Sequential steps in hematogenous metastasis of cancer cells studied by in vivo videomicroscopy

Understanding metastatic spread of cancer is of upmost importance to developing successful strategies to treat this disease. In this review, we present a picture of the process of hematogenous metastasis from the initial arrest of cancer cells, their extravasation, postextravasation migration, and their replication to form tumors, based on experimental results using in vivo videomicroscopy. The cancer cells are initially arrested by size constraints within minutes of entering the circulation and with little hemodynamic destruction. Within 24-48 h >80% of these cancer cells extravasate as single cells by adhesion to and spreading along the vessel wall, often using pseudopodial projections to move into the surrounding tissue without disrupting the microcirculation. Some of the extravasated cells also use pseudopodial projections to migrate to specific structures in the tissue where they can replicate. Many cancer cells can persist as dormant cells, neither dividing nor undergoing apoptosis. Only a small fraction of extravasated cells begin to divide to form micrometastases, and only a very small fraction of these micrometastases continue to grow to form tumors. Possible clinical implications are that (1) initial arrest and extravasation may be difficult to prevent and thus may be poor therapeutic targets; (2) dormant single cells will not be affected by conventional cancer therapies which are designed to treat actively growing cells; and (3) regulation of growth of cells after extravasation is key to determining whether clinically evident metastases form - this stage of metastasis thus offers promising targets for new antimetastasis drugs.