Tumor angiogenesis in patients with laryngeal cancer

Expression of prostate-specific membrane antigen in the neovasculature of primary tumors and lymph node metastasis of laryngeal squamous cell carcinomas

Background

Prostate-specific membrane antigen (PSMA) expression is encountered in tumor-associated neovascularization.

Methods

PSMA-antibody was applied to the paraffin blocks of 51 patients who were diagnosed with squamous cell carcinoma of the larynx and underwent laryngectomy and one who underwent lymph node dissection. The percentage of vascular expression in tumoral and extratumoral stroma and lymph nodes and intensity score in tumoral epithelium were evaluated and divided into groups according to the level of PSMA expression. Final PSMA expression was determined by multiplying intensity and percentage scores.

Results

The mean age was 61±10 years. Patients with perineural invasion, cartilage invasion, and local invasion exhibited higher PSMA expression scores. Age, tumor differentiation, tumor diameter, perineural invasion, tumor localization, capsular invasion, depth of invasion, surgical margin status, local invasion, nodal metastasis, TNM classification, and stage were similar in high and low PSMA expression groups. There was no PSMA expression in extratumoral vascular stroma. Significantly higher PSMA expression was observed in the vascular endothelium of metastatic lymph nodes compared with reactive lymph nodes. Patients with advanced-stage disease exhibited higher PSMA vascular expression scores compared to those with earlier stages (p<.001). PSMA expression was not correlated with overall survival, disease-specific survival, or disease-free survival (p>.05).

Conclusions

Our study suggests that higher PSMA expression is associated with cartilage invasion, local invasion, and advanced-stage of disease. PSMA expression can be utilized for detection of lymph node metastasis and has some predictive role in cases of neck metastasis.

Quantitative assessment of CD15 positive tissue eosinophils in Oral Squamous Cell Carcinoma: effects on mast cells and tumor angiogenesis

BACKGROUND

The present study determines to correlate eosinophil, mast cell and microvessel densities with the histopathological grades and clinical staging of Oral Squamous Cell Carcinoma (OSCC) cases, as the potential role of inflammatory mediators within tumor stroma remains debatable.

METHODS

The study sample comprised 60 cases consisting of 40 cases of Well to moderately differentiated OSCC (group 1) and 20 cases of poorly differentiated OSCC (group 2). Immunohistochemistry with anti-CD15 antibody and antifactor VIII antibody; and toluidine blue special stain were employed for the detection of eosinophils, microvessels, and mast cells, respectively.

RESULTS

The mean numbers of eosinophils, mast cells, and microvessels per high power field in group 1 and group 2 were 15.37±11.86 and 12.62±14.30, 6.00±4.84 and 4.51±4.51, 13.96±6.25 and 6.62±2.05, respectively. Eosinophil density had a positive correlation with both mast cell and microvessel density. Also, the correlation of primary tumor size (T status) with microvessel density was found to be statistically significant (P≤0.05).

CONCLUSIONS

The cohesive interpretation of the aforementioned mediators in OSCC suggested that while these variables correlate well with the differentiation of tumor, the quantification did not correlate with the clinical staging of the disease.

An Inflammation-Immunity Classifier of 11 Chemokines for Prediction of Overall Survival in Head and Neck Squamous Cell Carcinoma

BACKGROUND Chemokines are important in inflammation, immunity, tumor progression, and metastasis. The purpose of this research was to find an integrated-RNA signature of chemokine family genes to predict the survival prognosis in head and neck squamous carcinoma (HNSC) patients. MATERIAL AND METHODS Relevant data of 504 HNSC patients were extracted from The Cancer Genome Atlas (TCGA) database. Through analyzing RNA sequencing data, the univariate Cox model was used to identify chemokine family genes associated with survival and then to develop a multiple-RNA signature in the training set. The prediction value of this multiple-RNA signature was further verified in the validation and entire sets. The receiver operating characteristic curves were used to assess the predictive value of this multiple-RNA signature. RESULTS Eleven chemokines were included in this prognostic signature. Based on this 11-chemokine signature, we further categorized patients as high or low risk. Compared with low-risk patients, high-risk patients had shorter overall survival (OS) time in the training set [hazard ratio (HR)=3.497, 95% confidence interval (CI)=2.142-5.711, p<0.001], validation set (HR=3.575, 95% CI=1.988-6.390, p<0.001), and entire set (HR=3.416, 95% CI=2.363-4.939, p<0.001). This 11-chemokine signature was an independent prognostic factor for OS in these datasets (p<0.05). The AUC values for predicting overall survival within 48 months in the training, validation, and entire sets were 0.71, 0.69, and 0.69, respectively. CONCLUSIONS This 11-chemokine signature could serve as a reliable prognostic tool for HNSC patients and might be useful to guide individualized treatment or even gene target therapy for high-risk patients.

CD31 and VEGF are prognostic biomarkers in early-stage, but not in late-stage, laryngeal squamous cell carcinoma

Background

Patients suffering from squamous cell carcinoma of the larynx (LSCC) with lymphatic metastasis have a relatively poor prognosis and often require radical therapeutic management. The mechanisms which drive metastasis to the lymph nodes are largely unknown but may be promoted by a pro-angiogenic tumor microenvironment. In this study, we examined whether the number of microvessels and the expression level of vascular endothelial growth factor (VEGF) in the primary tumor are correlated with the degree of lymph node metastasis (N-stage), tumor staging (T) and survival time in LSCC patients.

Methods

Tissue-Microarrays of 97 LSCC patients were analyzed using immunohistochemistry. The expression of VEGF was scored as intensity of staining (low vs high) and the number of CD31-positive vessels (median </≥7 vessels per visual field) was counted manually. Scores were correlated with N-stage, T-stage and 5-year overall survival rate.

Results

A high expression of angiogenic biomarkers was not associated with poor overall survival in the overall cohort of patients. Instead high CD31 count was associated with early stage cancer (p = 0.004) and in this subgroup high VEGF expression correlated with poor survival (p = 0.032). Additionally, in early stage cancer a high vessel count was associated with an increased recurrence rate (p = 0.004).

Conclusion

Only in the early stage subgroup a high expression of angiogenic biomarkers was associated with reduced survival and an increased rate of recurrence. Thus, biomarkers of angiogenesis may be useful to identify high risk patients specifically in early stage LSCC.

Cyclin D1, p53, MIB1, Intratumoral Microvessel Density, and Human Papillomavirus in Advanced Laryngeal Carcinoma: Association with Nodal Metastasis

OBJECTIVE: We sought to study various parameters in laryngeal squamous cell carcinoma (LSCC) that might predict nodal metastasis.

STUDY DESIGN AND SETTING: Sixty-four LSCCs were examined with respect to their histopathology and, using immunohistochemistry, their proliferative capacity (MIB1), p53 and cyclin D1 status, and intratumoral microvessel density. The presence of human papillomavirus was ascertained by the polymerase chain reaction.

RESULTS: Histopathologically, most tumors had an infiltrating/mixed growth pattern and a diminished inflammatory reaction at the growing margin. In addition, 56% of the tumors were positive for MIB1, with 64% showing p53 overexpression; 70% were positive for cyclin D1; and 59% showed increased tumor microvessel density. Of 42 cases analyzed, 9.5% were positive for human papillomavirus 16.

CONCLUSIONS: Of the parameters studied, a diminished lymphocytic inflammatory response at the periphery ( P < 0.05) and cyclin D1 overexpression ( P < 0.001) correlated significantly with cervical nodal metastasis at presentation.

SIGNIFICANCE: Cyclin D1 overexpression, easily assessed on biopsy samples, may thus help in optimizing therapy at the outset.

Effect of Laryngeal Squamous Cell Carcinoma Tissue Implantation on the Chick Embryo Chorioallantoic Membrane: Morphometric Measurements and Vascularity

BACKGROUND

The aim of this study was to develop chick embryo chorioallantoic membrane (CAM) model of laryngeal squamous cell carcinoma (LSCC) and to evaluate the morphological and morphometric characteristics and angiogenic features of it.

METHODS

Fresh LSCC tissue samples obtained from 6 patients were implanted onto 15 chick embryo CAMs. Morphological, morphometric, and angiogenic changes in the CAM and chorionic epithelium were evaluated up to 4 days after the tumor implantation. Immunohistochemical analysis (34βE12, CD31, and Ki67 staining) was performed to detect cytokeratins and tumor endothelial cells and to evaluate the proliferative capacity of the tumor before and after implantation on the CAM.

RESULTS

The implanted LSCC tissue samples survived on the CAM in all the experiments and retained the essential morphologic characteristics and proliferative capacity of the original tumor. Implants induced thickening of both the CAM (103-417%, p = 0.0001) and the chorionic epithelium (70-140%, p = 0.0001) and increase in number of blood vessels (75-148%, p = 0.0001) in the CAM.

CONCLUSIONS

This study clarifies that chick embryo CAM is a relevant assay for implanting LSCC tissue and provides the first morphological and morphometric characterization of the LSCC CAM model that opens new perspectives to study this disease.

CT perfusion can predict overexpression of CXCL8 (interleukin-8) in head and neck squamous cell carcinoma

BACKGROUND AND PURPOSE

Increased angiogenesis in head and neck squamous cell carcinoma correlates to more aggressive tumors with increased morbidity. Because both elevated blood flow and high serum CXCL8 levels are correlated with increased angiogenesis, our objective was to see if elevated blood flow measured with CT perfusion correlated with CXCL8 levels, thereby helping to identify candidates for targeted therapies that inhibit the Bcl-2 proangiogenic pathway associated with CXCL8.

MATERIALS AND METHODS

Seven patients with locally recurrent or metastatic head and neck squamous cell carcinoma were enrolled in the trial. These patients underwent CT perfusion and the following parameters were measured: blood volume, blood flow, capillary permeability, and MTT; relative values were calculated by dividing by normal-appearing muscle. Serum was drawn for CXCL8 enzyme-linked immunosorbent assay analysis in these patients.

RESULTS

There was a significant positive correlation between the CXCL8 levels and relative blood flow (r = 0.94; P = .01). No correlation was found between CXCL8 and relative blood volume, relative capillary permeability, or relative MTT.

CONCLUSIONS

Relative blood flow may be useful as a surrogate marker for elevated CXCL8 in patients with head and neck squamous cell cancer. Patients with elevated relative blood flow may benefit from treatment targeting the Bcl-2 proangiogenic pathways.

Esophageal squamous cell carcinoma: assessing tumor angiogenesis using multi-slice CT perfusion imaging

OBJECTIVES

The purpose of this study was to investigate the correlation between multi-slice computed tomographic perfusion imaging (CTPI) parameters and immunohistologic markers of angiogenesis in esophageal squamous cell carcinoma (ESCC).

METHODS

Fifty patients with histologically proven esophageal squamous cell carcinoma were enrolled in this study. All subjects underwent multi-slice CT perfusion scan. The hemodynamic parameters of vascular tumor, including blood volume (BV), blood flow (BF), mean transit time (MTT) and permeability surface (PS) were generated. All the ESCC specimens were stained immunohistochemically to identify CD31 for quantification of microvessel density (MVD). CTPI parameters were correlated with MVD by using Pearson correlation analysis.

RESULTS

The value of CT perfusion parameters of ESCC were as follows: BF 116.71 ± 47.59 ml/100 g/min, BV 6.74 ± 2.70 ml/100 g, MTT 6.42 ± 2.84 s, PS 13.82 ± 6.25 ml/100 g/min. The mean MVD of all 50 tumor specimens was 34.44 ± 19.75. The PS values were significantly higher in ESCC patients with involvement of lymph node than those without involvement of lymph node (p < 0.01). Blood volume and permeability surface were positively correlated with MVD (p < 0.01), whereas no significant correlation was observed between MVD and BF or between MVD and MTT.

CONCLUSIONS

Blood volume and permeability surface were positively correlated with MVD. CTPI could reflect the angiogenesis in ESCC.

Vascularity index of laryngeal cancer derived from 3-D ultrasound: a predicting factor for the in vivo assessment of cervical lymph node status

To demonstrate whether a calculated vascularity index (VI) can predict metastases of cervical lymph nodes, the VI values of the primary tumors were obtained by using 3-D sonography in 87 subjects with laryngeal cancer confirmed by laryngoscope and biopsy. N-staging of the subjects was determined by pathological nodal harvesting. The relationship between the VI and pathological N-staging was evaluated by correlation coefficient. To test the accuracy of the VI for predicting cervical lymph node involvement, a receiver operating characteristic (ROC) curve was constructed, and the best operating point was determined by Youden's index. For comparison, 2-D sonography was applied to detect metastatic cervical lymph nodes. The accuracy, sensitivity and specificity of the VI, 2-D sonography and a combination of the two methods for diagnosis of metastatic cervical lymph nodes were compared. There was a positive linear correlation between the VI and pN-staging (r=0.740, p<0.001). The area under the ROC curve for the VI was 0.919. The best operating point of the VI was 4.4565, which derived higher sensitivity than that of 2-D sonography (95% vs. 81%, p=0.031), but lower specificity (75% vs. 95%, p=0.012). The combination of the two methods yielded a higher accuracy (97% vs. 85% and 89%, p=0.002 and 0.016), a higher sensitivity to 2-D sonography (95% vs. 81%, p=0.031) and a higher specificity to VI (98% vs. 75%, p=0.002). The VI of laryngeal cancer can be a useful factor for predicting metastases of cervical lymph nodes.

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

INTRODUCTION AND OBJECTIVES

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

MATERIAL AND METHODS

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

RESULTS

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

CONCLUSIONS

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

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

OBJECTIVES

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Inducible nitric oxide synthase expression in various laryngeal lesions in relation to carcinogenesis, angiogenesis, and patients' prognosis

CONCLUSIONS

The inducible nitric oxide synthase (iNOS) expression leading to vascular endothelial growth factor (VEGF) overexpression may be useful as a factor for predicting recurrence after initial treatment and prognosis in laryngeal squamous cell carcinoma (SCC).

OBJECTIVE

We analyzed expression of iNOS, p53, and VEGF in various laryngeal lesions.

MATERIALS AND METHODS

The study samples consisted of 63 SCC, 20 dysplasia, 7 polyp, and 5 normal epithelium of the larynx. The expression of iNOS, p53, and VEGF was identified by immunohistological methods.

RESULTS

No positive immunostaining for iNOS, p53, and VEGF was observed in normal epithelium and polyps. In contrast, with the progression from mild/moderate dysplasia to severe dysplasia to carcinoma, their expression levels increased. In dysplasia, there was a significant positive correlation among expression of iNOS, p53, and VEGF. In SCC, iNOS expression correlated with VEGF overexpression and microvessel density, but not with p53 overexpression. In SCC, the expression of iNOS and VEGF significantly increased in patients who developed local recurrence and/or metastases after initial treatments. Kaplan-Meier analysis showed that disease-free survival was significantly shorter in patients with iNOS or VEGF expression. Multivariate analysis showed expression of iNOS and VEGF as independent indicators for poor disease-free survival.

Prognostic relevance of CD105+ microvessel density in HNSCC patient outcome

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

Preradiotherapy Hemoglobin Level but not Microvessel Density Predicts Locoregional Control and Survival in Laryngeal Cancer Treated with Primary Radical Radiotherapy

PURPOSE

To evaluate the roles of preradiotherapy hemoglobin level and microvessel density (MVD) as predictive factors for tumor control and survival in patients with laryngeal cancer treated with primary radiotherapy.

EXPERIMENTAL DESIGN

Two hundred and fourteen patients with stage I-IV laryngeal cancer were included in the analysis. Patients were treated with once daily fractionated radiotherapy over 6.5 weeks or twice daily fractionated radiotherapy over 4.5 weeks up to total doses of 62 to 68 Gy. Preradiotherapy hemoglobin levels were obtained from patient journals, and pretreatment tumor biopsies were stained with CD34 antibody for the counting of microvessels. The prognostic implication of preradiotherapy hemoglobin level and MVD on tumor control and survival was tested.

RESULTS

Five-year locoregional control probability was 88.9% for patients with preradiotherapy hemoglobin levels >137.5 g/L (median) and 64.4% for patients with preradiotherapy hemoglobin levels <137.5 g/L (P = 0.01). The corresponding figures for disease-free survival were 87.8 and 62.8% (P = 0.007), respectively, and for overall survival 58.1 and 40.3% (P < 0.001), respectively. In multivariate analysis, tumor stage and preradiotherapy hemoglobin level were significant prognostic factors for locoregional control and disease-free survival, whereas tumor stage, preradiotherapy hemoglobin-level, gender, and age were significant prognostic factors for overall survival. No correlation was found between MVD and tumor control and survival.

CONCLUSION

Preradiotherapy hemoglobin level, but not MVD, predicts locoregional control and survival in patients with laryngeal cancer treated with radiotherapy.

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

AIMS

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Clinical relevance of microvessel density in laryngeal squamous cell carcinomas

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

Molecular markers predictive of response and prognosis in the patient with advanced squamous cell carcinoma of the head and neck: evolution of a model beyond TNM staging

Advanced head and neck cancer is a disease with poor prognosis. TNM staging is an inadequate prognostic indicator of individual response to evolving multimodal therapies. New markers have been studied in progressively more refined analyses. Even though their role in predicting response and prognosis of head and neck cancer is still under evolution, it is becoming clear that individual markers are inadequate in constructing a prognostically meaningful tumor profile for each patient. Rather the combined study of a number of well-characterized markers acting in unrelated cellular pathways may be much more successful in defining prognostic patient categories of greater utility than traditional TNM staging. Special attention should also be paid to the expression pattern and location of tumor markers within the biopsy specimen as these parameters also appear to influence prognostic significance.