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<!DOCTYPE html> <html lang="en" class="no-js"> <head> <meta charset="UTF-8"> <meta http-equiv="X-UA-Compatible" content="IE=edge"> <meta name="applicable-device" content="pc,mobile"> <meta name="viewport" content="width=device-width, initial-scale=1"> <meta name="robots" content="max-image-preview:large"> <meta name="access" content="Yes"> <meta name="360-site-verification" content="1268d79b5e96aecf3ff2a7dac04ad990" /> <title>Mesenchymal and stemness circulating tumor cells in early breast cancer diagnosis | BMC Cancer</title> <meta name="citation_abstract" content="Epithelial mesenchymal transition (EMT) is a crucial event likely involved in dissemination of epithelial cancer cells. This process enables them to acquire migratory/invasive properties, contributing to tumor and metastatic spread. To know if this event is an early one in breast cancer, we developed a clinical trial. The aim of this protocol was to detect circulating tumor cells endowed with mesenchymal and/or stemness characteristics, at the time of initial diagnosis. Breast cancer patients (n = 61), without visceral or bone metastasis were enrolled and analysis of these dedifferentiated circulating tumor cells (ddCTC) was realized. AdnaGen method was used for enrichment cell selection. Then, ddCTC were characterized by RT-PCR study of the following genes: PI3Kα, Akt-2, Twist1 (EMT markers) and ALDH1, Bmi1 and CD44 (stemness indicators). Among the studied primary breast cancer cohort, presence of ddCTC was detected in 39% of cases. This positivity is independant from tumor clinicopathological factors apart from the lymph node status. Our data uniquely demonstrated that in vivo EMT occurs in the primary tumors and is associated with an enhanced ability of tumor cells to intravasate in the early phase of cancer disease. These results suggest that analysis of circulating tumor cells focused on cells showing mesenchymal or stemness characteristics might facilitate assessment of new drugs in clinical trials."/> <meta name="journal_id" content="12885"/> <meta name="dc.title" content="Mesenchymal and stemness circulating tumor cells in early breast cancer diagnosis"/> <meta name="dc.source" content="BMC Cancer 2012 12:1"/> <meta name="dc.format" content="text/html"/> <meta name="dc.publisher" content="BioMed Central"/> <meta name="dc.date" content="2012-03-23"/> <meta name="dc.type" content="OriginalPaper"/> <meta name="dc.language" content="En"/> <meta name="dc.copyright" content="2012 Barrière et al; licensee BioMed Central Ltd."/> <meta name="dc.rights" content="http://creativecommons.org/licenses/by/2.0"/> <meta name="dc.rightsAgent" content="reprints@biomedcentral.com"/> <meta name="dc.description" content="Epithelial mesenchymal transition (EMT) is a crucial event likely involved in dissemination of epithelial cancer cells. This process enables them to acquire migratory/invasive properties, contributing to tumor and metastatic spread. To know if this event is an early one in breast cancer, we developed a clinical trial. The aim of this protocol was to detect circulating tumor cells endowed with mesenchymal and/or stemness characteristics, at the time of initial diagnosis. Breast cancer patients (n = 61), without visceral or bone metastasis were enrolled and analysis of these dedifferentiated circulating tumor cells (ddCTC) was realized. AdnaGen method was used for enrichment cell selection. Then, ddCTC were characterized by RT-PCR study of the following genes: PI3Kα, Akt-2, Twist1 (EMT markers) and ALDH1, Bmi1 and CD44 (stemness indicators). Among the studied primary breast cancer cohort, presence of ddCTC was detected in 39% of cases. This positivity is independant from tumor clinicopathological factors apart from the lymph node status. Our data uniquely demonstrated that in vivo EMT occurs in the primary tumors and is associated with an enhanced ability of tumor cells to intravasate in the early phase of cancer disease. These results suggest that analysis of circulating tumor cells focused on cells showing mesenchymal or stemness characteristics might facilitate assessment of new drugs in clinical trials."/> <meta name="prism.issn" content="1471-2407"/> <meta name="prism.publicationName" content="BMC Cancer"/> <meta name="prism.publicationDate" content="2012-03-23"/> <meta name="prism.volume" content="12"/> <meta name="prism.number" content="1"/> <meta name="prism.section" content="OriginalPaper"/> <meta name="prism.startingPage" content="1"/> <meta name="prism.endingPage" content="7"/> <meta name="prism.copyright" content="2012 Barrière et al; licensee BioMed Central Ltd."/> <meta name="prism.rightsAgent" content="reprints@biomedcentral.com"/> <meta name="prism.url" content="https://link.springer.com/articles/10.1186/1471-2407-12-114"/> <meta name="prism.doi" content="doi:10.1186/1471-2407-12-114"/> <meta name="citation_pdf_url" content="https://bmccancer.biomedcentral.com/counter/pdf/10.1186/1471-2407-12-114"/> <meta name="citation_fulltext_html_url" content="https://link.springer.com/articles/10.1186/1471-2407-12-114"/> <meta name="citation_journal_title" content="BMC Cancer"/> <meta name="citation_journal_abbrev" content="BMC Cancer"/> <meta name="citation_publisher" content="BioMed Central"/> <meta name="citation_issn" content="1471-2407"/> <meta name="citation_title" content="Mesenchymal and stemness circulating tumor cells in early breast cancer diagnosis"/> <meta name="citation_volume" content="12"/> <meta name="citation_issue" content="1"/> <meta name="citation_publication_date" content="2012/12"/> <meta name="citation_online_date" content="2012/03/23"/> <meta name="citation_firstpage" content="1"/> <meta name="citation_lastpage" content="7"/> <meta name="citation_article_type" content="Research article"/> <meta name="citation_fulltext_world_readable" content=""/> <meta name="citation_language" content="en"/> <meta name="dc.identifier" content="doi:10.1186/1471-2407-12-114"/> <meta name="DOI" content="10.1186/1471-2407-12-114"/> <meta name="size" content="149057"/> <meta name="citation_doi" content="10.1186/1471-2407-12-114"/> <meta name="citation_springer_api_url" content="http://api.springer.com/xmldata/jats?q=doi:10.1186/1471-2407-12-114&api_key="/> <meta name="description" content="Epithelial mesenchymal transition (EMT) is a crucial event likely involved in dissemination of epithelial cancer cells. This process enables them to acquire migratory/invasive properties, contributing to tumor and metastatic spread. To know if this event is an early one in breast cancer, we developed a clinical trial. The aim of this protocol was to detect circulating tumor cells endowed with mesenchymal and/or stemness characteristics, at the time of initial diagnosis. Breast cancer patients (n = 61), without visceral or bone metastasis were enrolled and analysis of these dedifferentiated circulating tumor cells (ddCTC) was realized. AdnaGen method was used for enrichment cell selection. Then, ddCTC were characterized by RT-PCR study of the following genes: PI3Kα, Akt-2, Twist1 (EMT markers) and ALDH1, Bmi1 and CD44 (stemness indicators). Among the studied primary breast cancer cohort, presence of ddCTC was detected in 39% of cases. This positivity is independant from tumor clinicopathological factors apart from the lymph node status. Our data uniquely demonstrated that in vivo EMT occurs in the primary tumors and is associated with an enhanced ability of tumor cells to intravasate in the early phase of cancer disease. These results suggest that analysis of circulating tumor cells focused on cells showing mesenchymal or stemness characteristics might facilitate assessment of new drugs in clinical trials."/> <meta name="dc.creator" content="Barrière, Guislaine"/> <meta name="dc.creator" content="Riouallon, Alain"/> <meta name="dc.creator" content="Renaudie, Joël"/> <meta name="dc.creator" content="Tartary, Michel"/> <meta name="dc.creator" content="Rigaud, Michel"/> <meta name="dc.subject" content="Cancer Research"/> <meta name="dc.subject" content="Oncology"/> <meta name="dc.subject" content="Surgical Oncology"/> <meta name="dc.subject" content="Health Promotion and Disease Prevention"/> <meta name="dc.subject" content="Biomedicine, general"/> <meta name="dc.subject" content="Medicine/Public Health, general"/> <meta name="citation_reference" content="citation_journal_title=J Clin Oncol; citation_title=Circulating tumor cells: a useful predictor of treatment efficacy in metastatic breast cancer; citation_author=MC Liu, PG Shields, RD Warren, P Cohen, M Wilkinson, YL Ottaviano, SB Rao, J Eng-Wong, F Seillier-Moiseiwitsch, AM Noone, C Isaacs; citation_volume=27; citation_publication_date=2009; citation_pages=5153-5159; citation_doi=10.1200/JCO.2008.20.6664; citation_id=CR1"/> <meta name="citation_reference" content="citation_journal_title=J Natl Cancer Inst; citation_title=Anti-epithelial cell adhesion molecule antibodies and the detection of circulating normal-like breast tumor cells; citation_author=AM Sieuwerts, J Kraan, J Bolt, P van der Spoel, F Elstrodt, M Schutte, JW Martens, JW Gratama, S Sleijfer, JA Foekens; citation_volume=101; citation_publication_date=2009; citation_pages=61-66; citation_doi=10.1093/jnci/djn419; citation_id=CR2"/> <meta name="citation_reference" content="citation_journal_title=Cancer Cell; citation_title=Systemic spread is an early step in breast cancer; citation_author=Y Hüsemann, JB Geigl, F Schubert, P Musiani, M Meyer, E Burghart, G Forni, R Eils, T Fehm, G Riethmüller, CA Klein; citation_volume=13; citation_publication_date=2008; citation_pages=58-68; citation_doi=10.1016/j.ccr.2007.12.003; citation_id=CR3"/> <meta name="citation_reference" content="citation_journal_title=Clin Cancer Res; citation_title=Cancer stem cells and metastasis: lethal seeds; citation_author=MS Wicha; citation_volume=12; citation_publication_date=2006; citation_pages=5606-5607; citation_doi=10.1158/1078-0432.CCR-06-1537; citation_id=CR4"/> <meta name="citation_reference" content="citation_journal_title=Nat Rev Cancer; citation_title=Parallel progression of primary tumours and metastases; citation_author=CA Klein; citation_volume=9; citation_publication_date=2009; citation_pages=302-312; citation_doi=10.1038/nrc2627; citation_id=CR5"/> <meta name="citation_reference" content="citation_journal_title=Science; citation_title=Perspective on cancer cell metastasis; citation_author=CL Chaffer, RA Weinberg; citation_volume=331; citation_publication_date=2011; citation_pages=1559-1564; citation_doi=10.1126/science.1203543; citation_id=CR6"/> <meta name="citation_reference" content="citation_journal_title=Nat Rev Cancer; citation_title=Epithelial-mesenchymal transitions in tumour progression; citation_author=JP Thiery; citation_volume=2; citation_publication_date=2002; citation_pages=442-454; citation_doi=10.1038/nrc822; citation_id=CR7"/> <meta name="citation_reference" content="citation_journal_title=Cancer Lett; citation_title=Circulating tumor cells with a putative stem cell phenotype in peripheral blood of patients with breast cancer; citation_author=PA Theodoropoulos, H Polioudaki, S Agelaki, G Kallergi, Z Saridaki, D Mavroudis, V Georgoulias; citation_volume=288; citation_publication_date=2010; citation_pages=99-106; citation_doi=10.1016/j.canlet.2009.06.027; citation_id=CR8"/> <meta name="citation_reference" content="citation_journal_title=Breast Cancer Res Treat; citation_title=Transforming growth factor-beta signaling: emerging stem cell target in metastatic breast cancer?; citation_author=AR Tan, G Alexe, M Reiss; citation_volume=115; citation_publication_date=2009; citation_pages=453-495; citation_doi=10.1007/s10549-008-0184-1; citation_id=CR9"/> <meta name="citation_reference" content="citation_journal_title=J Cell Sci; citation_title=Phosphoinositide 3-kinase signalling pathways; citation_author=DA Cantrell; citation_volume=114; citation_publication_date=2001; citation_pages=1439-1445; citation_id=CR10"/> <meta name="citation_reference" content="citation_journal_title=Breast Cancer Res; citation_title=Akt2: a role in breast cancer metastasis; citation_author=NM Chau, M Ashcroft; citation_volume=6; citation_publication_date=2004; citation_pages=55-57; citation_doi=10.1186/bcr739; citation_id=CR11"/> <meta name="citation_reference" content="citation_journal_title=Cancer Res; citation_title=Twist transcriptionally up-regulates AKT2 in breast cancer cells leading to increased migration, invasion, and resistance to paclitaxel; citation_author=GZ Cheng, J Chan, Q Wang, W Zhang, CD Sun, LH Wang; citation_volume=67; citation_publication_date=2007; citation_pages=1979-1987; citation_doi=10.1158/0008-5472.CAN-06-1479; citation_id=CR12"/> <meta name="citation_reference" content="citation_journal_title=Nat Cell Biol; citation_title=Tumorigenesis: Twist1 links EMT to self-renewal; citation_author=A Martin, A Cano; citation_volume=12; citation_publication_date=2010; citation_pages=924-925; citation_doi=10.1038/ncb1010-924; citation_id=CR13"/> <meta name="citation_reference" content="citation_journal_title=Cell Stem Cell; citation_title=ALDH1 is a marker of normal and malignant human mammary stem cells and a predictor of poor clinical outcome; citation_author=C Ginestier, MH Hur, E Charafe-Jauffret, F Monville, J Dutcher, M Brown, J Jacquemier, P Viens, CG Kleer, S Liu, A Schott, D Hayes, D Birnbaum, MS Wicha, G Dontu; citation_volume=1; citation_publication_date=2007; citation_pages=555-567; citation_doi=10.1016/j.stem.2007.08.014; citation_id=CR14"/> <meta name="citation_reference" content="citation_journal_title=Proc Natl Acad Sci USA; citation_title=Prospective identification of tumorigenic breast cancer cells; citation_author=M Al-Hajj, MS Wicha, A Benito-Hernandez, SJ Morrison, MF Clarke; citation_volume=100; citation_publication_date=2003; citation_pages=3983-3988; citation_doi=10.1073/pnas.0530291100; citation_id=CR15"/> <meta name="citation_reference" content="citation_journal_title=Breast Cancer Res; citation_title=Stem cell and epithelial-mesenchymal transition markers are frequently overexpressed in circulating tumor cells of metastatic breast cancer patients; citation_author=B Aktas, M Tewes, T Fehm, S Hauch, R Kimmig, S Kasimir-Bauer; citation_volume=11; citation_publication_date=2009; citation_pages=R46; citation_doi=10.1186/bcr2333; citation_id=CR16"/> <meta name="citation_reference" content="citation_title=The influence of removal of primary tumor on incidence and phenotype of circulating tumor cells in primary breast cancer; citation_inbook_title=Breast Cancer Res Treat; citation_publication_date=2011; citation_id=CR17; citation_author=M Banys; citation_author=N Krawczyk; citation_author=S Becker; citation_author=J Jakubowska; citation_author=A Staebler; citation_author=D Wallwiener; citation_author=T Fehm; citation_author=R Rothmund"/> <meta name="citation_reference" content="citation_journal_title=Ann Hum Genet; citation_title=he log-likelihood ratio (the G test), Methods and tables for tests of heterogeneity in contingency tables; citation_author=B Woolf; citation_volume=21; citation_publication_date=1957; citation_pages=397-409; citation_doi=10.1111/j.1469-1809.1972.tb00293.x; citation_id=CR18"/> <meta name="citation_reference" content="citation_journal_title=BMC Cancer; citation_title=Distinct distribution and prognostic significance of molecular subtypes of breast cancer in Chinese women: a population-based cohort study; citation_author=Y Su, Y Zheng, W Zheng, K Gu, Z Chen, G Li, Q Cai, W Lu, XO Shu; citation_volume=11; citation_publication_date=2011; citation_pages=292-303; citation_doi=10.1186/1471-2407-11-292; citation_id=CR19"/> <meta name="citation_reference" content="citation_journal_title=Ann Oncol; citation_title=Circulating tumor cell detection and transcriptomic profiles in early breast cancer patients; citation_author=F Reyal, F Valet, P de Cremoux, C Mathiot, C Decraene, B Asselain, E Brain, S Delaloge, S Giacchetti, M Marty, JY Pierga, FC Bidard; citation_volume=22; citation_publication_date=2011; citation_pages=1458-1459; citation_doi=10.1093/annonc/mdr144; citation_id=CR20"/> <meta name="citation_reference" content="citation_journal_title=Chin J Cancer; citation_title=Epithelial-mesenchymal transition in breast cancer progression and metastasis; citation_author=Y Wang, BP Zhou; citation_volume=30; citation_publication_date=2011; citation_pages=603-611; citation_doi=10.5732/cjc.011.10226; citation_id=CR21"/> <meta name="citation_reference" content="citation_journal_title=Cell Cycle; citation_title=Metformin regulates breast cancer stem cell ontogeny by transcriptional regulation of the epithelial-mesenchymal transition (EMT) status; citation_author=A Vazquez-Martin, C Oliveras-Ferraros, S Cufí, S Del Barco, B Martin-Castillo, JA Menendez; citation_volume=9; citation_publication_date=2010; citation_pages=3807-3814; citation_doi=10.4161/cc.9.18.13131; citation_id=CR22"/> <meta name="citation_reference" content="citation_journal_title=Nat Cell Biol; citation_title=Bmi1 is essential in Twist1-induced epithelial-mesenchymal transition; citation_author=MH Yang, DS Hsu, HW Wang, HJ Wang, HY Lan, WH Yang, CH Huang, SY Kao, CH Tzeng, SK Tai, SY Chang, OK Lee, KJ Wu; citation_volume=12; citation_publication_date=2010; citation_pages=982-992; citation_doi=10.1038/ncb2099; citation_id=CR23"/> <meta name="citation_reference" content="citation_journal_title=Breast Cancer Res; citation_title=Epithelial to mesenchymal transition markers expressed in circulating tumour cells of early and metastatic breast cancer patients; citation_author=G Kallergi, MA Papadaki, E Politaki, D Mavroudis, V Georgoulias, S Agelaki; citation_volume=13; citation_publication_date=2011; citation_pages=R59; citation_doi=10.1186/bcr2896; citation_id=CR24"/> <meta name="citation_reference" content="citation_journal_title=Cell; citation_title=The epithelial-mesenchymal transition generates cells with properties of stem cells; citation_author=SA Mani, W Guo, MJ Liao, EN Eaton, A Ayyanan, AY Zhou, M Brooks, F Reinhard, CC Zhang, M Shipitsin, LL Campbell, K Polyak, C Brisken, J Yang, RA Weinberg; citation_volume=133; citation_publication_date=2008; citation_pages=704-715; citation_doi=10.1016/j.cell.2008.03.027; citation_id=CR25"/> <meta name="citation_reference" content="citation_journal_title=PLoS One; citation_title=Generation of breast cancer stem cells through epithelial-mesenchymal transition; citation_author=AP Morel, M Lièvre, C Thomas, G Hinkal, S Ansieau, A Puisieux; citation_volume=3; citation_publication_date=2008; citation_pages=e2888; citation_doi=10.1371/journal.pone.0002888; citation_id=CR26"/> <meta name="citation_reference" content="citation_journal_title=N Engl J Med; citation_title=Cytokeratin-positive cells in the bone marrow and survival of patients with stage I, II, or III breast cancer; citation_author=S Braun, K Pantel, P Müller, W Janni, F Hepp, CR Kentenich, S Gastroph, A Wischnik, T Dimpfl, G Kindermann, G Riethmüller, G Schlimok; citation_volume=342; citation_publication_date=2000; citation_pages=525-533; citation_doi=10.1056/NEJM200002243420801; citation_id=CR27"/> <meta name="citation_reference" content="citation_journal_title=Br J Cancer; citation_title=Prognosis based on primary breast carcinoma instead of pathological nodal status; citation_author=S Ménard, R Bufalino, F Rilke, N Cascinelli, U Veronesi, MI Colnaghi; citation_volume=70; citation_publication_date=1994; citation_pages=709-712; citation_doi=10.1038/bjc.1994.379; citation_id=CR28"/> <meta name="citation_reference" content="citation_journal_title=J Clin Oncol; citation_title=Circulating tumor cells: not all detected cells are bad and not all bad cells are detected; citation_author=MS Wicha, DF Hayes; citation_volume=29; citation_publication_date=2011; citation_pages=1508-1511; citation_doi=10.1200/JCO.2010.34.0026; citation_id=CR29"/> <meta name="citation_reference" content="citation_journal_title=Int J Cancer; citation_title=Characterization of metastatic breast cancer patients with nondetectable circulating tumor cells; citation_author=M Mego, U De Giorgi, S Dawood, X Wang, V Valero, E Andreopoulou, B Handy, NT Ueno, JM Reuben, M Cristofanilli; citation_volume=129; citation_publication_date=2011; citation_pages=417-423; citation_doi=10.1002/ijc.25690; citation_id=CR30"/> <meta name="citation_author" content="Barrière, Guislaine"/> <meta name="citation_author_institution" content="Astralab clinical laboratory, Limoges, France"/> <meta name="citation_author" content="Riouallon, Alain"/> <meta name="citation_author_institution" content="Department of gynecology and surgery, Clinique du Colombier, Limoges, France"/> <meta name="citation_author" content="Renaudie, Joël"/> <meta name="citation_author_institution" content="Department of gynecology and surgery, Clinique du Colombier, Limoges, France"/> <meta name="citation_author" content="Tartary, Michel"/> <meta name="citation_author_institution" content="Astralab clinical laboratory, Limoges, France"/> <meta name="citation_author" content="Rigaud, Michel"/> <meta name="citation_author_institution" content="Astralab clinical laboratory, Limoges, France"/> <meta property="og:url" content="https://link.springer.com/article/10.1186/1471-2407-12-114"/> <meta property="og:type" content="article"/> <meta property="og:site_name" content="SpringerLink"/> <meta property="og:title" content="Mesenchymal and stemness circulating tumor cells in early breast cancer diagnosis - BMC Cancer"/> <meta property="og:description" content="Background Epithelial mesenchymal transition (EMT) is a crucial event likely involved in dissemination of epithelial cancer cells. This process enables them to acquire migratory/invasive properties, contributing to tumor and metastatic spread. To know if this event is an early one in breast cancer, we developed a clinical trial. The aim of this protocol was to detect circulating tumor cells endowed with mesenchymal and/or stemness characteristics, at the time of initial diagnosis. Breast cancer patients (n = 61), without visceral or bone metastasis were enrolled and analysis of these dedifferentiated circulating tumor cells (ddCTC) was realized. Methods AdnaGen method was used for enrichment cell selection. Then, ddCTC were characterized by RT-PCR study of the following genes: PI3Kα, Akt-2, Twist1 (EMT markers) and ALDH1, Bmi1 and CD44 (stemness indicators). Results Among the studied primary breast cancer cohort, presence of ddCTC was detected in 39% of cases. This positivity is independant from tumor clinicopathological factors apart from the lymph node status. Conclusions Our data uniquely demonstrated that in vivo EMT occurs in the primary tumors and is associated with an enhanced ability of tumor cells to intravasate in the early phase of cancer disease. These results suggest that analysis of circulating tumor cells focused on cells showing mesenchymal or stemness characteristics might facilitate assessment of new drugs in clinical trials."/> <meta property="og:image" content="https://static-content.springer.com/image/art%3A10.1186%2F1471-2407-12-114/MediaObjects/12885_2011_Article_3155_Fig1_HTML.jpg"/> <meta name="format-detection" content="telephone=no"> <link rel="apple-touch-icon" sizes="180x180" href=/oscar-static/img/favicons/darwin/apple-touch-icon-92e819bf8a.png> <link rel="icon" type="image/png" sizes="192x192" href=/oscar-static/img/favicons/darwin/android-chrome-192x192-6f081ca7e5.png> <link rel="icon" type="image/png" sizes="32x32" href=/oscar-static/img/favicons/darwin/favicon-32x32-1435da3e82.png> <link rel="icon" type="image/png" sizes="16x16" href=/oscar-static/img/favicons/darwin/favicon-16x16-ed57f42bd2.png> <link rel="shortcut icon" data-test="shortcut-icon" 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This process enables them to acquire migratory/invasive properties, contributing to tumor and metastatic spread. To know if this event is an early one in breast cancer, we developed a clinical trial. The aim of this protocol was to detect circulating tumor cells endowed with mesenchymal and/or stemness characteristics, at the time of initial diagnosis. Breast cancer patients (n = 61), without visceral or bone metastasis were enrolled and analysis of these dedifferentiated circulating tumor cells (ddCTC) was realized. \nAdnaGen method was used for enrichment cell selection. Then, ddCTC were characterized by RT-PCR study of the following genes: PI3Kα, Akt-2, Twist1 (EMT markers) and ALDH1, Bmi1 and CD44 (stemness indicators). Among the studied primary breast cancer cohort, presence of ddCTC was detected in 39% of cases. This positivity is independant from tumor clinicopathological factors apart from the lymph node status. Our data uniquely demonstrated that in vivo EMT occurs in the primary tumors and is associated with an enhanced ability of tumor cells to intravasate in the early phase of cancer disease. These results suggest that analysis of circulating tumor cells focused on cells showing mesenchymal or stemness characteristics might facilitate assessment of new drugs in clinical trials.","datePublished":"2012-03-23T00:00:00Z","dateModified":"2012-03-23T00:00:00Z","pageStart":"1","pageEnd":"7","license":"https://creativecommons.org/licenses/by/2.0","sameAs":"https://doi.org/10.1186/1471-2407-12-114","keywords":["Cancer Stem Cell","Epithelial Mesenchymal Transition","Circulate Tumor Cell","Metastatic Breast Cancer Patient","Primary Breast Cancer Patient","Cancer Research","Oncology","Surgical Oncology","Health Promotion and Disease Prevention","Biomedicine","general","Medicine/Public Health"],"image":["https://media.springernature.com/lw1200/springer-static/image/art%3A10.1186%2F1471-2407-12-114/MediaObjects/12885_2011_Article_3155_Fig1_HTML.jpg"],"isPartOf":{"name":"BMC Cancer","issn":["1471-2407"],"volumeNumber":"12","@type":["Periodical","PublicationVolume"]},"publisher":{"name":"BioMed Central","logo":{"url":"https://www.springernature.com/app-sn/public/images/logo-springernature.png","@type":"ImageObject"},"@type":"Organization"},"author":[{"name":"Guislaine Barrière","affiliation":[{"name":"Astralab clinical laboratory","address":{"name":"Astralab clinical laboratory, Limoges, France","@type":"PostalAddress"},"@type":"Organization"}],"@type":"Person"},{"name":"Alain Riouallon","affiliation":[{"name":"Clinique du Colombier","address":{"name":"Department of gynecology and surgery, Clinique du Colombier, Limoges, France","@type":"PostalAddress"},"@type":"Organization"}],"@type":"Person"},{"name":"Joël Renaudie","affiliation":[{"name":"Clinique du Colombier","address":{"name":"Department of gynecology and surgery, Clinique du Colombier, Limoges, France","@type":"PostalAddress"},"@type":"Organization"}],"@type":"Person"},{"name":"Michel Tartary","affiliation":[{"name":"Astralab clinical laboratory","address":{"name":"Astralab clinical laboratory, Limoges, France","@type":"PostalAddress"},"@type":"Organization"}],"@type":"Person"},{"name":"Michel Rigaud","affiliation":[{"name":"Astralab clinical laboratory","address":{"name":"Astralab clinical laboratory, Limoges, France","@type":"PostalAddress"},"@type":"Organization"}],"email":"rigaud.michel@yahoo.fr","@type":"Person"}],"isAccessibleForFree":true,"@type":"ScholarlyArticle"},"@context":"https://schema.org","@type":"WebPage"}</script> </head> <body class="" >  <noscript> <iframe src="https://www.googletagmanager.com/ns.html?id=GTM-MRVXSHQ" height="0" width="0" style="display:none;visibility:hidden"></iframe> </noscript>   <noscript data-test="gtm-body"> <iframe src="https://www.googletagmanager.com/ns.html?id=GTM-MRVXSHQ" height="0" width="0" style="display:none;visibility:hidden"></iframe> </noscript>  <div class="u-visually-hidden" aria-hidden="true" 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circulating tumor cells in early breast cancer diagnosis </div> <div data-test="inCoD" data-track-context="sticky banner"> <div class="c-pdf-container"> <div class="c-pdf-download u-clear-both u-mb-16"> <a href="/content/pdf/10.1186/1471-2407-12-114.pdf" class="u-button u-button--full-width u-button--primary u-justify-content-space-between c-pdf-download__link" data-article-pdf="true" data-readcube-pdf-url="true" data-test="pdf-link" data-draft-ignore="true" data-track="content_download" data-track-type="article pdf download" data-track-action="download pdf" data-track-label="button" data-track-external download> <span class="c-pdf-download__text">Download PDF</span> <svg aria-hidden="true" focusable="false" width="16" height="16" class="u-icon"><use xlink:href="#icon-eds-i-download-medium"/></svg> </a> </div> </div> </div> </div> </div> <div class="c-article-header"> <header> <ul class="c-article-author-list c-article-author-list--short" data-test="authors-list" data-component-authors-activator="authors-list"><li class="c-article-author-list__item"><a data-test="author-name" data-track="click" data-track-action="open author" data-track-label="link" href="#auth-Guislaine-Barri_re-Aff1" data-author-popup="auth-Guislaine-Barri_re-Aff1" data-author-search="Barrière, Guislaine">Guislaine Barrière</a><sup class="u-js-hide"><a href="#Aff1">1</a></sup>, </li><li class="c-article-author-list__item"><a data-test="author-name" data-track="click" data-track-action="open author" data-track-label="link" href="#auth-Alain-Riouallon-Aff2" data-author-popup="auth-Alain-Riouallon-Aff2" data-author-search="Riouallon, Alain">Alain Riouallon</a><sup class="u-js-hide"><a href="#Aff2">2</a></sup>, </li><li class="c-article-author-list__item c-article-author-list__item--hide-small-screen"><a data-test="author-name" data-track="click" data-track-action="open author" data-track-label="link" href="#auth-Jo_l-Renaudie-Aff2" data-author-popup="auth-Jo_l-Renaudie-Aff2" data-author-search="Renaudie, Joël">Joël Renaudie</a><sup class="u-js-hide"><a href="#Aff2">2</a></sup>, </li><li class="c-article-author-list__item c-article-author-list__item--hide-small-screen"><a data-test="author-name" data-track="click" data-track-action="open author" data-track-label="link" href="#auth-Michel-Tartary-Aff1" data-author-popup="auth-Michel-Tartary-Aff1" data-author-search="Tartary, Michel">Michel Tartary</a><sup class="u-js-hide"><a href="#Aff1">1</a></sup> & </li><li class="c-article-author-list__show-more" aria-label="Show all 5 authors for this article" title="Show all 5 authors for this article">…</li><li class="c-article-author-list__item"><a data-test="author-name" data-track="click" data-track-action="open author" data-track-label="link" href="#auth-Michel-Rigaud-Aff1" data-author-popup="auth-Michel-Rigaud-Aff1" data-author-search="Rigaud, Michel" data-corresp-id="c1">Michel Rigaud<svg width="16" height="16" focusable="false" role="img" aria-hidden="true" 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xlink:href="#icon-eds-i-arrow-right-medium"></use> </svg></a></p> </li> </ul> </div> <div class="u-mt-32"> </div> </header> </div> <div data-article-body="true" data-track-component="article body" class="c-article-body"> <section aria-labelledby="Abs1" data-title="Abstract" lang="en"><div class="c-article-section" id="Abs1-section"><h2 class="c-article-section__title js-section-title js-c-reading-companion-sections-item" id="Abs1">Abstract</h2><div class="c-article-section__content" id="Abs1-content"><h3 class="c-article__sub-heading" data-test="abstract-sub-heading">Background</h3><p>Epithelial mesenchymal transition (EMT) is a crucial event likely involved in dissemination of epithelial cancer cells. This process enables them to acquire migratory/invasive properties, contributing to tumor and metastatic spread. To know if this event is an early one in breast cancer, we developed a clinical trial. The aim of this protocol was to detect circulating tumor cells endowed with mesenchymal and/or stemness characteristics, at the time of initial diagnosis. Breast cancer patients (n = 61), without visceral or bone metastasis were enrolled and analysis of these dedifferentiated circulating tumor cells (ddCTC) was realized.</p><h3 class="c-article__sub-heading" data-test="abstract-sub-heading">Methods</h3><p> <i>AdnaGen</i> method was used for enrichment cell selection. Then, ddCTC were characterized by RT-PCR study of the following genes: PI3Kα, Akt-2, Twist1 (EMT markers) and ALDH1, Bmi1 and CD44 (stemness indicators).</p><h3 class="c-article__sub-heading" data-test="abstract-sub-heading">Results</h3><p>Among the studied primary breast cancer cohort, presence of ddCTC was detected in 39% of cases. This positivity is independant from tumor clinicopathological factors apart from the lymph node status.</p><h3 class="c-article__sub-heading" data-test="abstract-sub-heading">Conclusions</h3><p>Our data uniquely demonstrated that <i>in vivo</i> EMT occurs in the primary tumors and is associated with an enhanced ability of tumor cells to intravasate in the early phase of cancer disease. These results suggest that analysis of circulating tumor cells focused on cells showing mesenchymal or stemness characteristics might facilitate assessment of new drugs in clinical trials.</p></div></div></section> <div class="app-peer-review"> <a class="app-peer-review__link" href="/article/10.1186/1471-2407-12-114/peer-review" data-track="click" data-track-category="article body" data-track-action="open peer review reports" data-track-label="10.1186/1471-2407-12-114"> <svg class="u-icon app-peer-review__icon" aria-hidden="true" focusable="false"> <use xlink:href="#icon-eds-i-file-report-medium"></use> </svg> View this article's peer review reports </a> </div> <div data-test="cobranding-download"> </div> <section aria-labelledby="inline-recommendations" data-title="Inline Recommendations" class="c-article-recommendations" data-track-component="inline-recommendations"> <h3 class="c-article-recommendations-title" id="inline-recommendations">Similar content being viewed by others</h3> <div class="c-article-recommendations-list"> <div class="c-article-recommendations-list__item"> <article class="c-article-recommendations-card" itemscope itemtype="http://schema.org/ScholarlyArticle"> <div class="c-article-recommendations-card__img"><img src="https://media.springernature.com/w215h120/springer-static/image/art%3A10.1007%2Fs00018-021-04064-6/MediaObjects/18_2021_4064_Fig1_HTML.png" loading="lazy" alt=""></div> <div class="c-article-recommendations-card__main"> <h3 class="c-article-recommendations-card__heading" itemprop="name headline"> <a class="c-article-recommendations-card__link" itemprop="url" href="https://link.springer.com/10.1007/s00018-021-04064-6?fromPaywallRec=false" data-track="select_recommendations_1" data-track-context="inline recommendations" data-track-action="click recommendations inline - 1" data-track-label="10.1007/s00018-021-04064-6">Breast cancer circulating tumor cells with mesenchymal features—an unreachable target? 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J Clin Oncol. 2009, 27: 5153-5159. 10.1200/JCO.2008.20.6664." href="/article/10.1186/1471-2407-12-114#ref-CR1" id="ref-link-section-d41524584e474">1</a>]. The term CTC encompasses all types of cells which are considered as foreign entities in the blood having some cancerous characters. Often, in this whole population, cells with tumorigenic potential are not detected. Results are essentially supported by cell counting data arising from CellSearch (Veridex, Raritan, NJ). This method has been cleared by FDA but is not endorsed, like others, by ASCO recommendations. Recent studies have suggested that CellSearch technique may underestimate the number of CTC [<a data-track="click" data-track-action="reference anchor" data-track-label="link" data-test="citation-ref" aria-label="Reference 2" title="Sieuwerts AM, Kraan J, Bolt J, van der Spoel P, Elstrodt F, Schutte M, Martens JW, Gratama JW, Sleijfer S, Foekens JA: Anti-epithelial cell adhesion molecule antibodies and the detection of circulating normal-like breast tumor cells. J Natl Cancer Inst. 2009, 101: 61-66." href="/article/10.1186/1471-2407-12-114#ref-CR2" id="ref-link-section-d41524584e477">2</a>]. Blood intravasation of cancer cells from a primary breast carcinoma is an early event, leading to metastasis [<a data-track="click" data-track-action="reference anchor" data-track-label="link" data-test="citation-ref" aria-label="Reference 3" title="Hüsemann Y, Geigl JB, Schubert F, Musiani P, Meyer M, Burghart E, Forni G, Eils R, Fehm T, Riethmüller G, Klein CA: Systemic spread is an early step in breast cancer. Cancer Cell. 2008, 13: 58-68. 10.1016/j.ccr.2007.12.003." href="/article/10.1186/1471-2407-12-114#ref-CR3" id="ref-link-section-d41524584e480">3</a>, <a data-track="click" data-track-action="reference anchor" data-track-label="link" data-test="citation-ref" aria-label="Reference 4" title="Wicha MS: Cancer stem cells and metastasis: lethal seeds. Clin Cancer Res. 2006, 12: 5606-5607. 10.1158/1078-0432.CCR-06-1537." href="/article/10.1186/1471-2407-12-114#ref-CR4" id="ref-link-section-d41524584e483">4</a>]. Klein <i>et al</i> proposed a parallel progression between early primary tumor and dissemination of tumor cells [<a data-track="click" data-track-action="reference anchor" data-track-label="link" data-test="citation-ref" aria-label="Reference 5" title="Klein CA: Parallel progression of primary tumours and metastases. Nat Rev Cancer. 2009, 9: 302-312. 10.1038/nrc2627." href="/article/10.1186/1471-2407-12-114#ref-CR5" id="ref-link-section-d41524584e490">5</a>]. Evidence has emerged that CTC present a heterogeneity as the one described for primary tumors. Subpopulations of CTC: cancer stem cells, tumor amplifying cells (<i>i.e</i> progenitors) and tumor initiating cells arise from epithelial cancer cells of the primary tumor undergoing epithelial mesenchymal transition (EMT) program [<a data-track="click" data-track-action="reference anchor" data-track-label="link" data-test="citation-ref" aria-label="Reference 6" title="Chaffer CL, Weinberg RA: Perspective on cancer cell metastasis. Science. 2011, 331: 1559-1564. 10.1126/science.1203543." href="/article/10.1186/1471-2407-12-114#ref-CR6" id="ref-link-section-d41524584e496">6</a>, <a data-track="click" data-track-action="reference anchor" data-track-label="link" data-test="citation-ref" aria-label="Reference 7" title="Thiery JP: Epithelial-mesenchymal transitions in tumour progression. Nat Rev Cancer. 2002, 2: 442-454. 10.1038/nrc822." href="/article/10.1186/1471-2407-12-114#ref-CR7" id="ref-link-section-d41524584e499">7</a>]. Targeting these types of cells, cancer stem cells [<a data-track="click" data-track-action="reference anchor" data-track-label="link" data-test="citation-ref" aria-label="Reference 8" title="Theodoropoulos PA, Polioudaki H, Agelaki S, Kallergi G, Saridaki Z, Mavroudis D, Georgoulias V: Circulating tumor cells with a putative stem cell phenotype in peripheral blood of patients with breast cancer. Cancer Lett. 2010, 288: 99-106. 10.1016/j.canlet.2009.06.027." href="/article/10.1186/1471-2407-12-114#ref-CR8" id="ref-link-section-d41524584e502">8</a>] and mesenchymal cells in the blood, would provide more clinically relevant prognosis and predictive information than simple CTC counting. Their analysis should help in a more tight follow-up of the disease progression.</p><p>For epithelial malignancies, EMT is a crucial event in the dissemination of cancer cells. Carcinoma epithelial cells are linked to their neighbours and to basal membranes by protein junctions which are abolished when cells acquire a migratory mesenchymal phenotype. The EMT process is regulated by pleiotropic cytokines such as TGFβ acting through the "cadherin switch" [<a data-track="click" data-track-action="reference anchor" data-track-label="link" data-test="citation-ref" aria-label="Reference 9" title="Tan AR, Alexe G, Reiss M: Transforming growth factor-beta signaling: emerging stem cell target in metastatic breast cancer?. Breast Cancer Res Treat. 2009, 115: 453-495. 10.1007/s10549-008-0184-1." href="/article/10.1186/1471-2407-12-114#ref-CR9" id="ref-link-section-d41524584e508">9</a>]. Cell adhesion proteins are transcriptionally repressed by classical EMT-related signaling pathways. Among them, PI3Kα/Akt-2/mTOR network acts to modulate cell survival, migration and resistance to anoikis and apoptosis [<a data-track="click" data-track-action="reference anchor" data-track-label="link" data-test="citation-ref" aria-label="Reference 10" title="Cantrell DA: Phosphoinositide 3-kinase signalling pathways. J Cell Sci. 2001, 114: 1439-1445." href="/article/10.1186/1471-2407-12-114#ref-CR10" id="ref-link-section-d41524584e511">10</a>, <a data-track="click" data-track-action="reference anchor" data-track-label="link" data-test="citation-ref" aria-label="Reference 11" title="Chau NM, Ashcroft M: Akt2: a role in breast cancer metastasis. Breast Cancer Res. 2004, 6: 55-57. 10.1186/bcr739." href="/article/10.1186/1471-2407-12-114#ref-CR11" id="ref-link-section-d41524584e514">11</a>]. Twist transcriptionally up-regulates Akt-2 in breast cancer cells leading to increase migration and invasion [<a data-track="click" data-track-action="reference anchor" data-track-label="link" data-test="citation-ref" aria-label="Reference 12" title="Cheng GZ, Chan J, Wang Q, Zhang W, Sun CD, Wang LH: Twist transcriptionally up-regulates AKT2 in breast cancer cells leading to increased migration, invasion, and resistance to paclitaxel. Cancer Res. 2007, 67: 1979-1987. 10.1158/0008-5472.CAN-06-1479." href="/article/10.1186/1471-2407-12-114#ref-CR12" id="ref-link-section-d41524584e517">12</a>]. EMT is associated with acquisition of stem cell-like characteristics: Bmi1, a protein that promotes and maintains self-renewal, is a direct transcriptional target of the EMT inducer Twist1 [<a data-track="click" data-track-action="reference anchor" data-track-label="link" data-test="citation-ref" aria-label="Reference 13" title="Martin A, Cano A: Tumorigenesis: Twist1 links EMT to self-renewal. Nat Cell Biol. 2010, 12: 924-925. 10.1038/ncb1010-924." href="/article/10.1186/1471-2407-12-114#ref-CR13" id="ref-link-section-d41524584e520">13</a>]. Studies indicated that ALDH1, responsible for oxidation of retinol to retinoic acid, is a potent marker of breast cancer stem cells [<a data-track="click" data-track-action="reference anchor" data-track-label="link" data-test="citation-ref" aria-label="Reference 14" title="Ginestier C, Hur MH, Charafe-Jauffret E, Monville F, Dutcher J, Brown M, Jacquemier J, Viens P, Kleer CG, Liu S, Schott A, Hayes D, Birnbaum D, Wicha MS, Dontu G: ALDH1 is a marker of normal and malignant human mammary stem cells and a predictor of poor clinical outcome. Cell Stem Cell. 2007, 1: 555-567. 10.1016/j.stem.2007.08.014." href="/article/10.1186/1471-2407-12-114#ref-CR14" id="ref-link-section-d41524584e524">14</a>]. In breast cancer, CD44<sup>+</sup>/CD24<sup>-/low</sup> cells are known to be highly tumorigenic in immunodeficient mice [<a data-track="click" data-track-action="reference anchor" data-track-label="link" data-test="citation-ref" aria-label="Reference 15" title="Al-Hajj M, Wicha MS, Benito-Hernandez A, Morrison SJ, Clarke MF: Prospective identification of tumorigenic breast cancer cells. Proc Natl Acad Sci USA. 2003, 100: 3983-3988. 10.1073/pnas.0530291100." href="/article/10.1186/1471-2407-12-114#ref-CR15" id="ref-link-section-d41524584e531">15</a>]. These markers are useful for identification of CTC having EMT and/or stemness phenotypes. We named dedifferentiated circulating tumor cells (ddCTC) only the subpopulations having one or several mesenchymal and/or stemness characteristics. Due to these considerations, we started a preliminary study for detection of ddCTC at the time of the early breast cancer diagnosis. These analyses were performed before any therapy. EMT and stemness marker expressions were analyzed in order to identify ddCTC.</p></div></div></section><section data-title="Methods"><div class="c-article-section" id="Sec2-section"><h2 class="c-article-section__title js-section-title js-c-reading-companion-sections-item" id="Sec2">Methods</h2><div class="c-article-section__content" id="Sec2-content"><h3 class="c-article__sub-heading" id="Sec3">Patient population</h3><p>The study was conducted at the department of gynecological surgery (Private Hospital Clinique le Colombier) and Astralab laboratory (Department of specialized medical analyses) in Limoges Fr. Since January 2011, patients have been included and blood samples collected before any therapy. Among them, 61 patients were selected provided they showed the following criteria: age 40-75 years, breast cancer diagnosis confirmed by pathologist analysis of the primary tumor, absence of bone, visceral, cerebral metastasis (controlateral breast mammography, liver ultrasonography and entire body bone scanning). Axillary lymph node invasion was assessed.</p><p>This protocol was performed with the approval of the appropriate ethic local committee (Comité de protection des personnes Sud-Ouest et Outre-mer IV. France) and was in compliance with the Helsinki Declaration.</p><h3 class="c-article__sub-heading" id="Sec4">Sampling of biological material</h3><p>Blood samples of 7 ml were collected for cellular enrichment with <i>AdnaCollect</i> tubes (AdnaGen AG, Langenhagen, Germany) and were stored and shipped in the dark at 4-8°C. Samples were analysed within 24 hours. Blood collection tubes contain EDTA and an agent preventing illegitimate RNA expression. Selection and detection steps of CTC were led as published [<a data-track="click" data-track-action="reference anchor" data-track-label="link" data-test="citation-ref" aria-label="Reference 16" title="Aktas B, Tewes M, Fehm T, Hauch S, Kimmig R, Kasimir-Bauer S: Stem cell and epithelial-mesenchymal transition markers are frequently overexpressed in circulating tumor cells of metastatic breast cancer patients. Breast Cancer Res. 2009, 11: R46-10.1186/bcr2333." href="/article/10.1186/1471-2407-12-114#ref-CR16" id="ref-link-section-d41524584e558">16</a>, <a data-track="click" data-track-action="reference anchor" data-track-label="link" data-test="citation-ref" aria-label="Reference 17" title="Banys M, Krawczyk N, Becker S, Jakubowska J, Staebler A, Wallwiener D, Fehm T, Rothmund R: The influence of removal of primary tumor on incidence and phenotype of circulating tumor cells in primary breast cancer. Breast Cancer Res Treat. 2011, in press article, published on line" href="/article/10.1186/1471-2407-12-114#ref-CR17" id="ref-link-section-d41524584e561">17</a>]. They are briefly summarized.</p><h3 class="c-article__sub-heading" id="Sec5">Selection of CTC</h3><p>Tumor cells enrichment was realized by using immunomagnetic beads coated with three antibodies, one against EpCam, two others against Muc-1. One of the latter directed to an underglycosylated epitope, stably not accessible in other blood cells, is more specific of cancer cells. During this enrichment step of mesenchymal and stem breast cancer cells a special washing buffer procedure allowed to avoid excess of contaminating leucocytes. AdnaGen kits were used following supplier recommendations (<i>AdnaTest EMT-1/Stem</i> <i>CellSelect</i>, AdnaGen AG, Langenhagen, Germany).</p><h3 class="c-article__sub-heading" id="Sec6">Detection</h3><p>Then, <i>AdnaTest EMT-1/Stem CellDetect</i> kit was used, according to supplier information (AdnaGen AG, Langenhagen Germany). The analysis of tumor-associated mRNA, isolated from tumor cells, was performed by RT-PCR for the following transcripts: PI3Kα, Twist1, Akt-2 and ALDH1. Thermal profiles used are those recommended by the supplier.</p><p>We added CD44 and Bmi1 as subsidiary markers of stemness. For each one, RT sample previously obtained was amplified by singleplex PCR. Sequences of primers are: CD44 forward GCCCAATGCCTTTGATGGACC, CD44 reverse GCAGGGATTCTGTCTGTGCTG and Bmi1 forward CATTGTCTTTTCCGCCCGC, Bmi1 reverseCAAAGCACACACATCAGGTGGG. The thermal profile used for CD44 PCR was as follows: after15 min denaturation at 95°C, 33 cycles of PCR were carried out by denaturation at 94°C for 30 s, annealing/extension at 59°C for 30 s, and elongation for 72°C for 30 s. Termination of the PCR reaction was subsequently carried out at 72°C for 5 min followed by storage of the sample at 10°C. The one for Bmi1 was as follows: after 15 min denaturation at 95°C, 36 cycles of PCR were carried out by denaturation at 94°C for 30 s, annealing/extension at 59.7°C for 30 s, and elongation for 72°C for 30 s. Termination of the PCR reaction was subsequently carried out at 72°C for 5 min followed by storage of the sample at 10°C. The primers generate fragments of the following sizes (257 bp CD44 -132 bp Bmi1).</p><p>Sensiscript and HotStarTaq from Qiagen GmbH (Hilden, Germany) were used for RT and amplication of cDNA templates.</p><h3 class="c-article__sub-heading" id="Sec7">Electrophoretic analysis of PCR fragments</h3><p>Visualization of PCR fragments was carried out with 2100 bioanalyser (Dna1000 LabChip Agilent technologies). Peaks were considered as positive when concentration was ≥0.15 ng/μL (according to AdnaGen indications). CD44 and Bmi1 expressions were considered positive when transcript concentration was above 0.50 ng/μl. Blood collected from 20 healthy donors was investigated to determine this cut-off value. To confirm it, larger investigation will be implemented.</p><h3 class="c-article__sub-heading" id="Sec8">Statistical Analysis</h3><p>Statistical analysis were performed using Software XLStat2011. Khi2 test was used to establish a relationship between ddCTC detection and tumor characteristics or lymphatic invasion. As the size of the sample was small we controled Khi2 test results by using the Barnet Woolf [<a data-track="click" data-track-action="reference anchor" data-track-label="link" data-test="citation-ref" aria-label="Reference 18" title="Woolf B: he log-likelihood ratio (the G test), Methods and tables for tests of heterogeneity in contingency tables. Ann Hum Genet. 1957, 21: 397-409. 10.1111/j.1469-1809.1972.tb00293.x." href="/article/10.1186/1471-2407-12-114#ref-CR18" id="ref-link-section-d41524584e609">18</a>] and Adjusted R Squared tests.</p></div></div></section><section data-title="Results"><div class="c-article-section" id="Sec9-section"><h2 class="c-article-section__title js-section-title js-c-reading-companion-sections-item" id="Sec9">Results</h2><div class="c-article-section__content" id="Sec9-content"><h3 class="c-article__sub-heading" id="Sec10">Patient characteristics</h3><p>All patients (aged from 40 to 75 years, average 66 years) were studied at the time of newly diagnosed breast cancer and have been included after elimination of bone visceral and cerebral metastasis, whether they had or not an axillary lymphatic node invasion. Analyses were performed before any therapy. Table <a data-track="click" data-track-label="link" data-track-action="table anchor" href="/article/10.1186/1471-2407-12-114#Tab1">1</a> describes clinical and pathologists' characteristics of the tumor. This table indicated the major features of each tumor and their molecular characteristics as proposed in numerous publications [<a data-track="click" data-track-action="reference anchor" data-track-label="link" data-test="citation-ref" aria-label="Reference 19" title="Su Y, Zheng Y, Zheng W, Gu K, Chen Z, Li G, Cai Q, Lu W, Shu XO: Distinct distribution and prognostic significance of molecular subtypes of breast cancer in Chinese women: a population-based cohort study. BMC Cancer. 2011, 11: 292-303. 10.1186/1471-2407-11-292." href="/article/10.1186/1471-2407-12-114#ref-CR19" id="ref-link-section-d41524584e628">19</a>, <a data-track="click" data-track-action="reference anchor" data-track-label="link" data-test="citation-ref" aria-label="Reference 20" title="Reyal F, Valet F, de Cremoux P, Mathiot C, Decraene C, Asselain B, Brain E, Delaloge S, Giacchetti S, Marty M, Pierga JY, Bidard FC: Circulating tumor cell detection and transcriptomic profiles in early breast cancer patients. Ann Oncol. 2011, 22: 1458-1459. 10.1093/annonc/mdr144." href="/article/10.1186/1471-2407-12-114#ref-CR20" id="ref-link-section-d41524584e631">20</a>]. We distinguished four tumor types: luminal A (53 cases), luminal B (3 cases), overexpressed Her-2 (1 case) and triple negative carcinoma (4 cases). Values (mean ± SD) of Ki67 index were respectively for these tumor types: 11(± 7), 27 (± 3), 30, and 13 (± 3). Infiltrant lobular or infiltrant ductal carcinoma were indicated. Most of the patients had no positive axillary lymph nodes (45 upon 61); Four primary tumors expressed Her-2 (Dako, score 3 plus/Fish). Estrogen receptors (ER) were expressed in 95% of examined tumors.</p><div class="c-article-table" data-test="inline-table" data-container-section="table" id="table-1"><figure><figcaption class="c-article-table__figcaption"><b id="Tab1" data-test="table-caption">Table 1 Primary tumour and lymph node status of the total cohort</b></figcaption><div class="u-text-right u-hide-print"><a class="c-article__pill-button" data-test="table-link" data-track="click" data-track-action="view table" data-track-label="button" rel="nofollow" href="/article/10.1186/1471-2407-12-114/tables/1" aria-label="Full size table 1"><span>Full size table</span><svg width="16" height="16" focusable="false" role="img" aria-hidden="true" class="u-icon"><use xmlns:xlink="http://www.w3.org/1999/xlink" xlink:href="#icon-eds-i-chevron-right-small"></use></svg></a></div></figure></div> <h3 class="c-article__sub-heading" id="Sec11">EMT-Stemness detection</h3><p>Among 61 patients, 24 had ddCTC expressing at least one EMT or ALDH1 markers. Thus 39% of the total cohort were positive for ddCTC (Table <a data-track="click" data-track-label="link" data-track-action="table anchor" href="/article/10.1186/1471-2407-12-114#Tab2">2</a>). Moreover among this population 31%, 21% and 13% showed respectively EMT cell, stem cell, both EMT and stem cell markers (Figure <a data-track="click" data-track-label="link" data-track-action="figure anchor" href="/article/10.1186/1471-2407-12-114#Fig1">1a</a>). Rate analysis of markers for 24 positive patients is delineated in Figure <a data-track="click" data-track-label="link" data-track-action="figure anchor" href="/article/10.1186/1471-2407-12-114#Fig1">1b</a> (Twist1 13%, PI3Kα 67%, Akt-2 13%, and ALDH1 54%). When analyses detected at least one EMT marker or ALDH1, the sample was further examined for Bmi1 and CD44. For these 2 markers, we applied a transcript cut-off value of 0.50 ng/μL (specificity of the cut-off is more than 90%, as confirmed in 20 healthy donor samples). Thus, ddCTC detected by mesenchymal and/or ALDHI markers, were 67% and 33% positive for Bmi1 and CD44 respectively. Among 45 N<sup>-</sup> patients, 21 showed ddCTC and upon 16 N<sup>+</sup> patients only 3 had ddCTC.</p><div class="c-article-table" data-test="inline-table" data-container-section="table" id="table-2"><figure><figcaption class="c-article-table__figcaption"><b id="Tab2" data-test="table-caption">Table 2 Results of ddCTC detection and statistical analysis</b></figcaption><div class="u-text-right u-hide-print"><a class="c-article__pill-button" data-test="table-link" data-track="click" data-track-action="view table" data-track-label="button" rel="nofollow" href="/article/10.1186/1471-2407-12-114/tables/2" aria-label="Full size table 2"><span>Full size table</span><svg width="16" height="16" focusable="false" role="img" aria-hidden="true" class="u-icon"><use xmlns:xlink="http://www.w3.org/1999/xlink" xlink:href="#icon-eds-i-chevron-right-small"></use></svg></a></div></figure></div> <div class="c-article-section__figure js-c-reading-companion-figures-item" data-test="figure" data-container-section="figure" id="figure-1" data-title="Figure 1"><figure><figcaption><b id="Fig1" class="c-article-section__figure-caption" data-test="figure-caption-text">Figure 1</b></figcaption><div class="c-article-section__figure-content"><div class="c-article-section__figure-item"><a class="c-article-section__figure-link" data-test="img-link" data-track="click" data-track-label="image" data-track-action="view figure" href="/article/10.1186/1471-2407-12-114/figures/1" rel="nofollow"><picture><source type="image/webp" srcset="//media.springernature.com/lw685/springer-static/image/art%3A10.1186%2F1471-2407-12-114/MediaObjects/12885_2011_Article_3155_Fig1_HTML.jpg?as=webp"><img aria-describedby="Fig1" src="//media.springernature.com/lw685/springer-static/image/art%3A10.1186%2F1471-2407-12-114/MediaObjects/12885_2011_Article_3155_Fig1_HTML.jpg" alt="figure 1" loading="lazy"></picture></a></div><div class="c-article-section__figure-description" data-test="bottom-caption" id="figure-1-desc"><p> <b>Detection of circulating mesenchymal and cancer stem cells in early breast cancer</b>. <b>a)</b> Rates of ddCTC and cell subpopulations among the total cohort. <b>b)</b> Rates of EMT and stemness markers for 24 positive patients.</p></div></div><div class="u-text-right u-hide-print"><a class="c-article__pill-button" data-test="article-link" data-track="click" data-track-label="button" data-track-action="view figure" href="/article/10.1186/1471-2407-12-114/figures/1" data-track-dest="link:Figure1 Full size image" aria-label="Full size image figure 1" rel="nofollow"><span>Full size image</span><svg width="16" height="16" focusable="false" role="img" aria-hidden="true" class="u-icon"><use xmlns:xlink="http://www.w3.org/1999/xlink" xlink:href="#icon-eds-i-chevron-right-small"></use></svg></a></div></figure></div> <h3 class="c-article__sub-heading" id="Sec12">Statistical results</h3><p>Statistical studies indicated that ddCTC detection is an independant factor of the primary tumor characteristics but not of the lymph node status (Table <a data-track="click" data-track-label="link" data-track-action="table anchor" href="/article/10.1186/1471-2407-12-114#Tab2">2</a>). Results of Khi 2 test were corroborated by an other reliable test: Barnet Woolf. There was a relationship between ddCTC positivity and the absence of lymph node invasion <i>p</i> = 0.050, (risk = 5%) and values of Adjusted <i>R</i> <sup><i>2</i></sup> had a significance level for = 0.05. Presence of ddCTC was predominant when patients were lymph node negative: 47% of N<sup>-</sup> patients and 19% of N<sup>+</sup> patients were ddCTC positive. This correlation between lymphatic invasion and ddCTC was not previously demonstrated for patients at baseline primary breast cancer diagnosis. However we must keep in mind that lymphatic internal mammary chain has not been explored.</p></div></div></section><section data-title="Discussion"><div class="c-article-section" id="Sec13-section"><h2 class="c-article-section__title js-section-title js-c-reading-companion-sections-item" id="Sec13">Discussion</h2><div class="c-article-section__content" id="Sec13-content"><p>It seemed us important to develop analyses able to detect cells which are arising from EMT and spreading into the blood stream. Many arguments reported in recent literature sustained the choice of markers used in our study: PI3Kα, Akt-2, Twist1, ALDH1, Bmi1, CD44 [<a data-track="click" data-track-action="reference anchor" data-track-label="link" data-test="citation-ref" aria-label="Reference 14" title="Ginestier C, Hur MH, Charafe-Jauffret E, Monville F, Dutcher J, Brown M, Jacquemier J, Viens P, Kleer CG, Liu S, Schott A, Hayes D, Birnbaum D, Wicha MS, Dontu G: ALDH1 is a marker of normal and malignant human mammary stem cells and a predictor of poor clinical outcome. Cell Stem Cell. 2007, 1: 555-567. 10.1016/j.stem.2007.08.014." href="/article/10.1186/1471-2407-12-114#ref-CR14" id="ref-link-section-d41524584e2248">14</a>–<a data-track="click" data-track-action="reference anchor" data-track-label="link" data-test="citation-ref" aria-label="Reference 16" title="Aktas B, Tewes M, Fehm T, Hauch S, Kimmig R, Kasimir-Bauer S: Stem cell and epithelial-mesenchymal transition markers are frequently overexpressed in circulating tumor cells of metastatic breast cancer patients. Breast Cancer Res. 2009, 11: R46-10.1186/bcr2333." href="/article/10.1186/1471-2407-12-114#ref-CR16" id="ref-link-section-d41524584e2251">16</a>]. In breast cancer, some patients develop metastasis many years after the apparently successful therapy of the primary cancer. The residual cancer disease is based on the notion of occult metastatic tumor cells in bone marrow. Metastasis formation from epithelial tumors progresses through dissemination of tumor cells that can follow two major ways: bloodstream or lymphatic vessels [<a data-track="click" data-track-action="reference anchor" data-track-label="link" data-test="citation-ref" aria-label="Reference 6" title="Chaffer CL, Weinberg RA: Perspective on cancer cell metastasis. Science. 2011, 331: 1559-1564. 10.1126/science.1203543." href="/article/10.1186/1471-2407-12-114#ref-CR6" id="ref-link-section-d41524584e2254">6</a>]. Cancer cell invasion seems proceed from EMT program [<a data-track="click" data-track-action="reference anchor" data-track-label="link" data-test="citation-ref" aria-label="Reference 21" title="Wang Y, Zhou BP: Epithelial-mesenchymal transition in breast cancer progression and metastasis. Chin J Cancer. 2011, 30: 603-611. 10.5732/cjc.011.10226." href="/article/10.1186/1471-2407-12-114#ref-CR21" id="ref-link-section-d41524584e2257">21</a>]. The latter is associated and interacts with cellular pathways that confer new characteristics to the cells: apoptosis resistance, chemo and radio resistance. EMT can be viewed as a continuum of a progressive dedifferentiation leading to cells with stem-cell like properties. Overexpression of a few EMT regulators may be sufficient to generate the cancer stem cell phenotype [<a data-track="click" data-track-action="reference anchor" data-track-label="link" data-test="citation-ref" aria-label="Reference 22" title="Vazquez-Martin A, Oliveras-Ferraros C, Cufí S, Del Barco S, Martin-Castillo B, Menendez JA: Metformin regulates breast cancer stem cell ontogeny by transcriptional regulation of the epithelial-mesenchymal transition (EMT) status. Cell Cycle. 2010, 9: 3807-3814. 10.4161/cc.9.18.13131." href="/article/10.1186/1471-2407-12-114#ref-CR22" id="ref-link-section-d41524584e2260">22</a>]. A molecular link between EMT and stemness emerged with the finding that Bmi1 is a direct transcriptional target of the EMT inducer Twist1 [<a data-track="click" data-track-action="reference anchor" data-track-label="link" data-test="citation-ref" aria-label="Reference 23" title="Yang MH, Hsu DS, Wang HW, Wang HJ, Lan HY, Yang WH, Huang CH, Kao SY, Tzeng CH, Tai SK, Chang SY, Lee OK, Wu KJ: Bmi1 is essential in Twist1-induced epithelial-mesenchymal transition. Nat Cell Biol. 2010, 12: 982-992. 10.1038/ncb2099." href="/article/10.1186/1471-2407-12-114#ref-CR23" id="ref-link-section-d41524584e2264">23</a>]. These phenomena establish a hierarchy of cancer cell phenotypes from mesenchymal to stemness status.</p><p>Our results led to classify patients as follows. The first phenotype of ddCTC is essentially mesenchymal with markers of EMT. Among the 3 markers, the predominant one is PI3Kα, then in equal proportions Akt-2 and Twist1. The second phenotype is characterized by ALDH1 expression, a stemness marker. The third phenotype is a mixture of the two previous ones and represents 33% of positive patients.</p><p>Aktas <i>et al</i> evaluated 226 blood samples of 39 metastatic breast cancer patients during a follow-up of different therapies for the expression of the stem cell and EMT markers [<a data-track="click" data-track-action="reference anchor" data-track-label="link" data-test="citation-ref" aria-label="Reference 16" title="Aktas B, Tewes M, Fehm T, Hauch S, Kimmig R, Kasimir-Bauer S: Stem cell and epithelial-mesenchymal transition markers are frequently overexpressed in circulating tumor cells of metastatic breast cancer patients. Breast Cancer Res. 2009, 11: R46-10.1186/bcr2333." href="/article/10.1186/1471-2407-12-114#ref-CR16" id="ref-link-section-d41524584e2275">16</a>]. In 31% of detected CTC positive samples, 62% were positive for at least one of the EMT markers and 69% for ALDH1. Thus they demonstrated for the first time that a major proportion of CTC of metastatic breast cancer patients shows EMT and tumor stem cell characteristics. In another study, Kallergi <i>et al</i> identified in patients with early and metastatic breast cancer, CTC expressing Twist and vimentin. Higher incidence of these cells in metastasis disease than in early stage breast cancer supports the hypothesis that EMT is involved in metastatic potential of CTC [<a data-track="click" data-track-action="reference anchor" data-track-label="link" data-test="citation-ref" aria-label="Reference 24" title="Kallergi G, Papadaki MA, Politaki E, Mavroudis D, Georgoulias V, Agelaki S: Epithelial to mesenchymal transition markers expressed in circulating tumour cells of early and metastatic breast cancer patients. Breast Cancer Res. 2011, 13: R59-10.1186/bcr2896." href="/article/10.1186/1471-2407-12-114#ref-CR24" id="ref-link-section-d41524584e2281">24</a>]. Moreover the detection rates they reported are similar to ours. In our study, 39% of patients who were positive for EMT and ALDH1 markers had Bmi1 and CD44 positive cells in 67% and 33% respectively. The expression of Bmi1 and CD44 arose in 26% and 13% of ddCTC samples. These results support the stemness characters of these positive samples. Indeed it was shown that EMT generates cells with stem like properties [<a data-track="click" data-track-action="reference anchor" data-track-label="link" data-test="citation-ref" aria-label="Reference 25" title="Mani SA, Guo W, Liao MJ, Eaton EN, Ayyanan A, Zhou AY, Brooks M, Reinhard F, Zhang CC, Shipitsin M, Campbell LL, Polyak K, Brisken C, Yang J, Weinberg RA: The epithelial-mesenchymal transition generates cells with properties of stem cells. Cell. 2008, 133: 704-715. 10.1016/j.cell.2008.03.027." href="/article/10.1186/1471-2407-12-114#ref-CR25" id="ref-link-section-d41524584e2284">25</a>, <a data-track="click" data-track-action="reference anchor" data-track-label="link" data-test="citation-ref" aria-label="Reference 26" title="Morel AP, Lièvre M, Thomas C, Hinkal G, Ansieau S, Puisieux A: Generation of breast cancer stem cells through epithelial-mesenchymal transition. PLoS One. 2008, 3: e2888-10.1371/journal.pone.0002888." href="/article/10.1186/1471-2407-12-114#ref-CR26" id="ref-link-section-d41524584e2288">26</a>] and that the stemness factor Bmi1 is regulated by Twist1 [<a data-track="click" data-track-action="reference anchor" data-track-label="link" data-test="citation-ref" aria-label="Reference 23" title="Yang MH, Hsu DS, Wang HW, Wang HJ, Lan HY, Yang WH, Huang CH, Kao SY, Tzeng CH, Tai SK, Chang SY, Lee OK, Wu KJ: Bmi1 is essential in Twist1-induced epithelial-mesenchymal transition. Nat Cell Biol. 2010, 12: 982-992. 10.1038/ncb2099." href="/article/10.1186/1471-2407-12-114#ref-CR23" id="ref-link-section-d41524584e2291">23</a>].</p><p>It is the first time that ddCTC presence in the blood is demonstrated with such a high rate (24/61 patients) at least when the primary breast tumor is diagnosed without metastasis. If CTC are considered as a prognostic factor, our results showed clearly that detection of all cell phenotypes should be taken into account to have an idea of the disease progression. Ongoing trials in our laboratory indicate that ddCTC are more frequently detected than CTC characterized by <i>AdnaTestBreastCancerSelect</i> and <i>Detect</i> kits (GA733-2, Muc-1 and Her-2) in primary breast cancer patients. Preliminary results, upon 400 patients showed that 8% of patients are positive for CTC according to this previous basic AdnaGen kit (data not shown). This result is not so far from those of the literature. Banys et al. found 12% of positive patients upon about 209, by using the same analytical test [<a data-track="click" data-track-action="reference anchor" data-track-label="link" data-test="citation-ref" aria-label="Reference 17" title="Banys M, Krawczyk N, Becker S, Jakubowska J, Staebler A, Wallwiener D, Fehm T, Rothmund R: The influence of removal of primary tumor on incidence and phenotype of circulating tumor cells in primary breast cancer. Breast Cancer Res Treat. 2011, in press article, published on line" href="/article/10.1186/1471-2407-12-114#ref-CR17" id="ref-link-section-d41524584e2303">17</a>]. Braun <i>et al</i> demonstrated that incidence of bone marrow micrometastasis (disseminated tumor cells) was similar in patients with lymph node metastasis and those whithout [<a data-track="click" data-track-action="reference anchor" data-track-label="link" data-test="citation-ref" aria-label="Reference 27" title="Braun S, Pantel K, Müller P, Janni W, Hepp F, Kentenich CR, Gastroph S, Wischnik A, Dimpfl T, Kindermann G, Riethmüller G, Schlimok G: Cytokeratin-positive cells in the bone marrow and survival of patients with stage I, II, or III breast cancer. N Engl J Med. 2000, 342: 525-533. 10.1056/NEJM200002243420801. Erratum in: N Engl J Med 2000, 343: 308" href="/article/10.1186/1471-2407-12-114#ref-CR27" id="ref-link-section-d41524584e2309">27</a>]. Moreover Menard <i>et al</i> suggested that lymph node metastasis are not necessarily associated with cancer hematogenous spread [<a data-track="click" data-track-action="reference anchor" data-track-label="link" data-test="citation-ref" aria-label="Reference 28" title="Ménard S, Bufalino R, Rilke F, Cascinelli N, Veronesi U, Colnaghi MI: Prognosis based on primary breast carcinoma instead of pathological nodal status. Br J Cancer. 1994, 70: 709-712. 10.1038/bjc.1994.379." href="/article/10.1186/1471-2407-12-114#ref-CR28" id="ref-link-section-d41524584e2316">28</a>]. Our results stress that absence of lymph node invasion is not a criteria of non dissemination. Among 45 N<sup>-</sup> patients 47% showed a ddCTC positive profile and upon 16 N<sup>+</sup> patients only 19% had a positive profile. Nevertheless such a result does not weaken the negative pronostic value of lymph node invasion. These results could be explained as indicated by Chaffer and Weinberg that spread to other sites occurs mostly via the blood stream [<a data-track="click" data-track-action="reference anchor" data-track-label="link" data-test="citation-ref" aria-label="Reference 6" title="Chaffer CL, Weinberg RA: Perspective on cancer cell metastasis. Science. 2011, 331: 1559-1564. 10.1126/science.1203543." href="/article/10.1186/1471-2407-12-114#ref-CR6" id="ref-link-section-d41524584e2323">6</a>]. Our results are in agreement with their observations. Albeit statistical results indicated a relationship between axillary node invasion and detection of ddCTC, the significance level had a borderline value (<i>p</i> = 0.05). These preliminary statistical results have to be confirmed by a larger trial avoiding an inaccurate inference of Khi2.</p><p>Some methods for CTC analyses detect entities that by all criteria are cancer cells but which lack the ability to invade, proliferate and cause metastasis [<a data-track="click" data-track-action="reference anchor" data-track-label="link" data-test="citation-ref" aria-label="Reference 29" title="Wicha MS, Hayes DF: Circulating tumor cells: not all detected cells are bad and not all bad cells are detected. J Clin Oncol. 2011, 29: 1508-1511. 10.1200/JCO.2010.34.0026." href="/article/10.1186/1471-2407-12-114#ref-CR29" id="ref-link-section-d41524584e2333">29</a>]. We can speculate according to these previous publications, that the CTC population is an heterogeneous one. According to these observations, our results showed dedifferentiated EMT and stemness subpopulations in primary breast cancer patients. Such a discrimination had been suggested by Mego <i>et al.</i> [<a data-track="click" data-track-action="reference anchor" data-track-label="link" data-test="citation-ref" aria-label="Reference 30" title="Mego M, De Giorgi U, Dawood S, Wang X, Valero V, Andreopoulou E, Handy B, Ueno NT, Reuben JM, Cristofanilli M: Characterization of metastatic breast cancer patients with nondetectable circulating tumor cells. Int J Cancer. 2011, 129: 417-423. 10.1002/ijc.25690." href="/article/10.1186/1471-2407-12-114#ref-CR30" id="ref-link-section-d41524584e2339">30</a>]. Indeed they demonstrated that metastatic breast cancer patients, had substantially different prognosis correlated to CTC subpopulations. A future prospective study is warranted to determine the incidence of ddCTC characterization on the prognosis. We believe that follow-up of ddCTC may facilitate the monitoring of therapeutic agents targeting these cells.</p></div></div></section><section data-title="Conclusions"><div class="c-article-section" id="Sec14-section"><h2 class="c-article-section__title js-section-title js-c-reading-companion-sections-item" id="Sec14">Conclusions</h2><div class="c-article-section__content" id="Sec14-content"><p>Most CTC studies have been conducted in metastatic breast cancer to establish the prognostic value of this marker. Very few studies have been devoted to CTC in primary breast cancer. In a cohort of patients without metastasis, our results showed that ddCTC with EMT and stemness characteristics can be detected. Although they are tumor initiating cells, majority of them are often not detected by generally used technologies in clinical trials. The demonstration of EMT program activation, leading to invasive properties and stemness of cancer cells, seems to be a new way to characterize CTC. The relationship between ddCTC and lymph node invasion suggests that blood is a major dissemination route. The disease status should be analyzed by the quantitative measurement of EMT gene expression. It could be efficient to control new drugs targeting mesenchymal cells. Eradication of ddCTC would be the proof of therapeutic effectiveness in clinical trials.</p></div></div></section> </div> <section data-title="Abbreviations"><div class="c-article-section" id="abbreviations-section"><h2 class="c-article-section__title js-section-title js-c-reading-companion-sections-item" id="abbreviations">Abbreviations</h2><div class="c-article-section__content" id="abbreviations-content"><dl class="c-abbreviation_list"><dt class="c-abbreviation_list__term u-text-bold u-float-left u-pr-16" style="min-width:50px;"><dfn>ddCTC:</dfn></dt><dd class="c-abbreviation_list__description u-mb-24"> <p>Dedifferentiated circulating tumor cells</p> </dd><dt class="c-abbreviation_list__term u-text-bold u-float-left u-pr-16" style="min-width:50px;"><dfn>EMT:</dfn></dt><dd class="c-abbreviation_list__description u-mb-24"> <p>Epithelial to mesenchymal transition</p> </dd><dt class="c-abbreviation_list__term u-text-bold u-float-left u-pr-16" style="min-width:50px;"><dfn>CTC:</dfn></dt><dd class="c-abbreviation_list__description u-mb-24"> <p>Circulating tumor cell.</p> </dd></dl></div></div></section><div id="MagazineFulltextArticleBodySuffix"><section aria-labelledby="Bib1" data-title="References"><div class="c-article-section" id="Bib1-section"><h2 class="c-article-section__title js-section-title js-c-reading-companion-sections-item" id="Bib1">References</h2><div class="c-article-section__content" id="Bib1-content"><div data-container-section="references"><ol class="c-article-references" data-track-component="outbound reference" data-track-context="references section"><li class="c-article-references__item js-c-reading-companion-references-item" data-counter="1."><p class="c-article-references__text" id="ref-CR1">Liu MC, Shields PG, Warren RD, Cohen P, Wilkinson M, Ottaviano YL, Rao SB, Eng-Wong J, Seillier-Moiseiwitsch F, Noone AM, Isaacs C: Circulating tumor cells: a useful predictor of treatment efficacy in metastatic breast cancer. J Clin Oncol. 2009, 27: 5153-5159. 10.1200/JCO.2008.20.6664.</p><p class="c-article-references__links u-hide-print"><a data-track="click_references" rel="nofollow noopener" data-track-label="10.1200/JCO.2008.20.6664" data-track-item_id="10.1200/JCO.2008.20.6664" data-track-value="article reference" data-track-action="article reference" href="https://doi.org/10.1200%2FJCO.2008.20.6664" aria-label="Article reference 1" data-doi="10.1200/JCO.2008.20.6664">Article</a> <a data-track="click_references" rel="nofollow noopener" data-track-label="link" data-track-item_id="link" data-track-value="pubmed reference" data-track-action="pubmed reference" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&dopt=Abstract&list_uids=19752342" aria-label="PubMed reference 1">PubMed</a> <a data-track="click_references" rel="nofollow noopener" data-track-label="link" data-track-item_id="link" data-track-value="pubmed central reference" data-track-action="pubmed central reference" href="http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4879719" aria-label="PubMed Central reference 1">PubMed Central</a> <a data-track="click_references" data-track-action="google scholar reference" data-track-value="google scholar reference" data-track-label="link" data-track-item_id="link" rel="nofollow noopener" aria-label="Google Scholar reference 1" href="http://scholar.google.com/scholar_lookup?&title=Circulating%20tumor%20cells%3A%20a%20useful%20predictor%20of%20treatment%20efficacy%20in%20metastatic%20breast%20cancer&journal=J%20Clin%20Oncol&doi=10.1200%2FJCO.2008.20.6664&volume=27&pages=5153-5159&publication_year=2009&author=Liu%2CMC&author=Shields%2CPG&author=Warren%2CRD&author=Cohen%2CP&author=Wilkinson%2CM&author=Ottaviano%2CYL&author=Rao%2CSB&author=Eng-Wong%2CJ&author=Seillier-Moiseiwitsch%2CF&author=Noone%2CAM&author=Isaacs%2CC"> Google Scholar</a> </p></li><li class="c-article-references__item js-c-reading-companion-references-item" data-counter="2."><p class="c-article-references__text" id="ref-CR2">Sieuwerts AM, Kraan J, Bolt J, van der Spoel P, Elstrodt F, Schutte M, Martens JW, Gratama JW, Sleijfer S, Foekens JA: Anti-epithelial cell adhesion molecule antibodies and the detection of circulating normal-like breast tumor cells. J Natl Cancer Inst. 2009, 101: 61-66.</p><p class="c-article-references__links u-hide-print"><a data-track="click_references" rel="nofollow noopener" data-track-label="10.1093/jnci/djn419" data-track-item_id="10.1093/jnci/djn419" data-track-value="article reference" data-track-action="article reference" href="https://doi.org/10.1093%2Fjnci%2Fdjn419" aria-label="Article reference 2" data-doi="10.1093/jnci/djn419">Article</a> <a data-track="click_references" rel="nofollow noopener" data-track-label="link" data-track-item_id="link" data-track-value="cas reference" data-track-action="cas reference" href="/articles/cas-redirect/1:CAS:528:DC%2BD1MXltFSltQ%3D%3D" aria-label="CAS reference 2">CAS</a> <a data-track="click_references" rel="nofollow noopener" data-track-label="link" data-track-item_id="link" data-track-value="pubmed reference" data-track-action="pubmed reference" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&dopt=Abstract&list_uids=19116383" aria-label="PubMed reference 2">PubMed</a> <a data-track="click_references" rel="nofollow noopener" data-track-label="link" data-track-item_id="link" data-track-value="pubmed central reference" data-track-action="pubmed central reference" href="http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2639293" aria-label="PubMed Central reference 2">PubMed Central</a> <a data-track="click_references" data-track-action="google scholar reference" data-track-value="google scholar reference" data-track-label="link" data-track-item_id="link" rel="nofollow noopener" aria-label="Google Scholar reference 2" href="http://scholar.google.com/scholar_lookup?&title=Anti-epithelial%20cell%20adhesion%20molecule%20antibodies%20and%20the%20detection%20of%20circulating%20normal-like%20breast%20tumor%20cells&journal=J%20Natl%20Cancer%20Inst&doi=10.1093%2Fjnci%2Fdjn419&volume=101&pages=61-66&publication_year=2009&author=Sieuwerts%2CAM&author=Kraan%2CJ&author=Bolt%2CJ&author=van%20der%20Spoel%2CP&author=Elstrodt%2CF&author=Schutte%2CM&author=Martens%2CJW&author=Gratama%2CJW&author=Sleijfer%2CS&author=Foekens%2CJA"> Google Scholar</a> </p></li><li class="c-article-references__item js-c-reading-companion-references-item" data-counter="3."><p class="c-article-references__text" id="ref-CR3">Hüsemann Y, Geigl JB, Schubert F, Musiani P, Meyer M, Burghart E, Forni G, Eils R, Fehm T, Riethmüller G, Klein CA: Systemic spread is an early step in breast cancer. Cancer Cell. 2008, 13: 58-68. 10.1016/j.ccr.2007.12.003.</p><p class="c-article-references__links u-hide-print"><a data-track="click_references" rel="nofollow noopener" data-track-label="10.1016/j.ccr.2007.12.003" data-track-item_id="10.1016/j.ccr.2007.12.003" data-track-value="article reference" data-track-action="article reference" href="https://doi.org/10.1016%2Fj.ccr.2007.12.003" aria-label="Article reference 3" data-doi="10.1016/j.ccr.2007.12.003">Article</a> <a data-track="click_references" rel="nofollow noopener" data-track-label="link" data-track-item_id="link" data-track-value="pubmed reference" data-track-action="pubmed reference" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&dopt=Abstract&list_uids=18167340" aria-label="PubMed reference 3">PubMed</a> <a data-track="click_references" data-track-action="google scholar reference" data-track-value="google scholar reference" data-track-label="link" data-track-item_id="link" rel="nofollow noopener" aria-label="Google Scholar reference 3" href="http://scholar.google.com/scholar_lookup?&title=Systemic%20spread%20is%20an%20early%20step%20in%20breast%20cancer&journal=Cancer%20Cell&doi=10.1016%2Fj.ccr.2007.12.003&volume=13&pages=58-68&publication_year=2008&author=H%C3%BCsemann%2CY&author=Geigl%2CJB&author=Schubert%2CF&author=Musiani%2CP&author=Meyer%2CM&author=Burghart%2CE&author=Forni%2CG&author=Eils%2CR&author=Fehm%2CT&author=Riethm%C3%BCller%2CG&author=Klein%2CCA"> Google Scholar</a> </p></li><li class="c-article-references__item js-c-reading-companion-references-item" data-counter="4."><p class="c-article-references__text" id="ref-CR4">Wicha MS: Cancer stem cells and metastasis: lethal seeds. Clin Cancer Res. 2006, 12: 5606-5607. 10.1158/1078-0432.CCR-06-1537.</p><p class="c-article-references__links u-hide-print"><a data-track="click_references" rel="nofollow noopener" data-track-label="10.1158/1078-0432.CCR-06-1537" data-track-item_id="10.1158/1078-0432.CCR-06-1537" data-track-value="article reference" data-track-action="article reference" href="https://doi.org/10.1158%2F1078-0432.CCR-06-1537" aria-label="Article reference 4" data-doi="10.1158/1078-0432.CCR-06-1537">Article</a> <a data-track="click_references" rel="nofollow noopener" data-track-label="link" data-track-item_id="link" data-track-value="pubmed reference" data-track-action="pubmed reference" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&dopt=Abstract&list_uids=17020960" aria-label="PubMed reference 4">PubMed</a> <a data-track="click_references" data-track-action="google scholar reference" data-track-value="google scholar reference" data-track-label="link" data-track-item_id="link" rel="nofollow noopener" aria-label="Google Scholar reference 4" href="http://scholar.google.com/scholar_lookup?&title=Cancer%20stem%20cells%20and%20metastasis%3A%20lethal%20seeds&journal=Clin%20Cancer%20Res&doi=10.1158%2F1078-0432.CCR-06-1537&volume=12&pages=5606-5607&publication_year=2006&author=Wicha%2CMS"> Google Scholar</a> </p></li><li class="c-article-references__item js-c-reading-companion-references-item" data-counter="5."><p class="c-article-references__text" id="ref-CR5">Klein CA: Parallel progression of primary tumours and metastases. Nat Rev Cancer. 2009, 9: 302-312. 10.1038/nrc2627.</p><p class="c-article-references__links u-hide-print"><a data-track="click_references" rel="nofollow noopener" data-track-label="10.1038/nrc2627" data-track-item_id="10.1038/nrc2627" data-track-value="article reference" data-track-action="article reference" href="https://doi.org/10.1038%2Fnrc2627" aria-label="Article reference 5" data-doi="10.1038/nrc2627">Article</a> <a data-track="click_references" rel="nofollow noopener" data-track-label="link" data-track-item_id="link" data-track-value="cas reference" data-track-action="cas reference" href="/articles/cas-redirect/1:CAS:528:DC%2BD1MXjsFSrsr8%3D" aria-label="CAS reference 5">CAS</a> <a data-track="click_references" rel="nofollow noopener" data-track-label="link" data-track-item_id="link" data-track-value="pubmed reference" data-track-action="pubmed reference" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&dopt=Abstract&list_uids=19308069" aria-label="PubMed reference 5">PubMed</a> <a data-track="click_references" data-track-action="google scholar reference" data-track-value="google scholar reference" data-track-label="link" data-track-item_id="link" rel="nofollow noopener" aria-label="Google Scholar reference 5" href="http://scholar.google.com/scholar_lookup?&title=Parallel%20progression%20of%20primary%20tumours%20and%20metastases&journal=Nat%20Rev%20Cancer&doi=10.1038%2Fnrc2627&volume=9&pages=302-312&publication_year=2009&author=Klein%2CCA"> Google Scholar</a> </p></li><li class="c-article-references__item js-c-reading-companion-references-item" data-counter="6."><p class="c-article-references__text" id="ref-CR6">Chaffer CL, Weinberg RA: Perspective on cancer cell metastasis. Science. 2011, 331: 1559-1564. 10.1126/science.1203543.</p><p class="c-article-references__links u-hide-print"><a data-track="click_references" rel="nofollow noopener" data-track-label="10.1126/science.1203543" data-track-item_id="10.1126/science.1203543" data-track-value="article reference" data-track-action="article reference" href="https://doi.org/10.1126%2Fscience.1203543" aria-label="Article reference 6" data-doi="10.1126/science.1203543">Article</a> <a data-track="click_references" rel="nofollow noopener" data-track-label="link" data-track-item_id="link" data-track-value="cas reference" data-track-action="cas reference" href="/articles/cas-redirect/1:CAS:528:DC%2BC3MXjs1Cgtbo%3D" aria-label="CAS reference 6">CAS</a> <a data-track="click_references" rel="nofollow noopener" data-track-label="link" data-track-item_id="link" data-track-value="pubmed reference" data-track-action="pubmed reference" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&dopt=Abstract&list_uids=21436443" aria-label="PubMed reference 6">PubMed</a> <a data-track="click_references" data-track-action="google scholar reference" data-track-value="google scholar reference" data-track-label="link" data-track-item_id="link" rel="nofollow noopener" aria-label="Google Scholar reference 6" href="http://scholar.google.com/scholar_lookup?&title=Perspective%20on%20cancer%20cell%20metastasis&journal=Science&doi=10.1126%2Fscience.1203543&volume=331&pages=1559-1564&publication_year=2011&author=Chaffer%2CCL&author=Weinberg%2CRA"> Google Scholar</a> </p></li><li class="c-article-references__item js-c-reading-companion-references-item" data-counter="7."><p class="c-article-references__text" id="ref-CR7">Thiery JP: Epithelial-mesenchymal transitions in tumour progression. Nat Rev Cancer. 2002, 2: 442-454. 10.1038/nrc822.</p><p class="c-article-references__links u-hide-print"><a data-track="click_references" rel="nofollow noopener" data-track-label="10.1038/nrc822" data-track-item_id="10.1038/nrc822" data-track-value="article reference" data-track-action="article reference" href="https://doi.org/10.1038%2Fnrc822" aria-label="Article reference 7" data-doi="10.1038/nrc822">Article</a> <a data-track="click_references" rel="nofollow noopener" data-track-label="link" data-track-item_id="link" data-track-value="cas reference" data-track-action="cas reference" href="/articles/cas-redirect/1:CAS:528:DC%2BD38Xksl2ltr8%3D" aria-label="CAS reference 7">CAS</a> <a data-track="click_references" rel="nofollow noopener" data-track-label="link" data-track-item_id="link" data-track-value="pubmed reference" data-track-action="pubmed reference" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&dopt=Abstract&list_uids=12189386" aria-label="PubMed reference 7">PubMed</a> <a data-track="click_references" data-track-action="google scholar reference" data-track-value="google scholar reference" data-track-label="link" data-track-item_id="link" rel="nofollow noopener" aria-label="Google Scholar reference 7" href="http://scholar.google.com/scholar_lookup?&title=Epithelial-mesenchymal%20transitions%20in%20tumour%20progression&journal=Nat%20Rev%20Cancer&doi=10.1038%2Fnrc822&volume=2&pages=442-454&publication_year=2002&author=Thiery%2CJP"> Google Scholar</a> </p></li><li class="c-article-references__item js-c-reading-companion-references-item" data-counter="8."><p class="c-article-references__text" id="ref-CR8">Theodoropoulos PA, Polioudaki H, Agelaki S, Kallergi G, Saridaki Z, Mavroudis D, Georgoulias V: Circulating tumor cells with a putative stem cell phenotype in peripheral blood of patients with breast cancer. Cancer Lett. 2010, 288: 99-106. 10.1016/j.canlet.2009.06.027.</p><p class="c-article-references__links u-hide-print"><a data-track="click_references" rel="nofollow noopener" data-track-label="10.1016/j.canlet.2009.06.027" data-track-item_id="10.1016/j.canlet.2009.06.027" data-track-value="article reference" data-track-action="article reference" href="https://doi.org/10.1016%2Fj.canlet.2009.06.027" aria-label="Article reference 8" data-doi="10.1016/j.canlet.2009.06.027">Article</a> <a data-track="click_references" rel="nofollow noopener" data-track-label="link" data-track-item_id="link" data-track-value="cas reference" data-track-action="cas reference" href="/articles/cas-redirect/1:CAS:528:DC%2BC3cXnvFyltA%3D%3D" aria-label="CAS reference 8">CAS</a> <a data-track="click_references" rel="nofollow noopener" data-track-label="link" data-track-item_id="link" data-track-value="pubmed reference" data-track-action="pubmed reference" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&dopt=Abstract&list_uids=19619935" aria-label="PubMed reference 8">PubMed</a> <a data-track="click_references" data-track-action="google scholar reference" data-track-value="google scholar reference" data-track-label="link" data-track-item_id="link" rel="nofollow noopener" aria-label="Google Scholar reference 8" href="http://scholar.google.com/scholar_lookup?&title=Circulating%20tumor%20cells%20with%20a%20putative%20stem%20cell%20phenotype%20in%20peripheral%20blood%20of%20patients%20with%20breast%20cancer&journal=Cancer%20Lett&doi=10.1016%2Fj.canlet.2009.06.027&volume=288&pages=99-106&publication_year=2010&author=Theodoropoulos%2CPA&author=Polioudaki%2CH&author=Agelaki%2CS&author=Kallergi%2CG&author=Saridaki%2CZ&author=Mavroudis%2CD&author=Georgoulias%2CV"> Google Scholar</a> </p></li><li class="c-article-references__item js-c-reading-companion-references-item" data-counter="9."><p class="c-article-references__text" id="ref-CR9">Tan AR, Alexe G, Reiss M: Transforming growth factor-beta signaling: emerging stem cell target in metastatic breast cancer?. Breast Cancer Res Treat. 2009, 115: 453-495. 10.1007/s10549-008-0184-1.</p><p class="c-article-references__links u-hide-print"><a data-track="click_references" rel="noopener" data-track-label="10.1007/s10549-008-0184-1" data-track-item_id="10.1007/s10549-008-0184-1" data-track-value="article reference" data-track-action="article reference" href="https://link.springer.com/doi/10.1007/s10549-008-0184-1" aria-label="Article reference 9" data-doi="10.1007/s10549-008-0184-1">Article</a> <a data-track="click_references" rel="nofollow noopener" data-track-label="link" data-track-item_id="link" data-track-value="cas reference" data-track-action="cas reference" href="/articles/cas-redirect/1:CAS:528:DC%2BD1MXmsVCrtLg%3D" aria-label="CAS reference 9">CAS</a> <a data-track="click_references" rel="nofollow noopener" data-track-label="link" data-track-item_id="link" data-track-value="pubmed reference" data-track-action="pubmed reference" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&dopt=Abstract&list_uids=18841463" aria-label="PubMed reference 9">PubMed</a> <a data-track="click_references" data-track-action="google scholar reference" data-track-value="google scholar reference" data-track-label="link" data-track-item_id="link" rel="nofollow noopener" aria-label="Google Scholar reference 9" href="http://scholar.google.com/scholar_lookup?&title=Transforming%20growth%20factor-beta%20signaling%3A%20emerging%20stem%20cell%20target%20in%20metastatic%20breast%20cancer%3F&journal=Breast%20Cancer%20Res%20Treat&doi=10.1007%2Fs10549-008-0184-1&volume=115&pages=453-495&publication_year=2009&author=Tan%2CAR&author=Alexe%2CG&author=Reiss%2CM"> Google Scholar</a> </p></li><li class="c-article-references__item js-c-reading-companion-references-item" data-counter="10."><p class="c-article-references__text" id="ref-CR10">Cantrell DA: Phosphoinositide 3-kinase signalling pathways. J Cell Sci. 2001, 114: 1439-1445.</p><p class="c-article-references__links u-hide-print"><a data-track="click_references" rel="nofollow noopener" data-track-label="link" data-track-item_id="link" data-track-value="cas reference" data-track-action="cas reference" href="/articles/cas-redirect/1:CAS:528:DC%2BD3MXjsVyiu74%3D" aria-label="CAS reference 10">CAS</a> <a data-track="click_references" rel="nofollow noopener" data-track-label="link" data-track-item_id="link" data-track-value="pubmed reference" data-track-action="pubmed reference" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&dopt=Abstract&list_uids=11282020" aria-label="PubMed reference 10">PubMed</a> <a data-track="click_references" data-track-action="google scholar reference" data-track-value="google scholar reference" data-track-label="link" data-track-item_id="link" rel="nofollow noopener" aria-label="Google Scholar reference 10" href="http://scholar.google.com/scholar_lookup?&title=Phosphoinositide%203-kinase%20signalling%20pathways&journal=J%20Cell%20Sci&volume=114&pages=1439-1445&publication_year=2001&author=Cantrell%2CDA"> Google Scholar</a> </p></li><li class="c-article-references__item js-c-reading-companion-references-item" data-counter="11."><p class="c-article-references__text" id="ref-CR11">Chau NM, Ashcroft M: Akt2: a role in breast cancer metastasis. Breast Cancer Res. 2004, 6: 55-57. 10.1186/bcr739.</p><p class="c-article-references__links u-hide-print"><a data-track="click_references" rel="noopener" data-track-label="10.1186/bcr739" data-track-item_id="10.1186/bcr739" data-track-value="article reference" data-track-action="article reference" href="https://link.springer.com/doi/10.1186/bcr739" aria-label="Article reference 11" data-doi="10.1186/bcr739">Article</a> <a data-track="click_references" rel="nofollow noopener" data-track-label="link" data-track-item_id="link" data-track-value="cas reference" data-track-action="cas reference" href="/articles/cas-redirect/1:CAS:528:DC%2BD2cXotVSlu74%3D" aria-label="CAS reference 11">CAS</a> <a data-track="click_references" rel="nofollow noopener" data-track-label="link" data-track-item_id="link" data-track-value="pubmed reference" data-track-action="pubmed reference" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&dopt=Abstract&list_uids=14680486" aria-label="PubMed reference 11">PubMed</a> <a data-track="click_references" data-track-action="google scholar reference" data-track-value="google scholar reference" data-track-label="link" data-track-item_id="link" rel="nofollow noopener" aria-label="Google Scholar reference 11" href="http://scholar.google.com/scholar_lookup?&title=Akt2%3A%20a%20role%20in%20breast%20cancer%20metastasis&journal=Breast%20Cancer%20Res&doi=10.1186%2Fbcr739&volume=6&pages=55-57&publication_year=2004&author=Chau%2CNM&author=Ashcroft%2CM"> Google Scholar</a> </p></li><li class="c-article-references__item js-c-reading-companion-references-item" data-counter="12."><p class="c-article-references__text" id="ref-CR12">Cheng GZ, Chan J, Wang Q, Zhang W, Sun CD, Wang LH: Twist transcriptionally up-regulates AKT2 in breast cancer cells leading to increased migration, invasion, and resistance to paclitaxel. Cancer Res. 2007, 67: 1979-1987. 10.1158/0008-5472.CAN-06-1479.</p><p class="c-article-references__links u-hide-print"><a data-track="click_references" rel="nofollow noopener" data-track-label="10.1158/0008-5472.CAN-06-1479" data-track-item_id="10.1158/0008-5472.CAN-06-1479" data-track-value="article reference" data-track-action="article reference" href="https://doi.org/10.1158%2F0008-5472.CAN-06-1479" aria-label="Article reference 12" data-doi="10.1158/0008-5472.CAN-06-1479">Article</a> <a data-track="click_references" rel="nofollow noopener" data-track-label="link" data-track-item_id="link" data-track-value="cas reference" data-track-action="cas reference" href="/articles/cas-redirect/1:CAS:528:DC%2BD2sXit12qurY%3D" aria-label="CAS reference 12">CAS</a> <a data-track="click_references" rel="nofollow noopener" data-track-label="link" data-track-item_id="link" data-track-value="pubmed reference" data-track-action="pubmed reference" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&dopt=Abstract&list_uids=17332325" aria-label="PubMed reference 12">PubMed</a> <a data-track="click_references" data-track-action="google scholar reference" data-track-value="google scholar reference" data-track-label="link" data-track-item_id="link" rel="nofollow noopener" aria-label="Google Scholar reference 12" href="http://scholar.google.com/scholar_lookup?&title=Twist%20transcriptionally%20up-regulates%20AKT2%20in%20breast%20cancer%20cells%20leading%20to%20increased%20migration%2C%20invasion%2C%20and%20resistance%20to%20paclitaxel&journal=Cancer%20Res&doi=10.1158%2F0008-5472.CAN-06-1479&volume=67&pages=1979-1987&publication_year=2007&author=Cheng%2CGZ&author=Chan%2CJ&author=Wang%2CQ&author=Zhang%2CW&author=Sun%2CCD&author=Wang%2CLH"> Google Scholar</a> </p></li><li class="c-article-references__item js-c-reading-companion-references-item" data-counter="13."><p class="c-article-references__text" id="ref-CR13">Martin A, Cano A: Tumorigenesis: Twist1 links EMT to self-renewal. Nat Cell Biol. 2010, 12: 924-925. 10.1038/ncb1010-924.</p><p class="c-article-references__links u-hide-print"><a data-track="click_references" rel="nofollow noopener" data-track-label="10.1038/ncb1010-924" data-track-item_id="10.1038/ncb1010-924" data-track-value="article reference" data-track-action="article reference" href="https://doi.org/10.1038%2Fncb1010-924" aria-label="Article reference 13" data-doi="10.1038/ncb1010-924">Article</a> <a data-track="click_references" rel="nofollow noopener" data-track-label="link" data-track-item_id="link" data-track-value="cas reference" data-track-action="cas reference" href="/articles/cas-redirect/1:CAS:528:DC%2BC3cXht1aktb7F" aria-label="CAS reference 13">CAS</a> <a data-track="click_references" rel="nofollow noopener" data-track-label="link" data-track-item_id="link" data-track-value="pubmed reference" data-track-action="pubmed reference" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&dopt=Abstract&list_uids=20885418" aria-label="PubMed reference 13">PubMed</a> <a data-track="click_references" data-track-action="google scholar reference" data-track-value="google scholar reference" data-track-label="link" data-track-item_id="link" rel="nofollow noopener" aria-label="Google Scholar reference 13" href="http://scholar.google.com/scholar_lookup?&title=Tumorigenesis%3A%20Twist1%20links%20EMT%20to%20self-renewal&journal=Nat%20Cell%20Biol&doi=10.1038%2Fncb1010-924&volume=12&pages=924-925&publication_year=2010&author=Martin%2CA&author=Cano%2CA"> Google Scholar</a> </p></li><li class="c-article-references__item js-c-reading-companion-references-item" data-counter="14."><p class="c-article-references__text" id="ref-CR14">Ginestier C, Hur MH, Charafe-Jauffret E, Monville F, Dutcher J, Brown M, Jacquemier J, Viens P, Kleer CG, Liu S, Schott A, Hayes D, Birnbaum D, Wicha MS, Dontu G: ALDH1 is a marker of normal and malignant human mammary stem cells and a predictor of poor clinical outcome. Cell Stem Cell. 2007, 1: 555-567. 10.1016/j.stem.2007.08.014.</p><p class="c-article-references__links u-hide-print"><a data-track="click_references" rel="nofollow noopener" data-track-label="10.1016/j.stem.2007.08.014" data-track-item_id="10.1016/j.stem.2007.08.014" data-track-value="article reference" data-track-action="article reference" href="https://doi.org/10.1016%2Fj.stem.2007.08.014" aria-label="Article reference 14" data-doi="10.1016/j.stem.2007.08.014">Article</a> <a data-track="click_references" rel="nofollow noopener" data-track-label="link" data-track-item_id="link" data-track-value="cas reference" data-track-action="cas reference" href="/articles/cas-redirect/1:CAS:528:DC%2BD2sXhsVahtrvF" aria-label="CAS reference 14">CAS</a> <a data-track="click_references" rel="nofollow noopener" data-track-label="link" data-track-item_id="link" data-track-value="pubmed reference" data-track-action="pubmed reference" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&dopt=Abstract&list_uids=18371393" aria-label="PubMed reference 14">PubMed</a> <a data-track="click_references" rel="nofollow noopener" data-track-label="link" data-track-item_id="link" data-track-value="pubmed central reference" data-track-action="pubmed central reference" href="http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2423808" aria-label="PubMed Central reference 14">PubMed Central</a> <a data-track="click_references" data-track-action="google scholar reference" data-track-value="google scholar reference" data-track-label="link" data-track-item_id="link" rel="nofollow noopener" aria-label="Google Scholar reference 14" href="http://scholar.google.com/scholar_lookup?&title=ALDH1%20is%20a%20marker%20of%20normal%20and%20malignant%20human%20mammary%20stem%20cells%20and%20a%20predictor%20of%20poor%20clinical%20outcome&journal=Cell%20Stem%20Cell&doi=10.1016%2Fj.stem.2007.08.014&volume=1&pages=555-567&publication_year=2007&author=Ginestier%2CC&author=Hur%2CMH&author=Charafe-Jauffret%2CE&author=Monville%2CF&author=Dutcher%2CJ&author=Brown%2CM&author=Jacquemier%2CJ&author=Viens%2CP&author=Kleer%2CCG&author=Liu%2CS&author=Schott%2CA&author=Hayes%2CD&author=Birnbaum%2CD&author=Wicha%2CMS&author=Dontu%2CG"> Google Scholar</a> </p></li><li class="c-article-references__item js-c-reading-companion-references-item" data-counter="15."><p class="c-article-references__text" id="ref-CR15">Al-Hajj M, Wicha MS, Benito-Hernandez A, Morrison SJ, Clarke MF: Prospective identification of tumorigenic breast cancer cells. Proc Natl Acad Sci USA. 2003, 100: 3983-3988. 10.1073/pnas.0530291100.</p><p class="c-article-references__links u-hide-print"><a data-track="click_references" rel="nofollow noopener" data-track-label="10.1073/pnas.0530291100" data-track-item_id="10.1073/pnas.0530291100" data-track-value="article reference" data-track-action="article reference" href="https://doi.org/10.1073%2Fpnas.0530291100" aria-label="Article reference 15" data-doi="10.1073/pnas.0530291100">Article</a> <a data-track="click_references" rel="nofollow noopener" data-track-label="link" data-track-item_id="link" data-track-value="cas reference" data-track-action="cas reference" href="/articles/cas-redirect/1:CAS:528:DC%2BD3sXivFSqtbs%3D" aria-label="CAS reference 15">CAS</a> <a data-track="click_references" rel="nofollow noopener" data-track-label="link" data-track-item_id="link" data-track-value="pubmed reference" data-track-action="pubmed reference" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&dopt=Abstract&list_uids=12629218" aria-label="PubMed reference 15">PubMed</a> <a data-track="click_references" rel="nofollow noopener" data-track-label="link" data-track-item_id="link" data-track-value="pubmed central reference" data-track-action="pubmed central reference" href="http://www.ncbi.nlm.nih.gov/pmc/articles/PMC153034" aria-label="PubMed Central reference 15">PubMed Central</a> <a data-track="click_references" data-track-action="google scholar reference" data-track-value="google scholar reference" data-track-label="link" data-track-item_id="link" rel="nofollow noopener" aria-label="Google Scholar reference 15" href="http://scholar.google.com/scholar_lookup?&title=Prospective%20identification%20of%20tumorigenic%20breast%20cancer%20cells&journal=Proc%20Natl%20Acad%20Sci%20USA&doi=10.1073%2Fpnas.0530291100&volume=100&pages=3983-3988&publication_year=2003&author=Al-Hajj%2CM&author=Wicha%2CMS&author=Benito-Hernandez%2CA&author=Morrison%2CSJ&author=Clarke%2CMF"> Google Scholar</a> </p></li><li class="c-article-references__item js-c-reading-companion-references-item" data-counter="16."><p class="c-article-references__text" id="ref-CR16">Aktas B, Tewes M, Fehm T, Hauch S, Kimmig R, Kasimir-Bauer S: Stem cell and epithelial-mesenchymal transition markers are frequently overexpressed in circulating tumor cells of metastatic breast cancer patients. Breast Cancer Res. 2009, 11: R46-10.1186/bcr2333.</p><p class="c-article-references__links u-hide-print"><a data-track="click_references" rel="noopener" data-track-label="10.1186/bcr2333" data-track-item_id="10.1186/bcr2333" data-track-value="article reference" data-track-action="article reference" href="https://link.springer.com/doi/10.1186/bcr2333" aria-label="Article reference 16" data-doi="10.1186/bcr2333">Article</a> <a data-track="click_references" rel="nofollow noopener" data-track-label="link" data-track-item_id="link" data-track-value="pubmed reference" data-track-action="pubmed reference" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&dopt=Abstract&list_uids=19589136" aria-label="PubMed reference 16">PubMed</a> <a data-track="click_references" rel="nofollow noopener" data-track-label="link" data-track-item_id="link" data-track-value="pubmed central reference" data-track-action="pubmed central reference" href="http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2750105" aria-label="PubMed Central reference 16">PubMed Central</a> <a data-track="click_references" data-track-action="google scholar reference" data-track-value="google scholar reference" data-track-label="link" data-track-item_id="link" rel="nofollow noopener" aria-label="Google Scholar reference 16" href="http://scholar.google.com/scholar_lookup?&title=Stem%20cell%20and%20epithelial-mesenchymal%20transition%20markers%20are%20frequently%20overexpressed%20in%20circulating%20tumor%20cells%20of%20metastatic%20breast%20cancer%20patients&journal=Breast%20Cancer%20Res&doi=10.1186%2Fbcr2333&volume=11&publication_year=2009&author=Aktas%2CB&author=Tewes%2CM&author=Fehm%2CT&author=Hauch%2CS&author=Kimmig%2CR&author=Kasimir-Bauer%2CS"> Google Scholar</a> </p></li><li class="c-article-references__item js-c-reading-companion-references-item" data-counter="17."><p class="c-article-references__text" id="ref-CR17">Banys M, Krawczyk N, Becker S, Jakubowska J, Staebler A, Wallwiener D, Fehm T, Rothmund R: The influence of removal of primary tumor on incidence and phenotype of circulating tumor cells in primary breast cancer. Breast Cancer Res Treat. 2011, in press article, published on line</p><p class="c-article-references__links u-hide-print"><a data-track="click_references" data-track-action="google scholar reference" data-track-value="google scholar reference" data-track-label="link" data-track-item_id="link" rel="nofollow noopener" aria-label="Google Scholar reference 17" href="http://scholar.google.com/scholar_lookup?&title=The%20influence%20of%20removal%20of%20primary%20tumor%20on%20incidence%20and%20phenotype%20of%20circulating%20tumor%20cells%20in%20primary%20breast%20cancer&publication_year=2011&author=Banys%2CM&author=Krawczyk%2CN&author=Becker%2CS&author=Jakubowska%2CJ&author=Staebler%2CA&author=Wallwiener%2CD&author=Fehm%2CT&author=Rothmund%2CR"> Google Scholar</a> </p></li><li class="c-article-references__item js-c-reading-companion-references-item" data-counter="18."><p class="c-article-references__text" id="ref-CR18">Woolf B: he log-likelihood ratio (the G test), Methods and tables for tests of heterogeneity in contingency tables. Ann Hum Genet. 1957, 21: 397-409. 10.1111/j.1469-1809.1972.tb00293.x.</p><p class="c-article-references__links u-hide-print"><a data-track="click_references" rel="nofollow noopener" data-track-label="10.1111/j.1469-1809.1972.tb00293.x" data-track-item_id="10.1111/j.1469-1809.1972.tb00293.x" data-track-value="article reference" data-track-action="article reference" href="https://doi.org/10.1111%2Fj.1469-1809.1972.tb00293.x" aria-label="Article reference 18" data-doi="10.1111/j.1469-1809.1972.tb00293.x">Article</a> <a data-track="click_references" rel="nofollow noopener" data-track-label="link" data-track-item_id="link" data-track-value="cas reference" data-track-action="cas reference" href="/articles/cas-redirect/1:STN:280:DyaG2s%2Fot1ensQ%3D%3D" aria-label="CAS reference 18">CAS</a> <a data-track="click_references" rel="nofollow noopener" data-track-label="link" data-track-item_id="link" data-track-value="pubmed reference" data-track-action="pubmed reference" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&dopt=Abstract&list_uids=13435648" aria-label="PubMed reference 18">PubMed</a> <a data-track="click_references" data-track-action="google scholar reference" data-track-value="google scholar reference" data-track-label="link" data-track-item_id="link" rel="nofollow noopener" aria-label="Google Scholar reference 18" href="http://scholar.google.com/scholar_lookup?&title=he%20log-likelihood%20ratio%20%28the%20G%20test%29%2C%20Methods%20and%20tables%20for%20tests%20of%20heterogeneity%20in%20contingency%20tables&journal=Ann%20Hum%20Genet&doi=10.1111%2Fj.1469-1809.1972.tb00293.x&volume=21&pages=397-409&publication_year=1957&author=Woolf%2CB"> Google Scholar</a> </p></li><li class="c-article-references__item js-c-reading-companion-references-item" data-counter="19."><p class="c-article-references__text" id="ref-CR19">Su Y, Zheng Y, Zheng W, Gu K, Chen Z, Li G, Cai Q, Lu W, Shu XO: Distinct distribution and prognostic significance of molecular subtypes of breast cancer in Chinese women: a population-based cohort study. BMC Cancer. 2011, 11: 292-303. 10.1186/1471-2407-11-292.</p><p class="c-article-references__links u-hide-print"><a data-track="click_references" rel="noopener" data-track-label="10.1186/1471-2407-11-292" data-track-item_id="10.1186/1471-2407-11-292" data-track-value="article reference" data-track-action="article reference" href="https://link.springer.com/doi/10.1186/1471-2407-11-292" aria-label="Article reference 19" data-doi="10.1186/1471-2407-11-292">Article</a> <a data-track="click_references" rel="nofollow noopener" data-track-label="link" data-track-item_id="link" data-track-value="pubmed reference" data-track-action="pubmed reference" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&dopt=Abstract&list_uids=21749714" aria-label="PubMed reference 19">PubMed</a> <a data-track="click_references" rel="nofollow noopener" data-track-label="link" data-track-item_id="link" data-track-value="pubmed central reference" data-track-action="pubmed central reference" href="http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3157458" aria-label="PubMed Central reference 19">PubMed Central</a> <a data-track="click_references" data-track-action="google scholar reference" data-track-value="google scholar reference" data-track-label="link" data-track-item_id="link" rel="nofollow noopener" aria-label="Google Scholar reference 19" href="http://scholar.google.com/scholar_lookup?&title=Distinct%20distribution%20and%20prognostic%20significance%20of%20molecular%20subtypes%20of%20breast%20cancer%20in%20Chinese%20women%3A%20a%20population-based%20cohort%20study&journal=BMC%20Cancer&doi=10.1186%2F1471-2407-11-292&volume=11&pages=292-303&publication_year=2011&author=Su%2CY&author=Zheng%2CY&author=Zheng%2CW&author=Gu%2CK&author=Chen%2CZ&author=Li%2CG&author=Cai%2CQ&author=Lu%2CW&author=Shu%2CXO"> Google Scholar</a> </p></li><li class="c-article-references__item js-c-reading-companion-references-item" data-counter="20."><p class="c-article-references__text" id="ref-CR20">Reyal F, Valet F, de Cremoux P, Mathiot C, Decraene C, Asselain B, Brain E, Delaloge S, Giacchetti S, Marty M, Pierga JY, Bidard FC: Circulating tumor cell detection and transcriptomic profiles in early breast cancer patients. Ann Oncol. 2011, 22: 1458-1459. 10.1093/annonc/mdr144.</p><p class="c-article-references__links u-hide-print"><a data-track="click_references" rel="nofollow noopener" data-track-label="10.1093/annonc/mdr144" data-track-item_id="10.1093/annonc/mdr144" data-track-value="article reference" data-track-action="article reference" href="https://doi.org/10.1093%2Fannonc%2Fmdr144" aria-label="Article reference 20" data-doi="10.1093/annonc/mdr144">Article</a> <a data-track="click_references" rel="nofollow noopener" data-track-label="link" data-track-item_id="link" data-track-value="cas reference" data-track-action="cas reference" href="/articles/cas-redirect/1:STN:280:DC%2BC3MrltVKnuw%3D%3D" aria-label="CAS reference 20">CAS</a> <a data-track="click_references" rel="nofollow noopener" data-track-label="link" data-track-item_id="link" data-track-value="pubmed reference" data-track-action="pubmed reference" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&dopt=Abstract&list_uids=21525400" aria-label="PubMed reference 20">PubMed</a> <a data-track="click_references" data-track-action="google scholar reference" data-track-value="google scholar reference" data-track-label="link" data-track-item_id="link" rel="nofollow noopener" aria-label="Google Scholar reference 20" href="http://scholar.google.com/scholar_lookup?&title=Circulating%20tumor%20cell%20detection%20and%20transcriptomic%20profiles%20in%20early%20breast%20cancer%20patients&journal=Ann%20Oncol&doi=10.1093%2Fannonc%2Fmdr144&volume=22&pages=1458-1459&publication_year=2011&author=Reyal%2CF&author=Valet%2CF&author=de%20Cremoux%2CP&author=Mathiot%2CC&author=Decraene%2CC&author=Asselain%2CB&author=Brain%2CE&author=Delaloge%2CS&author=Giacchetti%2CS&author=Marty%2CM&author=Pierga%2CJY&author=Bidard%2CFC"> Google Scholar</a> </p></li><li class="c-article-references__item js-c-reading-companion-references-item" data-counter="21."><p class="c-article-references__text" id="ref-CR21">Wang Y, Zhou BP: Epithelial-mesenchymal transition in breast cancer progression and metastasis. Chin J Cancer. 2011, 30: 603-611. 10.5732/cjc.011.10226.</p><p class="c-article-references__links u-hide-print"><a data-track="click_references" rel="nofollow noopener" data-track-label="10.5732/cjc.011.10226" data-track-item_id="10.5732/cjc.011.10226" data-track-value="article reference" data-track-action="article reference" href="https://doi.org/10.5732%2Fcjc.011.10226" aria-label="Article reference 21" data-doi="10.5732/cjc.011.10226">Article</a> <a data-track="click_references" rel="nofollow noopener" data-track-label="link" data-track-item_id="link" data-track-value="cas reference" data-track-action="cas reference" href="/articles/cas-redirect/1:CAS:528:DC%2BC3MXhtlylt7rE" aria-label="CAS reference 21">CAS</a> <a data-track="click_references" rel="nofollow noopener" data-track-label="link" data-track-item_id="link" data-track-value="pubmed reference" data-track-action="pubmed reference" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&dopt=Abstract&list_uids=21880181" aria-label="PubMed reference 21">PubMed</a> <a data-track="click_references" rel="nofollow noopener" data-track-label="link" data-track-item_id="link" data-track-value="pubmed central reference" data-track-action="pubmed central reference" href="http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3702729" aria-label="PubMed Central reference 21">PubMed Central</a> <a data-track="click_references" data-track-action="google scholar reference" data-track-value="google scholar reference" data-track-label="link" data-track-item_id="link" rel="nofollow noopener" aria-label="Google Scholar reference 21" href="http://scholar.google.com/scholar_lookup?&title=Epithelial-mesenchymal%20transition%20in%20breast%20cancer%20progression%20and%20metastasis&journal=Chin%20J%20Cancer&doi=10.5732%2Fcjc.011.10226&volume=30&pages=603-611&publication_year=2011&author=Wang%2CY&author=Zhou%2CBP"> Google Scholar</a> </p></li><li class="c-article-references__item js-c-reading-companion-references-item" data-counter="22."><p class="c-article-references__text" id="ref-CR22">Vazquez-Martin A, Oliveras-Ferraros C, Cufí S, Del Barco S, Martin-Castillo B, Menendez JA: Metformin regulates breast cancer stem cell ontogeny by transcriptional regulation of the epithelial-mesenchymal transition (EMT) status. Cell Cycle. 2010, 9: 3807-3814. 10.4161/cc.9.18.13131.</p><p class="c-article-references__links u-hide-print"><a data-track="click_references" rel="nofollow noopener" data-track-label="10.4161/cc.9.18.13131" data-track-item_id="10.4161/cc.9.18.13131" data-track-value="article reference" data-track-action="article reference" href="https://doi.org/10.4161%2Fcc.9.18.13131" aria-label="Article reference 22" data-doi="10.4161/cc.9.18.13131">Article</a> <a data-track="click_references" rel="nofollow noopener" data-track-label="link" data-track-item_id="link" data-track-value="cas reference" data-track-action="cas reference" href="/articles/cas-redirect/1:CAS:528:DC%2BC3MXit1aht7g%3D" aria-label="CAS reference 22">CAS</a> <a data-track="click_references" rel="nofollow noopener" data-track-label="link" data-track-item_id="link" data-track-value="pubmed reference" data-track-action="pubmed reference" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&dopt=Abstract&list_uids=20890129" aria-label="PubMed reference 22">PubMed</a> <a data-track="click_references" data-track-action="google scholar reference" data-track-value="google scholar reference" data-track-label="link" data-track-item_id="link" rel="nofollow noopener" aria-label="Google Scholar reference 22" href="http://scholar.google.com/scholar_lookup?&title=Metformin%20regulates%20breast%20cancer%20stem%20cell%20ontogeny%20by%20transcriptional%20regulation%20of%20the%20epithelial-mesenchymal%20transition%20%28EMT%29%20status&journal=Cell%20Cycle&doi=10.4161%2Fcc.9.18.13131&volume=9&pages=3807-3814&publication_year=2010&author=Vazquez-Martin%2CA&author=Oliveras-Ferraros%2CC&author=Cuf%C3%AD%2CS&author=Del%20Barco%2CS&author=Martin-Castillo%2CB&author=Menendez%2CJA"> Google Scholar</a> </p></li><li class="c-article-references__item js-c-reading-companion-references-item" data-counter="23."><p class="c-article-references__text" id="ref-CR23">Yang MH, Hsu DS, Wang HW, Wang HJ, Lan HY, Yang WH, Huang CH, Kao SY, Tzeng CH, Tai SK, Chang SY, Lee OK, Wu KJ: Bmi1 is essential in Twist1-induced epithelial-mesenchymal transition. Nat Cell Biol. 2010, 12: 982-992. 10.1038/ncb2099.</p><p class="c-article-references__links u-hide-print"><a data-track="click_references" rel="nofollow noopener" data-track-label="10.1038/ncb2099" data-track-item_id="10.1038/ncb2099" data-track-value="article reference" data-track-action="article reference" href="https://doi.org/10.1038%2Fncb2099" aria-label="Article reference 23" data-doi="10.1038/ncb2099">Article</a> <a data-track="click_references" rel="nofollow noopener" data-track-label="link" data-track-item_id="link" data-track-value="pubmed reference" data-track-action="pubmed reference" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&dopt=Abstract&list_uids=20818389" aria-label="PubMed reference 23">PubMed</a> <a data-track="click_references" data-track-action="google scholar reference" data-track-value="google scholar reference" data-track-label="link" data-track-item_id="link" rel="nofollow noopener" aria-label="Google Scholar reference 23" href="http://scholar.google.com/scholar_lookup?&title=Bmi1%20is%20essential%20in%20Twist1-induced%20epithelial-mesenchymal%20transition&journal=Nat%20Cell%20Biol&doi=10.1038%2Fncb2099&volume=12&pages=982-992&publication_year=2010&author=Yang%2CMH&author=Hsu%2CDS&author=Wang%2CHW&author=Wang%2CHJ&author=Lan%2CHY&author=Yang%2CWH&author=Huang%2CCH&author=Kao%2CSY&author=Tzeng%2CCH&author=Tai%2CSK&author=Chang%2CSY&author=Lee%2COK&author=Wu%2CKJ"> Google Scholar</a> </p></li><li class="c-article-references__item js-c-reading-companion-references-item" data-counter="24."><p class="c-article-references__text" id="ref-CR24">Kallergi G, Papadaki MA, Politaki E, Mavroudis D, Georgoulias V, Agelaki S: Epithelial to mesenchymal transition markers expressed in circulating tumour cells of early and metastatic breast cancer patients. Breast Cancer Res. 2011, 13: R59-10.1186/bcr2896.</p><p class="c-article-references__links u-hide-print"><a data-track="click_references" rel="noopener" data-track-label="10.1186/bcr2896" data-track-item_id="10.1186/bcr2896" data-track-value="article reference" data-track-action="article reference" href="https://link.springer.com/doi/10.1186/bcr2896" aria-label="Article reference 24" data-doi="10.1186/bcr2896">Article</a> <a data-track="click_references" rel="nofollow noopener" data-track-label="link" data-track-item_id="link" data-track-value="pubmed reference" data-track-action="pubmed reference" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&dopt=Abstract&list_uids=21663619" aria-label="PubMed reference 24">PubMed</a> <a data-track="click_references" rel="nofollow noopener" data-track-label="link" data-track-item_id="link" data-track-value="pubmed central reference" data-track-action="pubmed central reference" href="http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3218948" aria-label="PubMed Central reference 24">PubMed Central</a> <a data-track="click_references" data-track-action="google scholar reference" data-track-value="google scholar reference" data-track-label="link" data-track-item_id="link" rel="nofollow noopener" aria-label="Google Scholar reference 24" href="http://scholar.google.com/scholar_lookup?&title=Epithelial%20to%20mesenchymal%20transition%20markers%20expressed%20in%20circulating%20tumour%20cells%20of%20early%20and%20metastatic%20breast%20cancer%20patients&journal=Breast%20Cancer%20Res&doi=10.1186%2Fbcr2896&volume=13&publication_year=2011&author=Kallergi%2CG&author=Papadaki%2CMA&author=Politaki%2CE&author=Mavroudis%2CD&author=Georgoulias%2CV&author=Agelaki%2CS"> Google Scholar</a> </p></li><li class="c-article-references__item js-c-reading-companion-references-item" data-counter="25."><p class="c-article-references__text" id="ref-CR25">Mani SA, Guo W, Liao MJ, Eaton EN, Ayyanan A, Zhou AY, Brooks M, Reinhard F, Zhang CC, Shipitsin M, Campbell LL, Polyak K, Brisken C, Yang J, Weinberg RA: The epithelial-mesenchymal transition generates cells with properties of stem cells. Cell. 2008, 133: 704-715. 10.1016/j.cell.2008.03.027.</p><p class="c-article-references__links u-hide-print"><a data-track="click_references" rel="nofollow noopener" data-track-label="10.1016/j.cell.2008.03.027" data-track-item_id="10.1016/j.cell.2008.03.027" data-track-value="article reference" data-track-action="article reference" href="https://doi.org/10.1016%2Fj.cell.2008.03.027" aria-label="Article reference 25" data-doi="10.1016/j.cell.2008.03.027">Article</a> <a data-track="click_references" rel="nofollow noopener" data-track-label="link" data-track-item_id="link" data-track-value="cas reference" data-track-action="cas reference" href="/articles/cas-redirect/1:CAS:528:DC%2BD1cXmsVOru7w%3D" aria-label="CAS reference 25">CAS</a> <a data-track="click_references" rel="nofollow noopener" data-track-label="link" data-track-item_id="link" data-track-value="pubmed reference" data-track-action="pubmed reference" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&dopt=Abstract&list_uids=18485877" aria-label="PubMed reference 25">PubMed</a> <a data-track="click_references" rel="nofollow noopener" data-track-label="link" data-track-item_id="link" data-track-value="pubmed central reference" data-track-action="pubmed central reference" href="http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2728032" aria-label="PubMed Central reference 25">PubMed Central</a> <a data-track="click_references" data-track-action="google scholar reference" data-track-value="google scholar reference" data-track-label="link" data-track-item_id="link" rel="nofollow noopener" aria-label="Google Scholar reference 25" href="http://scholar.google.com/scholar_lookup?&title=The%20epithelial-mesenchymal%20transition%20generates%20cells%20with%20properties%20of%20stem%20cells&journal=Cell&doi=10.1016%2Fj.cell.2008.03.027&volume=133&pages=704-715&publication_year=2008&author=Mani%2CSA&author=Guo%2CW&author=Liao%2CMJ&author=Eaton%2CEN&author=Ayyanan%2CA&author=Zhou%2CAY&author=Brooks%2CM&author=Reinhard%2CF&author=Zhang%2CCC&author=Shipitsin%2CM&author=Campbell%2CLL&author=Polyak%2CK&author=Brisken%2CC&author=Yang%2CJ&author=Weinberg%2CRA"> Google Scholar</a> </p></li><li class="c-article-references__item js-c-reading-companion-references-item" data-counter="26."><p class="c-article-references__text" id="ref-CR26">Morel AP, Lièvre M, Thomas C, Hinkal G, Ansieau S, Puisieux A: Generation of breast cancer stem cells through epithelial-mesenchymal transition. PLoS One. 2008, 3: e2888-10.1371/journal.pone.0002888.</p><p class="c-article-references__links u-hide-print"><a data-track="click_references" rel="nofollow noopener" data-track-label="10.1371/journal.pone.0002888" data-track-item_id="10.1371/journal.pone.0002888" data-track-value="article reference" data-track-action="article reference" href="https://doi.org/10.1371%2Fjournal.pone.0002888" aria-label="Article reference 26" data-doi="10.1371/journal.pone.0002888">Article</a> <a data-track="click_references" rel="nofollow noopener" data-track-label="link" data-track-item_id="link" data-track-value="pubmed reference" data-track-action="pubmed reference" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&dopt=Abstract&list_uids=18682804" aria-label="PubMed reference 26">PubMed</a> <a data-track="click_references" rel="nofollow noopener" data-track-label="link" data-track-item_id="link" data-track-value="pubmed central reference" data-track-action="pubmed central reference" href="http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2492808" aria-label="PubMed Central reference 26">PubMed Central</a> <a data-track="click_references" data-track-action="google scholar reference" data-track-value="google scholar reference" data-track-label="link" data-track-item_id="link" rel="nofollow noopener" aria-label="Google Scholar reference 26" href="http://scholar.google.com/scholar_lookup?&title=Generation%20of%20breast%20cancer%20stem%20cells%20through%20epithelial-mesenchymal%20transition&journal=PLoS%20One&doi=10.1371%2Fjournal.pone.0002888&volume=3&publication_year=2008&author=Morel%2CAP&author=Li%C3%A8vre%2CM&author=Thomas%2CC&author=Hinkal%2CG&author=Ansieau%2CS&author=Puisieux%2CA"> Google Scholar</a> </p></li><li class="c-article-references__item js-c-reading-companion-references-item" data-counter="27."><p class="c-article-references__text" id="ref-CR27">Braun S, Pantel K, Müller P, Janni W, Hepp F, Kentenich CR, Gastroph S, Wischnik A, Dimpfl T, Kindermann G, Riethmüller G, Schlimok G: Cytokeratin-positive cells in the bone marrow and survival of patients with stage I, II, or III breast cancer. N Engl J Med. 2000, 342: 525-533. 10.1056/NEJM200002243420801. Erratum in: N Engl J Med 2000, 343: 308</p><p class="c-article-references__links u-hide-print"><a data-track="click_references" rel="nofollow noopener" data-track-label="10.1056/NEJM200002243420801" data-track-item_id="10.1056/NEJM200002243420801" data-track-value="article reference" data-track-action="article reference" href="https://doi.org/10.1056%2FNEJM200002243420801" aria-label="Article reference 27" data-doi="10.1056/NEJM200002243420801">Article</a> <a data-track="click_references" rel="nofollow noopener" data-track-label="link" data-track-item_id="link" data-track-value="cas reference" data-track-action="cas reference" href="/articles/cas-redirect/1:STN:280:DC%2BD3c7jt1ejsw%3D%3D" aria-label="CAS reference 27">CAS</a> <a data-track="click_references" rel="nofollow noopener" data-track-label="link" data-track-item_id="link" data-track-value="pubmed reference" data-track-action="pubmed reference" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&dopt=Abstract&list_uids=10684910" aria-label="PubMed reference 27">PubMed</a> <a data-track="click_references" data-track-action="google scholar reference" data-track-value="google scholar reference" data-track-label="link" data-track-item_id="link" rel="nofollow noopener" aria-label="Google Scholar reference 27" href="http://scholar.google.com/scholar_lookup?&title=Cytokeratin-positive%20cells%20in%20the%20bone%20marrow%20and%20survival%20of%20patients%20with%20stage%20I%2C%20II%2C%20or%20III%20breast%20cancer&journal=N%20Engl%20J%20Med&doi=10.1056%2FNEJM200002243420801&volume=342&pages=525-533&publication_year=2000&author=Braun%2CS&author=Pantel%2CK&author=M%C3%BCller%2CP&author=Janni%2CW&author=Hepp%2CF&author=Kentenich%2CCR&author=Gastroph%2CS&author=Wischnik%2CA&author=Dimpfl%2CT&author=Kindermann%2CG&author=Riethm%C3%BCller%2CG&author=Schlimok%2CG"> Google Scholar</a> </p></li><li class="c-article-references__item js-c-reading-companion-references-item" data-counter="28."><p class="c-article-references__text" id="ref-CR28">Ménard S, Bufalino R, Rilke F, Cascinelli N, Veronesi U, Colnaghi MI: Prognosis based on primary breast carcinoma instead of pathological nodal status. Br J Cancer. 1994, 70: 709-712. 10.1038/bjc.1994.379.</p><p class="c-article-references__links u-hide-print"><a data-track="click_references" rel="nofollow noopener" data-track-label="10.1038/bjc.1994.379" data-track-item_id="10.1038/bjc.1994.379" data-track-value="article reference" data-track-action="article reference" href="https://doi.org/10.1038%2Fbjc.1994.379" aria-label="Article reference 28" data-doi="10.1038/bjc.1994.379">Article</a> <a data-track="click_references" rel="nofollow noopener" data-track-label="link" data-track-item_id="link" data-track-value="pubmed reference" data-track-action="pubmed reference" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&dopt=Abstract&list_uids=7917924" aria-label="PubMed reference 28">PubMed</a> <a data-track="click_references" rel="nofollow noopener" data-track-label="link" data-track-item_id="link" data-track-value="pubmed central reference" data-track-action="pubmed central reference" href="http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2033423" aria-label="PubMed Central reference 28">PubMed Central</a> <a data-track="click_references" data-track-action="google scholar reference" data-track-value="google scholar reference" data-track-label="link" data-track-item_id="link" rel="nofollow noopener" aria-label="Google Scholar reference 28" href="http://scholar.google.com/scholar_lookup?&title=Prognosis%20based%20on%20primary%20breast%20carcinoma%20instead%20of%20pathological%20nodal%20status&journal=Br%20J%20Cancer&doi=10.1038%2Fbjc.1994.379&volume=70&pages=709-712&publication_year=1994&author=M%C3%A9nard%2CS&author=Bufalino%2CR&author=Rilke%2CF&author=Cascinelli%2CN&author=Veronesi%2CU&author=Colnaghi%2CMI"> Google Scholar</a> </p></li><li class="c-article-references__item js-c-reading-companion-references-item" data-counter="29."><p class="c-article-references__text" id="ref-CR29">Wicha MS, Hayes DF: Circulating tumor cells: not all detected cells are bad and not all bad cells are detected. J Clin Oncol. 2011, 29: 1508-1511. 10.1200/JCO.2010.34.0026.</p><p class="c-article-references__links u-hide-print"><a data-track="click_references" rel="nofollow noopener" data-track-label="10.1200/JCO.2010.34.0026" data-track-item_id="10.1200/JCO.2010.34.0026" data-track-value="article reference" data-track-action="article reference" href="https://doi.org/10.1200%2FJCO.2010.34.0026" aria-label="Article reference 29" data-doi="10.1200/JCO.2010.34.0026">Article</a> <a data-track="click_references" rel="nofollow noopener" data-track-label="link" data-track-item_id="link" data-track-value="pubmed reference" data-track-action="pubmed reference" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&dopt=Abstract&list_uids=21422428" aria-label="PubMed reference 29">PubMed</a> <a data-track="click_references" data-track-action="google scholar reference" data-track-value="google scholar reference" data-track-label="link" data-track-item_id="link" rel="nofollow noopener" aria-label="Google Scholar reference 29" href="http://scholar.google.com/scholar_lookup?&title=Circulating%20tumor%20cells%3A%20not%20all%20detected%20cells%20are%20bad%20and%20not%20all%20bad%20cells%20are%20detected&journal=J%20Clin%20Oncol&doi=10.1200%2FJCO.2010.34.0026&volume=29&pages=1508-1511&publication_year=2011&author=Wicha%2CMS&author=Hayes%2CDF"> Google Scholar</a> </p></li><li class="c-article-references__item js-c-reading-companion-references-item" data-counter="30."><p class="c-article-references__text" id="ref-CR30">Mego M, De Giorgi U, Dawood S, Wang X, Valero V, Andreopoulou E, Handy B, Ueno NT, Reuben JM, Cristofanilli M: Characterization of metastatic breast cancer patients with nondetectable circulating tumor cells. 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Our special thanks to Pr Fernand Boutros-Toni (departement of Epidemiology and Statistics- Medicine Faculty of Limoges) for statistical analysis.</p></div></div></section><section aria-labelledby="author-information" data-title="Author information"><div class="c-article-section" id="author-information-section"><h2 class="c-article-section__title js-section-title js-c-reading-companion-sections-item" id="author-information">Author information</h2><div class="c-article-section__content" id="author-information-content"><h3 class="c-article__sub-heading" id="affiliations">Authors and Affiliations</h3><ol class="c-article-author-affiliation__list"><li id="Aff1"><p class="c-article-author-affiliation__address">Astralab clinical laboratory, 7-11 Avenue de Lattre de Tassigny, 87000, Limoges, France</p><p class="c-article-author-affiliation__authors-list">Guislaine Barrière, Michel Tartary & Michel Rigaud</p></li><li id="Aff2"><p class="c-article-author-affiliation__address">Department of gynecology and surgery, Clinique du Colombier, 92 avenue Albert Thomas, 87100, Limoges, France</p><p class="c-article-author-affiliation__authors-list">Alain Riouallon & Joël Renaudie</p></li></ol><div class="u-js-hide u-hide-print" data-test="author-info"><span class="c-article__sub-heading">Authors</span><ol class="c-article-authors-search u-list-reset"><li id="auth-Guislaine-Barri_re-Aff1"><span class="c-article-authors-search__title u-h3 js-search-name">Guislaine Barrière</span><div class="c-article-authors-search__list"><div class="c-article-authors-search__item c-article-authors-search__list-item--left"><a href="/search?dc.creator=Guislaine%20Barri%C3%A8re" class="c-article-button" data-track="click" data-track-action="author link - 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All authors read and approved the final manuscript.</p></div></div></section><section data-title="Authors’ original submitted files for images"><div class="c-article-section" id="Sec15-section"><h2 class="c-article-section__title js-section-title js-c-reading-companion-sections-item" id="Sec15">Authors’ original submitted files for images</h2><div class="c-article-section__content" id="Sec15-content"><div data-test="supplementary-info"><div id="figshareContainer" class="c-article-figshare-container" data-test="figshare-container"></div><p>Below are the links to the authors’ original submitted files for images. </p><div class="c-article-supplementary__item" data-test="supp-item" id="MOESM1"><h3 class="c-article-supplementary__title u-h3"><a class="print-link" data-track="click" data-track-action="view supplementary info" data-test="supp-info-link" data-track-label="authors’ original file for figure 1" href="https://static-content.springer.com/esm/art%3A10.1186%2F1471-2407-12-114/MediaObjects/12885_2011_3155_MOESM1_ESM.pdf" data-supp-info-image="">Authors’ original file for figure 1</a></h3></div><div class="c-article-supplementary__item" data-test="supp-item" id="MOESM2"><h3 class="c-article-supplementary__title u-h3"><a class="print-link" data-track="click" data-track-action="view supplementary info" data-test="supp-info-link" data-track-label="authors’ original file for figure 2" href="https://static-content.springer.com/esm/art%3A10.1186%2F1471-2407-12-114/MediaObjects/12885_2011_3155_MOESM2_ESM.doc" data-supp-info-image="">Authors’ original file for figure 2</a></h3></div><div class="c-article-supplementary__item" data-test="supp-item" id="MOESM3"><h3 class="c-article-supplementary__title u-h3"><a class="print-link" data-track="click" data-track-action="view supplementary info" data-test="supp-info-link" data-track-label="authors’ original file for figure 3" href="https://static-content.springer.com/esm/art%3A10.1186%2F1471-2407-12-114/MediaObjects/12885_2011_3155_MOESM3_ESM.doc" data-supp-info-image="">Authors’ original file for figure 3</a></h3></div></div></div></div></section><section data-title="Rights and permissions"><div class="c-article-section" id="rightslink-section"><h2 class="c-article-section__title js-section-title js-c-reading-companion-sections-item" id="rightslink">Rights and permissions</h2><div class="c-article-section__content" id="rightslink-content"> <p> <b>Open Access</b> This article is published under license to BioMed Central Ltd. 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data-title="About this article"><div class="c-article-section" id="article-info-section"><h2 class="c-article-section__title js-section-title js-c-reading-companion-sections-item" id="article-info">About this article</h2><div class="c-article-section__content" id="article-info-content"><div class="c-bibliographic-information"><div class="c-bibliographic-information__column"><h3 class="c-article__sub-heading" id="citeas">Cite this article</h3><p class="c-bibliographic-information__citation">Barrière, G., Riouallon, A., Renaudie, J. <i>et al.</i> Mesenchymal and stemness circulating tumor cells in early breast cancer diagnosis. <i>BMC Cancer</i> <b>12</b>, 114 (2012). https://doi.org/10.1186/1471-2407-12-114</p><p class="c-bibliographic-information__download-citation u-hide-print"><a data-test="citation-link" data-track="click" data-track-action="download article citation" data-track-label="link" data-track-external="" rel="nofollow" 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