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Liquid biopsy and NSCLC

    Domenico Trombetta

    Laboratory of Oncology, IRCCS “Casa Sollievo della Sofferenza” Hospital, San Giovanni Rotondo (FG), Italy

    ,
    Angelo Sparaneo

    Laboratory of Oncology, IRCCS “Casa Sollievo della Sofferenza” Hospital, San Giovanni Rotondo (FG), Italy

    ,
    Federico Pio Fabrizio

    Laboratory of Oncology, IRCCS “Casa Sollievo della Sofferenza” Hospital, San Giovanni Rotondo (FG), Italy

    &
    Lucia Anna Muscarella

    *Author for correspondence:

    E-mail Address: l.muscarella@operapadrepio.it

    Laboratory of Oncology, IRCCS “Casa Sollievo della Sofferenza” Hospital, San Giovanni Rotondo (FG), Italy

    Published Online:https://doi.org/10.2217/lmt-2016-0006

    In the era of high-throughput molecular screening and personalized medicine, difficulty in determining whether cancer mutations are truly ‘actionable’ remains a gray zone in NSCLC. The most important prerequisite to perform such investigations is the tumor tissue retrieval via biopsy at diagnosis and after occurrence of resistance. Blood-based liquid biopsy as circulating tumor cells, circulating tumor DNA and exosomes can offer a fast and non-invasive method to elucidate the genetic heterogeneity of patients, the screening and patient stratification and give a dynamic surveillance for tumor progression and monitor treatments response. Here we prospectively discuss the three main approaches in the blood-biopsy field of lung cancer patients and its clinical applications in patient management. We also outline some of the analytical challenges that remain for liquid biopsy techniques in demonstrating that it could represent a true and actionable picture in lung cancer management for the implementation into clinical routine.

    Papers of special note have been highlighted as: • of interest; •• of considerable interest

    References

    • 1 Ma M, Zhu H, Zhang C, Sun X, Gao X, Chen G. “Liquid biopsy”-ctDNA detection with great potential and challenges. Ann. Transl. Med. 3(16), 235 (2015).
    • 2 Kawaguchi T, Holland WS, Gumerlock PH. Methods for isolation and genetic analysis of circulating tumor DNA in patient plasma. Methods Mol. Med. 85, 257–262 (2003).
    • 3 Alix-Panabieres C, Pantel K. Challenges in circulating tumour cell research. Nat. Rev. Cancer 14(9), 623–631 (2014). • This report proposes a conceptual framework of circulating tumor cells assays and point out current challenges of circulating tumor cell research, which might structure this dynamic field of translational cancer research.
    • 4 Kosaka N. Decoding the secret of cancer by means of extracellular vesicles. J. Clin. Med. 5(2), 22 (2016).
    • 5 Aceto N, Bardia A, Miyamoto DT et al. Circulating tumor cell clusters are oligoclonal precursors of breast cancer metastasis. Cell 158(5), 1110–1122 (2014).
    • 6 Grover PK, Cummins AG, Price TJ, Roberts-Thomson IC, Hardingham JE. Circulating tumour cells: the evolving concept and the inadequacy of their enrichment by EpCAM-based methodology for basic and clinical cancer research. Ann. Oncol. 25(8), 1506–1516 (2014).
    • 7 Maheswaran S, Sequist LV, Nagrath S et al. Detection of mutations in EGFR in circulating lung-cancer cells. N. Engl. J. Med. 359(4), 366–377 (2008).
    • 8 Cohen SJ, Punt CJ, Iannotti N et al. Prognostic significance of circulating tumor cells in patients with metastatic colorectal cancer. Ann. Oncol. 20(7), 1223–1229 (2009).
    • 9 Stott SL, Lee RJ, Nagrath S et al. Isolation and characterization of circulating tumor cells from patients with localized and metastatic prostate cancer. Sci. Transl. Med. 2(25), 25ra23 (2010).
    • 10 Krebs MG, Hou JM, Sloane R et al. Analysis of circulating tumor cells in patients with non-small cell lung cancer using epithelial marker-dependent and -independent approaches. J. Thorac. Oncol. 7(2), 306–315 (2012).
    • 11 Yu M, Bardia A, Wittner BS et al. Circulating breast tumor cells exhibit dynamic changes in epithelial and mesenchymal composition. Science 339(6119), 580–584 (2013).
    • 12 Tjensvoll K, Nordgard O, Smaaland R. Circulating tumor cells in pancreatic cancer patients: methods of detection and clinical implications. Int. J. Cancer 134(1), 1–8 (2014).
    • 13 Sullivan JP, Nahed BV, Madden MW et al. Brain tumor cells in circulation are enriched for mesenchymal gene expression. Cancer Discov. 4(11), 1299–1309 (2014).
    • 14 Luo X, Mitra D, Sullivan RJ et al. Isolation and molecular characterization of circulating melanoma cells. Cell Rep. 7(3), 645–653 (2014).
    • 15 Comen E, Norton L. Self-seeding in cancer. Recent Results Cancer Res. 195, 13–23 (2012).
    • 16 Comen E, Norton L, Massague J. Clinical implications of cancer self-seeding. Nat. Rev. Clin. Oncol. 8(6), 369–377 (2011). •• The self-seeding model was proposed in this article to answer to many of the mysteries inherent to cancer metastasis. Reframing our understanding of metastasis within the self-seeding model offers new opportunities for prevention and cure of metastatic cancer.
    • 17 Krebs MG, Sloane R, Priest L et al. Evaluation and prognostic significance of circulating tumor cells in patients with non-small-cell lung cancer. J. Clin. Oncol. 29(12), 1556–1563 (2011).
    • 18 Normanno N, Rossi A, Morabito A et al. Prognostic value of circulating tumor cells’ reduction in patients with extensive small-cell lung cancer. Lung Cancer 85(2), 314–319 (2014).
    • 19 Igawa S, Gohda K, Fukui T et al. Circulating tumor cells as a prognostic factor in patients with small cell lung cancer. Oncol. Lett. 7(5), 1469–1473 (2014).
    • 20 Hamilton G, Rath B, Holzer S, Hochmair M. Second-line therapy for small cell lung cancer: exploring the potential role of circulating tumor cells. Transl. Lung Cancer Res. 5(1), 71–77 (2016).
    • 21 Dorsey JF, Kao GD, MacArthur KM et al. Tracking viable circulating tumor cells (CTCs) in the peripheral blood of non-small cell lung cancer (NSCLC) patients undergoing definitive radiation therapy: pilot study results. Cancer 121(1), 139–149 (2015).
    • 22 Hofman V, Bonnetaud C, Ilie MI et al. Preoperative circulating tumor cell detection using the isolation by size of epithelial tumor cell method for patients with lung cancer is a new prognostic biomarker. Clin. Cancer Res. 17(4), 827–835 (2011).
    • 23 Bayarri-Lara C, Ortega FG, Cueto Ladron De Guevara A et al. Circulating tumor cells identify early recurrence in patients with non-small cell lung cancer undergoing radical resection. PLoS ONE 11(2), e0148659 (2016).
    • 24 Hofman V, Ilie M, Long E et al. Detection of circulating tumor cells from lung cancer patients in the era of targeted therapy: promises, drawbacks and pitfalls. Curr. Mol. Med. 14(4), 440–456 (2014).
    • 25 Zhang C, Guan Y, Sun Y, Ai D, Guo Q. Tumor heterogeneity and circulating tumor cells. Cancer Lett. 374(2), 216–223 (2016).
    • 26 Marchetti A, Del Grammastro M, Felicioni L et al. Assessment of EGFR mutations in circulating tumor cell preparations from NSCLC patients by next generation sequencing: toward a real-time liquid biopsy for treatment. PLoS ONE 9(8), e103883 (2014).
    • 27 Punnoose EA, Atwal S, Liu W et al. Evaluation of circulating tumor cells and circulating tumor DNA in non-small cell lung cancer: association with clinical endpoints in a Phase II clinical trial of pertuzumab and erlotinib. Clin. Cancer Res. 18(8), 2391–2401 (2012).
    • 28 Sawada T, Watanabe M, Fujimura Y et al. Sensitive cytometry based system for enumeration, capture and analysis of gene mutations of circulating tumor cells. Cancer Sci. 107(3), 307–314 (2016).
    • 29 Hata AN, Niederst MJ, Archibald HL et al. Tumor cells can follow distinct evolutionary paths to become resistant to epidermal growth factor receptor inhibition. Nat. Med. 22(3), 262–269 (2016). •• Acquired resistance caused by the EGFR T790M gatekeeper mutation in lung cancer can occur either by selection of pre-existing EGFR T790M-positive clones or via genetic evolution of initially EGFR T790M-negative drug-tolerant cells. This provides evidence that clinically relevant drug-resistant cancer cells can both pre-exist and evolve from drug-tolerant cells and they point to therapeutic opportunities to prevent or overcome resistance in the clinic.
    • 30 Douillard JY, Ostoros G, Cobo M et al. Gefitinib treatment in EGFR mutated caucasian NSCLC: circulating-free tumor DNA as a surrogate for determination of EGFR status. J. Thorac. Oncol. 9(9), 1345–1353 (2014).
    • 31 Pailler E, Adam J, Barthelemy A et al. Detection of circulating tumor cells harboring a unique ALK rearrangement in ALK-positive non-small-cell lung cancer. J. Clin. Oncol. 31(18), 2273–2281 (2013).
    • 32 Ilina O, Friedl P. Mechanisms of collective cell migration at a glance. J. Cell Sci. 122(Pt 18), 3203–3208 (2009).
    • 33 Erpenbeck L, Schon MP. Deadly allies: the fatal interplay between platelets and metastasizing cancer cells. Blood 115(17), 3427–3436 (2010).
    • 34 Berezovskaya O, Schimmer AD, Glinskii AB et al. Increased expression of apoptosis inhibitor protein XIAP contributes to anoikis resistance of circulating human prostate cancer metastasis precursor cells. Cancer Res. 65(6), 2378–2386 (2005).
    • 35 Luzzi KJ, MacDonald IC, Schmidt EE et al. Multistep nature of metastatic inefficiency: dormancy of solitary cells after successful extravasation and limited survival of early micrometastases. Am. J. Pathol. 153(3), 865–873 (1998).
    • 36 Glinsky VV, Glinsky GV, Glinskii OV et al. Intravascular metastatic cancer cell homotypic aggregation at the sites of primary attachment to the endothelium. Cancer Res. 63(13), 3805–3811 (2003).
    • 37 Im JH, Fu W, Wang H et al. Coagulation facilitates tumor cell spreading in the pulmonary vasculature during early metastatic colony formation. Cancer Res. 64(23), 8613–8619 (2004).
    • 38 Gabriel MT, Calleja LR, Chalopin A, Ory B, Heymann D. Circulating tumor cells: a review of non-EpCAM-based approaches for cell enrichment and isolation. Clin. Chem. 62(4), 571–581 (2016).
    • 39 Naito T, Tanaka F, Ono A et al. Prognostic impact of circulating tumor cells in patients with small cell lung cancer. J. Thorac. Oncol. 7(3), 512–519 (2012).
    • 40 Scheel C, Weinberg RA. Cancer stem cells and epithelial–mesenchymal transition: concepts and molecular links. Semin. Cancer Biol. 22(5–6), 396–403 (2012).
    • 41 Karabacak NM, Spuhler PS, Fachin F et al. Microfluidic, marker-free isolation of circulating tumor cells from blood samples. Nat. Protoc. 9(3), 694–710 (2014).
    • 42 Lin HK, Zheng S, Williams AJ et al. Portable filter-based microdevice for detection and characterization of circulating tumor cells. Clin. Cancer Res. 16(20), 5011–5018 (2010).
    • 43 Hofman V, Long E, Ilie M et al. Morphological analysis of circulating tumour cells in patients undergoing surgery for non-small cell lung carcinoma using the isolation by size of epithelial tumour cell (ISET) method. Cytopathology 23(1), 30–38 (2012).
    • 44 Ozkumur E, Shah AM, Ciciliano JC et al. Inertial focusing for tumor antigen-dependent and -independent sorting of rare circulating tumor cells. Sci. Transl. Med. 5(179), 179ra147 (2013).
    • 45 Mandel P, Metais P. [Les acides nucléiques du plasma sanguin chez l'homme]. C. R. Seances Soc. Biol. Fil. 142(3–4), 241–243 (1948).
    • 46 Diehl F, Li M, Dressman D et al. Detection and quantification of mutations in the plasma of patients with colorectal tumors. Proc. Natl Acad. Sci. USA 102(45), 16368–16373 (2005).
    • 47 Allegra CJ, Jessup JM, Somerfield MR et al. American Society of Clinical Oncology provisional clinical opinion: testing for KRAS gene mutations in patients with metastatic colorectal carcinoma to predict response to anti-epidermal growth factor receptor monoclonal antibody therapy. J. Clin. Oncol. 27(12), 2091–2096 (2009).
    • 48 Alix-Panabieres C, Schwarzenbach H, Pantel K. Circulating tumor cells and circulating tumor DNA. Annu. Rev. Med. 63, 199–215 (2012).
    • 49 Perkins G, Yap TA, Pope L et al. Multi-purpose utility of circulating plasma DNA testing in patients with advanced cancers. PLoS ONE 7(11), e47020 (2012).
    • 50 Figg WD 2nd, Reid J. Monitor tumor burden with circulating tumor DNA. Cancer Biol. Ther. 14(8), 697–698 (2013).
    • 51 Diaz LA Jr, Bardelli A. Liquid biopsies: genotyping circulating tumor DNA. J. Clin. Oncol. 32(6), 579–586 (2014). •• Recent advances in the sensitivity and accuracy of DNA analysis have allowed for genotyping of cell-free DNA for somatic genomic alterations found in tumors. The ability to detect and quantify tumor mutations has proven effective in tracking tumor dynamics in real-time as well as serving as a liquid biopsy that can be used for a variety of clinical and investigational applications not previously possible.
    • 52 Mouliere F, Robert B, Arnau Peyrotte E et al. High fragmentation characterizes tumour-derived circulating DNA. PLoS ONE 6(9), e23418 (2011).
    • 53 Mauger F, Dulary C, Daviaud C, Deleuze JF, Tost J. Comprehensive evaluation of methods to isolate, quantify, and characterize circulating cell-free DNA from small volumes of plasma. Anal. Bioanal. Chem. 407(22), 6873–6878 (2015).
    • 54 Benesova L, Belsanova B, Suchanek S et al. Mutation-based detection and monitoring of cell-free tumor DNA in peripheral blood of cancer patients. Anal. Biochem. 433(2), 227–234 (2013).
    • 55 Diehl F, Li M, Dressman D et al. Detection and quantification of mutations in the plasma of patients with colorectal tumors. Proc. Natl Acad. Sci. USA 102(45), 16368–16373 (2005).
    • 56 Xue X, Teare MD, Holen I, Zhu YM, Woll PJ. Optimizing the yield and utility of circulating cell-free DNA from plasma and serum. Clin. Chim. Acta 404(2), 100–104 (2009).
    • 57 Fong SL, Zhang JT, Lim CK, Eu KW, Liu Y. Comparison of 7 methods for extracting cell-free DNA from serum samples of colorectal cancer patients. Clin. Chem. 55(3), 587–589 (2009).
    • 58 Schwarzenbach H, Hoon DS, Pantel K. Cell-free nucleic acids as biomarkers in cancer patients. Nat. Rev. Cancer 11(6), 426–437 (2011).
    • 59 Norton SE, Luna KK, Lechner JM, Qin J, Fernando MR. A new blood collection device minimizes cellular DNA release during sample storage and shipping when compared to a standard device. J. Clin. Lab. Anal. 27(4), 305–311 (2013).
    • 60 Sherwood JL, Corcoran C, Brown H, Sharpe AD, Musilova M, Kohlmann A. Optimised pre-analytical methods improve KRAS mutation detection in circulating tumour DNA (ctDNA) from patients with non-small cell lung cancer (NSCLC). PLoS ONE 11(2), e0150197 (2016).
    • 61 El Messaoudi S, Rolet F, Mouliere F, Thierry AR. Circulating cell free DNA: preanalytical considerations. Clin. Chim. Acta 424, 222–230 (2013).
    • 62 Norton SE, Lechner JM, Williams T, Fernando MR. A stabilizing reagent prevents cell-free DNA contamination by cellular DNA in plasma during blood sample storage and shipping as determined by digital PCR. Clin. Biochem. 46(15), 1561–1565 (2013).
    • 63 Bettegowda C, Sausen M, Leary RJ et al. Detection of circulating tumor DNA in early- and late-stage human malignancies. Sci. Transl. Med. 6(224), 224ra224 (2014).
    • 64 Brevet M, Johnson ML, Azzoli CG, Ladanyi M. Detection of EGFR mutations in plasma DNA from lung cancer patients by mass spectrometry genotyping is predictive of tumor EGFR status and response to EGFR inhibitors. Lung Cancer 73(1), 96–102 (2011).
    • 65 Goto K, Ichinose Y, Ohe Y et al. Epidermal growth factor receptor mutation status in circulating free DNA in serum: from IPASS, a Phase III study of gefitinib or carboplatin/paclitaxel in non-small cell lung cancer. J. Thorac. Oncol. 7(1), 115–121 (2012).
    • 66 Nakamura T, Sueoka-Aragane N, Iwanaga K et al. Application of a highly sensitive detection system for epidermal growth factor receptor mutations in plasma DNA. J. Thorac. Oncol. 7(9), 1369–1381 (2012).
    • 67 Chen YM, Fan WC, Tseng PC et al. Plasma epidermal growth factor receptor mutation analysis and possible clinical applications in pulmonary adenocarcinoma patients treated with erlotinib. Oncol. Lett. 3(3), 713–717 (2012).
    • 68 Thress KS, Brant R, Carr TH et al. EGFR mutation detection in ctDNA from NSCLC patient plasma: a cross-platform comparison of leading technologies to support the clinical development of AZD9291. Lung Cancer 90(3), 509–515 (2015).
    • 69 Marchetti A, Palma JF, Felicioni L et al. Early prediction of response to tyrosine kinase inhibitors by quantification of EGFR mutations in plasma of NSCLC patients. J. Thorac. Oncol. 10(10), 1437–1443 (2015). •• This is the first study showing a strong correlation between the EGFR copy number mutations in the first days of treatment and clinical response with relevant implications for patient management.
    • 70 Fenizia F, De Luca A, Pasquale R et al. EGFR mutations in lung cancer: from tissue testing to liquid biopsy. Future Oncol. 11(11), 1611–1623 (2015).
    • 71 Luo J, Shen L, Zheng D. Diagnostic value of circulating free DNA for the detection of EGFR mutation status in NSCLC: a systematic review and meta-analysis. Sci. Rep. 4, 6269 (2014).
    • 72 Bordi P, Del Re M, Tiseo M. Crizotinib resensitization by compound mutation. N. Engl. J. Med. 374(18), 1790 (2016).
    • 73 Liang W, He Q, Chen Y et al. Metastatic EML4ALK fusion detected by circulating DNA genotyping in an EGFR-mutated NSCLC patient and successful management by adding ALK inhibitors: a case report. BMC Cancer 16, 62 (2016).
    • 74 Jamal-Hanjani M, Wilson GA, Horswell S et al. Detection of ubiquitous and heterogeneous mutations in cell-free DNA from patients with early-stage non-small-cell lung cancer. Ann. Oncol. 27(5), 862–867 (2016).
    • 75 Begum S, Brait M, Dasgupta S et al. An epigenetic marker panel for detection of lung cancer using cell-free serum DNA. Clin. Cancer Res. 17(13), 4494–4503 (2011).
    • 76 Wielscher M, Vierlinger K, Kegler U, Ziesche R, Gsur A, Weinhausel A. Diagnostic performance of plasma DNA methylation profiles in lung cancer, pulmonary fibrosis and COPD. EBioMedicine 2(8), 927–934 (2015).
    • 77 Zhang Y, Wang R, Song H et al. Methylation of multiple genes as a candidate biomarker in non-small cell lung cancer. Cancer Lett. 303(1), 21–28 (2011).
    • 78 Nie K, Jia Y, Zhang X. Cell-free circulating tumor DNA in plasma/serum of non-small cell lung cancer. Tumour Biol. 36(1), 7–19 (2015).
    • 79 Zhang Y, Wang R, Song H et al. Methylation of multiple genes as a candidate biomarker in non-small cell lung cancer. Cancer Lett. 303(1), 21–28 (2011).
    • 80 Lee SM, Park JY, Kim DS. Methylation of TMEFF2 gene in tissue and serum DNA from patients with non-small cell lung cancer. Mol. Cells 34(2), 171–176 (2012).
    • 81 Zhang YW, Miao YF, Yi J, Geng J, Wang R, Chen LB. Transcriptional inactivation of secreted frizzled-related protein 1 by promoter hypermethylation as a potential biomarker for non-small cell lung cancer. Neoplasma 57(3), 228–233 (2010).
    • 82 Hoffmann AC, Vallbohmer D, Prenzel K et al. Methylated DAPK and APC promoter DNA detection in peripheral blood is significantly associated with apparent residual tumor and outcome. J. Cancer Res. Clin. Oncol. 135(9), 1231–1237 (2009).
    • 83 Li M, Chen WD, Papadopoulos N et al. Sensitive digital quantification of DNA methylation in clinical samples. Nat. Biotechnol. 27(9), 858–863 (2009). • The methyl-BEAMing technology was developed to enable absolute quantification of the number of methylated molecules in a sample and was applied to detect methylation in DNA from plasma.
    • 84 Heitzer E, Ulz P, Geigl JB. Circulating tumor DNA as a liquid biopsy for cancer. Clin. Chem. 61(1), 112–123 (2015).
    • 85 Murtaza M, Dawson SJ, Tsui DW et al. Non-invasive analysis of acquired resistance to cancer therapy by sequencing of plasma DNA. Nature 497(7447), 108–112 (2013).
    • 86 Stewart EL, Tan SZ, Liu G, Tsao MS. Known and putative mechanisms of resistance to EGFR targeted therapies in NSCLC patients with EGFR mutations – a review. Transl. Lung Cancer Res. 4(1), 67–81 (2015).
    • 87 Denis MG, Vallee A, Theoleyre S. EGFR T790M resistance mutation in non small-cell lung carcinoma. Clin. Chim. Acta 444, 81–85 (2015).
    • 88 Zheng D, Ye X, Zhang MZ et al. Plasma EGFR T790M ctDNA status is associated with clinical outcome in advanced NSCLC patients with acquired EGFR-TKI resistance. Sci. Rep. 6, 20913 (2016).
    • 89 Thress KS, Paweletz CP, Felip E et al. Acquired EGFR C797S mutation mediates resistance to AZD9291 in non-small cell lung cancer harboring EGFR T790M. Nat. Med. 21(6), 560–562 (2015). •• The cell-free plasma DNA collected from subjects with advanced lung cancer whose tumors had developed resistance to the EGFR-tyrosine kinase inhibitor AZD9291 was studied. A new acquired EGFR C797S mutation was identified as new mechanism of acquired resistance to AZD9291.
    • 90 Imamura F, Uchida J, Kukita Y et al. Monitoring of treatment responses and clonal evolution of tumor cells by circulating tumor DNA of heterogeneous mutant EGFR genes in lung cancer. Lung Cancer 94, 68–73 (2016).
    • 91 Valadi H, Ekstrom K, Bossios A, Sjostrand M, Lee JJ, Lotvall JO. Exosome-mediated transfer of mRNAs and microRNAs is a novel mechanism of genetic exchange between cells. Nat. Cell Biol. 9(6), 654–659 (2007).
    • 92 Yanez-Mo M, Siljander PR, Andreu Z et al. Biological properties of extracellular vesicles and their physiological functions. J. Extracell. Vesicles 4, 27066 (2015).
    • 93 Kahlert C, Kalluri R. Exosomes in tumor microenvironment influence cancer progression and metastasis. J. Mol. Med. (Berl.) 91(4), 431–437 (2013). • This review highlights the functional relevance of exosomes in cancer, as related to tumor microenvironment, tumor immunology, angiogenesis and metastasis.
    • 94 Kowal J, Arras G, Colombo M et al. Proteomic comparison defines novel markers to characterize heterogeneous populations of extracellular vesicle subtypes. Proc. Natl Acad. Sci. USA 113(8), E968–E977 (2016).
    • 95 Valadi H, Ekstrom K, Bossios A, Sjostrand M, Lee JJ, Lotvall JO. Exosome-mediated transfer of mRNAs and microRNAs is a novel mechanism of genetic exchange between cells. Nat. Cell Biol. 9(6), 654–659 (2007).
    • 96 Balaj L, Lessard R, Dai L et al. Tumour microvesicles contain retrotransposon elements and amplified oncogene sequences. Nat. Commun. 2, 180 (2011).
    • 97 Turchinovich A, Weiz L, Langheinz A, Burwinkel B. Characterization of extracellular circulating microRNA. Nucleic Acids Res. 39(16), 7223–7233 (2011).
    • 98 Nolte-'t Hoen EN, Buermans HP, Waasdorp M, Stoorvogel W, Wauben MH, T Hoen PA. Deep sequencing of RNA from immune cell-derived vesicles uncovers the selective incorporation of small non-coding RNA biotypes with potential regulatory functions. Nucleic Acids Res. 40(18), 9272–9285 (2012).
    • 99 Colombo M, Raposo G, Thery C. Biogenesis, secretion, and intercellular interactions of exosomes and other extracellular vesicles. Annu. Rev. Cell Dev. Biol. 30, 255–289 (2014).
    • 100 Ratajczak J, Wysoczynski M, Hayek F, Janowska-Wieczorek A, Ratajczak MZ. Membrane-derived microvesicles: important and underappreciated mediators of cell-to-cell communication. Leukemia 20(9), 1487–1495 (2006).
    • 101 De Toro J, Herschlik L, Waldner C, Mongini C. Emerging roles of exosomes in normal and pathological conditions: new insights for diagnosis and therapeutic applications. Front Immunol. 6, 203 (2015).
    • 102 Mathivanan S, Fahner CJ, Reid GE, Simpson RJ. ExoCarta 2012: database of exosomal proteins, RNA and lipids. Nucleic Acids Res. 40(Database issue), D1241–D1244 (2012).
    • 103 Weidle UH, Birzele F, Kollmorgen G, Ruger R. Molecular basis of lung tropism of metastasis. Cancer Genomics Proteomics 13(2), 129–139 (2016).
    • 104 Qin X, Xu H, Gong W, Deng W. The tumor cytosol miRNAs, fluid miRNAs, and exosome miRNAs in lung cancer. Front. Oncol. 4, 357 (2015).
    • 105 Zhang HG, Zhuang X, Sun D, Liu Y, Xiang X, Grizzle WE. Exosomes and immune surveillance of neoplastic lesions: a review. Biotech. Histochem. 87(3), 161–168 (2012).
    • 106 Zhang HG, Grizzle WE. Exosomes: a novel pathway of local and distant intercellular communication that facilitates the growth and metastasis of neoplastic lesions. Am. J. Pathol. 184(1), 28–41 (2014).
    • 107 He M, Crow J, Roth M, Zeng Y, Godwin AK. Integrated immunoisolation and protein analysis of circulating exosomes using microfluidic technology. Lab. Chip 14(19), 3773–3780 (2014).
    • 108 Jakobsen KR, Paulsen BS, Baek R, Varming K, Sorensen BS, Jorgensen MM. Exosomal proteins as potential diagnostic markers in advanced non-small cell lung carcinoma. J. Extracell. Vesicles 4, 26659 (2015).
    • 109 Jorgensen M, Baek R, Pedersen S, Sondergaard EK, Kristensen SR, Varming K. Extracellular vesicle (EV) array: microarray capturing of exosomes and other extracellular vesicles for multiplexed phenotyping. J. Extracell. Vesicles 18, 2 (2013).
    • 110 Chen C, Skog J, Hsu CH et al. Microfluidic isolation and transcriptome analysis of serum microvesicles. Lab. Chip 10(4), 505–511 (2010).
    • 111 Witwer KW. Circulating microRNA biomarker studies: pitfalls and potential solutions. Clin. Chem. 61(1), 56–63 (2015).
    • 112 Eitan E, Zhang S, Witwer Kw, Mattson MP. Extracellular vesicle-depleted fetal bovine and human sera have reduced capacity to support cell growth. J. Extracell. Vesicles 4, 26373 (2015).
    • 113 Thakur BK, Zhang H, Becker A et al. Double-stranded DNA in exosomes: a novel biomarker in cancer detection. Cell Res. 24(6), 766–769 (2014).
    • 114 Balaj L, Lessard R, Dai L et al. Tumour microvesicles contain retrotransposon elements and amplified oncogene sequences. Nat. Commun. 2, 180 (2011).
    • 115 Thakur BK, Zhang H, Becker A et al. Double-stranded DNA in exosomes: a novel biomarker in cancer detection. Cell Res. 24(6), 766–769 (2014).
    • 116 Nilsson RJ, Karachaliou N, Berenguer J et al. Rearranged EML4–ALK fusion transcripts sequester in circulating blood platelets and enable blood-based crizotinib response monitoring in non-small-cell lung cancer. Oncotarget 7(1), 1066–1075 (2016).
    • 117 Rabinowits G, Gercel-Taylor C, Day JM, Taylor DD, Kloecker GH. Exosomal microRNA: a diagnostic marker for lung cancer. Clin. Lung Cancer 10(1), 42–46 (2009).
    • 118 Sharma A, Khatun Z, Shiras A. Tumor exosomes: cellular postmen of cancer diagnosis and personalized therapy. Nanomedicine (Lond.) 11(4), 421–437 (2016). • This review provides an updated information in exosomes isolation strategies, presence of exosomes biomarkers and importance of tumor-derived exosomes in gauging tumor heterogeneity for their potential use in cancer diagnosis, therapy.
    • 119 Fontana S, Saieva L, Taverna S, Alessandro R. Contribution of proteomics to understanding the role of tumor-derived exosomes in cancer progression: state of the art and new perspectives. Proteomics 13(10–11), 1581–1594 (2013).