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Molecular Mechanisms and Immune Regulation in Prostate Cancer

Submitted:

23 May 2026

Posted:

26 May 2026

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Abstract
Prostate cancer is formed of a hetergeneous population with different biological properties.They initially form a small part of the normal stromal microenviroment, but are able through cell to cell contact and via exsomes, small nanoparticles containing DNA, mRNA, microRNA, long non-coding RNA, enzymes, chemokines and cytokines are transform the normal stromal cells into tumour associated cells to create an immunosuppressive environment as well as inhibiting the antitumour immune response. Matrix metalloproteinases are able to degrade not only the basement mnbrane but also the extracelular matrix allowing the exosomes to disseminate via the circulation. They are organotrophic, homing in to specific tissues such as bone. Here they create the premetastatic niche devoid of cancer cells and cause an immunosuppressive environement as well as inducing changes in the host cells, producing myeloid derived suppressor cells of which some migrate to the primary tumour inhibiting the antitumour immune response further. Prostate cancer cells can disseminate even before the cancer is detected and thus escape curative therapy. If they survive the shear forces of the circulation and the antitumour immune response they are able to implant in the premetastatic niche transforming it into the metastatic niche. Here they enter a latent state or dormancy which may last for months or years, but later can “awake” to form metastasis. This review critically analyzes the celular and molecular mechanisms which produce this process from celular aspects to the signaling pathways responsable for this process. Multiple mechanisms are involved in a coordinated fashion to permit the survival of the cancer cells; from celular changes in host cells and immunomodulation via chemokines and cytokines. It emphasizes the role of microRNA and long non-coding RNA in this process, and that patients with higher Gleason scores have a worse prognosis in terms of biochemical free survial at ten years. Therefore, a precisión medical approach may improve the biochemical free survival rate without affecting the role of these signaling pathways in normal cells. This includes the modulation of interleukin expresion,elimination of exosomes or the inhibition of important enzymes such as MMP-2 thus mitigating the residual recurrence risk that persists with conventional therapy.
Keywords: 
prostate cancer
;  
immunosuppression
;  
exosomes
;  
micrometastasis
;  
dormancy
Subject: 
Medicine and Pharmacology  -   Urology and Nephrology

Introduction

In 2016 19% of all American men diagnosised with cancer had prostate cancer of whom 9% died [1]. By 2025 this figure had risen to 30% of all male cancers, a yearly increase of 3% with an estimated prostate cancer deathos of 35,770 in 2025 [2]. Prostate cancer is heterogenous in nature with different subtypes of prostate cancer cells existing in the same primary tumour. It has been reported that cancer cells can be detected in the circulation even before a diagnosis is made [3,4]. Prostate cancer can also be divided into different subtypes with different phenotypic and genotypic characteristics and this may affect treatment decisions [5,6,7]. It is important to note that prostate cancer cells do not exist alone, but form a small part of the normal stromal microenvironment (SME). This microenviroment includes normal fibroblasts which produce the essentials of the extracellular surroundings, including the secretion of collagen, fibrin, and proteoglycans. These aggregates form fibrils, sheet-line networks which control the molecular density of the extracellular matrix in the form of rigidity and tensional forces inhibiting the motility of cells [8,9,10,11]. The SME also contains macrophages, CD4 FOXP4 regulatory T-lymphocytes, Natural Killer (NK cells) and CD8 cytotoxic lymphocytes. The SME also contains enzymes such as matrix metalloproteinase 2, cytokines and chemokines which provides a dynamically changing microenvorinment [12,13]. Prostate cancer cells are able to transform normal fibroblasts into cancer associated fibroblasts (CAFs).The interaction of prostate cancer cells and fibroblasts also promotes the proteolytic processing of basement membrane proteins, in addition to that caused by metalloproteinases [14,15]. In vitro experiments using normal prostate epithelial cells, fibroblasts and different cancer lines may explain some of these molecular mechanisms. Using co-culture models it has been reported that there is cross-talk between normal fibroblasts and normal prostatic epithelial cells and prostatic cancer cell lines [16]. This maybe by direct cell to cell contact or via exosomes which by exocytosis are released into the SME [17]. Exosomes are 50-150 nm vesicles with a lipid membrane containing DNA, mRNA, microRNA, long non-coding RNA (ncRNA), enzymes such as matrix metrallaproteinase 2 (MMP-2), cytotokines and chemokines [17]. Due to their lipid membrane they are able to fuse with normal fibroblasts and release their contents, transforming them into CAFs. CAFs play an important role of re-shaping the primary tumour environment [17]. They increase the stiffening of the extracellular matrix inhibiting the mobility and ingress of cells such as NK cells and CTLs [16,19,20] and direct migration to other tissues [19]. These morphomechanics of CAFs are associated with differing patient outcomes [20]. CAFs are different than normal stromal fibroblasts in terms of their triptosome expression [18]. In in vitro, experiments there were differences in gene expression and ncRNAs [18].
Prostate cancer cells are able to recruit CD4-FOXP3 regulatory T-cells (Tregs) into the TME as well as CTLs . The key regulator in this process are macrophages in recruiting both types of lymphocytes via the CXCL12/CXCR4 pathway [22]: Tregs directly alter the CTL function and that Interlukin 2 is critical in reshaping the TME. Tregs deplete interleukin 2 and via interleukin 2/STAT5 pathways cause CTL exhaustion thus increasing the immunosuppressive nature of the TME. Cancer cells also cause the proliferation of Tregs further increasing immunosuppression of the TME [22,23]. There are differences between the transcriptosome expression of normal fibroblasts and CAFs. One study identified 818 differentially expressed mRNAs and 17 lc RNA and 15 potential ncRNA-mi (micro)-RNA-mRNA in CAFS. This may present a potential target for specific treatments [23]. The profile of CAFs is different between the primary tumour and metastasis [24]. In metastatic disease the proportion of CAFs is increased and there is also extra-cellular remodeling and TFG-β signaling. This is associated with decreased survival of the patient. They also increased the infiltration by immunosuppressive immune cells and immunosupressive molecules [24]. CAFs are heterogeneous with differing properties, for example C1 ABCA8 CAFs showed an increased proliferation as compared to other subtypes. They play an important role in the proliferation of prostate cancer cells, increasing the cancer cell growth and potential ability to cause metastatic spread [25]. Finally, in vitro experiments have reported the interaction between CAFs and prostate cancer cells changing the extracellular matrix and producing growth factors and matrix metalloproteinases thus promoting cancer cell dissemination [25,26].
Infiltrating macrophages are known as tumour associated macrophages (CAMs), with two different subtypes, M1 and M2. The M2 type promote tumour progression by causing immune suppression, invasion, angiogenesis and metastasis by remodelling the extracellular microenvironment [27]. M2 TAMs are found mainly in areas of high CAF activity, implying intercellular crosstalk [27]. CAFs are able to recruit monocytes into the TME which are precursors of macrophages and cause their differentiation into immunosuppressive M2 macrophages, inhibiting the antitumour immune response [27]. M2 CAMs express an increased level of programmed death cell protein 1; this suppresses both the inate and adquired immune response as well as decreasing their own anti-tumour effect [27,28]. There is positive feedback between CAMs and CAFs, CAMs induce the proliferation and invasion of CAFs [29].
Matrix metalloproteinase-2 (MMP-2) is a gelatinase and has an important role in prostate cancer. It is able to degrade the basement membrane and the extracellular matrix releasing immunosuppressive cytokines and chemokines.It is produced as an inactive zymogen and activated by other enzymes such as MMP-1 or free radicals via the cysteine switch [30,31]. By degrading the extracellular matrix it is able to create pathways in order that exosmones and later cancer cells can disseminate into the circulation, the cancer cells being termed circulating tumour cells (CTCs). MMP-2 is also able to increase the suppressive immune system.
predicting biochemical failure in men with bone marrow micrometastasis after curative therapy [32]. The role of MMP-2 in the metastatic cascade has recently reviewed [33].
Exosomes play a pivotal role both within the primary TMA, systemic spread, organotrophy and the formation of the pre-metastatic niche. They are nanoparticles of between 50-150 nm with a lipid membrane. They contain DNA, mRNA, miRNA, ling-RNA, enzymes including MMP-2, chemokines, cytokines proteins and lipids [34,35,36]. Cancer cells release different subtypes of exosomes, especially with regards to their composition between cancer cells and CAFs [36]. Immune cells may uptake exosomes which results in immunosuppression, transferring their contents into monocytes, altering the expression of CCR6 and CD44v7/8 which activates the Akt pathway resulting in the conversion of the normal monocytes into CAMs [36]. They also increase the immunosuppressive environment by activating Tregs via TGF ß -1 [36]. Exosomes not only play a part in oncolocgy but form part of normal physiological processes [37] In patients with prostate cancer they are released from cancer cells by exocytosis and by having a lipid based membrane easily can enter normal host cells where they release their contents and regulate the TME [38]. They remodel the gene expression and the molecular structure of the premetastatic niche. The cell adhesion receptor integrins regulate organotrophic homing of cancer and immune cells and circulating exosomes [39,40]. The integration of these exosomes modulates the host defence mechanisms as well as anti-tumour lymphocytes [38]. Exosomes also home into specific tissues via cytokines, derived from the TME, by binding to cells that express the specific cytokine receptor and thus their biodistribution.[41]. Exosomes are regulated by autocrine and/or paracrine mechanisms and the TME aids their release [34,35,36].
HIF-1 increases the production of exosomes significantly in a time dependent manner, secretes and activates Rab22A. The overexpression of Rab22A effects the morphology and function of early exosomes and alters the recruitment of exosomal proteins. Upregulaion of Rab27A and decreasing the expression of Rab7, LAMP1/2 and Neu1 increases exosomes dissemination from the cancer cells, as does the activation of TGF-α/Akt/PRAS40 [36,37,38]. As previously mentioned,. Exosomes express intergrin β1 which is associated with bone as the target tissue [36]. Phosphorylation of Talin 1 via Cdk5 kinase activates β1 integrin allowing binding to the normal cells in the target tissue [37] and recently reviewed by Geng et al. [38]. The exosomes enter the host cells and release their contents causing various changes in the normal microenvironment. They cause immunosuppression with a decrease in the number and anti-tumour immune response in CD4, CD8 and NK-cells [31]. Exosomes also inhibit CTL production via the expression of PD-L1 reducing their capability of proliferation, production of cytokines and thus anti-tumour response [39]. They are also capable of activating TGFß activating the TGFß/SMAD signalling pathway in normal fibroblasts converting them into CAFs [40]. The exosomes are able to firstly initiate the epithelial to mesenchymal transition thereby facilitating cancer cell dissemination; secondly they prepare the pre-metastatic niche, that is one without cancer cells present and transforming the host cells to change the normal environment to be immunosuppressive in nature [41].
miRNAs are RNAs which are noncoding and play a part in the epithelial to mensenchymal transition allowing cancer cells to disseminate. They are able to change the normal stromal microenvironement into a TME, the expression of miRNA via DLK-DIO3 stem cells is associated with treatment failure [42,43]. miRNAs therefore have an important role in the premetastatic niche. They are able to change bone remodelling and to help support cancer growth. The expression of miRNAs enables them to bind to othe miRNAs affecting osteoblast and osteoclast differentiation and the proliferation of the tumour cells by abnormal remodelling of the TME and thus enable tumour growth [43]. Under the relative hypoxic conditions of the bone marrow MMP-2 activity is increased. This is increased by an increase in the production of MMP-9 and , fibronectin, collagen and CD11b positive cells. Under hypoxic conditions MMPs remodel the TME to a protumour TME [44]. The role of PD-L1 is to increase the elimination of cancer cells and expressed on the surface of CLTs, however cancer cells also express variable quantities of this protein. It is correlated with aggressive prostate cancer, those with a high Gleason scores and is correlated in a negative form of CTL infiltration. The secretion of PD-L1 in the premetastatic niche is increased by the JAK/STAt3 pathway by increasing the number myeloid derived suppressor cells (MSDCs). These are able to suppress CTL infiltration and thus increase the immunosuppressive environment, decreasing the anti-tumour immune response [45]. MDSCs also promote cancer progession by miR-95 trnasfer to cancer cells. In the premetastaic niche the levels of miR95 are increased, possibly by binding to cancer cells and as a tumour promotor to JunB and increases the proliferation, invasion and the epithelial to mesenchymal transition, this results in the higher expression of this biomarker and is associated with a worse prognosis, linking the miRNA-95/Jun-b signalling pathway as a possible target for treatment [46]. MDSCs cells also increase the formation of the premetastic niche; by immunosuppression, vascular leakage, remodelling of the excellular matrix and angiogenesis. They also,by non-immunological pathways promote cancer proliferation and metastasis [47,48].
In addition to remodelling the TME some are able to disemiate to further inhibit NK-cells and CTLs further increasing thee immunosuppressive enviroment of the primary tumour and was recently reviewed by Xu et al. [49]. The miRNAs are associated with the progression of prostate cancer. An elevated level of miR-19a-3p and miRNA 23b-3p are found in aggressive cancer as compared to low grade tumours [50]. There is an association between miR-7-5p with the number of CAMs. mRNA-96 increases cell to cell communication through upregulation of the adhesion molecules E-cadherin and Epcam which increases the tumour cells ability to bind to osteoblasts and as such increases the proliferation of tumour cells [51]. Furthermore, microvesicules also increase cancer cell proliferation and interate with adipocytes, fibroblasts and mesenchymal stem cells [51]. Overexpression of CXCR-4 is promoted by the TFG-β, with an elevated expression of CXCR-4 there is an increased potential for cancer cells to migrate, SDF-1 in the microenvironment increases the ability of CXCR-4 cancer cells to invade target tissues [52]. Studies have reported that SFF-1 expression is associated with increased CXC.E.4 expression inducing the growth, proliferation and migration from the premetastatic niche [53]. ST6 β-galactoside α2,6-sialltransferase (ST6GAL 1) is upregulated in prostate cancer. It mediates α2-6 linked sialylation of N-glycosylated proteins and released from exosomes which exist as both soluble and membrane forms and is associated with aggressive prostate cancer [54]. ST6GAL1 is transferred in its soluble form to the cancer cells, the expression of Nogo-66. Receptor homolog 2 (NgR2) and β3 intrigrin inhibits this transfer and are increased in aggressive prostate cancer and may promote the risk of metastasis in part by the same mechanisms that form the premetastatic niche [54].
MMP-2 does not only create pathways for the dissemination of exosomes but later tumour cells, where they are known as circulating tuomur cells (CTCs). These cells home into the premetastatic niche, they may also implant in other tissues but do not proliferate. Exosomes also under hypoxia conditions that are found in the bone marrow are able increase the activity of MMP-2 in premetastastic niche [55].
Exosomes also transform bone marrow monocytes and macrophages in to myeloid derived suppressive cells which as mentioned previously inhibit the antitumour immune response. Some disseminate to the primary tumour while other remain in the bone marrow pre-metastatic niche. MDSCs are immature macrophages, myeloid derived and dendritic cells being related to a poorer prognosis and increased immunosuppression in the TME [56]. They have been detected outside of the blood stream, including the primary tumour, pre-metastatic and metastatic niches [57]. In these sites MDSCs the number of increases as well as their differention; these processes ares mediated by a variety of molecules and groth factors. These include granulocyte-monocyte, granulocyte, granulocyte-macrophage growth factors and vascular endothelial growth factor. [58]. This transformation to MDSCs is caused by primary tumour exosomes through miRNAs and non-coding RNAs and miR-494 inducing the activity of TGFβ [59]. An increased level of IL-6 has been associated with an increased immunosuppressive TME by increasing the number and activity of MDSCs [60]. MDSC also remodel the TME of the pre-metastatic niche; this achieved by the production of metalloproteinases and angiogenetic factors, increasing the immunosuppressic¡ve TME caused by MDSCs [61]. MDSCs are also to suppress the anti-tumour immune response and promote the survival of the implanted tumour cells. They use multiple mechanissms to do this, inhibiting the activity of NK cells, CTL and dendritic cells decreasingtheir activation and profileration. MDSCs also increase the immunosuppressive TME by inducing Tregs via cytokines [62]. The activity and number of MDSCs is increased via TNFβ which increases the activity and function of miRNA, non-codingRNA and miRNA 94 and has recently been reviewed [63]. MDSCs are also involved in the establishment of the metastatic niche. CTCs which survive the shear forces of the circulation and antitumoural immune response are able to bind to E-selectin on the MDSC surface to create the metastatic niche, E-secretin being increased via the expression of IL-1β [64].

Minimal Residual Disease, Latency and the Immune Reaction

Minimal residual disease (MRD) has been defined as small foci of cancer cells located in distant tissues. In prostate cancer they can found in some patients after curative radical prostatectomy, implying their dissemination was prior to curative therapy. Three subtypes of MRD have been described; those patients negative for both micrometastasis and CTCs (Group 1), those patients with only micrometastasis (Group 2) and finaly those with CTCs irrespective of micrometastasis (Group 3). In pT2 cancers treated with radical prostatectomy as monotherapy the subtype determined the time to the end of the latency period and biochemical failure free survival [65]. (Table 1)
It is well known that the higher the Gleason score the worse is the prognosis. Dividing the pT2 and pT3a patients into two subgroups those with Gleason 6 and compared gthem to those with Gleason 7 tumours. In each subtype of MRD Gleason 6 patients had a longer latency period and higher biochemical reccurence free survival at ten years: In Group 1 99% versus 98%, in Group 2 90% versus 68% and Group 3 19% versus 5% respectively.The difference in the ten year biochemical recurrence survival rate remained between MRD subgroups. [66].
Even after curative treatment micrometastasis may remain dormant or latent by entering the G0-G1 phase of the mitotic cycle and evading the anti-tumour immune response [67]. It is beyond the scope of this review to discuss other mechanisms but to focus on the immune system. With the removal of the primary tumour, there is no release of exosomes, immunosuppressive cytokines and chemokines, thus reducing drastically their effect of the micrometastatic TME. The latent period may depend, in part, on a balance between the immunosuppressive nature of cancer cells and the antitumour immune system [65]. This is based on the interaction of CTLs, NK cells and is regulated by IFNγ [65, 66]. By this mechanism the anti-tumour immune response may control the micrometastasis [67], causing an increased density of immune cells in the TME. In vivo studies have reported that decreased CD4+ and CD8+ lymphocytes cause cancer cells to escape from the latent period [68, 69]. Prostate cancer cells via the expression of HLA I increase the action of NK cells and CTLs , playing a key role in the cytotoxic response of the immune system and dormancy [70]. Different mechansims have been suggested they may act alone or in conjunction. Due to clonal instability prostate cancer cells be able to evade the antitumour immune response. Interleukin 8 and monocyte chemoattractant protein-1, at least in breast cancer, increases cancer cell proliferation [71] as well as up-regulating vascular cell adhesion protein 1 (VCAM-1) and periostin (POSTN) which can induce the end of the latent period [72]. CAFs in the micrometastasis, as in the primary tumour; increases the matrix stiffness inhibiting the ingress of CTLs and NK-cells. Prostate cancer cells found in the bone marrow down regulate TGF-β2 expression which in turn activates myosin light chain kinase which decreases the latent period [73]. Changes in the TME decreases the function of CTL and is defined as immunoediting [74].
Cancer cells in the dormant state and those cells which are cycling slowly may not be recognized by CTLs as well as NK-cell immunosurveillance [75]. Dormant tumour cells which express SOX9 impair NK-cell cytotoxic function via the downregulation of ULBP activators of NKG2D receptors further imparing NK-cells cytoxic function [75]. CAFs may also participate, not only by increasing the stiffness of the TME but also by the secretion of interleukin-6 decreasing CTL infiltration [75]. The intrinsic pathway of immune suppression is via the activation of oncogenes, which results in the secretion of cytokines, decreasing the antitumour response [76]. TGFβ exerts many immunosuppressive effects and maybe a key player in the TME and the end of dormancy, by decreasing the number of CTLs and increasing the number of Tregs [77]. Whether new forms of treatment may eliminate or maintain the cancer cells in a dormant state without affecting the function of non-cancer cells is a role to developed.

Conclusions

When a prostate cancer develops it forms a small part of the normal stromal microenvironment. By the aforementioned mechanisms it is able to transform this microenvironment into a immunosuppressive tumour microenvironement, converting normal stromal cells into cancer associated cells. It also is able to inhibit the anti-tumour immune reponse which occurs early in the disease even before “curative” therapy, which explains the presence of minimal residual disease. Exosomes secreted by the tumour cells are organotropic and implant in distant tissues forming by the same mechanisms an immunosuppressive environment. These premetastatic niches do not contain tumour cells, but create an environment that will aid their implantation forming the metastatic niche. Later cancer cells can enter the blood stream, CTCs and if survive the shear forces of the circulation and the antitumour immune response implant in these niches. They enter a latent or dormancy period of a variable time but may “awaken” to produce metastasis. The higher the Gleason score the shorter the latency period, time to biochemical failure and a shorter biochemical failure free survival. These aforemention mechanisms maybe be able to be used to divise new treatment pathways.

Ethical Considerations

Ethical Committee approval was not required for this review according to the declaration of Helsinki and the Chilean law on patient’s rights.

Funding

No funding was required for this review.

Conflicts of Interest

The author has no conflicts of interest.

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Table 1. Biochemical failure free survival according to minimal residual group. 
Table 1. Biochemical failure free survival according to minimal residual group. 
MRD Group 3 year biochemical free failure survival 5 year biochemical free failure survival 10 year biochemical free failure survival Median latency period (time to first biochemical failure)
Group 1 100% 100% 98% 9.9 years (7 years)
Group 2 100% 100% 77% 8 years (3 years)
Group 3 67% 47% 12% 4 years (18 months)
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Copyright: This open access article is published under a Creative Commons CC BY 4.0 license, which permit the free download, distribution, and reuse, provided that the author and preprint are cited in any reuse.
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