Liquid biopsy, consisting in the non-invasive analysis of circulating tumor-derived material (the Tumor Circulome), represents an innovative tool in precision oncology to overcome current limitations associated with tissue biopsies. Within the tumor circulome, ctDNA and CTCs are the only components whose clinical application is FDA-cleared. Extracellular vesicles, ctRNA and tumor-educated platelets are relatively novel tumor circulome constituents with promising potential at each stage of cancer management. Here, we discuss the clinical applications of each element of the tumor circulome and the prevailing factors that currently limit implementation in clinical practice. We also detail the most recent technological developments in the field, which demonstrate potential in improving the clinical value of liquid biopsies. Commented [GDR3R2]: Thanks for doing that Commented [MK(2]: Please include all weblinks in a separate section before "References", entitled "Resources" Commented [MK(1]: Please include all weblinks in a separate section before "References", entitled "Resources" Commented [MK(4]: Since this is how it is depicted in the Figure. Commented [MK(5]: I suggest that this be converted into "Key Figure". The Figure represents the contents of the review well. Commented [MK(6]: Are the authors talking about advances in sample isolation? I'd encourage you to give examples to align the readers to what advancements the authors are referring to. Commented [GDR7R6]: Done with some of the innovations discussed in the following chapters.

The confinement of multiple myeloma (MM) to the bone marrow microenvironment requires an invasive bone marrow biopsy to monitor the malignant compartment. The existing clinical tools used to determine treatment response and tumor relapse are limited in sensitivity mainly because they indirectly measure tumor burden inside the bone marrow and fail to capture the patchy, multisite tumor infiltrates associated with MM. Microparticles (MPs) are 0.1- to 1.0-μm membrane vesicles, which contain the cellular content of their originating cell. MPs are functional mediators and convey prothrombotic, promalignant, proresistance, and proinflammatory messages, establishing intercellular cross talk and bypassing the need for direct cell-cell contact in many pathologies. In this study, we analyzed plasma cell–derived MPs (CD138+) from deidentified MM patients (n = 64) and normal subjects (n = 18) using flow cytometry. The morphology and size of the MPs were further analyzed using scanning electron microscopy. Our study shows the proof of a systemic signature of MPs in MM patients. We observed that the levels of MPs were significantly elevated in MM corresponding to the tumor burden. We provide the first evidence for the presence of MPs in the peripheral blood of MM patients with potential applications in personalized MM clinical monitoring.

Cancer management paradigms are shifting towards a personalized approach thanks to the advent of the -omics technologies. Liquid biopsies, consisting in the sampling of blood and other bodily fluids, are emerging as a valid alternative to circulating tumor biomarkers and tumor tissue biopsies for cancer diagnosis, routine monitoring and prognostication. The content of a liquid biopsy is referred to as the "tumor circulome". Among its components, circulating tumor DNA (ctDNA), including both cell-free and exosome-associated DNA, is the most widely characterized element. ctDNA analysis has a tremendous capability in the diagnostic arena. Its potential has been demonstrated at each level of disease staging and management and supported by a recent FDA approval for companion diagnostic, and the investments being made by pharmaceutical companies in this sector are numerous. The approaches available for ctDNA analysis allow both quantitative and qualitative studies and range from PCR and dPCR-mediated single/multiple gene mutational assessment to whole genome next generation sequencing and methylation mapping. Although the principal object of a liquid biopsy is blood, other body fluids such as urine and saliva show potential as complementary DNA sources for tumor analysis. In this review we provide a synopsis on the state of play of current ctDNA application. We discuss the clinical significance of ctDNA analysis and review the state of the art of technologies being currently developed to this aim. We also discuss the current issues limiting ctDNA application and highlight the promising approaches being developed to overcome these.

BackgroundBreast cancer is the most frequently diagnosed cancer in women. Resident macrophages at distant sites provide a highly responsive and immunologically dynamic innate immune response against foreign infiltrates. Despite extensive characterization of the role of macrophages and other immune cells in malignant tissues, there is very little known about the mechanisms which facilitate metastatic breast cancer spread to distant sites of immunological integrity. The mechanisms by which a key healthy defense mechanism fails to protect distant sites from infiltration by metastatic cells in cancer patients remain undefined.Breast tumors, typical of many tumor types, shed membrane vesicles called microparticles (MPs), ranging in size from 0.1–1 μm in diameter. MPs serve as vectors in the intercellular transfer of functional proteins and nucleic acids and in drug sequestration. In addition, MPs are also emerging to be important players in the evasion of cancer cell immune surveillance.MethodsA comparative analysis of effects of MPs isolated from human breast cancer cells and non-malignant human brain endothelial cells were examined on THP-1 derived macrophages in vitro. MP-mediated effects on cell phenotype and functionality was assessed by cytokine analysis, cell chemotaxis and phagocytosis, immunolabelling, flow cytometry and confocal imaging. Student’s t-test or a one-way analysis of variance (ANOVA) was used for comparison and statistical analysis.ResultsIn this paper we report on the discovery of a new cellular basis for immune evasion, which is mediated by breast cancer derived MPs. MPs shed from multidrug resistant (MDR) cells were shown to selectively polarize macrophage cells to a functionally incapacitated state and facilitate their engulfment by foreign cells.ConclusionsWe propose this mechanism may serve to physically disrupt the inherent immune response prior to cancer cell colonization whilst releasing mediators required for the recruitment of distant immune cells. These findings introduce a new paradigm in cancer cell biology with significant implications in understanding breast cancer colonization at distant sites. Most importantly, this is also the first demonstration that MPs serve as conduits in a parallel pathway supporting the cellular survival of MDR cancer cells through immune evasion.

Abstract. Multiple myeloma (MM) is a mature B cell neoplasm that results in multi-organ failure. The median age of onset, diverse clinical manifestations, heterogeneous survival rate, clonal evolution, intrinsic and acquired drug resistance have impact on the therapeutic management of the disease.

Multiple myeloma is an incurable cancer of bone marrow plasma cells, with a 5-year survival rate of 43%. Its incidence has increased by 126% since 1990. Treatment typically involves high-dose combination chemotherapy, but therapeutic response and patient survival are unpredictable and highly variable-attributed largely to the development of multidrug resistance (MDR). MDR is the simultaneous cross-resistance to a range of unrelated chemotherapeutic agents and is associated with poor prognosis and survival. Currently, no clinical procedures allow for a direct, continuous monitoring of MDR. We identified circulating large extracellular vesicles (specifically microparticles (MPs)) that can be used to monitor disease burden, disease progression and development of MDR in myeloma. These MPs differ phenotypically in the expression of four protein biomarkers: a plasma-cell marker (CD138), the MDR protein, P-glycoprotein (P-gp), the stem-cell marker (CD34); and phosphatidylserine (PS), an MP marker and mediator of cancer spread. Elevated levels of P-gp + and PS + MPs correlate with disease progression and treatment unresponsiveness. Furthermore, P-gp, PS and CD34 are predominantly expressed in CD138 − MPs in advanced disease. In particular, a dual-positive (CD138 − P-gp + CD34 + ) population is elevated in aggressive/unresponsive disease. Our test provides a personalised liquid biopsy with potential to address the unmet clinical need of monitoring MDR and treatment failure in myeloma.

A major obstacle to chemotherapeutic success in cancer treatment is the development of drug resistance. This occurs when a tumour fails to reduce in size after treatment or when there is clinical relapse after an initial positive response to treatment. A unique and serious type of resistance is multidrug resistance (MDR). MDR causes the simultaneous cross resistance to unrelated drugs used in chemotherapy. MDR can be acquired through genetic alterations following drug exposure, or as discovered by us, through alternative pathways mediated by the transfer of functional MDR proteins and nucleic acids by extracellular vesicles (M Bebawy V Combes E Lee R Jaiswal J Gong A Bonhoure GE Grau, 23 9 1643 1649, 2009).Multiple myeloma is an incurable cancer of bone marrow plasma cells. Treatment involves high dose combination chemotherapy and patient response is unpredictable and variable due to the presence of multisite clonal tumour infiltrates. This clonal heterogeneity can contribute to the development of MDR. There is currently no approved clinical test for the minimally invasive testing of MDR in myeloma.Extracellular vesicles comprise a group of heterogeneous cell-derived membranous structures which include; exosomes, microparticles (microvesicles), migrasomes and apoptotic bodies. Extracellular vesicles serve an important role in cellular communication through the intercellular transfer of cellular protein, nucleic acid and lipid cargo. Of these, microparticles (MPs) originate from the cell plasma membrane and vary in size from 0.1-1um. We have previously shown that MPs confer MDR through the transfer of resistance proteins and nucleic acids. A test for the early detection of MDR would benefit clinical decision making, improve survival and support rational drug use. This review focuses on microparticles as novel clinical biomarkers for the detection of MDR in Myeloma and discusses their role in the therapeutic management of the disease.

Introduction: Multiple Myeloma (MM) is an incurable hematological malignancy affecting plasma cells marked by highly heterogeneous survival rates and confinement of the disease to bone marrow (BM). Relapse is a significant impediment in the clinical setting and the development of multidrug resistance (MDR) to therapy is the main cause of relapse. Currently, risk stratification to MM sub-groups and categorization of complete response to therapy are established on molecular and cytogenetic markers using bone marrow biopsies. We are exploring the clinical significance of plasma cell derived microparticles as a novel prognostic indicator in MM. Materials and Methods: We have analysed 79 de-identified MM patients and 24 normal subjects. Platelet free plasma was centrifuged and plasma cell derived MPs were identified and quantified by flow cytometry using Annexin V450, CD138 APC, anti-P-glycoprotein (P-gp)-FITC (17F9) in BD TruCount tubes. Platelet derived MPs were excluded from the analysis using CD41a-PE. All patient samples were compared to age-matched healthy volunteers. Western blot analysis was conducted on MP lysates probing for the presence of Lung-Resistance related Protein (LRP) and P-glycoprotein (P-gp). Morphology and the size of MP fraction from MM patients were investigated using scanning electron micrographs Results: The number of systemic MPs and CD138+MPs were found to be significantly higher in MM patient samples compared to the healthy volunteers. MDR markers (LRP & P-gp) were expressed on systemic MPs from relapsing MM patients. MPs from patients were spherical in shape and had smooth surface consistent with those isolated from the MM cell line OPM2. Conclusions: There are elevated numbers of systemic MPs in all the 79 MM subjects (across all disease stages) compared to the healthy volunteers. The expressions of CD138 on MPs in the MM patients offer a sensitive assessment of disease progression and therapeutic outcome. Systemic MPs from MM patients carry a ‘snapshot’ of the less accessible bone marrow compartment and may provide a novel systemic ‘biosignature’ of MM progression and therapeutic outcome in the clinical setting. The MDR markers on systemic MPs may support dosage regimen and therapeutic decisions in MM clinical setting. Acknowledgements: This project has ethical approval from Sydney Local Health District Human Research Ethics Committee (CRGH)- EC00118 # HREC/11/CRGH/223 (CH62/6/2011/150). We would like to thank all the volunteers whom have contributed to this study. Citation Format: Sabna Rajeev Krishnan, Mary Bebawy, Ross Duncan Brown, Frederick Luk, Yiulam Kwan. Microparticles as novel prognostic markers in multiple myeloma. [abstract]. In: Proceedings of the 106th Annual Meeting of the American Association for Cancer Research; 2015 Apr 18-22; Philadelphia, PA. Philadelphia (PA): AACR; Cancer Res 2015;75(15 Suppl):Abstract nr 5306. doi:10.1158/1538-7445.AM2015-5306