Circulating tumor cell characterization and classification by novel combinatorial dual-color (CoDuCo) in situ hybridization and supervised machine learning

Metastatic prostate cancer is a highly heterogeneous and dynamic disease and practicable tools for patient stratification and resistance monitoring are urgently needed. Liquid biopsy analysis of circulating tumor DNA and circulating tumor cells (CTCs) are promising, but due to the diversity of resistance mechanisms, comprehensive testing is essential. Previously, we demonstrated that CTCs can be characterized by mRNA-based in situ padlock probe hybridization. Now, we have developed a novel combinatorial dual-color (CoDuCo) approach with increased multiplex capacity of up to 15 distinct markers, complemented by semi-automated image analysis and machine learning-assisted CTC classification. Here, we present three exemplary cases of patient samples in which the CoDuCo assay visualized diverse resistance mechanisms (AR-V7, neuroendocrine differentiation (SYP, CHGA, NCAM1)), as well as druggable targets and predictive markers (PSMA, DLL3, SLFN11). The combination of high multiplex capacity and microscopy-based single-cell analysis is a unique and powerful feature of the CoDuCo in situ assay. This synergy enables the identification and characterization of CTCs with epithelial, epithelial-mesenchymal, and neuroendocrine phenotypes, the detection of CTC clusters, and the visualization of CTC heterogeneity. In conclusion, the assay is a promising tool for monitoring the dynamic molecular changes associated with drug response and resistance in prostate cancer.