Cancer cells cyclically lose and regain drug-resistant highly tumorigenic features characteristic of a cancer stem-like phenotype.

Drug resistance and brisk tumor initiation have traditionally been viewed as preexisting phenotypes present in small subpopulations of neoplastic cells sometimes termed cancer stem cells. However, recent work in cancer cell lines has shown that drug-resistant tumor-initiating features can emerge de novo within fractionated subpopulations of cells initially lacking these phenotypes. In the present study, we asked whether such phenotypic plasticity exists broadly in unperturbed cancer cell lines and tumor xenografts growing spontaneously without interventions such as drug selection or fractionation into subpopulations used in prior studies. To address this question, we used side population (SP) analysis combined with fluorescence labeling to identify a drug-resistant highly tumorigenic subpopulation and to track and analyze its interaction with the larger phenotypically negative population over time. Remarkably, we observed that SP size fluctuated in a cyclical manner: first contracting via differentiation into the non-SP (NSP) and then reexpanding via simultaneous direct conversion of numerous NSP cells back to the SP phenotype both in culture and in tumor xenografts. These findings show for the first time that adaptive, cancer-promoting traits such as drug resistance and brisk tumor initiation arise not only as solitary events under selective pressures but also as highly orchestrated transitions occurring concurrently in large numbers of cells even without specifically induced drug selection, ectopic gene expression, or fractionation into subpopulations. This high level of coordinated phenotypic plasticity bears consideration when using cancer cell lines as experimental models and may have significant implications for therapeutic efforts targeting cancer stem cells, which are marked by a drug-resistant tumor-initiating phenotype.