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Metastatic heterogeneity in pancreatic cancer: mechanisms and opportunities for targeted intervention
Ravikanth Maddipati
Ravikanth Maddipati
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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 2

Site-specific tumor-stroma interactions regulating metastatic outgrowth.

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Site-specific tumor-stroma interactions regulating metastatic outgrowth....
At distant sites, tumor cells encounter tissue microenvironments distinct from the primary tumor. Colonization depends partly on how they adapt to and reprogram local immune and metabolic niches. Here, we outline key tumor-intrinsic and -extrinsic interactions enabling liver and lung metastases, drawing on evidence from diverse cancer types, including PDAC. (A) Liver: Often considered tolerogenic, the liver epithelial and immune environments can be coopted by tumor cells to stimulate outgrowth. For instance, hepatocyte-derived plexin B2 activates epithelial programs in tumor cells, while induction of STAT3/SAA1 signaling in hepatocytes suppresses T cell responses. Tumor cell–induced damage of hepatocytes can trigger efferocytosis, which activates tumor-promoting myeloid cells. Antitumor Kupffer cells and NK cell responses are limited by tumor cells and local immunosuppression. Additional quiescent stellate cells that help maintain dormancy may be reprogrammed by monocyte-derived granulin or ECM stiffening into activated myofibroblasts that promote metastatic growth. (B) Lung: The lung harbors a distinct immune and metabolic niche compared with the liver. It contains type I and lipid-rich type II pneumocytes, alveolar macrophages, and immune defenses adapted to airborne pathogens and particulates. In PDAC, elevated immune infiltration in the lung may slow metastatic progression; however, multiple protumorigenic factors can facilitate growth, as described in other cancer types. Increased oxygen availability stimulates Tregs, while surfactant-derived lipids (e.g., palmitic acid) can fuel tumor growth. Both pneumocyte subtypes can suppress T cell activity and drive neutrophil recruitment, leading to NET formation or diminished NK cell function. Tumor cells further adapt by shifting to oxidative phosphorylation or downregulating STING to limit immune activation. Changes in pyruvate metabolism can influence collagen remodeling and Coco expression can counteract BMP signaling, both enabling metastatic expansion.

Copyright © 2026 American Society for Clinical Investigation
ISSN: 0021-9738 (print), 1558-8238 (online)

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