Metastasis is the major cause of death in colorectal cancer (CRC) patients. Circulating tumor cells (CTCs) are the biologic correlate of metastasis. Despite the clinical relevance of CTCs, there has been little progress in understanding their biology in detail; particularly the phenotype of CTCs with metastasis-forming capacities is still unknown. In this article we discuss the benefits and limitations of mouse models of CRC-derived CTCs.
Keywords: Colorectal cancer; Tumor cells; Metastasis; Primary tumor
Colorectal CancerColorectal cancer (CRC) is one of the most common tumor diseases [1] and has high mortality and morbidity rates especially in metastatic stages [2]. The vast majority of CRC-related deaths are due to distant metastases, most prominently to the liver, rather than the primary tumor [2]. Metastasis is a multi-step process during which the cells develop a migratory phenotype and detach from the primary tumor, invade the local vasculature and survive in circulation, extravasate into distant organs and finally outgrow to manifest metastatic lesions [3,4]. The presence of circulating tumor cells (CTCs) in the blood stream of the patients indicates metastatic activity and is a negative prognostic factor in all stages of CRC [5][6][7][8][9][10].Metastatic dissemination is a dynamic process requiring dramatic phenotypic alterations in order for the tumor cells to survive the challenges posed in circulation and by the microenvironment at the distant metastatic sites. Hence, CTCs require a considerable degree of plasticity in order to successfully complete the process of metastasis. As distant metastases are generally phenotypically similar to the primary tumor [11], most of these phenotypic changes must be reversible. Prominent examples of this plasticity are epithelial-to-mesenchymal transition (EMT), which CTCs undergo to gain a migratory phenotype by down-regulation of epithelial markers (E-cadherin, EpCAM) and upregulation of mesenchymal markers (N-cadherin, vimentin); and mesenchymal-to-epithelial transition (MET) in the target organ, ultimately resulting in epithelial metastases [12][13][14][15][16][17].Although tumors shed millions of CTCs into circulation [18], in most patients only a few metastases arise during the course of the disease. Therefore, it is conceivable that only a very small fraction of CTCs is actually capable of forming distant metastases. It is these few CTCs with metastasis-forming capacities which must be identified and characterized in order to conceive novel anti-metastatic therapeutics. The phenotype of metastasis-forming CTCs has already been narrowed down in breast cancer-derived CTCs [19]; however, tens of thousands of cells had to be screened and thousands of metastasis-forming CTCs had to be injected into mice in order to induce metastases in these animals. As CTCs are a much rarer event in CRC than in breast cancer, such an approach seems hardly possible in CRC. Additionally, the still rather large amount of CTCs needed to induce tumors in mice indicates the ...