Why the stroma matters in breast cancer

Survival and recurrence rates in breast cancer are variable for common diagnoses, and therefore the biological underpinnings of the disease that determine those outcomes are yet to be fully understood. As a result, translational medicine is one of the fastest growing arenas of study in tumor biology. With advancements in genetic and imaging techniques, archived biopsies can be examined for purposes other than diagnosis. There is a great deal of evidence that points to the stroma as the major regulator of tumor progression following the initial stages of tumor formation, and the stroma may also contribute to risk factors determining tumor formation. Therefore, aspects of stromal biology are well-suited to be a focus for studies of patient outcome, where statistical differences in survival among patients provide evidence as to whether that stromal component is a signpost for tumor progression. In this review we summarize the latest research done where breast cancer patient survival was correlated with aspects of stromal biology, which have been put into four categories: reorganization of the extracellular matrix (ECM) to promote invasion, changes in the expression of stromal cell types, changes in stromal gene expression, and changes in cell biology signaling cascades to and from the stroma.     

Stromal gene expression predicts clinical outcome in breast cancer

Although it is increasingly evident that cancer is influenced by signals emanating from tumor stroma, little is known regarding how changes in stromal gene expression affect epithelial tumor progression. We used laser capture microdissection to compare gene expression profiles of tumor stroma from 53 primary breast tumors and derived signatures strongly associated with clinical outcome. We present a new stroma-derived prognostic predictor (SDPP) that stratifies disease outcome independently of standard clinical prognostic factors and published expression-based predictors. The SDPP predicts outcome in several published whole tumor-derived expression data sets, identifies poor-outcome individuals from multiple clinical subtypes, including lymph node-negative tumors, and shows increased accuracy with respect to previously published predictors, especially for HER2-positive tumors. Prognostic power increases substantially when the predictor is combined with existing outcome predictors. Genes represented in the SDPP reveal the strong prognostic capacity of differential immune responses as well as angiogenic and hypoxic responses, highlighting the importance of stromal biology in tumor progression.     

The role of heparins and nano-heparins as therapeutic tool in breast cancer

Glycosaminoglycans are integral part of the dynamic extracellular matrix (ECM) network that control crucial biochemical and biomechanical signals required for tissue morphogenesis, differentiation, homeostasis and cancer development. Breast cancer cells communicate with stromal ones to modulate ECM mainly through release of soluble effectors during cancer progression. The intracellular cross-talk between cell surface receptors and estrogen receptors is important for the regulation of breast cancer cell properties and production of ECM molecules. In turn, reorganized ECM-cell surface interface modulates signaling cascades, which regulate almost all aspects of breast cell behavior. Heparan sulfate chains present on cell surface and matrix proteoglycans are involved in regulation of breast cancer functions since they are capable of binding numerous matrix molecules, growth factors and inflammatory mediators thus modulating their signaling. In addition to its anticoagulant activity, there is accumulating evidence highlighting various anticancer activities of heparin and nano-heparin derivatives in numerous types of cancer. Importantly, heparin derivatives significantly reduce breast cancer cell proliferation and metastasis in vitro and in vivo models as well as regulates the expression profile of major ECM macromolecules, providing strong evidence for therapeutic targeting. Nano-formulations of the glycosaminoglycan heparin are possibly novel tools for targeting tumor microenvironment. In this review, the role of heparan sulfate/heparin and its nano-formulations in breast cancer biology are presented and discussed in terms of future pharmacological targeting.     

Breast cancer cells induce cancer-associated fibroblasts to secrete hepatocyte growth factor to enhance breast tumorigenesis

It has been well documented that microenvironment consisting of stroma affects breast cancer progression. However, the mechanisms by which cancer cells and fibroblasts, the major cell type in stroma, interact with each other during tumor development remains to be elucidated. Here, we show that the human cancer-associated fibroblasts (CAFs) had higher activity in enhancing breast tumorigenecity compared to the normal tissue-associated fibroblasts (NAFs) isolated from the same patients. The expression level of hepatocyte growth factor (HGF) in these fibroblasts was positively correlated with their ability to enhance breast tumorigenesis in mice. Deprivation of HGF using a neutralizing antibody reduced CAF-mediated colony formation of human breast cancer cells, indicating that CAFs enhanced cancer cell colony formation mainly through HGF secretion. Co-culture with human breast cancer MDA-MB-468 cells in a transwell system enhanced NAFs to secret HGF as well as promote tumorigenecity. The newly gained ability of these "educated" NAFs became irreversible after continuing this process till fourth passage. These results suggested that breast cancer cells could alter the nature of its surrounding fibroblasts to secrete HGF to support its own progression through paracrine signaling.     

Milking the stroma in triple-negative breast cancer

Comment on: Witkiewicz AK, et al. Cell Cycle 2012; 1108–1117Investment in the post-genomic molecular dissection of breast cancer has resulted in an emphasis on prognostic and predictive markers, signatures derived to stratify the disease and the drive to generate targeted therapies. However, there remain significant challenges to individualize therapeutic targeting and improve the prognosis for the thousands of women who die each year from the heterogeneous range of breast cancers. This is particularly true for poor prognosis “triple-negative” breast cancers (TNBC), most prevalent in young and African American women, lacking the established therapeutic targets of estrogen receptor, progesterone receptor or HER2.Research has largely focused on the epithelial component of breast cancer rather than the tumor microenvironment, now recognized as a key hallmark of cancer.¹ In vitro, animal models and observations on clinical material² are now moving to consider physiological mechanisms by which stromal cells may influence breast epithelial and carcinoma cells.Witkiewicz et al.³ build on published evidence from the Lisanti group that cancer cells secrete hydrogen peroxide, initiating oxidative stress and aerobic glycolysis in tumor stroma, with L-lactate secretion from cancer-associated fibroblasts fueling oxidative mitochondrial metabolism in epithelial cancer cells: the “reverse Warburg effect.”They demonstrate stromal monocarboxylate transporter 4 (MCT4), detected by immunohistochemistry, as a functional marker of stromal hypoxia, oxidative stress, aerobic glycolysis and L-lactate efflux. High stromal MCT4 expression (but, critically, not epithelial MCT4) was associated with poor prognosis in TNBC patients. Combined high stromal MCT4 and loss of stromal caveolin-1 identify particularly poor prognostic TNBC.Thus, development of cancer may not lie solely in genetic or epigenetic epithelial changes, but with acquired functional changes in the stromal infrastructure of the breast. This supports the concept of epithelial malignant changes consequent with ecological and evolutionary opportunity.⁴ The “parasitic” character of tumor cells feeding off stromal cells highlights the need to seriously consider both ecological and biophysical concepts.⁵ We need to think beyond “intraspecific” competition among clonal subpopulations in the tumor and to consider tumor and stromal cells as distinct populations in a cancer ecosystem, with a range of “interspecific” competitive, exploitative and opportunistic interactions. Furthermore, the reverse Warburg effect relies on the inefficient diffusion of nutrients from stromal cells to tumor cells in a complex three-dimensional space. The extracellular space is brought to the foreground, and physical properties of molecular transport in this space may have as much impact on tumor growth as intricate cellular processes. The importance of the spatial arena is also apparent when contrasting the reverse Warburg effect with angiogenesis. In the former, tumor cells are exploiting their local environment, which will presumably be of limited yield, whereas angiogenesis taps the nutrients of the entire organism—­an effectively infinite reservoir for a growing tumor. In the reverse Warburg effect, a balance of ecological and biophysical factors underpins the sustainability of this mode of cancer nutrition. A two-compartment model coupling oxidative epithelial cells with glycolytic fibroblasts reflects increased expression of hypoxia-associated genes as a component part of prognostic stromal signatures.⁶ Further evidence of stromal/epithelial interaction comes from evidence that the effects of radiation on normal breast epithelium in vivo is at least partially dependent on the stromal context.⁷Manipulation of the tumor microenvironment to promote an anticancer phenotype challenges the cancer treatment paradigm. The long-established antidiabetes biguanide drugs offer a low-toxicity opportunity to disrupt the reverse Warburg effect. Metformin may target the cancer mitochondria³ and phenformin induce stromal sclerosis, at least in a breast cancer xenograft model,⁸ in addition to in vivo AMPK pathway and insulin-mediated systemic effects of metformin in women with breast cancer.⁹ The reverse Warburg effect challenges our therapeutic focus on breast cancer epithelium. Stromal MCT4 expression with caveolin-1 loss identifies poor prognostic TNBC patients and emphasizes the roles of the tumor microenvironment and ecological interactions between distinct populations of cells. The challenges now revolve around therapeutic manipulation of the stroma/epithelial interaction and the extracellular space, and testing these concepts in pre-invasive and metastatic settings where stromal changes may provide tissue niches of evolutionary opportunity for malignant cells.     

CD105 Expression on CD34-Negative Spindle-Shaped Stromal Cells of Primary Tumor Is an Unfavorable Prognostic Marker in Early Breast Cancer Patients

Several studies have confirmed that the breast tumor microenvironment drives cancer progression and metastatic development. The aim of our research was to investigate the prognostic significance of the breast tumor microenvironment in untreated early breast cancer patients. Therefore, we analyzed the association of the expression of α-SMA, FSP, CD105 and CD146 in CD34-negative spindle-shaped stromal cells, not associated with the vasculature, in primary breast tumors with classical prognostic marker levels, metastatic recurrence, local relapse, disease-free survival, metastasis-free survival and the overall survival of patients. In the same way, we evaluated the association of the amount of intra-tumor stroma, fibroblasts, collagen deposition, lymphocytic infiltration and myxoid changes in these samples with the clinical-pathological data previously described. This study is the first to demonstrate the high CD105 expression in this stromal cell type as a possible independent marker of unfavorable prognosis in early breast cancer patients. Our study suggests that this new finding can be useful prognostic marker in the clinical-pathological routine.     

Stroma in breast development and disease

It is increasingly apparent that normal and malignant breast tissues require complex local and systemic stromal interactions for development and progression. During development, mammary cell fate specification and differentiation require highly regulated contextual signals derived from the stroma. Likewise, during breast carcinoma development, the tissue stroma can provide tumor suppressing and tumor-promoting environments that serve to regulate neoplastic growth of the epithelium. This review focuses on the role of the stroma as a mediator of normal mammary development, as well as a critical regulator of malignant conversion and progression in breast cancer. Recognition of the important role of the stroma during the progression of breast cancers leads to the possibility of new targets for treatment of the initial breast cancer lesion as well as prevention of recurrence.     

Hyaluronan in breast cancer: correlations with nitric oxide synthases and tyrosine nitrosylation.

Reactive oxygen species (ROS), including nitric oxide (NO(*)), are associated with all steps of carcinogenesis. Hyaluronan (HA), a high-molecular-mass glycosaminoglycan overexpressed in a variety of human malignancies also has ROS-scavenging properties. We histochemically studied the level of HA in breast carcinoma cells and their stroma and compared it with the expression of NO(*) synthases (NOSs), major antioxidant enzymes, and nitrotyrosine. We also assessed whether the level of HA correlates with traditional prognostic factors of breast cancer and survival. Stromal HA level was moderate or high in all the samples studied (n=185), and 84% of the lesions showed HA-positive carcinoma cells. Intense stromal HA signal was associated with high neuronal NOS expression (p=0.009), whereas tumor-cell associated HA was inversely correlated with nitrotyrosine expression (p=0.027). Of the traditional prognostic factors, tumor cell-associated HA was correlated with poor differentiation (p=0.011), and high stromal HA levels were associated with aggressive features of the carcinomas such as large primary tumor (p=0.002), poor differentiation (p=0.019), and estrogen (p=0.012) and progesterone receptor negativity (p=0.009). High stromal HA level also significantly predicted poorer survival. The strong positive correlation between neuronal NOS and stromal HA could reflect NO(*)-stimulated synthesis of HA, an extracellular matrix alteration that favors breast cancer progression. Furthermore, it is suggested that, while acting as a scavenger of NO(*)-derived radicals, cell-associated HA undergoes partial fragmentation, release from receptors, and further degradation in lysosomes, and thus becomes undetectable in histological sections.     

RGS-GAIP-interacting protein controls breast cancer progression

Although the importance of RGS-GAIP-interacting protein (GIPC) in the biology of malignant cells is well known, the molecular mechanism of GIPC in the inhibition of tumor progression has not been identified. This study focused on elucidating the molecular role of GIPC in breast cancer progression. By using a human breast tumor specimen, an in vivo mouse model, and breast cancer cell lines, we showed for the first time that GIPC is involved in breast cancer progression through regulation of breast cancer cell proliferation, survival, and invasion. Furthermore, we found that the Akt/Mdm2/p53 axis, insulin-like growth factor-1 receptor, matrix metalloproteinase-9, and Cdc42 were downstream of GIPC signaling in breast cancer cells. Moreover, we showed that wild-type p53 reduced GIPC-induced breast cancer cell survival, whereas mutant p53 inhibited GIPC-induced cell invasion. Finally, we demonstrated that an N-myristoylated GIPC peptide (CR1023, N-myristoyl-PSQSSSEA) capable of blocking the PDZ domain of GIPC successfully inhibited MDA-MB-231 cell proliferation, survival, and further in vivo tumor growth. Taken together, these findings demonstrate the importance of GIPC in breast tumor progression, which has a potentially significant impact on the development of therapies against many common cancers expressing GIPC, including breast and renal cancer.     

Fibrosis and cancer: A strained relationship

Tumors are characterized by extracellular matrix (ECM) deposition, remodeling, and cross-linking that drive fibrosis to stiffen the stroma and promote malignancy. The stiffened stroma enhances tumor cell growth, survival and migration and drives a mesenchymal transition. A stiff ECM also induces angiogenesis, hypoxia and compromises anti-tumor immunity. Not surprisingly, tumor aggression and poor patient prognosis correlate with degree of tissue fibrosis and level of stromal stiffness. In this review, we discuss the reciprocal interplay between tumor cells, cancer associated fibroblasts (CAF), immune cells and ECM stiffness in malignant transformation and cancer aggression. We discuss CAF heterogeneity and describe its impact on tumor development and aggression focusing on the role of CAFs in engineering the fibrotic tumor stroma and tuning tumor cell tension and modulating the immune response. To illustrate the role of mechanoreciprocity in tumor evolution we summarize data from breast cancer and pancreatic ductal carcinoma (PDAC) studies, and finish by discussing emerging anti-fibrotic strategies aimed at treating cancer.     

Basal-like breast cancer cells induce phenotypic and genomic changes in macrophages

Basal-like breast cancer (BBC) is an aggressive subtype of breast cancer that has no biologically targeted therapy. The interactions of BBCs with stromal cells are important determinants of tumor biology, with inflammatory cells playing well-recognized roles in cancer progression. Despite the fact that macrophage-BBC communication is bidirectional, important questions remain about how BBCs affect adjacent immune cells. This study investigated monocyte-to-macrophage differentiation and polarization and gene expression in response to coculture with basal-like versus luminal breast cancer cells. Changes induced by coculture were compared with changes observed under classical differentiation and polarization conditions. Monocytes (THP-1 cells) exposed to BBC cells in coculture had altered gene expression with upregulation of both M1 and M2 macrophage markers. Two sets of M1 and M2 markers were selected from the PCR profiles and used for dual immunofluorescent staining of BBC versus luminal cocultured THP-1s, and cancer-adjacent, benign tissue sections from patients diagnosed with BBCs or luminal breast cancer, confirming the differential expression patterns. Relative to luminal breast cancers, BBCs also increased differentiation of monocytes to macrophages and stimulated macrophage migration. Consistent with these changes in cellular phenotype, a distinct pattern of cytokine secretion was evident in macrophage-BBC cocultures, including upregulation of NAP-2, osteoprotegerin, MIG, MCP-1, MCP-3, and interleukin (IL)-1β. Application of IL-1 receptor antagonist (IL-1RA) to cocultures attenuated BBC-induced macrophage migration. These data contribute to an understanding of the BBC-mediated activation of the stromal immune response, implicating specific cytokines that are differentially expressed in basal-like microenvironments and suggesting plausible targets for modulating immune responses to BBCs.     

Loss of caveolin-1 and gain of MCT4 expression in the tumor stroma: Key events in the progression from an in situ to an invasive breast carcinoma

The progression from in situ to invasive breast carcinoma is still an event poorly understood. However, it has been suggested that interactions between the neoplastic cells and the tumor microenvironment may play an important role in this process. Thus, the determination of differential tumor-stromal metabolic interactions could be an important step in invasiveness.

The expression of stromal Caveolin-1 (Cav-1) has already been implicated in the progression from ductal carcinoma in situ (DCIS) to invasive ductal carcinoma (IDC). Additionally, stromal Cav-1 expression has been associated with the expression of stromal monocarboxylate transporter 4 (MCT4) in invasive breast cancer. However, the role of stromal MCT4 in invasiveness has never been explored, neither the association between Cav-1 and MCT4 in the transition from breast DCIS to IDC.

Therefore, our aim was to investigate in a series of breast cancer samples including matched in situ and invasive components, if there was a relationship between stromal Cav-1 and MCT4 in the progression from in situ to invasive carcinoma. We found loss of stromal Cav-1 in the progression to IDC in 75% of the cases. In contrast, MCT4 stromal expression was acquired in 87% of the IDCs. Interestingly, a concomitant loss of Cav-1 and gain of MCT4 was observed in the stroma of 75% of the cases, when matched in situ and invasive carcinomas were compared. These results suggest that alterations in Cav-1 and MCT4 may thus mark a critical point in the progression from in situ to invasive breast cancer.     

Quantitative proteomics study of breast cancer cell lines isolated from a single patient: Discovery of TIMM17A as a marker for breast cancer

The proteins involved in breast cancer initiation and progression are still largely elusive. To gain insights into these processes, we conducted quantitative proteomic analyses with 21T series of breast cell lines, which include a normal, primary tumor and a metastatic tumor that were isolated from a single patient. Stable isotope labeling of amino acid in cell culture followed by LC‐MS/MS analysis was performed and deregulated proteins were identified using statistical analysis. Gene ontology analysis revealed that proteins involved in metabolic processes were the most deregulated in both tumorigenesis and metastasis. Interaction network analysis indicated that ERBB2 signaling played a critical role in tumorigenesis. In addition to known markers such as ERBB2 and E‐cadherin, novel markers, including BRP44L, MTHFD2 and TIMM17A, were found to be overexpressed in 21T breast cancer cells and verified in additional breast cell lines. mRNA expression analysis as well as immunohistochemistry analysis in breast cancer tissues indicated that expression level of TIMM17A was directly correlated with tumor progression, and survival analysis suggested that TIMM17A was a powerful prognosis factor in breast cancer. More interestingly, overexpression and siRNA knockdown experiments indicated an oncogenic activity of TIMM17A in breast cancer. Our study provides a list of potential novel markers for breast cancer tumorigenesis and metastasis using a unique cell model. Further studies on TIMM17A as well as other markers on the list may reveal mechanisms that result in more effective therapeutics for cancer treatment.     

Monocytes secrete CXCL7 to promote breast cancer progression

Certain immune cells and inflammatory cytokines are essential components in the tumor microenvironment to promote breast cancer progression. To identify key immune players in the tumor microenvironment, we applied highly invasive MDA-MB-231 breast cancer cell lines to co-culture with human monocyte THP-1 cells and identified CXCL7 by cytokine array as one of the increasingly secreted cytokines by THP-1 cells. Further investigations indicated that upon co-culturing, breast cancer cells secreted CSF1 to induce expression and release of CXCL7 from monocytes, which in turn acted on cancer cells to promote FAK activation, MMP13 expression, migration, and invasion. In a xenograft mouse model, administration of CXCL7 antibodies significantly reduced abundance of M2 macrophages in tumor microenvironment, as well as decreased tumor growth and distant metastasis. Clinical investigation further suggested that high CXCL7 expression is correlated with breast cancer progression and poor overall survival of patients. Overall, our study unveils an important immune cytokine, CXCL7, which is secreted by tumor infiltrating monocytes, to stimulate cancer cell migration, invasion, and metastasis, contributing to the promotion of breast cancer progression.Subject terms: Breast cancer, Cancer microenvironment, Target identification, Chemokines