Vascular Endothelial Growth factor-D Levels Research Articles

Impact of diabetes on vascular endothelial growth factor D and cardiovascular mortality in patients with suspected or known coronary artery disease: the ANOX study

Abstract Background Vascular endothelial growth factor D (VEGF-D) is a secreted glycoprotein that can induce lymphangiogenesis and angiogenesis. We recently demonstrated that serum levels of VEGF-D are independently associated with all-cause mortality in patients with suspected or known coronary artery disease (CAD). However, the impact of diabetes mellitus (DM) on the association between VEGF-D and cardiovascular (CV) mortality in those patients is unclear. Methods Serum VEGF-D levels were measured in 2418 patients with suspected or known CAD undergoing elective coronary angiography. The primary outcome was CV death. The secondary outcomes were all-cause death, major adverse CV events (MACE) defined as a composite of CV death, nonfatal myocardial infarction, and nonfatal stroke, and heart failure (HF) hospitalization. Patients were divided into 2 groups according to the presence (DM, n=1087) or absence (non-DM, n=1331) of DM, and followed up over a 6-year period. Results During the follow-up, 166 (81 DM and 85 non-DM) patients died from CV disease, 536 (284 DM and 252 non-DM) patients died from any cause, 297 (156 DM and 141 non-DM) patients developed MACE, and 268 (131 DM and 137 non-DM) patients developed HF hospitalization. After adjustment for potential clinical confounders and established CV biomarkers (i.e., N-terminal pro-brain natriuretic peptide, high-sensitivity cardiac troponin I, and high-sensitivity C-reactive protein), VEGF-D levels were significantly associated with all-cause death (hazard ratio [HR] for 1-SD increase, 1.20; 95% confidence interval [CI], 1.08–1.33) and HF hospitalization (HR, 1.23; 95% CI, 1.08–1.40), but not with CV death (HR, 1.18; 95% CI, 0.98–1.43) or MACE (HR, 1.11; 95% CI, 0.96–1.28), in DM patients, while VEGF-D levels were significantly associated with CV death (HR, 1.24; 95% CI, 1.08–1.43) and MACE (HR, 1.16; 95% CI, 1.03–1.32), but not with all-cause death (HR, 1.10; 95% CI, 0.99–1.22) or HF hospitalization (HR, 1.13; 95% CI, 0.99–1.28), in non-DM patients. The addition of VEGF-D levels to the model with potential clinical confounders and established CV biomarkers did not improve the prediction of CV death (P=0.92 for continuous net reclassification improvement [NRI], P= 0.32 for integrated discrimination improvement [IDI]), all-cause death (P=0.098 for NRI, P=0.12 for IDI), MACE (P=0.80 for NRI, P=0.53 for IDI) or HF hospitalization (P=0.96 for NRI, P=0.39 for IDI) in DM patients, whereas the addition of VEGF-D levels significantly improved the prediction of CV death (P=0.002 for NRI, P=0.03 for IDI) and all-cause death (P<0.001 for NRI, P=0.02 for IDI), but not that of MACE (P=0.11 for NRI, P= 0.09 for IDI) or HF hospitalization (P=0.89 for NRI, P=0.83 for IDI), in non-DM patients. Conclusions In patients with suspected or known CAD, the VEGF-D level independently predicted CV mortality in non-DM, but not in DM patients. The association between VEGF-D and CV mortality was attenuated in the presence of DM.

Association of Vascular endothelial factor D with pulmonary hypertension in heart failure: the PREHOSP-CHF Study

Abstract Background Pulmonary hypertension (PH) complicated with heart failure (HF) is associated with increased morbidity and mortality. Vascular endothelial growth factor D (VEGF-D), one of key regulators of lymphangiogenesis, was reported to be higher in HF patients with pulmonary congestion on chest X-ray. Furthermore, we previously reported that HF patients with high VEGF-D had higher incidence of major adverse cardiovascular events (MACE), defined as cardiovascular death or heart failure hospitalization. Purpose To investigate the association of VEGF-D with pulmonary hypertension in patients with HF. Methods The PREHOSP-CHF study is a multicenter prospective cohort study to determine the predictive value of angiogenesis-related biomarkers in HF. A total of 1,024 patients (mean age 75.5±12.6 years; 58.7% male) admitted to acute decompensated HF were included in the analyses. Serum levels of VEGF-D, as well as N-terminal pro B-type natriuretic peptide (NT-proBNP), high sensitivity cardiac troponin-I (hs-cTnI), high sensitivity C reactive protein (hs-CRP), were measured at the time of discharge. PH was assessed by tricuspid regurgitation velocity (TRV) in echocardiography. Patients were followed-up over two years. Results Data on PH was obtained in 932 patients. Of these, 44 (4.7%) and 223 (23.9%) patients showed PH (TRV>3.4 m/s) and borderline PH (TRV>2.8 m/s), respectively. Patients with PH/borderline PH were significantly older and had lower body mass index. Prevalence of prior HF hospitalization, HF with preserved ejection fraction, atrial fibrillation, anemia, and chronic kidney disease were higher in patients with PH/borderline PH. Levels of NT-proBNP and VEGF-D, but not hs-cTnI or hs-CRP, were higher in patients with PH/borderline PH (Figure). Levels of NT-proBNP and VEGF-D had weak but significant correlation with TRV (NT-proBNP, R2=0.04, P<0.001; VEGF-D, R2=0.05, P<0.001). After adjustment for these factors, VEGF-D levels were significantly correlated with TRV (β, 3.29; SEM, 0.85, P<0.001). During the follow-up, 12 in PH, 34 in borderline PH, and 53 in no PH patients developed MACE. Unadjusted Hazard ratios [95% confidence intervals] for MACE compared to no PH were 2.44 [1.58-3.60] in PH, and 1.62 [1.26-2.05] in borderline PH. When we divided each PH group into two groups based on the median of VEGF-D levels of each group (no PH, 387 pg/ml; borderline PH, 479 pg/ml; PH, 549 pg/ml), patients with high VEGF-D showed significantly higher incidence of MACE in no PH (unadjusted hazard ratio, 1,70; 95% confidence intervals, 1.29-2.26), and tended to show high incidence of MACE in borderline PH group (unadjusted hazard ratio, 1,39; 95% confidence intervals, 0.93-2.09) and PH group (unadjusted hazard ratio, 1,83; 95% confidence intervals, 0.84-4.18). Conclusions VEGF-D levels were independently associated with PH in patients with HF, and might serve as a predictive biomarker for PH, as well as prognostic biomarker for MACE among patients with HF.

Clinical features of pulmonary hypertension in lymphangioleiomyomatosis

Objective: To describe the prevalence of lymphangioleiomyomatosis-pulmonary hypertension (LAM-PH), to explore the clinical features of patients with LAM-PH, and to evaluate the role of pulmonary artery optical coherence tomography (OCT) in the diagnosis of LAM-PH. Methods: Among 234 patients diagnosed with LAM in our center from June 2017 to August 2023, echocardiography was performed in 167 patients, 15 patients with PH indicated by echocardiography were selected as the LAM-PH group. From the remaining 152 patients, 32 patients were randomly selected as the control group. We compared the demographic data, clinical manifestations, pulmonary function, blood gas analysis, and serum vascular endothelial growth factor D (VEGF-D) levels between the two groups. We also evaluated the data from right heart catheterization in five patients and the images from optical coherence tomography of pulmonary arteries in two patients. Results: Echocardiography showed pulmonary hypertension in 15 patients (8.98%). Compared with the control group, LAM-PH group had a higher proportion of patients receiving oxygen therapy. Patients with PH had lower FEV1, FVC, FEV1/FVC, DLCO and higher serum VEGF-D levels compared with those without PH. Right heart catheterization was performed in five patients. Five patients had a pre-capillary pattern and three of these patients had severe pulmonary hypertension. Optical coherence tomography showed that there were no obvious abnormalities in the intima and lumen of the blood vessels in the two patients. Conclusions: The prevalence of PH in LAM is low. Patients in the LAM-PH group had more severe hypoxemia, worse lung function and higher serum VEGF-D levels than those in the control group. PH in LAM is mainly pre-capillary. Optical coherence tomography can evaluate the pulmonary artery vascular condition and help to identify the cause of pulmonary hypertension in LAM patients.

Diagnostic value of serum vascular endothelial growth factor-D in Korean patients with lymphangioleiomyomatosis.

Lymphangioleiomyomatosis (LAM) is a rare multisystemic disorder characterized by the proliferation of abnormal smooth muscle-like cells. Although serum vascular endothelial growth factor-D (VEGF-D) is currently used as a diagnostic biomarker for LAM, its diagnostic value in Korean patients is unclear. To evaluate the diagnostic value of serum VEGF-D for LAM in Korean patients. A multicenter prospective cohort study. Serum samples were prospectively collected from five medical institutions, from patients with LAM (n = 40) and controls (n = 24; healthy participants = 3, other cystic lung diseases = 13, idiopathic pulmonary fibrosis = 4, idiopathic nonspecific interstitial pneumonia = 4). Serum VEGF-D levels were measured using the enzyme-linked immunosorbent assay, and the diagnostic value was evaluated using receiver operating characteristic (ROC) curve analysis. The mean age of patients with LAM was 44.5 years, and all were female (controls: 47.8 years; female: 70.8%, p < 0.001). The serum VEGF-D levels were significantly higher in patients with LAM than those in the control group (median: 708.9 pg/mL vs 325.3 pg/mL, p < 0.001). In the ROC curve analysis, serum VEGF-D levels showed good predicting performance for LAM diagnosis (area under the curve = 0.918) with an optimal cut-off value of 432.7 pg/mL (sensitivity = 85.0%, specificity = 87.5%). When 800 pg/mL was used as the cut-off value, the specificity of serum VEGF-D for LAM diagnosis increased to 100.0%. Our results suggest that serum VEGF-D may be a useful biomarker for diagnosing LAM in Korean patients, similar to previous reports.

Prospective Observational Study of Ramucirumab Plus Docetaxel After Combined Chemoimmunotherapy in Patients With Non-Small-Cell Lung Cancer.

A history of pre-administration of immune checkpoint inhibitors has been reported to be associated with good outcomes of ramucirumab (RAM) plus docetaxel (DOC) combination therapy for advanced non-small-cell lung cancer (NSCLC). However, existing knowledge on the clinical significance of RAM and DOC following combined chemoimmunotherapy is limited. Therefore, we evaluated the efficacy and safety of RAM plus DOC therapy after combined chemoimmunotherapy and attempted to identify the predictors of its outcomes. This multicenter, prospective study investigated the efficacy and safety of RAM plus DOC after combined chemoimmunotherapy. The primary endpoint was progression-free survival (PFS). Secondary endpoints were the objective response rate (ORR), disease control rate (DCR), overall survival (OS), and incidence of adverse events. An exploratory analysis measured serum cytokine levels at the start of treatment. Overall, 44 patients were enrolled from 10 Japanese institutions between April 2020 and June 2022. The median PFS and OS were 6.3 and 22.6 months, respectively. Furthermore, the ORR and DCR were 36.4% and 72.7%, respectively. The high vascular endothelial growth factor D (VEGF-D) group had a significantly shorter PFS and OS. A combination of high VEGF-A and low VEGF-D levels was associated with a longer PFS. Our results showed that RAM plus DOC after combined chemoimmunotherapy might be an effective and relatively feasible second-line treatment for patients with advanced NSCLC in a real-world setting.

Role of vascular endothelial growth factor D in lung adenocarcinoma immunotherapy response.

To identify key genes associated with tumor-associated macrophages (TAMs), tumor immunotherapy, in the prognosis of lung adenocarcinoma (LUAD). The mRNA expression profiles of LUAD samples were obtained from The Cancer Genome Atlas (TCGA) database. The "CIBERSORT" R package was employed to calculate the proportion of innate immune cell infiltration in both tumor and adjacent normal tissues. TAM-associated genes in LUAD were identified to construct a prognostic risk model using weighted gene correlation network analysis (WGCNA), Least Absolute Shrinkage and Selection Operator (LASSO), and multivariate Cox regression analyses (COX). The IMvigor210 cohort was utilized to validate the roles of these genes as predictors of immunotherapy response. Tissue microarrays, immunofluorescence staining, and mRNA level detection methods were used to determine the correlation of risk factors in LUAD tissues. CIBERSORT analysis revealed significant differences in innate immune cells between tumor and adjacent tissues. Seventy-four differential genes linked to these cells were identified from WGCNA. Four hub genes (endothelin receptor type B, vascular endothelial growth factor D (VEGFD), latent transforming growth factor beta binding protein 4 (LTBP4), and fibroblast growth factor receptor 4 (FGFR4)) in the TAM prognostic model were identified as independent prognostic risk factors (P < 0.05). VEGFD expression was identified as a low-risk factor for LUAD prognosis prediction (P < 0.05). Moreover, low-risk patients exhibited higher sensitivity to anti-PD-L1 therapy compared to high-risk patients (P < 0.05). VEGFD levels were negatively correlated with programmed cell death 1 (PD-1) levels (r = -0.363; P < 0.05), suggesting that VEGFD may serve as a predictor for anti-PD-1 treatment. VEGFD is associated with innate immunity in LUAD, it can predict LUAD prognosis, and therefor may be a potential predictor for anti-PD-1 treatment in patients with LUAD.

Abstract 15495: Serial Measurement of Vascular Endothelial Growth Factor-D in Heart Failure: The PREHOSP-CHF Study

Background: Vascular endothelial growth factor-D (VEGF-D) is a secreted glycoprotein that can act as lymphangiogenic and angiogenic growth factors. We recently reported that VEGF-D appeared to be a prognostic marker for major adverse cardiovascular events (MACE), defined as a composite of cardiovascular death or heart failure hospitalization (HF), in patients with HF. However, the prognostic value of changes of VEGF-D is unknown. Methods: The PREHOSP-CHF study is a nationwide prospective survey of patients with HF in Japan. Serum VEGF-D levels were measured in 203 patients (mean age, 75 years; male, 62%; mean ejection fraction, 45%) at both baseline and 6-month follow-up. We set the cut-off level of VEGF-D as 366 pg/ml, based on the ROC analysis of the entire cohort of the PREHOSP-CHF study. We defined increased VEGF-D as transition from low VEGF-D to high VEGF-D and decreased VEGF-D as transition from high to low. We investigated the association of changes of VEGF-D levels with the incidence of MACE after 6 months. Results: Mean VEGF-D levels at baseline and 6-month follow-up were 449±199 pg/ml and 519±230 pg/ml, respectively. During the 2-year follow-up, 18 patients developed MACE before 6-month follow-up, and 42 patients developed MACE after 6-month follow up. Based on levels of VEGF-D at baseline, patients with high VEGF-D showed significantly higher incidence of MACE than those without. After excluding the patients developed MACE before 6-month follow-up, 11 of 105 patients with high VEGF-D moved to the low VEGF-D group at 6-month follow-up, and 34 of 78 patients with low VEGF-D moved to the high VEGF-D group. Landmark analysis after 6 months showed that incidence of MACE was significantly higher in patients with increased VEGF-D than those without in the low VEGF-D group, and tended to be lower in patients with deceased VEGF-D than those without in the high VEGF-D group. After adjustment for ejection fraction, N-terminal B-type natriuretic peptide levels, and VEGF-D levels at baseline, increased VEGF-D were also significantly associated with the incidence of MACE after 6 months (hazard ratio per 10 pg/ml increase, 1.02; 95% confidence interval 1.00-1.03; P=0.04). Conclusions: In patients with HF, changes in VEGF-D might serve as a prognostic marker for MACE.

Plasma VEGF-D and sFLT-1 are potential biomarkers of hemodynamics and congestion in heart failure and following heart transplantation

BackgroundInflammation and tyrosine-kinases are known mediators in the pathobiology of cardiovascular disease. Plasma biomarkers reflecting these systems may provide a non-invasive complement reflecting haemodynamics, aiding in clinical decision-making. We therefore aimed to investigate the plasma levels of vascular and inflammatory proteins, and their associations with invasive haemodynamics in advanced heart failure (HF) before, and at multiple follow-ups after heart transplantation (HT). MethodsUsing multiplex sandwich immunoassays, absolute plasma concentrations of nine vascular and inflammatory proteins were assessed in 26 patients with advanced HF, before-HT, and at four-weeks, six-months, and one-year after-HT. Right heart catheterization (RHC) haemodynamics were assessed at the time of blood sampling. Repeated measures correlations were performed to evaluate the overall intra-individual development of plasma protein levels in relation to haemodynamics’ development over time. ResultsOut of nine proteins included initially, in advanced HF, elevated plasma levels of vascular endothelial growth factor D (VEGF-D) and soluble fms-like tyrosine kinase-1 (sFlt-1) decreased most markedly, at four-weeks (p<0.0001), and decreased further at six-months (p<0.05) and at the one-year follow-ups after-HT (p<0.05). Over time, plasma VEGF-D correlated strongest with haemodynamic parameters including pulmonary arterial wedge pressure (PAWP) (rmr= 0.75, 95% bootstrapped confidence interval (CI) 0.61-0.84, p<0.0001), followed by mean right atrial pressure (MRAP) (rmr= 0.74, 95% CI 0.61-0.82, p<0.0001), and mean pulmonary arterial pressure (mPAP) (rmr= 0.74, 95% CI 0.58-0.82, p<0.0001). Plasma sFlt-1 correlated also with multiple haemodynamic parameters including PAWP (rmr= 0.66, 95% CI 0.58-0.79, p<0.0001), MRAP (rmr= 0.64, 95% CI 0.58-0.81, p<0.0001), and mPAP (rmr= 0.61, 95% CI 0.51-0.76, p<0.0001). ConclusionsIn advanced HF, elevated plasma VEGF-D and sFlt-1 levels decrease early, already within four weeks after HT, and further throughout the first year postoperatively. Our findings support that high plasma VEGF-D and sFlt-1 concentrations before HT are related to congestion, and overall haemodynamic improvement. Plasma VEGF-D and sFlt-1 may consequently be potential non-invasive biomarkers for monitoring hemodynamic deterioration and congestion in HF, and surveillance after HT.

Determinants of Progression and Mortality in Lymphangioleiomyomatosis

Lymphangioleiomyomatosis is a progressive diffuse cystic lung disease with approximately 85%survival at 10 years. The determinants of disease progression and mortality after the introduction of sirolimus therapy and vascular endothelial growth factor D (VEGF-D) as a biomarker have not been well defined. Which factors, including VEGF-D and sirolimus therapy, influence disease progression and survival prognosis in patients with lymphangioleiomyomatosis? The progression dataset and the survival dataset included 282 and 574 patients, respectively, from Peking Union Medical College Hospital, Beijing, China. A mixed-effects model was used to compute the rate of decline in FEV1, and generalized linear models were used to identify variables affecting FEV1 decline. A Cox proportional hazards model was used to explore the association between clinical variables and the outcomes of death or lung transplantation in patients with lymphangioleiomyomatosis. VEGF-D levels and sirolimus treatment were associated with FEV1 changes and survival prognosis. Compared with patients with VEGF-D of< 800 pg/mL at baseline, patients with VEGF-D of≥ 800 pg/mL lost FEV1 faster (SE, -38.86mL/y; 95%CI, -73.90 to -3.82mL/y; P= .031). The 8-year cumulative survival rates of patients with VEGF-D of≥ 2,000 pg/mL and< 2,000 pg/mL were 82.9%and 95.1%, respectively (P= .014). The generalized linear regression model also demonstrated the benefit of delaying the decline of FEV1 by 65.56mL/y (95%CI, 29.06-102.06mL/y) in patients treated with sirolimus compared with those without sirolimus (P< .001). The 8-year risk of death was reduced by 85.1%(hazard ratio, 0.149; 95%CI, 0.075-0.299) after sirolimus treatment. After inverse treatment probability weighting, the risks of death in the sirolimus group were reduced by 85.6%. CT scan results of grade III severity were associated with worse progression than results of grades I or II severity. Patients with baseline FEV1 of 70%predicted or St. George's Respiratory Questionnaire Symptoms domain 50 or higher predicted a higher risk of worse survival. Serum VEGF-D levels, a biomarker of lymphangioleiomyomatosis, are associated with disease progression and survival. Sirolimus therapy is associated with slower disease progression and better survival in patients with lymphangioleiomyomatosis. ClinicalTrials.gov; No.: NCT03193892; URL: www. gov.

Safety and Efficacy of Combined Resveratrol and Sirolimus in Lymphangioleiomyomatosis

A critical need exists to develop remission-inducing therapies for lymphangioleiomyomatosis. Is the addition of resveratrol safe and more efficacious than sirolimus alone in patients with lymphangioleiomyomatosis? We conducted a phase 2, dose-escalating, open-label trial of resveratrol in patients with lymphangioleiomyomatosis receiving a stable regimen of sirolimus. Resveratrol was started at 250mg/d and escalated every 8weeks to maximum dose of 1,000mg/d over 24weeks. The primary outcome was≥ 42%decline in serum vascular endothelial growth factor D (VEGF-D) levels on combined therapy compared with baseline VEGF-D levels on sirolimus. Secondary objectives included an assessment of the safety profile and the effect on lung function and health-related quality of life (HRQOL). Longitudinal change in outcome measures was assessed using linear mixed models. Adverse effects were tabulated using the National Cancer Institute's Common Terminology Criteria for Adverse Events version4. Twenty-five patients with lymphangioleiomyomatosis with a median age of 51 years were enrolled. Pulmonary function parameters at study inclusion were: FEV1: median absolute, 1.72 L; 64%predicted; FVC: median absolute, 2.99 L; 96%predicted; and diffusing capacity of the lungs for carbon monoxide: median absolute, 14.68mL/mmHg/min; 37%predicted. The median serum VEGF-D value at baseline was 617 pg/mL. Patients entered the study with a median sirolimus dose of 2mg/d with median trough level of 6.3ng/mL. Despite some GI side effects, the addition of resveratrol was well tolerated. Although the primary outcome was not met, a statistically significant reduction in serum VEGF-D levels and improvement in HRQOL during the study was found. The addition of resveratrol was safe and well tolerated in patients with lymphangioleiomyomatosis taking sirolimus and was associated with modest improvement in HRQOL. Larger controlled trials of this combination might be warranted to assess definitively the usefulness of resveratrol as an additive therapy in lymphangioleiomyomatosis. ClinicalTrials.gov; No.: NCT03253913; URL: www. gov.

A NOVEL CASE OF LYMPHANGIOLEIOMYOMATOSIS AND PULMONARY LIGHT CHAIN DEPOSITION DISEASE

A NOVEL CASE OF LYMPHANGIOLEIOMYOMATOSIS AND PULMONARY LIGHT CHAIN DEPOSITION DISEASE

VEGF-D Serum Level as a Potential Predictor of Lymph Node Metastasis and Prognosis in Vulvar Squamous Cell Carcinoma Patients.

BackgroundRadical surgical resection of the primary tumor with mono/bilateral inguinofemoral lymph node dissection is the standard treatment for invasive vulvar squamous cell carcinoma (VSCC) and is frequently related to severe morbidity. Tailoring surgical treatment is of paramount importance, and a comprehensive preoperative evaluation is mandatory. Vascular endothelial growth factor D (VEGF-D) is considered a regulator of lymphangiogenesis involved in tumor spread via lymphatic vessels. The aim of this study was to evaluate the potential of VEGF-D in the prediction of inguinofemoral lymph node metastasis.MethodsWe analyzed the preoperative levels of serum VEGF-D (sVEGF-D) from two independent cohorts of patients with VSCC by enzyme-linked immunosorbent assay and its protein expression on tumor tissue by immunohistochemistry. Logistic regression was performed to identify the independent risk factors for lymph node metastasis, and Cox proportional hazard model was used for survival analysis.ResultsHigh levels of sVEGF-D, but not tissue VEGF-D, significantly correlated with positive groin nodes and a more advanced International Federation of Gynecologists and Obstetricians (FIGO) stage. In multivariable analysis, a high sVEGF-D level was an independent predictor of lymph node metastasis and worse prognosis. A prediction model based on sVEGF-D, tumor grade assessed on biopsy, tumor diameter, and lymph node clinical evaluation was able to predict lymph node metastasis, reaching C-index values of 0.79 and 0.73 in the training and validation cohorts, respectively.ConclusionsThe preoperative sVEGF-D level might be a reliable biomarker for the prediction of lymph node metastasis and prognosis in patients with VSCC, supporting better clinical/surgical decision. Multicenter prospective studies are required to confirm our findings.

Could VEGF-D level have a role in clinical risk scoring, estimation of thrombus burden, and treatment in acute pulmonary thromboembolism?

Pulmonary embolism (PE) is usually a complication of deep vein thrombosis and is an important cause of mortality and morbidity. Vascular endothelial growth factor D (VEGF-D) is a secretory protein that plays a role in the remodelling of blood vessels and the lymphatic system. This study aimed to determine the relationship between VEGF-D level and clinical risk scoring in patients with PE. The study included 117 patients admitted for PE that were divided into four groups: high-risk patients (n=35), high-intermediate-risk patients (n=30), low-intermediate-risk patients (n=24), and low-risk patients (n=28). Plasma VEGF-D was measured from peripheral venous blood samples (5mL) using a commercial enzyme-linked immunosorbent assay (ELISA) kit. Pulmonary Artery Obstruction Index (PAOI) was calculated from CT angiography imaging. There was no significant difference in troponin-I and NT-proBNP levels between the high-intermediate-risk and high-risk PE patients (P=.134, .146). VEGF-D and PAOI levels were found to be statistically significantly higher in high-risk patients compared with high-intermediate-risk patients (P=.016, .001). VEGF-D level was moderately correlated with mean pulmonary artery pressure and PAOI (r=.481, P=.01; r=.404, P=.01). In ROC curve analysis, a cut-off of 370.1pg/mL for VEGF-D had 91.4% sensitivity and 67% specificity in the differentiation of high-intermediate-risk and high-risk PE patients. This study showed that plasma VEGF-D level was more reliable than troponin-I and NT-proBNP in clinical risk scoring and demonstrating thrombus burden. VEGF-D can be used as a biomarker in clinical risk scoring and estimation of thrombus burden in patients with acute PE.

Abstract 13409: Impact of Smoking on Vascular Endothelial Growth Factor D and Mortality in Patients With Suspected or Known Coronary Artery Disease: The ANOX Study

Background: Smoking is a risk factor for mortality in the general population and in patients with coronary artery disease (CAD). Vascular endothelial growth factor D (VEGF-D) is a secreted glycoprotein that can act as lymphangiogenic and angiogenic growth factors. Recently, we demonstrated that circulating VEGF-D levels are associated with the risk of mortality in patients with suspected or known CAD. However, whether VEGF-D levels differ according to smoking status and whether smoking modifies the relationship between VEGF-D and mortality in those patients are unknown. Methods: Using data from a multicenter, prospective cohort of 2418 patients with suspected or known CAD, we assessed the association between smoking status and VEGF-D and the impact of smoking status on the association between VEGF-D levels and the risk of all-cause death. VEGF-D was measured in 955 never smokers, 1035 former smokers, and 428 current smokers enrolled in the ANOX Study. Patients were followed up over 3 years. Results: The mean age (standard deviation [SD]) of the patients was 70.6 (10.4) years; 67.2% were men. Current smokers exhibited significantly higher levels of VEGF-D compared to former smokers and never smokers (median [interquartile range], 343 [214-556], 312 [201-500], 291 [182-485] pg/mL, respectively; P =0.006). Stepwise multiple linear regression analysis revealed that the log-transformed VEGF-D level was independently associated with current smoking ( P =0.002), but not with former smoking. After adjusting for potential clinical confounders, the VEGF-D level was significantly associated with all-cause death in never smokers (hazard ratio per 1-SD increase [HR], 1.31; 95% confidence interval [CI], 1.10-1.55) and in former smokers (HR, 1.22; 95% CI, 1.08-1.37), but not in current smokers (HR, 0.92; 95% CI, 0.65-1.22). Furthermore, VEGF-D provided incremental prognostic information to the model with potential clinical confounders and the established cardiovascular biomarkers in never smokers, but not in former smokers or in current smokers. Conclusions: Current smoking was independently associated with higher levels of VEGF-D. The prognostic value of VEGF-D on mortality was most pronounced in never smokers among patients with suspected or known CAD.

Novel folliculin gene mutation and an elevated serum vascular endothelial growth factor-D level in the context of cystic lung disease

Birt-Hogg-Dubé syndrome (BHD) is a rare autosomal dominant genetic disorder characterized by the development of benign cutaneous neoplasms, renal tumors, and pulmonary cysts. Caused by mutations in the folliculin (FLCN) gene on chromosome 17, the pulmonary manifestations observed in BHD include multiple subpleural cysts that are frequently associated with pneumothorax. Diffuse cystic lung disease is also commonly encountered in lymphangioleiomyomatosis (LAM), either in isolation or in the context of tuberous sclerosis complex (TS). The diagnosis of BHD is confirmed by identifying pathogenic FLCN germline mutations. Modern evidence, however, supports using serum vascular endothelial growth factor-D (VEGF-D) levels in differentiating LAM from other cystic lung diseases, including BHD, with high specificity. This case report describes the unique finding of an elevated VEGF-D serum level (1290 pg/ml) in a patient with cystic lung disease, bilateral pneumothorax and a novel disease-causing mutation (E280X) in the FLCN gene.

Effects of yoga on exercise capacity in patients with lymphangioleiomyomatosis: a nonrandomized controlled study

ObjectiveTo evaluate the effects of yoga on exercise capacity and quality of life in patients with lymphangioleiomyomatosis (LAM), a rare cystic lung disease in women.Patients and methodsThis was a nonrandomized, controlled study conducted in Beijing, China (August 27, 2017 – April 26, 2018). Twenty-six participants were allocated to the intervention (yoga) group (n = 13) or control group (n = 13). The yoga intervention involved a 24-week program of yoga class training for 90 min once a week and no fewer than 2 at-home sessions per week (at least 15 min per session). The 6-min walking distance (6MWD), lung function, serum vascular endothelial growth factor-D (VEGF-D) levels, quality of life, and symptoms of anxiety and depression were measured at baseline, 12-week and 24-week follow-up. An incremental cardiopulmonary exercise test was conducted at baseline and the 24-week follow-up.ResultsEleven patients completed the yoga training program. The yoga group exhibited improvements in the following outcomes versus those of the control group: 6MWD (+ 55 ± 29 m vs + 18 ± 49 m, P = 0.04), anaerobic threshold (3.4 ± 2.4 ml/min/kg vs 1.6 ± 1.4 ml/min/kg, P = 0.035) and peak work load (11.7 ± 14.6 W vs 0.2 ± 9.1 W, P = 0.027). There was no significant difference in peak oxygen consumption (VO2peak), lung function, VEGF-D level, and quality of life between the yoga and control groups. No adverse effects were found in the yoga group.ConclusionYoga is a feasible and safe intervention for pulmonary rehabilitation and potentially improves exercise capacity in patients with LAM.Trial registration(Clinical trial registration number at www.chictr.org.cn: ChiCTR-OON-1701274)

Plasma VEGF-D and PlGF levels according to prior use of biologics among metastatic colorectal cancer: Preliminary results from GI-SCREEN CRC-Ukit study.

178 Background: Plasma vascular endothelial growth factor-D (VEGF-D) level is a potential predictor for ramucirumab efficacy in patients (pts) with metastatic colorectal cancer (mCRC), while a high VEGF-A and placental growth factor (PlGF) level in bevacizumab naïve pts receiving 2nd-line FOLFIRI plus aflibercept may suggest relatively higher activity. However, there are a few data associating 1st-line antiangiogenic treatments as well as anti-EGFR with angiogenic factors. Methods: This prospective longitudinal study aims to investigate an association between plasma angiogenesis-related mediators and clinical outcomes in mCRC. Serial plasma collections were done at time points of pre- and post-treatments of either 1st- or 2nd-line. Comprehensive measurements of 17 mediators were analyzed by the multiplex assay with Luminex technology. Here we report an association between levels of VEGF-D, PlGF and patient backgrounds. Results: From Sep 2017 to Aug 2019, 375 samples from 317 pts were enrolled in this analysis. Baseline characteristics were follows; 169 samples at pre-1st-line (pre-1L), 151 with prior bevacizumab treatment (post-bev) and 55 with prior anti-EGFR antibody (post-EGFR); median age, 66 years; male gender, 58%; RAS mutant, 46%; left-sided primary, 76%. In pre-1L, the median values of VEGF-D/ PlGF were 264/ 7.21 pg/mL without a clear association between the two in each patient (r = 0.094) and any baseline characteristics. Compared to pre-1L, the values of VEGF-D/ PlGF showed significantly higher in post-bev (median VEGF-D/ PlGF; 346/ 23.5 pg/mL, respectively). Moreover, there was no clear relationship between the two cytokines in each patient (r = 0.190). In 37 pts with serial blood collection, VEGF-D/ PlGF levels showed similar trends. In addition, VEGF-D/ PlGF levels in post-EGFR tended to be higher than those in pre-1L (median VEGF-D/ PlGF; 395/ 9.11 pg/mL, respectively). Conclusions: The VEGF-D/ PlGF may be separately induced by bev treatment as well as anti-EGFR therapy, suggesting the possibility of usefulness for selecting a better antiangiogenic inhibitor by measuring baseline VEGF-D/ PlGF. Clinical trial information: UMIN000028616.

P5526Vascular endothelial growth factor-D and mortality in suspected or known coronary heart disease patients with chronic kidney disease: a subanalysis of the ANOX study

Abstract Background Chronic kidney disease (CKD) is an independent risk factor for the development and progression of coronary heart disease (CHD). Vascular endothelial growth factor-D (VEGF-D) is a secreted glycoprotein that can act as lymphangiogenic and angiogenic growth factors through binding to its specific receptors, VEGFR-3 (Flt-4) and VEGFR-2 (KDR/Flk-1). VEGF-D signaling via VEGFR-3 plays an important role in lipoprotein metabolisms which may contribute to CHD. VEGF-D signaling has been used as a therapeutic target of human diseases such as lymphangioleiomyomatosis and refractory angina. Furthermore, in clinical settings, the VEGF-D level is already established as a diagnostic biomarker for lymphangioleiomyomatosis. However, the prognostic value of VEGF-D in suspected or known CHD patients with CKD is unknown. Methods Serum VEGF-D levels were measured in 999 suspected or known CHD patients with CKD undergoing elective coronary angiography, enrolled in the development of novel biomarkers related to angiogenesis or oxidative stress to predict cardiovascular events (ANOX) study, and followed up for 3 years. The primary outcome was all-cause death. The secondary outcomes were cardiovascular death, and major adverse cardiovascular events (MACE) defined as a composite of cardiovascular death, nonfatal myocardial infarction, and nonfatal stroke. Results During the follow-up, 154 patients died from any cause, 61 died from cardiovascular disease, and 96 developed MACE. After adjustment for established risk factors, VEGF-D levels were significantly associated with all-cause death (hazard ratio [HR] for 1-SD increase, 1.41; 95% confidence interval [CI], 1.27–1.56), cardiovascular death (HR, 1.48; 95% CI, 1.28–1.71), and MACE (HR, 1.34; 95% CI, 1.18–1.53). Even after incorporation of N-terminal pro-brain natriuretic peptide, contemporary sensitive cardiac troponin-I, and high-sensitivity C-reactive protein into a model with established risk factors, the addition of VEGF-D levels further improved the prediction of all-cause death (continuous net reclassification improvement [NRI], 0.272; 95% CI, 0.100–0.445; P=0.002; integrated discrimination improvement [IDI], 0.015; 95% CI, 0.003–0.027; P=0.013), but not that of cardiovascular death (NRI, 0.230; 95% CI, −0.029 to 0.488; P=0.082; IDI, 0.012; 95% CI, −0.007 to 0.031; P=0.207) or MACE (NRI, 0.102; 95% CI, −0.106 to 0.310; P=0.337; IDI, 0.005; 95% CI, −0.005 to 0.015; P=0.337). Conclusions In suspected or known CHD patients with CKD undergoing elective coronary angiography, elevated VEGF-D levels may predict all-cause mortality independent of established risk factors and cardiovascular biomarkers. Acknowledgement/Funding The ANOX study is supported by a Grant-in-Aid for Clinical Research from the National Hospital Organization

P5529Vascular endothelial growth factor-D and mortality in suspected or known coronary heart disease patients with diabetes: a subanalysis of the ANOX study

Abstract Background Diabetes is a risk factor for coronary heart disease (CHD), but further risk stratification in patients with diabetes is necessary to improve the prediction and prevention of cardiovascular events and deaths. Vascular endothelial growth factor-D (VEGF-D) is a secreted glycoprotein that can act as lymphangiogenic and angiogenic growth factors through binding to its specific receptors, VEGFR-3 (Flt-4) and VEGFR-2 (KDR/Flk-1). VEGF-D signaling via VEGFR-3 plays an important role in lipoprotein metabolisms which may contribute to CHD. VEGF-D signaling has been used as a therapeutic target of human diseases such as lymphangioleiomyomatosis and refractory angina. Furthermore, in clinical settings, the VEGF-D level is already established as a diagnostic biomarker for lymphangioleiomyomatosis. However, the prognostic value of VEGF-D in suspected or known CHD patients with diabetes is unknown. Methods Serum VEGF-D levels were measured in 1,087 suspected or known CHD patients with diabetes undergoing elective coronary angiography, enrolled in the development of novel biomarkers related to angiogenesis or oxidative stress to predict cardiovascular events (ANOX) study, and followed up for 3 years. The primary outcome was all-cause death. The secondary outcomes were cardiovascular death, and major adverse cardiovascular events (MACE) defined as a composite of cardiovascular death, nonfatal myocardial infarction, and nonfatal stroke. Results During the follow-up, 147 patients died from any cause, 47 died from cardiovascular disease, and 94 developed MACE. After adjustment for established risk factors, VEGF-D levels were significantly associated with all-cause death (hazard ratio [HR] for 1-SD increase, 1.34; 95% confidence interval [CI], 1.21–1.47), cardiovascular death (HR, 1.40; 95% CI, 1.18–1.62), and MACE (HR, 1.22; 95% CI, 1.07–1.40). Even after incorporation of N-terminal pro-brain natriuretic peptide, contemporary sensitive cardiac troponin-I, and high-sensitivity C-reactive protein into a model with established risk factors, the addition of VEGF-D levels further improved the prediction of all-cause death (continuous net reclassification improvement [NRI], 0.258; 95% CI, 0.088–0.429; P=0.003; integrated discrimination improvement [IDI], 0.013; 95% CI, 0.002–0.024; P=0.022), but not that of cardiovascular death (NRI, 0.046; 95% CI, −0.245–0.336; P=0.759; IDI, 0.013; 95% CI, −0.005–0.031; P=0.146) or MACE (NRI, 0.064; 95% CI, −0.146–0.274; P=0.552; IDI, 0.001; 95% CI, −0.002–0.004; P=0.557). Conclusions In suspected or known CHD patients with diabetes undergoing elective coronary angiography, elevated VEGF-D levels may predict all-cause mortality independent of established risk factors and cardiovascular biomarkers. Acknowledgement/Funding The ANOX study is supported by a Grant-in-Aid for Clinical Research from the National Hospital Organization

Serum vascular endothelial growth factor-D as a diagnostic and therapeutic biomarker for lymphangioleiomyomatosis.

BackgroundIn lymphangioleiomyomatosis (LAM), tuberous sclerosis gene mutations activate the mechanistic target of the rapamycin pathway, resulting in vascular endothelial growth factor-D (VEGF-D) overproduction. While the utility of serum VEGF-D testing for the diagnosis of LAM is outlined in ATS/JRS LAM Guidelines, the assay has not been fully validated for Asian populations. Our aims were to validate serum VEGF-D testing in Japan, by directly comparing measurements in Japan and the U.S., determining the diagnostic cut-off for serum VEGF-D levels among the Japanese women with typical thin walled cystic change on CT, and determining the performance of VEGF-D as a prognostic biomarker.Subjects and methodsWe determined serum VEGF-D levels from 108 LAM patients, 14 disease controls, and 51 healthy volunteers from the Japanese population. Measurements of 61 LAM patients were compared to those from the principal VEGF-D laboratory in the U.S at Cincinnati Children’s Hospital Medical Center. We correlated baseline serum VEGF-D levels with baseline and longitudinal clinical data to determine how pregnancy, sirolimus or gonadotrophin-releasing hormone (GnRH) agonists influence serum VEGF-D levels.ResultsSerum VEGF-D measurements in Japan and the U.S. were very similar. Baseline serum VEGF-D levels effectively distinguished LAM from other diseases and healthy volunteers at a cut-off level of 645 pg/ml and were diagnostically specific at 800 pg/ml, consistent with the recommendations of the ATS/JRS LAM Guidelines. Baseline serum VEGF-D correlated negatively with the DLco baseline % predicted and with the annual decrease in DLco % predicted. There was no significant association between baseline serum VEGF-D level and the outcomes of death or transplant. Serum VEGF-D levels markedly decreased during treatment with sirolimus, but not with GnRH analogues. Serum VEGF-D levels of most LAM patients did not increase over time, and neither pregnancy nor menopause significantly modulated serum VEGF-D levels.ConclusionsSerum VEGF-D is a useful diagnostic and therapeutic biomarker for LAM. Satisfactory precision and international inter-laboratory agreement of the clinical assay support VEGF-D recommendations in the ATS/JRS LAM Guidelines for the Japanese population.