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Metastatic heterogeneity in pancreatic cancer: mechanisms and opportunities for targeted intervention
Ravikanth Maddipati
Ravikanth Maddipati
Published July 15, 2025
Citation Information: J Clin Invest. 2025;135(14):e191943. https://doi.org/10.1172/JCI191943.
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Review Series

Metastatic heterogeneity in pancreatic cancer: mechanisms and opportunities for targeted intervention

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Abstract

Pancreatic ductal adenocarcinoma (PDAC) remains among the most lethal cancers, with metastasis as the primary driver of mortality. While metastatic mechanisms are shared across malignancies, PDAC metastasis poses unique therapeutic challenges due to the presence of extensive tumor heterogeneity, desmoplasia, and immunosuppression — features that enable diverse migratory behaviors and therapeutic resistance. Recent advances have shown that metastatic progression in PDAC emerges from dynamic interactions between tumor cell–intrinsic and microenvironmental factors, each adapting to evolving stressors throughout the metastatic cascade. In the primary tumor, genomic instability and epigenetic reprogramming generate subclones with heightened invasive potential, while dense stromal reactions and myeloid-dominated immune suppression facilitate escape. During circulation, PDAC cells employ distinctive survival strategies through homotypic clustering and heterotypic interactions with blood components. At distant sites, PDAC cells adapt to organ-specific microenvironments through context-dependent metabolic and immune modulation, resulting in phenotypes that diverge from the primary tumor. In this Review, we examine how tumor-stroma crosstalk mechanisms shape metastatic progression in PDAC, provide a framework for understanding why conventional therapies often fail against metastatic disease, and highlight emerging opportunities for stage- and site-specific therapeutic interventions that target these unique adaptations.

Authors

Ravikanth Maddipati

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Figure 1

Tumor cell–intrinsic and –extrinsic regulation of the metastatic cascade.

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Tumor cell–intrinsic and –extrinsic regulation of the metastatic cascade...
The schematic highlights key factors implicated in regulating metastasis across multiple cancers, including PDAC. Metastasis unfolds through a series of sequential steps — local invasion, intravasation, circulation, extravasation, and eventual outgrowth, each imposing distinct selective pressures on tumor cells. Intrinsic factors such as MYC or KRAS amplifications, epigenetic changes, and EMT states endow cells with invasive capabilities and enable remodeling of the TME. By secreting cytokines, chemokines, and extracellular vesicles, these invasive tumor cells recruit or reprogram myeloid cells, fibroblasts, and the ECM to facilitate local tissue invasion. Once in circulation, tumor cells travel individually or in clusters, influenced in part by whether they undergo “classical” versus partial EMT. Platelets and neutrophils also protect CTCs from immune attack (e.g., by NK cells), while cluster formation mitigates exposure to shear stress and metabolic changes (e.g., increased ROS). Dissemination can occur through lymphatic routes or along nerves, guided by specific stromal interactions. Upon reaching distant sites, tumor cells extravasate via leaky capillaries, aided by ongoing interactions with platelets and neutrophils. However, these new environments can be hostile. To overcome local barriers, tumor cells may precondition “premetastatic niches” through tumor-derived factors that induce immunosuppression and ECM remodeling. Dormancy can further enhance survival, allowing cells to adapt gradually. Many disseminated cells never progress, but others resume proliferation in response to external signals and by leveraging their intrinsic programs (e.g., EMT states, metabolic rewiring). Ultimately, site-specific interactions between tumor cells and the surrounding tissue microenvironment dictate outgrowth and metastatic heterogeneity. MET, mesenchymal-epithelial transition; PIGF, placental growth factor.

Copyright © 2025 American Society for Clinical Investigation
ISSN: 0021-9738 (print), 1558-8238 (online)

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