Integrated multiplex analysis of cell death regulators in stage II colorectal cancer suggests patients with ‘persister’ cell profiles fail to benefit from adjuvant chemotherapy

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Objective: Inducing tumour cell apoptosis is a primary objective of chemotherapy but, to date, there are no validated biomarkers of apoptosis sensitivity or resistance. Our objective was to image multiple apoptosis pathway proteins at single cell level and determine multi-protein associations with recurrence risk and chemotherapy response in patients with stage II colorectal cancer (CRC). Methods and analysis: 108) or were treated with surgery only (n=86). K-means clustering of >600 000 cancer cells and cell level intensities of APAF1, procaspase-9, procaspase-3, XIAP, SMAC, BAX, BAK, BCL2, BCL-XL, MCL-1, procaspase-8, BID, FADD, FLIP, RIP3 and CIAP1 identified distinct cell cluster profiles. Results: Chemotherapy-treated patients with a higher percentage of cell clusters with low procaspase-3 and high XIAP had a higher risk of recurrence. This was validated in an independent cohort of adjuvant chemotherapy-treated high-risk patients with stage II CRC. We also applied two established system models of apoptosis initiation and execution to estimate cellular apoptosis sensitivity and show that these cell clusters do not appear to have impaired mitochondrial outer membrane permeabilisation sensitivity, but downstream procaspase-3 cleavage is compromised. This represents a key characteristic of drug-tolerant 'persister' cells. Conclusion: This study represents the most comprehensive analysis to date of apoptosis protein distribution at single cell level in CRC tumours. Our study identifies a subgroup of patients with stage II CRC with an apoptosis-resistant 'persister' cell profile who do not benefit from adjuvant chemotherapy.

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