Background
Breast cancer (BC) is one of the most common malignancies in women and the second leading cause of metastases in the brain [
1]. BC brain metastases (BCBM) have a poor prognosis and restricted therapeutic response due to the minimal blood-brain barrier (BBB) penetration of chemotherapeutic and targeted agents [
2,
3]. Existing conventional therapies including surgical resection, whole-brain radiation therapy (WBRT), stereotactic radiosurgery (SRS), targeted drugs, and immune checkpoint inhibitors are seldom curative in BM [
4]. Consequently, the median survival of BM patients is about a year after diagnosis [
5].
The characteristic of cancer metastases and progression is determined by the reciprocal and dynamic interactions between the cancer cells and stromal cells as part of the tumor microenvironment (TME) in the host tissue; this interaction supports in cancer cell survival, invasion, and distant metastasis [
6,
7]. TME, particularly the stromal components, is a vital and critical part of the contemporary development of BC therapeutic strategies [
8]. Stromal cancer-associated fibroblasts (CAFs), are considered the most vital TME elements and are emerging therapeutic targets for BCBM. Although CAF populations are presumed to be heterogeneous in TME and have been known to promote tumorigenesis and metastasis, their precise functions in systemic or metastatic cancers are not fully elucidated [
9].
Previous studies have shown that various CAFs subtypes are pro- or anti-tumorigenic, with their biological actions reliant on their specific tumor conditions [
10,
11]. Specific CAF subtypes may affect tumor growth and/or inhibition, possibly according to the primary tumor types and locations [
11]. The depletion of α-SMA in the tumor stroma prompts immunosuppression and cancer progression with shortened survival in pancreatic cancer patients [
12]. A high expression of α-SMA is associated with longer overall survival (OS) after tumor resection in hepatocellular carcinoma and pancreatic cancer [
13]. Besides, the abundant expression of stromal fibroblast activation protein (FAP) is also related to longer OS and disease-free survival (DFS) in patients with invasive ductal carcinoma of the breast [
14]. These studies, therefore, argued that stromal CAFs may slow the progression of the tumor and thus increase the patient’s survival.
Numerous CAF markers have been used in clinical and biological studies of CAFs in human cancer so far [
15], but the current study was conducted with a focus on PDGFR-β and α-SMA. We investigated the expression level of these markers of the stromal CAFs in BCBMs and evaluated he correlation of their expressions with clinico-pathological variables. In addition, we analyzed the recurrence-free survival (RFS) and overall survival (OS) rates according to the expression levels of CAF markers and clinico-pathological variables.
Discussion
Metastases remain a leading cause of drug resistance and tumor-induced death in BC patients [
20]. Therefore, even though advanced chemotherapy based on molecular biology have improved patient survival, the development and trial of new treatment strategy have been continued with an aim of overcoming mechanisms of drug resistance and tumor relapse [
21]. The TME plays a fundamental role in tumor development and progression. The study of TME might provide an insight into the novel therapeutic strategies. The fibroblasts are the most abundant cells in TME of solid tumors, such as BC, and are considered the most important elements in TME [
22]. Some studies have investigated the role of CAFs in the primary site for tumor progression and distance metastases in BC [
23‐
26]. Among the various CAF markers studied in BC [
15], PDGFR-β and α-SMA were found to be important markers dividing the subpopulation of CAF. In particular, it has been reported that PDGFR-β plays an important role in identifying vascular CAF and its origin [
27]. It has been reported that α-SMA can be used as an important marker for the subpopulation of CAFs associated with immune evasion of BC [
28]. In addition, PDGFR-β was also identified as a marker of CAF, which plays an important role in forming the immunosuppressive TME of BC [
29]. However, several studies have been conducted on PDGFR-β and α-SMA as CAF markers in the primary BC, but few studies have been conducted on PDGFR-β and α-SMA in BCBM. The present study aimed to investigate the clinical influence of metastatic site CAFs, especially with high expression of PDGFR-β/α-SMA, on clinical characteristics and prognosis of BCBM patients.
As CAF profiles are modified by reciprocal interaction with cancer cells, each CAFs might express various characteristics in correlation with different features of cancer cells [
30]. Our results disclosed differential expression of PDGFR-β and α-SMA in the stroma of the metastatic site according to the molecular subtype of BC. Specifically, the expression of PDGFR-β was relatively low in the TN type. Our study is in line with a previous study which reported that low PDGFR-β expression in the primary site was more likely to be observed in the TN type [
31]. Survival rates of BC patients were affected by the molecular subtypes of BCBM, the same as our data [
32]. Furthermore, we observed that a higher expression of PDGFR-β or α-SMA indicated a good prognosis, particularly for RFS of patients with BCBM. CAF-related proteins also play an intrinsic role in tumor progression or suppression [
33]. Some studies have supported that increased CAF protein subset in the TME tends to prolong the survival of cancer patients [
12,
14]. We supposed that one of the heterogeneous CAFs subtypes, especially with high expression of PDGFR-β/α-SMA in BCBM may repress recurrence of tumor in the resection area and was sparsely related with TN, the most aggressive cancer cell subtype. However, regarding OS, the expression of the two markers had no statistical significance, and rather, the survival rate tended to be somewhat longer in the high expression groups. It is presumed that there are multiple factors for the different trends of RFS and OS in relation to the expression of these markers. Other than the fact that the TN molecular subtype acts as a very strong factor in determining the survival rate of BC patients, it is presumed that this may be the result of a complex action of various factors constituting the TME. The definite role of CAF components with regard to the survival rates of BC patients needs to be clarified in the future studies from a larger cohort of patients.
Usually, PDGFR-β and α-SMA are expressed in the stromal fibroblast and help in tissue remodeling, collagen turnover, and the wound healing process [
34,
35]. Particularly, the activation and proliferation of fibroblast and production of ECM elements, known as a desmoplastic reaction, represents aspects of cancer progression and clinical outcomes in BC [
24]. In the present study, there was a significant correlation between tumor nature (solid or cyst) and the expression of PDGFR-β/α-SMA. The expression of PDGFR-β/α-SMA in BCBM may also be interrelated with desmoplastic reactions. Even more, altered mechanical features of the TME such as ECM stiffness cause fibrosis by developing mechano-activation of fibroblasts. Therefore, it implies that differential expression of PDGFR-β/α-SMA according to tumor natures is correlated with desmoplastic features of BC and different mechanical stress of TME, regardless of the prognosis [
36].
Previous studies have classified CAFs subtypes according to morphologic characteristics or molecular profiles [
29,
30]. In the present study, the distribution of CAFs varied according to morphologic differences and could be grouped into three patterns (A, B, C). The pattern B type’s CAFs encased individual cancer cells or intermingled closely with small tumor nests. In CAFs in pattern B types, the expression levels of PDGFR-β and α-SMA were relatively high. The morphologic pattern is often related to the molecular profile and further to the functional aspect. However, unlike the correlation between the expression of PDGFR-β/α-SMA and tumor progression, there was no significant connection between our morphologic subtypes and patient clinical features. Therefore, a more detailed and suitable morphologic classification of CAFs is required for a more cost-effective prediction of prognosis with simple tissue analysis.
It is hard to anticipate the prognosis of patients with BCBM, although several prognostic factors have been suggested, which are associated with poor prognosis. As age, KPS, tumor subtypes, extracranial metastasis, and the number of BM are associated with survival in patients with BCBM, these factors were used to identify patients with good or bad prognosis [
37,
38]. However, the above mentioned factors did not show a significant association with poor prognosis in the present study, except for tumor subtypes. Those factors only showed a tendency to relate to RFS, and PDGFR-β/α-SMA also showed a tendency to a similar degree. There is a low possibility for PDGFR-β/α-SMA to be a strong prognostic biomarker, further large-scale studies should verify PDGFR-β/α-SMA as feasible biomarkers to help ameliorate predicting the patient’s prognosis with BCBM. Because this was a retrospective study with a relatively small number of patients, there may be a possibility of selection bias. In addition, this study was a simple clinico-radiological and pathological investigation using only two CAF markers. To determine the exact role of CAFs for patients with BM from BC, a further prospective study with a large sample size and more detailed information on various CAF markers is needed.
Conclusions
Our study showed different expressions levels of PDGFR-β and α-SMA in stromal CAFs of BMs according to molecular subtypes of BC. The expression of the markers was lower in TN patients, the most aggressive molecular subtype, compared to other Luminal or HER2+ BC patients. Besides, this study investigated the correlation between stromal CAFs with high PDGFR-β/α-SMA expression and favorable prognosis of BCBM patients. More aggressive BC could be capable of metastasis to the brain, and recurrence after surgical resection, with CAFs subtype with low PDGFR-β/α-SMA expression. The present study aimed to show the clinical influence of metastatic site CAFs, in connection with biomarkers, PDGFR-β and α-SMA. Owing to the limitations of this study, further research on the exact role of CAFs is needed to provide an insight into the development of new therapeutic strategies for BCBM patients with a dismal prognosis.
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