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Letter: “Prognostic Value of Initial Tumor Parameters After Metastatic Relapse: Do Not Miss the Tumoral Stroma”

To the Editor: We read with great interest the article by Planchat and colleagues (1) “Prognostic value of initial tumor parameters after metastatic relapse” in the Cancer Investigation November 2011 issue. We congratulate the authors and would like to make some comments. This interesting retrospective study regarding the prognostic factors of initial tumor parameters on metastatic disease included 511 breast cancer patients. The parameters taken into account mainly concerned the initial characteristics of the breast tumor cells (Scarff–Bloom–Richardson (SBR) grade, hormone receptor) as well as the node involvement. May we put forward that, according to this comprehensive series, the impact of the tumor stroma was not studied as a prognosis criteria, while this was done regarding the “true” tumor cells characteristics. For example, scirrhous breast carcinoma (characterized by low cellularity and a predominantly strong extensive fibrous stroma component) may have only local and very slow development lasting more than 20 years (the so-called “cancer en cuirasse”) (2, 3). Such a strong stromal reaction associated with desmoid-type fibromatosis (DTF) has been reported as displaying an improved clinical outcome (4). Indeed, a stiff matrix may provide a high tension state (5), precluding neovasculature formation (6). Apoptosis and tumoral growth inhibition may also be induced by the application of solid stress (7). This may explain the slow growing development (apparent stability) of some breast cancers (mainly spiculated masses and architectural distorsions) over many years (8). Conversely, solitary fibroblastic fibrous tumor (SFT) in breast carcinoma may display a poor prognosis (9). Indeed, epithelial-mesenchymal transition (transformation of epithelial tumor cells into mesenchymal “stromal” cell phenotype) may be a key element of the tumor spread mechanism, as tumor mesenchymal cell spread will lead to distant metastasis where tumor cell will express a definitive epithelial phenotype (reversion to an epithelial phenotype) (10). Finally, the importance of the stroma is also related to the secretion of many factors. The tumor-associated