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Egg Shaped Wind Instrument 7 Letters
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Received: 16 July 2022 / Revised: 9 August 2022 / Accepted: 16 August 2022 / Published: 18 August 2022
(This article belongs to the special issue Advances and Updates in Prognostic and Predictive Biomarkers of Urological Malignancy)
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Circulating tumor cells (CTCs) are a promising biomarker for the risk of prostate cancer aggressiveness and metastasis and play a role in the processes of tumor migration and metastasis. CTC clusters, which have different physical and biological properties than individual CTCs, are collections of tumor cells and non-malignant cells, resulting in greater metastatic potential. Therefore, this review aims to summarize the current knowledge about CTC clusters in metastases as well as related biological properties and to propose possibilities for their use in diagnostic and therapeutic practice.
Prostate cancer (PCa) shows high cellular heterogeneity among patients. Therefore, there is an urgent need for more accurate real-time detection methods, both in prognosis and treatment in clinical settings. Clusters of circulating tumor cells (CTCs), a population of tumor cells and non-malignant cells in the blood of patients with tumors, are a promising non-invasive tool for screening PCa progression and identifying potential benefit groups. CTC clusters are associated with tumor metastasis and possess stem-like characteristics, likely attributable to epithelial-mesenchymal transition (EMT). Additionally, these biological properties of CTC clusters, particularly the androgen receptor V7, indicate the potential to reflect curative effects, guide treatment modalities, and predict prognosis in PCa patients. Here, we discuss the role of CTC clusters in the mechanisms underlying PCa metastasis and clinical applications, with the goal of informing more appropriate clinical decisions, and ultimately, improving the overall survival of PCa patients.
Circulating tumor cells; circulating clusters of tumor cells; prostate cancer; epithelial-mesenchymal transition; metastases; androgen receptor V7 circulating tumor cells; circulating clusters of tumor cells; prostate cancer; epithelial-mesenchymal transition; metastases; androgen receptor V7
In the United States, prostate cancer (PCa) is the most common cancer diagnosed in men [ 1 , 2 , 3 ]. Since prostate-specific antigen (PSA) was widely applied to detect asymptomatic PCa during the early 1990s , the overall incidence of PCa in men has generally decreased. This revealed the enormous benefit of inspection tools. However, it has recently been found that early detection of PCa by PSA testing has led to overdiagnosis and overtreatment. Therefore, there is an urgent need for alternative tools . Liquid biopsy, defined as the analysis of tumor cells and tumor products in blood and other body fluids , is an alternative to tissue biopsies. It can be used to diagnose and screen tumors in real time. In addition, it is a non-invasive and replicable way to monitor circulating tumor cells (CTCs), cell-free DNA (cfDNA), cell-free RNA (cfRNA), and extracellular vesicles and particles (EVP). Studies have shown that the diagnostic efficiency of CTC is superior to that of PSA when the patient’s PSA level is between 4-10 ng/mL . In conclusion, biomarkers and CTC enumeration demonstrate prospective assessment of prognosis and treatment efficacy in metastatic PCa [8, 9, 10].
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CTCs are rare in peripheral blood. For example, the prevalence of single CTCs is 1 to 10 CTCs in 10
White blood cells  and CTC clusters are estimated to account for only 2–5% of all CTC events detected in the circulation  . Characteristic CTC markers for isolation include epithelial cell adhesion molecules (EpCAM; transmembrane glycoprotein), vimentin (VIM; cytoskeletal structural protein), and cytokeratins (CK8, 18, 19). According to the biomarkers and physical characteristics of CTCs, several recent methods have been devised to enrich and isolate CTCs from blood cells (especially white blood cells) (Table 1). For example, devices have been developed for the isolation and detection of CTCs based on the presence of specific proteins (CellSearch
(Menarini Silicon Biosystems, Bologna, Italy), CTC-chip, RosetteSep), gene transcripts (AdnaTest), size (microfluidic chips), density (Oncoquick), electrical charge, secretion of specific proteins (EPISPOT) and invasive properties  . To date, CTCs have been reported in various solid tumors including breast cancer [ 14 ], prostate cancer, lung cancer [ 15 ], colon cancer [ 16 ], liver cancer [ 17 ], and head and neck cancer [ 18 ]. CTCs are generally referred to as either single CTCs or CTC clusters, with the latter thought to have a 23- to 50-fold greater metastatic potential [ 12 , 19 ]. Studies suggest that a CTC cluster contains at least 2 tumor cells (and up to 100) and a few non-malignant cells including but not limited to a heterogeneous group of cells, for example, tumor-associated macrophages (TAMs), cancer-associated fibroblasts (CAFs), white blood cells, epithelial cells and platelets [20, 21, 22, 23, 24, 25]. In contrast to single CTCs, CTC clusters exhibit characteristic phenotypes, gene expression, and metastasis patterns, indicating unique biological properties in neoplasm metastasis. CTC clusters can be detected in men with localized PCa or metastatic PCa, and there are higher numbers of CTC clusters in men with advanced PCa during multiple stages of cancer recurrence and metastasis [ 22 , 26 , 27 , 28 , 29 ]. Moreover, CTC clusters were also detected in xenograft (PDX) models derived from prostate cancer patients. This provided a new tool to investigate PCa metastasis .
Many questions remain about CTC clusters. For example, is the direct derivation of CTC clusters from primary tumors or single CTCs in peripheral blood? Likewise, the relationship and interaction between CTC clusters and individual CTCs remains unclear. How do CTC clusters metastasize? How are CTC clusters related to stem cells? In this context, these topics are discussed with an emphasis on the relationship between CTC clusters and PCa metastasis, as well as the prospective application of CTC clusters in clinical settings.
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To date, despite the lack of strong evidence that CTC clusters and individual CTCs are two completely distinct and independent cells, the contrast between CTC clusters and individual CTCs based on physical properties and biological characteristics has been reported in many tumors. In patients with tumors, single CTCs are more common than CTC clusters, and CTC clusters consisting of several tumor cells are larger than single CTCs. This reduces the potential for extravasation. However, CTC clusters have been observed to reversibly develop into single chains when passing through blood vessels . Non-malignant cells in CTC clusters are involved in extravasation and stabilize CTC clusters in peripheral blood . In addition, single CTCs are unable to form polyclonal metastatic foci in distant organs, but CTC clusters have a greater ability to metastasize and also have the potential to form polyclonal metastatic foci . In conclusion, composition, survival advantage and metastatic potential are the main differences between CTC clusters and individual CTCs.
EMT is a complex cellular pathway in which epithelial cells lose epithelial characteristics (eg cell-to-cell adhesion) and acquire mesenchymal characteristics (eg increased migratory abilities) . Experimental evidence accumulated over decades indicates that tumor cells in CTC clusters undergo EMT, as demonstrated by the detection of EMT biomarkers [ 30 , 38 , 39 ]. Evidence also reveals that EMT has potential relevance to mechanisms underlying tumor metastasis, generation and maintenance of cancer stem cells (CSCs), as well as drug resistance [ 40 ]. At the molecular level, loss of the adherens junction protein E-cadherin is considered a hallmark of EMT . The result is an increase in mesenchymal markers such as vimentin, N-cadherin, α-smooth muscle actin (α-SMA) and fibronectin . Satelli et al. reported that FOXC2, an EMT-specific marker, could be detected in CTCs from 10 patients with metastatic PCa. However, the epithelial markers EpCAM and E-cadherin are absent in these cells, indicating a mesenchymal phenotype . Surprisingly, Yu et al. found an association between the expression of mesenchymal markers and CTC clusters in human breast cancer samples, instead of individual migratory cells . This focused subsequent research on CTC clusters and EMT. In PCa-based PDX models, CTC clusters