Stuart John Ellem

The Dual, Opposing Roles of Estrogen in the Prostate

Both androgens and estrogens play a significant role in the prostate and are critical for normal prostate growth and development. The role of androgens in the prostate and in prostate disease is well known, however, the role for estrogens in the prostate and in prostate disease is complex and is still only just beginning to be appreciated. Our understanding of the role and action of estrogens in the prostate has advanced significantly recently due to important discoveries, including the discovery of a second estrogen receptor subtype (ER‐β), the detection of aromatase in the prostate, and the identification of rapid nongenomic estrogen signaling. We now know that estrogens are essential for normal tissue homeostasis within the prostate and that too little or too much leads to perturbation of the glands growth and the emergence of disease. We are also beginning to recognize the importance and differential roles of the estrogen receptors ER‐α and ER‐β. Specifically, the activation of ER‐α leads to aberrant proliferation, inflammation, and the development of premalignant lesions, while, in contrast, the activation of ER‐β is critical in prostatic stromal−epithelial cell signaling and mediating antiproliferative effects that balance the proliferative action of androgens on the epithelia. These data have established the importance and complexity of estrogen action. We now know that estrogens have the capacity to exert both beneficial and adverse effects in the prostate via ER‐β and ER‐α, respectively. Based on this, the selective targeting of estrogen action may form the basis of new therapies for prostate disease.

Aromatase and regulating the estrogen:androgen ratio in the prostate gland

Although androgens and estrogens both play significant roles in the prostate, it is their combined action--and specifically their balance--that is critically important in maintaining prostate health and tissue homeostasis in adulthood. In men, serum testosterone levels drop by about 35% between the ages of 21 and 85 while estradiol levels remain constant or increase. This changing androgen:estrogen (T:E) ratio has been implicated in the development of benign and malignant prostate disease. The production of estrogens from androgens is mediated by the aromatase enzyme, the aberrant expression of which plays a critical role in the development of malignancy in a number of tissues. The normal prostate expresses aromatase within the stroma, while there is an induction of epithelial expression in malignancy with altered promoter utilisation. This may ultimately lead to an altered T:E ratio that is associated with the development of disease. The role of estrogen and the T:E balance in the prostate is further complicated by the differential actions of both estrogen receptors, alpha and beta. Stimulation of ERalpha leads to aberrant proliferation, inflammation and pre-malignant pathology; whereas activation of ERbeta appears to have beneficial effects regarding cellular proliferation and a putative protective role against carcinogenesis. Overall, these data reveal that homeostasis in the normal prostate involves a finely tuned balance between androgens and estrogens. This has identified estrogen, in addition to androgens, as integral to maintaining normal prostate health, but also as an important mediator of prostate disease.

Treating prostate cancer: a rationale for targeting local oestrogens.

Prostate cancer is the most commonly diagnosed cancer and the second most common cause of cancer-related death in men, and benign prostatic hyperplasia is the most common benign condition known to occur in ageing men. Oestrogen has been implicated in the development of prostate cancer, and offers a promising new avenue for treatment. Despite this, the role of oestrogens in the prostate is complex. This Perspective presents a rationale for a targeted approach for the treatment of prostate disease through the use of selective oestrogen-receptor modulators in conjunction with contemporary androgen-ablation therapy.

Estrogen action on the prostate gland: a critical mix of endocrine and paracrine signaling

Although modern biotechnology has provided us with a greater understanding of the molecular events in endocrine-related diseases, such as benign prostatic hyperplasia and prostate cancer, these conditions continue to be a significant healthcare problem world-wide. As the number of men afflicted by these diseases will only continue to grow with the aging population, finding new strategies and new therapeutic options for the treatment of both of these diseases is crucial. A better knowledge of the mechanisms of hormone action is pivotal to making progress in the development of new hormone-based therapies. This is fundamental to increasing our understanding of the endocrine, paracrine, and autocrine signaling mechanisms in the prostate and in prostate disease, distinguishing the effects and role of each, and identifying where and how this communication goes wrong.

Estrogen‐regulated development and differentiation of the prostate

Both androgens and estrogens play a significant role in the prostate and are critical for normal prostate growth and development, as well as the maintenance of adult prostatic homeostasis throughout life. It is the balance of these two hormones, rather than each individually, that is important for prostatic development and differentiation. Estrogen action is mediated by the estrogen receptors, ERalpha and ERbeta. ERalpha is expressed throughout the prostatic tissue during fetal and early neonatal life, and if activated inappropriately, produces late-life disease, including inflammation and emergence of pre-malignant pathologies. In contrast, ERbeta expression is initiated after ERalpha, is localized primarily to the epithelium, and appears to be important during later periods of development such as puberty and adulthood, acting to regulate cellular proliferation and differentiation in the adult tissue. Therefore, there is also a spatial and temporal balance between ERalpha and ERbeta that is critical for development. Together with the shifting balance between androgens and estrogens themselves, the subtle, yet critical, balance between the activity of ERalpha and ERbeta is what ultimately determines the response of the prostate to estrogen, and is crucial for prostate health.

Increased Endogenous Estrogen Synthesis Leads to the Sequential Induction of Prostatic Inflammation (Prostatitis) and Prostatic Pre-Malignancy

Prostatitis causes substantial morbidity to men, through associated urinary symptoms, sexual dysfunction, and pelvic pain; however, 90% to 95% of cases have an unknown etiology. Inflammation is associated with the development of carcinoma, and, therefore, it is imperative to identify and study the causes of prostatitis to improve our understanding of this disease and its role in prostate cancer. As estrogens cause prostatic inflammation, here we characterize the murine prostatic phenotype induced by elevated endogenous estrogens due to aromatase overexpression (AROM+). Early-life development of the AROM+ prostate was normal; however, progressive changes culminated in chronic inflammation and pre-malignancy. The AROM+ prostate was smaller at puberty compared with wild-type controls. Mast cell numbers were significantly increased at puberty and preceded chronic inflammation, which emerged by 40 weeks of age and was characterized by increased mast cell, macrophage, neutrophil, and T-lymphocyte numbers. The expression of key inflammatory mediators was also significantly altered, and premalignant prostatic intraepithelial neoplasia lesions emerged by 52 weeks of age. Taken together, these data link estrogens to prostatitis and premalignancy in the prostate, further implicating a role for estrogen in prostate cancer. These data also establish the AROM+ mouse as a novel, non-bacterial model for the study of prostatitis.

A bioengineered microenvironment to quantitatively measure the tumorigenic properties of cancer-associated fibroblasts in human prostate cancer

Stromal-epithelial cell interactions play an important role in cancer and the tumor stroma is regarded as a therapeutic target. In vivo xenografting is commonly used to study cellular interactions not mimicked or quantified in conventional 2D culture systems. To interrogate the effects of tumor stroma (cancer-associated fibroblasts or CAFs) on epithelia, we created a bioengineered microenvironment using human prostatic tissues. Patient-matched CAFs and non-malignant prostatic fibroblasts (NPFs) from men with moderate (Gleason 7) and aggressive (Gleason 8-9 or castrate-resistant) prostate cancer were cultured with non-tumorigenic BPH-1 epithelial cells. Changes in the morphology, motility and phenotype of BPH-1 cells in response to CAFs and NPFs were analyzed using immunofluorescence and quantitative cell morphometric analyses. The matrix protein gene expression of CAFs, with proven tumorigenicity in vivo, had a significantly different gene expression profile of matrix proteins compared to patient matched NPFs. In co-culture with CAFs (but not NPFs), BPH-1 cells had a more invasive, elongated phenotype with increased motility and a more directed pattern of cell migration. CAFs from more aggressive tumors (Gleason 8-9 or CRPC) were not quantitatively different to moderate grade CAFs. Overall, our bioengineered microenvironment provides a novel 3D in vitro platform to systematically investigate the effects of tumor stroma on prostate cancer progression.

Breaking through a roadblock in prostate cancer research: An update on human model systems

Prostate cancer is a prevalent disease that affects the aging male population. Whilst there have been significant advances of our biological understanding of the disease, clinical translation of promising agents continues to lag behind. In part, this is due to a paucity of relevant experimental and pre-clinical models required to further develop effective prevention and therapeutic strategies. Genetically modified cell lines fail to entirely represent the genetic and molecular diversity of primary human specimens, particularly from localised disease. Furthermore, primary prostate cancer tissues are extremely difficult to grow in the laboratory and virtually all human models, whether they grow as xenografts in immune-deficient animals or as cell cultures, are genetically modified by the investigator or derived from patients with advanced metastatic disease. In this review, we discuss the latest advances and improvements to current methods of xenografting human primary prostate cancer, and their potential application to translational research.

Brief Report: A Bioassay to Identify Primary Human Prostate Cancer Repopulating Cells

Cancer cells are heterogeneous in both their phenotypes and ability to promote tumor growth and spread. Xenografting is used to identify the most highly capable cells of regenerating tumors, referred to as cancer repopulating cells. Because prostate cancers (PCas) rarely grow as xenografts, indentifying PCa repopulating cells has not been possible. Here, we report improved methods to xenograft localized primary PCa tissues using chimeric grafts with neonatal mouse mesenchyme. Xenograft survival of tumor tissue was significantly increased by neonatal mesenchyme (six of six patients, 66% of grafts, versus four of six patients, 41% of grafts) and doubled the proliferation index of xenografted cancer cells. When applied to isolated PCa cells, neonatal mesenchyme effectively reconstituted PCas and increased xenograft survival (four of nine patients; 32% of grafts with mesenchyme and 0% without), and supported active cancer cell proliferation. Using this assay, we showed that unfractionated α2β1integrinhi and α2β1integrinlo cells from primary localized PCas demonstrated tumor formation at comparable rates, similar to previous reports using metastatic specimens. Thus, this new protocol efficiently established tumors and enabled proliferative expansion of both intact tumor tissue and fractionated cancer cells, providing a bioassay to identify and therapeutically target PCa repopulating cells. STEM CELLS 2011;29:1310–1314

In vitro modeling of the prostate cancer microenvironment

Prostate cancer is the most commonly diagnosed malignancy in men and advanced disease is incurable. Model systems are a fundamental tool for research and many in vitro models of prostate cancer use cancer cell lines in monoculture. Although these have yielded significant insight they are inherently limited by virtue of their two-dimensional (2D) growth and inability to include the influence of tumour microenvironment. These major limitations can be overcome with the development of newer systems that more faithfully recreate and mimic the complex in vivo multi-cellular, three-dimensional (3D) microenvironment. This article presents the current state of in vitro models for prostate cancer, with particular emphasis on 3D systems and the challenges that remain before their potential to advance our understanding of prostate disease and aid in the development and testing of new therapeutic agents can be realised.