Vascular Proliferation Index Research Articles

Clinicopathological and prognostic significance of nestin expression in patients with breast cancer: a systematic review and meta-analysis

BackgroundNestin has been revealed to promote tumorigenesis, progression, metastasis, and angiogenesis of breast cancer. Although the prognostic and clinicopathological impact of nestin expression on breast cancer patients has been assessed in several independent studies, their results remained conflicting. Therefore, we performed this meta-analysis to elucidate the prognostic and clinicopathological association of nestin expression with breast cancer.MethodsA comprehensive literature search was performed in the electronic databases PubMed, EMBASE, Web of Science, the Cochrane Library, China National Knowledge Infrastructure (CNKI), and the Wangfang Data. The statistical analysis was conducted using Stata 15.0 and Review Manager 5.3.ResultsA total of 15 studies with 6066 breast cancer patients were included in this meta-analysis. Pooled results indicated that positive expression of nestin was significantly associated with reduced breast cancer-specific survival (BCSS, univariate analysis, HR = 2.11, 95% CI [1.79, 2.49], P < 0.00001; multivariate analysis, HR = 1.30, 95% CI [1.06, 1.60], P = 0.01), worse overall survival (OS, univariate analysis, HR = 1.88, 95% CI [1.31, 2.71], P = 0.0007; multivariate analysis, HR = 1.89, 95% CI [1.34, 2.67], P = 0.0003) and poorer recurrence-free survival (univariate analysis, HR = 2.60, 95% CI [1.52, 4.46], P = 0.0005), but not with distant metastasis-free survival in univariate analysis (P > 0.05). In addition, increased nestin expression was correlated with younger age, higher tumor grade, larger tumor size, positive blood vessel invasion and high vascular proliferation index, but not with lymph node metastasis or lymph vessel invasion. Nestin was preferentially expressed in invasive ductal carcinoma, triple-negative breast cancer and basal-like subtypes. Nestin expression was inversely associated with the expression of ER and PR, but not with HER-2. Conversely, nestin expression was positively correlated with the expression of basal-like markers CK5, P-cadherin and EGFR. Moreover, nestin expression was strongly associated with the presence of five basal-like profiles (BLP1-5).ConclusionsThis meta-analysis revealed the prognostic value and clinicopathological significance of nestin expression in breast cancer. Nestin is an independent prognostic factor for worse BCSS and OS of breast cancer patients. Nestin is also a valuable biomarker for unfavorable clinicopathological features and tumor angiogenesis of breast cancer. Therefore, nestin is a promising therapeutic target for malignant breast cancer, especially for TNBC and basal-like phenotype.

Prognostic value of uPAR expression and angiogenesis in primary and metastatic melanoma.

Angiogenesis is important for the progression of cutaneous melanoma. Here, we analyzed the prognostic impact of the angiogenic factor urokinase plasminogen activator resecptor (uPAR), vascular proliferation index (VPI) and tumor necrosis as a measure of hypoxia in a patient series of nodular melanomas (n = 255) and matched loco-regional metastases (n = 78). Expression of uPAR was determined by immunohistochemistry and VPI was assessed by dual immunohistochemistry using Factor-VIII/Ki67 staining. Necrosis was recorded based on HE-slides. As novel findings, high uPAR expression and high VPI were associated with each other, and with increased tumor thickness, presence of tumor necrosis, tumor ulceration, increased mitotic count and reduced cancer specific survival in primary melanoma. In matched cases, VPI was decreased in metastases, whereas the frequency of necrosis was increased. Our findings demonstrate for the first time the impact on melanoma specific survival of uPAR expression and VPI in primary tumors, and of increased necrosis as an indicator of tumor hypoxia in loco-regional metastases. These findings support the importance of tumor angiogenesis in melanoma aggressiveness, and suggest uPAR as an indicator of vascular proliferation and a potential biomarker in melanoma.

Microvascular proliferation is associated with aggressive tumour features and reduced survival in lung adenocarcinoma.

Despite new treatment options in lung cancer, there is still a need for better biomarkers to assist in therapy decisions. Angiogenesis has been associated with tumour growth and dissemination, and the vascular proliferation index (VPI) is a valuable prognostic marker in other tumours. Nestin, a marker of immature endothelium, was previously applied in combination with Ki67 for proliferating endothelium as a novel marker (Nestin‐Ki67) of ongoing angiogenesis. Here, the prevalence and prognostic impact of vascular proliferation on lung cancer‐specific survival (LCSS) in lung adenocarcinomas was studied. Selected tumour slides from a cohort of 210 patients treated surgically for adenocarcinoma at Haukeland University Hospital (Norway) from 1993 to 2010 were stained for Nestin‐Ki67. VPI, the ratio between the density of proliferating vessels and the overall microvessel density were used, and the cut‐off value was set at 4.4% (upper quartile). High VPI was associated with the presence of blood vessel invasion (p = 0.007) and tumour necrosis (p = 0.007). Further, high VPI was significantly associated with reduced LCSS (p = 0.020). By multivariate analysis, VPI remained an independent prognostic factor for reduced LCSS (HR 1.7; 95% CI 1.04–2.68; p = 0.033) when adjusted for other prognostic clinico‐pathological features. In conclusion, microvessel proliferation assessed using the VPI was associated with aggressive tumour features such as blood vessel invasion and tumour necrosis and, independently, decreased LCSS. This marker should be further explored in separate cohorts, and in trials of anti‐angiogenesis therapy.

Quantifying tumour vascularity in non-luminal breast cancers

AimsMicrovessel density (MVD), proliferating MVD (pMVD) and vascular proliferation index (VPI) are methods used to quantify tumour vascularity in histopathological sections. In this study, we assessed MVD, pMVD and VPI...

Strong Expression of Hypoxia-Inducible Factor-1α (HIF-1α) Is Associated with Axl Expression and Features of Aggressive Tumors in African Breast Cancer.

PurposeInhibition of hypoxia-inducible factor (HIF) and Axl receptor tyrosine kinase is being evaluated for targeted therapy in solid tumors. Both HIF-1α and Axl influence tumor growth and metastatic potential, and they have been linked to treatment failure in many cancers. However, there is a lack of reports on HIF-1α expression in African breast cancer, which has a poor prognosis, and novel treatment targets must therefore be established. Here, we aimed to evaluate HIF-1α in relation to Axl expression, angiogenesis markers, and other tumor characteristics in a series of African breast cancer.MethodsUsing immunohistochemistry, we examined 261 invasive breast cancers on tissue microarrays for HIF-1α and Axl as well as several other markers, and a subset of 185 cases had information on VEGF (vascular endothelial growth factor) expression, microvessel density (MVD), proliferating microvessel density (pMVD) and vascular proliferation index (VPI) for important comparisons.ResultsStrong HIF-1α expression was associated with increased Axl (p = 0.007), VEGF (p<0.0005), and p53 (p = 0.032) expression, as well as high tumor cell proliferation by Ki-67 (p = 0.006), and high tumor grade (p = 0.003). Tumors with strong HIF-1α expression had significantly higher MVD (p = 0.019) and higher pMVD (p = 0.027) than tumors with weak expression.ConclusionsHigh HIF-1α expression is significantly associated with Axl and VEGF expression, and with markers of poor prognosis in this series of breast cancer, suggesting HIF-1α and Axl as potential therapeutic targets in African breast cancer.

Abstract B03: The predictive value of microvessel density, vascular proliferation index and markers of VEGF associated angiogenesis in patients with metastatic melanoma treated with bevacizumab monotherapy

Abstract Background: Angiogenesis is a hallmark of cancer and essential for tumor growth and metastases. As previously published, clinical benefit was observed in 31% of patients with metastatic melanoma who were treated with bevacizumab monotherapy. Response evaluation was done according to the RECIST guidelines; overall response (OR) defines patients with complete or partial response, clinical benefit (CB) includes also stable disease for at least 6 months. The main objective of this study was to identify predictive markers of anti-angiogenic treatment. Here, we focus on the correlation between microvessel density and treatment response. Methods: 35 patients were enrolled in an open-label single arm phase II clinical trial at Haukeland University Hospital, Norway, and were treated with bevacizumab 10mg/kg q14 until disease progression or intolerable toxicity (ClinicalTrials.gov: NCT00139360). Paraffin embedded tissue of primary tumors and metastases as well as blood samples were available for investigation. Tissue sections were double stained with antibodies for Factor VIII and Ki67. The sections were screened for areas with the highest density of Factor VIII positive vessels. For assessment of microvessel density (MVD), the number of Factor VIII positive vascular units within the tumor was registered in three high power fields (HPFs). Microvessels with co-expression of Ki67 in the nucleus and Factor VIII in the cytoplasm of endothelial cells (ECs) were defined as proliferating vessels (pMVD) and were counted in the same HPFs. The ratio between pMVD and MVD was defined as vascular proliferation index (VPI). In addition, the presence of glomeroid microvascular proliferations (GMPs) was registered in tissue sections stained with Factor VIII mono. GMPs, a marker for VEGF associated angiogenesis, were defined as focal glomerulus-like aggregates of multi-layered Factor VIII positive ECs with a minimum of 15 cells. Associations with response as well as with various angiogenic factors in tissue and blood samples were analyzed. Results: High pMVD and VPI were significantly associated with high expression of vascular endothelial growth factor A (VEGF-A) in primary melanomas (Mann-Whitney U test, p=0.023; p=0.032). In addition, high MVD in metastases was associated with high expression of VEGF-A in metastases and low VEGF-A concentration in plasma (Mann-Whitney U test, p=0.036; p=0.046). However, expression of VEGF-A in primary melanomas or metastases was not associated with treatment response. All primary melanomas with GMPs show expression of VEGF-A in ECs (Chi-square test p=0.029). High MVD in primary tumors predicted CB (Mann-Whitney U test, p=0.042). However, this correlation was not observed in the metastases. Still, neither MVD in primary melanomas nor in metastases was correlated with OR to bevacizumab monotherapy in patients with metastatic melanoma. VPI and pMVD in primary melanomas or metastases were not correlated to any kind of treatment response. Similarly, the presence of GMP in primary melanomas or metastases did not show any correlation to treatment response. Conclusion: Although a significant association was present between MVD in primary lesions and CB, neither MVD, pMVD or VEGF expression seems to be robust predictive markers of response to bevacizumab monotherapy for metastatic melanoma. Further investigation is ongoing to identify predictive biomarkers in this trial. Citation Format: Cornelia Schuster, Lars A. Akslen, Oddbjørn Straume. The predictive value of microvessel density, vascular proliferation index and markers of VEGF associated angiogenesis in patients with metastatic melanoma treated with bevacizumab monotherapy. [abstract]. In: Proceedings of the AACR Special Conference: Tumor Angiogenesis and Vascular Normalization: Bench to Bedside to Biomarkers; Mar 5-8, 2015; Orlando, FL. Philadelphia (PA): AACR; Mol Cancer Ther 2015;14(12 Suppl):Abstract nr B03.

Microvascular proliferation in luminal A and basal-like breast cancer subtypes

AimsThe aims of this study were to examine microvessel density (MVD), proliferating MVD (pMVD) and Vascular Proliferation Index (VPI) in basal-like phenotype (BP) and luminal A subtypes of breast cancer...

Abstract 2651: Nestin expression in tumor cells is associated with the basal-like phenotype and aggressive features in breast cancer.

Abstract Background: Nestin, neuroepithelial stem cell protein, is an intermediate filament protein originally described as a neuronal stem cell/progenitor marker during central nervous system development. Nestin is also expressed in immature or progenitor cells in non-neural tissues, including the basal/myoepithelial layer of the mammary gland and immature blood vessels. Recently, nestin positivity has been reported in different cancer types, and on this background we wanted to evaluate nestin positivity in breast cancer. Materials and methods: Immunohistochemical staining of nestin was done on tissue microarray slides from two independent series of breast cancer. Series 1 was a nested case-control study of interval and screening detected breast cancer based on the Norwegian Mammography Screening Program in Hordaland County during 1996-2001, giving a series of 190 patients with invasive breast cancer. Series 2 included 192 cases of invasive breast carcinoma from 1990-2002 identified in the Kampala Cancer Registry, and at the Department of Pathology, Makerere University College of Health Sciences (MakCHS), Kampala, Uganda. Evaluation of staining was done using staining index, where the staining index (values 0-9) was obtained as a product of staining intensity (0-3) and proportion of immunopositive cells (&amp;lt;10%, 1; 10-50%, 2; &amp;gt;50%, 3). A staining index above 0 was regarded as positivity for nestin. Results: In both series, nestin positivity in tumor cells was significantly associated with higher histologic grade; grade 1-2 vs. grade 3, (p&amp;lt;0.0005), negativity for estrogen receptor (p&amp;lt;0.0005) and progesterone receptor (p=0.001 in series 1 and p&amp;lt;0.0005 in series 2), high tumor cell proliferation by Ki-67 (p&amp;lt;0.0005 and p=0.005 in series 1 and 2, respectively), positivity for p53 (p=0.001 in series 1 and p=0.010 in series 2) and increased activation of angiogenesis estimated by vascular proliferation index (VPI)(p=0.035 in series 1 and p=0.001 in series 2). Concerning basal cell markers, nestin positivity in tumor cells was significantly associated with cytokeratin 5/6 and p-cadherin, with p-values &amp;lt;0.0005 in both series. Further, strong associations were seen with the triple negative phenotype (p&amp;lt;0.0005) and with five immunohistochemical profiles for the basal-like phenotype (1-5), with odds ratios from 7.1-18.3 and 10.7-18.1 in series 1 and 2, respectively. Conclusion: In these two series of breast cancer, nestin expression in tumor cells was significantly associated with features of aggressive breast cancer disease such as higher histologic grade, negativity for estrogen and progesterone receptors and high tumor cell proliferation by Ki-67. Further, nestin positivity was significantly associated with basal cell markers, the triple negative phenotype and the basal-like phenotype. Citation Format: Kristi Krüger, Hawa Nalwoga, Karin Collett, Jarle B. Arnes, Turid Aas, Lars A. Akslen. Nestin expression in tumor cells is associated with the basal-like phenotype and aggressive features in breast cancer. [abstract]. In: Proceedings of the 104th Annual Meeting of the American Association for Cancer Research; 2013 Apr 6-10; Washington, DC. Philadelphia (PA): AACR; Cancer Res 2013;73(8 Suppl):Abstract nr 2651. doi:10.1158/1538-7445.AM2013-2651

Vascular proliferation is associated with survival in pancreatic ductal adenocarcinoma

In pancreatic ductal adenocarcinoma (PDAC), the benefit of current chemotherapy and radiation therapy is very limited, even in radically resected patients. New treatment strategies, for example based on the inhibition of the tumour's blood supply, need to be explored. We have investigated angiogenesis markers and their associations with relapse and survival in 52 histologically confirmed cases of PDAC. Angiogenesis in the primary tumour was evaluated by microvessel density (MVD), vascular proliferation index (VPI) and the presence of glomeruloid microvascular proliferations (GMP). These features were analysed in the context of clinicopathological variables, KRAS mutation status, relapse location and survival. MVD (median 134 microvessels/mm(2) , range 88-177) and VPI (median 3.2%, range 1.6-4.9) were associated with larger tumour size and lymph node metastasis. MVD was also related to the occurrence of liver metastases. Both variables were associated with survival in univariate and multivariate analyses. GMPs were present in 32 (62%) of the cases. Patients who exhibited MVD and VPI values above median, and GMP positivity, had a median survival of only 4.2 months after surgery. In conclusion, the angiogenesis markers MVD and VPI have a significant impact on survival. By also including GMP, a subgroup of PDAC patients with particularly short survival could be identified.

Microvessel proliferation by co-expression of endothelial nestin and Ki-67 is associated with a basal-like phenotype and aggressive features in breast cancer

BackgroundTo quantify tumour angiogenesis, microvessel density (MVD) has been widely used. We here present a novel angiogenesis marker, microvessel proliferation (MVP), based on dual immunohistochemical staining of nestin and Ki-67. Immature endothelial cells express nestin, and when co-expressed with the proliferation marker Ki-67, the number of proliferating immature blood vessels can be measured. Materials and methodsMicrovessel proliferation was evaluated in 178 breast cancer samples and estimated by vascular proliferation index (VPI), the ratio between the number of vessels containing proliferating endothelial cells and the total number of immature vessels. ResultsHigh VPI was strongly associated with several markers of aggressive breast cancer, such as negative oestrogen receptor (ER) status (p = 0.003), high tumour cell proliferation by Ki-67 (p = 0.004), high p53 expression (p = 0.001), and five profiles for the basal-like phenotype (odds ratios (OR); range 3.4–6.3). Also, high VPI was significantly associated with interval detected breast cancer compared with screening detected lesions (p < 0.0005), and adverse outcome in univariate and multivariate survival analysis (p = 0.034 and p = 0.022, respectively). ConclusionMicrovessel proliferation is a novel marker of ongoing angiogenesis and was associated with aggressive tumour features, basal-like phenotypes, interval presentation, and prognosis in this series of breast cancer.

Lipocalin 2 expression is associated with aggressive features of endometrial cancer

BackgroundIncreased expression of lipocalin 2 (LCN2) has been observed in several cancers. The aim of the present study was to investigate LCN2 in endometrial cancer in relation to clinico-pathologic phenotype, angiogenesis, markers of epithelial-mesenchymal transition (EMT), and patient survival.MethodsImmunohistochemical staining was performed using a human LCN2 antibody on a population-based series of endometrial cancer patients collected in Hordaland County (Norway) during 1981-1990 (n = 256). Patients were followed from the time of primary surgery until death or last follow-up in 2007. The median follow-up time for survivors was 17 years. Gene expression data from a prospectively collected endometrial cancer series (n = 76) and a publicly available endometrial cancer series (n = 111) was used for gene correlation studies.ResultsExpression of LCN2 protein, found in 49% of the cases, was associated with non-endometrioid histologic type (p = 0.001), nuclear grade 3 (p = 0.001), >50% solid tumor growth (p = 0.001), ER and PR negativity (p = 0.028 and 0.006), and positive EZH2 expression (p < 0.001). LCN2 expression was significantly associated with expression of VEGF-A (p = 0.021), although not with other angiogenesis markers examined (vascular proliferation index, glomeruloid microvascular proliferation, VEGF-C, VEGF-D or bFGF2 expression). Further, LCN2 was not associated with several EMT-related markers (E-cadherin, N-cadherin, P-cadherin, β-catenin), nor with vascular invasion (tumor cells invading lymphatic or blood vessels). Notably, LCN2 was significantly associated with distant tumor recurrences, as well as with the S100A family of metastasis related genes. Patients with tumors showing no LCN2 expression had the best outcome with 81% 5-year survival, compared to 73% for intermediate and 38% for the small subgroup with strong LCN2 staining (p = 0.007). In multivariate analysis, LCN2 expression was an independent prognostic factor in addition to histologic grade and FIGO stage.ConclusionIncreased LCN2 expression is associated with aggressive features and poor prognosis in endometrial cancer.

Abstract 1372: Microvessel proliferation by co-expression of endothelial nestin and Ki-67 is associated with a basal-like phenotype and aggressive features in breast cancer

Abstract Angiogenesis, the formation of new blood vessels from pre-existing ones, is essential in tumour growth and metastasis. Microvessel density (MVD) is the most widely used method for quantification of tumour angiogenesis. We here present a novel angiogenesis marker, microvessel proliferation (MVP) based on a dual immunohistochemical stain of nestin and Ki-67. Nestin is an intermediate filament protein expressed in a variety of undifferentiated cells, including newly synthesized endothelial cells (1-3), and used in this study to stain the vasculature. Proliferating cells were recognized by their Ki-67 positivity, and immature microvessels were recognized by their nestin positivity combined with their morphology. Proliferating microvessels contains endothelial cells co-expressing nestin and Ki-67. Microvessel proliferation was estimated by vascular proliferation index (VPI), the ratio of vessels containing immature proliferating endothelial cells, and the total number of immature vessels. VPI was evaluated in 178 breast cancer tissue sections. High VPI showed significant association to several markers of aggressive breast cancer, including negative estrogen receptor (ER) status (p=0.003), high tumour cell proliferation by Ki-67 (p=0.004), high p53 expression (p=0.001), five immunohistochemical profiles for the basal-like phenotype (odds ratios (OR); range 2.8-6.3), and the triple negative phenotype (TNP)(p=0.040). Concerning the mode of detection, high VPI was three times more likely to be presented in an interval detected breast cancer compared with a screening detected (OR: 3.0, p&amp;lt;0.0005). Both in univariate and multivariate analysis, high VPI was significantly associated with poor survival (p=0.034 and p=0.022, respectively). In conclusion, activated angiogenesis, estimated by microvessel proliferation, is associated with several markers of aggressive breast cancer phenotype, basal-like breast cancer, interval detection, and a significant predictor of prognosis in this series of breast cancer. 1. Lendahl U, Zimmerman LB, McKay RD. CNS stem cells express a new class of intermediate filament protein. Cell. 1990 Feb 23;60(4):585-95. 2. Mokry J, Cizkova D, Filip S, Ehrmann J, Osterreicher J, Kolar Z, et al. Nestin expression by newly formed human blood vessels. Stem Cells Dev. 2004 Dec;13(6):658-64. 3. Mokry J, Ehrmann J, Karbanova J, Cizkova D, Soukup T, Suchanek J, et al. Expression of intermediate filament nestin in blood vessels of neural and non-neural tissues. Acta Medica (Hradec Kralove). 2008;51(3):173-9. Citation Format: {Authors}. {Abstract title} [abstract]. In: Proceedings of the 103rd Annual Meeting of the American Association for Cancer Research; 2012 Mar 31-Apr 4; Chicago, IL. Philadelphia (PA): AACR; Cancer Res 2012;72(8 Suppl):Abstract nr 1372. doi:1538-7445.AM2012-1372

Vascular proliferation is increased in basal-like breast cancer

Based on molecular sub-classification, basal-like breast cancer is associated with aggressive behavior. These tumors are frequently triple negative and lack traditional treatment targets. Angiogenesis, one of the hallmarks of cancer, is important for the local growth and spread of malignant tumors and is now a treatment target. The aim of this study was to explore whether angiogenesis is increased in relation to certain molecular subtypes of breast cancer with special focus on the basal-like category. Altogether, we analyzed a total of 431 breast cancers from two independent series after dual immunohistochemical staining of Factor VIII for endothelial cells and Ki-67 for proliferating cells. We then determined vascular proliferation in the most vascularized areas of the tumor. In both Series I and II, high vascular proliferation index (VPI) was significantly associated with expression of cytokeratin 5/6 (P = 0.001, 0.010), P-cadherin (P < 0.0005, <0.0005), epidermal growth factor receptor (P = 0.003, 0.001), the basal-like subtype (P = 0.001, 0.011), and the core basal phenotype (P = 0.002, 0.002), respectively. In Series I, high VPI was associated with the triple negative phenotype (P = 0.004) and p63 expression (P = 0.008). Tumor angiogenesis, as measured by vascular proliferation, was increased in the basal-like subtype in two independent breast cancer series and may thus be a possible treatment target in this category. Studies are required to evaluate whether this novel angiogenesis marker can be used to stratify patients for anti-angiogenesis treatment.

Vascular Proliferation Is Important for Clinical Progress of Endometrial Cancer

Angiogenesis is essential for tumor growth, invasion, and metastatic spread. Whereas microvessel density (MVD) has been widely used as a measure of tumor-associated angiogenesis, we now wanted to examine the significance of other angiogenic markers, especially vascular proliferation (by Ki-67/factor VIII staining) and the degree of pericyte coverage [by alpha-smooth muscle actin (alpha-SMA)/factor VIII staining], in a large and population-based series of endometrial carcinoma with complete follow-up. Due to limited information on the role of lymphangiogenesis in these tumors, lymphatic vessel density (LVD) by LYVE-1 staining was also determined, as well as selected angiogenic factors [vascular endothelial growth factor (VEGF)-A, VEGF-C, VEGF-D and basic fibroblast growth factor (bFGF)], which could possibly be related to vascular proliferation and lymphangiogenesis. The information on angiogenic phenotype was related to clinicopathologic features and disease progress. Median vascular proliferation, as estimated by vascular proliferation index (VPI), was 3.9% and high VPI was associated with features of aggressive tumors and decreased survival. The prognostic effect of VPI was superior to that of MVD. Presence of pericyte coverage, as estimated by the alpha-SMA index (SMAI), was 35% and low SMAI was significantly associated with vascular invasion by tumor cells and impaired prognosis. Peritumoral lymphatic vessels (LVD-pt) were found in 39.5% of the cases and high LVD-pt was significantly associated with aggressive tumor features and decreased survival. In multivariate survival analysis, only the extent of vascular proliferation had independent prognostic effect, in addition to well-known clinicopathologic factors, whereas MVD did not have significant prognostic value. In conclusion, our study indicates that vascular proliferation is a meaningful variable in assessing the angiogenic phenotype of endometrial carcinoma.