Increased microvessel density in mucinous compared with malignant serous and benign tumours of the ovary

The Development of a Three-Dimensional Platform for Patient-Derived Ovarian Cancer Tissue Models: A Systematic Literature Review

There is an unmet biomedical need for ex vivo tumour models that would predict drug responses and in turn help determine treatment regimens and potentially predict resistance before clinical studies. Research has shown that three dimensional models of ovarian cancer (OvCa) are more realistic than two dimensional in vitro systems as they are able to capture patient in vivo conditions in more accurate manner. The vast majority of studies aiming to recapitulate the ovarian tumour morphology, behaviors, and study chemotherapy responses have been using ovarian cancer cell lines. However, despite the advantages of utilising cancer cell lines to set up a platform, they are not as informative as systems applying patient derived cells, as cell lines are not able to recapitulate differences between each individual patient characteristics. In this review we discussed the most recent advances in the creation of 3D ovarian cancer models that have used patient derived material, the challenges to overcome and future applications.

Assessment of solid components of borderline ovarian tumor and stage I carcinoma: added value of combined diffusion- and perfusion-weighted magnetic resonance imaging

Background

We sought to determine the value of combining diffusion-weighted (DW) and perfusion-weighted (PW) sequences with a conventional magnetic resonance (MR) sequence to assess solid components of borderline ovarian tumors (BOTs) and stage I carcinomas.

Methods

Conventional, DW, and PW sequences in the tumor imaging studies of 70 patients (BOTs, n=38; stage I carcinomas, n=32) who underwent surgery with pathologic correlation were assessed. Two independent radiologists calculated the parameters apparent diffusion coefficient (ADC), K^trans (vessel permeability), and V_e (cell density) for the solid components. The distribution on conventional MR sequence and mean, standard deviation, and 95% confidence interval of each DW and PW parameter were calculated. The inter-observer agreement among the two radiologists was assessed. Area under the receiver operating characteristic curve (AUC) and multivariate logistic regression were performed to compare the effectiveness of DW and PW sequences for average values and to characterize the diagnostic performance of combined DW and PW sequences.

Results

There were excellent agreements for DW and PW parameters between radiologists. The distributions of ADC, K^trans, and V_e values were significantly different between BOTs and stage I carcinomas, yielding AUCs of 0.58 and 0.68, 0.78 and 0.82, and 0.70 and 0.72, respectively, with ADC yielding the lowest diagnostic performance. The AUCs of the DW, PW, and combined PW and DW sequences were 0.71±0.05, 0.80±0.05, and 0.85±0.05, respectively.

Conclusion

Combining PW and DW sequences to a conventional sequence potentially improves the diagnostic accuracy in the differentiation of BOTs and stage I carcinomas.

Clinical significance of melanoma cell adhesion molecule CD146 and VEGFA expression in epithelial ovarian cancer

Ovarian cancer is the fifth most common type of cancer in females; however, its asymptomatic progression and the lack of an efficient screening strategy leads to late diagnosis. The present study aimed to investigate the expression levels of cluster of differentiation (CD)146 and vascular endothelial growth factor A (VEGFA) in epithelial ovarian cancer, and their clinical significance. A total of 52 ovarian samples were tested, of which 22 were from patients with epithelial ovarian cancer and 30 were from non-cancer patients. The relative gene expression of CD146 and VEGFA was quantified using reverse transcription-quantitative polymerase chain reaction analysis. Western blotting was used to determine the protein expression levels. The relative gene expression levels of CD146 and VEGFA in tumor tissues were significantly increased compared with the control (4.92±0.44 vs. 1.05±0.06 and 3.08±0.17 vs. 1.06±0.07, P<0.01). The protein expression levels of CD146 and VEGFA in tumor tissue were also significantly increased compared with the control (0.70±0.02 vs. 0.41±0.07 and 0.54±0.01 vs. 0.26±0.01, P<0.01). There was a positive correlation between the expression levels of CD146 and VEGFA genes (r=0.78) and between the two proteins (r=0.69). Dot density frequency analysis indicated that CD146 and VEGFA were specifically present in tumor tissues. In conclusion, CD146 and VEGFA are co-overexpressed in ovarian cancer; their potential as tumor biomarkers or therapeutic targets for the treatment of ovarian cancer requires further investigation.

Reliability of preoperative evaluation of postmenopausal ovarian tumors

Background

Preoperative evaluation of ovarian tumors is challenging. This study was undertaken to evaluate the performance of conventional two-dimensional (2D) ultrasound and CA125 in predicting malignant or benign nature of pelvic masses, and to investigate if three-dimensional power Doppler (3DPD) ultrasound provides any added value. Ninety-six postmenopausal and four perimenopausal women with supposed ovarian tumors were examined by standardized 2D and 3DPD ultrasounds preoperatively. The tumors were evaluated using the risk of malignancy index (RMI), International Ovarian Tumors Analysis (IOTA) group simple rules, expert opinion, IOTA logistic regression model 2 (LR2) and 3D vascular indices, and were postoperatively compared to histopathological results.

Results

Ninety-eight tumors turned out to be ovarian in origin. Of these, 66 were benign and 32 malignant. RMI (cut-off value 200), simple rules, expert opinion and LR2 (cut-off value 25) were used to predict malignant nature of the tumors and had sensitivities of 71.9, 90.6, 87.5 and 90.6%, and specificities of 80.3, 84.6, 92.4 and 77.3%, respectively. When the 3D vascularization flow index (VFI) was added to RMI and LR2, the accuracy of the test improved from 77.6 to 81.4% and from 81.6 to 86.5%, respectively, at the expense of sensitivity, while VFI gave no added benefit for simple rules and expert opinion. Agreement between two examiners using expert opinion was good (Cohen’s kappa = 0.89).

Conclusions

The subjective opinion of an expert seems to be the most reliable method in assessing ovarian tumors, and the 3DPD indices seem to provide no significant added value.

Expression of a novel endothelial marker, C-type lectin 14A, in epithelial ovarian cancer and its prognostic significance

OBJECTIVE

The purpose of this study was to evaluate microvessel density (MVD) as assessed by C-type lectin 14A (CLEC14A), which is a new marker for endothelial cells, and compare its expression to CD31 and CD105 in epithelial ovarian cancer (EOC).

METHODS

MVD was evaluated in tumors (n = 50) from patients with EOC who underwent primary surgery and in patients with EOC who received preoperative chemotherapy (n = 49) using immunohistochemistry with antibodies to CLEC14A, CD31 and CD105. The median duration of follow-up was 24.5 months (range 1-101 months). The effect of prognostic factors on event-free survival (EFS) and overall survival (OS) was assessed using the Cox regression model.

RESULTS

The amount of residual disease was found to be an independent prognostic factor in multivariate analysis with respect to EFS (P = 0.009) and OS (P < 0.001). The mean MVD of CLEC14A (MVD = 6), in tumors from patients who underwent primary surgery, was significantly lower than that of CD31 (MVD = 25, P < 0.0001) and CD105 (MVD = 11, P = 0.018). However, there was no significant correlation between MVD as detected by these markers and clinical outcome. There was no expression of CLEC14A in tumors from patients who received preoperative chemotherapy and the MVD of CD31 and CD105 was significantly reduced (P = 0.001 and 0.006, respectively) in this set of patients.

CONCLUSION

This study demonstrates MVD as detected by CLEC14A in EOC. Treatment with chemotherapy reduces tumor blood vessels significantly. We suggest that CLEC14A may be a more specific endothelial marker to assess tumor angiogenesis.

Predictive and prognostic protein biomarkers in epithelial ovarian cancer: recommendation for future studies

Epithelial ovarian cancer is the most lethal gynecological malignancy. Due to its lack of symptoms, this disease is diagnosed at an advanced stage when the cancer has already spread to secondary sites. While initial rates of response to first treatment is >80%, the overall survival rate of patients is extremely low, mainly due to development of drug resistance. To date, there are no reliable clinical factors that can properly stratify patients for suitable chemotherapy strategies. Clinical parameters such as disease stage, tumor grade and residual disease, although helpful in the management of patients after their initial surgery to establish the first line of treatment, are not efficient enough. Accordingly, reliable markers that are independent and complementary to clinical parameters are needed for a better management of these patients. For several years, efforts to identify prognostic factors have focused on molecular markers, with a large number having been investigated. This review aims to present a summary of the recent advances in the identification of molecular biomarkers in ovarian cancer patient tissues, as well as an overview of the need and importance of molecular markers for personalized medicine in ovarian cancer.

Does sphere volume affect the performance of three-dimensional power Doppler virtual vascular sampling for predicting malignancy in vascularized solid or cystic-solid adnexal masses?

OBJECTIVE

To assess whether, when using spherical sampling with Virtual Organ Computer-Aided Analysis (VOCAL) for calculating three-dimensional (3D) power Doppler angiography (PDA) indices, the sphere volume affects performance in the prediction of malignancy in vascularized cystic-solid or solid adnexal masses.

METHODS

One hundred and thirty-eight women (mean +/- SD age, 51.8 +/- 14.1 years) diagnosed as having vascularized cystic-solid or solid adnexal masses on B-mode and two-dimensional (2D) power Doppler ultrasound were evaluated by 3D-PDA prior to surgery. Five women had bilateral masses, giving a total number of 143 masses analyzed. Vascularization was assessed using VOCAL software. 3D-PDA vascular indices (vascularization index (VI), flow index (FI) and vascularization flow index (VFI)) from the most vascularized area within papillary projections and solid areas were calculated automatically using spherical sampling. Five different volumes of sphere were used (1 cm(3), 2 cm(3), 3 cm(3), 4 cm(3) and 5 cm(3)) in each case. A definitive histological diagnosis was obtained in each case after surgical tumor removal.

RESULTS

One hundred and seventeen (82%) masses were malignant and 26 (18%) were benign. Morphological evaluation revealed 34 (24%) unilocular solid masses, 49 (34%) multilocular solid masses and 60 (42%) mostly solid masses. The 1-cm(3) sphere could be used in 100% of the cases, the 2-cm(3) sphere could be used in 98.2% of the cases and the 3-5-cm(3) spheres could be used in 97.2% of the cases. The median VI, FI and VFI for all sphere volumes were significantly higher in malignant compared with non-malignant tumors. Receiver-operating characteristics curve analysis showed that VI and VFI, independently of sphere volume, were better predictors of malignancy than was FI. The best cut-off values for the 3D-PDA indices differed depending on sphere volume. VI was significantly more specific than were VFI and FI.

CONCLUSIONS

Sphere volume does not affect the performance of 3D-PDA. We recommend the use of different cut-off values for 3D-PDA indices for discriminating between benign and malignant adnexal masses, depending on the sphere volume used. Use of VI is preferable due to its higher specificity.

PlGF expression in pre-invasive and invasive lesions of uterine cervix is associated with angiogenesis and lymphangiogenesis

Most vascular endothelial growth factors (VEGF) have been shown to be associated with lymphangiogenesis and angiogenesis in various cancers. However, whether placental growth factor (PlGF), a rarely mentioned VEGF member, is involved in the pathogenesis of uterine cervical lesions remains unclear. To address this issue, we examined the relationship between PlGF expression and clinicopathologic variables in patients with pre-invasive and invasive lesions of uterine cervix. Sixty-two cervical specimens were immunostained with PlGF polyclonal antibody to define PlGF expression, and monoclonal antibodies D2-40 and CD34 to evaluate the lymphatic vessel density (LVD) and blood vessel density (BVD) of the lesions. PlGF mRNA level was detected by RT-PCR in all lesions from fresh tissues. We found that the levels of PlGF protein and mRNA expression were related to clinical stages (p < 0.05), but not to other clinicopathologic variables. No significant difference in PlGF expression was observed between squamous carcinoma and adenocarcinoma. Increased LVD and BVD were all associated with advanced stages (p < 0.001). Although LVD was strongly correlated with BVD, only high LVD was associated with pelvic lymphatic metastasis. Moreover, the level of PlGF expression was associated with both BVD(r = 0.715, p < 0.001) and LVD(r = 0.321, p < 0.05). Together, our study suggests that PlGF may participate in both tumor-associated angiogenesis and lymphangiogenesis of cervical carcinogenesis.

Evaluation of two different methods for vascular sampling by three-dimensional power Doppler angiography in solid and cystic-solid adnexal masses

OBJECTIVE

To analyze two different methods for performing three-dimensional power Doppler angiography (3D-PDA) vascular sampling in solid and cystic-solid adnexal masses.

METHODS

Twenty-one 3D-PDA volumes from 18 consecutive and unselected solid or cystic-solid adnexal masses (13 malignant and five benign) were analyzed. A single examiner (J. L. A.) acquired all the volumes according to a predetermined scanning protocol. Two different observers (one inexperienced and the other experienced) calculated 3D-PDA vascular indices (vascularization index (VI), flow index (FI) and vascularization flow index (VFI)) from solid tumor areas. First, manual sampling (Plane A, 15 degrees rotation-step) was performed, and 1 week later 5-cm(3) sphere sampling from the most vascularized area was carried out. The observers made a record of any difficulty that they encountered in delineating the solid areas of tumors or in distinguishing true tumor vessels from pre-existing vessels, the time spent performing each analysis was recorded and inter- and intraobserver reproducibility was evaluated for each method using intraclass correlation coefficients (ICC).

RESULTS

In four (19.0%) of the 21 volumes sphere sampling could not be performed because it was not possible to obtain a sphere smaller than 5.5 cm(3). This happened in cases in which image zooming was used when acquiring the 3D volume. The inexperienced observer encountered more difficulty, but not significantly more, than the experienced observer when analyzing 3D-PDA volumes both by manual sampling (29% vs. 14% of cases) and 5-cm(3) sphere sampling (35% vs. 18% of cases). The mean time spent by the inexperienced observer was significantly greater (P < 0.001) than that spent by the experienced observer both for manual sampling (6.11 min vs. 1.85 min) and 5-cm(3) sphere sampling (2.93 min vs. 2.15 min). Contrary to the findings for the experienced observer, the inexperienced observer required less time to perform sphere sampling than they did manual sampling. Interobserver agreement was high for both methods: ICC for manual volume, 0.993; manual VI, 0.908; manual FI, 0.913; manual VFI, 0.914; sphere volume, 0.949; sphere VI, 0.954; sphere FI 0.850; and sphere VFI, 0.953. Intraobserver reproducibility was also high, with all ICCs above 0.99.

CONCLUSIONS

Manual and 5-cm(3) sphere sampling are reproducible methods for 3D-PDA vascular sampling. Caution is required when image zoom is used at the time of acquiring the volume because this may prevent sphere sampling. Difficulties found in performing both manual and sphere sampling do not seem to significantly affect the reproducibility of Doppler index calculations.

Three-dimensional power Doppler vascular sonographic sampling for predicting ovarian cancer in cystic-solid and solid vascularized masses

OBJECTIVE

The purpose of this study was to explore the role of 3-dimensional (3D) power Doppler (PD) sonography to discriminate between benign and malignant cystic-solid and solid vascularized adnexal masses and to define cutoff values for 3D PD indices to be used in a clinical setting.

METHODS

A total of 143 consecutive women (mean age, 50.4 years; range, 17-82 years) with diagnoses of cystic-solid or solid vascularized adnexal masses on B-mode and 2-dimensional PD sonography were evaluated by 3D PD sonography before surgery. Three-dimensional PD sonography was used to assess vascularization within papillary projections and solid areas with a virtual organ computer-aided analysis program. Three-dimensional PD vascular indices (vascularization index [VI], flow index [FI], and vascularization-flow index [VFI]) were automatically calculated. A definitive histologic diagnosis was obtained in each case.

RESULTS

A total of 113 masses (74%) were malignant, and 39 (26%) were benign. Morphologic evaluation revealed 30 unilocular solid masses (19.7%), 43 multilocular solid masses (28.3%), and 79 mostly solid masses (52%). The mean VI (9.365% versus 3.3%; P< .001), FI (34.318 versus 28.794; P< .001), and VFI (3.233 versus 1.15; P<0.01) were significantly higher in malignant tumors. No differences were found in the resistive index, pulsatility index, and peak systolic velocity. Receiver operating characteristic analysis revealed an area under the curve of 0.77 (95% confidence interval, 0.69-0.85), 0.71 (0.60-0.81), and 0.75 (0.66-0.83) for the VI, FI and VFI, respectively. For reducing the false-positive rate by almost one-third, sensitivity values for the VI (cutoff, 1.556%), FI (25.212), and VFI (0.323) were 92%, 95%, and 93%, respectively.

CONCLUSIONS

Three-dimensional PD vascular indices could be helpful for reducing the false-positive rate in cystic-solid and solid vascularized adnexal masses.

Vascular endothelial growth factor expression in ovarian cancer: a model for targeted use of novel therapies?

PURPOSE

Angiogenesis has a vital role in tumor growth and metastasis, and vascular endothelial growth factor (VEGF) represents a potent cytokine in this process. However, the influence of VEGF in ovarian cancer remains controversial. Interest has focused on the use of antiangiogenic drugs in ovarian cancer. This study aims to establish the pattern of expression and effect on prognosis of VEGF in a large population of ovarian cancer patients and to potentially identify a cohort in whom antiangiogenic therapy is appropriate.

EXPERIMENTAL DESIGN

Using a tissue microarray of 339 primary ovarian cancers, the expression of VEGF was assessed immunohistochemically. Coupled to a comprehensive database of clinicopathologic variables, its effect on these factors and survival was studied.

RESULTS

Tumors expressing high levels of VEGF had significantly poorer survival (P = 0.04). Factors shown to predict prognosis independently of each other were age, International Federation of Gynecologists and Obstetricians stage, and the absence of macroscopic disease after surgery. VEGF was independently predictive of prognosis on multivariate analysis (P = 0.02). There was no correlation between VEGF and any clinicopathologic variable. High expression of VEGF was seen in only 7% of the tumors, suggesting that the role of antiangiogenic drugs may be limited to a small subset of patients.

CONCLUSION

High VEGF expression occurs in a small proportion of ovarian cancers, and this independently predicts poor prognosis. The small percentage of tumors with high levels of VEGF activity suggests that the role of bevacizumab may potentially be limited to a few patients; these patients could be targeted by molecular profiling.

Epithelial ovarian tumors: value of dynamic contrast-enhanced MR imaging and correlation with tumor angiogenesis

PURPOSE

To retrospectively evaluate the diagnostic performance of dynamic contrast material-enhanced magnetic resonance (MR) imaging for the characterization of ovarian epithelial tumors, by using histologic findings as the reference standard, and to correlate dynamic contrast-enhanced MR imaging findings with angiogenesis biomarkers.

MATERIALS AND METHODS

Ethics committee approval was obtained, with waiver of informed consent. Patients consented to having their data used for future retrospective research. Forty-one women (age range, 22-73 years) with 48 epithelial ovarian tumors underwent dynamic contrast-enhanced MR imaging before surgical excision. In case of bilateral tumors (n = 7), only the most complex tumor was analyzed. Thus, 41 tumors (12 benign, 13 borderline, and 16 invasive) were examined with dynamic contrast-enhanced MR imaging and immunohistochemical methods. Dynamic contrast-enhanced MR imaging parameters (enhancement amplitude [EA], time of half rising [T(max)], and maximal slope [MS]) were analyzed according to histopathologic findings, microvessel density, pericyte coverage index (PCI), and vascular endothelial growth factor receptor 2 (VEGFR-2) expression. Statistical analyses were performed by using Kruskal-Wallis, Fisher exact, and Spearman tests and receiver operating curve analysis.

RESULTS

EA was higher for invasive tumors than for benign (P < .001) and borderline (P < .05) tumors. T(max) was longer for benign tumors than for borderline (P < .05) and invasive (P < .01) tumors. MS was steeper for invasive tumors than for benign (P < .001) and borderline (P < .001) tumors. PCI was lower in invasive tumors than in borderline (P < .05) and benign (P < .05) tumors. Microvessels showed stronger immunohistochemical VEGFR-2 expression in invasive tumors than in benign or borderline tumors (P < .05). MS correlated with a lower PCI (r = -0.34, P = .04) and stronger VEGFR-2 expression by using both epithelial (r = 0.41, P < .01) and endothelial (r = 0.66, P < .001) cells.

CONCLUSION

The early enhancement patterns of ovarian epithelial tumors on dynamic contrast-enhanced MR images can help distinguish among benign, borderline, and invasive tumors and were found to correlate with tumoral angiogenic status.

Prognostic Value of Measurements of Angiogenesis in Serous Carcinoma of the Ovary

The study objective was to determine whether tumor vascularity correlates with patient survival, to compare newer semiautomated methods of angiogenesis assessment to older methods, and to determine if advanced image analysis methods can offer useful patient outcome data in serous ovarian cancer. Using the specific endothelial marker CD34, microvessel determinations were quantified in 132 serous ovarian tumors by manual counting at final magnifications of x 200 and x 400 in the most highly vascular areas. Computer-assisted image analysis microvessel counts, endothelial area estimates, and minimum spanning tree (MST) analysis of capillary architecture, which involves assessment of intercapillary distances, were correlated with traditional manual techniques.Manual, semiautomated, and advanced image analysis methods were found to be highly reproducible and express strong correlation with one another. Univariate cyclooxygenase analysis revealed angiogenesis parameters to be highly significant predictors for overall survival (OS) and disease-free survival. Multivariate cyclooxygenase analysis revealed maximum MST (P = 0.009), length MST (P = 0.005), 1 nearest neighbor (P <or= 0.01) and mean microvessel density (x 400) (P = 0.0001) to be significant predictors for OS, and mean endothelial area (P <or= 0.01) and stage (P = 0.001) significant predictors for disease-free survival. Despite showing prognostic significance on univariate analysis, most clinicopathologic parameters did not retain independent significance on multivariate analysis. Microvessel determination is an independent prognostic indicator for survival in patients with serous ovarian carcinoma. Computer-assisted image analysis is a highly reproducible method of assessment capable of accurately evaluating tumor vascularity. Minimum spanning tree analysis of capillary architecture was found to be the strongest prognosticator for OS, suggesting this to be a promising marker.

Tumor markers in ovarian carcinoma

This review analyzes in 2 ways the prognostic value of markers found in ovarian carcinomas before chemotherapy. It is known that neoangiogenesis, cyclooxygenase activity, and host responsiveness to chemotherapy can be evaluated by means of specific molecules recognized as tumor markers. However, host response as well as tumor histotype, grade of differentiation, clinical characteristics, and histopathologic characteristics must also be taken into account when selecting a treatment. Analysis must therefore focus on the molecular basis of aggressive disease, on tumor peculiarity, on the efficacy of chemotherapy, and on the host's response to the tumor. Although treatment may be more aggressive in patients with unfavorable prognostic elements, it may be modulated according to the molecular and cellular biology of the tumor and the host's response. When the tumor's molecular characterization contributes to the choice of treatment, prognostic markers may turn into predictive markers.

Lymphangiogenesis of normal endometrium and endometrial adenocarcinoma

BACKGROUND

Information about lymphatics and lymphangiogenesis in the human endometrium is limited. We investigated the distribution of endometrial lymphatic vessels during the normal menstrual cycle and in association with endometrial adenocarcinoma and investigated the expression of lymphangiogenic growth factors, vascular endothelial growth factor (VEGF)-C, VEGF-D and VEGF receptor-3 (VEGF-R3).

METHODS AND RESULTS

Full thickness uterine samples (n = 23 proliferative; n = 23 secretory) and endometrial adenocarcinoma samples (n = 7 grade I; n = 10 grade III) were collected for the study and analysed by immunohistochemistry and western blotting. Lymphatic vessels of the functionalis were significantly reduced compared with basalis (P = 0.001) across the menstrual cycle with lymphatics of the basalis sometimes intimately associated with spiral arterioles. Lymphatic vessels of endometrial adenocarcinomas were located intra-tumoural and peri-tumoural with significant increases in the peri-tumoural lymphatic vessels compared with normal basalis (P = 0.02). Interestingly, high-grade adenocarcinoma vessels containing tumour emboli demonstrated a mixed blood/lymphatic endothelial cell phenotype. VEGF-C and VEGF-D were immunolocalized in glandular epithelium and some stromal cells with the staining intensity of this localization increasing in endometrial adenocarcinoma. Protein analysis identified VEGF-C (58, 41, 31 and 21 kD) and VEGF-D (56, 41, 31 and 21 kD) and VEGF-R3 (148 and 65 kD) peptides in normal endometrium, with significant increases in several of these peptides for VEGF-C and VEGF-D and no changes in protein expression for VEGF-R3 in endometrial adenocarcinoma.

CONCLUSION

Endometrial lymphatics are significantly reduced in the functionalis, and increases in endometrial adenocarcinoma peri-tumoural lymphatics are associated with increases in VEGF-C and VEGF-D peptides.

Potential predictors of chemotherapy response in ovarian cancer--how do we define chemosensitivity?

OBJECTIVE

The aim of this study was to assess whether microvessel density (measured by CD31), vascular endothelial growth factor (VEGF) or multidrug resistance (MDR1) could determine the response to chemotherapy or act as prognostic factors in ovarian cancer.

METHODS

Seventy-nine ovarian specimens were immunostained. Pearson correlation, 1-way ANOVA and chi-square were used for univariate analysis. Kaplan Meier survival curves were used, log-rank was used for univariate analysis and a Cox proportional hazards regression model was used for multivariate evaluation. Response to chemotherapy was assessed after 6 months and again after 1 year.

RESULT

Quantifying VEGF proved to be a valuable independent prognostic indicator in progression-free survival (PFS) (p<0.05) and overall survival (OS) (p<0.0001). VEGF correlated with response to chemotherapy at the 6-month interval (r=0.446, p<0.001) but failed to correlate at the 1-year interval. Increased staining with CD31 was associated with decreased PFS (p<0.01) and OS (p<0.01) in univariate but not multivariate analysis. MDR1 failed to act as a prognostic marker or as a predictor of response to chemotherapy.

CONCLUSION

VEGF correlates with response to chemotherapy at the 6-month but not the 12-month interval. What should our criteria be for determining sensitivity to chemotherapy? CD31, VEGF and MDR1 do play a role in some ovarian malignancies but other factors are likely to be involved and perhaps molecular profiling will determine which factors will be important for determining the response to chemotherapy.

Bevacizumab combination therapy in recurrent, platinum-refractory, epithelial ovarian carcinoma: A retrospective analysis

BACKGROUND

The study was undertaken to determine the safety and efficacy of the monoclonal, antivascular endothelial growth factor antibody bevacizumab in combination with cytotoxic chemotherapy for women with platinum-refractory ovarian cancer.

METHODS

A retrospective analysis of women who received bevacizumab in combination with a cytotoxic agent was performed. Response was determined by measurable disease or assessment of serial cancer antigen (CA) 125 measurements.

RESULTS

Twenty-three patients were identified. The patients were heavily pretreated with a median of 7 prior regimens including a median of 3 prior platinum regimens. The combination regimen included cyclophosphamide in 15 (65%), 5-fluorouracil (5-FU) in 6 (26%), docetaxel in 1 (4%), and gemcitibine/liposomal doxorubicin in 1 (4%). Two (9%) women developed chylous ascites during treatment. CTC Grade 4-5 toxicities occurred in 4 (17%) subjects. Gastrointestinal perforation occurred in 2 (9%) patients. Measurable disease was present in 22. The overall best response rate was 35% and all 8 were partial responses (PRs). Stable disease was found in a further 10 (44%) women, whereas progressive disease was observed in 5 (22%). The median time to progression was 5.6 months in patients with a PR and 2.3 months in subjects with stable disease. Three (13%) women experienced a progression-free interval (PFI) of >6 months. At last follow-up, 8 (35%) subjects had died of disease, whereas 15 (65%) women were alive with disease.

CONCLUSIONS

Combination bevacizumab therapy demonstrated activity in heavily pretreated women with ovarian cancer. Gastrointestinal perforations were identified in 9%. Despite the toxicity of the regimen, prospective studies, particularly in less heavily pretreated patients, are warranted.

Role of lymphangiogenesis in epithelial ovarian cancer

We investigated the significance of lymphatic count, vascular count and angiogenic growth factors using immunohistochemistry in 108 tumour specimens of epithelial ovarian cancer with antibodies to lymphatic vessel endothelial hyaluronan receptor (LYVE-1), platelet endothelial cell adhesion molecule CD31, vascular endothelial growth factor (VEGF) and thymidine phosphorylase (TP) in epithelial ovarian cancer to understand the pathogenesis of metastasis in ovarian cancer. The effect of prognostic variables on progression-free and overall survival was assessed. On multivariate analysis, bulky residual disease after surgery was the best prognostic indicator (P<0.001) for progression-free and overall survival (P<0.001). Lymphatic count was statistically significant as a prognostic factor for progression-free (P=0.05) and overall survival (P=0.04). However, lymphatic count did not impact on survival curves. No correlation was found between lymphatic count and age, histological subtype, FIGO stage or residual disease. Vascular count, VEGF or TP expressions were not significant in either analysis. Lymphatic spread may be significant in aiding metastases in ovarian cancer but requires other biological factors to act in conjunction, as it does not have clearcut prognostic significance. Dissemination of ovarian cancer does not occur primarily through vascular or lymphatic routes but may occur through direct intraperitoneal spread of disease.

Vascular atypia and irregularity on surface as signs of malignant adnexal mass: a complementary method of laparoscopic assessment

STUDY OBJECTIVE

To evaluate the risk of malignancy associated with the main macroscopic findings observed on adnexal masses during a laparoscopic approach.

DESIGN

Prospective series of consecutive patients (Canadian Task Force classification II-2).

SETTING

Tertiary care university hospital.

PATIENTS

One hundred fifteen patients were included. Ninety-eight had benign and 17 malignant adnexal masses.

INTERVENTIONS

Diagnostic and operative laparoscopy.

MEASUREMENTS AND MAIN RESULTS

Adnexal images were obtained during laparoscopy, recorded, and analyzed according to irregularity on surface, presence of atypical vessels, lobular form, absence of coral-like surface, implants, large-volume ascites, and cloudy or hemorrhagic ascites. A logistic regression was applied, and the independent findings associated with malignant disease were atypical vessels (OR 16.37; 95% CI 2.85-94.13; p <.01) and irregularity on tumor surface (OR 43.41; 95% CI 8.02-234.96; p <.05). In this way, 95% of the cases were correctly diagnosed.

CONCLUSIONS

Atypical vessels and irregularity on tumor surface were important criteria of malignancy during laparoscopic treatment of adnexal masses. The recognition of these features can be helpful in choosing the ideal surgical approach mainly when the preoperative evaluation is unsatisfactory.

Microvessel quantification in benign and malignant ovarian tumors

Microvessel density (MVD) in 92 paraffin sections of ovarian samples of different histologic subtypes was correlated with microvessel counts from 58 corresponding frozen sections. Anti-human von Willebrand factor antibody was used as an endothelial marker. MVD was performed in neovascular hotspots using a Quantimet 500+ Image Analyzer. The highest vessel density (HVD) and average vessel density (AVD) of three fields at the x 200 and x 400 magnification were recorded. There was a strong correlation between the HVD and AVD at the x 200 and x 400 magnifications when comparing fixed with frozen sections (correlation coefficients at x 200 for the HVD was 0.37, P = 0.005 and AVD was 0.30, P = 0.02; correlation coefficients at x 400 for the HVD was 0.38, P = 0.003 and AVD was 0.37, P = 0.004). In the fixed tissue, the HVD and AVD at both these magnifications were significantly greater in the group containing functional cysts; this was also the case for the frozen sections. These findings are consistent with the development of a microcirculation necessary for the growth and maturation of such cysts, and this appears to be greater than that in tumors. The good correlation between MVD in fixed and frozen sections suggests that such observations represent a true reflection of ovarian angiogenesis in both physiologic and pathologic states.

Prognostic significance of microvessel density and vascular endothelial growth factor expression in advanced ovarian serous carcinoma

The aim of the study was to test the prognostic value of the microvessel density (MVD) within the tumor and the vascular endothelial growth factor (VEGF) expression on clinical response to chemotherapy, on brief disease-free interval, and on cause-specific survival in advanced ovarian serous carcinoma. We evaluated 83 ovarian carcinomas homogeneous for stage, type and grade histologic, surgical, and chemotherapeutic treatment. Brief disease-free interval and cause-specific survival rates (Kaplan-Meier method) were compared using the log-rank test. A multivariate analysis (Cox-proportional hazards model) was used to determine the independent effect of each variable on prognosis. Overall 60 and 120 months cause-specific survival rates were 27.7% and 2.4%, respectively. The brief disease-free interval rate was 66.2%. In univariate analysis, VEGF (P = 0.0001 and P = 0.016), MVD (P < 0.0005), and the FIGO stage IIIC even more than FIGO stage IIIA (P = 0.01 and P < 0.0005, respectively) were associated with survival and brief disease-free interval, and the residual tumor was associated with survival (P = 0.021). In multivariate analysis, the factors that were independent predictors of survival were MVD (P < 0.0005), VEGF (P = 0.027), and the FIGO stage IIIC even more than FIGO stage IIIA (P = 0.013). Moreover, MVD was an independent predictor also of brief disease relapse (P = 0.001). Both MVD and VEGF were correlated with clinical response to chemotherapy (P = 0.01 and P = 0.037). Our data suggest that MVD and VEGF may have prognostic significance in advanced ovarian serous carcinoma.

Pretreatment serum hemoglobin level and a preliminary investigation of intratumoral microvessel density in advanced ovarian cancer

OBJECTIVE

The primary aim of this study was to evaluate the prognostic and predictive value of pretreatment serum hemoglobin level (Hb) in advanced ovarian cancer; second aim was to perform a preliminary investigation of intratumoral microvessel density (IMD).

METHODS

The influence on survival and response to treatment of several clinico-pathological features, including Hb, was analyzed in 72 patients with advanced ovarian cancer. IMD was assessed in tumor specimens of 25 of the 72 patients to compare three different endothelial markers: anti-FactorVIII, anti-CD31 and anti-CD34. In this subgroup of patients, a preliminary analysis of the prognostic and predictive value of IMD, and its relationship with Hb and other clinico-pathological features, was performed.

RESULTS

Hb >or= 12 g/dl was significantly associated with a better overall survival in univariate analysis (P = 0.0181) and was the only independent prognostic variable in multivariate analysis (P = 0.0160). Hb was directly related to progression-free survival (P = 0.0240) and complete response to treatment (P = 0.016). In the preliminary investigation of IMD, mean microvessel count did not show any significant difference among the three endothelial markers used, but anti-CD34 revealed a more consistent staining reaction. The relationship between IMD and complete response to treatment was found near to statistical significance (P = 0.05); Hb and IMD were inversely related (r = -0.47; P = 0.045).

CONCLUSIONS

Hb has a prognostic and predictive value in advanced ovarian cancer. In our preliminary study, which was performed on a limited number of patients, we found anti-CD34 to be an optimal marker for IMD determination, IMD to be a possible predictive factor of complete response to treatment, and IMD and Hb to be inversely related.

Expression of the angopoietin-1, angopoietin-2, Tie2, and vascular endothelial growth factor gene in epithelial ovarian cancer

OBJECTIVES

Angiopoietin/Tie2 system with vascular endothelial growth factor (VEFG) is known to be important for the initiation of angiogenesis in tumors. The aim was to evaluate whether angiopoietin/Tie2 system with VEFG affects prognosis in patients of epithelial ovarian cancer.

METHODS

Angiopoietin-1 (Ang-1), Angiopoietin-2 (Ang-2), Tie2, and VEGF gene expression were analyzed by real-time quantitative reverse transcription-polymerase chain reaction (RT-PCR) in 85 epithelial ovarian cancer surgical specimens. These gene expressions were correlated with clinical-pathological parameters, microvessel density (MVD), and patients' survival.

RESULTS

Ang-1/Ang-2 gene expression ratio, VEGF, and Tie2 gene expression significantly associated with MVD, respectively (P < 0.0001, P = 0.024, P = 0.005). The patients with low Ang-1/Ang-2 gene expression ratio and high VEGF gene expression were found to have a significantly higher MVD when compared to others (P = 0.0003). Moreover, there was a significant difference between the values of MVD in patients with low Ang-1/Ang-2 gene expression ratio and high VEGF and high Tie2 gene expression and those in others (P = 0.0025). FIGO stage (P = 0.014), residual disease (P = 0.042), histological grade (P = 0.028), Ang-1/Ang-2 gene expression ratio (P = 0.010), and combination of Ang-1/Ang-2 gene expression ratio and VEGF gene expression (P = 0.019), were found to be significantly associated with a poor prognosis in univariate Cox regression analysis. Multivariate Cox regression analysis revealed that FIGO stage is an independent prognostic factor (P = 0.035). Low Ang-1/Ang-2 gene expression ratio had a tendency to be an independent prognostic factor (P = 0.061).

CONCLUSIONS

Angiogenesis occurred by angiopoietin/Tie2 system in concert with VEGF in epithelial ovarian cancer did not affect patients' survival. However, gene expression of Ang-1 and Ang-2 might present a pertinent diagnostic tool to select a high-risk group of patients independent of clinical-pathological parameters and a new insight to understand the biology of epithelial ovarian cancer.

Angiogenesis in epithelian ovarian cancer

Angiogenesis, the development of new blood vessels from the existing vasculature, is an essential component of solid tumour growth and metastasis. Several angiogenic factors are expressed by many tumours, suggesting that tumours promote their own vascularisation by activating the host endothelium. This review will discuss various angiogenic stimulators and inhibitors in epithelian ovarian cancer (EOC), including vascular endothelial growth factor and platelet derived endothelial cell growth factor/thymidine phosphorylase. The analysis of tumour vascularisation by microvessel density will also be discussed and the relevance of these markers of angiogenesis in the prognosis of EOC will be assessed.

Hypoxia-inducible factor 1 alpha (HIF-1 alpha) gene expression in human ovarian carcinoma

Hypoxia-inducible factor 1 alpha (HIF-1 alpha) that regulates genes involved in response to hypoxia and promotes neo-angiogenesis, is a transcriptional factor for vascular endothelial cell growth factor (VEGF). The aim of this study was to examine the expression of HIF-1 alpha and VEGF gene expressions and their relation to angiogenesis, clinicopathologic variables and survival in the patient with human ovarian carcinoma. We retrospectively analyzed HIF-1 alpha and VEGF gene expression levels using reverse transcriptase polymerase chain reaction (RT-PCR) in 60 ovarian carcinomas. Intratumoral microvessel density (IMD) was assessed by immunostaining endothelial cells, using anti-CD 31 antibody in frozen sections. The relationships between the expression level of these genes, IMD and clinicopathologic variables were evaluated by Student's t-test and chi-square tests. Survival analysis was performed by Kaplan-Meier curves. HIF-1 alpha or VEGF gene expression level was independent of age, clinical stage and histological subtype besides grade of tumor. There was no relationship between HIF-1 alpha or VEGF gene expression level and IMD in all carcinomas (R=0.118 and 0.224, respectively). In addition, a weak association between HIF-1 alpha and VEGF gene expression level was observed (R=0.300, P=0.020). The association between VEGF gene expression and IMD was observed (R=0.501, P=0.016). However, no association between IMD and HIF-1 alpha gene expression was observed. Further, both HIF-1 alpha and VEGF gene expression levels had no effect on survival in the patient with ovarian carcinoma. These results suggest that VEGF upregulated by HIF-1 alpha gene may be involved in angiogenesis of some type of ovarian carcinoma, but the expression levels of both genes have no effect on survival in the patients with ovarian carcinoma.

Different features of angiogenesis between ovarian and breast carcinoma

Angiogenesis assessed by immunohistochemical staining for endothelial cells has been widely accepted as an independent prognostic factor in human breast carcinoma. However, the clinicopathologic significance of angiogenesis is still being argued in ovarian carcinoma. Therefore, we retrospectively analyzed the clinicopathologic significance of angiogenesis in ovarian carcinoma compared with that in breast carcinoma. After vessels were stained with CD34-monoclonal antibody, the areas with the highest number of intratumoral microvessels were assessed in a 200x field in 42 ovarian carcinoma and 41 breast carcinoma. Intratumoral microvessel density (IMD) in ovarian carcinoma was significantly lower than that in breast carcinoma. Further, the difference of IMD from tumor to tumor in ovarian carcinoma was smaller than that in breast carcinoma. IMD was correlated with tumor grade, but not with other clinicopathologic variables in ovarian carcinoma. Although the patients with high-IMD tumor revealed a poorer prognosis than those with low-IMD tumor in breast carcinoma, IMD had no influential effects on the survival of the patients with ovarian carcinoma. Our comparative analysis of IMD in ovarian carcinoma with that in breast carcinoma indicates that angiogenesis may play an important role in the transient of ovarian neoplasms, but not in the progression of ovarian carcinomas, and that the biological roles of angiogenesis might be different, depending on histologic subtype.

An immunohistochemical analysis of fibroid vasculature

This study aimed to compare vascular parameters between fibroid and myometrium. From 10 uteri, specimens were taken from small fibroids (<0.5 cm), from the inner and outer parts of large fibroids (>3 cm), and from myometrium. Antibodies to endothelial cell markers CD31, CD34, factor VIII-related antigen (FVIII), and Ulex europaeus lectin were used in routine immuno- and lectin chemistry protocols. Parameters calculated were vascular area (VA), microvascular density (MD) and vascular luminal diameter. VA measures showed that myometrium had a greater area stained than small fibroids (P = 0.03) using CD31 and both inner (P = 0.04) and outer (P = 0.01) regions of large fibroids using FVIII, and than all groups (small, P = 0.02; inner, P = 0.02; outer, P = 0.006) using the lectin U. europaeus. MD was higher in myometrium than all uterine fibroid groups (small, P = 0.009; inner, P = 0.01; outer, P = 0.01) using U. europaeus lectin, than both regions of large (inner, P = 0.04; outer, P = 0.02) fibroids using FVIII, and than outer regions of large fibroids using CD31 (P < 0.05). There were significantly larger diameter vessels in myometrium and large fibroids compared with small fibroids using CD34, FVIII and the lectin U. europaeus (P </= 0.04). These differences in vasculature may represent differences in angiogenesis and vascular remodelling.

Prognostic significance of vascular endothelial growth factor expression in human ovarian carcinoma

The influence of vascular endothelial growth factor (VEGF) expression and microvessel density (MVD) on prognosis and the relationship between VEGF expression and MVD in ovarian carcinoma are not well defined. We studied VEGF expression in parallel with MVD by immunohistochemistry in 94 ovarian tumours (64 malignant, 13 borderline, and 17 benign) and correlated the results with the clinicopathologic prognostic factors of the disease to clarify their significance in this disease. Assessment of VEGF mRNA isoforms by RT-PCR was also performed. Of the malignant, borderline, and benign ovarian tumours respectively, two (3%), four (31%) and 16 (94%) were negative, 31 (48%), seven (54%) and one (6%) had low expressions, and 31 (48%), two (15%) and none (0%) had high expressions of VEGF. There were significant associations between the VEGF expression and disease stage (P= 0.002), histologic grade (P= 0.0004), and patient outcome (P= 0.0002). MVD did not correlate significantly with the clinicopathologic parameters. Likewise, no correlation was found between MVD and VEGF expression. The survival of patients with high VEGF expression was significantly worse than that of patients with low and negative VEGF expression (P = 0.0004). Multivariate analysis revealed that disease stage and VEGF expression were significant and independent prognostic indicators of overall survival time (P = 0.008 and P = 0.006 respectively). These findings suggest that in conjunction with the established clinicopathologic prognostic parameters of ovarian carcinoma, VEGF expression may enhance the predictability of patients at high risk for tumour progression who are potential candidates for further aggressive therapy.

The management of borderline epithelial tumors of the ovary

The histopathological diagnosis and treatment of borderline epithelial tumors of the ovary (BTO) still pose problems to both pathologists and gynecologists. BTO is a disease of younger, fertile females and generally has an excellent prognosis. A minority of patients, however, succumb to this disease. A review of the literature is given addressing aspects of epidemiology, histology, treatment and prognosis, resulting in a proposal for the management of serous and mucinous borderline tumors of the ovary.

Vasculogenic mimicry and tumor angiogenesis

Tumors require a blood supply for growth and hematogenous dissemination. Much attention has been focused on the role of angiogenesis-the recruitment of new vessels into a tumor from pre-existing vessels. However, angiogenesis may not be the only mechanism by which tumors acquire a microcirculation. Highly aggressive and metastatic melanoma cells are capable of forming highly patterned vascular channels in vitro that are composed of a basement membrane that stains positive with the periodic acid-Schiff (PAS) reagent in the absence of endothelial cells and fibroblasts. These channels formed in vitro are identical morphologically to PAS-positive channels in histological preparations from highly aggressive primary uveal melanomas, in the vertical growth phase of cutaneous melanomas, and in metastatic uveal and cutaneous melanoma. The generation of microvascular channels by genetically deregulated, aggressive tumor cells was termed "vasculogenic mimicry" to emphasize their de novo generation without participation by endothelial cells and independent of angiogenesis. Techniques designed to identify the tumor microcirculation by the staining of endothelial cells may not be applicable to tumors that express vasculogenic mimicry. Although it is not known if therapeutic strategies targeting endothelial cells will be effective in tumors whose blood supply is formed by tumor cells in the absence of angiogenesis, the biomechanical and molecular events that regulate vasculogenic mimicry provide opportunities for the development of novel forms of tumor-targeted treatments. The unique patterning characteristic of vasculogenic mimicry provides an opportunity to design noninvasive imaging techniques to detect highly aggressive neoplasms and their metastases.

Angiogenesis of the ovary

We present current data pertaining to angiogenesis of the ovary throughout the follicular and luteal phases of the ovarian cycle, in various ovarian pathologic conditions and in benign and neoplastic diseases. MEDLINE, Current Contents, and Index Medicus were searched for studies published between January 1966 and October 1998. All studies that incorporated human and animal models of angiogenesis of the normal ovarian physiologic state and pathologic conditions including both benign and neoplastic ovarian diseases were reviewed. Current literature supports that angiogenesis is an important component of both follicular and luteal phases of the ovarian cycle that correlates well with maturation of secretory endometrium. Angiogenesis also participates in various pathologic processes of the ovary, including follicular cyst formation, polycystic ovary, ovarian hyperstimulation syndrome, and both benign and malignant ovarian neoplasms. In the future a knowledge of specific angiogenic patterns of various pathologic processes may assist in the application of antiangiogenic medications in targeted therapy of benign and neoplastic diseases of the ovary.

Study on tumor angiogenesis in epithelial ovarian carcinoma

To investigate tumor angiogenesis in benign, borderline and malignant epithelial ovarian tumors and its relation with the pathogenesis of ovarian carcinoma, polycolonal antibody directed against human von Willebrand factor (factor VIII) was used to measure the microvessel density (MVD) in 66 cases (11 benign, 10 borderline, and 45 malignant) of epithelial ovarian tumors by using immunohistochemistry. The results showed that the mean MVD in epithelial ovarian cancer (31.7 +/- 11.2, 400 X) was higher than in benign and borderline tumors (16.7 +/- 6.3, 20.7 +/- 8.8 respectively, P < 0.05). There was no difference in MVDs among those in different tumor grades (P > 0.05). But there was significant difference in MVDs among those in different tumor stages (P < 0.05). MVD in stage III-IV cancer was higher than that in stage I-II (P < 0.05). It is concluded that the tumor angiogenesis is an early event in ovarian tumorgenesis. The increased tumor micovessel might be responsible for tumor development.

VEGF, VEGFR-1, VEGFR-2, microvessel density and endothelial cell proliferation in tumours of the ovary

VEGF is an angiogenic factor with potent endothelial cell (EC) proliferative actions. Our aim was to investigate whether expression of VEGF and its receptors and EC proliferation differ between ovarian tumour types and regions of the vasculature. VEGF, VEGFR-1, VEGFR-2 and EC proliferation were examined immuno-histochemically, and in situ hybridisation (ISH) studies of VEGF mRNA expression were performed and assessed in regions of high (HVD) and average (AVD) vessel density. VEGF immunostaining was significantly stronger in HVD regions of malignant compared with borderline serous tumours. VEGF immunostaining did not differ between tumour types; however, the percentage of VEGFR-1- and VEGFR-2-positive vessels was significantly lower in mucinous tumours. No differences were observed between HVD and AVD regions. VEGF ISH signal was observed in 2/7 borderline mucinous tumours, 8/14 malignant serous tumours and 5/13 benign tumours. The EC proliferation index was significantly lower in the HVD regions of serous relative to benign tumours. A negative correlation between VEGFR-1 immunostaining and microvessel density was observed in benign and serous tumours. However, EC proliferation index and VEGFR-1 positivity were positively correlated in benign tumours. Our results suggest that VEGF may play a role in the control of angiogenesis in serous and benign tumours but it does not appear to contribute to the previously reported higher microvessel density in mucinous tumours or to influence heterogeneity of microvessel density in ovarian tumours.

Macrophages and microvessel density in tumors of the ovary

Macrophages are members of the mononuclear phagocyte system and synthesize and release many angiogenesis stimulators and inhibitors. Previous studies have demonstrated heterogeneous macrophage populations in ovarian tumors. The aim of this study was to compare macrophage number between different types of ovarian tumors and between regions of high (HVD) and average (AVD) microvessel density (MVD). Macrophages were visualized using CD68 antibody. Previously determined regions of HVD and AVD were located on CD68 immunostained sections and image analysis software was used to count the number of positively stained cells per square millimeter. CD68-positive macrophage number did not differ between benign, mucinous, and serous ovarian tumors or between regions of HVD and AVD (ANOVA; P > 0.05). In both HVD and AVD regions of benign tumors, macrophage number positively correlated with MVD (Spearman rank correlation coefficient; P < 0.03). In contrast, a small but significant negative correlation between macrophage number and MVD was observed in HVD regions of serous tumors (Spearman rank correlation coefficient; P > 0.05). Macrophage infiltration does not appear to differ between ovarian tumor types; however, macrophages may have a positive influence on the vascularization of benign ovarian tumors.