Archive for the ‘Metastases’ Category

MIT Researchers Target Cancer’s Most Deadly Phase

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Posted 25 Dec 2011 — by James Street
Category Lung Metastases, Metastases, metastases
Author: Marcia Stone : Posted to Decoded Science on December 24, 2011 at 2:12 pm
Invasive human breast cancer: Image courtesy of Robert Weinberg

If malignant cells could be kept from wandering about the body and colonizing new sites, the number of cancer deaths would be cut by about 90%. However, it’s become apparent in recent years that metastasis isn’t a simple, random process; it’s a well-orchestrated sequence of events most of which are largely unknown.

In fact, “[metastasis] remains the most poorly understood component of cancer pathogenesis,” says Robert A. Weinberg, PhD, Professor of Biology at the Massachusets Institute of Technology (MIT) in Cambridge. Professor Weinberg helped identify ras, the first human oncogene, in the 1970s and a few years later the first known tumor suppressor gene, Rb.  Most recently, Weinberg’s team at the MIT Whitehead Institute for Biomedical Research created the first genetically-defined human cancer cells.

Robert A. Weinberg Discusses his Latest Research with Colleagues at the SKI in December

Understanding how metastasis works has great clinical potential and this is why, Weinberg told cancer experts at the Sloan-Kettering Institute’s President’s Research Seminar, held at the Rockefeller Research Laboratories (RRL) in New York City on December 14th, the scientists in his laboratory are vigorously investigating this “most enigmatic” aspect of cancer.

For starters, the Weinberg and colleagues have organized the complex metastatic cascade into two major parts: first, the physical translocation of a cancer cell from its primary tumor to a distant site and second, colonization.  An understanding of the first step, physical dissemination, is in sight he says. However, colonization is far more complicated and may require several more years of research before the traits a cancer cell needs to implant and grow in alien soil are fully understood.

Nonetheless, knowing how a cancer cell escapes the confines of a tumor and explores adjacent environments is expected to prove important for preventing metastasis in people with early cancer lesions. Designing effective therapies for patients with already-established disease will have to wait.

“Tumor-Initiating” Cancer Stem Cells (CSCs) 

“The discovery of CSCs has forced  major rethinking of tumor biology,” says Weinberg, adding that a variety of cancer-associated traits once ascribed to tumor cell populations as a whole are now known to be associated with one or another subpopulations of CSCs.  CSCs exist side-by-side with normal self-renewing stem cells (SCs); but unlike SCs, CSCs have greatly enhanced tumor-initiating potential thus the ability to seed new cancers.

One critical role of CSCs in metastasis is obvious, Weinberg notes; they act as founder cells, spawning vast numbers of descendants. Indeed, the very traits that define CSCs – self-renewal and tumor initiating ability – also define successful metastasis. However CSCs have other less well-recognized attributes necessary for metastasis: motility, invasiveness, and a heightened resistance to apoptosis. This implies that a multifaceted biological program exists within a primary tumor empowering some cancer cells to escape and start colonies elsewhere. It also suggests that cancer is a systemic disease long before any of the malignant cells begin migrating.

The Epithelial-to-Mesenchymal Transition

Embryonic tissue differentiates with a program known as the EMT, shorthand for “epithelial-to-mesenchymal transition,” which is also activated during cancer invasion and metastasis.  “The EMT enables both normal and neoplastic epithelial cells to acquire mesenchymal cells attributes such as motility, invasiveness, and a resistance to apoptosis,” Weinberg says. Carcinoma cells with mesenchymal attributes can not only physically disseminate, they can self-renew which enables them to seed new environments. Long-term exposure to stroma-associated signals also helps keep cells in the mesenchymal/stem-cell state in a self-sustaining, stable fashion.  Additionally, their resistance to programmed cell death or apoptosis is, “surely critical to the ability of the migrating cells to survive the rigors of the voyage” from primary tumors to distant sites, he adds.

Moreover, primary carcinomas, the Weinberg team’s target cancers, release signals that recruit inflammatory cells to the tumor. This both helps assemble a highly functional, tumor-supporting environment, or stroma, and keeps some of the cells in a biologically-abnormal activated state.  However, while conceptually appealing, Weinberg cautions that the role of EMT in metastasis remains unproven.

Cancer Colonization 

Pelvis with bone metastasis: Image courtesy of Diagnostic pathology

Although EMT programs seem critical for the physical dissemination of carcinoma cells, they don’t appear capable of initiating and sustaining colonization.  Colonization, Weinberg emphasizes, seems to entail a far more complex set of phenomena, and have a relatively small number of unifying general principles. The tissue microenvironment of a primary tumor is likely to differ markedly from that of a secondary site which requires the wandering cancer cell to make substantial adaptive changes in order to survive and multiply. These changes appear to be dictated by both the microenvironment of the primary tumor as well as that of the landing site.

In general, says Weinberg, colonization is an extremely inefficient process, and most cancer cells that successfully translocate from a primary to a secondary site don’t survive more than 24 hours in their new home. This is good news because the outcome of successful colonization is a rapidly expanding macrometastasis that disseminates a shower of secondary metastases. Moreover, cancer cells being dispatched from the successful new colony are likely to be invested with the kinds of genetic programs that make it easier for them to migrate and colonize a variety of tissues.  These cells are so much more fit than their ancestors that the “throngs of secondary metastases derived from the initial metastatic shower soon eclipse the initiating metastasis that spawned them,” Weinberg stresses.

Sources:

Robert A. Weinberg, Ph.D. 2011 Calloway Lecture: EMT, Cancer Stem Cells and Malignant Progression. December 14, 2011.

Chaffer, C. L., Weinberg, R. A. A Perspective on Cancer Cell Metastasis. Science: 331:1559-1564, 25 March 2011. Accessed December 24, 2011.

Mani, S. A., Guo, W., Liao Mai-Jing, et al. The Epithelial-Mesenchymal Transition Generates Cells with Properties of Stem Cells. Cell: 133, 704-715, 16 May 2008.

Mukherjee, S. The Emperor of All Maladies: A Biography of Cancer. New York City. Scribner. (2010). ISBN 978-1-4391-0795-9.

 

Vitamin D could help in fighting pediatric bone cancer

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Posted 17 Dec 2011 — by James Street
Category Dog Osteosarcoma, Local Recurrence, Lung Metastases, Metastases, Osteosarcoma, Vitamin D

Posted by Laura HerringDecember 16, 2011 at 9:05 a.m.

A study by a group of Kansas University researchers found that vitamin D can cause cancerous bone cells to turn to normal bone cells.

The findings, which were published in the Journal of Orthopaedic Research, could lead to a new treatment in fighting pediatric bone cancer, which has a survival rate of 60 percent to 70 percent.

Recent studies have shown vitamin D can inhibit the growth of malignant cells in breast, prostate and colon cancer. Kim Templeton, an orthopedic surgeon at Kansas University Hospital, was among the experts on a panel that discussed vitamin D research and cancer. She was surprised that none of the studies or trials included the effect of vitamin D on osteosarcoma, a malignant bone tumor that mainly affects children and adolescents.

“It’s the most common type of bone cancer in kids and teenagers and vitamin D is critical to bone health,” she said. So an interdisciplinary team at the Kansas University Medical Center came together to study how vitamin D affects bone cancer. The team used cancerous tumor cells to do the research.

“My question was if the tumor recognizes Vitamin D and if it would help control the cells,” Templeton said. In the laboratory tests, not only did the cancerous cells recognize the vitamin D, but it prevented the osteosarcoma cells from replicating as quickly and promoted the growth of normal bone cells.

“What should happen and what does happen (in the lab) is always two different things,” Templeton said. “So, I was happy it turned out the way we thought it would.”

The findings are important for a cancer who hasn’t seen the treatment methods or rate of survival change in the past 20 to 25 years. Most osteosarcoma patients undergo 10 weeks of chemotherapy before the tumor is removed.

The findings suggest that a normal size dose of vitamin D could become another tool in the treatment of osteosarcoma. Unlike chemotherapy, normal doses of vitamin D don’t have any negative side effects and it is inexpensive.

Before clinical trials on humans can began, researchers would have to test the effects of vitamin D on animals, which might include large dogs since they have a high rate of osteosarcoma.

Templeton said the findings don’t suggest people should start taking vitamin D to prevent bone cancer. Although that is a connection researchers might study in the future.

By Christine Metz

N-acetyl-cysteine (NAC)–is an anticarcinogenic and antimutagenic agent

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Posted 21 Nov 2011 — by James Street
Category Antiagiogenesis, Metastases, metastases, N-acetylcisteine

N-acetyl-cysteine (NAC)–is an anticarcinogenic and antimutagenic agent; it inhibits IL-6 as well as invasion and metastasis of malignant cells
N-acetyl-cysteine (NAC) is the acetylated precursor of the amino acids L-cysteine and reduced glutathione. Historically, it is used as a mucolytic agent in respiratory illnesses as well as an antidote for acetaminophen hepatotoxicity, but more recently its credits have grown. Animal and human studies have shown it to be a powerful antioxidant and a potential therapeutic agent in the treatment of cancer (Bongers et al. 1995; van Zandwijk 1995).

The biological value of NAC is attributed to its sulfhydryl group, while its acetyl-substituted amino group offers protection against oxidative and metabolic processes (Bonanomi et al. 1980; Sjodin et al. 1989). In vitro studies showed NAC to be directly antimutagenic and anticarcinogenic; in vivo, NAC inhibited mutagenicity of a number of mutagenic materials (De Flora et al. 1986, 1992).

NAC has both chemopreventive and therapeutic potential in malignancies arising in the lung, skin, breast, liver, head, and neck (van Zandwijk 1995; Izzotti 1998). NAC is effective in inhibiting tumor cell growth in melanoma, prostate cells, and astrocytoma cell lines (the latter is a primary tumor in the brain) (Albini et al. 1995; Arora-Kuruganti et al. 1999; Chiao et al. 2000). Neovascularization (new blood vessel growth) is crucial for tumor mass expansion and metastasis. NAC inhibited invasion and metastasis of malignant cells by up to 80% by preventing angiogenesis (De Flora et al. 1996).

A number of cancers express IL-6 and other potentially dangerous cytokines. NAC inhibited (in a dose-dependent manner) the synthesis of IL-6 by alveolar macrophage (Munoz et al. 1996; Gosset et al. 1999).

Peak plasma levels of NAC occur approximately 1 hour after an oral dose; 12 hours after dosing, it is undetectable. Despite a relatively low bioavailability (4-10%), research has shown NAC to be clinically effective (Borgstrom et al. 1986). A suggested NAC therapeutic dosage is usually in the range of 600 mg per day.

Modified Citrus Pectin (MCP)–retards cancer growth and metastasis

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Posted 21 Nov 2011 — by James Street
Category Diet and Prostate Cancer, Lung Metastases, Metastases, Modified Citrus Pectin (MCP), Prostate Cancer, PSA testing

Modified citrus pectin (MCP), also known as fractionated pectin, is a complex polysaccharide obtained from the peel and pulp of citrus fruits. Through pH and temperature modifications, the pectin is broken down into shorter, nonbranched, galactose-rich, carbohydrate chains. The shorter chains dissolve more readily in water, making them better absorbed than ordinary, long-chain pectin. The short polysaccharide units afford MCP its ability to access and bind tightly to galactose-binding lectins (galectins) on the surface of certain types of cancers. By binding to lectins, MCP is able to powerfully address the threat of metastasis (Strum et al. 1999).

In order for metastasis to occur, cancerous cells must first bind or clump together; galectin is thought responsible for much of cancer’s metastatic potential by providing the binding site (Raz et al. 1987; Guess et al. 2003; Pienta et al. 1995). MCP appears small enough to access and bind tightly with galectins, inhibiting (or blocking) aggregation of tumor cells and adhesion to surrounding tissue (Kidd 1996). Deprived of the capacity to adhere, cancer cells fail to metastasize.

Men with prostate cancer who took 15 grams of MCP a day had a slowdown in the doubling time of their PSA levels. (Lengthening of doubling time represents a decrease in the rate of cancer growth.) Interestingly, rats injected with prostate adenocarcinoma and given MCP (in drinking water) showed a significant reduction in metastasis (compared to control animals), although the primary tumor was unaffected. According to Dr. Kenneth Pienta (leader of the Michigan Cancer Foundation), MCP may be the first oral method of preventing spontaneous prostate cancer metastasis (Pienta et al. 1995; Guess et al. 2003).

As with prostate adenocarcinoma, research shows that metastasis of breast cancer cell lines requires aggregation and adhesion of the cancerous cells to tissue endothelium in order for it to invade neighboring structures (Glinsky et al. 2000). To test the anti-adhesive properties of MCP, researchers evaluated (in an in vitro model) breast carcinoma cell lines MCF-7 and T-47D. The study concluded that MCP countered the adhesion of malignant cells to blood vessel endothelium and subsequently inhibited metastasis (Naik et al. 1995). MCP decreased metastasis of melanoma to the lung by more than 90% in laboratory animals (Platt et al. 1992).

Because MCP is a soluble fiber, no pattern of adverse reaction has been recorded in the scientific literature, apart from a self-limiting loose stool at high doses. MCP dosages are usually expressed in grams, with a typical adult dose ranging from 6-30 grams divided throughout the day. MCP’s apparent safety and proven antimetastatic action, and the lack of other proven therapies against metastasis appear to justify its inclusion in a comprehensive orthomolecular anticancer regimen (Kidd 1996). Pecta-Sol is the brand name of the original modified citrus pectin (MCP. The dosage for Pecta-Sol is about 15 grams a day.

Tyrosine Isomers Mediate the Classical Phenomenon of Concomitant Tumor Resistance

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Posted 19 Nov 2011 — by James Street
Category Metastases, metastases, Tyrosine
  1. Raúl A. Ruggiero1,
  2. Juan Bruzzo1,
  3. Paula Chiarella1,
  4. Pedro di Gianni1,
  5. Martín A. Isturiz1,
  6. Susana Linskens2,
  7. Norma Speziale2,
  8. Roberto P. Meiss3,
  9. Oscar D. Bustuoabad1, and
  10. Christiane D. Pasqualini1

+ Author Affiliations


  1. Authors’ Affiliations:1División Medicina Experimental, Academia Nacional de Medicina; 2Facultad de Farmacia y Bioquímica, UBA; and 3Instituto de Estudios Oncológicos, Academia Nacional de Medicina, Buenos Aires, Argentina
  1. Corresponding Author:
    Raúl A. Ruggiero, División Medicina Experimental, Academia Nacional de Medicina, Pacheco de Melo 3081 (1425), Buenos Aires, Argentina. Phone: 54-11-4805-3411; Fax: 54-11-4803-9475; E-mail: ruloruggiero@yahoo.com.ar

Abstract

Concomitant tumor resistance (CR) is a phenomenon originally described in 1906 in which a tumor-bearing host is resistant to the growth of secondary tumor implants and metastasis. Although recent studies have indicated that T-cell–dependent processes mediate CR in hosts bearing immunogenic small tumors, manifestations of CR induced by immunogenic and nonimmunogenic large tumors have been associated with an elusive serum factor. In this study, we identify this serum factor as tyrosine in its meta and ortho isoforms. In three different murine models of cancer that generate CR, both meta-tyrosine and ortho-tyrosine inhibited tumor growth. In addition, we showed that both isoforms of tyrosine blocked metastasis in a fourth model that does not generate CR but is sensitive to CR induced by other tumors. Mechanistic studies showed that the antitumor effects of the tyrosine isoforms were mediated, in part, by early inhibition of mitogen-activated protein/extracellular signal-regulated kinase pathway and inactivation of STAT3, potentially driving tumor cells into a state of dormancy. By revealing a molecular basis for the classical phenomenon of CR, our findings may stimulate new generalized approaches to limit the development of metastases that arise after resection of primary tumors, an issue of pivotal importance to oncologists and their patients. Cancer Res; 71(22); 7113–24. ©2011 AACR.

Footnotes

  • Note: Supplementary data for this article are available at Cancer Research Online (http://cancerres.aacrjournals.org/).

  • R.A. Ruggiero, M.A. Isturiz, N. Speziale, O.D. Bustuoabad, and C.D. Pasqualini are members of Research Career of CONICET; Juan Bruzzo and Paula Chiarella are Fellows of CONICET.

  • Received February 17, 2011.
  • Revision received August 16, 2011.
  • Accepted September 2, 2011.

Key protein fuelling growth of cancer identified

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Posted 03 Nov 2011 — by James Street
Category Lung Metastases, Metastases, Understanding Cancer

Last Updated: Monday, October 31, 2011,17:11

Washington: Scientists have identified a key mechanism of metastasis that could lead to blocking tumor growth if their findings are confirmed.

Lead researcher David Waisman, Ph.D., professor in the Departments of Biochemistry and Molecular Biology and Pathology, and Canada Research Chair in Cancer Research at Dalhousie University in Nova Scotia, detailed the key role the macrophage cell surface protein S100A10 plays in allowing macrophages to move to the site of tumor growth – a process that is essential to tumor development.

Waisman said the findings are an example of the complicated biology of cancer.

“We used to think that the only cells that mattered in a tumor were the cancer cells, and that’s it, but now we are beginning to see that other cells must collaborate with cancer cells to drive tumor growth and permit an evolution of the cancer cells into metastatic cells. This change is what causes poor prognosis and ultimately what kills the patient,” he said.

Waisman and colleagues discovered that tumors do not grow without macrophage assistance. These macrophages must come from the blood or from other locations in the tissues. How they are able to move through the tissues or from the blood supply into the tumor had always been a mystery.

These macrophages need to chew their way through the tissue that forms a barrier around the growing tumor in order to move into the tumor site and combine with the cancer cells. The researchers found on the outside surface of the macrophage is a protein called S100A10, which enables the macrophage to remove the tissue barriers retarding migration to the tumor site.

Theoretically, blocking either the macrophages or S100A10 chemically could slow, or even stop, tumor growth, Waisman said.

The study was recently published in the journal Cancer Research.

Molecular alterations as target for therapy in metastatic osteosarcoma: a review of literature

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Posted 30 Oct 2011 — by James Street
Category Educational, Metastases, Osteosarcoma, Understanding Cancer
Clinical & Experimental Metastasis
Official Journal of the Metastasis Research Society
© The Author(s) 2011
10.1007/s10585-011-9384-x

Review

Molecular alterations as target for therapy in metastatic osteosarcoma: a review of literature

J. PosthumaDeBoer1, M. A. Witlox2, G. J. L. Kaspers3 and B. J. van Royen1, 4 Contact Information

(1) Department of Orthopaedic Surgery, VU University Medical Center, De Boelelaan 1117, 1081 HV Amsterdam, The Netherlands
(2) Department of Orthopaedic Surgery, Westfries Gasthuis, Hoorn, The Netherlands
(3) Paediatric Oncology/Haematology, VU University Medical Center, Amsterdam, The Netherlands
(4) VU University Medical Center, PO Box 7057, 1007 MB Amsterdam, The Netherlands

Contact Information B. J. van Royen
Email: bj.vanroyen@vumc.nl

Received: 15 July 2010  Accepted: 18 March 2011  Published online: 2 April 2011

Abstract

Treating metastatic osteosarcoma (OS) remains a challenge in oncology. Current treatment strategies target the primary tumour rather than metastases and have a limited efficacy in the treatment of metastatic disease. Metastatic cells have specific features that render them less sensitive to therapy and targeting these features might enhance the efficacy of current treatment. A detailed study of the biological characteristics and behaviour of metastatic OS cells may provide a rational basis for innovative treatment strategies. The aim of this review is to give an overview of the biological changes in metastatic OS cells and the preclinical and clinical efforts targeting the different steps in OS metastases and how these contribute to designing a metastasis directed treatment for OS.

Keywords  Drug resistance – Metastasis – Osteosarcoma – Therapy

Abbreviations  Bcl-2

B cell lymphoma 2 associated oncogene

- Bcl-XL

Bcl2-like 1

- CXCR4

Chemokine (C-X-C-motif) receptor 4

- CXCL

Chemokine (C-X-C-motif) ligand

- ECM

Extracellular matrix

- EGFR

Epidermal growth factor receptor

- ERK

Extracellular signal regulated kinase

- FAK

Focal adhesion kinase

- GH

Growth hormone

- HLA

Human leukocyte antigen

- IGF-1R

Insulin-like growth factor 1 receptor

- IFN-α

Interferon-alpha

- IL

Interleukin

- JAK

Janus kinase

- mAB

Monoclonal antibody

- MAP(K)

Mitogen-activated protein (kinase)

- MMP

Matrix metalloproteinase

- MTP-PE

Muramyl tripeptide phosphatidyl ethanolamine

- mTOR

Mammalian target of rapamycin

- NF-κB

Nuclear factor-kappa B

- NK cells

Natural killer cells

- PI3K

Phosphatidylinositol 3-kinase

- PDGF-R

Platelet-derived growht factor receptor

- OS

Osteosarcoma

- SARC

Sarcoma Alliance for Research through Collaboration

- STAT

Signal transducer and activator of transcription

- TGF-β

Transforming growth factor-beta

- VEGF

Vascular endothelial growth factor

- WIF-1

Wnt inhibitory factor 1


Introduction

Osteosarcoma (OS) is the most common primary malignant bone tumour in children and adolescents. The estimated incidence rate worldwide is 4/million/year, with a peak incidence at the age of 15–19 years [1]. In OS there is a high tendency to metastatic spread. Approximately 20% of patients present with lung metastases at initial diagnosis and, additionally, in 40% of patients metastases occur at a later stage. Eighty percent of all metastases arise in the lungs, most commonly in the periphery of the lungs, and exhibit resistance to conventional chemotherapy [27]. The 5-year survival rate for OS patients with metastases is 20% compared to 65% for patients with localised disease and most deaths associated with OS are the result of metastatic disease [5, 811].

For patients with pulmonary metastasis, especially those who have metastasis at initial diagnosis, the combination of radical metastasectomy and chemotherapy offers the best outcome and even potential cure. Nevertheless, recurrent development of pulmonary metastases after initial radical metastasectomy is reported to be high and repeated metastasectomies are sometimes performed. As metastasectomy does yield an improved survival in most patients it should therefore always be performed when feasible [2, 4, 1214].

In order to improve survival, the ultimate questions to be answered are: Why does OS metastasize, particularly to the lungs? And, more importantly: Why does therapy fail in metastatic disease? In this regard, we hypothesise that drug resistance is a key issue in the failure to control metastatic disease. It has been shown that OS lung metastases display a biological behaviour different from the primary tumours [2, 1427]. Metastases are comprised of cell clones that differ from primary tumours with respect to ploidy, enzyme profile, karyotype and chemosensitivity [2, 2832]. Therapeutic regimens that target primary tumours are therefore unlikely to be successful in the treatment of metastatic disease.

Metastasis is considered to be the final though most critical step in tumorigenesis of malignant tumours [33]. The metastatic cancer cells subsequently complete the following steps: Invasion through the extracellular host matrix and entrance into the circulation (I), survival in the circulation (II) and evasion of the host immune system (III), arrest and extravasation at a target organ site (IV), adherence and survival in the target organ microenvironment (V, VI) and finally formation of neovasculature to allow growth at the target organ site (VII) [14, 3336]. Each step is of equal importance and must be fully completed by the tumour cell to achieve successful metastasis. The altered biological behaviour in metastatic cells is the result of specific molecular changes. We will discuss each of these specific steps with special attention to the molecules involved in OS metastasis (Table 1) and implications for therapy. Over the last decade, much research has been performed to try to unravel the biology of OS metastasis and many (pre)clinical studies have attempted to discover new treatment options for metastatic OS. For example, gene expression profiling of metastatic cells using a cDNA microarray approach has identified genes responsible for metastasis [27, 3739]. Also, expression levels of specific proteins in OS lung metastases have been analysed. In these studies, expression levels of proteins involved in metastases link the molecular aberrancies to clinical outcome in terms of survival rates. These alterations may also provide novel drug targets [21, 23, 25, 36, 4042]. Table 2 summarises (pre)clinical studies for treating OS metastases.

Table 1 Steps of metastasis in OS and molecular alterations that contribute to each process
Steps of metastasis Molecular involvement References
I Migration and invasion MMPs [10, 14, 16, 18, 19, 27, 34, 35, 4446]
m-Calpain [35, 43]
Wnt [9, 35, 46, 47]
Src [35, 44]
Notch [41, 4850]
II (a) Anoikis resistance PI3K/Akt [9, 14, 16, 51]
Src/PI3k/Akt [9, 14, 16, 44]
Src/Ras/MAPK [18, 35]
NF-κB [27]
Wnt/β-catenin [14]
BcL family [9, 35, 51]
(b) Apoptosis resistance Src [9, 16, 18, 35, 44]
NF-κB [27, 44, 51, 67]
Wnt/β-catenin [14, 17, 19, 46, 47, 53, 54]
Fas/FasL [5, 23, 28, 36, 55, 56]
III Evasion of immune system HLA-1 [14, 60]
IL-10 [14]
Fas [62]
IV Arrest and extravasation CXCR4-CXCL12 [9, 10, 14, 15, 22, 42, 69]
CXCR3-CXCL9-11 [10]
CXCR4/MMPs [9, 10, 15]
CXCR3-4/Erk/NF-κB [10, 67]
V Adherence Ezrin/MAPK/Akt [14, 21, 25, 35]
Ezrin/β4-Integrin/PI3K [70]
CD44/Akt/mTOR [14, 19, 21]
VI Dormancy Integrin-α5β1 [73, 74]
Integrin-α5β1/Erk/p38 [14, 35]
Bcl-XL [14, 35]
IGF/PI3K [75]
ECM [73, 74]
VII Angiogenesis and proliferation EGFR. PDGFR, VEGF, IGFR, TGF-β [9, 14, 35, 40, 68, 77, 78, 81]
MMPs [9, 44, 78]
VEGF/Erk/NF-κB [35, 68]
VEGF/PI3K [35, 40]
EGFR/Src/Ras/MAPK/STAT3 [9, 18]
Src [14, 35, 44]
Integrin/PI3K/Erk1-2 [9, 35, 67, 75]
Wnt/β-catenin/CyclinD-Survivin [46, 52]

Table 2 Preclinical and clinical studies targeting specific molecules in OS metastasis
Steps of metastasis Target Drug References
Preclinical
I Migration and Invasion Notch [41, 50]
II (a) Anoikis resistance
(b) Apoptosis resistance Preclinical
Wnt [46, 52]
Src [18]
Clincial
Src
Dasatinib [60]
www.clinicaltrials.gov/NCT00752206
III Evasion of immune system Preclinical
Fas
IL12 [36, 56, 62]
IL18 [63]
Gemcitabine [55]
Clinical
Fas
Liposomal MTP-PE [64]
IFN-α [61, 66]
IV Arrest and extravasation Preclinical
CXCR4 [22]
CXCR3 [10]
V Adherence Preclinical
Ezrin [21, 25, 45, 70]
VI Dormancy
VII Proliferation and angiogenesis Preclinical
Endostatin [83]
IGF-1R [79, 84]
Clinical
IGF-1R
OncoLar [78]
R1507 www.clinicaltrials.gov/NCT00642941
SCH717454 www.clinicaltrials.gov/NCT00617890

The aim of this review is to give an overview of the biology of metastatic OS cells and of (pre)clinical efforts targeting the different steps in OS metastases and how these may contribute to designing a metastasis directed treatment for OS.


OS metastasis

(I) Migration and invasion

Migration of cells away from the primary tumour and invasion through the extracellular matrix (ECM) towards the bloodstream is considered the first step contributing to metastasis. In OS, it has been described that MetalloProteinases (MMPs) 2 and 9 and m-Calpain play a role in degradation of the ECM [10, 14, 16, 18, 19, 27, 34, 35, 4346]. Also, the Wnt/β-catenin pathway and Src-kinase are implicated as inducers of migration [9, 35, 46, 47]. In OS, Notch is a relatively recently identified pathway and has been identified as a promoter of invasion in OS. In highly metastatic OS cell lines there is an upregulation of the Notch1 and Notch2 receptor, as well as the Notch induced gene Hes1. In patient samples, expression of the Hes1 gene inversely correlated with survival [41, 4850].

(Pre)clinical studies: Notch

In a preclinical setting, downregulation of the Notch signalling pathway has been shown to impair the invasiveness of cell lines, but has no effect on cell proliferation or in vitro tumorigenesis. Notch-inhibited cell lines had less potential to form lung metastases in an orthotopic mouse model when compared to untreated cell lines. The exact mechanism through which inhibition of the Notch pathway and its target gene Hes1 leads to reduced invasion still remains unknown [41, 50].

(IIa) Survival in the bloodstream

Dissemination of cancer cells through the body requires the cells to survive in the circulation. Non-malignant cells, as well as non-metastatic tumour cells, become apoptotic after loss of cell–cell adhesions or interaction with the ECM in their original tissue. This specific mode of apoptosis is called anoikis. One reason for this type of apoptosis to occur is that Integrin signalling ceases to exist in solitary cells. Under adherent conditions, survival is often mediated through Integrin signalling pathways in which Focal adhesion kinase (FAK) is a central player. FAK activates the important PI3K/Akt survival pathway. Metastatic tumour cells evade anoikis by intrinsically activated survival pathways via for example PI3K or Akt signalling, independent of extrinsic Integrin and FAK signalling [9, 14, 16, 51]. Src kinase can also activate the PI3K/Akt and the Ras/MAPK survival pathways independent of FAK signalling and thus stimulate ainoikis resistance [9, 14, 16, 18, 35, 44, 51]. Other survival mechanisms are also of importance in the evasion of ainoikis, such as activation the nuclear factor-kappa B (NF-κB) pathway [27, 51] and Wnt-mediated upregulation of the β-catenin activity. High levels of β-catenin expression have been shown to be associated with a metastatic phenotype in OS [14, 19, 20, 46]. Finally, overexpression of anti-apoptotic genes such as Bcl-2, Bcl-XL or FAK is exploited by solitary metastatic cells to obtain a survival benefit [9, 35, 51].

(IIb) Apoptosis resistance

The survival of tumour cells through all stages of metastasis (not only in the bloodstream) is paramount to successful metastasis. Mechanisms involved in apoptosis resistance throughout metastasis include activation of the Src and NF-κB pathways and the overexpression of anti-apoptotic genes [9, 44, 46, 51, 52]. Wnt-signalling is also involved in resistance to apoptosis throughout other steps of metastasis and is considered to be important for tumour progression in general. Upon binding of Wnt to one of its receptors, β-catenin degradation in the cytoplasm is prevented. After β-catenin is stabilised it translocates to the nucleus where it co-regulates oncogene transcription and cell cycle progression and hence promotes survival and proliferation [14, 17, 46, 47, 53, 54].

In established metastases, the tumour cells are confronted with receptor-mediated cell death. Binding of Fas on the surface of metastatic cells to its Fas-ligand (FasL) expressed constitutively on lung tissue, activates the Fas-apoptosis pathway and leads to cell death. Cross-linkage of Fas with FasL on one cell results in apoptosis as well [36, 55]. Resistance to death-receptor-induced apoptosis is commonly seen and is highly important for the successful maintenance of metastases. The Fas/Fas-ligand pathway is a death receptor pathway that is often down-regulated in metastatic cell populations, rather than in primary tumours [23, 28, 36]. The Fas pathway is also of influence on chemotherapy-induced apoptosis and thus on its therapeutic efficacy [56]. Much (pre) clinical research has been performed concerning this pathway in metastatic OS and promising results have been obtained. These results are discussed following the section on immune evasion, since the Fas pathway plays a role in that as well.

Thus, apoptosis resistance is very much exploited by the metastatic cell and this feature is likely to contribute to resistance to therapy in metastatic OS [51, 52]. The failure to induce apoptosis upon treatment is thought to be the result of a misbalance between pro- and anti-apoptotic signalling. Restoration of this balance, thereby creating an environment in favour of pro-apoptotic signalling could theoretically enhance treatment with cytotoxic agents [9, 35, 45, 51, 5658].

(Pre)clinical studies: Wnt and Src

The Wnt-pathway is a putative therapeutic target because a majority of OS samples show aberrant activation of this pathway, leading to the transcription of oncogenes and cell cycle progression. This in turn leads to proliferation and enhanced survival [46, 53, 59]. When targeting the Wnt-pathway, activating mutations in downstream molecules for example β-catenin can be of negative influence as it may bypass Wnt inhibition and preserve the invasive phenotype of the metastatic cell [19]. A preclinical study by Leow et al. [52] has shown that inhibition of the Wnt/β-catenin pathway resulted in lower levels of nuclear β-catenin, resulting in a decreased expression of β-catenin target genes. This led to an inhibition of migratory potential through downregulation of MMP-9, and a decrease in expression of Cyclin-D, c-myc and Survivin. The latter was responsible for an anti-proliferative effect and an increase in cell death. These results were recently confirmed by Rubin et al. [46], who showed that re-expression of Wnt inhibitory factor 1 (WIF-1), a secreted Wnt-antagonist, inhibited Wnt signalling and reduced tumour growth and metastasis in OS mouse models. These results show a possible therapeutic benefit of Wnt-pathway disruption in the treatment of metastatic OS.

Src-kinase is a kinase that is involved in almost all steps of cancer metastasis, namely in proliferation, adhesion, migration, survival and angiogenesis [44]. Based on its multi-step involvement in metastasis, it could be an interesting therapeutic target in OS metastasis. Pre-clinical work shows that Src inhibition with Dasatinib effectively inhibits Src phosphorylation in primary tumours; however, it did not impair the development of pulmonary metastases. Histopathological analysis of both OS primary tumours and lung nodules showed minimal Src-kinase phosphorylation after treatment with Dasatinib. However, Src-kinase phosphorylation was low in untreated lung metastasis as well. This suggests that Dasatinib was effective in inhibiting Src-pathway activation in OS cells, but it is not clear what the phosphorylation status is during the stages of OS metastasis and how this influences the process [18]. The use of Dasatinib in patients with advanced (osteo)sarcomas was examined recently by the SARC (Sarcoma Alliance for Research through Collaboration) in a phase II clinical trial. Disappointingly, preliminary results show no treatment effect of Dasatinib as a single agent in patients with overt lung metastases [60]. The same group is looking into the effectiveness of Src inhibition with a more specific Src-kinase inhibitor (Saracatinib) to obtain progression free survival among patients with resectable OS lung metastases (clinicaltrials.gov/NCT00752206).

(III) Evasion of the immune system

Another important precondition for the survival of metastatic cells is the evasion of the host immune surveillance throughout all the steps of metastasis. Tumour cells, either circulating or at the site of metastases, can modulate the immune system of the host in order to achieve a survival advantage. Down-regulation of cell surface receptor HLA class 1 is one of such mechanisms. This impairs the recognition of tumour cells by the host cytotoxic T-lymphocytes. Tumour cells can also induce the production of immunosuppressive molecules such as IL-10 [14, 61]. Modulation of the immune system such that it recognizes and destroys (circulating) tumour cells would be a successful anti-metastatic treatment. Interferons are cytokines that can affect the recognition of tumour cells by the immune system by influencing the (re)expression of HLA molecules on the cell surface. Interferons also exert an anti-proliferative effect on OS cells through pathways that are yet unknown [61]. The balance between the intrinsic downregulation of HLA molecules of the tumour cells and the effect of Interferon stimulation will eventually determine whether the circulating tumour cell is cleared by the immune system or not.

Fas also plays a role in immune evasion. Fas expression leads to recognition by, and activation of cytotoxic natural killer (NK) cells and promotes elimination from the circulation by the host immune system. Successful down-regulation of the Fas molecule on the cell surface or corruption of downstream elements in the Fas pathway provides metastatic tumour cells with a survival advantage in the circulation and leads to an increase in metastatic potential. Patient samples from pulmonary OS metastases have been shown to be Fas-negative [40, 62]. Indeed, absence of Fas expression correlates with disease progression and poor survival outcome [23, 36, 55, 62].

(Pre)clinical studies: Fas

As the Fas receptor pathway is so important in the survival of metastatic cells, it is an attractive therapeutic target. Restoration of the Fas death pathway has been tried with success in preclinical models. Interleukin-12 (cytokine) therapy can achieve a dose-dependent upregulation of Fas on the surface of OS cells as well as a stimulation of cytotoxic T-cells and NK-cells. This renders the metastatic cells more sensitive to Fas-induced cell death in the microenvironment of the lung and enhances clearage of the cells from the circulation by the host immune system [36]. A drawback is the potent immunostimulatory effect of Interleukin-12 that can induce severe adverse effects after systemic administration in patients [56, 62].

In an in vivo experiment, intranasal administration of IL-12 resulted in Fas overexpression on OS lung metastases, leading to a decrease in tumour burden. Combination therapy with Ifosfamide, which induces the expression of FasL on the tumours, could further augment anti-tumour effect [28, 56].

IL-18 was reported to have similar effects on the activation of T-cells and NK-cells, as well as induction of the expression of FasL on already Fas expressing tumours. This compound did not, however, exert an anti-tumour effect in mice bearing OS lung metastases [63].

Gemcitabine is an agent that upregulates Fas-expression when administered as an aerosol therapy in mice bearing OS lung metastases. Gemcitabine aerosol therapy has been shown to effectively reduce size and number of pulmonary metastases [5, 55].

Liposomal MTP-PE (muramyl tripeptide phosphatidyl ethanolamine) is a promising agent for clinical use as it can induce endogenous IL-12 production and thus provide an up-regulation of Fas on OS cells but without the systemic toxicity encountered when exogenous IL-12 is administered to patients [28]. MTP-PE is a synthetic analogue of a component of bacterial cell walls. As an immunomodulatory agent it can also stimulate monocytes and macrophages to exert anti-tumour activity. The Children’s Oncology Group performed a prospective randomised phase III clinical trial with this compound in patients with high-grade conventional OS with metastases at diagnosis. Treatment with liposomal MTP-PE improved overall survival, irrespective of the chemotherapy regimen. These data are promising and suggest that there is a critical role for the Fas death pathway in chemotherapy response which can be exploited in clinical practice to enhance the efficacy of chemotherapy in OS [40, 64, 65].

(Pre)clinical studies: Immune modulation

Modulation of the immune system to exert anti-tumour activity by the addition of interferon-α (IFN-α) as a maintenance treatment after standard chemotherapeutic treatment is currently under investigation in the EURAMOS-1 trial, which is an initiative of the European and American Osteosarcoma Study Group [66]. IFN-α is immunomodulatory and able to stimulate a host-anti-tumour immune reaction and induce anti-proliferative signalling via the JAK/STAT1 pathway [58]. Accrual of patients for this worldwide trial is due to be completed in July 2011 [61, 66].

(IV) Arrest and extravasation

The mechanism of arrest of metastatic tumour cells at the distant organ sites remains controversial. One hypothesis is that metastatic cells are larger than ordinary cells in the circulation and that they become trapped in the microcirculation of a capillary bed. When trapped they form micro-embolisms and start interaction with the local environment. It is striking, however, that different tumour types have an organ specific preference for metastasis. The metastatic behaviour of OS is very distinct as over 80% of all metastases arise in the lungs and other organs usually remain unaffected. This suggests that the circulating tumour cell specifically ‘homes’ to distinct molecules that are expressed on the endothelium of the organ of preference. Although it might be trapped in different capillary beds throughout the body, it will interact with the surface molecules on the endothelium of the organ of interest rather than with endothelium at other sites [35]. There is evidence of endothelium-specific tropism in OS [10, 14, 15, 22, 42, 67]. The processes of exit of the circulation and invasion at the distant organ site are mediated by chemokines and proteinases. Proteinases are responsible for extravasation whereas chemokines determine the site at which circulating tumour cells adhere [9, 15]. Chemokines were initially thought to regulate leukocyte trafficking and homing, but recently they are also known as important components in the regulation of site-specific metastasis as they bind to G-protein coupled receptors on the plasma membrane of specific cells, in the case of OS to receptors in the lung [14, 42, 6769]. CXCR-4, a commonly expressed chemokine in OS, is involved in site-specific metastasis. Its sole ligand is CXCL12 which is expressed abundantly in the lung. Binding of CXCR-4 to CXCL12 allows adherence and extravasation of OS cells in the lung [9, 10, 14, 15, 22, 42, 69]. Laverdiere et al. [42] found that CXCR-4 expression levels in patient samples inversely correlated to event-free and overall survival. There was a positive correlation between CXCR-4 expression in primary tumours and the presence of metastases at initial diagnosis. Interestingly, expression levels of CXCR-4 were similar in primary tumours and lung metastases. This suggests that CXCR-4 expression is not regulated during metastasis, but is simply present. It could be of predictive value for the formation of metastasis.

CXCR-3, another chemokine, is expressed by OS as well as other malignancies. Its ligands are CXCL9, -10 and -11, all of which are expressed by lung, and this molecule is thought to co-operate with CXCR-4. Apart from mediating adherence, the interactions of CXCR-3 and -4 with their respective ligands also trigger pathways involved in other necessary events in metastasis, namely in invasion, survival and proliferation in the secondary tissue [10, 22, 67].

For example, hypoxia upregulates CXCR-3 and -4 expression, which in turn induce the expression of MMP-2 and -9 on the cell surface and modulate the microenvironment into an inflammation-like condition, abundant with growth factors and stimulation of angiogenesis. Furthermore, binding of CXCR-4 to CXCL12 can activate the NF-κB survival pathway via ERK (Extracellular-signal-Regulating-Kinase)-signalling and stimulate proliferation through MAPK signalling. Thus, apart from facilitating seeding at the distant organs site, chemokines play a very important role in the modulation of the microenvironment into a place permissive for the tumour cells to proliferate [9, 10, 15, 67].

(Pre)clinical studies: Chemokines

CXCR-4 is the most important chemokine-player in OS. Kim et al. [22] have demonstrated a reduction in metastatic tumour burden in an orthotopic mouse model in which cells were treated with a CXCR-4 inhibitor prior to injection of tumour cells into the mice. However, reduction of metastatic tumour burden without pre-treatment could not been shown consistently. The authors argue that the critical event, namely binding of CXCR-4 to CXCL12 with consecutive activation of signalling pathways, granting survival and proliferation, occurs too early in the establishment of metastases for inhibitory therapy of CXCR-4 to be beneficial for the patient with already existing metastasis. To what extent CXCR-4 inhibition could be beneficial in a preventive setting requires additional studies.

CXCR-3 inhibition was tested in an animal model for human OS lung metastases and showed a significant decrease in the development and progression of pulmonary lesions compared to the non-treated group [10].

(V) Adherence

Establishment at a distant organ requires the metastatic cell to connect to its new environment and re-establish cell–cell adhesions. Ezrin is a membrane-cytoskeleton linker protein that plays an important role in cell–microenvironment interaction. It is thought to facilitate anchorage of OS cells to lung tissue, as well as to enhance survival mechanisms in the new environment through Integrin mediated activation of Akt and MAPK survival pathways [14, 21, 25, 35]. The exact mechanism through which Ezrin mediates metastasis is not entirely clear, however, recently Wan et al. [70] discovered that β4-Integrin is an important mediator. β4-Integrin can bind Ezrin and Ezrin is required for the maintenance of this protein. β4-Integrin can activate the PI3K pathway and thus stimulate survival and proliferation in the newly arrived cells in the lung. β4-Integrin is found to be highly expressed in OS tumour samples from both primary and metastatic lesions. Furthermore, it was shown that β4-Integrin knockdown inhibits the formation of OS lung metastasis in vivo, and leads to prolonged survival.

High expression of Ezrin correlated with a higher risk of metastatic relapse and poor survival in OS patients [21, 25]. Furthermore, it was found to be 3-fold overexpressed in lung metastases in a murine model for OS lung metastases [38]. CD44 is another surface molecule that can form a complex with Ezrin and correlates with metastasis and poor prognosis. Apart from influence on the cytoskeleton and cell shape, CD44 controls proliferation, growth arrest and survival via the Akt/mTOR pathway [14, 19, 21].

(Pre)clinical studies: Ezrin

Suppression of Ezrin with a full-length anti-Ezrin construct did not inhibit primary tumour growth in a mouse model of OS, but it effectively inhibited the formation of metastases. It was speculated that metastatic OS cells express phosphorylated Ezrin only early after arrival in the lung, and this causes limited efficacy of suppression of Ezrin in readily established metastases, since its essential function in metastasis, namely connecting with the target organ site had already been fulfille [21]. Recently however, Ren et al. [25] suggested that Ezrin phosphorylation is not only present in the early stage of metastasis, but also late in tumour progression, at the leading edge of large metastasic lesions. This finding was verified on sections of patient OS metastases.

Pignochino et al. [45] reported that Sorafenib inhibited invasion via reduction in MMP-2 production and inhibited survival via downregulation of Ezrin-activated MAPK/Akt signalling. Furthermore, Sorafenib could also induce apoptosis in OS cells through downregulation of members of the anti-apoptotic Bcl-2 family. Wan et al. [70] showed that inhibition of Ezrin-related β4-Integrin can reduce metastasis in a mouse model. Taken together, targeting Ezrin seems promising in the management of OS lung metastases.

(VI) Dormancy

Dormancy refers to a prolonged period of survival of single cells or small micrometastases. OS patients can progress with metastases after a disease free interval of many years [71, 72]. This is likely explained by the presence of micrometastases in a dormant state, which at some point are triggered develop into gross metastases.

Little is known concerning the biological processes regulating dormancy in OS. The anti-apoptotic gene Bcl-XL is thought to be involved in the survival of dormant cells, as well as α5β1-Integrin mediated activation of NF-κB. Furthermore the dormant state is thought to be regulated by the ratio between the ERK and p38-MAPK proteins, also steered by Integrin-α5β1 signalling [14, 35, 73, 74].

The mechanisms by which dormant tumour cells are at one point triggered to start proliferating are yet unaccounted for, however, the microenvironment is thought to play a regulatory role. Tumour outgrowth is dependent on vascularisation, and it has been suggested that endothelial cells in the microenvironment can both activate dormant tumour cells through cell-to-cell signalling and induce angiogenesis for nutrition [74]. The ECM is also thought to be involved in activation of dormant cells, as it serves as a source of growth and survival signals. It has been postulated that micrometastases that fail to properly connect to the ECM remain in the dormant state because they remain deprived of growth- and angiogenic signalling and go into quiescence as a means to survive. Anchorage to the ECM would stimulate cells to convert to a proliferative state via β1-Integrin signalling [73]. The microenvironment can be regulated by the tumour cells themselves, but also by host stromal cells. Leucocytes and macrophages can modulate the ECM to either form a pro- or anti-angiogenic microenvironment. Apart from this, other mediating factors can also be influenced by stromal cells. For example, Wnt can be secreted from macrophages, and cytokines secreted by stromal cells can upregulate the intracellular Wnt/β-catenin signalling pathway and hence induce survival and proliferation in a late stage in the process of metastasis [9, 35, 54, 73]. Also, bone marrow derived progenitor cells (creating a ‘pre-metastatic niche’) can modulate the microenvironment and thus influence whether solitary cells or micrometastases remain dormant or are allowed to progress [68, 73]. In an effort to elucidate the cellular mechanisms that establish the switch of dormant to rapidly growing cells, Almog et al. [75] designed an in vivo model for dormancy of various cancers, including OS, and performed gene-expression analysis of cells in the dormant state versus cells in a proliferative state. They found that during dormancy, there is an upregulation of anti-angiogenic proteins. In this pre-angiogenic situation, the tumour cells would lack the nutrition and oxygen needed to proliferate. The cells that had switched to the proliferative phenotype had elevated RNA levels of common cancer pathways such as PI3K- and IGF-pathways. They also found that Endocan was upregulated in rapidly proliferating cells, a protein that is also expressed on tumour endothelial cells. This might indicate that endothelial changes support the switch of cells from dormancy into the proliferative state.

Dormancy could have a role in therapy resistance in OS metastases, however, whether this applies to OS and to what extent remains unknown. In general, dormancy can bring about drug resistance because non-proliferating cells are not so susceptible to conventional treatment. Most treatment modalities induce DNA damage which is usually more lethal to rapidly proliferating cells [14, 73, 76]. To intervene in this step of metastasis seems difficult. Angiogenesis seems to be an important factor. Elucidation of mechanisms that steer the switch from dormant to proliferative state may give some options. If it would be possible to keep the cells locked in the dormant state, it may grant the patient stable metastatic disease with prolonged survival.

(VII) Angiogenesis and proliferation

Tumour growth and progression is often restricted by vascularisation and thus nutrition. Hypoxia leads to the upregulation of growth factor receptors, angiogenic cytokines and proteolytic enzymes, among which EGFR, PDGF-R, VEGF, IGF-1R, TGF-β, IL-8 and MMPs, all of these providing neo-angiogenesis and allowing proliferation. These molecules can be overexpressed by the tumour cell population itself, but can also be provided by host endothelial (progenitor) cells during neo-angiogenesis [9, 14, 35, 40, 44, 68, 77]. Apart from induction of neo-angiogenesis, VEGF also provides the tumour cells with a survival benefit via activation of ERK-1/2/NF-κB and PI3K pathways [35].

Players involved in provision of vasculature and nourishment are often encountered in other processes within OS metastasis as well. For example, Src-kinase activity is regulated through various growth factor receptors, such as EGFR and Integrin receptors. Src activation leads to Ras/MAPK signalling and activation of the transcription factor STAT3, allowing cell cycle progression and production of angiogenic factors such as fibroblast growth factor, VEGF and IL-8. Src phosphorylation by EGFR especially is considered to stimulate the onset of hyper-proliferation of tumour cells and induction of vascular permeability and neovascularisation [18, 44].

Proliferation of OS cells at a distant organ site is often mediated by Receptor-Tyrosine-Kinase or Integrin induced activation of PI3K and ERK1/2 pathways [9, 35, 67]. Alterations in cell cycle regulation can also promote proliferation by facilitating progression through the cell cycle checkpoints and speeding up the cycle. For example, the Wnt/β-catenin pathway is of influence on both G1/S and G2/M progression via activation of Cyclin-D by c-myc and activation of Survivin respectively [46, 52].

The Insulin-Like-Growth-Factor 1 (IGF-1) Receptor axis is also implicated in the development of OS. It is striking that most OS arise during or shortly after puberty. The influence of GH and IGF-1 on bone growth steer the longitudinal growth during the adolescent growth spurt and contribute to approximately 50% of bone cell proliferation. As there is a peak incidence of OS during the adolescent growth spurt, it is conceivable that there could be GH/IGF-1 axis involvement in tumour development. IGF-1R signalling can activate the PI3K/Akt/mTOR pathway and stimulate survival and proliferation in tumour cells [40, 7779].

(Pre)clinical studies: Angiogenesis

As OS is a highly vascularised tumour, a rationale exists to use this feature as a therapeutic target. High serum-VEGF levels correlate with metastatic relapse, tumour progression, poor response to chemotherapy and a decrease in survival [40, 77, 80]. Endostatin is an endogenous angiogenesis inhibitor, produced by tumours itself, involved in repression of neo-angiogenesis and is commonly expressed in human OS samples. It can also induce apoptosis in endothelial cells. Given its important role in angiogenesis, it was hypothesised that Endostatin could impair OS tumour growth and metastasis [18, 77, 81, 82]. However, in a murine model of OS lung metastasis, Endostatin failed to induce tumour shrinkage in the lungs, although, it did retard growth of lung nodules. Treatment with this drug will not cure OS patients, but it may result in stable metastatic disease with prolonged survival [83].

(Pre)clinical studies: Proliferation

Pharmacologic inhibition of the GH/IGF-1 axis and thus IGF-1R pathways has been explored. However, whereas there is evidence that IGF-1R signalling is important to primary OS growth, the extent to which IGF-1R (inhibition) could regulate OS metastases is not clear. In 2002, Mansky et al. [78] performed a phase I study in OS patients with metastatic and/or recurrent disease testing the clinical efficacy of the Somatostatin analog OncoLar. OncoLar was shown to significantly reduce circulating IGF-1 in patients. However, all patients enrolled showed disease progression.

More recently, fully humanised monoclonal antibodies (mABs) directed against the IGF-1R were tested in preclinical and clinical setting. In vivo IGF-1R inhibition with monoclonal antibodies induced growth retardation in subcutaneous models of OS [79, 84]. Whether this growth delay will also be shown in OS metastasis is unknown. The SARC-011 clinical trial is evaluating the treatment effect of R1507, a mAB targeting the IGF-1R in patients with recurrent sarcomas, including OS (clinicaltrials.gov/NCT00642941). In another clinical trial the efficacy of SCH717454, also targeting the IGF-1R, is evaluated in relapsed OS patients. In this trial, both inoperable patients and patients in whom metastasectomy is feasible are included. The latter group will be treated pre- and post-metastasectomy and might, apart from tumour response rate, give information about progression-free survival (clinicaltrials.gov/NCT00617890).


Conclusion

In conclusion, this review summarises potential molecular alterations that contribute to metastasis in OS and gives an overview of (pre)clinical efforts to develop new therapeutic targets for the treatment of metastatic OS. In spite of these efforts, OS metastasis is not yet well understood and there has been little evolvement in the treatment of this disease over the last decade. We hypothesise that certain molecular alterations seen in metastatic cells can also contribute to resistance to chemotherapy, and targeting these features might enhance the efficacy of current treatments. Further unravelling the biology of OS metastasis will hopefully provide new insights to be used as a rational basis for innovative metastasis directed treatments for OS.

Acknowledgements

We would like to acknowledge prof. E.S. Kleinerman (M.D. Anderson Cancer Center, Houston, TX, USA) for her input and guidance in the preparation of this manuscript. JP is supported by the Individualised Musculoskeletal Regeneration and Reconstruction Network (Danish Research Council) Aarhus, Denmark and by VONK: VUmc Onderzoek naar Kinderkanker (Stichting Research Fonds Kindergeneeskunde VUmc) Amsterdam, the Netherlands.
Open Access

This article is distributed under the terms of the Creative Commons Attribution Noncommercial License which permits any noncommercial use, distribution, and reproduction in any medium, provided the original author(s) and source are credited.

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Wirral mum has been given three months to live if she doesn’t get life saving treatment abroad

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Posted 20 Oct 2011 — by James Street
Category Etiology and cause of osteosarcoma, Immune System, Metastases, Osteosarcoma

Oct 19 2011 by Linda Foo Guest, Birkenhead News

A WIRRAL mum has been given three months to live if she doesn’t get life saving treatment abroad.

For the past four years mum-of-two Susan Saul has been battling a rare form of bone cancer which was first diagnosed after she gave birth to her second daughter Estelle.

Susan, 39, has osteosarcoma, which eats away the bone.

The cancer started in her knee and spread to her femur but it has now spread to Sue’s pelvis, spine and rib.

Medics think the Pensby mum may have contracted it while pregnant.

Susan, mum to Seren, eight, and Estelle, four, told the News: “We do not know when it came, but it might have been from a trip when I was pregnant and I put immense pressure on my leg to stop myself from falling. I was in pain after that. Who knows, it could have been lying dormant?”

Sue needs £45,000 to receive life saving treatment in Germany or China. Friends and family have organised a series of fundraisers for the coming months, but so far they have raised £10,000 from a curry night, bike ride, and hairdressing event.

Husband Marcus said: “We have been busy researching and managed to uncover some solutions – this has gone from a position of no hope to some hope.

“There are two major treatments available in China or Germany and the doctors are very optimistic which is good.

“In Germany they can give her chemotherapy emovolisation, but the main hope is in adoptive immunisation which enhances your immune system.

“In China they use the adoptive immunisation method or gene therapy which gives cancer patients a severe fever and kicks starts the system. It is very cutting edge.

“The NHS have been brilliant, they have all been amazing and have said they will speak to doctors abroad about Sue’s condition.

“It is very humbling what the community have done, we are bowled over with everyone’s support.”

SAVE Our Sue fundraising events organised for the coming months include a music night at the Casa Bar on Hope Street, Liverpool city centre on October 29 from 7pm. Tickets cost £7 and can be purchased from Ian Carroll on             07824 359201      .

Scientists Claim Differentiated Cancer Cells Can Convert to Stem-Like Cells to Maintain Equilibrium

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Posted 19 Aug 2011 — by James Street
Category Metastases, metastases, Stem Cell Research, Understanding Cancer

GEN News Highlights: Aug 18, 2011

Cells in individual tumors can interconvert into different cell types including reverting into cancer stem cells in order to maintain equilibria in terms of the proportion of cells existing in different states within the cancer, researchers claim.They found that rather than existing as a hierarchical society in which all cells are derived from cancer stem cells, cancers exist as a decentralized society of different cell types that can sense when one type of cell has been depleted and generate new cells of the relevant type to take their place.

The group included scientists at the Massachusetts of Institute of Technology Broad Institute, Tufts University, and Harvard Medical School. Details are published in Cell in a paper titled “Stochastic State Transitions Give Rise to Phenotypic Equilibrium in Populations of Cancer Cells.” Results could have significant implications for cancer cell therapy, claim lead researchers Eric S. Lander, Ph.D., and Piyush B. Gupta, Ph.D., because removing cancer stem cells will just prompt other cell types in the tumor to convert into stem cells to top up the population.
One of the puzzling features of cancer cell populations is their ability to retain phenotypic equilibrium over extended periods of time, the team writes. Populations of cancer cells often harbor subpopulations with specific cell-surface marker profiles, which are stably maintained across many cell divisions in culture.

To investigate the basis of this equilibrium-maintaining phenomenon further, the researchers isolated and separately cultured three cell types—stem-like, basal, and luminal—from two different human breast cancer lines derived from primary tumors. Each of the three cell types was confirmed to display specific morphological and cell surface marker characteristics.

These relatively pure subpopulations of cells, which each represented a given differentiation state, were then allowed to expand in culture, and  relevant population dynamics monitored over time. Surprising, the researchers found that when they assessed the relative proportions of stem-like, basal, and luminal cells in each originally ‘pure’ population after expansion, there had been an evident rapid progression back to equilibrium proportions.

Two lines of evidence indicated that this progression was due to interconversion between states, rather than as a result of differential growth rates of cells in the basal, stem-like, or luminal states, they claim. Firstly, there was no difference in the proliferation rates of the stem-like, basal, or luminal subpopulations sorted from either of the two stem cell lines: they all replicated at about the same rate.

Secondly, given the purity of the original sorted populations and the rapid rate of return to equilibrium proportions, some minority subpopulations would need to have been dividing at more than three times per day to achieve the observed proportions through differential growth rate alone. “Such a high proliferation rate is implausible because even the most rapidly dividing human cells— embryonic stem cells—require at least 24 hours to complete a proliferation cycle,” they claim.

Based on the notion that interconversion between cell states was therefore occurring, the team used data from their expanded breast cancer cell populations to developed a Markov model, in which the cell type transition probabilities depend only on a cell’s current state, not on its prior state. The inferred Markov transition probabilities thus make it possible to quantitatively predict how a population of cells evolves over time, given the initial proportions of cells in different states.

The resulting model made several predictions about how the cell populations would develop, and these were confirmed in the cultured breast cancer populations, the researchers note. However, a number of unexpected predictions also emerged. One of these was that basal and luminal cells can transition back into a stem-like state: “that is, cancer stem-like cells can arise from non-stem-like cells.” This essentially contradicts current concepts relating to normal tissues, which assume a rigid lineage-hierarchy in which stem cells can give rise to nonstem cells, but not vice versa, they write.

They tested this particular prediction by implanting either freshly sorted, or sorted and then cultured subpopulations of tumor cells in mice. As expected according to traditional dogma, only the stem-like fraction could efficiently seed tumors, and neither the luminal nor basal fraction was capable of doing so.

However, because the lack of tumor-seeding ability displayed by the basal and luminals could have been due to their inability to survive after transplantation, the researchers repeated the exercise by co-inoculating the cells with GFP-labeled, irradiated parental carrier cells from one of the breast cancer lines. Under these conditions, all three fractions (stem-like, basal, and luminal) were equally capable of efficiently seeding tumors.

Moreover, examination of the tumors arising from basal and luminal subpopulations mixed with irradiated carrier cells revealed the presence of significant numbers of stem-like cells. The proportions of basal, stem-like, and luminal cells contained in the resulting tumors were comparable irrespective of the sorted subpopulation initially used to seed the tumor.

“Collectively, these results demonstrated that the luminal and basal fractions can indeed regenerate functional stem-like cells in vivo and suggested that convergence toward equilibrium cell-state proportions could be occurring due to cell-state interconversion within tumors,” the authors write. “A specific prediction of this quantitative model is that any subpopulation of cancer cells will return to a fixed equilibrium of cell-state proportions over time, provided that it is possible through one or more interconversions to transition between any two states.”

The de novo generation of cancer stem cells has implications for the effectiveness of anticancer therapies focused on killing this cell type, because of the ability of other cancer cell types to regenerate cancer stem cells after cessation of therapy and lead to renewed tumor growth, they add. “Therefore, in order to be effective, cancer therapies will need to combine agents that are selectively toxic to cancer stem cells with agents that either target the bulk noncancer stem cell populations within tumors or inhibit transitions from noncancer stem cell to cancer stem cell states.”

The team claims their model could also be extended to other biological settings in which stochastic state transitions occur, either in normal or diseased contexts.

Model for in vivo progression of tumors based on co-evolving cell population and vasculature

Scientific Reports
1,
Article number:
31
doi:10.1038/srep00031
Received
Accepted
Published

With countless biological details emerging from cancer experiments, there is a growing need for minimal mathematical models which simultaneously advance our understanding of single tumors and metastasis, provide patient-personalized predictions, whilst avoiding excessive hard-to-measure input parameters which complicate simulation, analysis and interpretation. Here we present a model built around a co-evolving resource network and cell population, yielding good agreement with primary tumors in a murine mammary cell line EMT6-HER2 model in BALB/c mice and with clinical metastasis data. Seeding data about the tumor and its vasculature from in vivo images, our model predicts corridors of future tumor growth behavior and intervention response. A scaling relation enables the estimation of a tumor’s most likely evolution and pinpoints specific target sites to control growth. Our findings suggest that the clinically separate phenomena of individual tumor growth and metastasis can be viewed as mathematical copies of each other differentiated only by network structure.

Figures at a glance

Introduction

A multitude of biological processes ranging from genetic and epigenetic mutations, DNA damage, to complex intra- and intercellular signaling dynamics undoubtedly play key roles in triggering cancer in a given patient1, 2, 3, 4, 5, 6. However, for many of these biological processes the various detailed biochemical reactions that take place are unknown. Similarly, the exact interplay between processes can also be ambiguous. Rather, it is the qualitative effect of varying a particular reactant or altering the environmental conditions in a systematic fashion that we observe, without necessarily understanding all of the underlying processes involved. For example, once formed, tumors seem to evolve in a fairly generic way: They either lie dormant, or grow, fed by the underlying network vasculature, capable of generating new vessels via angiogenesis when needed7. Generally, an absence of nutrients will tend to reduce growth, while sufficient supply leads to a progression in tumor cell behavior from differentiation and proliferation to migration7. Metastasis of cancer to lymph nodes and other organs, thought to be the most lethal aspect of the disease, likewise may depend on myriad patient-specific factors concerning the lymphatic system, immune response, micro-environmental factors and general patient health8. However, once again, the actual process is fairly generic – involving the spread of cancer cells from the primary tumor through the lymphatic and circulatory systems. Most fundamentally, at the heart of all these processes is the essential interplay between an evolving population of cancer cells which is fed by – and feeds back on – an underlying blood vessel network structure which supplies nutrients to the tumor and tissue, but simultaneously provides a transport network through which cancer cells can metastasize to other parts of the body and drugs are delivered to the tumor. Yet, the blood vessel structure is typically highly irregular in tumors, and further complicated by the highly dynamic structural growth and degradation interplay with the evolving tumor mass, making an averaged description for modeling purposes insufficient. These factors clearly emphasize the importance of incorporating relevant network structures not only for tumor progression prognosis, but also for the analysis of effective treatments. For these reasons, to model the progression of tumor growth behavior it may be more productive and informative to implement universally observed, and biologically derived, qualitative behavior in the model dynamics. Such qualitative mechanisms have proved to be useful in building models which correlate well with experimental findings, deepening our understanding of the basic underlying processes and making practical predictions possible9.

Early tumor models often resembled a theoretical exercise, looking at averaged behavior whilst neglecting the importance of environmental heterogeneities at various length-scales – or were computationally too expensive due to the ambitiously detailed nature of the model setup and sheer number of cells necessary to investigate long term behavior9, 10, 11. All models by design are simplifications and approximations based on assumptions of the true biological system. Cancer models, regardless of mathematical rigor and modeling complexity, are typically criticized as too simplistic for complex tumor-related phenomena9. However, promisingly, a rapidly growing number of models have seen a close symbiotic collaboration between theoreticians, biologists, oncologists and clinicians, which has lead to novel predictions emerging from the model results, which were subsequently experimentally verified9, 10, 11, 12, 13, 14, 15, 16.

We believe that the greatest shortcoming is the current lack of implementation of clinical images into models as initial conditions for patient specific prognosis9, 10, 11, 12, 13, 14, 15, 16. Most are seeded with artificial initial conditions of cancer size, shape and density, as well as environmental parameters, struggling to combine the model with data gathered from clinical images17, 18, 19. Great advances in imaging techniques have enabled more and more accurate visualization of the problem zone, allowing for a wide range in length scales, and time resolution, particularly at the molecular level. However, these have not been successfully implemented into tissue level cancer modeling mainly due to multi-scale compatibility issues. Indeed, the majority of models are inflexible to even the simplest extensions, modifications or re-scaling. A direct one-to-one mapping of all cells is unfeasible20, 21, 22, 23, 24, 25, 26, 27, 28, 29, whilst modeling the global spatially-averaged behavior fails to describe important cellular and environmental heterogeneities in the system which may be particularly important during early tumor growth12, 30, 31, 32, 33, 34, 35, 36, 37, 38, 39.

Here we present a simple multi-scale model which addresses two fundamental issues. First, the uncertainties in the details of the biological processes are accounted for by describing behavior in local regions by a well established averaged behavior growth equation, whilst preserving the heterogeneities in each region; second, the ability to take advantage of invaluable data gathered from patient images, to be used as seed for the model for comparison and further development, taking an appropriately coarse-grained length scale for the model to adapt to the image resolution. We realize that many more details could be included in a model of primary cancer growth or metastasis. Many models and methodologies exist, ranging in length and time scale, capturing the biology of intra and intercellular signaling up to tissue level dynamics, each successfully mimicking some part of the complex emerging phenomena such as tumor growth, angiogenesis and metastasis. Yet each also comes with limitations. The primary purpose of the presented model is a complementary one to existing models, seeing how far one can go in explaining a wide range of clinical data using a simplified and minimal, adaptive and multi-scalable, yet most crucially, data driven approach to understand and predict a patient’s highly personalized tumor progression from early growth through to metastasis and even treatment strategy analysis using a single model.

Our model seeded with in vivo data predicts robust growth corridors of future tumor growth behavior in good agreement with a murine mammary cell line EMT6-HER2 model in BALB/c mice, as well as reproducing clinical human patient data of metastasis. Moreover, the model predicts a hidden scaling relation between the underlying nutrient supplying vessel structure and cancer co-evolution, a finding which estimates a tumor’s most likely evolution, and more importantly, pinpoints specific vessel target sites to optimally control tumor growth.

Results

In vivo data implementation in mathematical model

A mathematical model was developed to purposefully seed up-to-date patient information for a personalized prognosis, and to bridge the gap between the length scale extremes of current mathematical modeling efforts (see Methods section for model description). A minimal-mechanism of a co-evolving nutrient network and cancer population is applied to the growth of a single tumor. Key to the individualized prognosis is the implementation of in vivo images as initial conditions. Later in the paper, we show how exactly the same multi-scale mathematical model can be applied at the level of systemic metastasis simply by making a change in the biological interpretation of its network features.

Figure 1 illustrates the methodology of extracting and coarse-graining information from immunofluorescent stained in vivo images whilst preserving the heterogeneity of initial vessel density, and hence nutrient supply, of a tumor. The cellular activity inside local regions, created by the boxes of the imposed grid, is described by the biologically ubiquitous discrete logistic map, which is a good approximation of the universally observed Gompertzian growth behavior of cancer40, which preserves the biological importance of the unit cell, and accounts for the local cell-cell and cell-microenvironment interactions41, 42, 43. From a mathematical modeling point of view, previous applications of the logistic equation to cancer either apply the logistic equation to the entire tumor44 or form a continuous time spatial diffusion equation which allows the unrealistic transfer of arbitrarily small amounts of cancer across space. The presented application is novel since the discretization into smaller regions, forming a grid of coupled autonomous logistic equations, allows universal growth behavior in each region to be applied using appropriate growth rates extracted from an image (regional vessel density), whilst coupling allows inter-regional diffusion, migration and communication. Our model specifically accounts for the fact that cancer consists physically of discrete units (cells) and hence there is a lower bound below which a continuous formulation of cell density becomes incorrect, yet above which the changing size and mass of cells deems a continuous description valid.

Figure 1: Model setup.
Model setup.

Schematic of implementing in vivo immunofluorescent image data into the mathematical model as initial condition. The right half illustrates the step-by-step procedure of extracting and coarse graining information from the in vivo images. The tumor growth behavior in each box is modeled as Logistic growth, and the model equations capture the fundamental interplay between an evolving population of cancer cells which is fed by – and feeds back on – an underlying nutrient network, and its spreading through transport processes. The blue inset shows the time ordering of events at each time step of the mathematical model.

Experimental in vivo growth data fitting to model

To test the agreement of the model results to in vivo growth data, the model was seeded with in vivo images of muscle vasculature from the flanks of untreated BALB/c mice as initial condition, representing potential regions of primary tumor growth (implantation zone in mouse model). Figure 2 shows a growth corridor (blue shaded area) predicted from our model. The corridor is formed by the blue dashed line, which is the average growth curve of 2000 model simulations, where the tumor seed was virtually implanted at different locations on the image for each run, and the solid blue lines are the standard deviation. Hence, Fig. 2 predicts the most likely growth behavior if a cancer were to originate somewhere in the environment depicted by the image. Assuming BALB/c mice generally have similar initial conditions (image in Fig. 2), the flanks of 5 mice were implanted with murine mammary cell line EMT6-HER2, whose growth data (dark blue points) fall inside the growth corridor with good agreement. Similar analysis was repeated with many more images of various other regions of the flanks in BALB/c mice confirming robust behavior in the predicted growth corridors.

Figure 2: Model substantiation.
Model substantiation.

Fit of in vivo experimental growth data to a growth corridor determined by the model seeded with an image of initial muscle vascular structure in BALB/c mice. The growth corridor (shaded region) is formed by the average growth curve of virtual tumor implantations (blue dashed line), and standard deviation (solid blue lines), showing good agreement with growth data. The yellow circle and box are representative regions with fast and slow growth curves respectively. The three insets show sample growth patterns of the virtual tumor with (a) necrotic core and proliferating ring46 (b) diffusive growth in nutrient rich environments47 (c) multiple source growth. The purple data points show growth data of EMT6-HER2 tumors treated with an endostatin-antibody fusion protein, and the dashed purple line model results, where we mimicked the decreasing effect of the protein on the vasculature. The model used the same number of injections and time interval as in the in vivo experiments.

The yellow circle and box in Fig. 2 are representative regions with fast and slow growth curves respectively. The three insets Fig. 2a–2c show sample growth patterns of the virtual tumor. Interestingly, the distance between high density vessel sources is of vital importance (as analyzed Fig. 3). In the absence of angiogenesis, should the maximum radius, l, to which a tumor can grow from a single source be smaller than the distance to the next vessel, d, then the tumor will remain a finite size, and eventually starve and die, as shown in Fig. 2b. However, if l > d, Fig. 2c depicts how a neighboring source can facilitate continued growth.

Figure 3: Growth behavior in finite source environments.
Growth behavior in finite source environments.

Finite number of sources may be due to anti-angiogenic treatment. For example, (a) is an immunofluorescent image of short, scattered vessels inside an EMT6-HER2 tumor treated with an endostatin-antibody fusion protein, (b) is the coarse-grained result for model implementation, and (c) shows the remaining sources if a threshold is applied. Model results suggest that small clusters of cancer cells remaining around vessels can lead to more aggressive re-growth (inset of (c)). (d) – (g) illustrate the collapse of data points onto a linear relationship by accounting for appropriate average distance between sources and final radius of tumor (see inset illustrations). The distance between sources is calculated of (d) all sources when maximally distributed, (e) all sources in the system at actual position, (f) sources inside the tumor (g) sources inside the tumor yet neglecting the sources on the perimeter of the tumor where the tumor cell density is too small to result in growth.

Systematic treatment strategy analysis

Also, we briefly illustrate the efficacy of the model to systematically analyze all possible treatment strategies (dosage, interval, frequency of which drug/treatment combination), to predict personalized treatment effectiveness. The dashed purple line in Fig. 2 shows that our model’s predictions of treatment are also consistent with in vivo experiments. Results are shown for BALB/c mice implanted with cell line EMT6-HER2, and subsequently injected with αHER2-huEndo fusion proteins45 which is an endostatin-antibody fusion protein specifically engineered to target the HER2 receptor and limit the growth of adjacent blood vessels through the action of a fused anti-angiogenic endostatin domain. By measuring the biological effect of a single injection of the endostatin-antibody fusion protein on the tumor, the model subsequently simulated the same number of injections and same time interval as in the in vivo experiments with good agreement. A systematic analysis of all possible treatment strategies of varying dosage, frequency, and schedule will be presented elsewhere.

Universal growth behavior scaling from vessel location

Given the dynamic interplay of the growing tumor with the underlying vessel structure, Fig. 3 analyses the growth behavior in finite source environments (Fig. 3a–3c), where the distance between vessels, alluded to in Fig. 2a–2c, becomes important to the tumor’s progression. For example, Fig. 3a shows an immunofluorescent image of vessels inside an EMT6-HER2 tumor that has been treated with an endostatin-antibody fusion protein45 resulting in a finite number of short, small-clustered and scattered vessels. Model results suggest that in cases where small clusters of cancer cells survive around remaining vessels (even after anti-angiogenic treatment) islands of re-growth can occur, as shown in the inset of Fig. 3c, leading to a more aggressive re-growth rate than before treatment. The heterogeneous nature of remaining vessel locations not only presents the problem of indefinite re-growth of cancer by movement beyond the finite radius each vessel can sustain individually, but also the additional challenge of optimizing and analyzing drug delivery strategies for efficacy and efficiency. Specifically, the vasculature in a tumor is highly irregular in structure creating regions completely void of vessels and regions densely packed with vessels. This implies that drug delivery will be highly disproportional not reaching all areas of the tumor48. Even with the advent of a genetically targeted approach where a drug is specifically designed for a patient, there still exists a need for delivery analysis locally in primary tumors as well as globally via metastatic spread. Our model is ideally suited to systematically analyze the effect of vascular structure on delivery, in addition to the countless possible multiple drug therapies48, to help optimize experimental design by taking into account the heterogeneities of the system which usually cause variation and hence unpredictability.

Much like forest fires49 or nutrient source manipulation in conservation corridor analysis50, the distance between vessel sources is key in determining the most likely progression of a tumor. Hence, in Fig. 3, we identify a measure based on the distance between sources to predict its evolution, and hence identify the key targets which allow control and limitation of the final tumor growth size. The results of Fig. 3g show that as long as the initial vasculature heterogeneity can be quantified, the diversity in final tumor size disappears under an universal scaling. The initial vasculature structure can be used to assess where a particular patient’s tumor sits on this scaled curve thereby providing a prediction of its final size.

Figures 3d–3g show the same data using different measures of average distance between sources and each dot is one realization of the model simulations. Central to the universal scaling of Fig. 3g is identifying which sources to include, as illustrated in the insets of Figs. 3d–3g. In Fig. 3d, we calculated the average distance between all sources, where the sources were assumed to be maximally separated, and plotted against the final radius of the tumor, rmax. Figure 3e calculates the average distance between all sources using the actual position of the sources within the system. Yet, as argued in Fig. 2a–2c sources only become significant if their distance is smaller than the potential radius of the growing tumor. Hence, in Fig. 3f, only the distances between sources on or inside the final tumor boundary were included. This resulted in the clusters of points below the red line of Fig. 3e to be pushed closer to the red line, as indicated by the blue arrow. Finally, the scatter below the red line of Fig. 3f can be explained by circumstances where the growing tumor does reach another source, yet the cancer cell density pushed into them is below a critical threshold, too little to result in cell proliferation. Hence, eliminating such cases resulted in the final plot Fig. 3g.

The results of Fig. 3 illustrate the important possibility of systematically targeting specific vessels. For example, in Fig 3c, say a cancer seed originating from the three sources in the centre is predicted to result in a final tumor radius depicted by the red circle determined from Fig. 3f. Inside the radius is a fourth source, highlighted by the green arrow in Fig. 3c, which would facilitate further growth to a new radius. Hence, one could minimally target the single source (green arrow) to prevent further growth, rather than taking more invasive measure, and thus, perhaps preserve functionality of the affected system. This analysis has a powerful consequence, in that, it gives the surgeon an exact size of tumor to remove, or which vessel sources to block in order to control the final size of the tumor.

Multi-scalability of local model to predict global metastasis data

Finally, we explore the extendibility and multi-scalability of the model to the global phenomenon of metastasis. Metastasis is usually treated as an entirely separate topic in modeling since the underlying biology is different. However, as illustrated in Fig. 4, we successfully apply the same model equations to both single tumors and metastasis, simply by changing the interpretation of the terms: Instead of the cancer cell diffusion to neighboring boxes on a regular lattice representing free space for growth, the boxes represent lymph nodes and the underlying inter-box connections the lymphatic system. As shown in the lower panel of Fig. 4, the growth within each box is now a macro-level version of the single tumor model in which we use the logistic growth map to apply to the entire space in which a tumor may grow. In other words, we simply apply our exact same mathematical equations (Eqns. (1)–(3) in Methods) on a different scale, and with a different network for diffusion (Fig. 4). As discussed in Ref. (8), cancer cells can spread to other organs at every time step from the beginning of the primary tumor’s growth.

Figure 4: Model implementation and results of metastasis.
Model implementation and results of metastasis.

Metastasis uses the same model as for single tumor growth. The upper panel shows average cumulative distribution plotted for different underlying networks: random (blue solid) and scale-free (orange solid). The clinical data (red circles) lies somewhere between the two types of networks suggesting that the precise network structure does not matter to make a first-order prediction. The red dashed line is a fit to the clinical data by varying the r distribution51. Finally, the green dashed line shows the Poisson complementary cumulative distribution function with mean equal to the mean number of affected sites from the clinical data. It is the expected curve based on the assumption that nodes get infected independently (i.e. random), and illustrates that the empirical and theory are fat-tailed compared to purely random. The lower panel shows a schematic of the similarities of single tumor growth and metastasis using the same model.

Interestingly, as shown in Fig. 4, the results do not depend sensitively on the choice of network – as long as it is irregular (e.g. random or scale-free). The upper panel shows metastasis on different underlying networks: random (blue solid) and scale-free (orange solid). Clearly, the clinical data (red circles) lies somewhere between the two types of networks. Generally, diffusion on networks is reasonably insensitive to the network structure as long as the distribution of links is fairly broad, and the distance over which the diffusion takes place is short. In other words, the cancer does not spread far enough into the network to feel the difference between a random network and scale-free network – at least, to first order. This implies that knowledge of people’s precise lymphatic network details are not required in order to make a first-order prediction of the probability that n nodes will be positive. The red dashed line in Fig. 4 is a fit to the clinical data53. The green dashed line shows the Poisson complementary cumulative distribution function with mean equal to the mean number of affected sites from the clinical data, which demonstrates that the empirical data and theory are fat-tailed compared to purely random.

Discussion

The ever increasing number of discoveries about the biological processes underlying tumor progression, set against the many aspects which still remain unknown or ambiguous, has led to the creation of many extremely complex mathematical descriptions (perhaps motivated by the desire to include as many biological details as possible) which are computationally intensive and include many unknown parameters. These models can be generally categorized into two extremes: The molecular level, trying to understand the intra and intercellular signaling dynamics of individual or small clusters of cells, and the tissue level, modeling the emergence of phenomena such as angiogenesis and metastasis. Yet, the molecular models are difficult to scale up to enough cells to comprise a full organ, whilst the tissue level models often lack the heterogeneities vital to an accurate, and personalized, prediction.

In this paper, we presented a model which aims to bridge this gap, and provide a practical, multi-scale model capable to be seeded with in vivo images to predict the most likely tumor growth behavior through prediction corridors, as well as subsequent spreading behavior of metastasis. For both length scales, the model results show good agreement to in vivo growth data of a cell line EMT6-HER2 model in BALB/c mice, as well as clinical human patient data of metastasis. Furthermore, we outline the use of the model for systematic treatment analysis, focusing on the effect of vascular structure on drug delivery. A novel scaling relationship between the tumor and the underlying nutrient sources not only predicts the most likely progression of the tumor, but also identifies key vessel target sites to optimally control tumor growth.

Despite its quantitative accuracy and simplicity, our model’s neglect of the wealth of known biological details associated with cell biology and physiology, may attract criticism of our minimal-model approach as resembling the ‘Consider a spherical cow…’ cliché typically levied at physicists. However, the existing gap between model sophistication and clinical need demands the exploration of such an approach in our opinion. The unique coupling of image data with the mathematical model allows information about the heterogeneity of the system to be preserved, and more importantly, be utilized for individualized prognosis. Hence, the model cancer growth is directly driven by in vivo information and demonstrates a new approach to modeling cancer growth using patient specific data, showing good agreement at multiple length scales for a variety of phenomena. As such it complements existing theoretical approaches rather than replacing them, and can be integrated with them in the future.

Methods

Mathematical model

The blue inset of Fig.1 shows the time ordering of events at each time step of the mathematical model, and corresponds to two coupled, discrete equations applied within each box of the grid. The first equation is:

where and are the cancer concentrations at the beginning and end of time interval Δt. The tumor growth rate, ri,n, at time step n in box i is assumed to be directly proportional to the vessel density in box i extracted from the image. As described below (see Image information extraction), the initial cancer, , and endothelial cell densities, ri,n = 0, are extracted from in vivo images stained for both types of cells at time t = 0.

At this stage only vessel density is considered as the primary driving force of growth rate. Nutrients determine individual cell behavior and thus population response. Yet, rather than applying a single r as was done in previous models44, we split the system for maximal heterogeneity, making the model highly non-deterministic.

Furthermore, the model equations capture the tendency of any overcrowding of cancer cells to crush the vasculature or cause it to regress, leading to lower nutrient supply52 and thus slower growth. Hence, the equation for vessel density (i.e. cancer growth rate) is given by:

Following our methodology of implementing a coarse grained view of an universally observed growth behavior, the single parameter α incorporates all details which may contribute to the vessel density such as vessel stabilizing and/or destabilizing factors, (anti) angiogenic growth factors, as well as any therapeutic agents. This may be crude and biologically unsatisfying, yet due to its observation driven nature, in short, this setup captures the co-evolving, dynamic, feedback-driven interplay between cancer and the underlying nutrient network52.

Finally, cancer cell mobility to neighboring boxes is modeled via simple diffusion:

where again, similar to α, β represents all properties of the environment, which could influence the ease of cancer cell diffusion53, as well as other local gradients such as chemotaxis and haptotaxis. More specifically, α is some function of growth promotion (negative α) and inhibition (positive α) factors which influence angiogenesis and nutrient deprivation conditions via the adaptive and feedback-driven value of ri,n at all time steps. Despite a long list of possible influences, we expect as a first approximation that the values of α and β will take on similar values for patients from similar risk groups. In the future, we will make α and β functions of specific factors, making the model more biologically accurate and hence more patient specific. For example as a first proof-of-principle, we show in Fig. 2 that the effect of an anti-angiogenic endostatin-antibody fusion protein which breaks down the vessel structure and halts angiogenesis (as verified by in vivo images), can be successfully mimicked by reflecting the fusion proteins destructive effect on the vessels by means of a positive value of α in the model.

Image information extraction

Without loss of information the image colors are converted to grayscale for easier manipulation. A grid is imposed, where each box size of the grid is chosen to correspond to approximately 100 cells. The box size can be adapted according to the system and type of image. Finally, the individual pixel values contained in each grid are added and averaged, to represent the average vessel density in each box. These values then provide the initial condition for the tumor’s evolution, making the model as patient-specific as desired. This procedure can be repeated for any property of interest.

In vivo imaging procedure

In vivo immunofluorescent images of the muscle vascular structure in the flanks of BALB/c mice were taken prior to implantation s.c. contra-laterally of murine mammary tumor cell line EMT6-HER2 (1×106 cells per mouse). Two mice were sacrificed for blood vessel analysis. Histologic sections of muscle from the sacrificed mice were analyzed using immunofluorescent staining for DAPI (red color; example image has 10× magnification).

Growth corridor analysis

We only seeded blood vessel structure for Fig. 2 since an analysis was done prior to implantation of the tumor seed. Hence, we virtually implanted a tumor in the mathematical model, recorded the resulting growth curve, and repeated this procedure 2000 times (corresponding to approximately a 10% sample size), each time using a different location. Furthermore, this procedure was repeated with images from various locations in the flanks of the BALB/c mice. Similar initial conditions can be seeded into the model concerning the size and location of an already growing tumor. Immunofluorescent images can be taken of the growing tumor, and hence, a similar procedure can be performed. The chosen parameter values for the presented results are at this stage arbitrary, yet our general findings are robust to variations in α and β. A table of parameter values for various cell line types will be presented elsewhere.

Endostatin-antibody fusion protein treatment

BALB/c mice (n = 4 per group) were implanted s.c. contralaterally with EMT6 and EMT6-HER2 (1×106 cells per mouse), followed on day 4 by equimolar injections every other day (7 time treatments) of αHER2-huEndo-P125A (42 μg), or PBS. On day 12, two mice were sacrificed for the blood vessel analysis after four treatments. We analyzed histologic sections of tumors from the sacrificed mice using immunofluorescent staining for PECAM (vessels) and DAPI for counter-staining of the nucleus. Although still a preliminary result, the dashed purple line in Fig. 2 is an average of 1000 model results where we mimicked the inhibitory effect of the protein on the vasculature formation.

Metastasis network analysis

For each of the 100 sites (or nodes), we drew ri from a normal distribution N(µ = 1, σ = 0.2) and took α, β for non-primary tumor sites to be β = 0.8, α = 0.2. Furthermore, for each trial we seeded the tumor at a randomly picked primary site with C0 = 0.5, and β‘ = 0.6, α‘ = 0.4. The average cumulative distribution of 3000 trials is plotted for both types of networks, where a new network was generated for each trial. The clinical data was fitted by varying the r distribution; in this case a skewed distribution with peak close to r = 0.01. However, the same fit can be achieved by starting from a random network and simply adding more and more links, slowly tending towards a scale-free network.

Author information

Affiliations

  1. Division of Theoretical Bioinformatics (B080), German Cancer Research Center (DKFZ), Im Neuenheimer Feld 580, 69120 Heidelberg, Germany

    • Sehyo C. Choe
  2. Department of Bioinformatics and Functional Genomics, Institute of Pharmacy and Molecular Biotechnology (IPMB) and Bioquant, Heidelberg University, Im Neuenheimer Feld 267, 69120 Heidelberg, Germany

    • Sehyo C. Choe
  3. Department of Physics, University of Miami, 1320 Campo Sano Ave., Coral Gables, Florida 33146, USA

    • Guannan Zhao,
    • Zhenyuan Zhao &
    • Neil F. Johnson
  4. Sylvester Comprehensive Cancer Center, University of Miami, 1475 NW 12th Ave., Florida 33136, USA

    • Joseph D. Rosenblatt,
    • Hyun-Mi Cho &
    • Seung-Uon Shin
  5. Division of Hematology/Oncology, University of Miami Miller School of Medicine, NW 12th Ave., Florida 33136, USA

    • Joseph D. Rosenblatt,
    • Hyun-Mi Cho &
    • Seung-Uon Shin

Contributions

S.C.C., N.F.J. and G.Z. worked on the data and data analysis. S.C.C. and N.F.J. worked on the model development. All authors participated in the write up and associated discussions, giving detailed feedback in all areas of the project.

Competing financial interests

The authors declare no competing financial interests.

Corresponding author

Correspondence to:

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