a transforming oncogene that encodes a 185-kDa transmembrane glycoprotein. In many but not all studies, amplification and/or overexpression of the human c-erbB2/neu oncogene has been correlated with poor prognosis and the number of lymph node metastases in node-positive breast cancer patients. We have shown that expression of the activated rat c-erbB2/neu oncogene in mouse embryo fibroblast 3T3 cells is sufficient to induce experimental metastases in nude mice. Important steps in the metastatic event are tumor cell adhesion to endothelial cells and invasion of basement membranes. Therefore, we further examined the ability of c-erbB2/neu oncogene-transformed 3T3 cells to adhere to microvessel endothelial cells and secrete basement membrane-degradative enzymes. The c-erbB2/neu oncogene-transformed 3T3 cells were shown to be more adherent and have higher gelatinase activities. Since we had previously shown that the adenovirus 5 E1A gene product can suppress c-erbB2/neu-induced transformation of 3T3 cells, we examined the possibility that E1A can abrogate the metastatic properties of c-erbB2/neu-transformed 3T3 cells. We found that introduction of the E1A gene into c-erbB2/neu-transformed 3T3 cells reduced the formation of experimental metastatic tumors and inhibited metastasis-associated properties, such as adhesion to microvessel endothelial cells, migration through a layer of reconstituted basement membrane (Matrigel) and secretion of basement membrane-degradative enzymes. The results indicate that the mechanism by which the c-erbB2/neu gene induces higher metastatic potential is to promote adhesion and invasion steps of the metastatic cascade. The E1A gene, which functions by inhibiting these steps, is thus a suppressor gene for c-erbB2/neu-induced experimental metastasis.
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Carcinoma of the breast and ovary account for one-third of all cancers occurring in women and together are responsible for approximately one-quarter of cancer-related deaths in females. The HER-2/neu proto-oncogene is amplified in 25 to 30 percent of human primary breast cancers and this alteration is associated with disease behavior. In this report, several similarities were found in the biology of HER-2/neu in breast and ovarian cancer, including a similar incidence of amplification, a direct correlation between amplification and over-expression, evidence of tumors in which overexpression occurs without amplification, and the association between gene alteration and clinical outcome. A comprehensive study of the gene and its products (RNA and protein) was simultaneously performed on a large number of both tumor types. This analysis identified several potential shortcomings of the various methods used to evaluate HER-2/neu in these diseases (Southern, Northern, and Western blots, and immunohistochemistry) and provided information regarding considerations that should be addressed when studying a gene or gene product in human tissue. The data presented further support the concept that the HER-2/neu gene may be involved in the pathogenesis of some human cancers.
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Peripheral blood progenitor cells (PBPCs) are increasingly used for autografting after high-dose chemotherapy. One advantage of PBPCs over the use of autologous bone marrow would be a reduced risk of tumor-cell contamination. However, the actual level of tumor cells contaminating PBPC harvests is poorly investigated. It is currently not known whether mobilization of PBPCs might also result in mobilization of tumor cells. We evaluated 358 peripheral blood samples from 46 patients with stage IV or high-risk stage II/III breast cancer, small cell (SCLC) or non-small cell (NSCLC) lung cancer, as well as other advanced malignancies for the detection of epithelial tumor cells. Monoclonal antibodies against acidic and basic cytokeratin components and epithelial antigens (HEA) were used in an alkaline phosphatase-anti-alkaline phosphatase assay with a sensitivity of 1 tumor cell within 4 x 10(5) total cells. Before initiation of PBPC mobilization, circulating tumor cells were detected in 2/7 (29%) patients with stage IV breast cancer and in 2/10 (20%) patients with extensive-disease SCLC, respectively. In these patients, an even higher number of circulating tumor cells was detected after chemotherapy with VP16, ifosfamide, and cisplatin (VIP) followed by granulocyte colony-stimulating factor (G-CSF). This approach has previously been shown to be highly effective in mobilizing PBPCs. In the 42 patients without circulating tumor cells during steady state, tumor cells were mobilized in 9/42 (21%) patients after VIP+G-CSF induced recruitment of PBPCs. The overall incidence of tumor cells varied between 4 and 5,600 per 1.6 x 10(6) mononuclear cells analyzed. All stage IV breast cancer patients and 50% of SCLC patients were found to concomitantly mobilize tumor cells and PBPCs. Kinetic analyses showed two patterns of tumor cell recruitment depending on the presence or absence of bone marrow disease: (1) early after chemotherapy (between days 1 and 7) in patients without marrow infiltration, and (2) between days 9 and 16 in patients with marrow infiltration, ie, within the optimal time period for the collection of PBPCs. We show that there is a high proportion of patients with circulating tumor cells under steady-state conditions, and in addition a substantial risk of concomitant tumor cell recruitment upon mobilization of PBPCs, particularly in stage IV breast cancer patients with bone marrow infiltration. The biologic and clinical significance of this finding is unknown at present.
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The invasion and migration occurring in primary neoplastic tissue explants were studied by using a three-dimensional collagen matrix model, subsequent time-lapse videomicroscopy, and computer-assisted cell tracking. We show that not only single cells but groups of clustered cells comprising 5 to more than 100 cells detach from the primary tumor lesion and migrate within the adjacent extracellular matrix. These clusters were highly polarized, resulting in a high directional persistence of migration. Locomoting cell clusters were observed in primary cultures from invasive oral squamous cell carcinomas (6 of 9), ductal breast carcinomas (2 of 3), and rhabdomyosarcoma (1 of 1), whereas normal oral mucosa (0 of 4) was cell cluster negative. Thus, locomoting cell clusters could be a novel and potentially important mechanism of cancer cell invasion and metastasis.
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The level of a c-erbB-2 related protein was determined in sera from 168 breast carcinoma patients, 12 females with benign breast disease, and 66 female controls using an ELISA (enzyme linked immunosorbent assay) kit. Elevated c-erbB-2 related protein level was detected in one of 13 preoperative sera (8%), two of 62 postoperative sera from patients without recurrent disease (3%), and 55 of 93 sera collected at recurrent disease (59%). Elevated serum levels were detected significantly more often in patients with distant metastases than in patients with recurrent disease restricted to loco-regional areas (68% versus 19%). Presence of elevated serum level was associated with ERBB2 gene amplification and c-erbB-2 protein overexpression in tumour. None of the patients who had normal ERBB2 gene copy number in tumour had elevated serum levels. Although the usefulness in postoperative prediction of the presence of micrometastases is somewhat questionable, the results suggest c-erbB-2 related protein to represent a novel tumour marker in serum and other body fluids from breast cancer patients at the time of diagnosis and during treatment monitoring.
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Previously, we and others have reported high levels of expression of the c-erbB-2/neu gene in non-small cell lung cancer cell lines and primary tumors. We have also found that expression of c-erbB-2/neu-encoded p185neu was correlated with lymph node metastasis in lung squamous cell carcinomas. To investigate the potential role of the c-erbB-2/neu gene in lung cancer metastasis systematically, we introduced the human c-erbB-2/neu gene into very low p185neu-expressing NCI-H460 human non-small cell lung cancer cells and then examined the experimental metastatic potentials among the parental NCI-H460 cells and stable transfectants with increased expression of p185neu. Compared with the parental NCI-H460 cells, the NCI-H460 transfectants overexpressing p185neu produced significantly more pulmonary and extrapulmonary metastatic tumors in nude mice. The changes in experimental metastatic potential in vivo were accompanied by increased invasiveness in vitro. In addition, important steps in the invasion and metastasis process, such as secretion of basement membrane-degradative enzymes and migration through reconstituted basement membrane (Matrigel), were also increased in the NCI-H460 transfectants overexpressing p185neu. Moreover, scanning electron microscopy revealed that the p185neu-overexpressing NCI-H460 transfectants had significantly more microvilli and membrane protrusions than the parental cells, correlating with the increased invasive properties of these cells. The results demonstrate that overexpression of p185neu can enhance the experimental metastatic potential of NCI-H460 human lung cancer cells by promoting invasion and the other steps in the metastatic cascade.
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The detection of blood-borne prostate cancer (PCA) cells may help with clinical staging and the further understanding of PCA metastases. We discovered prostate-specific antigen (PSA)-positive stained but not PSA mRNA-expressing blood cells by means of cell sorting and PSA reverse transcription-PCR in patients. Therefore, we developed a cytokeratin immunomagnetic method to isolate PSA-positive epithelial cells from the circulating blood of PCA patients. We obtained blood-borne single cells from 6 of 10 PCA patients and clustered cells from 8 of 10 PCA patients. Patients with benign prostate hyperplasia tested negative for cell clusters. The reported isolation method yielded prostate-derived cells or clusters of them from PCA-diagnosed patients.
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In order to investigate the prognostic significance of erbB-2 overexpression, immunohistochemical staining for the erbB-2 protein was performed on sections from paraffin blocks of 292 primary invasive breast cancers obtained from women enrolled in the National Surgical Adjuvant Breast and Bowel Project (NSABP) protocol B-06. Positive reaction indicative of erbB-2 overexpression was observed on tumor cells in 62 (21%) samples. Women whose cancers were judged to have erbB-2 overexpression had a significantly worse overall survival (P = .0012) with twice the mortality rate of women without detectable erbB-2 expression. No statistically significant effect was evident for disease-free survival (P = .22). In multivariate analysis, detection of erbB-2 overexpression was the second most predictive independent variable for survival after nodal status. Overexpression of erbB-2 was more common among tumors of poor nuclear grade (29%) than those of good nuclear grade (12%). The association of erbB-2 overexpression with decreased survival was evident only among women with tumors of good nuclear grade. In this subgroup, erbB-2 overexpression was associated with an approximately fivefold increase in mortality rate (P = .00001). The combined predictive value of erbB-2 overexpression and nuclear grade was evident regardless of their lymph node status. These results provide evidence that detection of erbB-2 overexpression may be an independent prognostic variable for patient survival. Moreover, when combined with evaluation of nuclear grade, it may be possible to use immunostaining for erbB-2 protein to identify patients at increased risk from within a relatively low-risk group.
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Two synthetic peptides from the predicted sequence of the human c-erbB-2 protein were synthesized and used to raise antisera in rabbits. The sequences chosen were identical to those in the homologous rat c-neu protein. The antibodies produced reacted with the immunizing peptides in ELISA but showed little or no cross-reaction with the partly homologous peptides found in equivalent positions in the human EGF receptor. Both antipeptide antibodies, and a monoclonal antibody (MAb) specific for the rat new protein, immuno-precipitated a 185-kDa protein from 35S-methionine-labelled lysates prepared from a rat cell line known to express high levels of the c-neu protein. The antipeptide antibodies also recognized a protein of the same size in Western blots. In addition, both antipeptide antibodies immunoprecipitated a 190-kDa protein from labelled cell lysates prepared from human and monkey cells. Antibodies to one of the peptides, which showed no detectable cross-reaction with human, rat or monkey EGF receptor, were used to examine the expression of the c-erbB-2 protein on a variety of cultured cell types. Eleven transformed, I non-established and 2 immortalized cell types were examined by immunoprecipitation for their level of expression of the c-erbB-2 protein and of the EGF receptor. The numbers of EGF receptors varied widely between different cell lines, whereas the level of the c-erbB-2 protein, which was found on all of the cell types examined, was more constant. The number of c-erbB-2 molecules present was estimated by autoradiography to be about 100,000 per cell. The antibodies were then used to examine the location and level of expression of the human c-erbB-2 and rat c-neu proteins in normal tissues. Immunohistochemical staining showed that the c-erbB-2 protein was highly expressed in rat kidney proximal tubules and loop of Henle. The c-enbB-2 protein was also present on normal human epithelial cells but in some cases with a different distribution to that of the EGF receptor.
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Numerous clinical trials are currently being implemented to evaluate the effectiveness of a variety of therapeutic regimens against primary breast cancer. There must be a rational biologic basis for the use of each component of the therapy. Principles upon which operation and systemic chemotherapy are employed in current trials are presented in this review. The basis for cancer surgery is undergoing a redefinition which is in keeping with present understanding of tumor biology. Anatomical principles of the past are being supplanted as a result of evidence indicating 1) breast cancer is predominantly a systemic disease at the time of diagnosis, 2) removal of a primary tumor affects host immunological mechanisms as well as residual tumor cell kinetics, 3) the role of lymphatics and lymph nodes differ from what had previously been promulgated, and 4) the significance of multicentricity is not as clear as might be presumed. Such considerations are giving rise to a new biological basis for cancer surgery. Several continuing surgical clinical trials being conducted by the National Surgical Adjuvant Breast Project (NSABP) should provide information which will substantiate or refute the justification for a change in oncologic surgical principles. A brief review of information regarding tumor cell kinetics, experiences with adjuvant therapy in animal model systems, and other considerations providing justification for the use of systemic adjuvant chemotherapy has been provided. From the spectrum of combined modality trials in progress throughout the world should come information within the next few years which will verify or repudiate not only concepts and principles upon which the use of adjuvant therapy is based, but the worth of those modalities presently representing our total therapeutic resources and upon which rest hope for the cure of breast cancer. Cancer 40:574–587, 1977.
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Numerous clinical trials are currently being implemented to evaluate the effectiveness of a variety of therapeutic regimens against primary breast cancer. There must be a rational biologic basis for the use of each component of the therapy. Principles upon which operation and systemic chemotherapy are employed in current trials are presented in this review. The basis for cancer surgery is undergoing a redefinition which is in keeping with present understanding of tumor biology. Anatomical principles of the past are being supplanted as a result of evidence indicating 1) breast cancer is predominantly a systemic disease at the time of diagnosis, 2) removal of a primary tumor affects host immunological mechanisms as well as residual tumor cell kinetics, 3) the role of lymphatics and lymph nodes differ from what had previously been promulgated, and 4) the significance of multicentricity is not as clear as might be presumed. Such considerations are giving rise to a new biological basis for cancer surgery. Several continuing surgical clinical trials being conducted by the National Surgical Adjuvant Breast Project (NSABP) should provide information which will substantiate or refute the justification for a change in oncologic surgical principles. A brief review of information regarding tumor cell kinetics, experiences with adjuvant therapy in animal model systems, and other considerations providing justification for the use of systemic adjuvant chemotherapy has been provided. From the spectrum of combined modality trials in progress throughout the world should come information within the next few years which will verify or repudiate not only concepts and principles upon which the use of adjuvant therapy is based, but the worth of those modalities presently representing our total therapeutic resources and upon which rest hope for the cure of breast cancer. Cancer 40:574–587, 1977.
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To evaluate the prognostic importance of immunocytochemically determined c-erbB-2 overexpression in the primary tumors of patients with breast cancer. Primary tumors from 1,506 breast cancer patients (760 node-negative and 746 node-positive) who were treated in the International (Ludwig) Breast Cancer Study Group Trial V were studied. Node-negative patients were allocated randomly to either a single cycle of perioperative chemotherapy (PeCT) or no adjuvant treatment, and node-positive patients received either a prolonged chemotherapy (with tamoxifen for postmenopausal patients) or a single perioperative cycle. Tumors from 16% of the node-negative patients and 19% of the node-positive patients were found to be c-erbB-2-positive. In both groups c-erbB-2 positivity correlated with negative progesterone receptors (PR), negative estrogen receptors (ER), and high tumor grade. Lobular carcinomas were all negative, and, thus support the view that such tumors represent a defined subtype of breast carcinoma. The expression of c-erbB-2 was prognostically significant for node-positive but not for node-negative patients. However, in both subgroups, the prognostic significance was greater for patients who had received more adjuvant therapy. For node-positive patients, the effect of prolonged-duration therapy on disease-free survival (DFS) was greater for patients without c-erbB-2 overexpression (hazards ratio [HR], = 0.57; 95% confidence interval [CI], 0.46 to 0.72) than for those with c-erbB-2 overexpression (HR, 0.77; 95% CI, 0.51 to 1.16). Similarly, for node-negative patients, the effect of PeCT on DFS was greater for those without c-erbB-2 overexpression (HR, 0.82; 95% CI, 0.61 to 1.09) than for those with c-erbB-2 overexpression (HR, 1.22; 95% CI, 0.66 to 2.25). We conclude that tumors with overexpression of the c-erbB-2 oncogene are less responsive to cyclophosphamide, methotrexate, and fluorouracil (CMF)-containing adjuvant therapy regimens than those with a normal amount of gene product.
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Amplification or overexpression of the human neu oncogene has been shown to correlate with the number of lymph node metastases in breast cancer patients, suggesting that expression of the neu oncogene may be associated with increased metastatic potential. However, there has been no systematic study on the role of the neu oncogene in metastasis to support this correlation. In our study, mouse embryo fibroblast 3T3 cells transformed by the mutation-activated rat neu oncogene exhibited metastatic properties both in vitro and in vivo, while parental 3T3 cells did not. Monoclonal antibodies capable of inducing down-regulation of the neu-encoded p185 protein reduced the metastatic potential induced by neu. These data provide strong experimental evidence that neu oncogene expression is sufficient for the induction of metastasis in the 3T3 cell system and supply a molecular basis supporting the correlations found in clinical observation. The results also suggest that neu-specific monoclonal antibodies may have preventative or therapeutic potential for neu-induced metastasis.
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The process of metastasis is not random. Rather, it consists of a series of linked, sequential steps that must be completed by tumor cells if a metastasis is to develop. Although some of the steps in this process contain stochastic elements, as a whole, metastasis favors the survival and growth of a few subpopulations of cells that preexist within the parent neoplasm. Moreover, metastases can have a clonal origin, and different metastases can originate from the proliferation of single cells. The outcome of metastasis depends on the interaction of metastatic cells with different organ environments. Organ-specific metastases have been demonstrated in a variety of experimental tumor systems. Moreover, we have found tumor growth that is specific to a particular site within one organ. Whether the same conclusions can be reached for human cancers remained unanswered until very recently. Studies from our laboratory and from others have shown that the implantation of human cancer cells derived from surgical specimens into correct anatomical sites of nude mice can provide a suitable model of metastasis of human tumors. Clonal analysis of a human renal carcinoma, colon carcinomas, and melanomas has revealed that these tumors are indeed heterogeneous for metastatic properties, an observation made only after orthotopic implantation. Thus, growth in the environment of specific organs can be selective and the environment per se influences this process. While it is clear that vascularity and local immunity can facilitate or retard tumor growth, we have concentrated on understanding how damage to an organ and the subsequent repair process can facilitate tumor cell proliferation. Accelerated growth of human colon cancer cells was found in hepatectomized nude mice, whereas accelerated growth of human renal cancer cells was found in nephrectomized nude mice. These data suggest that systemic physiological signals can be recognized by neoplastic cells presumably by mechanisms similar to those shared by their normal cell counterparts. In summary, the critical factors that regulate metastasis are the intrinsic properties of metastatic cells and host factors involved in homeostasis. The recent increase in our understanding of metastasis should provide important leads for developing more effective approaches to the treatment of disseminated cancer.
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In order to investigate the prognostic significance of erbB-2 overexpression, immunohistochemical staining for the erbB-2 protein was performed on sections from paraffin blocks of 292 primary invasive breast cancers obtained from women enrolled in the National Surgical Adjuvant Breast and Bowel Project (NSABP) protocol B-06. Positive reaction indicative of erbB-2 overexpression was observed on tumor cells in 62 (21%) samples. Women whose cancers were judged to have erbB-2 overexpression had a significantly worse overall survival (P = .0012) with twice the mortality rate of women without detectable erbB-2 expression. No statistically significant effect was evident for disease-free survival (P = .22). In multivariate analysis, detection of erbB-2 overexpression was the second most predictive independent variable for survival after nodal status. Overexpression of erbB-2 was more common among tumors of poor nuclear grade (29%) than those of good nuclear grade (12%). The association of erbB-2 overexpression with decreased survival was evident only among women with tumors of good nuclear grade. In this subgroup, erbB-2 overexpression was associated with an approximately fivefold increase in mortality rate (P = .00001). The combined predictive value of erbB-2 overexpression and nuclear grade was evident regardless of their lymph node status. These results provide evidence that detection of erbB-2 overexpression may be an independent prognostic variable for patient survival. Moreover, when combined with evaluation of nuclear grade, it may be possible to use immunostaining for erbB-2 protein to identify patients at increased risk from within a relatively low-risk group.
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There are two genes related to the viral erbB gene in the human genome. c-erbB-1 is the same as the gene for the epithelial-growth-factor (EGF) receptor, and c-erbB-2 encodes a receptor-like protein very similar to, but distinct from, the EGF receptor. Hybridisation analysis of DNA from 101 fresh human malignant tumours showed that the c-erbB-2 gene was amplified in 5 of 63 adenocarcinomas and none of 38 other types of tumours, whereas the c-erbB-1/EGF-receptor gene was amplified only in 1 of 8 squamous-cell carcinomas. Thus, the protein products of the amplified c-erbB-2 gene may have a role in the evolution of adenocarcinomas, as does the EGF receptor in some squamous-cell carcinomas.
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Amplification of the neu proto-oncogene in breast cancer has been reported to correlate with the presence of lymph-node metastases and with a poor prognosis. We describe a method for the immunohistochemical detection of overexpression of neu protein on formalin-fixed paraffin-embedded tissue, with the use of two different monoclonal antibodies. In a group of tumors with a known neu-gene copy number, intense membrane staining of tumor cells was present in all tumors with neu-gene amplification. Of 189 tumors from patients with Stage II breast cancer, 27 (14 percent) had neu-membrane staining. Neu overexpression was associated with larger tumor size (P = 0.006) but not with lymph-node involvement. Neu-protein expression in lymph-node metastases was the same as its expression in primary tumors. Among the patients with neu overexpression (median follow-up, 37 months), disease-free survival was not significantly shorter; overall survival was reduced significantly in these patients (P = 0.042), but this reduction did not remain significant after adjustment for tumor size. Of 45 ductal carcinomas in situ, 19 (42 percent) had neu-membrane staining. These 19 were all of the large-cell, comedo growth type. None of 16 ductal carcinomas in situ of small-cell, papillary, or cribriform growth type had neu overexpression. We conclude that neu overexpression may be an early step in the development of a distinct histologic type of carcinoma of the breast, but we could find no association of overexpression with lymph-node status or tumor recurrence.
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A novel v-erb-B-related gene, c-erb-B-2, which has been identified in the human genome, maps to human chromosome 17 at q21 (ref. 40), and seems to encode a polypeptide with a kinase domain that is highly homologous with, but distinct from, that of the epidermal growth factor (EGF) receptor. The c-erb-B-2 gene is conserved in vertebrates and it has been suggested that the neu gene, detected in a series of rat neuro/glioblastomas, is, in fact, the rat c-erb-B-2 gene. Amplification of the c-erb-B-2 gene in a salivary adenocarcinoma and a gastric cancer cell line MKN-7 suggests that its over-expression is sometimes involved in the neoplastic process. To determine the nature of the c-erb-B-2 protein, we have now molecularly cloned complementary DNA for c-erb-B-2 messenger RNA prepared from MKN-7 cells. Its sequence shows that the c-erb-B-2 gene encodes a possible receptor protein and allows an analysis of the similarity of the protein to the EGF receptor and the neu product. As a consequence of chromosomal aberration in MKN-7 cells, a 4.6-kilobase (kb) normal transcript and a truncated 2.3-kb transcript of c-erb-B-2 are synthesized at elevated levels. The latter transcript presumably encodes only the extracellular domain of the putative receptor.
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Two synthetic peptides from the predicted sequence of the human c-erbB-2 protein were synthesized and used to raise antisera in rabbits. The sequences chosen were identical to those in the homologous rat c-neu protein. The antibodies produced reacted with the immunizing peptides in ELISA but showed little or no cross-reaction with the partly homologous peptides found in equivalent positions in the human EGF receptor. Both antipeptide antibodies, and a monoclonal antibody (MAb) specific for the rat neu protein, immunoprecipitated a 185-kDa protein from 35S-methionine-labelled lysates prepared from a rat cell line known to express high levels of the c-neu protein. The antipeptide antibodies also recognized a protein of the same size in Western blots. In addition, both antipeptide antibodies immunoprecipitated a 190-kDa protein from labelled cell lysates prepared from human and monkey cells. Antibodies to one of the peptides, which showed no detectable cross-reaction with human, rat or monkey EGF receptor, were used to examine the expression of the c-erbB-2 protein on a variety of cultured cell types. Eleven transformed, I non-established and 2 immortalized cell types were examined by immunoprecipitation for their level of expression of the c-erbB-2 protein and of the EGF receptor. The numbers of EGF receptors varied widely between different cell lines, whereas the level of the c-erbB-2 protein, which was found on all of the cell types examined, was more constant. The number of c-erbB-2 molecules present was estimated by autoradiography to be about 100,000 per cell. The antibodies were then used to examine the location and level of expression of the human c-erbB-2 and rat c-neu proteins in normal tissues. Immunohistochemical staining showed that the c-erbB-2 protein was highly expressed in rat kidney proximal tubules and loop of Henle. The c-erbB-2 protein was also present on normal human epithelial cells but in some cases with a different distribution to that of the EGF receptor.
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The neu oncogene is repeatedly activated in neuro- and glioblastomas derived by transplacental mutagenesis of the BDIX strain of rat with ethylnitrosourea. Foci induced by the DNAs from such tumours on NIH 3T3 cells contain the neu oncogene and an associated phosphoprotein of relative molecular mass 185,000 (p185). Previous work has shown that the neu gene is related to, but distinct from, the gene encoding the EGF receptor (c-erb-B). Here we describe a neu complementary DNA clone isolated from a cell line transformed by this oncogene; the clone has biological activity in a focus-forming assay. The nucleotide sequence of this clone predicts a 1,260-amino-acid transmembrane protein product similar in overall structure to the EGF receptor. We found that 50% of the predicted amino acids of neu and the EGF receptor are identical; greater than 80% of the amino acids in the tyrosine kinase domain are identical. Our results suggest strongly that the neu gene encodes the receptor for an as yet unidentified growth factor.
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In most cell types intermediate or 10-mm filaments (IF) are a major cytoskeletal organization and, thus, directly or indirectly influence the structural appearance of the cytoplasm. In line with the cell type-specific expression patterns of different IF proteins in normal animal and human tissue, IF typing distinguishes the major tumor groups, as documented by results with several hundred human tumors classified by conventional histologic methods. Carcinomas are characterized by cytokeratins, sarcomas of muscle cells by desmin, nonmuscle sarcomas by vimentin, and gliomas by glial fibrillary acidic protein. Furthermore, certain tumors originating from the sympathetic nervous system, e.g., ganglioneuroblastoma, pheochromocytoma, and at least some neuroblastomas, are characterized by the presence of neurofilaments. Carcinomas can often be further subdivided with regard to their possible derivation by examining their cytokeratin profiles. The IF type characteristic of the cell of origin seems to be kept not only in the primary tumor but usually also in solid metastases. In general, tumors do not acquire additional IF types. Therefore, IF typing can provide an unambiguous and rapid characterization in certain cases, that are difficult to diagnose by conventional techniques. Some useful examples are the small cell tumors of childhood and the discrimination between undifferentiated carcinoma and lymphoma. IF typing of a few tumors has already led to a revision or reconsideration of the original light microscopic diagnosis. The combined results indicate that at least certain carcinomas, as well as certain other tumor types, seem to arise by the selective multiplication of a particular and identifiable cell type present in the normal tissue. The procedure is not restricted to tumor material. IF typing of Mallory bodies, Alzheimer's disease tangles, certain myopathies, and the cells of the amniotic fluid offers further interesting applications. Thus, IF typing should become a valuable new tool both in histology and surgical pathology.
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Carcinomas of different origin have been tested in immunofluorescence microscopy with the monoclonal murine antibodies CK1-CK4, which recognize a single cytokeratin polypeptide (human cytokeratin No. 18) present in simple but not in stratified squamous epithelia, and with the monoclonal antibody KG8.13 and guinea pig kerA antibodies, both of which recognize a variety of cytokeratins common to almost all epithelial cell types. Tumors derived from simple epithelia, including adenocarcinomas and some other tumors such as ductal breast carcinomas, were strongly stained by all three antibodies. So was a transitional carcinoma of the bladder. In contrast, basal cell epithelioma, cloacogenic carcinoma, and squamous cell carcinoma of skin, tongue, and esophagus appeared negative with CK1-CK4 but positive with the other two antibodies. Other squamous cell carcinomas derived from epiglottis and cervix uteri showed a mixture of positive and negative cells when tested with CK1-CK4, although all tumor cells were positive when tested with KG8.13 and with kerA. Thus, use of an appropriate collection of cytokeratin antibodies with different specificities not only allows tumors of epithelial origin to be distinguished from other tumor types but, in addition, allows a further subdivision of carcinomas in relation to their histologic origin.
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Cytokeratins 8 and 18 are most frequently co-expressed in simple epithelia and carcinomas. Fragments of these cytokeratins are released into the systemic circulation where they can be quantified and utilized as tumour markers. The present paper reports on a solid-phase sandwich monoclonal immunoassay, considered "epithelial tissue-specific", which recognizes fragments of human cytokeratins 8 and 18 of different sizes (10-50 kD). The evaluated ELISA and IRMA assays exhibited a detection limit of 0.1 microgram 1-1 and characteristically demonstrated a within-assay coefficient of variation (CV) of 1-4% and a between-assay CV of 3-5%. The long-term (300 days) repeatability of lyophilized samples tested in the assay was estimated to have a less than 10% CV. Of apparently healthy individuals, 95% were found to have serum concentrations of less than 0.95 micrograms 1-1. A highly significant difference was found between apparently healthy individuals and pancreatic cancer patients. Patients with metastatic disease showed a sensitivity of 93% and those with local disease 83%, at 95% specificity. This TPAcyk assay revealed good correlation (0.98) with the TPS assay detecting the specific M3 epitope of the tissue polypeptide antigen. The correlation with the long established polyclonal assay of tissue polypeptide antigen (TPA) was estimated to be 0.9.
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One of the possible drawbacks to autologous bone marrow (BM) and peripheral blood progenitor cell (PBPC) transplantation in breast cancer patients is the potential for tumor cell contamination in the transplanted product. To assess the presence of breast cancer cells, we have developed a flow-cytometric method using cytokeratin-FITC and CD45-phycoerythrin (PE) to detect very low levels of cytokeratin-positive (CK+) tumor cells in mononuclear cell (MNC) preparations. In a model system using PBMNC and the breast cancer cell line CAMA, the sensitivity of detection of this flow-cytometric method was one tumor cell in 200,000 MNC. This method was used to evaluate BM, PB, and apheresis products (AP) from 44 patients with metastatic breast cancer. When possible, stained cytologic examination was performed on smears of the unprocessed specimens and on flow cytometry-sorted cells. Results indicated that CK+ tumor cells could be detected by flow cytometry in all three specimen types. When present, however, the tumor content (per MNC) tended to be higher in BM than in PB or AP. Samples from a given patient taken serially over the course of chemotherapy revealed variable results, suggesting that the presence of tumor contamination may be sporadic and requires evaluation of each stem cell product. Of 75 samples tested with both flow cytometry and cytology, the results were concordant in 54 cases (72%). In the remaining samples, flow cytometry only was positive in 15 cases (20%), and cytology only was positive in six cases (8%). This flow-cytometric technique is useful in the evaluation of transplant products for CK+ tumor cell contamination.
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Drug resistance is a major impediment to the successful treatment of ovarian carcinoma. None of the earlier-identified resistance mechanisms, such as overexpression of the MDR1 gene product, P-glycoprotein (Pgp), has been shown to be a major determinant of clinical response to chemotherapy and survival for ovarian cancer patients. The multidrug resistance-associated protein (Mrp) and the lung resistance protein (Lrp, also called the p110 major vault protein), are newly described proteins associated with multidrug resistance in vitro. The aim of this retrospective study was to investigate the expression of Mrp and Lrp, in addition to Pgp, in advanced ovarian carcinoma and to determine whether such expression was predictive of response to chemotherapy and survival. Fifty-seven banked frozen specimens, previously collected and frozen at the time of diagnosis from an equal number of patients with International Federation of Gynecology and Obstetrics (FIGO) stage III or IV ovarian carcinoma, were immunostained for Pgp (with monoclonal antibodies [MAbs] MRK-16 and JSB-1), Mrp (with MAb MRPrl), and Lrp (with MAb LRP-56). All patients had received platinum- or alkylating-based chemotherapy after debulking surgery. Clinicopathologic parameters determined at diagnosis were retrospectively assessed for their relationship with Pgp, Mrp, and Lrp expression. Response to treatment and survival were compared between Pgp, Mrp, and Lrp expression groups. Qualitative variables were analyzed using Fisher's exact test or the chi-squared test. All reported P values are two-tailed. Nine (16%), 39 (68%), and 44 (77%) of the 57 tumor specimens examined showed positive immunostaining for Pgp, Mrp, and Lrp, respectively. Positive immunostaining for these proteins was not associated with any other prognostic factor examined. No association was found between Pgp and Mrp expression and response to chemotherapy and survival. In contrast, patients with Lrp-positive tumors had poorer response to chemotherapy (P = .004) and shorter progression-free (P = .003) and overall (P = .007) survival than Lrp-negative patients. Multivariate analysis of Lrp expression, FIGO stage, residual tumor after initial surgery, tumor grade, and presence or absence of ascites showed that only Lrp status was independently related to both progression-free survival and overall survival. Positive Lrp immunostaining in advanced ovarian carcinoma appears to be an indicator of poor response to standard chemotherapy (platinum or alkylating agents) and of adverse prognoses. The functional characterization of Lrp and related proteins may reveal new approaches to modulate Lrp-associated drug resistance. A large prospective study is warranted to confirm the prognostic value of Lrp.
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The ability of primary tumours to metastasize accounts for the majority of cancer deaths. The emergence of circulating carcinoma cells in the peripheral blood is supposed to be an indicator for cancer cell spread. We have focused on this phenomenon in order to develop a sensitive technique for enriching epithelial derived cells on the basis of a two-layer density gradient and subsequent immune magnetic cell sorting. Epithelial cells are possess a cytoskeleton containing an assembly of intermediate filaments. During carcinogenesis these filaments do not undergo modifications of antibody binding epitopes such as occur in the protein domains of surface markers. We have developed a two-layer density gradient in which the epithelial cells form a single density band. This was demonstrated by recovery experiments using [3H]thymidine-labelled epithelial cells which showed epithelial cells were enriched within this first step by a factor of 20. In a second step the MACS system was applied. Cells were stained with a performed FITC-conjugated mouse anti-human cytokeratin antibody bound to a rat anti-mouse antibody coupled to superparamagnetic particles (immune paramagnetic separation complex; IPSC) and subjected to high gradient magnetic fields. The two-step procedure was confirmed by dispersing 50 epithelial cells in 5 x 10(5), 5 x 10(6), 5 x 10(7), 5 x 10(8), 5 x 10(9) peripheral blood leucocytes. Specific binding of the preformed IPSC was demonstrated by flow cytometry, confocal laser, fluorescent and electron microscopy. The specificity of the method was further proved by dual staining with IPSC and anti-human PSA antibody of epithelial prostatic cells separated from peripheral blood in vitro. By means of this double-step separation method it was possible to isolate up to 15-20 cells out of 50 epithelial cells originally suspended into 5 x 10(7) to 5 x 10(9) human peripheral blood leucocytes. This represented an enrichment factor between 20,000 and 200,000, depending on the initial cell number. The immunologically captured epithelial cells can be used for further cytogenetic investigations such as in situ hybridization (ISH) and/or polymerase chain reaction (PCR) to detect cancer cell specific gene aberrations. This sensitive combined buoyant density immune magnetic cell separation technique is capable of detecting free carcinoma cells in the peripheral blood.
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We have determined the average gene copy numbers (AGCN) of the erbB-1 gene, encoding the epidermal growth factor receptor (EGF-R), the erbB-2 and the erbB-3 genes in breast, ovarian, oral, and lung cancer tissue by using double-differential PCR (ddPCR). The ddPCR method comprises the co-amplification of the single-copy gene HBB, the erbB-1, erbB-2 and erbB-3 oncogenes and the second single-copy reference gene SOD2 under equal reaction conditions. In a retrospective study the AGCN of the erbB genes and the time up to the appearance of metastases were subjected to life-table analysis in 128 women with primary breast cancer. Patients whose breast cancer tissue showed an AGCN for erbB-1 of less than 0.4 and greater then 1.6, as expected from the literature, for erbB-2 of greater than 2.0 and for erbB-3 of less than 1.75 had decreased disease-free survival (DFS). The quotient of erbB-1 and erbB-2 AGCN was the most significant in multivariate Cox analysis followed by nodal status and progesterone receptor status. In extensive studies a similar association between erbB AGCN and metastasis was seen in ovarian cancer and oral cancer, though erbB oncogene aberrations in those entities were not as frequent as in breast cancer. The AGCN of erbB oncogenes may not be of prognostic value in untreated lung cancer patients.
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Seven years after the initial studies of the prognostic value of the proto-oncogene c-erbB-2 in breast cancer, its role is still being defined. The interpretation of studies on the use of this gene and its protein product in prognostic and predictive tests for breast cancer is complicated by multiple methodologies and the inherent difficulties in the studies. The work has moved beyond the stage at which small studies with short follow-up (useful for hypothesis generation) are of value, to the stage in which large studies with sufficient statistical power to find significant correlations are central. These larger studies do not lend support for the use of c-erbB-2 in the evaluation of axillary-node-negative patients, the group of breast cancer patients for whom refinement of prognostic estimates is now most important. There are, however, hints that c-erbB-2 may have value in predicting response to certain treatments, though the studies so far are too few, often too small and too conflicting to reliably confirm this.
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Early dissemination of malignant cells is the main cause for metastatic relapse in patients with solid tumours. By use of monoclonal antibodies (mAbs) specific for cytokeratins, disseminated individual epithelial tumour cells can now be identified in mesenchymal organs such as bone marrow. Further to characterize such cells in patients with prostate cancer, an immunocytochemical procedure was developed for simultaneous labelling of cytokeratin component no. 18 (CK18) and prostate specific antigen (PSA). In a first step, cells were incubated with mAb ER-PR8 against PSA and secondary gold-conjugated goat anti-mouse antibodies. In a second step, biotinylated mAb CK2 to CK18 was applied as primary antibody and subsequently incubated with complexes of streptavidin-conjugated alkaline phosphatase, which were developed with the Newfuchsin substrate. The binding of gold-labelled antibodies was visualized by silver enhancement. The sensitivity and specificity of the technique was demonstrated on cryostat sections of hyperplastic prostatic tissue, and cytological preparations of LNCaP prostatic tumour cells. Double staining was restricted to cells derived from the secretory epithelium of the prostate. Cross-reactivity between both detection systems was excluded by several controls, including the use of unrelated antibodies of the same isotype and the staining of CK18+/PSA- HT29 colon carcinoma cells. CK18+ cells co-expressing PSA were found in bone marrow aspirates from 5 out of 13 patients with carcinomas of the prostate, a finding that is consistent with the relative fraction of double-positive LNCaP cells. The specificity of CK18 for epithelial tumour cells in bone marrow was supported by negative staining of 12 control aspirates from patients with benign prostatic hypertrophy.(ABSTRACT TRUNCATED AT 250 WORDS)
Article
The development of monoclonal antibodies (MAbs) to cytokeratins, which are integral components of the epithelial cytoskeleton, has made possible immunocytochemical detection of epithelial tumor cells. Importantly, this technique allows the detection of epithelial tumor cells that have metastasized from primary adenocarcinomas to secondary sites such as the bone marrow. The aim of the study was not only to detect micrometastatic cells in bone marrow, but also to assess the expression of nuclear proliferation markers (Ki-67 and p120) and the erbB2 oncogene (also known as ERBB2) in these cells and, thus, hopefully improve prognostic precision. Bone marrow aspirates were obtained from both sides of the upper iliac crest of 532 patients having definitive diagnoses of either breast or gastrointestinal cancer. The presence of micrometastatic epithelial tumor cells in bone marrow was assayed using the MAb cytokeratin 2 (CK2) to cytokeratin component 18 (CK18), in combination with the alkaline phosphatase-anti-alkaline phosphatase immunostaining technique. After primary screening of all marrow samples with MAb CK2, representative subgroups of CK18+ samples were selected for co-labeling with MAbs either to ErbB (n = 16), ErbB2 (n = 121), Ki-67 (n = 33), or p120 (n = 36) protein. An alternative labeling protocol based on the combination of immunogold and immunoenzymatic techniques was utilized to confirm the results derived from immunoenzymatic double staining. In total, single CK18-positive tumor cells were detected in 180 (33.8%) of 532 bone marrow aspirates, with few differences among patients with breast or gastrointestinal cancer in TNM stage M0 (i.e., no distant metastasis). In patients with overt metastasis (stage M1), however, the incidence of metastatic cells in marrow increased to 73.7% in breast cancer, 52.5% in gastric cancer, and 39.0% in colon cancer. Whereas expression of Ki-67 or p120 on micrometastatic cells was observed only in 11 (15.9%) of 69 cancer patients analyzed, ErbB2+/CK18+ cells were found in 48 (67.6%) of 71 breast cancer patients and 14 (28.0%) of 50 patients with gastrointestinal cancer (P = .0001). The incidence of ErbB2+/CK18+ cells was positively correlated with the clinical stage of tumor progression. The high incidence of ErbB2 expression on micrometastatic breast cancer cells in the bone marrow suggests that these cells might have been positively selected during early stages of metastasis. The majority of these cells appear to be in a dormant state of cell growth. Although support from clinical follow-up is still needed, this study demonstrates that, beyond the mere presence of micrometastatic cells in bone marrow, useful prognostic information can be obtained by analysis of additional cell growth markers.
Article
The role of molecular markers in predicting the response to treatment of breast cancer is poorly defined. The Cancer and Leukemia Group B (CALGB) conducted a randomized adjuvant-chemotherapy trial (CALGB 8541) comparing three doses (high, moderate, and low) of cyclophosphamide, doxorubicin, and fluorouracil in 1572 women with node-positive breast cancer. This study (CALGB 8869) was designed to determine whether the DNA index, the S-phase fraction, c-erbB-2 expression, or p53 accumulation could be used as a marker to identify a subgroup of patients more likely than others to benefit from high doses of chemotherapy. Tissue blocks were obtained from 442 patients randomly selected from the larger CALGB trial. Paraffin sections from the primary lesions were analyzed for DNA content, S-phase fraction, c-erbB-2 expression, and p53 accumulation. Patients randomly assigned to the high-dose regimen of adjuvant chemotherapy had significantly longer disease-free and overall survival if their tumors had c-erbB-2 overexpression. No further information was gained by adding the data on S-phase fraction or p53 accumulation to the analysis. There was no clear evidence of a dose-response effect in patients with minimal or no c-erbB-2 expression. There is a significant dose-response effect of adjuvant chemotherapy with cyclophosphamide, doxorubicin, and fluorouracil in patients with overexpression of c-erbB-2 but not in patients with no c-erbB-2 expression or minimal c-erbB-2 expression. Overexpression of c-erbB-2 may be a useful marker to identify the patients who are most likely to benefit from high doses of adjuvant chemotherapy.
Article
Amplification and over-expression of the HER-2/neu oncogene (also known as c-erbB-2) occurs in 20%-30% of invasive breast carcinomas. The extent to which HER-2/neu expression changes over time in association with tumor progression or is heterogeneous at different metastatic sites has received only limited study. Our purpose was to determine whether primary tumors differ from metastases in HER-2/neu protein content or whether metastases are heterogeneous in regard to HER-2/neu expression. In a retrospective study, we examined tumor tissue obtained at autopsy from two to five metastatic organ sites in each of 30 patients who died with metastatic breast carcinoma. Using an immunoperoxidase technique, we stained archival formalin-fixed, paraffin-embedded tissue sections with a monoclonal antibody to the 185-kilodalton protein product (p185) of the HER-2/neu gene. The tissue from eight of 30 patients showed strong diffuse reactivity for p185 at all metastatic sites examined. Tissues from six patients showed faint staining and tissues from 15 were negative, again with a congruent staining pattern. A single case showed discordant staining, in that two of four metastases showed faint staining, whereas the other two showed strong immunoreactivity. In 14 cases, we were able to obtain paraffin blocks from the original biopsy or surgical resection of the primary breast lesion. For these 14 patients, the average length of time between initial diagnosis and death was 4 years (range, 2-9). There was good correlation between results from autopsy and original surgical tissues. Expression of HER-2/neu appears to be relatively stable over time and is generally congruent at different metastatic sites. The fact that p185 immunoreactivity is rarely heterogeneous is encouraging, both for the potential use of HER-2/neu-related proteins as serum tumor markers and for innovative therapies targeted at p185 expression.
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