The relationship of angiogenesis to biological activity in human squamous cell carcinomas of the head and neck

A novel integrated platform for the identification of surgical margins in oral squamous cell carcinoma: results from a prospective single-institution series

BACKGROUND

The optimal surgical margins assessment is capital in oral squamous cell carcinoma (OSCC) management. We evaluated the clinical benefits of integrating intraoperative macroscopic margin (MM) assessment and narrow band imaging (NBI).

METHODS

Sixteen OSCC patients eligible for surgery were prospectively enrolled. For each patient, 2 to 6 bioptic samples of MM and NBI margins were obtained and histologically analyzed for the presence of dysplasia and lymphocytes. Microvessel density was investigated by CD34 immunohistochemistry.

RESULTS

Taken together, 104 specimens were analyzed, including 15% tumors, 33% MM, 33% NBI margins, and 19% MM-NBI overlapping margins. The NBI margins were closer to the lesion in 50% cases, while the same number of MM were more conservative than NBI, irrespective of the tumor site. The rate of histologically positive margins was similar among the two methods, akin to the microvessel density.

CONCLUSIONS

MM assessment should be integrated but not replaced with the NBI technology to allow for more conservative surgery.

Correlation of microvascular density and proliferation index in undifferentiated nasopharyngeal carcinoma

Background: Undifferentiated nasopharyngeal carcinoma is a highly malignant tumor with an endemic distribution. Several histologic parameters have been studied to provide prognostic information for patient management. Both proliferation index and microvascular density are commonly determined on such tumors, but the relationship between these two parameters has not been studied fully. Objectives: Determine the association between microvascular density and cellular proliferation in undifferentiated nasopharyngeal carcinoma. Methods: A series of 60 cases were studied in patients of Southeast Asian origin. Cellular proliferation was determined using Ki67 immunostaining, and vessel proliferation using CD31 immunostaining in terms of areas of increased staining (‘hot spots’). Ki67 results were scored on a scale of 0-4+ and CD31 results as a microvascular density/mm2. Results: The mean of the microvascular density was 22/mm2 in the Ki67-negative group (25 cases). In the Ki67- positive group (35 cases), the mean was 35/mm2. The difference between the positive and negative group was statistically significant (p <0.001). Microvascular density significantly increased as the Ki67 score increased (p<0.001). However, the ‘hot spots’ for microvascular density in tissue sections did not correspond to areas of increased cellular proliferation. Conclusion: Pathologists usually determine only one of these two prognostic factors when dealing with undifferentiated nasopharyngeal carcinoma. The proliferation index is suggested because it is easier to perform and can be done on small biopsies not to contain enough surface area for microvascular density determination.

Biological Parameters for the Choice of Antiangiogenic Therapy and Efficacy Monitoring

Angiogenesis is a tightly controlled process which depends on the balance between stimulating and inhibiting factors. When this balance is disrupted, angiogenesis acquires a pathological meaning. The list of molecules able to induce angiogenesis is heterogeneous with respect to their chemical characteristics and biological properties. Quantitative measurement of tumor angiogenesis is necessary for the choice of therapeutic strategies and as an endpoint for antiangiogenic therapy. We are developing a quantitative RT-PCR which measures the expression of specific factors in real time. With the use of this rapid technique, measurement of the expression of the angiogenic factors and inhibitors is also possible in specimens as small as biopsies.

Identification of α-enolase as a prognostic and diagnostic precancer biomarker in oral submucous fibrosis

AIMS

Diagnostic ambiguities regarding the malignant potentiality of oral submucous fibrosis (OSF), an oral precancerous condition having dysplastic and non-dysplastic isoforms are the major failure for early intervention of oral squamous cell carcinoma (OSCC) patients. Our goal is to identify proteomic signatures from biopsies that can be used as precancer diagnostic marker for patient suffering from OSF.

METHODS

The high throughput techniques adopting de novo peptide sequencing (1D SDS-PAGE coupled nanoLC MALDI tandem mass spectrometry (MS/MS)-based peptide mass fingerprint), immunohistochemistry (IHC), Western blot (WB) and real-time PCR (RT-PCR) analysis are considered for such biomarker identification and multilevel validations.

RESULTS

Alpha-enolase is identified as an overexpressed protein in biopsies of oral submucous fibrosis with dysplasia (OSFWD) compared with oral submucous fibrosis without dysplasia (OSFWT) and normal oral mucosa (NOM). Total proteome analysis of an overexpressed protein band around 47 kDa of OSFWD identifies 334 peptides corresponding to 61 human proteins. Among them α-enolase is identified as a prime protein with highest number of peptides (44 out of 334 peptides) and sequence coverage (66.4%). Furthermore, RT-PCR, WB and IHC analysis also show mRNA and tissue level upregulation of α-enolase in OSFWD validating α-enolase as precancer marker.

CONCLUSIONS

This study for the first time identifies and validates α-enolase as a novel biomarker for early diagnosis of malignant potentiality of OSF. Hence, the identified protein marker, α-enolase can help in early therapeutic intervention of OSF patients leading to the reduction of patient's pain, treatment cost and enhancement of patient's quality of life.

Association of Macrophages With Angiogenesis in Oral Epithelial Dysplasia, Oral Verrucous Carcinoma, and Oral Squamous Cell Carcinoma: An Immunohistochemical Study

The present study aimed to elucidate the role of tumor-associated macrophages (TAMs) and angiogenesis in tumor progression by assessing their immunohistochemical expression in oral epithelial dysplasia (OED), oral verrucous carcinoma (OVC), and oral squamous cell carcinoma (OSCC). About 20 histopathologically confirmed cases of OED, OVC, and OSCC each and 10 cases of normal oral mucosa taken as controls were stained immunohistochemically using CD68 and CD31 antibodies. The average TAM count and the microvessel density (MVD) were calculated for each group and expressed as mean±SD and compared using the Mann-Whitney U Test. Pearson correlation was applied to assess the correlation between TAM and MVD in different groups. The CD68 count was found to be significantly higher in all the groups as compared with controls, with the highest counts in OSCC, followed by OED and OVC. MVD was significantly higher in all the test groups as compared with controls. The increase in MVD was highly significant in OSCC as compared with OVC, and in OVC as compared with OED. No association could be determined between TAM and MVD. There does not seem to be any direct influence of macrophages on angiogenesis in the microenvironment of OED, OVC, and OSCC.

Stage-Dependent Expression of an Angiogenic Agent and Vascular Organization in Experimental Skin Tumor Development

Increased angiogenesis and expression of antibodies to vascular endothelial growth factor (VEGF), an angiogenic agent, have been shown in the tumor development of many tissues. Areas of skin expressing VEGF and total volume of vessels expressing laminin in the wall were measured in chemical carcinogen-exposed mice using CAS-200 morphometry apparatus having a sensitivity exceeding 99% and reproducibility exceeding 99%. The area of VEGF expression was increased in carcinogen-exposed skin, dysplasia and in well-differentiated squamous cell carcinomas, but decreased in squamous cell carcinomas with decreased degree of differentiation. The vessel volume increased prior to the formation of tumors in carcinogen-exposed skin as well as in highly malignant neoplasms. In well-differentiated squamous cell carcinomas with an expansive growth pattern, the vessels were parallel to the basal membrane, in moderately differentiated tumors the vessels were in the direction of tumor invasion, and in poorly differentiated tumors, active angiogenesis consisted of numerous, enlarged vessels within the tumor. This study showed increased VEGF expression and number of vessels occurring in early stages of skin tumor development, pointing to a role of angiogenesis in chemical risk assessment and in cancer prevention. Altered vessel structure and vessel arrangement were distinct in later stages of tumor growth and in malignant neoplasms, pointing to the utility of detailed vessel analysis in neoplasm characterization.

Combined PET/CT-perfusion in patients with head and neck cancers might predict failure after radio-chemotherapy: a proof of concept study

Background

[18F]FDG-PET/CT imaging is broadly used in head and neck cancer (HNSCC) patients. CT perfusion (CTP) is known to provide information about angiogenesis and blood-flow characteristics in tumors. The aim of this study was to evaluate the potential relationship of FDG-parameters and CTP-parameters in HNSCC preand post-therapy and the potential prognostic value of a combined PET/CT with CTP.

Methods

Thirteen patients with histologic proven HNSCC were prospectively included. All patients underwent a combined PET/CT with integrated CTP before and after therapy. Pre- and post-therapeutic data of CTP and PET of the tumors were compared. Differences were tested using Spearman’s rho test and Pearson’s correlation. A p-value of p <0.05 was considered statistically significant. Correlations were calculated using Pearson’s correlation. Bootstrap confidence intervals were calculated to test for additive confidence intervals.

Results

Three patients died due to malignancy recurrence, ten patients were free of recurrence until the end of the follow-up period. Patients with recurrent disease had significantly higher initial CTP-values compared to the recurrence-free patients: BFpre 267.4 (171.2)ml/100 mg/min, BVpre 40.9 (8.4)ml/100 mg and MTTpre 8.2 (6.1)sec. No higher SUVs initially but significantly higher TLG compared to patients without recurrence were found. Post-therapeutic PET-values differed significantly between the two groups: SUVmaxpost 6.0 (3.2), SUVmeanpost 3.6 (2.0) and TLG 21751.7 (29794.0).

Conclusion

In our proof of concept study, combined PET/CT with integrated CTP might show complementary prognostic data pre- and post chemo-radiotherapy. CTP may be used to predict local tumor recurrence, while FDGPET/CT is still needed for whole-body staging.

Diagnostic aids for detection of oral precancerous conditions

Oral cancer has a tendency to be detected at late stage which is detrimental to the patients because of its high mortality and morbidity rates. Early detection of oral cancer is therefore important to reduce the burden of this devastating disease. In this review article, the most common oral precancerous lesions are discussed and the importance of early diagnosis is emphasized. In addition, the most common non-invasive oral cancer devices that can aid the general practitioners in early diagnosis are also discussed.

Angiogenesis and lymphangiogenesis in early-stage laryngeal carcinoma: Prognostic implications

BACKGROUND

Many studies have recently emphasized the role of tumor angiogenesis and lymphangiogenesis in regional and distant spread of disease. Although early laryngeal cancer has a favorable oncologic outcome after conservative surgery or radiation therapy, we observed few cases with poor prognosis in terms of locoregional relapse, organ preservation, and survival. The aim of our study was to evaluate the immunohistochemical expression of CD31 and podoplanin to define angiogenic and lymphangiogenic patterns and their possible prognostic implications in previously untreated T1-T2 glottic squamous cell carcinoma.

METHODS

Four hundred twenty-eight patients with previously untreated early-stage laryngeal cancer underwent a laser surgical resection in the period between January 1994 and December 2007. Twenty-seven cases with poor outcome were identified and compared with a selected sample of 28 patients. All specimens were negative for the presence of high-risk human papillomavirus genotypes. Patients were followed up until death or for at least 24 months after treatment. Three-micrometer sections were obtained from formalin-fixed and paraffin-embedded tumoral tissues, and an immunohistochemical evaluation was performed. Monoclonal antibodies against CD31 and podoplanin were used for the detection of blood and lymphatic vessels, respectively. A morphometric measurement was used for the analysis of angiogenesis whereas lymphangiogenesis was studied with a semiquantitative technique. The data were analyzed by use of chi-square and Mann-Whitney tests as appropriate.

RESULTS

An increased tumor angiogenesis correlated with local relapse (p = .01), locoregional relapse (p = .01), and death of disease (p = .03). The presence of lymphatic vessels in peritumoral fields had an impact on local (p = .004) and locoregional recurrence (p = .01).

CONCLUSIONS

Evaluation of angiogenesis and lymphangiogenesis in early-stage laryngeal cancer could be useful to identify patients at higher risk of recurrence and consequently to modulate treatment planning and follow-up strategy.

The relationship between enhanced intensity and microvessel density of gastric carcinoma using double contrast-enhanced ultrasonography

The purpose of this study was to assess the value of double contrast-enhanced ultrasound (DCUS), in which intravenous microbubbles are used together with an oral contrast agent as a method to evaluate the microvascular density (MVD) of gastric cancer, and its relationship with the contrast-enhanced intensity (EI) in gastric carcinomas. Sixty-nine patients with gastric cancer were examined preoperatively using DCUS. The arrival time (AT), time-to-peak (TTP), peak (PI) and baseline (pre-injection) intensities (BI) of gastric carcinoma and normal gastric wall were measured. Contrast-enhanced intensity (PI minus BI) was calculated. A monoclonal antibody against CD34 was used to display vascular endothelial cells in the resected gastric carcinoma specimens and in normal gastric mucosal tissues, and MVD was calculated by counting CD34-positive vascular endothelial cells. The differences in AT, TTP, EI and MVD between gastric carcinoma specimens and normal gastric wall tissues were evaluated using Student's t-test. The relationships between EI and MVD in gastric cancer were analyzed by Spearman rank correlation analysis. Both EI and MVD were significantly higher in gastric carcinomas than in normal gastric wall (p<0.001). However, AT and TTP showed no significant differences between gastric carcinoma specimens and normal gastric wall tissues (p>0.05). There was a strong positive linear correlation between EI and MVD in gastric carcinoma (r=0.921, p<0.001). Double contrast-enhanced ultrasound is a useful method for evaluation of the MVD in gastric carcinomas in vivo. Contrast-enhanced intensity has a strong positive linear correlation with MVD and could form a new index for assessing angiogenesis and the biological behavior of gastric carcinomas.

[Prognostic significance of angiogenesis in surgically treated supraglottic squamous cell carcinomas of the larynx]

INTRODUCTION AND OBJECTIVES

It is now generally accepted that angiogenesis is crucial in tumour growth. However, controversy still exists regarding the prognostic significance of angiogenesis in head and neck carcinomas. The aim of this paper is to determine the prognostic significance of angiogenesis in a homogeneously treated group of supraglottic squamous cell carcinomas.

MATERIAL AND METHODS

108 patients surgically treated for squamous cell carcinoma of the supraglottic larynx were studied. Angiogenesis was estimated in the primary tumour and in the nodal metastases by determining microvessel density using the "hot spot" method. Anti-CD34 antibody was used to stain blood vessels.

RESULTS

The mean microvessel density in primary tumours was 72+/-34 vessels/mm(2) and 58.5+/-31.5 vessels/mm(2) in nodal metastases. No correlation was found between microvessel density in the primary tumours and the corresponding nodal metastasis (P=0.195). No significant differences in microvessel density were observed in relation to clinico-pathological parameters or survival (P=0.19).

CONCLUSIONS

Our results suggest that microvessel density is not a useful prognostic marker in surgically treated supraglottic squamous cell carcinomas.

Chapter 14. Measuring intratumoral microvessel density

For a tumor to grow beyond a limited volume of 1-2 mm(3), the tumor cells must not only proliferate, but they must be able to induce the growth of new capillary blood vessels from the host. As early as 1971, it was proposed that tumor growth was dependent on angiogenesis; and, that tumor cells and blood vessels composed a highly integrated ecosystem, that endothelial cells could be switched from a resting state to one of rapid growth by a diffusible signal from tumor cells, and that anti-angiogenesis may become an effective anti-cancer therapy. Indeed, now there is considerable indirect and direct evidence to show that tumor growth is angiogenesis dependent, that tumor cells can produce diffusible angiogenic regulatory molecules, and that angiogenesis inhibitors can slow or prevent tumor growth, and that angiogenesis is a relevant target for anti-cancer therapy. Measuring intratumoral microvessel density (iMVD) in vascular "hot spots" has been shown to correlate with aggressive tumor behavior. This chapter reviews the techniques available for measuring iMVD.

Microvessel density >or=60 does not predict for outcome after radiation treatment for locally advanced head and neck squamous cell carcinoma: results of a correlative study from the Radiation Therapy Oncology Group (RTOG) 90-03 Trial

OBJECTIVES

To assess whether microvessel density (MVD), an immunohistochemical marker for tumor vascularity, predicts for radiotherapy (RT) outcome in locally advanced HNSCC patients.

METHODS

A total of 459 patients, enrolled on the RTOG 90-03 trial, had biopsy specimens submitted, and a value for MVD determined, prior to definitive RT. 450 patients were analyzable for this study. Tumor microvessels were stained for factor VIII-related antigen using a standard immunoperoxidase method. The mean number of stained microvessel profiles, from three x200 fields containing the highest MVD (hot spot), was recorded as the MVD. A prospective value of >or=60 was chosen as the threshold for high MVD, tumor vascularity.

RESULTS

The median follow-up for the analyzable patients with MVD assessment was 22.0 months and 79.1 months for all living patients. There were no differences concerning the pretreatment characteristics between those RTOG 90-03 patients with a value for MVD and those without a value for MVD. Thus, the present study cohort possessed comparable characteristics with the entire RTOG 90-03 population. MVD values ranged from 5 to 80, with a median value of 30. Only 37 of 450 (8.2%) patients possessed an MVD >or=60. There were no outcome differences for patients with MVD <60 versus >or=60 on multivariate analysis for time to local-regional failure (P = 0.89), time to distant metastasis (P = 0.80), disease-free survival (P = 0.46), and overall survival (P = 0.39).

CONCLUSIONS

In this large, correlative study, a MVD >or=60, ie, high tumor vascularity, did not predict for outcome in locally advanced head and neck squamous cell carcinoma patients treated with radiotherapy.

The vascularisation of oral cavity tumours and tumour shell tissue determined by three-dimensional power Doppler sonography

The aim of the study was to determine and quantify the vascularity of oral cavity tumours and peritumoural tissue by using 3-D power Doppler sonography (3-D PDS) and to compare the vascularity of metastatic and nonmetastatic tumours. The investigation was carried out preoperatively on 49 patients with squamous carcinoma of the tongue and floor of the mouth. Collected data were analysed with the help of virtual program of computer-aided analysis (VOCAL)-imaging program by which the borders of a structure could be defined and vascularity quantified by analysing 3D colour histograms. Vascularity was defined by three indices, VI- vascularisation index, FI- flow index and VFI- vascularisation-flow index. The vascularity of oral cavity tumours was determined in 4 mm and 7 mm shells surrounding the tumour. Modified neck dissection was performed in all of the patients and lymph nodes were examined histologically. Peritumorous tissue vascularity was significantly higher in metastatic (N+ neck) than it was in nonmetastatic (N0 neck) tumours. Indices VI and VFI in 4 mm and 7 mm shells differed significantly between N+ and N0 tumours (p < 0.01). Flow index (FI) did not show any difference between N0 and N+ necks. The difference between vascularity indices VI and VFI of peritumorous tissue and tumour was also varied significantly between N0 and N+ neck (p < 0.05) and was higher in N+ tumours. With VOCAL software and 3-D power Doppler sonography, the vascularity of peritumorous tissue could be quantified successfully. Tumours which had metastasised showed richer vascularity in their shells and a greater difference in vascularity between the shell and tumour tissue.

Angiogenesis and Ewing sarcoma--relationship to pulmonary metastasis and survival

BACKGROUND/PURPOSE

Intratumoral angiogenesis quantified by microvessel density (MVD) has been shown to be a strong prognostic indicator in a number of malignant tumors. Its association with prognosis in Ewing sarcoma has not been previously studied. The aim of our study was to investigate the relationship between angiogenesis and clinical outcome in Ewing sarcoma.

METHODS

Twenty-seven patients with Ewing sarcoma were included in a retrospective immunohistochemical study. Sections from diagnostic biopsies were immunostained using anti-von Willebrand factor antibody and microvessels were counted at 400x magnification on three microscopic fields per patient. Microvessel density was correlated with overall and disease-free survival as a continuous variable using univariate regression analysis and as a dichotomous variable by Kaplan-Meier and log-rank analysis. Correlation between clinicopathologic variables and the degree of angiogenesis was tested using chi(2) test.

RESULTS

Increasing MVD was not confirmed to be a poor prognostic factor in univariate analysis. Also, statistically significant difference was not found in overall survival or disease-free survival between patients with high (>31.6 vessels per field) and low (<or=31.6 vessels per field) microvessel counts. Finally, there was no difference regarding the metastatic rate between patients with high and low microvessel counts.

CONCLUSIONS

Our results did not confirm increasing angiogenesis quantified by MVD to be predictive of prognosis or pulmonary metastasis in Ewing sarcoma. The diffuse pattern of distribution of microvessels found in Ewing sarcoma may be responsible for the observed lack of prognostic significance of angiogenesis. Future work is required to assess the prognostic importance of MVD in this disease.

Stromelysin 3, Ets-1, and vascular endothelial growth factor expression in oral precancerous and cancerous lesions: correlation with microvessel density, progression, and prognosis

PURPOSE

Identification of molecular changes characteristic of development and progression of oral cancer are of paramount importance for effective intervention. Stromelysin 3 (MMP11) is a unique matrix metalloproteinase shown to have dual function during cancer progression. The transcription factor Ets-1 and vascular endothelial growth factor (VEGF) are important proangiogenic factors in cancer. This study was designed to test the hypothesis that concomitant expression of stromelysin 3, Ets-1, and/or VEGF affects the development, progression, and prognosis of oral cancer.

PATIENTS AND METHODS

Immunohistochemical analysis of stromelysin 3, Ets-1, VEGF, and platelet/endothelial cell adhesion molecule 1 (a marker for intratumoral microvessel density) was carried out in serial paraffin embedded tissue sections of 220 oral squamous cell carcinomas (OSCC), 90 precancerous lesions (59 hyperplasias and 31 dysplasias), and 81 matched histologically normal oral tissues.

RESULTS

Ets-1, VEGF, and stromelysin 3 expression independently correlated with increased intratumoral microvessel density in precancerous lesions (P = 0.05, 0.001, and 0.026, respectively) as well as in SCCs (P = 0.005, 0.01, and 0.031, respectively). Logistic regression analysis revealed that concomitant expression of stromelysin 3 and Ets-1 (stromelysin 3(+)/ Ets-1(+) phenotype; odds ratio, 3.7; P = 0.001) was the most significant predictor for transition to precancerous stage, whereas dual expression of stromelysin 3 and VEGF (stromelysin 3(+)/ VEGF(+) phenotype; odds ratio, 2.07; P = 0.004) was the most important predictor for progression from precancerous stage to frank malignancy. Intriguingly, Ets-1 expression was significantly associated with VEGF expression and stromelysin 3 expression in precancerous tissues as well as OSCCs. Follow-up data for 144 patients for a maximum period of 115 months showed that VEGF [hazards ratio (HR), 4.532; P = 0.004] and Ets-1 (HR = 2.182; P = 0.049) expression significantly correlated with reduced disease-free survival in univariate analysis. In bivariate analysis, patients harboring Ets-1(+)/VEGF(+) phenotype had the worst survival (median disease-free survival, 50 months; HR, 2.943; P = 0.003). Multivariate analysis using Cox's proportional hazards model showed that increased VEGF expression was the most significant adverse prognosticator in OSCC patients (HR, 4.470; P = 0.004).

CONCLUSIONS

In conclusion, this study provides the first evidence of concomitant expression of stromelysin 3, VEGF, and Ets-1 in clinical specimens in different stages of development of oral cancer. In early stages, concomitant expression of stromelysin 3 and Ets-1 favors the development of a precancerous state, whereas dual expression of stromelysin 3 and VEGF is associated with progression from precancerous to cancerous state. VEGF expression is an adverse prognosticator for disease-free survival.

Polybrominated diphenyl ethers from a sponge of the Dysidea genus that inhibit Tie2 kinase

Tie2 kinase, an enzyme that supports angiogenesis essential for tumor growth and survival, was selected as a target in a search for naturally occurring inhibitors of potential utility for antitumor therapy. Two polybrominated diphenyl ethers, 3,5-dibromo-2-(2',4'-dibromophenoxy)phenol (1) and 4,6-dibromo-2-(2',4'-dibromophenoxy)phenol (2) were isolated from an extract prepared from Dysidea sp. after bioassay-guided fractionation.

Prognostic relevance of CD105+ microvessel density in HNSCC patient outcome

Angiogenesis is essential for the development and progression of malignant tumours, and there is increasing evidence that microvessel density (MVD) can be considered an indirect marker of neo-angiogenesis. However, there is still disagreement concerning the clinical relevance and prognostic significance of MVD in head and neck squamous cell carcinomas (HNSCCs). MVD was evaluated in 127 HNSCC patients by means of immunohistochemistry using monoclonal antibodies (mAbs) against CD34 and CD105 (endoglin), which has recently been described as a potent marker of neo-vascularisation in various malignancies. MVD was expressed as the mean number of vessels/mm2. The mean CD34+ and CD105+ MVD values were significantly higher in T3-T4 tumours and those in an advanced clinical stage; furthermore, CD105+ MVD was significantly higher in N+ tumours. The patients with a high CD105+ MVD had a significantly shorter disease-free and overall survival; CD34+ MVD was not associated with survival. Similarly, in the subset of lymph-node negative patients, higher CD105+ MVD values were significantly associated with either OS and DFS. Multivariate analysis showed that a high CD105+ MVD was the only independent marker of tumour recurrence or death. Our data suggest that CD105+ MVD may represent an additional prognostic factor in HNSCC patients providing more accurate data for the determination of prognosis and management in the subset of lymph node negative patients.

Microvessel density and expression of vascular endothelial growth factor, basic fibroblast growth factor, and platelet-derived endothelial growth factor in oral squamous cell carcinomas

Angiogenesis, the growth of capillary vessels, plays an important role in the metabolic functions of malignant tissues. Tumor growth and malignant transformation are considered to be dominated by uncontrolled angiogenesis. To understand the mechanism of increased vascularity associated with malignant tissues, we immunohistochemically evaluated microvessel density (MVD) and the expression of vascular endothelial growth factor (VEGF), basic fibroblast growth factor (bFGF), and platelet-derived endothelial growth factor (PDGF) in oral cancers. Microvessel density did not differ significantly between normal oral mucosa and epithelial dysplasia, but was significantly increased in tumor tissues. Expression of angiogenic factors was not found in normal oral mucosa, but increased in association with increasing vascularity in OSCC tissue. In tumor tissue, angiogenic factor expression correlated with MVD. MVD in OSCC was related to T stage, tumor differentiation, and stage of invasion. VEGF expression also correlated with tumor differentiation and the stage of invasion. These findings suggest that VEGF might play an important role in tumor angiogenesis of OSCC.

Tumor angiogenesis and outcome in osteosarcoma

Intratumoral angiogenesis quantified by microvessel density (MVD) has been shown to be a strong prognostic indicator in a number of malignant tumors. Its association with prognosis in bone sarcomas has been subject to less extensive research. The aim of this study was to investigate prognostic significance of angiogenesis in osteosarcoma. Thirty-nine patients with osteosarcoma were included in a retrospective immunohistochemical study. Sections from diagnostic biopsies were immunostained using anti-von Willebrand factor antibody and microvessels were counted at 400 x magnification on 3 microscopic fields per patient. MVD was correlated with overall and disease-free survival by Kaplan-Meier and log-rank analysis. Correlation between clinicopathological variables and the degree of angiogenesis was tested using a chi 2 test. Significant statistical difference was found regarding overall survival and disease-free survival between patients with high (> 32.3 vessels/field) and low (< or = 32.3 vessels/field) microvessel counts (log-rank test p = .0196 and p = .0147, respectively). The rate of metastasis was significantly higher in patients with high microvessel counts (p = .042). These findings strongly suggest that angiogenesis quantified by microvessel density is predictive of metastasis and poor prognosis in osteosarcoma.

Angiogenic factors in squamous cell carcinoma of the oral cavity: do they have prognostic relevance?

INTRODUCTION

Angiogenesis is a cascade-like mechanism which is essential for tumour growth and metastasis. Therefore the existence of angiogenic molecules and the density of activated endothelial cells in individual tumours is of major interest. MATERIAL/PATIENTS: In order to evaluate the prognostic significance of these molecules, the distribution pattern was studied of vascular endothelial growth factor (VEGF) and activated endothelial cells in tumours and normal, healthy oral mucosal specimens from 51 consecutive patients with primary oral squamous cell carcinoma.

STUDY DESIGN

Frozen sections (vascular endothelial growth factor) and paraffin-embedded sections (endoglin, CD105) were investigated quantitatively by immunohistochemistry. The Pearson correlation, the non-parametric Mann-Whitney test, the non-parametric Wilcoxon rank sum test with multiple comparisons and the non-parametric Kruskal-Wallis test with multiple comparisons were used for statistical analyses.

RESULTS

Endoglin expression in tumour tissue was significantly higher than in normal healthy mucosa (P<0.001). T1 tumours showed a significantly lower staining for endoglin compared with T2, T3 and T4 tumours but there was no increase with each T stage. No statistical correlation was found between VEGF expression and endoglin staining.

CONCLUSIONS

Even though there is controversy about the prognostic relevance of VEGF, our results suggest that the factor is not suitable to decide prognosis in oral cancer. Endoglin may have a significant role in the development of squamous cell carcinoma of the oral cavity and might be relatively more specific than commonly used endothelial markers.

Size, shape, structure, and direction of angiogenesis in laryngeal tumour development

AIMS

Angiogenesis and vessel organisation in laryngeal tumour development and progression were examined to determine characteristics of biological and clinical relevance.

METHODS

Automated quantitative image analysis was performed on 1451 factor VIII (FVIII) associated blood vessels with regard to occurrence, structure, size, shape, and staining intensity, in addition to vessel direction.

RESULTS

Vessel numbers were increased in preneoplastic states and severe dysplasia, in addition to squamous cell carcinomas, being greater in poorly differentiated carcinomas. Small regular vessels predominated in benign conditions and large, irregular vessels in malignant neoplasms. Vessel distribution was related to degree of differentiation in squamous cell carcinomas, with circumferential angiogenesis occurring in well differentiated neoplasms, directional angiogenesis in moderately differentiated tumours, and aberrant angiogenesis in less well differentiated neoplasms. Alterations in vessel shape increased significantly with increasing degree of malignancy. Comparing the characteristics of individual vessels showed vessel shape abnormalities and the intensity of FVIII staining to increase with vessel size.

CONCLUSIONS

Increased angiogenesis was an early event in laryngeal tumour development, with vessel structure, size, and shape related to the tumour growth pattern and behaviour.

Polymorphisms of the interleukin 10 gene promoter in patients from Brazil with epidermodysplasia verruciformis

BACKGROUND

Epidermodysplasia verruciformis (EV) is a rare genetic disorder characterized by development of lesions associated with human papillomavirus in early childhood and malignant transformation in approximately half of individuals during adulthood. The persistence of human papillomavirus infection in EV is thought to be a result of an immunogenetic defect, which determines the generation of several cytokines capable of down-regulating cell-mediated immunity.

OBJECTIVE

We sought to study the prevalence of interleukin 10 (IL-10) promoter polymorphisms in skin biopsy specimens of patients with EV compared with DNA samples from healthy individuals. Patients and methods DNA samples extracted from normal skin of 22 patients from Brazil with EV and blood samples from 27 healthy Brazilian individuals were studied for IL-10 promoter polymorphisms using restriction fragment length polymorphism analysis.

RESULTS

The patients with EV showed an increased rate of low-production genotypes of IL-10 compared with control subjects (P =.003). Patients with EV and skin cancer were more likely to have low-production IL-10 genotypes than patients with benign forms of EV.

CONCLUSION

IL-10 genotypes associated with low levels of IL-10 production may have an important role in the pathogenesis of EV, including the susceptibility for development of skin cancer in patients with EV.

Effect of neoadjuvant chemoradiotherapy on angiogenesis in oesophageal cancer

Background

Vascular endothelial growth factor (VEGF) levels are raised in the serum of patients with oesophageal carcinoma. The aim of this study was to evaluate the tumour microvasculature and the role of tumour-associated macrophages in VEGF production after neoadjuvant chemoradiotherapy and surgery for oesophageal cancer.

Methods

Sections from 92 consecutively resected oesophageal tumours were stained for VEGF, von Willebrand factor and CD68. Twenty-seven patients received preoperative chemoradiation and 65 underwent surgical excision alone. The cellular source of VEGF was determined by parallel-section staining. Microvessel density and macrophage count were determined for each tumour by means of image analysis software.

Results

There were no significant differences between the two groups in age, sex or tumour type. Local downstaging of disease was evident in most specimens of tumours that had received preoperative chemoradiation. All tumours stained positive for VEGF, including those demonstrating a complete pathological response. Staining of parallel sections confirmed macrophages as the principal source of VEGF. Mean microvessel density was 6·4 per high-power field (h.p.f.) in tumours that received preoperative chemoradiation compared with 5·3 per h.p.f. in those treated by surgery alone (P = 0·130). A significant increase in tumour-associated macrophage infiltration was noted in tumours treated with neoadjuvant chemoradiation (22·1 per h.p.f.) compared with those treated by surgery alone (14·3 per h.p.f.) (P = 0·042).

Conclusion

Preoperative chemoradiation had little effect on the local angiogenic profile of the tumour in patients with oesophageal cancer. Tumour-infiltrating macrophages seem to be the source of persistent VEGF production after chemoradiotherapy and might explain the raised serum levels. Addition of an antiangiogenic agent to this regimen may be worthwhile in patients with oesophageal carcinoma.

Expression and prognostic relevance of vascular endothelial growth factor (VEGF) and its receptor (FLT-1) in nephroblastoma

AIMS

To investigate the prognostic relevance of vascular endothelial growth factor (VEGF) and its receptor Flt-1 in nephroblastoma and whether tumour microvessel density (MVD) immunoreactivity, determined by the CD31 antigen, is related to the expression of VEGF and Flt-1.

METHODS

The expression of VEGF and Flt-1 and MVD were investigated by means of immunohistochemical analysis in 62 Wilms's tumours. Patients were treated preoperatively with chemotherapy and had a mean follow up of 5.7 years.

RESULTS

In general, VEGF and Flt-1 were expressed in normal kidney parenchyma and to a variable extent in the three main components of Wilms's tumour, namely: the blastemal, epithelial, and stromal cells. In tumour tissue, 52% and 47% of blastemal cells were positive for VEGF and Flt-1, respectively. A non-significant correlation was found between the expression of VEGF and Flt-1 in blastemal and epithelial cells and the clinicopathological stage. MVD was significantly higher in VEGF and Flt-1 positive tumours than in VEGF and Flt-1 negative tumours. Univariate analysis showed that the expression of VEGF and Flt-1 in blastemal cells was indicative of clinical progression and tumour specific survival. In addition, MVD expression was indicative of clinical progression. Epithelial staining was of no prognostic value. In a multivariate analysis, VEGF protein expression by blastemal cells was an independent prognostic marker for clinical progression.

CONCLUSIONS

These results indicate that VEGF and Flt-1 protein expression are closely related to MVD and seem to be an important predictor for poor prognosis in treated patients with Wilms's tumour. Therefore, the expression of these molecules in primary Wilms's tumour may be useful in identifying those patients at high risk of tumour recurrence and in guiding antiangiogenic treatment.

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.

Up-regulation of matrix metalloproteinase 9 by thrombospondin 1 in gastric cancer

BACKGROUND

Matrix metalloproteinase 9 (MMP-9) plays a key role in tumor cell invasion. It was recently reported that plasma levels of MMP-9 in patients with gastric cancer correlate with the tumors' metastatic potential. We previously demonstrated that thrombospondin 1 (TSP-1) up-regulates MMP-9 expression by endothelial cells and promotes tumor cell invasion. We hypothesized that TSP-1 plays a role in the up-regulation of MMP-9 in gastric cancer.

METHODS

MMP-9, TSP-1, and CSVTCG-specific TSP-1 receptor expression were measured by immunohistochemical staining in 31 consecutive gastric adenocarcinomas from patients who did not undergo neoadjuvant chemotherapy or radiation therapy. Additionally, we measured TSP-1, CSVTCG-specific TSP-1 receptor, and MMP-9 expression by Western blotting, zymography, and immunohistochemical staining in AGS gastric adenocarcinoma cells. We also investigated the effect of TSP-1 on MMP-9 expression by AGS cells.

RESULTS

TSP-1 localized to the tumor-associated extracellular matrix. CSVTCG-specific TSP-1 receptor and MMP-9 colocalized to tumor cells, fibroblasts, and tumor-associated microvessels. Intense staining for TSP-1, CSVTCG-specific TSP-1 receptor, and MMP-9 correlated with markers of aggressive tumor behavior. AGS gastric adenocarcinoma cells expressed high levels of CSVTCG-specific TSP-1 receptor but not TSP-1. TSP-1 up-regulated MMP-9 expression by AGS cells.

CONCLUSIONS

We conclude that TSP-1 plays a role in the up-regulation of MMP-9 expression in gastric cancer. Our data also suggest a correlation between expression of TSP-1, CSVTCG-specific TSP-1 receptor, and MMP-9 and the acquisition of an aggressive tumor phenotype.

Anti-apoptotic signaling of pleiotrophin through its receptor, anaplastic lymphoma kinase

The secreted growth factor pleiotrophin (PTN) can induce mitogenesis in cells that express the receptor for this growth factor, anaplastic lymphoma kinase (ALK). Here we examine the ability of PTN to produce anti-apoptotic signals. We demonstrate that PTN is a survival factor for SW-13 epithelial cells and show that ribozyme-mediated depletion of ALK from SW-13 cells abolishes this effect of PTN. Furthermore, in serum-starved NIH3T3 fibroblasts PTN prevents apoptosis (measured by annexin V staining) with an EC(50) of 0.2 ng/ml and induces cell growth at higher concentrations of PTN. A polyclonal antibody against the PTN ligand-binding domain of the ALK receptor (alpha-LBD) was a partial agonist for ALK in NIH3T3 cells. This alpha-LBD antibody showed high agonist activity for anti-apoptosis (56 +/- 9% relative to PTN), low agonist activity for cell growth (21 +/- 1% relative to PTN), and was an antagonist of PTN-induced cell growth (61 +/- 2% inhibition). Both MAP kinase and phosphatidylinositol (PI) 3-kinase cascades in NIH3T3 cells were activated by PTN, and this effect persisted for up to 3 h. Surprisingly, the anti-apoptotic effect of PTN was completely blocked by the MAP kinase inhibitor UO126, but was not affected by the PI 3-kinase inhibitor LY294002. In contrast, PTN-dependent cell growth required both MAPK and PI 3-kinase activity. We conclude that anti-apoptotic signaling of PTN through ALK in NIH3T3 fibroblasts is via the MAP kinase pathway.

Vascular architecture, hypoxia, and proliferation in first-generation xenografts of human head-and-neck squamous cell carcinomas

PURPOSE

To quantify the physiologic status of human tumor cells in relation to the tumor vasculature.

METHODS AND MATERIALS

Fourteen tumors of 11 first-generation xenograft lines of human head-and-neck squamous cell carcinoma were injected with the hypoxic cell marker pimonidazole, the proliferation marker BrdUrd, and the perfusion marker Hoechst 33342. Consecutive tissue sections were processed with immunohistochemical methods and analyzed with image-analysis techniques.

RESULTS

Three different hypoxic patterns were found: patchy, ribbon-like, and mixed. An image-analysis method was developed to quantify these, and an elongation index (length/width) was calculated for hypoxia. The mean elongation indices ranged from 2.0 to 28.3 and showed a good correlation with the visual scoring of hypoxic patterns. Comparative analysis of hypoxic and proliferating cells in zones around the tumor vasculature showed the presence of both hypoxic and proliferating cells in all zones up to 250 microm from the vessels. The largest coexistence of hypoxic and proliferating cells seemed to occur at 50-100 microm from the vessels.

CONCLUSIONS

The three hypoxic patterns could be quantified by an elongation index, which is an additional parameter that allows distinction of tumors with similar fractions of hypoxic cells. The analysis of hypoxic and proliferating cells as a function of distance from the tumor vasculature indicates that proliferation does occur also at low oxygen tensions.

Quantitative evaluation of angiogenesis in laryngeal cancer by digital image measurement of the vessel density

OBJECTIVE

the aim of our study was determination of the relationship between angiogenesis and clinical as well as histological features in laryngeal cancer.

METHODS

we used two different methods of estimation of the amount of microvessels in the series of 55 cases, e.g. classical count of endothelial cells group (h-MVD) and digital image measurement of the vessel density (VD).

RESULTS

neither h-MVD nor VD correlated significantly with clinical features of the tumour. The results of VD examination correlated significantly with the existence of nodal metastases (P=0.02). The relationship between h-MVD and N status was on the statistical borderline (P=0.07). Multivariate analysis of Cox's proportional hazards model revealed that only N status correlated significantly with patients' survival.

CONCLUSION

our results indicate that measurements of angiogenesis in laryngeal cancer may be of some value in predicting N status in laryngeal cancer patients. This issue should be confirmed in prospective studies.

Tumor angiogenesis as a predictive marker for organ preservation in patients with advanced laryngeal carcinoma

BACKGROUND

The purpose of this study was to retrospectively investigate tumor angiogenesis as a predictive marker for response to neoadjuvant chemotherapy, organ preservation, and survival in patients with advanced laryngeal carcinoma.

METHODS

A total of 332 patients with stage III (188 patients) or stage IV (144 patients) squamous cell carcinoma of the larynx were entered in the prospective trial conducted by the Department of Veteran Affairs Laryngeal Cancer Study Group. Of this patient population, 20 pretreatment biopsy specimens were available from the chemotherapy arm for immunohistochemical analysis of Factor VIII expression. Two blinded investigators determined microvessel density in each patient by manual inspection of 10 high-power (400 x) fields (HPF).

RESULTS

The patients who had a partial response (>50% decrease in tumor volume) or complete response to chemotherapy had a mean value of 20.90 (+/- 8.09 standard deviation [SD]) blood vessels per HPF. Those who did not respond to chemotherapy and thus required a total laryngectomy had a mean value of 32.99 (+/- 10.10 SD) vessels per HPF. The difference of the means was statistically significant using a two-tailed t test (P < .0085). Kaplan-Meier survival curve analysis also revealed that patients with vessel counts above the mean tended to have poorer survival than those below the mean regardless of treatment selection. The most-vascular tumors, those greater than 1 SD above the mean, had a statistically significant difference in survival and laryngeal preservation (P = .0345).

CONCLUSIONS

These results indicate that tumor angiogenesis, as measured by number of vessels per HPF, was associated with decreased responsiveness to chemotherapy and radiation for larynx preservation. The most-vascular tumors also were associated with poorer survival than those with lesser degrees of angiogenesis.

Endoglin (CD105) expression in squamous cell carcinoma of the oral cavity

BACKGROUND

Increasing evidence suggests that endoglin (CD105) is a new powerful marker of neovascularization in solid malignancies. To explain the rating of CD105 expression in 51 squamous cell carcinoma of the oral cavity (SCCOC) we analyzed CD105 expression in tumor tissue and adjacent normal healthy mucosa.

METHODS

Mean CD105 density was quantitated by counting the number of CD105-immunostained blood vessels. The results were compared with clinical parameters like T and N stage, grading, tumor localization, and specific characteristics of patients by means of statistical analysis.

RESULTS

Endoglin expression in tumor tissue was significantly higher than in normal healthy mucosa (p <.001). With the exception of T3 (n = 2), a higher T stage was correlated with higher endoglin expression. No statistical correlation was found in the analysis of patient's age, gender, and tumor localization.

CONCLUSIONS

Endoglin expression is up-regulated in SCCOC compared with normal healthy oral mucosa. Endoglin may have a significant role in the development of SCCOC and might be relatively more specific than commonly used endothelial markers.

Clinical relevance of microvessel density in laryngeal squamous cell carcinomas

The clinical implications of microvessel density (MVD) in head and neck tumors have not been fully elucidated. We investigated the clinicopathologic correlates and prognostic relevance of MVD in a series of 122 consecutive patients with surgically treated laryngeal squamous cell carcinoma followed-up for a mean of 79 months. MVD was evaluated after CD34 immunostaining in 3 250x microscopic fields representative of the "hot spot" area, and expressed as the mean value of the vessel counts per millimeter squared. The overall median value of the intratumoral vessel count was 69.5/mm(2). In the 20 cases we analyzed, MVD increased significantly from normal to dysplastic mucosa and infiltrating carcinoma (p = 0.0001). Nineteen carcinomas (15.6%) had MVD values that were equal to or lower than the highest MVD value (52.7/mm(2)) observed in normal mucosa samples (in which the median MVD count was 34.5/mm(2), range 16.6-52.7/mm(2), mean 35.1 +/- 11.5/mm(2)) and were therefore considered poorly vascularized. Periodic acid-Schiff (PAS) staining revealed intratumoral PAS-positive connective tissue septa in 13 cases (10.7%). The patients with poorly vascularized tumors showed a tendency toward a better prognosis, but the anatomical site, tumor extension and clinical stage were the only variables significantly associated with disease-free and overall survival.

Angiogenesis is redundant for tumour growth in lymph node metastases

AIMS

Angiogenesis is essential for the growth of solid tumours. As the role of angiogenesis is unclear in the pathogenesis of primary lymph node (LN) tumours, we wondered whether neoangiogenesis was important in supporting and promoting the growth of tumours in LNs.

METHODS AND RESULTS

We investigated 16 cases of squamous carcinoma involving oral cavity (n=9) and larynx/pyriform fossa (n=7), all of whom had lymph node metastases. Sections of the primary tumour, uninvolved mucosa, metastatic LN and nonmetastatic LN were double-immunostained with factor VIII-related antigen and MIB-1. Proliferating blood vessels, i.e. neoangiogenesis, was identified by coexpression of factor VIII-related antigen-stained blood vessels and MIB-1 staining of the endothelial cell nuclei. Counts were performed in an area of 4 mm2. Primary tumours (127-188.7), uninvolved mucosa (54-84.5) and metastatic LNs (123.5-167) had significantly lower vessel counts than nonmetastatic LNs (194-253.9) (P=0.003; P < 0.001; P < 0.001, respectively). With regard to neoangiogenesis, primary tumours (1.7-5) had significantly higher counts than uninvolved mucosa (0-0.4), nonmetastatic LNs (0-0.4) and metastatic LNs (0.9-2.4) (P < 0.001; P < 0.001; P=0.047, respectively).

CONCLUSIONS

Our data suggest that because of the rich native vascularity of lymph nodes, neoangiogenesis is redundant for the growth of metastatic tumour.

Neoangiogenesis in squamous cell carcinoma of the larynx - biological and prognostic associations

Tumor angiogenesis has been related to tumor growth and an increased probability of metastatic spread. Previous studies have led to conflicting views regarding the prognostic significance of angiogenesis in squamous cell carcinoma of the head and neck. To evaluate the role of tumor angiogenesis in the biology of squamous cell carcinoma of the larynx, we quantified the microvascular network in 59 primary laryngeal carcinomas and looked for an association with outcome. Microvessels were stained immunohistochemically using antibodies for factor VIII-related antigen and the antibody JC70 (CD-31). In each case, microvessels were counted in three fields at x200 magnification, in areas of most intense neovascularization. We found a significantly higher number of microvessels in tumors showing deeper levels of invasion.

Vascular architecture and hypoxic profiles in human head and neck squamous cell carcinomas

Tumour oxygenation and vasculature are determinants for radiation treatment outcome and prognosis in patients with squamous cell carcinomas of the head and neck. In this study we visualized and quantified these factors which may provide a predictive tool for new treatments. Twenty-one patients with stage III-IV squamous cell carcinomas of the head and neck were intravenously injected with pimonidazole, a bioreductive hypoxic marker. Tumour biopsies were taken 2 h later. Frozen tissue sections were stained for vessels and hypoxia by fluorescent immunohistochemistry. Twenty-two sections of biopsies of different head and neck sites were scanned and analysed with a computerized image analysis system. The hypoxic fractions varied from 0.02 to 0.29 and were independent from T- and N-classification, localization and differentiation grade. No significant correlation between hypoxic fraction and vascular density was observed. As a first attempt to categorize tumours based on their hypoxic profile, three different hypoxia patterns are described. The first category comprised tumours with large hypoxic, but viable, areas at distances even greater than 200 micrometer from the vessels. The second category showed a typical band-like distribution of hypoxia at an intermediate distance (50-200 micrometer) from the vessels with necrosis at greater distances. The third category demonstrated hypoxia already within 50 micrometer from the vessels, suggestive for acute hypoxia. This method of multiparameter analysis proved to be clinically feasible. The information on architectural patterns and the differences that exist between tumours can improve our understanding of the tumour micro-environment and may in the future be of assistance with the selection of (oxygenation modifying) treatment strategies.

Intratumoral microvessel density predicts local treatment failure of radically irradiated squamous cell cancer of the oropharynx

PURPOSE

To determine the predictive value of intratumoral microvessel density (IMD), and of the expression of p53, vascular endothelial growth factor (VEGF) and thrombospondin-1 (TSP-1) for the radiocurability of patients with squamous cell cancer of the oropharynx.

MATERIALS AND METHODS

139 patients with squamous cell cancer of the oropharynx were radically irradiated (median dose, 74 Gy) between 1991 and 1997. Biopsies from 100 patients were processed for immunohistochemistry. IMD was determined in hot spot areas of tissue stained with anti-CD31 at a magnification of x200. Staining for p53 was considered positive if more than 10% of the cell nuclei overexpressed the protein. Immunostaining of VEGF and TSP-1 was assessed semiquantitatively.

RESULTS

Increasing IMD (range, 54-282) was strongly correlated with incomplete remission of both the primary tumors (p = 0.01) and lymph node metastases (p = 0.02). Moreover, multivariate Cox regression analysis revealed local failure-free survival to decline with increasing IMD (IMD continuous: risk ratio = 1.01 per increase of 1 microvessel, p = 0. 0001; IMD categorical: </= 80: baseline, 81-110: risk ratio = 2.71, 111-130: risk ratio = 4.55, > 130: risk ratio = 13.01). Neither the expression of p53, nor that of VEGF or TSP-1 was associated with the treatment outcome or IMD, but VEGF and TSP-1 expression were positively correlated (p = 0.02).

CONCLUSION

IMD represents a powerful and independent predictive factor for local treatment failure in radically irradiated patients with squamous cell cancer of the oropharynx.

Metalloproteinase-9 immunoexpression and angiogenesis in thyroid follicular neoplasms: relation to clinical and histopathologic features

BACKGROUND

Thyroid follicular neoplasms (adenoma and carcinoma) may pose considerable difficulties to the differential diagnosis. Because such a distinction is not possible at fine-needle aspiration, surgery is often necessary. Clinical information such as age, sex, and node size is important in case of suspected carcinoma. Follicular carcinoma is characterized by capsular invasion, vascular invasion, and metastatic dissemination mainly by the hematogenic pathway. This invasion depends on collagen degradation in capsule and in subendothelial basement membrane. Collagen degradation has been widely researched in the angiogenesis process and in the hematogenic dissemination mechanism. In this study, we performed clinical and histopathologic assessment of 74 follicular neoplasms, as well as immunohistochemical reactions for CD-34 protein to estimate angiogenesis and for metalloproteinase-9, an enzyme that degrades type IV collagen.

METHODS

The research was carried out retrospectively in 74 patients who had surgery and were followed up at HC-FMUSP and IBCC. Clinical, histologic, and immunohistochemical variables were compared among the groups of follicular neoplasms and a control group of 36 patients with colloid goiter.

RESULTS

No significant statistical difference was found between patients with follicular adenoma and thyroid follicular carcinoma concerning sex (p =.092), age (p =.098), thyroid node size (p =.426), vascularization (p =.388), and immunostaining intensity for metalloproteinase-9 (p =.055). The proportion of immunoreactive cells for metalloproteinase-9 in follicular carcinoma cases was higher than that observed in follicular adenoma cases (p <.001). Patients in more advanced stages of carcinoma were more than 45 years old (p =.006), presented extensive invasion (p <.001), had less vascularization (p =.046), and a had higher proportion of immunoreactive cells for metalloproteinase-9 (p <.001).

CONCLUSIONS

The proportion of immunoreactive cells for metalloproteinase-9 in follicular carcinoma was higher than that observed in follicular adenoma, with a significant statistical difference (p <.001). This method must be developed to apply in material obtained by fine-needle aspiration to differentiate follicular adenoma from carcinoma.

Identification of a peptide blocking vascular endothelial growth factor (VEGF)-mediated angiogenesis

Vascular endothelial growth factor (VEGF) binding to the kinase domain receptor (KDR/FLK1 or VEGFR-2) mediates vascularization and tumor-induced angiogenesis. Since there is evidence that KDR plays an important role in tumor angiogenesis, we sought to identify peptides able to block the VEGF-KDR interaction. A phage epitope library was screened by affinity for membrane-expressed KDR or for an anti-VEGF neutralizing monoclonal antibody. Both strategies led to the isolation of peptides binding KDR specifically, but those isolated by KDR binding tended to display lower reactivities. Of the synthetic peptides corresponding to selected clones tested to determine their inhibitory activity, ATWLPPR completely abolished VEGF binding to cell-displayed KDR. In vitro, this effect led to the inhibition of the VEGF-mediated proliferation of human vascular endothelial cells, in a dose-dependent and endothelial cell type-specific manner. Moreover, in vivo, ATWLPPR totally abolished VEGF-induced angiogenesis in a rabbit corneal model. Taken together, these data demonstrate that ATWLPPR is an effective antagonist of VEGF binding, and suggest that this peptide may be a potent inhibitor of tumor angiogenesis and metastasis.

Expression of basic fibroblast growth factor protein and its down-regulation by interferons in head and neck cancer

BACKGROUND

Angiogenesis is crucial for tumor growth and metastasis. In several tumors, microvascular density has been shown to correlate with metastasis and aggressiveness. Basic fibroblast growth factor (bFGF) has potent angiogenic activity and has been identified in a wide variety of malignancies including head and neck squamous cell carcinomas (HNSCC). Material and Methods Frozen sections of 50 HNSCC were immunostained for von Willebrand factor and bFGF. Microvessels were counted by light microscopy; bFGF expression was studied at the light and electron microscopic level. Laryngeal cancer cell line HlaC79 was incubated with interferon (IFN) alpha and beta. bFGF quantification was performed by ELISA, and antiproliferative effects were determined by BrdU assay.

RESULTS

The mean number of blood vessels (77.5 +/- 23.7) is significantly increased in HNSCC compared with controls (17.1 +/- 5.9). bFGF protein expression was detected in all HNSCC but not in control tissue. An correlation between bFGF expression and mean number of microvessels was found (p <.001). However, no correlation between bFGF expression and the main clinicopathologic features was shown. The long-term exposure (144 hr) of HNSCC cells to noncytostatic concentrations of IFN alpha and beta (>10 U/mL) down-regulated the protein production of bFGF.

CONCLUSION

bFGF expression and angiogenesis are enhanced in HNSCC. The higher microvessel density in HNSCC with strong bFGF expression supports the importance of bFGF for tumor angiogenesis. IFN alpha and beta treatment leads to a down-regulation of bFGF expression independent of their antiproliferative effects, suggesting that IFN treatment might result in a reduction of angiogenesis in HNSCC.

Role of angiogenic factors: coexpression of interleukin-8 and vascular endothelial growth factor in patients with head and neck squamous carcinoma

OBJECTIVE/HYPOTHESIS

Angiogenesis has been used as a prognostic indicator in a variety of cancers and is believed to be controlled by angiogenic factors, including the cytokines interleukin-8 (IL-8) and vascular endothelial growth factor (VEGF). We hypothesized that the in vivo coexpression of both IL-8 and VEGF in head and neck tumors contributes to perpetuating tumor growth and metastasis by enhancing angiogenesis.

METHODS

Immunohistochemical analysis for IL-8 and VEGF was performed using specimens from 33 cancer patients and 6 control patients. We quantitatively evaluated levels of IL-8 and VEGF in tumor tissue homogenates from those same patients using enzyme-linked immunosorbent assay and radioimmunoassay. Comprehensive histories of each patient were taken and later analyzed for clinical correlations with IL-8 or VEGF levels.

RESULTS

IL-8 and VEGF were found to be colocalized within the head and neck squamous cell carcinoma (HNSCCA) tumor cells. In the head and neck tumor specimens, IL-8 levels ([38,152+/-1.8]x10(5) pg/mg total protein [TP]) were 22-fold greater than controls (1,721+/-2,122 pg/mg TP). The tumor levels of VEGF (1,304+/-6,037 pg/mg TP) were nearly fourfold higher than the controls (317+/-400 pg/mg TP. Interleukin-8 and VEGF levels were found to have a positive correlation (P< or = .0001). Patients exhibiting high levels in picograms per milligram of TP and/or number of moles of IL-8 and VEGF were found to clinically have more aggressive disease manifested by higher TNM stage, more recurrences, and shorter disease-free intervals (P< or =.03)

CONCLUSIONS

Marked increase in HNSCCA of IL-8 and VEGF underscores the importance of these angiogenic factors in this disease. Understanding the roles and interplay of angiogenic factors such as IL-8 and VEGF may have value in the treatment of HNSCCA.

Neoangiogenesis and squamous cell carcinoma of the tongue

The relationship between neoangiogenesis and prognosis was investigated in 51 patients with surgically resected squamous carcinomas of the tongue. Twenty-six patients had lymph node metastases treated by radical neck dissection. Potential methodological sources of variation in vascular counts were examined. Vessels were immunolabeled for CD34, and the vessel counts (VC)--as well as the vessel counts adjusted for tumor area (VV)--were obtained in the most vascular parts of the carcinomas. Vascular hot spots were distributed throughout the carcinomas. The VC per hot spot increased with increasing size of carcinoma, and was higher in the resected carcinoma than in the diagnostic biopsy in four of eight cases. VC was not related to the growth pattern of the carcinoma or to metastasis, but patients with nodal metastases tended to have a lower VV than those with no metastases (p = 0.049). The tumor-specific survival of the whole group was 59%, and patients with nodal metastases had a shorter survival than those without metastases (p = 0.008). Cox's proportional hazards model demonstrated that carcinomas with a low VC tended to have a good prognosis (p = 0.023). The results from this relatively small series of cases support the hypothesis that some measures of neoangiogenesis are independent predictors of the spread and prognosis of lingual carcinomas. The variations in methodology among different studies currently preclude an accurate assessment of the prognostic significance of neoangiogenesis.

Angiogenesis vs. response after combined chemoradiotherapy of squamous cell head and neck cancer

Oxygen/drug supply to cancer cells is an important factor defining response to radiotherapy and chemotherapy. Although tumor angiogenesis is considered an important prognostic marker, its role in the outcome of chemotherapy and radiotherapy is unknown. In the present study we examined the possible correlation of the degree of angiogenesis with response to cytotoxic therapy in locally advanced squamous cell head and neck cancer (HNC). Vascular grade (VG) was assessed immunohistochemically using the JC70 monoclonal antibody (MAb) in tumor specimens from 76 patients treated with platinum/5-fluorouracil (with or without methotrexate) induction chemotherapy (ICT) (n = 37) or concurrent chemoradiotherapy (CCRT) with cisplatin or carboplatin (n = 39). Seventeen of 76 analyzed patients had an overall microvessel score of < 11 (VGI), 25/76 of 11-30 (VG2), 16/76 of 31-50 (VG3) and 18/76 of > 50 (VG4). Complete response rate after ICT or after CCRT was higher in cases with an intermediate vascularization (VG2,3). Both local relapse-free and overall survival were significantly better in the VG2 group. Patients treated with CCRT had a better survival compared to those treated with ICT. This was mainly observed in VG1 tumors. Multivariate analysis showed that VG and treatment modality were independent prognostic factors for local relapse and survival. Intratumoral angiogenesis correlation with the cytotoxic therapy outcome is likely to follow a bell-shaped relation, the response being better in cases with an intermediate VG. This may be the consequence of 2 vasculature-dependent factors, i.e., the drug/oxygen availability and the ability of cancer cells to undergo rapid repopulation in optimally oxygenated conditions. Our pilot study stresses the importance of individualization of therapy according to VG.

Neo-angiogenesis in locally advanced squamous cell head and neck cancer correlates with thymidine phosphorylase expression and p53 nuclear oncoprotein accumulation

Thymidine phosphorylase (Th.P) is an angiogenic factor shown to induce endothelial cell migration and proliferation. On the other hand, loss of wild type p53 function leads to down-regulation of thrombospondin-1, an inhibitor of angiogenesis. In this immunohistochemical study we investigated the intratumoural angiogenesis and thymidine phosphorylase (Th.P) expression in paraffin-embedded bioptical material from 104 locally advanced squamous cell head and neck cancers. The nuclear accumulation of mutant p53 protein and the cytoplasmic expression of bcl-2 protein was also assessed. High vascular grade was observed in 56% and high Th.P tumour cell reactivity in 48% of cases. High microvessel score was associated with an increased percentage of cancer cells expressing thymidine phosphorylase (P = 0.001). Increased p53 nuclear accumulation also correlated with high vascular grade (P = 0.001). High histological grade and absence of bcl-2 overexpression were associated with lymph node involvement (P = 0.002 and P = 0.02 respectively). No correlation of clinically detected lymphadenopathy with angiogenesis and p53 was observed. We conclude that intense neo-angiogenesis in locally advanced squamous cell head neck cancer is a frequent event, which is associated with nuclear p53 accumulation and thymidine phosphorylase overexpression.

Nodal metastases: predictive factors

Squamous cell carcinoma of the upper respiratory and digestive tract has a high risk for neck metastasis, which reduces the probability of regional control and survival. We analyzed the literature and our own experience to review the possible risk factors for the occurrence of metastasis. The most significant risk factors were: tumor site and size, grade of histologic differentiation, tumor thickness (tongue and floor of mouth carcinoma), vascular embolization, and perineural infiltration. A series of biomarkers has been studied over the last 10 years, but no one has proved to be significant enough for clinical use. Based on several multivariate analysis, it is recommended elective treatment of the neck for high-risk patients.

Mechanism of lymph node metastases: current concepts

Advances in head and neck surgical techniques with aggressive adjuvant treatment have reduced the incidence of locoregional failure in many types of head and neck cancer. Failure to control distant disease, however, remains of the most frustrating aspects in the care of these patients. A strong foundation in the biology of invasion and metastasis is necessary to understand more clearly the reasons for the development of distant and locally recurrent disease. This article focuses on basic mechanisms of invasion and metastasis in head and neck squamous cell carcinoma.