Molecular Genetic Tools in Cancer Diagnosis and Treatment: Recent Advances and Challenges Ahead
Jaime F. Modiano, VMD, PhD
Department of Veterinary Clinical Sciences, College of Veterinary Medicine, Masonic Cancer Center, and Stem Cell Institute, University of Minnesota, Twin Cities (Minneapolis/St. Paul), MN, USA
Introduction
Gene expression profiling to classify human tumors into functional and clinically relevant subgroups has come of age since this method was first shown to segregate diffuse large B-cell lymphoma,2 breast cancer,39,71 and melanoma5 into defined subsets with distinct biological behaviors. The microarray platforms themselves have evolved, providing ever-increasing coverage of the human transcriptome with more robust annotation. Massive parallel sequencing technologies and full RNA sequencing now provide even greater detail by including all the variants from every RNA species.57
Yet, there are limitations that preclude immediate and widespread clinical application for these technologies. Surprisingly, cost is not a major limitation. Computational power and instrument costs (in shared resource environments) have reduced the cost of array-based analyses and RNAseq to << $500 per sample (in U.S. currency, 2010 value). Technical limitations are similarly trivial, assuming robust quality assurance and quality control protocols are in place. Rather, the major obstacles to clinical implementation are the magnitude of the datasets generated by these technologies and the paucity of individuals who are trained and capable of handling them. Thus, gene expression profiling has found a niche in accelerating basic research and as a tool to define predictive markers and therapeutic targets for a variety of cancers.24
The application of gene expression profiles in companion animals has lagged predictably behind that of humans. Eleven studies evaluating gene expression profiles in canine tumors or tumor cell lines were indexed in PubMed (August 2010),18,27,38,44,45,50,55,59,63,65,75 compared to > 20,000 for humans. This is likely a reflection of economics (and possibly journal selection in PubMed), and does not take into account dozens of ongoing studies applying microarray technologies to canine tumors. Still, it offers a series of opportunities to ask questions selectively, to use published data as a means to add value to new datasets, and as a framework to use appropriate technologies to ask highly relevant questions.
Our group and many collaborators have completed gene expression profiling for > 100 distinct tumors using the Affymetrix canine_2.0 platform. We have defined ways to integrate those data into newer, probably more efficient platforms, and so our current studies use Agilent microarrays and RNAseq almost exclusively. Nonetheless, we have learned valuable lessons from our Affymetrix microarray data, and this review will highlight some of those data as they address specific applications.
Gene Expression Profiling and Molecular Classification of Tumors: An Example Using Canine Lymphoma16
The diagnosis of canine lymphoma or canine non-Hodgkin lymphoma (archaically also called canine lymphosarcoma) encompasses a heterogeneous group of diseases with a broad range of clinical behavior, from relatively indolent to rapidly lethal. The major shared feature among these diseases is their etiology arising from malignant transformation of a lymphoreticular cell. The modified WHO classification system to stratify canine lymphoma was first published in 2002,68 and has since been revised and refined; yet, it remains to be universally adopted by the veterinary pathology community. This is due, at least partly, to the absence of definitive studies verifying that these represent distinct molecular subtypes with unique biological behavior and prognostic significance. Resistance also arises both from pathologists who are uncertain about payoffs for the additional training and time required to apply this classification to every lymphoma they review, as well as from clinicians who do not believe the use of this classification justifies the costs (and potential risk) of obtaining a tissue biopsy for every dog with lymphoma. These topics will be discussed at this meeting.
A history and current update of the modified WHO classification were published in the 6th edition of Schalm's Veterinary Hematology.49,69,70 This classification includes approximately 30 subtypes, but recent data confirm our experience that the six most common forms of diffuse large B-cell lymphoma (DLBCL), marginal zone (B-cell) lymphoma (MZL), Burkitt or Burkitt-like lymphoma (BL), T-zone lymphoma (TZL), lymphoblastic T-cell lymphoma/leukemia (LBT), and peripheral T cell lymphoma-not otherwise specified (PTCL), account for > 90% of all canine lymphomas.15,36,41 These tumors have consistent morphological and molecular characteristics, and T-cell tumors can be readily grouped according to aggressive (LBT, PTCL) and indolent (TZL) biological behavior. However, the cellular features that distinguish among B-cell tumors are subtle, and an association between subtype and clinical outcomes has been more elusive.
To date, genome-wide molecular features of canine lymphoma have not been interrogated in a sufficiently large sample size to refine the molecular classification, predictive value, or target discovery for this disease. As a prelude to this, we examined gene expression profiles of 36 primary tumors collected prospectively, and representing the six common subtypes defined above.16 Our results show that gene expression profiles clearly distinguish canine lymphomas based on their immunological ontogeny (i.e., derivation from B-cell or T-cell cell lineages). Furthermore, biological behavior was clearly associated with distinct patterns of gene expression in T-cell malignancies. Conversely, gene expression differences among the three subtypes of B-cell tumors were much more subtle, although there were differences in the architecture of the affected lymph nodes, differences were apparent when expression data were analyzed by gene set enrichment. Supervised analysis identified genes that are expressed differentially in dogs with B-cell lymphoma that show a robust response well to CHOP-based chemotherapy (survival > 15 months) vs. those that do not (survival < 14 months), although the expression of these genes does not seem to be regulated coordinately. Current work is focused on adapting this information to laboratory tests that are feasible and can provide prognostic and predictive information to help guide therapy. In summary, our data indicate that molecular profiling can help stratify complex neoplastic diseases into classifications that can help predict biological behavior. Ongoing and future work will narrow down most robust criteria to define each subtype and predict response to therapy using conventional and cost effective laboratory methodology in order to translate these findings to the clinical setting.
Gene Expression Profiling to Improve Prediction in Tumors with Clinically Heterogeneous Behavior: An Example Using Canine Osteosarcoma48,62
Osteosarcoma is a heterogeneous and chaotic disease that has confounded accurate molecular classification, prognosis, and prediction. This is an aggressive disease with a median survival of < 1 year (with current standard of care); however, up to 20% of dogs with osteosarcoma respond to therapy and survive > 2 years.35 This could be due to vigilance and early detection, but it more likely reflects variation in the biological behavior of this disease, mediated by tumor-intrinsic or tumor-autonomous properties. The histological classification of canine osteosarcoma is based on the type of matrix produced by tumors (osteoid, chondroid, or collagen), but this is not predictive of biological behavior or response to therapy. Other pathological and clinical features are similarly unreliable predictors of outcome.
This disease is no less of a conundrum when it occurs in people. The most commonly used prognostic factor in human patients with osteosarcoma is percent necrosis after neoadjuvant therapy, but recent studies indicate the correlation between necrosis and response to therapy is as low as 55% (not significantly better than "flipping a coin").7
We took advantage of the inherently reduced genetic heterogeneity present in dogs to reveal orthologous molecular subtypes of osteosarcoma. Using a cohort of 26 dogs with osteosarcoma, we identified a strong differential gene signature that segregated tumor samples into two groups with differential survival distributions, and which consisted of inversely correlated expression of genes associated with 'microenvironment-interaction' and 'cell cycle'. We next explored the reproducibility and the evolutionary conservation of this signature,48 applying the restricted osteosarcoma gene vectors to an independent cohort of dogs with osteosarcoma38 or to five independent cohorts of humans with osteosarcoma7,25,34,38. This approach confirmed (in dogs) and identified (in humans) the existence of previously uncharacterized, molecularly distinct subtypes of osteosarcoma that are prognostically significant. Furthermore, when this profile was combined with analysis of microRNA expression and DNA copy number aberrations,62 a clear picture arose suggesting three etiologically distinct, and highly evolutionarily conserved pathways lead to osteosarcoma in people and in dogs.
This illustrates how the narrower genetic diversity of dogs can be utilized to stratify complex diseases, to obtain molecular characterizations that may enhance prognosis and prediction, and potentially to identify clinically relevant therapeutic targets.
Gene Expression Profiling to Identify Tumor Ontogeny and the Contribution of Heritable Factors: An Example Using Canine Hemangiosarcoma58,59
Malignant soft tissue sarcomas that arise from or resemble constituents of blood vessels represent an understudied and poorly understood group of incurable tumors. In humans, these tumors include angiosarcomas (hemangiosarcomas and lymphangiosarcomas), Kaposi sarcomas, hemangioendotheliomas, and hemangiopericytomas, some of which are associated with medical or occupational exposures to ionizing radiation, viruses, and a variety of industrial and agricultural chemical agents. Their study is complicated by their infrequent occurrence, but their clinical significance is magnified because angiosarcomas in particular are associated with more frequent metastasis and greater patient morbidity and mortality than other soft tissue sarcomas.10,26,52
Other species also develop hemangiosarcomas. From a comparative perspective, hemangiosarcomas occur rarely in mice as a spontaneous disease, but the incidence is significantly increased in the B6C3F1 hybrid strain after exposure to various classes of pharmaceuticals, making these tumors a factor in risk assessment for drug development.10 Dogs are the only species where idiopathic (spontaneous) hemangiosarcoma occurs commonly. This disease has been estimated to account for up to 7% of malignant canine tumors,66 which would roughly translate into > 50,000 diagnoses per year in the United States. Regardless of species, treatment options for angiosarcoma and hemangiosarcoma are limited, and outcomes are generally unrewarding.8,19,21 The standard of care in both humans and dogs includes surgery and adjuvant chemotherapy. The median and 5-year survival rates for human patients with angiosarcoma are reported to be approximately 2 to 2.5 years and 30%, respectively.26 In dogs, the prognosis is equally grave: even though 10–15% of dogs with this disease survive 12 months or longer, most die within 3-months of their diagnosis.66 Despite anecdotal success using immunotherapy, as well as novel chemotherapy and antiangiogenic strategies to treat canine hemangiosarcoma,3,9,29,46,64,67 the past 30 years have brought no improvements in survival for dogs with this disease20.
The lack of effective treatments for humans and dogs with angiosarcoma and hemangiosarcoma is largely due to our incomplete understanding of the factors that promote the survival, growth, and metastases of these malignancies. Inflammation, hypoxia, and angiogenesis all might contribute to the pathogenesis of idiopathic hemangiosarcoma, or of hemangiosarcoma associated with exposure to non-genotoxic agents in each of the target species. The link between inflammation and cancer is becoming clearer, with macrophages and macrophage-derived cytokines playing a central role in modulating the tumor microenvironment to facilitate both tumor survival and metastasis.31,32,76 Macrophage activation and local tissue hypoxia are central components of the proposed mechanism of action that drives hemangiosarcoma in rodents exposed to a diverse array of compounds such as 2-butoxyethanol, peroxisome proliferator–activated receptor (PPAR) agonists and pregabalin.10 Parallels have been drawn between canine hemangiosarcoma cells and neoangiogenic endothelial cells in tumors.1,14 Vessel formation in hemangiosarcoma resembles the morphology of imbalanced, chaotic growth and maturation of neoangiogenic vessels seen in cancer, which is at least partly driven by pro-angiogenic factors such as vascular endothelial growth factor-A (VEGF).14,40 In fact, hemangiosarcoma cells elaborate growth factors that promote angiogenesis, including not only VEGF, but also platelet-derived growth factor-β (PDGFβ), and basic fibroblast growth factor (bFGF) in vitro.1,14,20,61 Signaling by each of these growth factors is partly dependent on activation of the phosphoinositide 3-kinase (PI3K) pathway, providing a possible connection between the processes of inflammation, hypoxia, and angiogenesis in the pathogenesis of hemangiosarcoma.22 In this regard, mutations of the PI3K antagonist, PTEN, are common in canine hemangiosarcoma; however, they are restricted to the C-terminal domain and do not affect the phosphorylation of Akt that occurs downstream from PI3K signaling.11 While it is possible that mutations in the C-terminal domain reduce the stability of PTEN73 or increase motility, and hence a cell's invasive potential,30,37 the precise effects of these mutations in canine hemangiosarcoma remain unclear. The genetic basis of abnormal patterns of growth and signaling requires further characterization.
Mutational events have been documented in sporadic angiosarcomas of humans and hemangiosarcomas of mice and dogs, including cancer-associated genes such as PTEN, Ras, VHL, p53, and connexin.12,17,23,33,47,51,60,74 In the case of canine hemangiosarcoma, PTEN mutations did not fully explain the increased levels of VEGF or other growth factors,11,14 prompting additional assessment of potential roles for mutations that inactivate specific oncogenes or tumor suppressor genes that can lead to elevated VEGF production. Yet, another possibility is that non-malignant cells are responsible for VEGF production in canine hemangiosarcoma,56 especially since co-existence of tumor cells with inflammatory cells is a common feature of this disease, and in some cases, the inflammatory cells may provide the principal source of VEGF11. In this scenario, VEGF-producing inflammatory cells could be reactive leukocytes incited by pathologic effects of tumor (e.g., tissue destruction), or macrophages and myeloid cells that are intrinsic components of the tumor microenvironment.31,56 A third possibility is that hemangiosarcomas originate from a multipotent bone marrow progenitor that can differentiate along the myeloid lineage,28,77 and these cells thus could reflect the ontogeny of the malignant cells and their plasticity to differentiate into multiple cell types.
While most tumors arise sporadically due to an accumulation of key somatic mutations, it can be presumed that individual genetic backgrounds contribute to the risk, phenotypes and biological behavior of cancer. Yet, until recently, experimental evidence for this presumption, as well as for the magnitude of its effect was lacking for any naturally occurring, non-heritable tumor in any species. Studies exploring how race and ethnicity influenced gene expression and disease susceptibility in humans found few differences, and none especially compelling.13,54,72 Dogs provide a useful surrogate for human ethnic groups. While they retain individual (outbred) traits, the derivation and maintenance of unique breeds has led to restricted gene pools. These restricted gene pools can be used to study heritable contributions to cancer susceptibility in animals that develop tumors spontaneously and share the human environment, but with the benefit of less ''noise'' from other phenotypic variation. In the case of hemangiosarcoma, there is an apparent predilection for certain breeds such as German Shepherd Dogs, Boxers, and Golden Retrievers.4,6,42,43,53,66 Given the strong association between breed and risk, we predicted that gene expression profiles in tumors such as hemangiosarcoma also would reflect features uniquely associated with the breed, and that breed-related gene expression profiles would uncover biologically and therapeutically significant pathways that would inform etiology and identify therapeutic targets.
We used an isolated in vitro system to examine gene expression in canine hemangiosarcoma, comparing data from a cohort of cell lines derived from malignant tumors as well as control endothelial cell lines derived from non-malignant proliferative lesions of the dog spleen (benign hematomas associated with nodular hyperplasia). Our hypotheses were that canine hemangiosarcoma would show characteristic gene expression profiles that would be informative for etiology and progression, and that hemangiosarcomas of Golden Retrievers would be distinguishable from histologically similar hemangiosarcomas of dogs from other breeds (non-Golden Retrievers) based on the overexpression or underexpression of genes preferentially concentrated in one or a few metabolic pathways.
Our results show that genes involved in inflammation, angiogenesis, adhesion, invasion, metabolism, cell cycle, signaling, and patterning can distinguish hemangiosarcoma cells from non-malignant endothelial cells.58 This signature did not simply reflect a cancer-associated angiogenic phenotype, as it also distinguished hemangiosarcoma from non-endothelial, moderately to highly angiogenic bone marrow-derived tumors (lymphoma, leukemia, osteosarcoma). Moreover, our results uncovered unique gene sets, also largely confined to these biological processes, which were uniquely enriched in hemangiosarcoma from a single dog breed (sharing a common genetic background).59
Our data show that inflammation and angiogenesis are important processes in the pathogenesis of vascular tumors, but a definitive ontogeny of the cells that give rise to these tumors remains to be established. The data do not yet distinguish whether functional or ontogenetic plasticity creates this phenotype, although they suggest that cells which give rise to hemangiosarcoma modulate their microenvironment to promote tumor growth and survival. Similarly, these data suggest that the traits leading to hemangiosarcoma are modulated by a spectrum of heritable traits which may result in greater risk of developing the disease itself or perhaps developing a subtype of the disease that shows more rapid progression. We propose that creative studies of naturally occurring canine cancer offer opportunities to integrate molecular data to stratify disease into pathologically relevant and clinically significant subtypes. Used judiciously, these data may assist in the identification of targets to develop effective strategies for prevention, control, and treatment.
Acknowledgments
The author wishes to acknowledge the valuable contributions of every member of his laboratory and his collaborators' laboratories without whom this work would not have been possible, as well as the funding agencies that have supported this work.
Disclosures
Dr. Modiano holds an equity interest in - and serves as a consultant for - ApopLogic Pharmaceuticals, Inc., the developer of Fasaret, a product that has been used in treatment of canine osteosarcoma. These relationships have been reviewed and managed by the University of Minnesota in accordance with its conflict of interest policies
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