Circulating Tumor Cells Clusters Research Articles

Abstract PO5-18-04: Effect of Digoxin on clusters of circulating tumor cells in patients with metastatic breast cancer (DICCT)

Abstract Background: The presence of circulating tumor cell (CTC) clusters is associated with tumor progression and with a bad prognosis in various cancer types1,2. In breast cancer, a pre-clinical model demonstrated that Na/K-ATPase inhibitors such as digoxin could dissolve CTC clusters and reduce metastasis3. DICCT is a single-arm, therapeutic exploratory phase I study aimed to examine whether digoxin can disrupt CTC clusters in metastatic breast cancer patients (NCT03928210). Material and methods: Metastatic breast cancer patients in whom clusters of CTCs have been detected were eligible. Patients with concomitant heart disease were excluded. After progressive disease in any line of therapy, a window of opportunity before initiation of subsequent systemic therapy was used to administer digoxin treatment for seven (7) days. For CTC detection, blood samples were processed with the FDA-cleared Parsortix system (ANGLE plc, UK). Captured CTCs were stained for EPCAM, HER2, EGFR (positive CTC selection) and CD45 (exclusion marker). To gain insight into the cluster-dissolution ability of digoxin, the primary endpoint was size of CTC clusters (i.e. number of cells within each cluster) under digoxin therapy. The cumulative effect of digoxin treatment on the primary endpoint was assessed by a linear regression model. Results: Nine (9) patients with CTC clusters detected at baseline were enrolled. A target level of digoxin above 0.7 ng/ml could be confirmed at day 7 for all patients. For quantitative and qualitative analysis of CTC clusters, 5.5 to 27 ml of blood were analyzed at baseline, at day 0 pre-treatment, and post 2 hours, 3 days and 7 days of digoxin treatment. The average cluster size ranged between 2 and 11.8 cells (median 2.9) considering all samples from all patients. Digoxin treatment reduced cluster size in 8 patients (88.9%) to different extents, and the proportion of CTC cluster over single CTCs was also reduced in 6 patients (66.7%). The effect of digoxin was evident in both homotypic (cancer cells only) and heterotypic (aggregates of CTCs and white blood cells) clusters. The treatment was well tolerated, and no adverse events related to the study treatment occurred. All patients completed the treatment according to the protocol. Conclusion: DICCT provides the first-in-human proof-of-principle that digoxin induces a partial dissolution of CTC clusters in patients with metastatic breast cancer at drug levels that are safe and well tolerated. Conceptualization of follow-up trials including Na/K-ATPase inhibitors and patient outcome endpoints are underway.

Acoustic Enrichment of Heterogeneous Circulating Tumor Cells and Clusters from Metastatic Prostate Cancer Patients.

There are important unmet clinical needs to develop cell enrichment technologies to enable unbiased label-free isolation of both single cell and clusters of circulating tumor cells (CTCs) manifesting heterogeneous lineage specificity. Here, we report a pilot study based on the microfluidic acoustophoresis enrichment of CTCs using the CellSearch CTC assay as a reference modality. Acoustophoresis uses an ultrasonic standing wave field to separate cells based on biomechanical properties (size, density, and compressibility), resulting in inherently label-free and epitope-independent cell enrichment. Following red blood cell lysis and paraformaldehyde fixation, 6 mL of whole blood from 12 patients with metastatic prostate cancer and 20 healthy controls were processed with acoustophoresis and subsequent image cytometry. Acoustophoresis enabled enrichment and characterization of phenotypic CTCs (EpCAM+, Cytokeratin+, DAPI+, CD45-/CD66b-) in all patients with metastatic prostate cancer and detected CTC-clusters composed of only CTCs or heterogeneous aggregates of CTCs clustered with various types of white blood cells in 9 out of 12 patients. By contrast, CellSearch did not detect any CTC clusters, but detected comparable numbers of phenotypic CTCs as acoustophoresis, with trends of finding a higher number of CTCs using acoustophoresis. Our preliminary data indicate that acoustophoresis provides excellent possibilities to detect and characterize CTC clusters as a putative marker of metastatic disease and outcomes. Moreover, acoustophoresis enables the sensitive label-free enrichment of cells with epithelial phenotypes in blood and offers opportunities to detect and characterize CTCs undergoing epithelial-to-mesenchymal transitioning and lineage plasticity.

Systematic optimization and evaluation of culture conditions for the construction of circulating tumor cell clusters using breast cancer cell lines

BackgroundCirculating tumor cell (CTC) clusters play a critical role in carcinoma metastasis. However, the rarity of CTC clusters and the limitations of capture techniques have retarded the research progress. In vitro CTC clusters model can help to further understand the biological properties of CTC clusters and their clinical significance. Therefore, it is necessary to establish reliable in vitro methodological models to form CTC clusters whose biological characteristics are very similar to clinical CTC clusters.MethodsThe assays of immunofluorescence, transmission electron microscopy, EdU incorporation, cell adhension and microfluidic chips were used. The experimental metastasis model in mice was used.ResultsWe systematically optimized the culture methods to form in vitro CTC clusters model, and more importantly, evaluated it with reference to the biological capabilities of reported clinical CTC clusters. In vitro CTC clusters exhibited a high degree of similarity to the reported pathological characteristics of CTC clusters isolated from patients at different stages of tumor metastasis, including the appearance morphology, size, adhesive and tight junctions-associated proteins, and other indicators of CTC clusters. Furthermore, in vivo experiments also demonstrated that the CTC clusters had an enhanced ability to grow and metastasize compared to single CTC.ConclusionsThe study provides a reliable model to help to obtain comparatively stable and qualified CTC clusters in vitro, propelling the studies on tumor metastasis.

Abstract SY34-01: Plasticity, dormancy, and glycosylation of circulating tumor cell clusters in response to therapy

Abstract Cellular plasticity and stemness properties enable dynamic changes of circulating tumor cells (CTCs) during cancer dissemination, such as aggregation or cohesion of single CTCs into multicellular CTC clusters with 20-100 times higher metastatic propensity than the singles. Our work demonstrated that stemness glycoproteins on breast cancer stem cells, such as CD44, CD81, and ICAM1 drive CTC aggregation in metastatic breast cancer, such as triple negative breast cancer (TNBC). To determine the glycosylation patterns in CTCs and its association with clinical outcomes, we established multiple CTC analysis approaches including CellSearch, flow cytometry, and immunohistochemistry using patient blood and tissue sections collected at the pre-treatment baseline and after-therapy timepoints. We found that chemotherapy-evasive CTC clusters are relatively quiescent with a specific loss of terminal sugar residues α2,6-sialic acids in glycoproteins. CTCs showed dynamic hypo-sialylation in the blood with loss of the sialyl-transferase ST6GAL1, promoting CTC cluster formation with cellular quiescence (proliferative dormancy) and evading chemotherapy in breast cancer. Seeded tumor cells regained ST6GAL1 to enable metastatic colonization. Many adhesion proteins and stemness drivers as glycoprotein substrates of ST6GAL1 drive CTC clustering and metastatic seeding. Neutralizing antibodies against these clustering drivers inhibit CTC cluster formation and improve therapy response, thereby blocking lung metastasis in TNBC. Citation Format: Huiping Liu. Plasticity, dormancy, and glycosylation of circulating tumor cell clusters in response to therapy [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2024; Part 2 (Late-Breaking, Clinical Trial, and Invited Abstracts); 2024 Apr 5-10; San Diego, CA. Philadelphia (PA): AACR; Cancer Res 2024;84(7_Suppl):Abstract nr SY34-01.

Abstract 2303: Identifying and stratifying circulating tumor cell cluster subtypes in metastatic breast cancer patients and evaluating their clinical outcomes

Abstract Background: Circulating tumor cell clusters (CTCCs) are aggregated groups of tumor cells that detached from primary tumors and circulate the bloodstream. However, while Circulating Tumor Cells (CTCs) are a well studied phenomenon, CTCCs remain relatively unexplored and ill-defined, with only a few descriptive investigations evaluating their clinical utility. Adding to CTCC complexity is that various subtypes exist, including homotypic clusters consisting of a homogenous population of tumor cells and heterotypic CTCCs made of CTCs with immune/stromal white blood cells (WBCs). Furthermore, CTCs can undergo Epithelial-Mesenchymal Transition (EMT), a process characterized by loss of epithelial traits and upregulation of mesenchymal traits, and can form clustered EMTs (CEMTs). Moreover, CTCs can fuse with macrophages forming Tumor Macrophage Hybrid Cells, aka Cancer-Associated Macrophage Like cells (CAMLs) when in circulation. We enumerated all these types of cells and complex aggregates in the peripheral blood of patients with metastatic breast cancer (mBC). Methods: We enumerated the 6 populations from patient samples enrolled in IRB aproved prospective pilot studies. Whole peripheral blood (7.5mL) was filtered and stained with cytokeratin (CK) & CD45/CD14 to identify CTCs. CTCs were defined as an intact DAPI nuclei and strong filamentous CK. Homotypic CTCCs were defined as ≥2 CTCs attached together. Heterotypic CTCCs were defined as ≥1 CTC attached to ≥1 WBC. EMTs were defined as having DAPI nuclei and weak non-filamentous CK. CEMTS were defined as ≥2 EMTs. CAMLs were defined as having an enlarged polynucleated DAPI, and positive for CD45/CD14 or non-filamentous CK. Median progression free survival (mPFS) and median overall survival (mOS) over 24 months (m) were evaluated. Results: We evaluated the blood of 79 mBC patients. Single CTCs were found in 57% of patients (n=34/79), homotypic CTCCs 15% (n=12/79), heterotypic CTCCs 66% (n=27/79), EMTs 56% (n=44/79), CEMTs 23% (n=18/79) and CAMLs 97% (n=77/79). Over 24 ms, patierns with detectable heterotypic CTCCs & homotypic CTCCs had the shortest response times at mPFS=2.8 & mOS=5.8 ms, or mPFS=2.1 & mOS=4.3 ms, respectively. This was followed by CTCs mPFS=3.7 & mOS=13.7 ms, EMTs mPFS=4.3 & mOS=14.4 ms, CAMLs mPFS=4.3 & mOS=14.4 ms, and CEMT mPFS=4.7 & mOS=13.2 ms. Additionally, CTCCs were rare in HER2+ patients at 4.4% (n=1/23), but no associations to other hormone statuses were found. Conclusion: CTCCs appear to represent an array of subtypes with different biological and clinical meanings. Here we enumerated CTCC subtypes in the blood of mBC patients and stratified the various types to clinical outcomes. These data suggest CTCCs are clinically important and further understanding of their biology in the context of tumor pathogenesis is needed. Citation Format: Daniel L. Adams, Carolina Reduzzi, Aravind Aryasomayajula, R. Katherine Alpaugh, Saranya Chumsri, Cha-Mei Tang, Giuseppe Del Priore, William V. Williams, Massimo Cristofanilli. Identifying and stratifying circulating tumor cell cluster subtypes in metastatic breast cancer patients and evaluating their clinical outcomes [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2024; Part 1 (Regular Abstracts); 2024 Apr 5-10; San Diego, CA. Philadelphia (PA): AACR; Cancer Res 2024;84(6_Suppl):Abstract nr 2303.

Abstract 7498: Acoustophoresis enriches tumor cell clusters from patients with metastatic prostate cancer

Abstract Purpose: A subset of aggressive prostate cancers (PCa) progress to invade surrounding tissue to form distant metastases by shed of circulating tumor cells (CTCs). However, due to the scarcity of CTCs among the millions of nucleated blood cells, there is an unmet need to improve CTC isolation assays. Our technique Acoustophoresis uses standing ultrasound waves in a flow-through microfluidic chamber to discriminate cells based on their size, density, and compressibility. Method: We analyzed the effectiveness of acoustophoretic circulating tumor cell (CTC) isolation from 6 mL PFA fixed red blood cell lysed blood from 12 metastatic prostate cancer patients and 20 healthy control subjects and compared it to the golden standard CellSearch. For acoustic cell separation, cells were diluted in 12 mL PBS based buffer and separated by acoustophoresis and analyzed by imaging flow cytometry using a standardized antibody panel (EpCAM, cytokeratin, CD45, CD66b, DAPI). Generally, CTCs, and clusters migrate faster than white blood cells (WBCs) when exposed to ultrasound in the microchannel during acoustophoresis and can therefore be separated from nucleated blood cells. Major findings: Our pilot study shows that acoustophoresis finds both singlets and clusters of CTCs in patients as well as aggregates of CTCs and WBCs. In total, 67 cancer cell containing cell clusters were identified. Most identified cell clusters were small, containing less than 4 cells. In addition, acoustophoresis is a label-free separation technique, and could therefore identify additional subclasses of CTCs among the detected CTCs with e.g., EpCAM low/- expression. Further, we provide extensive data for the effect of storage time on acoustophoretic separation performance for fixed prostate cancer cell line cells and WBCs. Demonstrating that sample processing can be done up to 72 hours after blood sampling. We believe this is to date the most comprehensive study of acoustic separation of CTCs in patients and control subjects. Conclusion: Label-free acoustophoresis is a potential method for future non-invasive molecular interrogation of metastatic cancers. We believe Acoustophoresis is a promising technology for CTC enrichment with the possibility to detect new subclasses of CTCs as well as cell clusters not detectable with CellSearch. CTC-clusters has previously been proposed as a promising and potent predictor to monitor progressive disease and is associated with earlier onset of metastatic disease and poor prognosis, which makes acoustophoresis ability to identify clusters of high interest. Citation Format: Cecilia Magnusson, Per Augustsson, Andreas Lenshof, Andreas Josefsson, Anders Bjartell, Yvonne Ceder, Hans Lilja, Thomas Laurell. Acoustophoresis enriches tumor cell clusters from patients with metastatic prostate cancer [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2024; Part 1 (Regular Abstracts); 2024 Apr 5-10; San Diego, CA. Philadelphia (PA): AACR; Cancer Res 2024;84(6_Suppl):Abstract nr 7498.

Abstract 1510: Cell-cell contacts regulate HER2 cellular localization and the transitions between migration and proliferation in breast cancer cells

Abstract Introduction: Epithelial-to-mesenchymal transition (EMT) is widely recognized as the primary mechanism regulating invasion and metastatic dissemination in carcinomas. In contrast, the mechanisms triggering single disseminated cancer cells (DCC) to reacquire their epithelial identity at ectopic sites, initiating metastasis formation, remain unclear. Since we had previously noted that HER2 expression levels and cellular density impact on migration and proliferation, we sought to determine whether they are involved in molecular mechanisms regulating transitions between proliferation and migration. Methods: To control HER2 expression levels we generated inducible cell models. Cell density was assessed by the number of cell-cell contacts or by the number of cells per area. Pathway analyses were performed by gene expression analysis, protein interactions by western blotting and mass spectrometry. Migration and proliferation were analyzed by functional assays including in vitro live cell imaging. Results: Migrating epithelial cells undergo reduced protein trafficking, resulting in a perinuclear deposition of HER2. This was accompanied by increased calcium ion regulation via phospholipase-C in the endoplasmic reticulum (ER). Upon the establishment of cell-cell contacts, particularly between cells expressing desmosome cadherin proteins, HER2 is redirected to the cell surface through direct physical binding with desmoplakin, facilitating proliferation signals. Then, PIP2 to PIP3 is converted through the activation of the PI3K pathway, concomitant with the upregulation of PDPK1. The PH domain of PDPK1 exhibits a high binding affinity to PIP2 molecules. Consequently, membrane localization of HER2 significantly diminishes PIP2 availability for the PLC pathway, redirecting cells towards proliferation. Patient sample analysis confirmed the loss of membrane-bound HER2 in solitary circulating tumor cells (CTCs), which was paralleled by increased plakoglobin, elevated ZEB1, and reduced KI67 protein levels. Conclusion: Cell-cell contacts determine the cellular localization and function of growth factor receptors like HER2. Single disseminating cancer cells therefore need to establish such contacts at metastatic sites to activate proliferation programs. Our data are in line with findings that circulating tumor cell clusters are associated with higher metastatic rates, the impact of specific metastatic niches for outgrowth and have implementation for the targeting of single DCC. Citation Format: Hedayatollah Hosseini, Saba Sameri, Shabnam Shahrivari, Carolina Fisch, Miriam Kokal, Michael Schletter, Paul Sylvester Hahn, Lisa Seider, Marisa Schübel, Durdam Das, Martin Hoffmann, Christian Werno, Kathrin Weidele, Vladan Milosevic, Arne Östman, Shamim Sarhadi, Joachim Wegener, Stefanie Michaelis, Florian Weber, Astrid Bruckmann, Ernst R. Tamm, Yuting Li, Christoph A. Klein. Cell-cell contacts regulate HER2 cellular localization and the transitions between migration and proliferation in breast cancer cells [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2024; Part 1 (Regular Abstracts); 2024 Apr 5-10; San Diego, CA. Philadelphia (PA): AACR; Cancer Res 2024;84(6_Suppl):Abstract nr 1510.

Abstract 7508: Distribution prophecy of circulating tumor cell clusters in CTC populace patients of epithelial cancers

Abstract Background: Role of CTCs in metastatic cancers to predict the % prediction of overall survival has been well-established. The effectiveness of three- or six-months adjuvant therapy in colorectal cancer estimation showed association of CTCs with the emergence of resistant cell clones. The presence of CTCs with clusters indicates an aggressiveness of the epithelial cancers. However, the presence of CTC clusters has not been evaluated in large populations. Here, we demonstrate the distribution prophecy of CTCs and CTC clusters in epithelial cancer patients. Methods: Retrospectively, 3458 patients' blood sample was analyzed for the presence and distribution of CTCs and CTC clusters using DCGI approved OncoDiscover platform having immunomagnetic multicomponent system mediated by anti EpCAM antibody. 1.5 mL of peripheral blood was analyzed to capture cells and clusters from Head & Neck, breast, and lung cancer patients. Earlier the sensitivity, specificity and accuracy of OncoDiscover assay was presented. CTCs and clusters were identified with CK 18 +ve, DAPI + ve and CD45 -ve staining using automated motorized fluorescence microscopy. CTCs clusters were defined by the presence of two or more CTCs bound together. Results: Out of 3458 epithelial cancer patients, 65.52 % patients showed the distribution of CTCs ~ 2262 (CTC numbers varied from 1-9/1.5 mL), while 7.54% patients showed CTC clusters (261 clusters). Total number of captured CTCs and clusters were 19345 (mean CTCs and cluster distribution was 5.59), while CTC were predominantly in 19037 numbers (98.41%) and clusters were 308 (1.59 %). Highest number of CTS were observed in HNC (52.98%) and breast cancers (22.75%), followed by lung cancer (5.65%). While, prophecy clusters were observed in breast cancers (26.95%), followed by lung (16.23%). Conclusions: The frequency and distribution of CTCs and CTC clusters was evaluated in epithelial cancers. Patients with CTC alone and patients having CTCs as well CTC clusters represent more aggressive disease and the progression of disease. The effectiveness of adjuvant therapy in epithelial cancers can be estimated with CTC and cluster for association of treatment outmoded with an emergence of resistant cell clones. Citation Format: Jayant Khandare, Gourishankar Aland, Ganesh Khutale, Saloni Andhari, Prathamesh Patil, Meghna Garbhe, Manoj Dongare, Tanvi Deshpande, Vikas Jadhav, Nirmal Raut, Gowhar Shafi, Atul Bharde, Aravindan Vasudevan, Sreeja Jayant. Distribution prophecy of circulating tumor cell clusters in CTC populace patients of epithelial cancers [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2024; Part 1 (Regular Abstracts); 2024 Apr 5-10; San Diego, CA. Philadelphia (PA): AACR; Cancer Res 2024;84(6_Suppl):Abstract nr 7508.

Circulating tumor cell clustering modulates RNA splicing and polyadenylation to facilitate metastasis

Circulating tumor cell (CTC) clusters exhibit significantly higher metastatic potential compared to single CTCs. However, the underlying mechanism behind this phenomenon remains unclear, and the role of posttranscriptional RNA regulation in CTC clusters has not been explored. Here, we conducted a comparative analysis of alternative splicing (AS) and alternative polyadenylation (APA) profiles between single CTCs and CTC clusters. We identified 994 and 836 AS events in single CTCs and CTC clusters, respectively, with ∼20% of AS events showing differential regulation between the two cell types. A key event in this differential splicing was observed in SRSF6, which disrupted AS profiles and contributed to the increased malignancy of CTC clusters. Regarding APA, we found a global lengthening of 3′ UTRs in CTC clusters compared to single CTCs. This alteration was primarily governed by 14 core APA factors, particularly PPP1CA. The modified APA profiles facilitated the cell cycle progression of CTC clusters and indicated their reduced susceptibility to oxidative stress. Further investigation revealed that the proportion of H2AFY mRNA with long 3′ UTR instead of short 3′ UTR was higher in CTC clusters than single CTCs. The AU-rich elements (AREs) within the long 3′ UTR of H2AFY mRNA enhance mRNA stability and translation activity, resulting in promoting cell proliferation and invasion, which potentially facilitate the establishment and rapid formation of metastatic tumors mediated by CTC clusters. These findings provide new insights into the mechanisms driving CTC cluster metastasis.

Proof-of-principle study using Saccharomyces cerevisiae for universal screening test for cancer through ultrasound-based size distinction of circulating tumor cell clusters

Proof-of-principle study using Saccharomyces cerevisiae for universal screening test for cancer through ultrasound-based size distinction of circulating tumor cell clusters

Deep learning-enabled detection of rare circulating tumor cell clusters in whole blood using label-free, flow cytometry.

Metastatic tumors have poor prognoses for progression-free and overall survival for all cancer patients. Rare circulating tumor cells (CTCs) and rarer circulating tumor cell clusters (CTCCs) are potential biomarkers of metastatic growth, with CTCCs representing an increased risk factor for metastasis. Current detection platforms are optimized for ex vivo detection of CTCs only. Microfluidic chips and size exclusion methods have been proposed for CTCC detection; however, they lack in vivo utility and real-time monitoring capability. Confocal backscatter and fluorescence flow cytometry (BSFC) has been used for label-free detection of CTCCs in whole blood based on machine learning (ML) enabled peak classification. Here, we expand to a deep-learning (DL)-based, peak detection and classification model to detect CTCCs in whole blood data. We demonstrate that DL-based BSFC has a low false alarm rate of 0.78 events per min with a high Pearson correlation coefficient of 0.943 between detected events and expected events. DL-based BSFC of whole blood maintains a detection purity of 72% and a sensitivity of 35.3% for both homotypic and heterotypic CTCCs starting at a minimum size of two cells. We also demonstrate through artificial spiking studies that DL-based BSFC is sensitive to changes in the number of CTCCs present in the samples and does not add variability in detection beyond the expected variability from Poisson statistics. The performance established by DL-based BSFC motivates its use for in vivo detection of CTCCs. Using transfer learning, we additionally validate DL-based BSFC on blood samples from different species and cancer cell types. Further developments of label-free BSFC to enhance throughput could lead to critical applications in the clinical detection of CTCCs and ex vivo isolation of CTCC from whole blood with minimal disruption and processing steps.

Isolation and Genomic Analysis of Circulating Tumor Cell Clusters in Cancer Patients.

The role of circulating tumor cell (CTC) clusters in the metastatic dissemination process is gaining increased attention. Besides homotypic clusters, heterotypic clusters that contain tumor cells admixed with normal cells are frequently observed in patients with solid tumors. Current methods used for cluster detection and enumeration do not allow an accurate estimation of the relative fractions of tumor cells. Here we describe a method for estimating tumor fraction of clusters including isolation and collection of single clusters, assessment of copy number alterations of single clusters by low-pass whole genome sequencing, and bioinformatic analysis of sequencing data.

Tumour immune microenvironment as the origin of heterotypic circulating tumour cell clusters and their impact on metastasis: An hypothesis

Cancer metastasis remains a significant challenge in cancer treatment, contributing to most cancer-related deaths. Circulating Tumour Cells (CTCs) are crucial for the formation of metastases, and the presence of heterotypic CTC clusters has been associated with higher metastatic potential. We hypothesize that the tumour immune microenvironment (TIME) serves as a possible site for the origin of heterotypic CTC clusters. The interactions between CTCs and non-malignant cells within the TIME can promote cluster formation, facilitate intravasation, survival in the bloodstream, and successful extravasation at secondary sites. The survival of CTCs in circulation is limited due to immune attacks and shear stress; while the formation of heterotypic clusters provides a survival advantage to CTCs by evading immune recognition. Understanding the origin and survival mechanisms of these CTC clusters in the blood is crucial for developing strategies to prevent and treat metastatic cancer. The hypothesis highlights the role of the TIME in modulating CTC behaviour and suggests that targeting tumour-associated immune cells may help disrupt CTC clusters and potentially inhibit metastasis at its early stage.

Classification of circulating tumor cell clusters by morphological characteristics using convolutional neural network-support vector machine

Metastasis is the leading cause of cancer-associated deaths, and the circulating tumor cell (CTC) cluster plays a significant role as a precursor to metastasis. Thus, there is a great demand for high-throughput identification of rare CTC clusters for prognostic diagnosis. Immunofluorescence staining is considered the gold standard for identifying CTCs. However, as CTC clusters are extremely heterogeneous cells, multiple staining markers are required for accurate discrimination. Additionally, the staining procedure is tedious and the analysis of large amounts of stained images is labor-intensive and error-prone. Recently, machine learning-based identification has been introduced to achieve accurate discrimination, but they still rely on immunofluorescence staining for dataset preparation. In this study, we developed a hybrid algorithm, a convolutional neural network support vector machine (CNN-SVM), for the accurate classification of CTC clusters without immunofluorescence staining. In dataset preparation, the Wright–Giemsa staining was used to highlight the morphological features of the cells. Four morphological characteristics that display the unique traits of cells were drawn with each eigenvector, as a result of learning, the algorithm classified CTC clusters of various configurations with a sensitivity and specificity of > 90%. Therefore, our algorithm is expected to be a powerful tool for cancer diagnosis and prognosis.

Prognostic Significance of Circulating Tumour Cells and Disseminating Circulating Tumour Cell Clusters in Epithelial Ovarian Cancer

Prognostic Significance of Circulating Tumour Cells and Disseminating Circulating Tumour Cell Clusters in Epithelial Ovarian Cancer

Acidosis promotes the metastatic colonization of lung cancer via remodeling of the extracellular matrix and vasculogenic mimicry.

Acidosis is a hallmark of the tumor microenvironment caused by the metabolic switch from glucose oxidative phosphorylation to glycolysis. It has been associated with tumor growth and progression; however, the precise mechanism governing how acidosis promotes metastatic dissemination has yet to be elucidated. In the present study, a long‑term acidosis model was established using patient‑derived lung cancer cells, to identify critical components of metastatic colonization via transcriptome profiling combined with both invitro and invivo functional assays, and association analysis using clinical samples. Xenograft inoculates of 1 or 10 acidotic cells mimicking circulating tumor cell clusters were shown to exhibit increased tumor incidence compared with their physiological pH counterparts. Transcriptomics revealed that profound remodeling of the extracellular matrix (ECM) occurred in the acidotic cells, including upregulation of the integrin subunit α‑4 (ITGA4) gene. In clinical lung cancer, ITGA4 expression was found to be upregulated in primary tumors with metastatic capability, and this trait was retained in the corresponding secondary tumors. Expression of ITGA4 was markedly upregulated around the vasculogenic mimicry structures of the acidotic tumors, while acidotic cells exhibited a higher ability of vasculogenic mimicry invitro. Acidosis was also found to induce the enrichment of side population cells, suggesting an enhanced resistance to noxious attacks of the tumor microenvironment. Taken together, these results demonstrated that acidosis actively contributed to tumor metastatic colonization, and novel mechanistic insights into the therapeutic management and prognosis of lung cancer were discussed.

Circulating tumor biomarkers in early-stage breast cancer: characteristics, detection, and clinical developments.

Breast cancer is the most common form of cancer in women, contributing to high rates of morbidity and mortality owing to the ability of these tumors to metastasize via the vascular system even in the early stages of progression. While ultrasonography and mammography have enabled the more reliable detection of early-stage breast cancer, these approaches entail high rates of false positive and false negative results Mammograms also expose patients to radiation, raising clinical concerns. As such, there is substantial interest in the development of more accurate and efficacious approaches to diagnosing breast cancer in its early stages when patients are more likely to benefit from curative treatment efforts. Blood-based biomarkers derived from the tumor microenvironment (TME) have frequently been studied as candidate targets that can enable tumor detection when used for patient screening. Through these efforts, many promising biomarkers including tumor antigens, circulating tumor cell clusters, microRNAs, extracellular vesicles, circulating tumor DNA, metabolites, and lipids have emerged as targets that may enable the detection of breast tumors at various stages of progression. This review provides a systematic overview of the TME characteristics of early breast cancer, together with details on current approaches to detecting blood-based biomarkers in affected patients. The limitations, challenges, and prospects associated with different experimental and clinical platforms employed in this context are also discussed at length.

A model for the dissemination of circulating tumour cell clusters involving platelet recruitment and a plastic switch between cooperative and individual behaviours

BackgroundIn spite of extensive research, cancer remains a major health problem worldwide. As cancer progresses, cells acquire traits that allow them to disperse and disseminate to distant locations in the body – a process known as metastasis. While in the vasculature, these cells are referred to as circulating tumour cells (CTCs) and can manifest either as single cells or clusters of cells (i.e., CTC clusters), with the latter being the most aggressive. The increased metastatic potential of CTC clusters is generally associated with cooperative group benefits in terms of survival, including increased resistance to shear stress, anoikis, immune attacks and drugs. However, the adoption of a group phenotype poses a challenge when exiting the vasculature (extravasation) as the large size can hinder the passage through vessel walls. Despite their significant role in the metastatic process, the mechanisms through which CTC clusters extravasate remain largely unknown. Based on the observed in vivo association between CTC clusters and platelets, we hypothesized that cancer cells take advantage of the platelet-derived Transforming Growth Factor Beta 1 (TGF-β1) – a signalling factor that has been widely implicated in many aspects of cancer, to facilitate their own dissemination. To address this possibility, we evaluated the effect of exogenous TGF-β1 on an experimentally evolved non-small cell lung cancer cell line that we previously developed and used to investigate the biology of CTC clusters.ResultsWe found that exogenous TGF-β1 induced the dissociation of clusters in suspension into adherent single cells. Once adhered, cells released their own TGF-β1 and were able to individually migrate and invade in the absence of exogenous TGF-β1. Based on these findings we developed a model that involves a TGF-β1-mediated plastic switch between a cooperative phenotype and a single-celled stage that enables the extravasation of CTC clusters.ConclusionsThis model allows for the possibility that therapies can be developed against TGF-β1 signalling components and/or TGF-β1 target genes to suppress the metastatic potential of CTC clusters. Considering the negative impact that metastasis has on cancer prognosis and the lack of therapies against this process, interfering with the ability of CTC clusters to switch between cooperative and individual behaviours could provide new strategies to improve patient survival.

New advances in circulating tumor cell‑mediated metastasis of breast cancer (Review).

Breast cancer stands as the most prevalent form of cancer affecting women, with metastasis serving as a leading cause of mortality among patients with breast cancer. Gaining a comprehensive understanding of the metastatic mechanism in breast cancer is essential for early detection and precision treatment of the disease. Circulating tumor cells (CTCs) play a vital role in this context, representing cancer cells that detach from tumor tissues and enter the bloodstream of cancer patients. These cells travel in the blood circulation as single cells or clusters. Recent research has shed light on the enhanced metastatic potential of CTC clusters compared to single CTCs, despite their limited occurrence. The aim of the present review was to explore recent findings on CTCs with a particular focus on the clustering phenomenon of CTCs observed in breast cancer. Additionally, the present review delved into the comparison between single CTCs and CTC clusters regarding their implications for the treatment and prognosis of patients diagnosed with metastatic breast cancer. By examining the role and mechanisms of CTCs in breast cancer metastasis, the present review provided an improved understanding of CTCs and their significance in early detection of breast cancer metastasis through peripheral blood analysis. Moreover, it contributed to the comprehension of cancer prognosis and prediction by highlighting the implications of CTCs in these aspects. Ultimately, the present study seeks to advance knowledge in the field and pave the way for improved approaches to breast cancer management.

Automated Image Analysis for Characterization of Circulating Tumor Cells and Clusters Sorted by Magnetic Levitation.

Magnetic levitation-based sorting technologies have revolutionized the detection and isolation of rare cells, including circulating tumor cells (CTCs) and circulating tumor cell clusters (CTCCs). Manual counting and quantification of these cells are prone to time-consuming processes, human error, and inter-observer variability, particularly challenging when heterogeneous cell types in 3D clusters are present. To overcome these challenges, we developed "Fastcount," an in-house MATLAB-based algorithm for precise, automated quantification and phenotypic characterization of CTCs and CTCCs, in both 2D and 3D. Fastcount is 120 times faster than manual counting and produces reliable results with a ±7.3% deviation compared to a trained laboratory technician. By analyzing 400 GB of fluorescence imaging data, we showed that Fastcount outperforms manual counting and commercial software when cells are aggregated in 3D or staining artifacts are present, delivering more accurate results. We further employed Fastcount for automated analysis of 3D image stacks obtained from CTCCs isolated from colorectal adenocarcinoma and renal cell carcinoma blood samples. Interestingly, we observed a highly heterogeneous spatial cellular composition within CTCCs, even among clusters from the same patient. Overall, Fastcount can be employed for various applications with lab-chip devices, such as CTC detection, CTCC analysis in 3D and cell detection in biosensors.