Abstract
In the last 15 years, stem cell biology has moved to the forefront of contemporary biomedicine. The recent rise to prominence of this distinctive category of cells rests on hopes of harnessing their unique proliferative powers to create novel cell therapies for a range of devastating and presently incurable diseases. This vision, articulated in the new and still emerging therapeutic paradigm of regenerative medicine has, since the mid-1990s, served as an animating force for stem cell research. Often forgotten in current discussions of stem cell innovation is an earlier chapter in stem cell-based therapy, that of bone marrow transplantation (BMT). Used as an adjunct to radio- and/or chemotherapy for cancer, the clinical pedigree of BMT stretches back to the late 1950s. Its therapeutic utility rests on the regenerative powers of the blood stem cell understood to be resident in the bone marrow. Common to BMT and current formulations of stem cells as regenerative therapies is an understanding of stem cells as a biological force for good. However, this may not be the whole story: stem cells may have a ‘dark side’ – one in which they may have a role in the pathogenesis of some forms of cancer. Today, this unsettling possibility finds form in the concept of the cancer stem cell (CSC). This posits a pathological counterpart to the ‘normal’ stem cell: in this model, the leukaemia-causing lesion is resident within an aberrant stem cell – the cancer stem cell – which gives rise to malignant tissue that is a ‘caricature’ of its normal counterpart. Here, in the movement from the normal to the pathological, the cardinal properties of the stem cell become a deadly force: the twin powers of self-renewal and proliferation serving to initiate, drive and sustain tumour growth. Seemingly, the more that is known about stem cells the less certain we are about their capabilities and their potential(s). In an era entranced by the idea of cellular therapies, the shadow cast by the cancer stem cell serves as a signal for caution in the future clinical use of stem cells. Focusing on the leukaemias, this article considers how the histories of BMT and the CSC each contain lessons for the future and emphasizes how our understanding of contemporary science is enriched by an appreciation of its past.
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Notes
Interview with stem cell biologist, 2005.
The origin of the cancer stem cell has been extensively theorized: it can be either the ‘normal’ stem cell resident within a tissue, or a progenitor cell that has acquired the ability for self-renewal, thereby conferring upon it the properties of a stem cell. The question as to which of these pathways leads to the cancer stem cell remains a highly charged debate.
Interview with cancer stem cell researcher, 2007.
For example, in the United Kingdom in 2004 there were 284 560 diagnoses of cancer, 7000 of which were for leukaemia, of which in turn, c. 1500 were in children. The most common forms of cancer were: breast (16 per cent); lung (13 per cent); bowel (13 per cent) and prostate (12 per cent). The overall mortality rate was c. 50 per cent.
In addition, the advent of the nuclear reactor offered a new supply of radioisotopes, including radiophosphorus, which interwar research had suggested might be useful against leukaemia – hopes that were not, in fact, realized.
The term ‘total’ care was coined to capture the growing array of different treatments embedded within radiochemotherapeutic regimens for leukaemia – including management of the side-effects of each element within the treatment protocol.
It is important to note, too, that in the late 1960s, Robert Good and colleagues pioneered the use of BMT in the treatment of various congenital immune deficient conditions, such as Severe Combined Immune Deficiency.
By the late 1980s, eight million people worldwide were registered with bone marrow donor registries such as the US National Marrow Donor Program established in 1984.
The GvL effect has been tremendously important in the continued and widened use of BMT where it constitutes a highly effective form of immunotherapy, serving as a powerful means to eradicate leukaemic cells not eradicated by radiation and/or chemotherapy.
The work of Furth and Kahn in 1937 had shown in the mouse that one leukaemic cell was sufficient to re-establish the disease: eradication of all leukaemic cells became a goal of treatment – and the failure to achieve this was theorized to be the basis for relapse.
Advances on the marrow donation side also served to facilitate the use of BMT. For example, the advent of cytokine mobilization techniques rendered donation a much less physiologically demanding procedure. Cytokines act to mobilize stem cells out of the bone marrow and into the peripheral (circulating) blood enabling blood stem cells to be harvested by apheresis – a procedure similar to collecting blood.
In the United Kingdom, the Paterson Research Laboratories of the Christie Cancer Hospital in Manchester became in the 1970s a leading centre for blood stem cell research through the work of Ray Schofield, Michael Dexter and Laszlo Lajtha. In this period, the work of Ray Bradley and Don Metcalf in Australia, and of the van Bekkum group in the Netherlands was also formative for the field.
This cell cannot be visualized by available techniques: it is undifferentiated, resembles many other cells found within the blood and does not readily ‘take up’ dyes used in cytological staining. For all the sophisticated techniques of molecular biology, the blood stem cell continues to elude those searching for it and its identity continues to be the subject of intense debate. Recently, one turn in this debate has seen the existence of the blood stem cell called into question, as some, including Dov Zipori, are posing the question as to whether ‘stem-ness’ is an ‘entity’ or ‘state’.
Influential figures in blood research – Ehrlich, Pappenheim, Maximow and Naegeli – all advanced competing theories about the nature and functions of such a cell.
Radioisotope tracer techniques using artificial radioisotopes newly available from the nuclear reactor, such as tritiated thymidine and different isotopes of iron, were also very important for the analysis of blood cells and the process of blood formation.
In the adult mouse when bone marrow function is impaired, for example, if it is damaged by radiation, the spleen serves as the site of de novo blood formation to ensure the ongoing replenishment/supply of mature blood cells and the recovery of the blood system.
Since this assay visualizes the proliferative effects of the blood stem cell, that is, the spleen colonies – it is regarded as ‘indirect’: the existence and number of blood stem cells is inferred.
This knowledge has been significant for clinical practice; for example, a genetic disposition to AML and CML renders inappropriate the use of autologous BMT in patients harbouring this genetic signature – because of the danger of re-introducing leukaemic cells. Such considerations have implications, too, for the use of umbilical cord blood.
This system uses non-obese diabetic/severe combined immuno-deficient mice, abbreviated to the NOD/SCID in vivo repopulation assay.
The question as to whether in AML (and CML) the stem cell harbouring the leukaemogenic lesion is the ‘normal’ blood stem cell or a cell that has acquired stem cell properties remains unresolved, a circumstance linked to the broader problem of identifying the blood stem cell. As with the ‘normal’ human blood stem cell, the cancer stem cell in leukaemia cannot be apprehended in the laboratory.
Interview with CSC researcher, December 2007.
Interview with CSC researcher, December 2007.
In the absence of ‘curative’ treatments in the conventional sense, surrogate or proxy markers of ‘cure’ have gained currency, for example: ‘curative’ as defined in terms of 5-year, disease-free survival. In patient cohort studies conducted over extended periods of time, statistical methods such as Kaplan–Meier plots are used to determine and define ‘curative’ therapies.
All data were taken from the US National Cancer Institute website, accessed 29 July 2009.
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Acknowledgements
The research on which this paper was based was funded in part by the ESRC under its Stem Cells CBAR II Programme [RES: 350-27-0005]. The author would also like to thank participants at the Emerging Diseases workshop held in 2008 at the BIOGUM Centre, University of Hamburg, where an earlier version of this article was presented.
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Kraft, A. Converging histories, reconsidered potentialities: The stem cell and cancer. BioSocieties 6, 195–216 (2011). https://doi.org/10.1057/biosoc.2011.3
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DOI: https://doi.org/10.1057/biosoc.2011.3