Carcinocythemia as the single extension of breast cancer: report of a case and review of the literature

Liquid Biopsy in Breast Cancer: Circulating Tumor Cells and Circulating Tumor DNA

Cancer is associated with gene mutations, and the analysis of tumor-associated mutations is increasingly used for diagnostic, prognostic, and treatment purposes. These molecular landscapes of solid tumors are currently obtained from surgical or biopsy specimens. However, during cancer progression and treatment, selective pressures lead to additional genetic changes as tumors acquire drug resistance. Tissue sampling cannot be performed routinely owing to its invasive nature and a single biopsy only provides a limited snapshot of a tumor, which may fail to reflect spatial and temporal heterogeneity. This dilemma may be solved by analyzing cancer cells or cancer cell-derived DNA from blood samples, called liquid biopsy. Liquid biopsy is one of the most rapidly advancing fields in cancer diagnostics and recent technological advances have enabled the detection and detailed characterization of circulating tumor cells and circulating tumor DNA in blood samples.Liquid biopsy is an exciting area with rapid advances, but we are still at the starting line with many challenges to overcome. In this chapter we will explore how tumor cells and tumor-associated mutations detected in the blood can be used in the clinic. This will include detection of cancer, prediction of prognosis, monitoring systemic therapies, and stratification of patients for therapeutic targets or resistance mechanisms.

Colorectal and gastric metastases from lobular breast cancer that resembled superficial neoplastic lesions

Breast cancer is the most common malignancy in women and has a risk of late recurrence. We report a case of metastasis to the stomach and colon 23 years after surgery, with characteristic findings. A 74-year-old woman underwent breast cancer resection at the age of 51. At the time, no additional therapy was performed despite the histological diagnosis of invasive lobular carcinoma with lymph node metastasis. Upper gastrointestinal endoscopy, which was performed as a follow-up for her chronic gastritis, revealed multiple erosions. Histology revealed diffuse proliferation of signet ring cell-like atypical cells, that were positive for cytokeratin CAM5.2 and estrogen receptor. These findings suggested metastasis from the invasive lobular breast carcinoma. Positron-emission tomography revealed sternal and vertebral metastases. Colonoscopy also performed to screen for intestinal metastasis revealed several lesions that resembled hyperplastic polyps. Although these lesions were not strongly suspected of metastasis, histology surprisingly revealed the same findings as the gastric metastasis. This case involved gastric and colorectal superficial metastases that were synchronously detected 23 years after primary treatment. We report that early-stage colorectal metastasis may resemble hyperplastic polyps, and biopsy should always be considered in patients with a history of breast cancer, regardless of years elapsed since treatment.

Genomic Instability in Circulating Tumor Cells

Simple Summary

In this review, we focus on recent advances in the detection and quantification of tumor cell heterogeneity and genomic instability of CTCs and the contribution of chromosome instability studies to genetic heterogeneity in CTCs at the single-CTC level.

Abstract

Circulating tumor cells (CTCs) can promote distant metastases and can be obtained through minimally invasive liquid biopsy for clinical assessment in cancer patients. Having both genomic heterogeneity and instability as common features, the genetic characterization of CTCs can serve as a powerful tool for a better understanding of the molecular changes occurring at tumor initiation and during tumor progression/metastasis. In this review, we will highlight recent advances in the detection and quantification of tumor cell heterogeneity and genomic instability in CTCs. We will focus on the contribution of chromosome instability studies to genetic heterogeneity in CTCs at the single-CTC level by discussing data from different cancer subtypes and their impact on diagnosis and precision medicine.

Carcinocythemia: First report in a cat and literature review

A 6-year-old female neutered European Shorthair cat was presented with a 2-day history of lethargy and hyporexia. On physical examination, the cat was slightly depressed and had a 2.5 cm nodule in the left 3^rd mammary gland. The hemogram revealed mild leukocytosis with mature neutrophilia and moderate thrombocytopenia. On blood smear evaluation, rare pleomorphic cells, possibly of epithelial origin, were observed mainly at the feathered edge. The animal died about 12 hours after presentation, and a necropsy was performed. On histopathology, the mammary nodule was diagnosed as a tubulopapillary adenocarcinoma with vascular invasion and widespread metastases. Immunocytochemical tests for cytokeratins (AE1/AE3) confirmed the epithelial phenotype of the neoplastic cells observed on the blood smear. The present report describes a feline mammary carcinoma with widespread metastases and the presence of malignant epithelial cells in the peripheral blood referred to as carcinocythemia. This condition has been previously described in people and dogs. To the author's knowledge, this is the first reported case of feline carcinocythemia. As in other species, the phenomenon was associated with a terminal phase of systemic malignancy.

Circulating Breast Carcinoma Cells Mimicking Therapy-Related Acute Myeloid Leukemia

Circulating tumor cells are rare in peripheral blood smears. We report the case of a patient with circulating breast carcinoma cells resembling circulating myeloid blasts and provide a brief review of the literature. Peripheral blood smears and a bone marrow aspirate were examined morphologically and by flow cytometry and fluorescence in situ hybridization (FISH). Bone marrow histology in conjunction with immunohistochemical stains was also evaluated. A population of atypical cells with blast-like morphology was present in the peripheral blood. Flow cytometry showed a 9% population of CD45 dim positive, CD13 partial positive, and CD15 variably positive cells. Peripheral blood FISH analysis revealed deletion 7q, gain of 8q, and deletions 16q and 17q in 32.5% to 36% of 200 interphase cells analyzed. The bone marrow biopsy showed cohesive groups of cytokeratin AE1/AE3 positive cells. Our report demonstrates that circulating carcinoma cells can mimic a high-grade myeloid neoplasm morphologically and by flow cytometry and FISH analysis.

Carcinocythaemia (carcinoma cell leukaemia) in a dog: an acute leukaemia-like picture due to metastatic carcinoma

An eight-year-old entire female boxer was presented with a two-week history of anorexia and lethargy and two-day history of unilateral left epistaxis. Clinical findings and laboratory test results suggested disseminated intravascular coagulation. On blood smear evaluation, occasional large epithelioid-like unclassified cells were detected. Occasionally these cells were organised in small clusters. Bone marrow examination revealed a marked infiltration by a malignant population of the same epithelioid-like cells. The dog was euthanased because of the guarded prognosis. Following histology and immunohistochemistry, a widespread undifferentiated carcinoma of unknown primary origin was diagnosed. To the authors' knowledge, this is the first case of carcinoma cell leukaemia reported in a dog. Carcinoma cell leukaemia is a rare oncological condition previously described in humans, characterised by non-haematopoietic neoplastic cells in peripheral blood.

Immunomagnetic separation technologies

The largest difficulty one faces in the development of technology for detection of circulating tumor cells (CTCs) is whether or not tumor cells are present in the blood and at what frequency. Although the introduction of the validated CellSearch system for CTC enumeration has facilitated CTC research the question remains whether CTC are missed or whether the CTC that are reported are indeed clinically relevant. To fulfill the promise of CTC as a real-time liquid biopsy they will need to be present in the blood volume tested and need to be isolated without losing the ability to test the presence of treatment targets. To characterize a sufficiently large number of CTCs in the majority of cancer patients the volume of blood needed is simply too large to process without enrichment prior to detection. Here, we review the detection of CTCs by flow cytometry and fluorescence microscopy with and without immunomagnetic enrichment.

Circulating tumor cells: a useful predictor of treatment efficacy in metastatic breast cancer

PURPOSE

Five or more circulating tumor cells (CTCs) per 7.5 mL of blood predicts for poorer progression-free survival (PFS) in patients with metastatic breast cancer (MBC). We conducted a prospective study to demonstrate that CTC results correlate strongly with radiographic disease progression at the time of and in advance of imaging.

PATIENTS AND METHODS

Serial CTC levels were obtained in patients starting a new treatment regimen for progressive, radiographically measurable MBC. Peripheral blood was collected for CTC enumeration at baseline and at 3- to 4-week intervals. Clinical outcomes were based on radiographic studies performed in 9- to 12-week intervals.

RESULTS

Sixty-eight patients were evaluable for the CTC-imaging correlations, and 74 patients were evaluable for the PFS analysis. Median follow-up was 13.3 months. A statistically significant correlation was demonstrated between CTC levels and radiographic disease progression in patients receiving chemotherapy or endocrine therapy. This correlation applied to CTC results obtained at the time of imaging (odds ratio [OR], 6.3), 3 to 5 weeks before imaging (OR, 3.1), and 7 to 9 weeks before imaging (OR, 4.9). Results from analyses stratified by type of therapy remained statistically significant. Shorter PFS was observed for patients with five or more CTCs at 3 to 5 weeks and at 7 to 9 weeks after the start of treatment.

CONCLUSION

We provide, to our knowledge, the first evidence of a strong correlation between CTC results and radiographic disease progression in patients receiving chemotherapy or endocrine therapy for MBC. These findings support the role of CTC enumeration as an adjunct to standard methods of monitoring disease status in MBC.

Characterization of circulating tumor cells by fluorescence in situ hybridization

Tumor cells in blood of patients with metastatic carcinomas have been associated with poor survival prospects. Further characterization of these cells may provide further insights into the metastatic process. Circulating Tumor Cells (CTC) were enumerated in 7.5 mL of blood with the CellSearch system. After enumeration of Cytokeratin+, CD45-, nucleated cells, the cells are fixed in the cartridge while maintaining their original position. Cartridges were hybridized with FISH probes against the centromeric regions of chromosome 1, 7, 8, and 17. Next fluorescence images of the FISH probes of the previous identified CTC were acquired. Leukocytes surrounding the CTC were used as internal controls. The number of copies of chromosome 1, 7, 8, and 17 could be determined in 118 CTC containing blood samples from 59 metastatic prostate cancer patients. The samples contained a total of 21,751 CTC (mean 184, median 16, SD 650). Chromosome counts were obtained in 61% of the relocated CTC. On an average, these CTC contained 2.8 copies of chromosome 1, 2.7 copies of chromosome 7, 3.1 copies of chromosome 8, and 2.3 copies of chromosome 17. CTC in which no chromosome count was obtained most likely underwent apoptosis indicated by the expression of M30. In 6/59 patients only diploid CTC were detected these samples, however, only contained 1-5 CTC. Heterogeneity in the chromosomal abnormalities was observed between CTC of different patients as well as among CTC of the same patient. Cytogenetic composition of CTC can be reliably assessed after they have been identified by the CellSearch system. The majority of CTC in hormone refractory prostate cancer are aneuploid confirming that they indeed are cancer cells. An extensive heterogeneity in the copy number of each of the chromosomes was observed.

Primary colonic signet ring cell carcinoma presenting carcinocythemia: an autopsy case

Primary colorectal signet ring cell carcinoma (SRCC) is a rare but distinctive type of mucin-producing adenocarcinoma of the large intestine with still controversial clinicopathological features and prognosis. We encountered primary colonic SRCC in a 51-year-old Japanese man with extensive bone metastasis ultimately leading to carcinocythemia before the initiation of chemotherapy and surgical intervention. Three days before death, besides progressive disseminated intravascular coagulation that had been present on admission, hematological examination showed sudden leukocytosis with nonhematopoietic cells that subsequently turned out to be signet ring cells (SRCs). Carcinocythemia, the presence of circulating cancer cells in peripheral blood, is considered to be a rare but an ominous phenomenon occurring in the advanced stage of certain types of cancers, particularly mammary lobular carcinoma. It can be assumed that carcinoma cells lacking intercellular cohesiveness and polarized cell membrane organization, including SRCs as well as lobular carcinoma cells, can readily get access to the peripheral circulation; however, to our knowledge, this is the first report of primary colorectal SRCC that presented carcinocythemia. Extensive bone metastatic sites, in the present case, may have functioned as a reservoir of circulating SRCs.

APT102, a novel adpase, cooperates with aspirin to disrupt bone metastasis in mice

Platelets contribute to the development of metastasis, the most common cause of mortality in cancer patients, but the precise role that anti-platelet drugs play in cancer treatment is not defined. Metastatic tumor cells can produce platelet alphaIIb beta3 activators, such as ADP and thromboxane A(2) (TXA(2)). Inhibitors of platelet beta3 integrins decrease bone metastases in mice but are associated with significant bleeding. We examined the role of a novel soluble apyrase/ADPase, APT102, and an inhibitor of TXA(2) synthesis, acetylsalicylic acid (aspirin or ASA), in mouse models of experimental bone metastases. We found that treatment with ASA and APT102 in combination (ASA + APT102), but not either drug alone, significantly decreased breast cancer and melanoma bone metastases in mice with fewer bleeding complications than observed with alphaIIb beta3 inhibition. ASA + APT102 diminished tumor cell induced platelet aggregation but did not directly alter tumor cell viability. Notably, APT102 + ASA treatment did not affect initial tumor cell distribution and similar results were observed in beta3-/- mice. These results show that treatment with ASA + APT102 decreases bone metastases without significant bleeding complications. Anti-platelet drugs such as ASA + APT102 could be valuable experimental tools for studying the role of platelet activation in metastasis as well as a therapeutic option for the prevention of bone metastases.

Detection of circulating tumor cells in patients with pancreatic cancer: a preliminary result

BACKGROUND/PURPOSE

It has been reported that circulating tumor cells (CTCs) can be used to predict survival in metastatic breast cancer. In this preliminary study, we examined the level of CTCs in pancreatic cancer (PC) patients to elucidate whether we could predict survival in PC.

METHODS

The eligible subjects, at Tokyo Medical University Hospital, were 26 patients with PC, 11 with chronic pancreatitis, and 10 healthy volunteers. Three PC patients underwent surgery, 18 patients (who were stage IV) were treated with gemcitabine (GEM), and 5 patients received best supportive care (BSC).

RESULTS

The CTC count was 1/7.5 ml blood or higher (defined as positive) in 11 of the 26 patients (42%; mean, 16.9/7.5 ml blood; range, 1-105/7.5 ml blood). Gemcitabine was administered to 6 of the 11 CTC-positive patients (3.8 courses on average). The treatment was continued for more than three courses in 2 patients, in both of whom the CTC count was only 1/7.5 ml blood. Operation was performed in 1 of the 11 CTC-positive patients. The remaining 4 patients of the 11 CTC-positive patients received only BSC. CTC was negative in 15 patients with PC (stage II, 1; stage III, 1; stage IVa, 7; and stage IVb, 6) and in the subjects with benign conditions. The median survival times (MSTs) of the CTC-positive and-negative patients were 110.5 and 375.8 days (P < 0.001). When the analysis was limited to the 14 stage-IVb patients, the MSTs of the CTC-positive and-negative patients were 52.5 and 308.3 days (P < 0.01).

CONCLUSIONS

The present study demonstrated that the detection of CTCs in peripheral blood may be useful to predict prognosis in patients with PC.

Apoptosis of circulating tumor cells in prostate cancer patients

BACKGROUND

The prescence of circulating tumor cells (CTCs) in the peripheral blood of cancer patients and their frequency has been correlated with disease status.

METHODS

In this study, CTCs were characterized by flow cytometry and fluorescence microscopy after immunomagnetic enrichment from 7.5-ml blood samples collected from patients with prostate cancer in evacuated blood-draw tubes that contained an anticoagulant and a preservative. Events were classified as tumor cell candidates if they expressed cytokeratin, lacked CD45, and stained with the nucleic acid dye 4,6-diamidino-2-phenylindole.

RESULTS

In the blood of prostate cancer patients, only few of these events were intact cells. Other CTC events appeared as damaged cells or cell fragments by microscopy. By flow cytometry, these events stained variably with 4,6-diamidino-2-phenylindole and frequently expressed the apoptosis-induced, caspase-cleaved cytokeratin 18. Similar patterns of cell disintegration were observed when cells of the prostate line LNCaP were exposed to paclitaxel before spiking the cells into normal blood samples.

CONCLUSIONS

The different observed stages of tumor cell degradation or apoptosis varied greatly between patients and were not found in blood of normal donors. Enumeration of CTCs and identification of CTCs undergoing apoptosis may provide relevant information to evaluate the response to therapy in cancer patients.

Circulating tumor cells, disease progression, and survival in metastatic breast cancer

BACKGROUND

We tested the hypothesis that the level of circulating tumor cells can predict survival in metastatic breast cancer.

METHODS

In a prospective, multicenter study, we tested 177 patients with measurable metastatic breast cancer for levels of circulating tumor cells both before the patients were to start a new line of treatment and at the first follow-up visit. The progression of the disease or the response to treatment was determined with the use of standard imaging studies at the participating centers.

RESULTS

Outcomes were assessed according to levels of circulating tumor cells at baseline, before the patients started a new treatment for metastatic disease. Patients in a training set with levels of circulating tumor cells equal to or higher than 5 per 7.5 ml of whole blood, as compared with the group with fewer than 5 circulating tumor cells per 7.5 ml, had a shorter median progression-free survival (2.7 months vs. 7.0 months, P<0.001) and shorter overall survival (10.1 months vs. >18 months, P<0.001). At the first follow-up visit after the initiation of therapy, this difference between the groups persisted (progression-free survival, 2.1 months vs. 7.0 months; P<0.001; overall survival, 8.2 months vs. >18 months; P<0.001), and the reduced proportion of patients (from 49 percent to 30 percent) in the group with an unfavorable prognosis suggested that there was a benefit from therapy. The multivariate Cox proportional-hazards regression showed that, of all the variables in the statistical model, the levels of circulating tumor cells at baseline and at the first follow-up visit were the most significant predictors of progression-free and overall survival.

CONCLUSIONS

The number of circulating tumor cells before treatment is an independent predictor of progression-free survival and overall survival in patients with metastatic breast cancer.