IntroductionTumor metastasis is a clonally selective process that occurs as part of tumor progression, a hypothesis supported by experimental and clinical research. Data supporting this hypothesis were first introduced by Fidler and Kripke in the late 1970s (1), providing a powerful model to gain insight into the mechanism(s) of metastasis. Studies of cellular genetic and epigenetic heterogeneity within tumors (1-3) support the selective process of metastasis, as have studies of clonal selection and cellular expansion following metastasis (4,5). In the original clonal selection studies (1), orthotopic tumor models were used because they faithfully reproduce clinical invasion, histopathology, cellular shedding, and metastasis (6), showing the clonal origin (1, 4) and selective mechanisms (7,8) of metastasis.
Clonal Selection in the Process of MetastasisThe growth of a tumor focus at a site distant to the primary tumor represents the final step in the multistep process of metastasis, which has the potential to incorporate numerous selective events. Implicit to the clonal selection hypothesis (Fig. 1) is the presence within the primary tumor of at least one tumor population that expresses all of the up-regulated or inactivated genes required to successfully complete the metastatic process. As such, primary tumors may also have cellular subpopulations that express none or some of the characteristics required to complete the metastatic process. A corollary to the clonal selection hypothesis is the suggestion that individual metastases can originate from multiple clonal subpopulations that may have occurred within the primary tumor, resulting in biological diversity among metastatic foci. Thus, primary tumors can have multiple clonal subpopulations capable of forming metastatic foci, resulting in individual metastases expressing different phenotypes (5, 7). Further, due to the genetic instability (9), a clonal metastasis can rapidly become heterogeneous (5, 10). Although the clonal selection hypothesis was formally shown within rodent models in 1977 (1), it is confirmed daily by clinical pathologists. Histologic examination of primary tumors shows cellular heterogeneity based on morphology and expression of membrane receptors. For example, morphologically diverse areas can occur within a tumor such as foci of ductal carcinoma in situ within a primary breast carcinoma. Similarly, estrogen receptor, Her2/neu, or p53 expression varies between and within tumors and metastases, ranging from 1% to >90% of cells. Thus, clonal selection of metastases can result in phenotypically diverse metastases (intrahost heterogeneity), such that within the same patient some metastases can be positive whereas others are negative for a specific phenotype.Clonal selection and intrahost metastatic heterogeneity have strongly been supported by murine studies (4, 5, 7). However, clinical support has been less extensive due to experimental and methodologic challenges. Metastatic tissue may be obtained asynchronously, relative to primary tumor t...