title: An increase in cancer stem cell population after primary systemic therapy is a poor prognostic factor in breast cancer.
abstract: BACKGROUND
  The cancer stem cell (CSC) hypothesis has important clinical implications for cancer therapeutics because of the proposed role of CSCs in chemoresistance. The aim of this study was to investigate changes in the CSC populations before and after primary systemic therapy (PST) and their prognostic role in human breast cancer.
  
  
  METHODS
  Paired samples (before and after PST) of breast cancer tissue were obtained from clinical stage II or III patients (n=92) undergoing PST with the regimen of doxorubicin plus docetaxel (AD) (n=50) or doxorubicin plus cyclophosphamide (AC) (n=42) and subsequent breast resection. The proportions of putative CSCs with CD44+/CD24- or aldehyde dehydrogenase 1+ (ALDH1+) phenotypes were determined by immunohistochemistry.
  
  
  RESULTS
  A higher proportion of CD44+/CD24- tumour cells and ALDH1 positivity in pre-chemotherapy tissue was correlated with higher histologic grade, oestrogen receptor (ER) negativity, high Ki-67 proliferation index and basal-like subtype of breast cancer. Aldehyde dehydrogenase 1 positivity in pre-chemotherapy biopsy was also associated with a higher rate of pathologic complete response following PST. In comparisons of putative CSC populations before and after PST, the proportions of CD44+/CD24- and ALDH1+ tumour cells were significantly increased after PST. The cases with increased CD44+/CD24- tumour cell populations after PST showed high Ki-67 proliferation index in post-chemotherapy specimens and those with increased ALDH1+ tumour cell population after PST were associated with ER negativity and p53 overexpression. Furthermore, cases showing such an increase had significantly shorter disease-free survival time than those with no change or a reduced number of CSCs, and the survival difference was most notable with regard to the changes of ALDH1+ tumour cell population in the patients who received AC regimen.
  
  
  CONCLUSIONS
  The present study provides the clinical evidence that the putative CSCs in breast cancer are chemoresistant and are associated with tumour progression, emphasising the need for targeting of CSCs in the breast cancer therapeutics.
authors.affiliation: Department of Pathology, Seoul National University Hospital, 28 Yeongon-dong, Jongno-gu, Seoul 110-744, Korea.
authors.forename: H E
authors.initials: HE
authors.lastname: Lee
authors.forename: J H
authors.initials: JH
authors.lastname: Kim
authors.forename: Y J
authors.initials: YJ
authors.lastname: Kim
authors.forename: S Y
authors.initials: SY
authors.lastname: Choi
authors.forename: S-W
authors.initials: SW
authors.lastname: Kim
authors.forename: E
authors.initials: E
authors.lastname: Kang
authors.forename: I Y
authors.initials: IY
authors.lastname: Chung
authors.forename: I A
authors.initials: IA
authors.lastname: Kim
authors.forename: E J
authors.initials: EJ
authors.lastname: Kim
authors.forename: Y
authors.initials: Y
authors.lastname: Choi
authors.forename: H S
authors.initials: HS
authors.lastname: Ryu
authors.forename: S Y
authors.initials: SY
authors.lastname: Park
mesh_terms: D000080924:Aldehyde Dehydrogenase 1 Family; D000971:Antineoplastic Combined Chemotherapy Protocols / Q000627:therapeutic use*; D001943:Breast Neoplasms / Q000188:drug therapy / Q000473:pathology; D051927:CD24 Antigen; D003520:Cyclophosphamide / Q000008:administration & dosage; D018450:Disease Progression; D018572:Disease-Free Survival; D000077143:Docetaxel; D004317:Doxorubicin / Q000008:administration & dosage; D006801:Humans; D018960:Hyaluronan Receptors / Q000032:analysis; D007527:Isoenzymes / Q000378:metabolism; D014411:Neoplastic Stem Cells / Q000187:drug effects / Q000473:pathology*; D010641:Phenotype; D011379:Prognosis; D050697:Retinal Dehydrogenase / Q000378:metabolism; D043823:Taxoids / Q000008:administration & dosage
chemical_list: D051927:CD24 Antigen; D018960:Hyaluronan Receptors; D007527:Isoenzymes; D043823:Taxoids; D000077143:Docetaxel; D004317:Doxorubicin; D003520:Cyclophosphamide; D000080924:Aldehyde Dehydrogenase 1 Family; C510223:ALDH1A1 protein, human; D050697:Retinal Dehydrogenase