Angiogenesis in colorectal cancer: prognostic and therapeutic implications

Utility of CD34 in Assessing Microvessel Density and Its Correlation With Clinicopathological Parameters in Colorectal Carcinoma Patients

Currently, the most commonly practiced method of reporting cases of colorectal carcinoma is done according to guidelines provided by the College of American Pathologists (8th edition) and the Royal College of Pathologists (UK). These guidelines include various histopathological parameters like tumor site, extent, histologic type, grade, margins, tumor budding, lymphovascular invasion, and perineural invasion. However, in the present guidelines, the immunohistochemistry-based marker of mean vessel density (MVD) has not been addressed as an important parameter. The present study gives an overview of the importance of MVD. MVD was statistically significant when correlated with tumor size, lymph node metastasis, grade, and vascular invasion. However, no statistical significance was observed when compared with age, perineural invasion, and stage of the tumor.

Prognostic impact of chemerin expression in colorectal cancer: A detailed analysis based on histological components and meta-analysis

This study aimed to elucidate the clinicopathological significance of chemerin immunohistochemical expression in colorectal cancer (CRC) based on histologic components. Immunohistochemistry was performed to detect chemerin in 266 human CRC tissues. Correlation between chemerin expression, clinicopathological characteristics, and survival in CRC. A meta-analysis was performed to claify the prognostic role of chemerin tissue expression in malignant tumors. Chemerin was expressed in 125 of 266 CRC tissues (47.0 %) and was significantly correlated with distant metastasis (P = 0.012). However, no significant correlation was observed between chemerin expression and other clinicopathological parameters. Subgroup analyses based on histological components showed that chemerin expression was significantly higher in CRCs with the mucinous component than in those without the mucinous component (P 0.001). However, there was no significant correlation between chemerin expression and the micropapillary component. Patients with chemerin expression had worse overall and recurrence-free survival rates (P = 0.017 and P = 0.009, respectively). The prognostic significance of chemerin was found in CRCs without the mucinous component but not in those with the mucinous component. Chemerin expression was significantly correlated with poor survival in breast and ovarian cancers in the meta-analysis. Chemerin expression significantly correlated with distant metastasis and poor survival in CRCs. The predictive role of patient prognosis is useful for CRCs, especially those with no mucinous component.

Development and validation of a Super learner-based model for predicting survival in Chinese Han patients with resected colorectal cancer

OBJECTIVE

Improved prognostic prediction for patients with colorectal cancer stays an important challenge. This study aimed to develop an effective prognostic model for predicting survival in resected colorectal cancer patients through the implementation of the Super learner.

METHODS

A total of 2333 patients who met the inclusion criteria were enrolled in the cohort. We used multivariate Cox regression analysis to identify significant prognostic factors and Super learner to construct prognostic models. Prediction models were internally validated by 10-fold cross-validation and externally validated with a dataset from The Cancer Genome Atlas. Discrimination and calibration were evaluated by Harrell concordence index (C-index) and calibration plots, respectively.

RESULTS

Age, T stage, N stage, histological type, tumor location, lymph-vascular invasion, preoperative carcinoembryonic antigen and sample lymph nodes were integrated into prediction models. The concordance index of Super learner-based prediction model (SLM) was 0.792 (95% confidence interval: 0.767-0.818), which is higher than that of the seventh edition American Joint Committee on Cancer TNM staging system 0.689 (95% confidence interval: 0.672-0.703) for predicting overall survival (P < 0.05). In the external validation, the concordance index of the SLM for predicting overall survival was also higher than that of tumor-node-metastasis (TNM) stage system (0.764 vs. 0.682, respectively; P < 0.001). In addition, the SLM showed good calibration properties.

CONCLUSIONS

We developed and externally validated an effective prognosis prediction model based on Super learner, which offered more reliable and accurate prognosis prediction and may be used to more accurately identify high-risk patients who need more active surveillance in patients with resected colorectal cancer.

The regulatory mechanism and biological significance of the Snail-miR590-VEGFR-NRP1 axis in the angiogenesis, growth and metastasis of gastric cancer

Vascular endothelial growth factor receptor (VEGFR) and neuropilins (NRPs), a co-receptor of VEGF, play a key role in the formation and development of blood vessels and in tumour growth and metastasis. However, whether VEGFR1/2 and NRP1 are regulated by the same upstream mechanism is unclear, especially in gastric cancer. We used prediction tools to detect miRNAs that may simultaneously regulate VEGFR1/2 and NRP1, and we finally determined that miR-590 can simultaneously regulate VEGFR1/2 and NRP1 in gastric cancer. We discovered that miR-590 was downregulated in gastric cancer tissues and cell lines, and this was related to the dysregulation of the transcription factor SNAIL. In addition, the overexpression of miR-590 inhibits the migration, invasion, proliferation and D-MVA levels of gastric cancer cells in vivo and in vitro by targeting VEGFR1/2 and NRP1. We also demonstrated that miR-590 may be a useful marker for the prognosis of gastric cancer with Kaplan–Meier survival analysis. Since the epithelial-to-mesenchymal transition (EMT) is an important mechanism of tumour invasion and metastasis and VEGFR1/2 and NRP1 can promote the occurrence of EMT, we speculated that miR-590 can regulate the occurrence of EMT. Immunoblot and immunofluorescence analyses confirmed that the overexpression of miR-590 can inhibit the EMT in gastric cancer cells. Since SNAIL is also a mesenchymal marker, our results revealed a new, positive feedback loop. As a transcription factor, SNAIL inhibits the expression of miR-590, thereby upregulating the expression levels of NRP1 and VEGFR1/2; this leads to the development of EMT in gastric cancer and the upregulation of SNAIL.

Endothelial cells in colorectal cancer

The dependence of tumor growth on neovascularization has become an important aspect of cancer biology. Tumor angiogenesis is one of the key mechanisms of tumorigenesis, growth and metastasis. The key events involved in this process are endothelial cell proliferation, migration, and vascular formation. Recent studies have revealed the importance of tumor-associated endothelial cells (TECs) in the development and progression of colorectal cancer (CRC), including epithelial proliferation, stem cell maintenance, angiogenesis, and immune remodeling. Decades of research have identified that the molecular basis of tumor angiogenesis includes vascular endothelial growth factors (VEGFs) and their receptor family, which are the main targets of antiangiogenesis therapy. VEGFs and their receptors play key roles in the pathology of angiogenesis, and their overexpression indicates poor prognosis in CRC. This article reviews the characteristics of the tumor vasculature and the role of TECs in different stages of CRC and immune remodeling. We also discuss the biological effects of VEGFs and their receptor family as angiogenesis regulators and emphasize the clinical implications of TECs in clinical treatment.

A competing-risks nomogram for predicting probability of death from CRC in Chinese Han patients with Stage I-III CRC

Background

Many patients with colorectal cancer are elderly with competing comorbidities. When constructing nomogram for assessing survival, we should consider the influence of competing risk. A competing-risks nomogram was developed to estimate the probability of death due to colorectal cancer for patients after curative surgery.

Methods

A total of 2442 patients with non-metastatic colorectal cancer were included to develop competing-risks nomogram. Competing-risks nomogram were established based on the results of Fine and Gray competing-risks proportional hazards model. To maximize the accuracy of prediction, model selection was not carried out, and non-linear continuous variables were flexibly modeled with restricted cubic splines. The nomogram was internal-validated by bootstrapping, and externally validated with a separate database of 299 patients from The Cancer Genome Atlas. The performance of this model was assessed by concordance index and a calibration curve.

Results

There were 332 patients died of colorectal cancer and 46 died of other causes during the follow-up period. Age, T stage, N stage, histological type, tumor location, adjuvant chemotherapy, preoperative carcinoembryonic antigen, lymph vascular invasion, lymph node ratio and sample lymph nodes were integrated into competing-risks nomogram. The competing-risks nomogram for predicting probability of death due to colorectal cancer with a concordance index of 0.768, ameliorating the stratification provided by the seventh edition tumor-node-metastasis staging system of the American Joint Committee on Cancer (AJCC). The concordance index for validation dataset was 0.783.

Conclusion

We developed and externally validated a competing-risks nomogram for Chinese Han patients with non-metastatic colorectal cancer, which could provide probability of death from colorectal cancer in the presence of competing risks.

Microsatellite instability and manifestations of angiogenesis in stage IV of sporadic colorectal carcinoma

Angiogenesis represents one of the critical mechanisms that facilitates carcinoma development. The study objective was to evaluate whether the microsatellite instability of colorectal carcinoma has impact on the angiogenesis activity in liver metastases.In a cohort of 80 randomly selected patients with stage IV colorectal carcinoma, 30% were recognized as microsatellite unstable (Microsatellite instability high-frequency (MSI-H)). The endothelial progenitor cell fraction (CD309+) was counted within the subpopulation of CD34+CD45+ cell and CD34+CD45- cells by flow cytometer. vascular endothelial growth factor (VEGF) factor levels were quantified in serum samples by enzyme-linked immunosorbent assay (ELISA). A control group consisted of 36 healthy volunteers. The relationship of genomic instability to angiogenesis activity was evaluated by multivariate analysis in comparison to the controls, adopting a P < .05 value as statistically significant.The expression of endothelial progenitor cells (EPCs) and VEGF was significantly higher in MSI-H compared to both microsatellite stability (MSS) patients and healthy controls (P < .008). Multi-parametric analysis showed microsatellite instability (OR=9.12, P < .01), metastases in both lobes (OR = 32.83, P < .001) and simultaneous metastases outside liver (OR = 8.32, P < .01), as independent factors associated with increased angiogenesis as assessed by measures of EPC and VEGF. A higher percentage of EPCs within the white blood cell fraction (total % EPCs / white blood cells (WBC)) and higher serum concentrations of VEGF were present in patients with MSI-H colorectal cancer, and not with MSS cancers (P < .001).MSI-H patients with colorectal cancer metastases are associated with the overexpression of circulating EPCs and VEGF, potentially driving angiogenesis. This should be considered in therapeutic decision-making.

Correlation between vascular endothelial growth factor-A expression and tumor location and invasion in patients with colorectal cancer

Background

Vascular endothelial growth factor-A (VEGF-A) has been observed as the predominant angiogenic factor in colorectal cancer (CRC) and the assessment of microvessel density (MVD) has been used to quantify tumor neoangiogenesis. This study aimed to determine clinicopathological and prognostic significance of both angiogenic markers in the local CRC patients.

Methods

We analyzed tissue samples obtained from 81 cases with CRC. VEGF-A expression and MVD counts were immunohistochemically detected using anti VEGF-A and CD31. The assessments of both markers were classified as low and high. Correlation between VEGF-A expression and MVD value and clinicopathological characteristics were examined using Chi-square test. The overall survival (OS) was plotted using the Kaplan-Meier method.

Results

High VEGF-A expression was found more frequently in the rectal location (P=0.042) and T4 tumors (P=0.041) compared to their counterparts. Older patients tended to show a higher MVD value compared to younger cases (P=0.062). In addition, survival analysis showed that males had a worse OS compared to females (P=0.029), and VEGF-A expression and MVD count did not correlate with patients' survival.

Conclusions

There were significant differences of VEGF-A expression according to tumor location and T invasion. Sex, but not angiogenic markers, had an influence on the survival of CRC patients.

Warburg effect, lactate dehydrogenase, and radio/chemo-therapy efficacy

The anaerobic metabolism of glucose by cancer cells, even under well-oxygenated conditions, has been documented by Otto Warburg as early as 1927. Micro-environmental hypoxia and intracellular pathways activating the hypoxia-related gene response, shift cancer cell metabolism to anaerobic pathways. In the current review, we focus on a major enzyme involved in anaerobic transformation of pyruvate to lactate, namely lactate dehydrogenase 5 (LDH5). The value of LDH5 as a marker of prognosis of cancer patients, as a predictor of response to radiotherapy (RT) and chemotherapy and, finally, as a major target for cancer treatment and radio-sensitization is reported and discussed. Clinical, translational and experimental data supporting the uniqueness of the LDHA gene and its product LDH5 isoenzyme are summarized and future directions for a metabolic treatment of cancer are highlighted.

Development and validation of a nomogram for predicting survival in Chinese han patients with resected colorectal cancer

BACKGROUND

Estimates of survival after curative colorectal cancer (CRC) surgery are the basis of patient care and treatment planning. A nomogram is a useful tool for individualized cancer prognosis.

METHODS

A total of 2450 patients with nonmetastatic CRC were included to develop a nomogram. Prognostic factors were identified and integrated by the Cox proportional hazards model. Then, we developed and validated a prognostic nomogram. The performance of this model was assessed by the concordance index (C-index) and a calibration curve. The nomogram was internally validated by bootstrapping and externally validated with a separate database of 299 patients from The Cancer Genome Atlas.

RESULTS

Age, T stage, N stage, histological type, tumor location, lymph-vascular invasion, preoperative carcinoembryonic antigen, and sample lymph nodes were integrated into the nomogram. The C-index of the nomogram for predicting overall survival was higher than that of the seventh edition American Joint Committee on Cancer TNM staging system (training data set, 0.76 vs 0.68, respectively; P < 0.001; validation data set, 0.78 vs 0.69, respectively; P = 0.003).

CONCLUSION

We developed a prognostic nomogram for patients with nonmetastatic CRC, which could provide a more individualized outcome prognostication than that afforded by the TNM staging system by using common clinicopathologic factors.

Comparing laparoscopic surgery with open surgery for long-term outcomes in patients with stage I to III colon cancer

BACKGROUND

Although the short-term advantages of laparoscopy for colon cancer (CC) over open surgery have been clearly demonstrated, there is little evidence available concerning the long-term outcomes. This study aimed to compare the long-term results of laparoscopic surgery versus open surgery in a cohort of CC patients from a single center.

METHODS

A series of 443 patients consecutively operated on for stage I to III CC between January 2006 and December 2013 were followed up. Patients were divided into two groups according to the surgical technique and were compared for disease-free survival (DFS) and overall survival (OS) before and after 1:1 propensity score matching.

RESULTS

Due to exclusions and drop-outs, the statistical analysis of the study is based on 398 patients. Open surgery was performed in 133 patients, and laparoscopic surgery was performed in 265. After propensity score matching, two comparable groups of 89 patients each were obtained. The 5-year DFS was 64.3% and 78.2% for patients in the open and laparoscopic resection groups, respectively [hazard ratio (HR) 0.63, 95% confidence interval (CI) 0.33-1.19; P = 0.148]. A 5-year OS of 72.1% and 86.8% was observed in the open and laparoscopic resection groups, respectively (HR 0.43, 95%CI 0.20-0.94; P = 0.026). The multivariate survival analysis demonstrated better results of laparoscopy compared with open surgery for both DFS (HR 0.43, 95%CI 0.23-0.78; P = 0.004) and OS (HR 0.28, 95%CI 0.14-0.59; P < 0.001).

CONCLUSIONS

Despite the limitations of a retrospective analysis, our study confirms better results for laparoscopic surgery in terms of DFS and OS compared with open surgery in CC treatment.

Vascular Endothelial Growth Factor (VEGF) Polymorphisms and Serum VEGF Levels in Women With Epithelial Ovarian Cancer, Benign Tumors, and Healthy Ovaries

OBJECTIVE

This study analyzed the relation of 5 single-nucleotide polymorphisms (SNPs) in the VEGF (vascular endothelial growth factor) gene in patients with epithelial ovarian cancer (EOC), compared with patients carrying benign tumors or healthy ovaries. We studied serum VEGF levels and the relation with SNPs and association between VEGF SNPs and haplotypes with progression-free survival (PFS) in patients with cancer.

METHODS

The genotyping of VEGF gene polymorphisms (-2578 C/A, -1154 G/A, -460 T/C, +405 G/C, +936 C/T) was performed in DNA isolated from blood samples of 100 women. The different genotypes were evaluated by quantitative real-time polymerase chain reaction. Vascular endothelial growth factor protein concentration was assessed in serum using solid-phase sandwich enzyme-linked immunosorbent assay.

RESULTS

We found statistically significant differences in the distribution of VEGF genotypes among the 3 groups of patients: -2578 C/A between those with EOC and healthy ovary (P = 0.04), -460 T/C between those with EOC and healthy ovary (P = 0.03), and -460 T/C between those with benign tumors and healthy ovary (P = 0.02). Vascular endothelial growth factor serum levels were analyzed in patients with EOC. Higher levels were found in patients with clear cell carcinoma compared with those with serous, mucinous, or endometrioid tumors (P < 0.05). No clear association was observed between VEGF SNPs and serum VEGF levels. There was no significant correlation between VEGF SNPs and PFS. In haplotype analysis, CGTCT and CGTGT showed worse prognosis without reaching the statistical significance. CGCGC and AGTGC haplotypes had statistically significant differences among patients with EOC, benign tumors, and healthy ovaries (Ps = 0.046 and 0.041, respectively).

CONCLUSIONS

The distribution of VEGF genotypes was different in patients with EOC, compared with those with benign tumors or women with healthy ovaries. Vascular endothelial growth factor serum levels were higher in patients with clear cell carcinoma. No correlation was found with improved PFS, but CGTCT and CGTGT haplotypes showed worse prognosis.

VEGFR2 regulates endothelial differentiation of colon cancer cells

Background

Recent studies suggested that cancer stem-like cells contribute to tumor vasculogenesis by differentiating into endothelial cells. However, such process is governed by still undefined mechanism.

Methods

At varying differentiation levels, three representative colon cancer cells were cultured in endothelial-inducing conditioned medium: human colon cancer cells HCT116 (HCT116) (poorly differentiated), SW480 (moderately differentiated), and HT29 (well differentiated). We tested for expression of endothelial markers (cluster of differentiation (CD) 31, CD34, and vascular endothelial (VE)-cadherin and their ability to form tube-like structures in 3D culture. We also observed VEGF secretion and expressions of endothelial markers and VEGFRs in HCT116 cells under hypoxia to simulate physiological conditions. In in vitro and in xenotransplantation experiments, VE growth factor receptor 2 (VEGFR2) antagonist SKLB1002 was used to test effect of VEGFR2 in endothelial differentiation of HCT116 cells. Expression levels of VEGFR2 and VE-cadherin were assessed by immunohistochemistry of human colon cancer tissues to evaluate clinicopathological significance of VEGFR2.

Results

After culturing in endothelial-inducing conditioned medium, poorly differentiated HCT116 cells expressed endothelial markers and formed tube-like structure in vitro. HCT116 cells secreted more endogenous VEGF and expressed higher VEGFR2 under hypoxia. SKLB1002 impaired endothelial differentiation in vitro and xenotransplantation experiments, suggesting a VEGFR2-dependent mechanism. Increased expression of VEGFR2 correlated with differentiation, metastasis/recurrence, and poor prognosis in 203 human colon cancer samples. Positive correlation was observed between VEGFR2 and VE-cadherin expression.

Conclusions

VEGFR2 regulates endothelial differentiation of colon cancer cell and may be potential platform for anti-angiogenesis cancer therapy.

Predictive clinical model of tumor response after chemoradiation in rectal cancer

Survival improvement in rectal cancer treated with neoadjuvant chemoradiotherapy (nCRT) is achieved only if pathological response occurs. Mandard tumor regression grade (TRG) proved to be a valid system to measure nCRT response. The ability to predict tumor response before treatment may significantly have impact the selection of patients for nCRT in rectal cancer. The aim is to identify potential predictive pretreatment factors for Mandard response and build a clinical predictive model design. 167 patients with locally advanced rectal cancer were treated with nCRT and curative surgery. Blood cell counts in peripheral blood were analyzed. Pretreatment biopsies expression of cyclin D1, epidermal growth factor receptor (EGFR), vascular endothelial growth factor (VEGF) and protein 21 were assessed. A total of 61 single nucleotide polymorphisms were characterized using the Sequenom platform through multiplex amplification followed by mass-spectometric product separation. Surgical specimens were classified according to Mandard TRG. The patients were divided as: "good responders" (Mandard TRG1-2) and "poor responders" (Mandard TGR3-5). We examined predictive factors for Mandard response and performed statistical analysis. In univariate analysis, distance from anal verge, neutrophil lymphocyte ratio (NLR), cyclin D1, VEGF, EGFR, protein 21 and rs1810871 interleukin 10 (IL10) gene polymorphism are the pretreatment variables with predictive value for Mandard response. In multivariable analysis, NLR, cyclin D1, protein 21 and rs1800871 in IL10 gene maintain predictive value, allowing a clinical model design.

CONCLUSION

It seems possible to use pretreatment expression of blood and tissue biomarkers, and build a model of tumor response prediction to neoadjuvant chemoradiation in rectal cancer.

Targeted therapies for colorectal cancer: Current status and future perspectives

Colorectal cancer (CRC) is a common malignant tumor of the digestive system. At present, traditional chemotherapy is often combined with targeted drugs to treat patients with metastatic colon cancer, in order to increase the response rate, prolong the progression free survival and overall survival, and improve the quality of life of patients. In this paper, we describe the molecular targets for targeted therapy of CRC and their distribution in CRC, which include vascular endothelial growth factor, epidermal growth factor receptor, cyclooxygenase-2, matrix metalloproteinase, receptor tyrosine kinase, PD-1/PD-L1, RAS, BRAF and so on. In addition, we review current targeted therapies for CRC, including antibody drugs, small molecule targeted drugs, fusion proteins, immune therapy and so on. This paper will provide a reference for individualized treatment of CRC.

5-Fluorouracil inhibits cell migration by induction of Sestrin2 in colon cancer cells

5-Fluorouracil (5-FU) is a chemotherapeutic agent used in the treatment of colorectal cancer. In this study, we investigated whether 5-FU induces Sestrin2 (SESN2), an antioxidant enzyme, and the role of SESN2 in 5-FU action in colon cancer cells. We found that 5-FU upregulated SESN2 protein expression in both HCT116 and HT29 cells. It also increased transcripts of SESN1 and SESN2, but not of SESN3. Furthermore, we investigated whether production of reactive oxygen species (ROS) was involved in 5-FU-induced SESN2 expression. 5-FU did not increase ROS production nor affect Nrf2 phosphorylation and expression levels. Moreover, SESN2 upregulation by 5-FU was not prevented by pretreatment with antioxidants. Next, we investigated p53 levels after 5-FU treatment to elucidate the regulation of SESN2 by 5-FU. An increase in p53 levels was detected following 5-FU treatment; pifithrin-α, an inhibitor of p53 activation, reversed 5-FU-induced SESN2 expression. 5-FU prevented serum-induced in vitro cell migration, but knockdown of SESN2 or treatment with pifithrin-α reversed a 5-FU-mediated decrease in cell migration. Taken together, our results suggest that 5-FU increases SESN2 levels via a p53-dependent pathway, which contributes to inhibition of cancer cell migration in vitro.

Sestrin2 inhibits hypoxia-inducible factor-1α accumulation via AMPK-mediated prolyl hydroxylase regulation

Sestrin2 (SESN2) is an antioxidant protein that modulates cellular redox homeostasis through regeneration of peroxiredoxins. It has beneficial effects in oxidative or metabolic stress conditions as an upstream regulator of AMP-activated protein kinase (AMPK). Since hypoxia causes oxidative and metabolic stress, this study investigated the effect of SESN2 on signaling pathways altered by hypoxia in colon cancer cells. SESN2 overexpression in HEK293 cells inhibited hypoxia-inducible factor-1α (HIF-1α), which plays a crucial role in tumor growth and development in hypoxia. Moreover, infection with adenovirus-SESN2 (Ad-SESN2) decreased hypoxia or CoCl₂-induced HIF-1α accumulation in colorectal cancer cells. Ad-SESN2 also reduced CoCl₂-induced hypoxia response element (HRE)-luciferase activity and mRNA level of HIF-1α-driven genes. Furthermore, Ad-SESN2 infected cells showed anti-metastatic effects in serum-induced cell migration and invasion in vitro. Ad-SESN2 facilitated the ubiquitination of HIF-1α protein and increased hydroxyl-HIF-1α (OH-HIF-1α) level. In contrast, treatment with dimethyloxalylglycine (DMOG), an inhibitor of prolyl hydroxylase (PHD), reversed Ad-SESN2-induced OH-HIF-1α and subsequently suppressed HIF-1α level. The inhibitory effects of SESN2 on the serum-induced in vitro cell migration and invasion were also abrogated by DMOG treatment. Furthermore, knockdown of AMPKα reversed Ad-SESN2-mediated increase of OH-HIF-1α and inhibition of HIF-1α. Dominant-negative form of AMPK also restored the Ad-SESN2 mediated decrease in HIF-1α accumulation. Lastly, Ad-SESN2 suppressed tumor growth in a mouse xenograft model. Taken together, these results suggest that SESN2 increases degradation of HIF-1α via AMPK-PHD regulation that contributes to inhibition of in vitro and in vivo tumorigenesis.

Nomograms for predicting prognostic value of inflammatory biomarkers in colorectal cancer patients after radical resection

Increasing evidence indicates that inflammation plays a vital role in tumorigenesis and progression. However, the prognostic value of inflammatory biomarkers in colorectal cancer (CRC) has not been established. In this study, a retrospective analysis was conducted in patients with CRC in Fudan University Shanghai Cancer Center (FUSCC) between April 1, 2007 and April 30, 2014, and 5,336 patients were identified eligible. Neutrophil-to-lymphocyte ratio (NLR), platelet-to-lymphocyte ratio (PLR), lymphocyte-to-monocyte ratio (LMR), and albumin/globulin ratio (AGR) were analyzed. Kaplan-Meier analysis was used to calculate the 5-year overall survival (OS) and disease-free survival (DFS). Cox regression analysis was performed to assess the prognostic factors. Nomograms were established to predict OS and DFS, and Harrell's concordance index (c-index) was adopted to evaluate prediction accuracy. As results, the 5-year OS was 79.2% and the 5-year DFS was 56.0% in the cohort. Patients were stratified into 2 groups by NLR (≤2.72 and >2.72), PLR (≤219.00 and >219.00), LMR (≤2.83 and >2.83) and AGR (<1.50 and ≥1.50). Patients with NLR > 2.72, PLR > 219.00, LMR ≤ 2.83 and AGR < 1.50 were significantly associated with decreased OS and DFS (p < 0.001). Multivariate analysis indicated that NLR, LMR and AGR were independent factors of OS (p = 0.047, p = 0.008 and p < 0.001, respectively) and DFS (p = 0.009, p < 0.001 and p = 0.008, respectively). In addition, nomograms on OS and DFS were established according to all significant factors, and c-indexes were 0.765 (95% CI: 0.744-0.785) and 0.735 (95% CI: 0.721-0.749), respectively. Nomograms based on OS and DFS can be recommended as practical models to evaluate prognosis for CRC patients.

Locally advanced rectal cancers with simultaneous occurrence of KRAS mutation and high VEGF expression show invasive characteristics

In this study, we investigated the mutation status of KRAS gene in pretherapeutic and preoperative biopsies in 63 specimens of locally advanced rectal cancers in order to evaluate its potential predictive and/or prognostic role. Regions of interest of KRAS exon 2 were amplified and visualized on 2% agarose gel. Obtained PCR products were subjected to direct sequencing. KRAS mutations were detected in 35% of patients, 91% of which were located in codon 12 and 9% in codon 13. In general, KRAS mutation status did not affect the response to neoadjuvant chemoradiotherapy (CRT). However, patients harboring mutated KRAS gene, simultaneously with high vascular endothelial growth factor (VEGF) expression, exhibited a worse response to CRT (p=0.030), a more frequent appearance of local recurrences and distant metastasis (p=0.003), and shorter overall survival (p=0.001) compared to all others. On the contrary, patients with GGT>GCT KRAS mutation exhibited a significantly better response to CRT than those with any other type of KRAS mutation (p=0.017). Moreover, the presence of GGT>GCT mutation was associated with low VEGF and Ki67 expression (p=0.012 in both cases), parameters related to less aggressiveness of the disease. Our results suggest that KRAS mutation status could have some predictive and prognostic importance in rectal cancer when analyzed together with other parameters, such as VEGF and Ki67 expression. In addition, it seems that not only the presence but the type of KRAS mutation is important for examining its impact on CRT response.

Clinicopathological significance of vascular endothelial growth factor, thymidine phosphorylase and microvessel density in colorectal cancer

Colorectal cancer is a common malignant disease, the incidence of which is increasing worldwide, therefore, identifying novel prognostic factors to improve adjuvant therapeutic strategies or postoperative monitoring is required. Angiogenesis, which is assessed by microvessel density (MVD), is significant in tumor growth and metastasis. However, the association between angiogenesis and clinical outcome remains controversial. In the present study, 84 surgically resected cases of colorectal cancer were examined to clarify the clinicopathological significance of vascular endothelial growth factor (VEGF), thymidine phosphorylase (TP) and cluster of differentiation (CD)34 expression levels. VEGF expression was identified to be significantly correlated with TP expression (r=0.45; P<0.0001) and MVD in the high VEGF expression group was observed to be significantly greater than that in the low VEGF expression group (P=0.0194). In the Dukes' stage D group, the MVD in the high TP expression group was significantly greater than that in the low TP expression group (P=0.0149). High VEGF expression was subsequently correlated with a short overall survival rate for patients exhibiting lymph node metastasis (P=0.0128); however, there was no significant difference in overall survival rate regarding the expression levels of TP and CD34. The results of the present study indicate that VEGF expression may serve as a prognostic factor for colorectal cancer patients exhibiting lymph node metastasis. Furthermore, angiogenesis, as assessed by MVD, is an important prognostic factor for tumor growth at the primary site.

Inflammation-based factors and prognosis in patients with colorectal cancer

Several parameters for predicting survival in patients with colorectal cancer have been identified, including the performance status, age, gender and tumor-node-metastasis (TNM) stage. Although the TNM stage is important and useful for predicting the prognosis and determining the appropriate treatment, it is well known that the survival time varies widely, even in patients with the same stage of disease. Therefore, the identification of new parameters capable of more precisely predicting patient survival is needed to help select the optimal treatment, especially in patients in the advanced stage of disease. Although the TNM stage reflects the tumor characteristics, cancer progression and survival are not determined solely based on the local characteristics of the tumor, but also the host systemic immune/inflammatory response. Therefore, using a combination of parameters that reflect both tumor characteristics and the host systemic inflammatory status is thought to be important for accurately predicting patient survival.

X-box binding protein 1 (XBP-1) enhances colorectal cancer cell invasion

In this study, we investigated the role of X-box binding protein 1 (XBP-1) and vascular endothelial growth factor receptor-2 (VEGF-R2) signalling in colorectal cancer (CRC) cells invasion by evaluating their extent of activation in CRC tissues and cell lines using immunohistochemistry, western blotting, and invasion assays. Results showed that XBP-1 is expressed at high levels in metastatic and poorly differentiated tissue samples, whereas it appeared relatively low in moderately and well-differentiated tissue samples compared to those in normal colon tissue. The XBP-1 immunoreactivity score (IRS) was positively associated with increasing tumour invasion. In vitro studies showed that overexpression of XBP-1 promoted cancer cell invasion, which was suppressed by inhibition of XBP-1 using small interfering RNA molecules (siRNA). Inhibition of XBP-1 expression significantly decreased levels of VEGF-R2.In conclusion, XBP-1 might be regarded as a novel predictive biomarker in CRC invasion and metastasis.

Circulating endothelial cells and their subpopulations: role as predictive biomarkers in antiangiogenic therapy for colorectal cancer

Several anticancer therapies have been developed to block angiogenesis, a key mechanism in tumor growth and metastasis. The predominantly cytostatic action of these compounds makes an assessment of their clinical activities inadequate if based only on the reduction of the tumor dimensions, as this may not reflect their true biologic efficacy. Thus, it is crucial to identify biomarkers that permit the recognition of potentially responsive subjects and to spare toxicity in those who are unlikely to benefit from treatment. Circulating endothelial cells (CECs) have been recently indicated as potential surrogate biomarkers of angiogenesis in several types of cancer. The possibility of rapidly quantifying these cells represents a promising tool for monitoring the clinical outcome of tumors with the potential to assess response to various treatments. However, the identification and quantification of CECs is technically difficult and not well standardized. A variety of methods to detect CECs in patients with solid tumors have been used; these are based on different technical approaches, combinations of surface markers, sample handling, and staining protocols. With an expanding interest in the field of potential clinical applications for CECs in oncology, the development of standardized protocols for analysis is mandatory. The aim of this review was to critically summarize the available data concerning the clinical value of CECs and their subpopulations as biomarkers of antiangiogenic therapy in patients with metastatic colorectal cancer.

Over-expression of beclin-1 in gallbladder carcinoma and its relationship with prognosis

AIM OF THE STUDY

We determined the expression of beclin-1 in gallbladder carcinoma, analyzed the association of beclin-1 expression with clinicopathologic parameters and prognosis, and investigated the relationship between microvessel density and beclin-1 expression.

MATERIAL AND METHODS

Tissue microarray blocks containing 118 primary gallbladder tumor sites were used. Clinical parameters and prognostic data were collected. Expression of beclin-1 in these specimens was analyzed by immunohistochemical studies and confirmed by Western blotting. Microvessel density was counted using immunohistochemical staining.

RESULTS

The overall rate of over-expression of beclin-1 was 68.1% (80 of 118). Over-expression of beclin-1 was significantly associated with TNM stage and liver metastasis. Over-expression of beclin-1 has no significant relationship with age, sex, lymphatic metastasis, or tumor differentiation. Based on the Kaplan-Meier method, over-expression of beclin-1 showed no significant difference for the overall survival rate in patients with gallbladder cancer. The multivariate Cox regression analysis demonstrated that beclin-1 was not an independent prognostic factor for gallbladder cancer.

CONCLUSIONS

Beclin-1 might play roles in the development of gallbladder cancer. However, beclin-1 may not be an effective prognostic factor for gallbladder cancer.

Targeting angiogenesis and tumor microenvironment in metastatic colorectal cancer: role of aflibercept

In the last decades, we have progressively observed an improvement in therapeutic options for metastatic colorectal cancer (mCRC) treatment with a progressive prolongation of survival. mCRC prognosis still remains poor with low percentage of 5-year survival. Targeted agents have improved results obtained with standard chemotherapy. Angiogenesis plays a crucial role in colorectal cancer growth, proliferation, and metastasization and it has been investigated as a potential target for mCRC treatment. Accordingly, novel antiangiogenic targeted agents bevacizumab, regorafenib, and aflibercept have been approved for mCRC treatment as the result of several phase III randomized trials. The development of a tumor permissive microenvironment via the aberrant expression by tumor cells of paracrine factors alters the tumor-stroma interactions inducing an expansion of proangiogenic signals. Recently, the VELOUR study showed that addition of aflibercept to FOLFIRI regimen as a second-line therapy for mCRC improved significantly OS, PFS, and RR. This molecule represents a valid second-line therapeutic option and its peculiar ability to interfere with placental growth factor (PlGF)/vascular endothelial growth factor receptor 1 (VEGFR1) axis makes it effective in targeting angiogenesis, inflammatory cells and in overcoming resistances to anti-angiogenic first-line treatment. Here, we discuss about Aflibercept peculiar ability to interfere with tumor microenvironment and angiogenic pathway.

Over-expression of survivin and VEGF in small-cell lung cancer may predict the poorer prognosis

The expression of survivin, an inhibitor of apoptosis can be seen in most tumors and is correlated with the angiogenic factor vascular endothelial growth factor (VEGF). But little is known about their contribution in small-cell lung cancer (SCLC). This study was designed to investigate the expression of survivin and VEGF in SCLC, and to explore their correlation with clinical-pathological feature and prognosis. Forty-five patients with pathological histology of SCLC were entered into this study. Forty-five cases of matched adjacent non-tumor samples and 10 samples of operated patients with benign lung tumor were also included as control. The expression of survivin and VEGF was detected by immunohistochemistry (IHC, SP). These two sets of data were processed and tested for correlation with major patients' characteristics, and overall survival. The correlations between survivin and VEGF expressions and the clinical-pathological features were evaluated by chi-square test. The correlation between survivin and VEGF expressions was analyzed by Spearman's rank correlation test; the overall survival was analyzed by the Kaplan-Meier method; and the relationship between clinical and pathological features and overall survival was analyzed by the Cox proportional hazard models. Positive expression rate of survivin and VEGF was significantly higher in SCLC than those of adjacent non-tumor tissues and benign lung tumor tissues (73.3 vs. 15.6 vs. 0 %, P < 0.05) and (75.6 vs. 20 vs. 0 %, P < 0.05), respectively. Survivin and VEGF expressions were significantly associated with lymph node metastasis (P = 0.003, 0.011) and clinical stage (P = 0.006, 0.021). The expression of survivin was significantly coincident with the expression of VEGF (r = 0.644, P = 0.000). The median overall survival in survivin positive group and VEGF positive group was significantly shorter than those in survivin negative and VEGF negative group, respectively (log-rank P = 0.000). Moreover, multivariate analysis showed that survivin expression (HR 0.224; 95 % CI 0.074-0.675; P = 0.008) and VEGF expression (HR 0.172; 95 % CI 0.054-0.559; P = 0.003) were statistically independent predictive factors of poorer prognosis for SCLC patients. Our results indicated that survivin and VEGF were over-expressed in small-cell lung cancer, each of them may be an independent poor prognostic factor.

The detection and role of lymphatic and blood vessel invasion in predicting survival in patients with node negative operable primary colorectal cancer

Although vascular invasion in colorectal cancer has been recognised since 1938, detection methods and results remain inconsistent. Vascular invasion is currently an independent prognostic factor in colorectal cancer influencing disease progression and survival. The vascular system consists of three components, arterial, venous and lymphatic vessels, all of which can be invaded but accurate distinction between the components remains difficult with routine staining techniques. Even though higher detection rates with elastica staining, for large vessel invasion, and recent techniques for immunohistochemistry for small vessel invasion, have been reported, a standardised method of detection has not been agreed upon which is reflected in the variability of published results. As a result of the Bowel Cancer Screening Programme in the UK it will be necessary to attempt to identify and stratify patients better, to be able to handle the stage migration to early node negative colorectal cancer. At present up to a third of patients, with node-negative colorectal cancer on conventional histopathological analysis, ultimately die of recurrent disease. It is therefore important to develop and standardised methods to identify lymphatic and blood vessel invasion which will influence ultimate survival. The present review summarises the current status of detection methods for these components of vascular invasion.

Prognostic significance of immunohistochemical expression of the angiogenic molecules vascular endothelial growth factor-A, vascular endothelial growth factor receptor-1 and vascular endothelial growth factor receptor-2 in patients with classical Hodgkin lymphoma

Angiogenesis leads to new blood vessel formation and is implicated in both physiological and pathological situations. The vascular endothelial growth factor (VEGF) family is the major mediator of this process. The aim of our study was to evaluate the expression of VEGF-A, vascular endothelial growth factor receptor-1 (VEGFR-1) and VEGFR-2 and their correlation with clinicopathological parameters and prognosis in patients with classical Hodgkin lymphoma (cHL), since the role of angiogenesis in this tumor still remains unclear. The immunohistochemical expression of VEGF-A, VEGFR-1 and VEGFR-2 was examined in 194 patients with cHL. The neoplastic Hodgkin Reed-Sternberg (HRS) cells expressed VEGF-A, VEGFR-1 and VEGFR-2 in 90.3%, 97.2% and 94.1% of cases, respectively. Only the expression of VEGFR-2 was positively correlated with serum albumin levels ≥ 4 g/dL. No correlation with patient outcome was observed. All three molecules were statistically correlated with ramifications of blood vessels. Summarizing, our results are not sufficient to consider VEGF-A and/or VEGF receptors as prognosticators in cHL.

Individualized therapy for metastatic colorectal cancer

Systemic therapeutic efficacy is central to determining the outcome of patients with metastatic colorectal cancer (CRC). In these patients, there is a critical need for predictive biomarkers to optimize efficacy whilst minimizing toxicity. The integration of a new generation of molecularly targeted drugs into the treatment of CRC, coupled with the development of sophisticated technologies for individual tumours as well as patient molecular profiling, underlines the potential for personalized medicine. In this review, we focus on the latest progress made within the genomic and proteomic fields, concerning predictive biomarkers for individualized therapy in metastatic CRC.

Complement inhibition in cancer therapy

For decades, complement has been recognized as an effector arm of the immune system that contributes to the destruction of tumor cells. In fact, many therapeutic strategies have been proposed that are based on the intensification of complement-mediated responses against tumors. However, recent studies have challenged this paradigm by demonstrating a tumor-promoting role for complement. Cancer cells seem to be able to establish a convenient balance between complement activation and inhibition, taking advantage of complement initiation without suffering its deleterious effects. Complement activation may support chronic inflammation, promote an immunosuppressive microenvironment, induce angiogenesis, and activate cancer-related signaling pathways. In this context, inhibition of complement activation would be a therapeutic option for treating cancer. This concept is relatively new and deserves closer attention. In this article, we summarize the mechanisms of complement activation on cancer cells, the cancer-promoting effect of complement initiation, and the rationale behind the use of complement inhibition as a therapeutic strategy against cancer.

Expression of vascular endothelial growth factor can predict distant metastasis and disease-free survival for clinical stage III rectal cancer following 30-Gy/10-f preoperative radiotherapy

PURPOSE

The purpose of this study was to analyze the prognostic value of vascular endothelial growth factor (VEGF) in patients with stage III rectal cancer treated with 30-Gy/10-fraction (f) preoperative radiotherapy and radical surgery.

METHODS

One hundred and sixteen patients with clinical stage III rectal cancer were studied. All patients underwent radical surgery after 30-Gy/10-f preoperative radiotherapy. Immunohistochemical examination of VEGF was performed on the resected tumor specimen. An immunohistochemical score established from the extension and intensity of the markers was used for analysis. The log-rank test and proportional hazards regression analysis were used to calculate the probability that this biomarker was associated with patient outcomes.

RESULTS

The expression of VEGF was identified among 74.1 % (86 of 116) of patients. We found an increased incidence of distant metastasis (19.8 vs. 3.3 %, p = 0.039) and a decreased 3-year disease-free survival rate (96.7 % vs. 72.7 %, p = 0.003) in patients with positive VEGF staining. In multivariate survival analysis, positive VEGF staining (hazard ratio (HR) = 9.364, 95 % confidence interval (CI) 1.298-71.519, p = 0.027) and ypN+ stage (HR = 2.714, 95 % CI 1.419-3.331, p = 0.000) were the independent prognostic factors for disease-free survival. Subgroup analyses showed that the expression of VEGF was significantly associated with increased distant metastasis rate and decreased DFS in patients with ypN+ stage.

CONCLUSIONS

VEGF expression may have potential value for predicting distant metastasis and disease-free survival in stage III rectal cancer after 30-Gy/10-f preoperative radiotherapy. Inhibition of VEGF in combination with radiotherapy may improve the patient outcomes.

Expression of vascular endothelial growth factor can predict distant metastasis and disease-free survival for clinical stage III rectal cancer following 30-Gy/10-f preoperative radiotherapy

PURPOSE

The purpose of this study was to analyze the prognostic value of vascular endothelial growth factor (VEGF) in patients with stage III rectal cancer treated with 30-Gy/10-fraction (f) preoperative radiotherapy and radical surgery.

METHODS

One hundred and sixteen patients with clinical stage III rectal cancer were studied. All patients underwent radical surgery after 30-Gy/10-f preoperative radiotherapy. Immunohistochemical examination of VEGF was performed on the resected tumor specimen. An immunohistochemical score established from the extension and intensity of the markers was used for analysis. The log-rank test and proportional hazards regression analysis were used to calculate the probability that this biomarker was associated with patient outcomes.

RESULTS

The expression of VEGF was identified among 74.1 % (86 of 116) of patients. We found an increased incidence of distant metastasis (19.8 vs. 3.3 %, p = 0.039) and a decreased 3-year disease-free survival rate (96.7 % vs. 72.7 %, p = 0.003) in patients with positive VEGF staining. In multivariate survival analysis, positive VEGF staining (hazard ratio (HR) = 9.364, 95 % confidence interval (CI) 1.298-71.519, p = 0.027) and ypN+ stage (HR = 2.714, 95 % CI 1.419-3.331, p = 0.000) were the independent prognostic factors for disease-free survival. Subgroup analyses showed that the expression of VEGF was significantly associated with increased distant metastasis rate and decreased DFS in patients with ypN+ stage.

CONCLUSIONS

VEGF expression may have potential value for predicting distant metastasis and disease-free survival in stage III rectal cancer after 30-Gy/10-f preoperative radiotherapy. Inhibition of VEGF in combination with radiotherapy may improve the patient outcomes.

Expression of vascular endothelial growth factor can predict distant metastasis and disease-free survival for clinical stage III rectal cancer following 30-Gy/10-f preoperative radiotherapy

PURPOSE

The purpose of this study was to analyze the prognostic value of vascular endothelial growth factor (VEGF) in patients with stage III rectal cancer treated with 30-Gy/10-fraction (f) preoperative radiotherapy and radical surgery.

METHODS

One hundred and sixteen patients with clinical stage III rectal cancer were studied. All patients underwent radical surgery after 30-Gy/10-f preoperative radiotherapy. Immunohistochemical examination of VEGF was performed on the resected tumor specimen. An immunohistochemical score established from the extension and intensity of the markers was used for analysis. The log-rank test and proportional hazards regression analysis were used to calculate the probability that this biomarker was associated with patient outcomes.

RESULTS

The expression of VEGF was identified among 74.1 % (86 of 116) of patients. We found an increased incidence of distant metastasis (19.8 vs. 3.3 %, p = 0.039) and a decreased 3-year disease-free survival rate (96.7 % vs. 72.7 %, p = 0.003) in patients with positive VEGF staining. In multivariate survival analysis, positive VEGF staining (hazard ratio (HR) = 9.364, 95 % confidence interval (CI) 1.298-71.519, p = 0.027) and ypN+ stage (HR = 2.714, 95 % CI 1.419-3.331, p = 0.000) were the independent prognostic factors for disease-free survival. Subgroup analyses showed that the expression of VEGF was significantly associated with increased distant metastasis rate and decreased DFS in patients with ypN+ stage.

CONCLUSIONS

VEGF expression may have potential value for predicting distant metastasis and disease-free survival in stage III rectal cancer after 30-Gy/10-f preoperative radiotherapy. Inhibition of VEGF in combination with radiotherapy may improve the patient outcomes.

The use of molecular markers as a method to predict the response to neoadjuvant therapy for advanced stage rectal adenocarcinoma

AIM

The response to combined neoadjuvant therapy for advanced stage rectal adenocarcinoma is predictive of outcome. In addition to both clinical and pathological features, the expression of a variety of molecules may provide another method of identifying tumour responsiveness to pre-operative therapy. The aim of this study was to evaluate several markers in the apoptotic pathway as well as expression of Cox-2 and vascular endothelial growth factor (VEGF) to determine their ability to predict response to neoadjuvant therapy.

METHOD

In total, 152 patients with advanced rectal adenocarcinoma were treated with neoadjuvant therapy followed by resection. Paraffin-embedded sections obtained before and after therapy were assessed by immunohistochemical staining for Cox-2, VEGF, p53, p21, p27, Bax, BCL-2 and apoptosis protease-activating factor 1 (APAF-1). These stains were correlated with tumour regression grade, complete pathological response and T-downstaging of the surgical specimen. Clinical and pathological data were also collected. Data were analysed using the χ2 and Spearman's correlation tests.

RESULTS

Pathological complete response was seen in 24.5% of patients. Amongst the apoptosis-associated markers, only APAF-1 expression was found to be significantly associated with tumour regression grade (P<0.001), complete pathological response (P<0.031) and T-downstaging (P<0.004). On multivariate analysis, APAF-1 expression was found to be independently associated with good tumour regression grade. In contrast, overexpression of Cox-2 and VEGF in pretreatment biopsies was related to less tumour regression (P<0.003) and less likelihood of T-downstaging (P<0.03).

CONCLUSION

Immunohistochemical evaluation of initial biopsy specimens of rectal cancer with APAF-1, Cox-2 and VEGF may predict tumour response to neoadjuvant therapy in patients with advanced rectal adenocarcinoma. Those with an expected limited response may be considered for other investigational neoadjuvant protocols.

Significance of survivin expression: Prognostic value and survival in stage III non-small cell lung cancer

This study was designed to determine the levels of survivin expression and identify its clinical significance as a prognostic factor for stage III non-small cell lung cancer (NSCLC). A total of 210 cases of stage III NSCLC were collected and the expression levels of survivin and vascular endothelial growth factor A (VEGF-A) in tumor tissues were investigated using immunohistochemistry (IHC). The medical records of the patients were reviewed to determine the association with clinical course. Of the 210 NSCLC tissues, 112 (53.3%) cases demonstrated positive expression of survivin protein. Coexpression of survivin and VEGF-A was identified. The 5-year survival rate of patients with positive survivin expression was significantly lower compared with the survivin-negative cancer patients (P<0.05). The expression of survivin in NSCLC correlated with tumor size. Survivin and VEGF-A were independent prognostic factors of stage III NSCLC. Survivin protein is a valuable marker of prognosis in stage III NSCLC patients.

Expression of thymidine phosphorylase in lymph nodes involved with mycosis fungoides and sézary syndrome

Thymidine phosphorylase may be overexpressed in both neoplastic cells and tumor stromal cells in a variety of malignancies. Our study explores thymidine phosphorylase expression in lymph nodes (LNs) from patients with mycosis fungoides (MF) or Sézary syndrome (SS). In MF/SS, the LNs may have a pathologic diagnosis of either dermatopathic lymphadenopathy (LN-DL) or involvement by MF/SS (LN-MF). We performed immunohistochemical staining on MF/SS lymph nodes using antibodies to thymidine phosphorylase, CD68, CD21, CD3, and CD4. In both LN-DL and benign nodes, thymidine phosphorylase staining was noted only in macrophages, dendritic cells, and endothelial cells. In LN-MF, thymidine phosphorylase expression was also noted in subsets of intermediate to large neoplastic T cells. Concurrent CD68, CD21, CD3, and CD4 staining supported the above observations. Similar results were noted in the skin and in LN-MF with large cell transformation. Other T-cell lymphomas were also examined (total 7 cases); only enteropathy-type T-cell lymphoma (1 case) showed TP positivity in neoplastic T lymphocytes. We demonstrated that thymidine phosphorylase staining is present in neoplastic T cells in mycosis fungoides. The exact mechanism needs further investigation.

Circulation of progenitor cells in obese and lean colorectal cancer patients

BACKGROUND

Colorectal cancer (CRC) is a common life-threatening malignancy; risk and progression are elevated in obesity. The purpose of this study was to measure the frequency of circulating CD34-positive endothelial and progenitor cells in the circulation and evaluate their potential values as CRC biomarkers.

METHODS

Blood was collected from 45 patients with CRC and compared with cancer-free control donors. Detection and enumeration of cells was carried out by flow cytometry on the basis of immunophenotypes established for the cell populations of interest: hematopoietic and endothelial circulating progenitor cells, endothelial cells, mesenchymal stromal cells (MSC), and CD34bright leukocytes (CD34b LC). Groups were compared using multivariate regression analysis. Receiver-operating characteristic (ROC) curve analysis was used to evaluate the diagnostic values.

RESULTS

After adjusting for age and body mass index (BMI), the mean frequencies of MSCs and CD34b LCs were significantly higher in the circulation of patients with CRC than in controls. The areas under the ROC curve were 0.77 and 0.82 for MSCs and CD34b LCs, respectively. The frequency of circulating MSCs, but not of the other cell populations, was also found to be significantly higher in the circulation of obese patients with CRC (BMI ≥ 30 kg/m(2)) than in lean patients with CRC and obese controls.

CONCLUSIONS

Increased frequency of MSCs and CD34b LCs in the peripheral blood may represent a new diagnostic marker for CRC.

IMPACT

BMI-dependent changes in circulating MSCs, potentially mobilized from white adipose tissue may reveal their trafficking to tumors, which could be one of the mechanistic links between obesity and cancer progression.

Immunohistochemical analysis of tumour regression grade for rectal cancer after neoadjuvant chemoradiotherapy

AIM

Tumour regression grade (TRG) as defined by Rödel et al. has been used as an independent prognostic factor for rectal carcinoma after preoperative treatment by chemoradiotherapy (CRT). Determination of TRG 2 and 3, semiquantitatively defined as more or less than 50% tumour regression, respectively, does not appear to correlate with prognosis. The purpose of this study was to find an immunohistochemical pattern to permit improved stratification of intermediate responders defined by disease free (DFS) and overall survival (OS).

METHOD

Immunohistochemistry of EGFR (epidermal growth factor receptor), VEGF (vascular endothelial growth factor), CD133 antibody, p53 antibody and Ki67 antibody was evaluated using tissue microarrays (TMA) on post-treatment surgical specimens from 88 patients. CD133 expression was confirmed in the whole section when available.

RESULTS

At a median follow-up of 40 months, TRG was found to be an independent predictor of DFS (P = 0.05) and OS (P = 0.001) but no differences were found between TRG 2 and 3 in terms of DFS (P = 0.74) or OS (P = 0.41). The results of TMA showed an immunohistochemically poor prognostic profile for intermediate responders configured by negativity of CD133 expression. However, when examining CD133 expression in the whole section, there was an intermediate correlation with TMA and the prognostic significance was lost.

CONCLUSION

The results did not confirm the value of immunohistochemistry in predicting the prognosis of patients with rectal cancer following neoadjuvant chemoradiotherapy. This questions the accuracy of TMA in detecting CD133 expression in this setting.

Inhibition of aldose reductase prevents colon cancer metastasis

Colon cancer is the third most common cause of cancer and is the second leading cause of cancer deaths in the USA. Although inhibition of aldose reductase (AR) is known to prevent human colon cancer cell growth in nude mice xenografts, the role of AR in the regulation of cancer metastasis is not known. We now demonstrate the mechanisms by which AR regulates colon cancer metastasis in vitro and in vivo. Inhibition of AR prevented the epidermal growth factor (EGF) or fibroblast growth factor (FGF)-induced migration and invasion of human colon cancer (HT29; KM20) cells by >70% and also inhibited (>80%) the adhesion of the cancer cells to endothelial cells. Treatment of endothelial cells with AR inhibitors significantly (∼85%) downregulated the EGF or FGF-induced expression of Inter-Cellular Adhesion Molecule-1, Vascular cell adhesion molecule-1 and vascular endothelial-cadherin. Furthermore, liver metastasis of green fluorescent protein-labeled KM20 cells injected into the spleen of athymic nude mice was significantly (>65%) prevented by AR inhibitor, fidarestat or ARsiRNA delivered systemically into the mice. Similar results were observed with HT29 cells. AR inhibition or ablation also prevented (70-90%) the increase in the levels of matrix metalloproteinase-2, cyclin D1, CD31, CD34 and the activation of nuclear factor-kappa-binding protein in metastatic liver. Thus, our results indicate that AR regulates cancer cell adhesion, invasion and migration events which initiate metastasis and therefore, AR inhibition could be a novel therapeutic approach for the prevention of colon cancer metastasis.

Immunohistochemical analysis of vascular density and area in colorectal carcinoma using different markers and comparison with clinicopathologic prognostic factors

Analysis of blood and lymphatic vessel in colorectal cancer is controversial in the literature, possibly due to variations in the methods of analysis. In this study, it was aimed to search for a reliable approach in the quantification of angio- and lymphangiovascular density and area as a prognostic factor and to compare such vessel counts in normal mucosa, adenomas and cancer. A retrospective study was performed on 60 sporadic colorectal cancer, 30 colorectal adenomas, and 10 colorectal non-neoplastic lesions. Archival tissues were submitted to immunohistochemical evaluation using antibodies to CD31, CD34, CD105, VEGF-A, VEGF-C, and D2-40. Microvessel density and total vascular area were determined by computer image analysis and values were compared in the three groups of lesions; the prognostic value of these parameters was evaluated in the group of colorectal cancer. Most markers showed progressive vessel counts from non-neoplastic tissue to carcinoma, both for microvessel density and total vascular area. Only microvessel density determined by CD34 in the central areas of the cancer correlated with recurrence/metastasis (p = 0.04) and survival (p = 0.02). Different methods of quantification (microvessel counting versus estimation of total vascular area), immunohistochemical markers (pan-endothelial marker versus neovessels and lymphatic markers), and areas of analysis (periphery versus inner portions of the lesion) were assessed using image analysis. The results corroborate the increase in vascularization of carcinoma and suggest that microvessel density determined by immunostaining for CD34 in the inner portion of the tumor might represent a prognostically relevant parameter in colorectal cancer.

Oncogenic engagement of the Met receptor is sufficient to evoke angiogenic, tumorigenic, and metastatic activities in rat intestinal epithelial cells

The deregulation of Met/hepatocyte growth factor (HGF) receptor tyrosine kinase signaling constitutes a common event in colorectal cancers. However, the physiopathological functions of such a deregulation remain poorly understood. In the present study, we investigated the role of the deregulation of Met receptor in the neoplastic transformation of intestinal epithelial cells. To do so, the normal, well-established and characterized rat intestinal epithelial IEC-6 cells were transduced with a retrovirus carrying the oncogenic constitutive active form of Met receptor, Tpr-Met. Herein, we show that compared with control IEC-6 cells, Tpr-Met-IEC-6 cells exhibit enhanced proliferation, loss of growth-contact inhibition, cell morphological alterations, actin cytoskeletal reorganization, loss of E-cadherin expression and anchorage-independent growth. Moreover, Tpr-Met-IEC-6 cells are conferred the capacity to produce the proangiogenic factor VEGF and to reduce the potent antiangiogenic factor thrombospondin-1. Of significance, Tpr-Met-IEC-6 cells are endowed with the ability to elicit angiogenic responses and to form tumors and metastases in vivo. Hence, our study demonstrates for the first time that the sole oncogenic engagement of Met receptor in normal intestinal epithelial cells is sufficient to induce a wide array of cancerous biological processes that are fundamental to the initiation and malignant progression of colorectal cancers.

Bevacizumab, capecitabine, amifostine, and preoperative hypofractionated accelerated radiotherapy (HypoArc) for rectal cancer: a Phase II study

PURPOSE

Bevacizumab has established therapeutic activity in patients with metastatic colorectal cancer, and anti-vascular endothelial growth factor therapy enhances the activity of radiotherapy in experimental models. We assessed the feasibility and efficacy of preoperative radiochemotherapy combined with bevacizumab in patients with rectal cancer.

METHODS AND MATERIALS

Nineteen patients with radiologic T3 and/or N+ rectal carcinoma were treated with preoperative conformal hypofractionated accelerated radiotherapy (3.4 Gy in 10 consecutive fractions) supported with amifostine (500-1,000 mg daily), capecitabine (600 mg/m(2) twice daily, 5 days per week), and bevacizumab (5 mg/kg every 2 weeks for 2 cycles). Surgery followed 6 weeks after the end of radiotherapy. A cohort of 14 sequential patients treated with the same regimen without bevacizumab was available for comparison.

RESULTS

Grade 2 or 3 diarrhea was noted in 7 of 19 patients (36.8%), which was statistically worse than patients receiving the same regimen without bevacizumab (p = 0.01). A higher incidence of Grade 2 or 3 proctalgia was also noted (21.1%) (p = 0.03). Bladder and skin toxicity was negligible. All toxicities regressed completely within 2 weeks after the end of therapy. Pathologic complete and partial response was noted in 7 of 19 cases (36.8%) and 8 of 19 cases (42.1%). Within a median follow-up of 21 months, none of the patients has had late complications develop and only 1 of 18 evaluable cases (5.5%) has had locoregional relapse.

CONCLUSIONS

Bevacizumab can be safely combined with hypofractionated radiotherapy and capecitabine as a preoperative radiochemotherapy regimen for patients with rectal cancer. The high pathologic complete response rates urges the testing of bevacizumab in randomized studies.

Effects of anti-VEGF treatment duration on tumor growth, tumor regrowth, and treatment efficacy

PURPOSE

Inhibition of the vascular endothelial growth factor (VEGF) axis is the basis of all currently approved antiangiogenic therapies. In preclinical models, anti-VEGF blocking antibodies have shown broad efficacy that is dependent on both tumor context and treatment duration. We aimed to characterize this activity and to evaluate the effects of discontinuation of treatment on the dynamics of tumor regrowth.

EXPERIMENTAL DESIGN

We evaluated the effects of anti-VEGF treatment on tumor growth and survival in 30 xenograft models and in genetic mouse models of cancer. Histologic analysis was used to evaluate the effects of treatment on tumor vasculature. We used a variety of treatment regimens to allow analysis of the effects of treatment duration and cessation on growth rate, survival, and vascular density.

RESULTS

Preclinical tumor models were characterized for their varied dependence on VEGF, thereby defining models for testing other agents that may complement or augment anti-VEGF therapy. We also found that longer exposure to anti-VEGF monoclonal antibodies delayed tumor growth and extended survival in established tumors from both cell transplants and genetic tumor models and prevented regrowth of a subset of residual tumors following cytoablative therapy. Discontinuation of anti-VEGF in established tumors resulted in regrowth at a rate slower than that in control-treated animals, with no evidence of accelerated tumor growth or rebound. However, more rapid regrowth was observed following discontinuation of certain chemotherapies. Concurrent administration of anti-VEGF seemed to normalize these accelerated growth rates.

CONCLUSIONS

In diverse preclinical models, continuous VEGF suppression provides maximal benefit as a single agent, combined with chemotherapy, or as maintenance therapy once chemotherapy has been stopped.

Circulating endothelial cells and endothelial progenitors as predictive markers of clinical response to bevacizumab-based first-line treatment in advanced colorectal cancer patients

BACKGROUND

Despite the consistent clinical results demonstrated by studies on anti-angiogenic drugs targeted against the vascular endothelial growth factor in metastatic colorectal cancer (mCRC) patients, no specific direct/indirect biomarker of their efficacy has been validated. In this field, circulating endothelial cells (CECs) and endothelial progenitor cells (CEPs) have recently been proposed as noninvasive biomarkers.

PATIENTS AND METHODS

The absolute numbers of CEPs, total CECs (tCECs) and their resting (rCECs) and activated subsets were evaluated by multiparameter flow cytometry in 40 mCRC patients at baseline and before the administration of the third and sixth course of a bevacizumab-based first-line treatment. Fifty healthy subjects were utilized as control.

RESULTS

The overall response rate was 80%, overall clinical benefit was 90% and median progression-free survival (PFS) was 13.8 months. In our patients, tCECs and rCECs were significantly increased compared with healthy subjects. The patients who achieved a radiological response showed, at baseline, a significant decrease of rCECs and a trend in decrease of tCECs in comparison with patients not achieving response. Finally, a baseline absolute number of tCEC and rCEC <40 cells/ml was evidenced in patients with a longer PFS. No correlation was found regarding CEP.

CONCLUSIONS

Our study suggests significant correlations between both tCEC and rCEC baseline levels and the antitumor efficacy of a bevacizumab-based combination therapy in mCRC patients, thus confirming that these biomarkers could be used in the clinical setting as an early predictor of tumor response.

Clinical significance of preoperative serum vascular endothelial growth factor, interleukin-6, and C-reactive protein level in colorectal cancer

Background

Angiogenesis is a multistep process in which many growth factors and cytokines have an essential role. Vascular endothelial growth factor (VEGF) is a potent angiogenic agent that acts as a specific mitogen for vascular endothelial cells through specific cell surface receptors. The interleukin-6 (IL-6) pathway is another mechanism linking angiogenesis to malignancy. C-reactive protein (CRP), a representative marker for inflammation, is known for its association with disease progression in many cancer types. The aim of this study was to determine preoperative serum levels of VEGF, IL-6, and CRP in colorectal carcinoma, and to correlate them with disease status and prognosis.

Methods

A 132 of 143 patients who underwent curative resection for colorectal cancer were enrolled in this study. 11 patients with resection margin positive were excluded. Factors considered in analysis of the relationship between VEGF, IL-6, and CRP and histological findings. Patient prognosis was investigated. Serum levels of VEGF and IL-6 were assessed using Enzyme-Linked Immuno-Sorbent Assay (ELISA), and CRP was measured using immunoturbidimetry.

Results

Median follow-up duration was 18.53 months (range 0.73-43.17 months) and median age of the patients was 62 years (range, 26-83 years). Mean and median levels of VEGF and CRP in colorectal cancer were significantly higher than in the normal control group; 608 vs. 334 pg/mL and 528 (range 122-3242) vs. 312 (range 16-1121) (p < 0.001); 1.05 mg/dL vs. 0.43 mg/dL and 0.22 (range 0.00-18.40) vs. 0.07 (range 0.02-6.94) (p = 0.002), respectively. However mean and median level of IL-6 in patients were not significantly higher than in control; 14.33 pg/mL vs. 5.65 pg/mL and 6.00 (range 1.02-139.17) vs. 5.30 (4.50-13.78) (p = 0.327). Although IL-6 and CRP levels were not correlated with other pathological findings, VEGF level was significantly correlated with tumor size (p = 0.012) and CEA (p = 0.038). When we established the cutoff value for VEGF (825 pg/mL), IL-6 (8.09 pg/mL), and CRP (0.51 mg/dL) by Receiver Operating Characteristic (ROC) curve, we noted that high VEGF levels tended to reduce overall survival (p = 0.053), but not significantly. However, IL-6 and CRP demonstrated no significance with regard to disease free survival (p = 0.531, p = 0.701, respectively) and overall survival (p = 0.563, p = 0.572, respectively). Multivariate analysis showed that VEGF (p = 0.032), CEA (p = 0.012), lymph node metastasis (p = 0.002), and TNM stage (p = 0.025) were independently associated with overall survival.

Conclusions

Preoperative serum VEGF and CRP level increased in colorectal cancer patients. High VEGF level has been proposed as a poor prognostic factor for overall survival in patients with colorectal cancer.

Gene expression profiles of epidermal growth factor receptor, vascular endothelial growth factor and hypoxia-inducible factor-1 with special reference to local responsiveness to neoadjuvant chemoradiotherapy and disease recurrence after rectal cancer surgery

AIMS

To establish a causal relationship between the gene expression profiles of angiogenetic molecular markers, including epidermal growth factor receptor (EGFR), vascular endothelial growth factor (VEGF) and hypoxia-inducible factor-1 (HIF-1), in rectal cancer and the local responsiveness to neoadjuvant chemoradiotherapy and subsequent disease recurrence.

MATERIALS AND METHODS

We examined the pre-treatment tumour biopsies (n=40) obtained from patients with rectal adenocarcinoma (clinical International Union Against Cancer stage ll/III) who were scheduled to receive neoadjuvant 5-fluorouracil-based chemoradiotherapy for EGFR, VEGF and HIF-1 expression by quantitative real-time polymerase chain reaction.

RESULTS

Responders (patients with significant tumour regression, i.e. pathological grades 2/3) showed significantly lower VEGF, HIF-1 and EGFR gene expression levels than the non-responders (patients with insignificant tumour regression, i.e. pathological grades 0/1) in the pre-treatment tumour biopsies. The elevated expression level of each gene could predict patients with a low response to chemoradiation. During the median follow-up of all patients (41 months; 95% confidence interval 28-60 months), 6/40 (15%) developed disease recurrence. Although local responsiveness to neoadjuvant chemoradiotherapy was associated with neither local nor systemic disease recurrence, lymph node metastasis and an elevated VEGF gene expression level were independent predictors of systemic disease recurrence. The 3-year disease-free survival rates of the patients with lower VEGF or EGFR expression levels were significantly lower than those of patients with higher VEGF or EGFR expression levels.

CONCLUSIONS

Analysing VEGF expression levels in rectal cancer may be of benefit in estimating the effects of neoadjuvant chemoradiotherapy and in predicting systemic recurrence after rectal cancer surgery.

The relationship of VEGF polymorphisms with serum VEGF levels and progression-free survival in patients with epithelial ovarian cancer

OBJECTIVE

The vascular endothelial growth factor (VEGF) is an important regulator of angiogenesis and vascular permeability of tumors. In the present study we evaluated the relation of five single nucleotide polymorphisms (SNPs) in the VEGF gene with progression-free survival. Furthermore, we evaluated the functional significance of the SNPs as determined by the influence on serum VEGF levels in ovarian cancer.

METHODS

Serum from 143 consecutive ovarian cancer patients referred for first line platinum/paclitaxel treatment were analyzed for serum VEGF levels using commercially available enzyme-linked immunosorbent assay (ELISA). VEGF gene polymorphisms (-2578 C/A, -1154 G/A, -460 T/C, +405 G/C and +936C/T) were determined by real time PCR using genomic DNA extracted from whole blood samples.

RESULTS

VEGF serum levels were significantly higher in carriers of the 2578C, 460T and 405C, alleles compared to non-carriers (p=0.003, p=0.003 and p=0.001, respectively). There was no significant correlation between VEGF SNP genotypes and progression-free survival. In haplotype analysis, the multivariate survival analysis showed that progression-free survival (PFS) for the patients with the AGCGC haplotype was significantly improved compared to patients with other haplotypes (HR 1.9, p=0.036).

CONCLUSIONS

VEGF polymorphisms were found to be significantly related with serum VEGF levels. The AGCGC haplotype was found to be independently associated with improved PFS.