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Logo of nihpaAbout Author manuscriptsSubmit a manuscriptHHS Public Access; Author Manuscript; Accepted for publication in peer reviewed journal;
Clin Cancer Res. Author manuscript; available in PMC 2011 January 1.
Published in final edited form as:
PMCID: PMC2874875

ALDH1-positive cancer stem cells mediate metastasis and poor clinical outcome in inflammatory breast cancer



To examine the role of cancer stem cells (CSCs) in mediating metastasis in Inflammatory breast cancer (IBC), and the association of these cells with patient outcome in this aggressive type of breast cancer.

Experimental Design

CSCs were isolated from SUM149 and MARY-X an IBC cell line and primary xenograft, by virtue of increased aldehyde dehydrogenase activity as assessed by the ALDEFLUOR assay. Invasion and metastasis of CSC populations were assessed by in vitro and mouse xenograft assays. Expression of ALDH1 was determined on a retrospective series of 109 IBC patients and this was correlated with histoclinical data. All statistical tests were two-sided. Log-rank tests using Kaplan-Meier analysis were employed to determine the correlation of ALDH1 expression with development of metastasis and patient outcome.


Both in vitro and xenograft assays demonstrated that invasion and metastasis in IBC are mediated by a cellular component that displays ALDH activity. Furthermore, expression of ALDH1 in IBC was an independent predictive factor for early metastasis and decreased survival in this patient population.


These results suggest that the metastatic, aggressive behavior of IBC may be mediated by a CSC component that displays ALDH enzymatic activity. ALDH1 expression represents the first independent prognostic marker to predict metastasis and poor patient outcome in IBC. The results illustrate how stem cell research can translate into clinical practice in the IBC field.

Keywords: Inflammatory breast carcinoma, Aldehyde dehydrogenase-Stem cell, Metastasis-SUM149-MARY-X


Inflammatory breast cancer (IBC) is an angio-invasive form of breast cancer associated with a high incidence of early nodal and systemic metastasis. In contrast to the recent decrease in breast cancer incidence in the United States, the annual incidence of IBC continues to rise (1,2) with an attendant increase in mortality (3). Despite advances in the use of systemic chemotherapy, the prognosis of IBC remains considerably worse than that of other locally-advanced breast cancers (1).

A number of molecular changes have been described in IBC including RHOC overexpression, hypomethylation of caveolin-1 or −2 promoters and deletion of the tumor suppressor WISP3 (48). In addition, IBCs have been reported to overexpress E-cadherin/α, β-catenin and angiogenic factors (4,7,914). While each of these genetic changes may contribute to the metastatic nature of IBC, no markers have been described that can predict the development of systemic metastasis or survival in IBC patients. Although ERBB2 expression is associated with aggressive behavior in most breast cancers, this is not the case in IBC (15).

There is increasing evidence that human breast cancers are driven by a tumor-initiating “cancer stem cell” (CSC) component that may contribute to tumor metastasis and therapeutic resistance (1620). Breast CSCs were initially characterized as CD44+/CD24/lin cells which were capable of serial transplantation in NOD/SCID mice (21). In addition to these markers, we have recently demonstrated that cells with stem cell properties in both normal and malignant breast samples can be identified by the expression of the enzyme aldehyde dehydrogenase 1 (ALDH1). Using flow cytometry and the ALDEFLUOR assay, which measures aldehyde dehydrogenase activity, we isolated CSCs from primary human mammary carcinomas grown as xenografts in NOD/SCID mice. In addition, ALDH1 immunostaining identified normal and malignant cancer stem cells in situ, in fixed paraffin-embedded sections (22).

The rare occurrence of IBC as well as the small size of tumor specimens contribute to the difficulties of studying the biology of this disease. This development of an immortalized cell line and xenograft model of human IBC have facilitated studies of IBC biology (23,24). In the present study, we have utilized in vitro assays as well as mouse models of the SUM149 IBC cell line and early passages of the MARY-X xenograft generated from a primary IBC tumor. We determined whether IBC contains CSCs and whether these cells mediate tumor invasion and metastasis. To investigate the clinical relevance of these findings, we examined the expression of the stem cell marker ALDH1 in tissue sections from patients with IBC. The in vitro studies and mouse xenografts provide evidence that the invasive and metastatic behavior of IBC is mediated by an ALDH1-positive cancer stem cell component. Furthermore, expression of this stem cell marker was associated with the development of early metastases and poor clinical outcome in IBC patients.


Additional data are available in the Supplementary Material and Methods section

Cell culture

SUM149, a gift from S Ethier to the University of Michigan, is a breast cancer cell line derived from a patient with primary IBC and is obtained from early passages only (<6 months)(25). ( SUM149 was grown in adherent conditions using the recommended culture medium (26). MARY-X, is human breast cancer xenograft established by Barsky and collaborators from a patient with IBC and exhibited the phenotype of florid LVI with tumor emboli formation in SCID and nude mice(9). When cultured in vitro, MARY-X gave rise to floating colonies termed spheroids. These primary spheroids could be maintained in suspension culture for periods up to 3 months(9).

ALDEFLUOR assay and separation of the ALDH positive population by FACS

The ALDEFLUOR kit (StemCell technologies, Durham, NC, USA) was used to isolate the population with a high ALDH enzymatic activity. SUM149 and MARY-X cells were suspended in ALDEFLUOR assay buffer containing ALDH substrate (BAAA, 1 µmol/l per 1×106 cells) and incubated for 40 minutes at 37°C. In each experiment a sample of cells was incubated with 50mmol/L of the specific ALDH inhibitor diethylaminobenzaldehyde (DEAB) as negative control. Flow cytometry sorting was conducted using a FACStarPLUS (Becton Dickinson). ALDEFLUOR fluorescence was excited at 488 nm and fluorescence emission was detected using a standard fluorescein isothiocyanate (FITC) 530/30 band pass filter. The sorting gates were established using the PI stained cells for viability and the ALDEFLUOR-stained cells treated with DEAB as negative controls.

Animal model and test of tumorigenicity

Tumorigenicity of ALDEFLUOR-positive, -negative and unseparated SUM149 and MARY-X cells was assessed in 3 independent sets of 3 NOD/SCID mice. Fat pads were cleared at 3 weeks of age prior to puberty and humanized by injecting a mixture of irradiated and non-irradiated immortalized human fibroblasts (1:1 irradiated:non-irradiated, 50,000 cells/100µl Matrigel/fat pad) as described in (22).

After sorting, the tumorigenicity of the ALDEFLUOR-positive, ALDEFLUOR-negative and unseparated populations of SUM149 and MARY-X cells was tested by inoculation of limiting dilutions of cells (50,000; 5,000; 500 cells) mixed with Matrigel (BD biosciences) (1:1) and implanted in the cleared humanized mammary fat pads 2–4 weeks later.

Lentivirus infection

For luciferase gene transduction, 70% confluent SUM149 cells and suspension culture of MARY-X single cells were incubated overnight with a 1:3 precipitated mixture of lentiviral supernatants Lenti-LUC-VSVG (Vector Core, University of Michigan, Ann Arbor, MI) in culture medium. The following day the SUM149 cells were harvested by trypsin/EDTA and subcultured at a ratio of 1:6 and MARY-X cells were maintained in suspension culture. After 1 week incubation, luciferase expression was verified by adding 2 µl D-luciferin 0.0003% (Promega, Madison, WI) in the culture medium and counting photon flux by device camera system (Xenogen, Alameda, CA).

Animal model and intracardiac inoculation

Six weeks old NOD/SCID mice were anesthetized with 1.75% isofluorane/air anesthesia and the left ventricule of the heart was injected with 50,000 or 100,000 cells (ALDEFLUOR-positive, -negative, unseparated) in 100 µL of sterile Dulbecco's PBS lacking Ca2+ and Mg2+. Experiments were done in duplicates for SUM149 and MARY-X

Bioluminescence detection

After cell inoculations, the animals were screened for metastasis using bioluminescence. Baseline bioluminescence was assessed before inoculation and each week thereafter. Mice were anesthetized with a 2% isofluorane/air mixture and given a single i.p. dose of 150 mg/kg D-luciferin (Promega, Madison, WI) in PBS. Animals were then re-anesthetized using 2% isofluorane/air mixture 6 minutes after administration of D-luciferin. For photon flux counting, we used a charge-coupled device camera system (Xenogen, Alameda, CA) with a nose-cone isofluorane delivery system and heated stage for maintaining body temperature. Results were analyzed after 2 to 12 minutes of exposure using Living Image software provided with the Xenogen imaging system. Signal intensity was quantified as the sum of all detected photon flux counts within a uniform region of interest manually placed during data post processing. Normalized photon flux represents the ratio of the photon flux detected each week after inoculations and the photon flux detected before inoculation.

Patients and tissues

IBC patients were selected from computerized clinico-pathological databases of Institut Paoli-Calmettes between 1976 and 2003 as consecutive cases with available paraffin-embedded tumoral specimen. IBC was clinically defined as T4d tumor (TNM, UICC), and metastatic patients at time of diagnosis were not included; the presence of dermal lymphatic emboli was not mandatory for IBC definition. One hundred and nine patients with IBC with a median follow up of 67 months were included. All details are in supplementary material and methods.

Immunohistochemistry and antibodies

Expression of ALDH1, BCL2, E-Cadherin, ER, MIB1, ERBB2, MUC1, and PR was measured by IHC and expression of CD24 and CD44 was measured by immunohistochemical double staining as well as by flow cytometry. The characteristics of the antibodies used and the details of the technique are listed in Supplementary Table 1 and in Supplementary material and methods. ALDH1 immunostaining was done as previously described (22), using positive external control for each experiment. For each slide, when internal controls (surrounding fibroblasts or histiocytes located in the stroma or between tumoral cells) were not stained for ALDH1, the slide was not included in the study. Results were expressed in terms of percentage (P) and intensity (I) of positive cells as described previously (22). Results were scored by the quick score (Q) (Q = P x I). Tumor presenting at least one ALDH1-positive cancer cell was considered as an ALDH1-positive tumor Scoring was estimated by two independent breast pathologists (ECJ, JJ) and the mean-value was used. Discrepancies were resolved under multiheaded microscope.

Statistical analysis

For in vitro experiments and animal models, results are presented as the mean ±SD for at least three repeated individual experiments for each group. Statistical analyses used the SPSS software (version 10.0.5). Correlations between sample groups and parameters were calculated with the Fisher’s exact test or the one-way ANOVA for independent samples. A p-value <0.05 was considered significant.

For the IBC retrospective series, data were summarized by frequencies and percentages for categorical variables, and by median and range for continuous variables. No missing data imputation technique was applied. To study associations among variables, univariate analysis was done using non-parametric Wilcoxon rank sum test, Chi-Square test or Fisher’s exact test when appropriate. Specific Survival (SS) and Metastasis-Free-Survival (MFS) rates were estimated by the Kaplan-Meier method using the following first event definitions: death by breast cancer for SS, first metastasis recurrence for MFS. Patients without events were censored at the time of last follow-up or at the date of death if they died for other reason than breast cancer. All survival times were calculated from the date of breast cancer diagnosis. Changes in the relative risk of events according to prognostic factors were assessed by using the log-rank test in univariate analysis. Multivariate analysis was done using Cox's proportional hazard models with a backward stepwise selection of variables to minimize the Akaike Information Criterion. All statistical tests were two-sided at the 5% level of significance, using the R 2.9.1 software.


Isolation and characterization of an ALDEFLUOR-positive cancer stem cell population in SUM149 and MARY-X models of IBC

The enzyme Aldehyde dehydrogenase (ALDH) has been a useful marker for isolating primitive stem cell populations. We have previously demonstrated that normal human mammary stem and progenitor cells as well as transformed tumor-initiating stem cells may be isolated by virtue of their expression of ALDH activity, as assessed by flow cytometry utilizing the ALDEFLUOR assay. To determine whether IBC contains a “cancer stem cell” population, we utilized two different models: SUM149, a breast cancer cell line derived from a patient with primary IBC (25) and MARY-X, a human IBC xenograft (9). Using the ALDEFLUOR assay, we isolated an ALDEFLUOR-positive component comprising 5.96±2.2% and 7.2±1.5% of the total cell population (Figure 1a–b, g–h) of SUM149 and MARY-X, respectively. The tumorigenicity of the ALDEFLUOR-positive, ALDEFLUOR-negative and unseparated populations of SUM-149 and MARY-X cells was tested by inoculation of limiting dilutions of cells (50,000; 5,000; 500 cells) into mammary fat pads of NOD/SCID mice that were humanized by the introduction of irradiated and non-irradiated human mammary fibroblasts (22,26). For the two models utilized, the fat pads injected with 50,000, 5,000 and 500 ALDEFLUOR-positive cells generated tumors whereas the ALDEFLUOR-negative cells failed to generate tumors even when 50,000 cells were inoculated (Figure 1d–f, j–l). A summary of the fat pad injected and the tumor formation in each case is in Supplementary Table 2. H&E staining of fat pad sections confirmed that tumors formed by the ALDEFLUOR-positive cells contained malignant cells with a histology similar to the initial tumors (Figure 1e, k). In contrast, only residual Matrigel, apoptotic cells and mouse tissue were seen at the sites of the ALDEFLUOR-negative cell injections (Figure 1f, l). As indicated in Figure 1d and 1j, the size and latency of tumor formation correlated with the number of ALDEFLUOR-positive cells injected, with 500 ALDEFLUOR-positive cells generating tumors within 30 days for SUM149 and 75 days for MARY-X. To demonstrate the self-renewal potential of the ALDEFLUOR-positive population, we performed three consecutive serial passages in NOD/SCID mice. With each inoculation, the ALDEFLUOR-positive but not ALDEFLUOR-negative cells were able to form tumors even when 500 cells were inoculated. The ability of a small number of ALDEFLUOR-positive cells to generate tumors that could be serially passaged demonstrates the self-renewal capacity of these cells.

Figure 1
The ALDEFLUOR-positive cell population of SUM149 and MARY-X cells displays properties of cancer stem cells

To determine the differentiation capacity of the ALDEFLUOR-positive population, the distribution of ALDEFLUOR-positive and ALDEFLUOR-negative cells was determined at each serial passage. As shown in Figure 1c and 1i, ALDEFLUOR-positive cells generated tumors that contained ALDEFLUOR-positive and -negative cells in a similar proportion to that found in the initial tumor. Utilizing the two models, we demonstrated that in addition to self-renewal, ALDEFLUOR-positive cells from SUM149 and MARY-X are able to differentiate, generating a population of ALDEFLUOR-negative non-self-renewing cells.

We next investigated the overlap between the ALDEFLUOR-positive population and the previously described breast CSC phenotype, CD44+/CD24−(21). Flow cytometry analysis of the SUM149 tumors showed that the ALDEFLUOR-positive population was enriched in CD44+/CD24 cells, with 13.5% of CD44+/CD24 cells in the ALDEFLUOR-positive population compared to only 3.02% in the ALDEFLUOR-negative population (Supplementary Figure 1). Because more than 98% of MARY-X cells are CD44+/CD24 we did not investigate the overlap between the two phenotypes (Supplementary Figure 1) in this model.

Invasion and metastasis

IBC has a high propensity for development of lymphagenic invasion and distant metastasis. To determine whether these properties were mediated by the cancer stem cell component, we utilized a Matrigel invasion assay to examine the ability of ALDEFLUOR-positive and -negative SUM149 cell populations to invade. As shown in Figure 2a, the percentage of ALDEFLUOR-positive SUM149 cells capable of invasion through Matrigel was more than three-fold higher than that of the ALDEFLUOR-negative population (p<0.05). To determine the metastatic capacity of these cell populations, we labeled SUM149 and MARY-X cells with a luciferase lentivirus reporter system. The luciferase-labeled cells were sorted using the ALDEFLUOR assay and ALDEFLUOR-positive, -negative and unseparated cells were introduced by intracardiac injection into NOD/SCID mice. For SUM149 and MARY-X, a suspension of 50,000 and 100,000 cells from each group were injected and the development of metastasis assessed by non-invasive luciferase bioluminescent imaging quantified by photon flux (27). As shown in Figure 2b–g, only ALDEFLUOR-positive and unseparated cells formed metastases in this assay. Histologic sections confirmed the presence of bone and lung metastases (Figure 2h–i) produced from injection of ALDEFLUOR-positive and unseparated cells. Furthermore, vertebral metastasis formed from intracardiac injection of ALDEFLUOR-positive MARY-X cells contained populations of ALDH1-positive and ALDH1-negative cells recapitulating the heterogeneity of the initial tumor.

Figure 2
The ALDEFLUOR-positive cell population of SUM149 and MARY-X cells mediates invasion and metastasis

In contrast, no metastases were detected in mice inoculated with either 50,000 or 100,000 ALDEFLUOR-negative cells. The absence of systemic metastasis was confirmed by histologic examination of sections of the liver, bones, brain and lung tissues. These results suggest that invasion and systemic metastasis in IBC are mediated by cells expressing the stem/progenitor cell marker ALDH1.

ALDH1 expression in a series of human inflammatory carcinomas

We have previously demonstrated that monoclonal antibodies to ALDH1 are able to identify normal and malignant breast stem/progenitor cells in fixed paraffin-embedded sections in situ (25). To determine the clinical relevance of expression of this stem/progenitor cell marker we examined the expression of ALDH1 in a series of 109 IBC patients treated at our institution between 1976 and 2003. ALDH1 was expressed in 34% of tumors with approximately 3–5% positively stained cells in these tumors (Figure 3a). This percentage of ALDH1 expression in this patient population is similar to that found in non-inflammatory breast cancer (22). ALDH1-positive cells were also detected in intralymphatic tumor emboli (Figure 3b–d) consistent with a role for these cells in tumor metastasis. ALDH1 expression correlated with the SBR grade, but there was no correlation with a number of other clinical and pathologic features including estrogen and progesterone receptors, BCL2, ERBB2, E-cadherin or MUC1 (Table 1).

Figure 3
ALDH1 expression in IBC patient tumors is associated with the development of metastasis and with decreased survival

In order to explore another marker of breast cancer stem cells in IBC, and to evaluate its correlation with ALDH expression, we investigated the presence of the CD44+/CD24phenotype in IBC archival specimens. The presence of CD44+/CD24 cells was evaluated by immunohistochemistry using double staining on paraffin sections (Supplementary Figure 2). The CD44+/CD24 phenotype was evaluated in 81 cases out of the 109 IBC samples, and was present in 51 cases. By comparison with non IBC tumors, we observed an increase of the percentage of tumors that displayed the CD44+/CD24− phenotype in IBC (63% in IBC versus 31% in non-IBC across literature data) (28). This phenotype in IBC was correlated with high proliferation index, absence of MUC1 expression, and with less lymph node invasion, which differed from previous reports of expression of this phenotype in non-IBC (Supplementary Table 3). More importantly, there was no correlation between the CD44+/CD24 phenotype and ALDH1-expression (Table 1).

ALDH1 expression correlates with the development of systemic metastasis and with decreased survival in IBC patients

To determine whether the expression of the stem cell marker ALDH1 correlated with the development of systemic metastasis and survival in IBC patients, Kaplan-Meier survival curves were constructed and compared by log-rank tests. ALDH1 expression correlated with the development of distant metastasis and with decreased survival in these patients. With a median follow-up of 67 months, ALDH1 expression strongly correlated with metastasis-free survival (MFS) (p=0.0152) as well as tumor-specific survival (SS) (p=0.0337) (Figure 3 e–f). The median MFS was 49 months in patients with ALDH1-negative tumors, compared to 20 months in patients with ALDH1-positive tumors (Table 2). Median SS was 63 months for patients whose tumors did not express ALDH1 compared to only 27 months for patients with tumors expressing ALDH1. Among other parameters tested in univariate analysis, BCL2 expression or ER/PR expression were also correlated with an increased MFS and SS (Table 2). In multivariate analysis using Cox proportional hazard models, ALDH1 was the only prognostic marker of MFS (p=0.0055, HR=2.81, 95%CI [1.355–5.815]) and the most powerful prognostic marker of SS (ALDH1: p=0.0012, HR=2.7, 95%CI [1.48–4.93]) when factors significant in univariate analysis (hormonal receptors and BCL2 expression) were included in the model (Table 3). BCL2 expression was still significant in the model for SS only (BCL2: p=0.031, HR=0.4, 95%CI [0.224–0.93]). In contrast, the expression of the CD44+/CD24 phenotype previously shown to be a CSC marker in non-IBC was not associated with either development of metastasis or patient survival (Supplementary Figure 3).

Table 2
Kaplan Meier univariate analysis of the Specific Survival (SS) and Metastasis Free Survival (MFS) of 74 inflammatory breast carcinomas
Table 3
Cox proportional hazard multivariate analysis in specific survival SS (n=77)


IBC is among the most angioinvasive and metastatic variants of human breast cancer. Molecular mechanisms have been implicated in IBC clinical aggressiveness. E-cadherin overexpression and dysfunctional, hyposialylated MUC1, may contribute to the metastatic route of IBC (10,29). The frequent overexpression of RHOC GTPase, hypomethylation of caveolin-1 or −2 promoters, or deletion of the tumor suppressor WISP3 that belongs to the CCN family, illustrates the ability of IBC cells to migrate through putative induction of epithelial to mesenchymal transition process (48,30)Yet, very few markers are available to improve IBC clinical course.

In this study, we have utilized in vitro and mouse models to demonstrate that inflammatory breast cancers contain a cellular component, characterized by expression of aldehyde dehydrogenase, that displays stem cell properties and is able to mediate IBC aggressive behavior.

ALDEFLUOR-positive cells from IBC cell line and xenograft displayed CSC properties and mediate metastasis

We have previously demonstrated the feasibility of utilizing established cell lines for studies of cancer stem cell biology (31). Of note, despite the availability of cell lines representing the different molecular subtypes of breast cancer, the establishment of similar models for IBC has been notoriously difficult. Strikingly, of the 50 cell lines and approximately 20 xenografts in vivo established in the past decades from breast cancers, only SUM149/190, MARY-X and WIBC-9 were derived from IBC and are currently available to study this type of cancer (9,24,32) . It highlights the importance of material available for stem cell studies in IBC. Indeed, tumor xenografting is mandatory to test stem cell properties including tumorigenicity upon serial passages and differentiation (16,22). In that case, the use of primary human breast tumors is not feasible since breast cancer has a well-documented low xenografting rate. Furthermore, due to the small size of tumors specimen available in IBC at time of diagnosis, these questions cannot be addressed for most inflammatory breast tumors. In this study, we utilized SUM149 IBC cell line and MARY-X xenograft which represents by all criteria, a tumor from human patient engrafted directly in vivo, with all IBC features (9,13).

We utilized in vitro and in vivo experiments, to test stem cell properties in cells that are expressing aldehyde dehydrogenase, an enzyme implicated in retinoic acid metabolism. These “canonical” stem cell properties include self-renewal as demonstrated by tumorigenicity upon serial passages, and differentiation as demonstrated by the ability to reconstitute the phenotypic heterogeneity of the initial tumor. Furthermore, we demonstrated that these ALDEFLUOR-positive cells are able to mediate tumor invasion in vitro and tumor metastasis in mouse xenografts. These properties recapitulate the aggressive behavior of IBC in patients. This is consistent with ALDH staining in tumor emboli described here and by others (33).

ALDH1 as an independent prognostic marker in IBC

Although it is clear that IBC has an extremely poor prognosis, there currently are no validated markers which predict outcome in this disease. In fact, well known markers such as ERBB2 are associated with the aggressive behavior of non-IBC and do not correlate with patient outcome in IBC (15, 34). The anti-apoptotic factor BCL2, which expression has been associated with improved SS in non-IBC, is for the first time described as an independent factor for SS in IBC (35). However, BCL2 expression is not significantly associated with longer MFS (Table 2) and is not correlated with the stem cell markers ALDH1 expression (Table 1) or CD44+/CD24 phenotype (Supplementary Table 3). In contrast, our work shows that expression of the stem cell marker ALDH1 is associated with development of early metastasis and is an independent prognostic marker for IBC. To our knowledge, ALDH1 is the only independent marker ever described in IBC to predict metastasis. Interestingly, the CD44+/CD24− phenotype shown to be associated with cancer stem cells for non-IBC was not associated with outcomes in IBC. This suggests either that ALDH1 and CD44+/CD24− are detecting distinct though overlapping cell populations or that the reliability of detection of CD44+/CD24− in fixed tumor tissue may be limited(16,36).

Even though cells that expressed ALDH1 have been shown to mediate poor prognosis and metastasis in IBC, the percentage of ALDH1 expression in this patient population is similar to that found in non-inflammatory breast cancer and is thus not sufficient to explain by itself the aggressive behavior of IBC. It remains true that expression of ALDH1 is associated with poor outcome and early metastasis in IBC, and we can assume that ALDH-expressing CSC exert different abilities in IBC and in non-IBC. In human hematopoietic system, only a subpopulation of ALDEFLUOR-positive stem cells, expressed CD133, are able to repopulate the murine bone marrow (37). In solid tumor, utilizing a pancreatic cell line xenografted in immunocompromised mice, only a fraction of pancreatic cancer stem cells carry the metastatic potential (38). Consequently, in breast tumor, only a subset of CSC may carry the metastatic potential. Hence, the proportion of metastatic CSC inside the ALDEFLUOR-positive CSC population can differ between IBC and non IBC and should explain the clinical discrepancies between the two clinical entities. Further studies are needed to isolate potential markers and validate this hypothesis.

Translational perspectives

We have demonstrated that IBC contained a cancer stem cell population that express aldehyde dehydrogenase and that ALDEFLUOR-positive IBC cells are highly invasive and mediate metastasis in mice. It is often thought that aggressive cancers may not be organized hierarchically or may have a predominant, rather than rare cancer stem cell population (39,40). Our work shows that this is not the case in IBC. Moreover, we have shown for the first time that the expression of the stem cell marker ALDH1 is associated with the development of systemic metastasis and decreased survival in IBC patients. Our data also suggest that in addition to mediating metastasis, cancer stem cells also have the ability to reconstitute the tumor heterogeneity of the primary tumor at these metastatic sites.

These results suggest that ALDEFLUOR-hierarchy in this subset of breast cancer with respect to its clinical behavior and biological diversity play an important role in mediating the aggressive course of IBC. Recent preclinical and neoadjuvant clinical studies in non-inflammatory breast cancer raised the hypothesis that this hierarchy may impact the clinical management of breast cancer patients. Hence, they have suggested that cancer stem cells in these tumors are relatively resistant to chemotherapy compared to the bulk tumor cell populations (41,42). Since cytotoxic chemotherapy is the current recommended treatment for IBC(43), it will be a major point to determine whether the cancer stem cell components of inflammatory breast cancer are also resistant to chemotherapy accounting for poor outcome in these patients. If this is the case, then alternative strategies aimed at targeting this cancer stem cell population will need to be developed. Based on the successful clinical application of differentiation therapy in acute promyelocytic leukemia, one of these strategies could be the induction of differentiation(44).This underlines the importance of the ALDH1 status in translating cancer stem cell research into IBC clinical practice.

Statement of Translational Relevance

Inflammatory breast cancer (IBC) carries a poor prognosis and early metastasis. The topic of this work is of major importance since we demonstrate that invasion and metastasis in IBC are mediated by a cellular subcomponent with stem cell characteristics expressing the stem cell marker Aldehyde dehydrogenase 1 (ALDH1). In addition, we show the clinical relevance of these findings in a series of 109 patients with IBC by demonstrating that the expression of ALDH1 is associated with early metastasis and decreased survival. These results might be important since there are currently no reliable markers that relate to metastasis of IBC. Our work suggests that the stem cell marker ALDH1 could provide such a tool and that ALDH1-positive cancer stem cells play an important role in mediating the clinically aggressive behavior of IBC. This study underlines the importance of the ALDH1 status in translating cancer stem cell research into clinical practice.

Supplementary Material

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We thank Jean-Paul Borg and Florence Monville for helpful discussions, Olivier Cabaud, Jeannine Geneix, Laetitia Repellini and the CIML flow cytometry core (P Grenot and M Malissen) for technical support.


Supported by NIH Grant CA101860 (MSW), CA29765 and P36CA45692 (MSW), Support from the Taubman Institute (MSW), Grant from Institut National du Cancer (PHRC 2006, PHRC 2007) (ECJ) and PL2008 (DB) and Institut Lilly (AO 2006)(ECJ) and Ligue Nationale contre le Cancer (Label DB 2007)(DB).

Max, S. Wicha has financial holdings and is a scientific advisor for Oncomed Pharmaceuticals.

Reference List

1. Hance KW, Anderson WF, Devesa SS, Young HA, Levine PH. Trends in inflammatory breast carcinoma incidence and survival: the surveillance, epidemiology, and end results program at the National Cancer Institute. J Natl Cancer Inst. 2005;97:966–975. [PMC free article] [PubMed]
2. Ravdin PM, Cronin KA, Howlader N, et al. The decrease in breast-cancer incidence in 2003 in the United States. N Engl J Med. 2007;356:1670–1674. [PubMed]
3. Yang CH, Cristofanilli M. The role of p53 mutations as a prognostic factor and therapeutic target in inflammatory breast cancer. Future Oncol. 2006;2:247–255. [PubMed]
4. Charafe-Jauffret E, Tarpin C, Bardou VJ, et al. Immunophenotypic analysis of inflammatory breast cancers: identification of an "inflammatory signature". J Pathol. 2004;202:265–273. [PubMed]
5. Kleer CG, Zhang Y, Pan Q, et al. WISP3 and RhoC guanosine triphosphatase cooperate in the development of inflammatory breast cancer. Breast Cancer Res. 2004;6:R110–R115. [PMC free article] [PubMed]
6. Van den Eynden GG, Van Laere SJ, Van dAI, et al. Overexpression of caveolin-1 and −2 in cell lines and in human samples of inflammatory breast cancer. Breast Cancer Res Treat. 2006;95:219–228. [PubMed]
7. Van Laere SJ, Van dAI, Van den Eynden GG, et al. Nuclear factor-kappaB signature of inflammatory breast cancer by cDNA microarray validated by quantitative real-time reverse transcription-PCR, immunohistochemistry, and nuclear factor-kappaB DNA-binding. Clin Cancer Res. 2006;12:3249–3256. [PubMed]
8. Wu M, Wu ZF, Kumar-Sinha C, Chinnaiyan A, Merajver SD. RhoC induces differential expression of genes involved in invasion and metastasis in MCF10A breast cells. Breast Cancer Res Treat. 2004;84:3–12. [PubMed]
9. Alpaugh ML, Tomlinson JS, Shao ZM, Barsky SH. A novel human xenograft model of inflammatory breast cancer. Cancer Res. 1999;59:5079–5084. [PubMed]
10. Alpaugh ML, Tomlinson JS, Ye Y, Barsky SH. Relationship of sialyl-Lewis(x/a) underexpression and E-cadherin overexpression in the lymphovascular embolus of inflammatory breast carcinoma. Am J Pathol. 2002;161:619–628. [PubMed]
11. Colpaert CG, Vermeulen PB, Fox SB, et al. The presence of a fibrotic focus in invasive breast carcinoma correlates with the expression of carbonic anhydrase IX and is a marker of hypoxia and poor prognosis. Breast Cancer Res Treat. 2003;81:137–147. [PubMed]
12. McCarthy NJ, Yang X, Linnoila IR, et al. Microvessel density, expression of estrogen receptor alpha, MIB-1, p53, and c-erbB-2 in inflammatory breast cancer. Clin Cancer Res. 2002;8:3857–3862. [PubMed]
13. Tomlinson JS, Alpaugh ML, Barsky SH. An intact overexpressed E-cadherin/alpha,beta-catenin axis characterizes the lymphovascular emboli of inflammatory breast carcinoma. Cancer Res. 2001;61:5231–5241. [PubMed]
14. Van dAI, Van Laere SJ, Van den Eynden GG, et al. Increased angiogenesis and lymphangiogenesis in inflammatory versus noninflammatory breast cancer by real-time reverse transcriptase-PCR gene expression quantification. Clin Cancer Res. 2004;10:7965–7971. [PubMed]
15. Zell JA, Tsang WY, Taylor TH, Mehta RS, Anton-Culver H. Prognostic impact of HER2 and hormone receptor status in inflammatory breast cancer (IBC): analysis of 2014 IBC patient cases from the California Cancer Registry. Breast Cancer Res. 2009;11:R9. [PMC free article] [PubMed]
16. Al Hajj M, Becker MW, Wicha M, Weissman I, Clarke MF. Therapeutic implications of cancer stem cells. Curr Opin Genet Dev. 2004;14:43–47. [PubMed]
17. Bonnet D, Dick JE. Human acute myeloid leukemia is organized as a hierarchy that originates from a primitive hematopoietic cell. Nat Med. 1997;3:730–737. [PubMed]
18. Li F, Tiede B, Massague J, Kang Y. Beyond tumorigenesis: cancer stem cells in metastasis. Cell Res. 2007;17:3–14. [PubMed]
19. Phillips TM, McBride WH, Pajonk F. The response of CD24(−/low)/CD44+ breast cancer-initiating cells to radiation. J Natl Cancer Inst. 2006;98:1777–1785. [PubMed]
20. Wicha MS, Liu S, Dontu G. Cancer stem cells: an old idea--a paradigm shift. Cancer Res. 2006;66:1883–1890. [PubMed]
21. Al Hajj M, Wicha MS, Benito-Hernandez A, Morrison SJ, Clarke MF. Prospective identification of tumorigenic breast cancer cells. Proc Natl Acad Sci U S A. 2003;100:3983–3988. [PubMed]
22. Ginestier C, Hur MH, Charafe-Jauffret E, et al. 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. [PMC free article] [PubMed]
23. Forozan F, Veldman R, Ammerman CA, et al. Molecular cytogenetic analysis of 11 new breast cancer cell lines. Br J Cancer. 1999;81:1328–1334. [PMC free article] [PubMed]
24. Hoffmeyer MR, Wall KM, Dharmawardhane SF. In vitro analysis of the invasive phenotype of SUM 149, an inflammatory breast cancer cell line. Cancer Cell Int. 2005;5:11. [PMC free article] [PubMed]
25. van Golen KL, Davies S, Wu ZF, et al. A novel putative low-affinity insulin-like growth factor-binding protein, LIBC (lost in inflammatory breast cancer), and RhoC GTPase correlate with the inflammatory breast cancer phenotype. Clin Cancer Res. 1999;5:2511–2519. [PubMed]
26. Kuperwasser C, Chavarria T, Wu M, et al. Reconstruction of functionally normal and malignant human breast tissues in mice. Proc Natl Acad Sci U S A. 2004;101:4966–4971. [PubMed]
27. Minn AJ, Gupta GP, Padua D, et al. Lung metastasis genes couple breast tumor size and metastatic spread. Proc Natl Acad Sci U S A. 2007;104:6740–6745. [PubMed]
28. Honeth G, Bendahl PO, Ringner M, et al. The CD44+/ Breast Cancer Res. 2008;10:R53. [PMC free article] [PubMed]
29. Yamauchi H, Cristofanilli M, Nakamura S, Hortobagyi GN, Ueno NT. Molecular targets for treatment of inflammatory breast cancer. Nat Rev Clin Oncol. 2009 [PubMed]
30. Huang W, Zhang Y, Varambally S, et al. Inhibition of CCN6 (Wnt-1-induced signaling protein 3) down-regulates E-cadherin in the breast epithelium through induction of snail and ZEB1. Am J Pathol. 2008;172:893–904. [PubMed]
31. Charafe-Jauffret E, Ginestier C, Iovino F, et al. Breast Cancer Cell Lines Contain Functional Cancer Stem Cells with Metastatic Capacity and a Distinct Molecular Signature. Cancer Res. 2009 [PMC free article] [PubMed]
32. Shirakawa K, Kobayashi H, Sobajima J, et al. Inflammatory breast cancer: vasculogenic mimicry and its hemodynamics of an inflammatory breast cancer xenograft model. Breast Cancer Res. 2003;5:136–139. [PMC free article] [PubMed]
33. Xiao Y, Ye Y, Yearsley K, Jones S, Barsky SH. The lymphovascular embolus of inflammatory breast cancer expresses a stem cell-like phenotype. Am J Pathol. 2008;173:561–574. [PubMed]
34. Dawood S, Gonzalez-Angulo AM, Peintinger F, et al. Efficacy and safety of neoadjuvant trastuzumab combined with paclitaxel and epirubicin: a retrospective review of the M. D. Anderson experience. Cancer. 2007;110:1195–1200. [PubMed]
35. Callagy GM, Webber MJ, Pharoah PD, Caldas C. Meta-analysis confirms BCL2 is an independent prognostic marker in breast cancer. BMC Cancer. 2008;8:153. [PMC free article] [PubMed]
36. Dontu G. Breast cancer stem cell markers - the rocky road to clinical applications. Breast Cancer Res. 2008;10:110. [PMC free article] [PubMed]
37. Hess DA, Wirthlin L, Craft TP, et al. Selection based on CD133 and high aldehyde dehydrogenase activity isolates long-term reconstituting human hematopoietic stem cells. Blood. 2006;107:2162–2169. [PubMed]
38. Hermann PC, Huber SL, Herrler T, et al. Distinct populations of cancer stem cells determine tumor growth and metastatic activity in human pancreatic cancer. Cell Stem Cell. 2007;1:313–323. [PubMed]
39. Passegue E, Rafii S, Herlyn M. Cancer stem cells are everywhere. Nat Med. 2009;15:23. [PubMed]
40. Quintana E, Shackleton M, Sabel MS, et al. Efficient tumour formation by single human melanoma cells. Nature. 2008;456:593–598. [PMC free article] [PubMed]
41. Li X, Lewis MT, Huang J, et al. Intrinsic resistance of tumorigenic breast cancer cells to chemotherapy. J Natl Cancer Inst. 2008;100:672–679. [PubMed]
42. Yu F, Yao H, Zhu P, et al. let-7 regulates self renewal and tumorigenicity of breast cancer cells. Cell. 2007;131:1109–1123. [PubMed]
43. Dawood S, Cristofanilli M. What progress have we made in managing inflammatory breast cancer? Oncology (Williston Park) 2007;21:673–679. [PubMed]
44. Petrie K, Zelent A, Waxman S. Differentiation therapy of acute myeloid leukemia: past, present and future. Curr Opin Hematol. 2009;16:84–91. [PubMed]