Background and Aims: Well-differentiated neuro-endocrine ileal carcinoids are composed of serotonin-producing enterochromaffin (EC) cells. Life expectancy is determined by metastatic spread to the liver because medical treatment options are still very limited. Selective inhibition of angiogenesis or lymphangiogenesis might prevent tumour growth and metastatic spread. We examined the role of the vascular endothelial growth factors (VEGFs) A, B, C, D, and their receptors (VEGFRs) 1, 2, 3 in angiogenesis and lymphangiogenesis of ileal EC cell carcinoids with and without liver metastases. Methods: The expression of various VEGFs and VEGFRs was determined by quantitative real-time RT-PCR in healthy mucosa, primary tumour, lymph node metastases and liver metastases of 25 patients with ileal EC cell carcinoids. Microvessel density (MVD) was determined by CD-31 staining in primary tumours and lymphatic vessel density (LVD) by LYVE-1 staining. VEGF expression levels, MVD, LVD, and patients’ survival time were correlated using logistic regression and Kaplan-Meier survival analysis. Results: VEGF-A was highly expressed with no difference between normal mucosa and tumours. VEGF-B and -D as well as VEGFR-1 and -2 expression levels were significantly increased in the tumours when compared to normal mucosa. Patients with liver metastasis, however, had a significantly lower expression of the factors A, B, and C and the receptors 2 and 3. MVD in primary tumours positively correlated with the expression of VEGF ligands and their receptors, except for VEGF-D. LVD did not correlate with any VEGF ligand or receptor. Interestingly, low expression levels of VEGF-B were associated with poor survival. Conclusion: Patients with more aggressive metastatic spreading had relatively decreased expression levels of VEGF ligands and receptors. Thus, anti-angiogenic therapy may not be a suitable target in metastatic ileal EC cell carcinoids.

1.
Levy AD, Sobin LH: From the archives of the AFIP: gastrointestinal carcinoids: imaging features with clinicopathologic comparison. Radiographics 2007;27:237–257.
2.
Capella C, Heitz PU, Hofler H, Solcia E, Kloppel G: Revised classification of neuroendocrine tumours of the lung, pancreas and gut. Virchows Arch 1995;425:547–560.
3.
Janson ET, Holmberg L, Stridsberg M, Eriksson B, Theodorsson E, Wilander E, Oberg K: Carcinoid tumors: analysis of prognostic factors and survival in 301 patients from a referral center. Ann Oncol 1997;8:685–690.
4.
Tomassetti P, Campana D, Piscitelli L, Casadei R, Nori F, Brocchi E, Santini D, Pezzilli R, Corinaldesi R: Endocrine tumors of the ileum: factors correlated with survival. Neuroendocrinology 2006;83:380–386.
5.
Roukos DH, Kappas AM: Perspectives in the treatment of gastric cancer. Nat Clin Pract Oncol 2005;2:98–107.
6.
Hofler H, Stier A, Schusdziarra V, Siewert JR: Classification of neuroendocrine tumors of the gastrointestinal tract and pancreas and its therapeutic relevance. Chirurg 1997;68:107–115.
7.
Carmeliet P, Jain RK: Angiogenesis in cancer and other diseases. Nature 2000;407:249–257.
8.
Das S, Skobe M: Lymphatic vessel activation in cancer. Ann NY Acad Sci 2008;1131:235–241.
9.
Ferrara N, Gerber HP, LeCouter J: The biology of VEGF and its receptors. Nat Med 2003;9:669–676.
10.
Nash AD, Baca M, Wright C, Scotney PD: The biology of vascular endothelial growth factor-B (VEGF-B). Pulm Pharmacol Ther 2006;19:61–69.
11.
Makinen T, Veikkola T, Mustjoki S, Karpanen T, Catimel B, Nice EC, Wise L, Mercer A, Kowalski H, Kerjaschki D, Stacker SA, Achen MG, Alitalo K: Isolated lymphatic endothelial cells transduce growth, survival and migratory signals via the VEGF-C/D receptor VEGFR-3. EMBO J 2001;20:4762–4773.
12.
Tammela T, Enholm B, Alitalo K, Paavonen K: The biology of vascular endothelial growth factors. Cardiovasc Res 2005;65:550–563.
13.
Schnirer II, Yao JC, Ajani JA: Carcinoid – A comprehensive review. Acta Oncol 2003;42:672–692.
14.
Terris B, Scoazec JY, Rubbia L, Bregeaud L, Pepper MS, Ruszniewski P, Belghiti J, Flejou J, Degott C: Expression of vascular endothelial growth factor in digestive neuroendocrine tumours. Histopathology 1998;32:133–138.
15.
Zhang J, Jia Z, Li Q, Wang L, Rashid A, Zhu Z, Evans DB, Vauthey JN, Xie K, Yao JC: Elevated expression of vascular endothelial growth factor correlates with increased angiogenesis and decreased progression-free survival among patients with low-grade neuroendocrine tumors. Cancer 2007;109:1478–1486.
16.
Couvelard A, O’Toole D, Turley H, Leek R, Sauvanet A, Degott C, Ruszniewski P, Belghiti J, Harris AL, Gatter K, Pezzella F: Microvascular density and hypoxia-inducible factor pathway in pancreatic endocrine tumours: negative correlation of microvascular density and VEGF expression with tumour progression. Br J Cancer 2005;92:94–101.
17.
Rindi G, Kloppel G, Couvelard A, Komminoth P, Korner M, Lopes JM, McNicol AM, Nilsson O, Perren A, Scarpa A, Scoazec JY, Wiedenmann B: TNM staging of midgut and hindgut (neuro) endocrine tumors: a consensus proposal including a grading system. Virchows Arch 2007;451:757–762.
18.
Rad R, Gerhard M, Lang R, Schoniger M, Rosch T, Schepp W, Becker I, Wagner H, Prinz C: The Helicobacter pylori blood group antigen-binding adhesin facilitates bacterial colonization and augments a nonspecific immune response. J Immunol 2002;168:3033–3041.
19.
Rad R, Brenner L, Bauer S, Schwendy S, Layland L, da Costa CP, Reindl W, Dossumbekova A, Friedrich M, Saur D, Wagner H, Schmid RM, Prinz C: CD25+/Foxp3+ T cells regulate gastric inflammation and Helicobacter pylori colonization in vivo. Gastroenterology 2006;131:525–537.
20.
Weidner N, Semple JP, Welch WR, Folkman J: Tumor angiogenesis and metastasis – Correlation in invasive breast carcinoma. N Engl J Med 1991;324:1–8.
21.
Florez-Vargas A, Vargas SO, Debelenko LV, Perez-Atayde AR, Archibald T, Kozakewich HP, Zurakowski D: Comparative analysis of D2–40 and LYVE-1 immunostaining in lymphatic malformations. Lymphology 2008;41:103–110.
22.
Sipos B, Klapper W, Kruse ML, Kalthoff H, Kerjaschki D, Kloppel G: Expression of lymphangiogenic factors and evidence of intratumoral lymphangiogenesis in pancreatic endocrine tumors. Am J Pathol 2004;165:1187–1197.
23.
Bashshur ZF, Haddad ZA, Schakal A, Jaafar RF, Saab M, Noureddin BN: Intravitreal bevacizumab for treatment of neovascular age-related macular degeneration: a one-year prospective study. Am J Ophthalmol 2008;145:249–256.
24.
Fieth C, Kebig A, Mohr K: Angiogenesis inhibitors in cancer therapy. Bevacizumab against colon carcinoma. Pharm Unserer Zeit 2007;36:442–445.
25.
La Rosa S, Uccella S, Finzi G, Albarello L, Sessa F, Capella C: Localization of vascular endothelial growth factor and its receptors in digestive endocrine tumors: correlation with microvessel density and clinicopathologic features. Hum Pathol 2003;34:18–27.
26.
Nagy JA, Vasile E, Feng D, Sundberg C, Brown LF, Detmar MJ, Lawitts JA, Benjamin L, Tan X, Manseau EJ, Dvorak AM, Dvorak HF: Vascular permeability factor/vascular endothelial growth factor induces lymphangiogenesis as well as angiogenesis. J Exp Med 2002;196:1497–1506.
27.
Burton JB, Priceman SJ, Sung JL, Brakenhielm E, An DS, Pytowski B, Alitalo K, Wu L: Suppression of prostate cancer nodal and systemic metastasis by blockade of the lymphangiogenic axis. Cancer Res 2008;68:7828–7837.
28.
Aase K, Lymboussaki A, Kaipainen A, Olofsson B, Alitalo K, Eriksson U: Localization of VEGF-B in the mouse embryo suggests a paracrine role of the growth factor in the developing vasculature. Dev Dyn 1999;215:12–25.
29.
Li X, Aase K, Li H, von Euler G, Eriksson U: Isoform-specific expression of VEGF-B in normal tissues and tumors. Growth Factors 2001;19:49–59.
30.
Salven P, Lymboussaki A, Heikkila P, Jaaskela-Saari H, Enholm B, Aase K, von EG, Eriksson U, Alitalo K, Joensuu H: Vascular endothelial growth factors VEGF-B and VEGF-C are expressed in human tumors. Am J Pathol 1998;153:103–108.
31.
Otrock ZK, Makarem JA, Shamseddine AI: Vascular endothelial growth factor family of ligands and receptors: review. Blood Cells Mol Dis 2007;38:258–268.
32.
Bhardwaj S, Roy H, Gruchala M, Viita H, Kholova I, Kokina I, Achen MG, Stacker SA, Hedman M, Alitalo K, Yla-Herttuala S: Angiogenic responses of vascular endothelial growth factors in periadventitial tissue. Hum Gene Ther 2003;14:1451–1462.
33.
Reichelt M, Shi S, Hayes M, Kay G, Batch J, Gole GA, Browning J: Vascular endothelial growth factor-B and retinal vascular development in the mouse. Clin Experiment Ophthalmol 2003;31:61–65.
34.
Rissanen TT, Markkanen JE, Gruchala M, Heikura T, Puranen A, Kettunen MI, Kholova I, Kauppinen RA, Achen MG, Stacker SA, Alitalo K, Yla-Herttuala S: VEGF-D is the strongest angiogenic and lymphangiogenic effector among VEGFs delivered into skeletal muscle via adenoviruses. Circ Res 2003;92:1098–1106.
35.
Silvestre JS, Tamarat R, Ebrahimian TG, Le-Roux A, Clergue M, Emmanuel F, Duriez M, Schwartz B, Branellec D, Levy BI: Vascular endothelial growth factor-B promotes in vivo angiogenesis. Circ Res 2003;93:114–123.
36.
Wafai R, Tudor EM, Angus JA, Wright CE: Vascular effects of FGF-2 and VEGF-B in rabbits with bilateral hind limb ischemia. J Vasc Res 2009;46:45–54.
37.
Wright CE: Effects of vascular endothelial growth factor (VEGF)A and VEGFB gene transfer on vascular reserve in a conscious rabbit hindlimb ischaemia model. Clin Exp Pharmacol Physiol 2002;29:1035–1039.
38.
Mould AW, Greco SA, Cahill MM, Tonks ID, Bellomo D, Patterson C, Zournazi A, Nash A, Scotney P, Hayward NK, Kay GF: Transgenic overexpression of vascular endothelial growth factor-B isoforms by endothelial cells potentiates postnatal vessel growth in vivo and in vitro. Circ Res 2005;97:e60–e70.
39.
Li Y, Zhang F, Nagai N, Tang Z, Zhang S, Scotney P, Lennartsson J, Zhu C, Qu Y, Fang C, Hua J, Matsuo O, Fong GH, Ding H, Cao Y, Becker KG, Nash A, Heldin CH, Li X: VEGF-B inhibits apoptosis via VEGFR-1-mediated suppression of the expression of BH3-only protein genes in mice and rats. J Clin Invest 2008;118:913–923.
40.
Hanrahan V, Currie MJ, Gunningham SP, Morrin HR, Scott PA, Robinson BA, Fox SB: The angiogenic switch for vascular endothelial growth factor (VEGF)-A, VEGF-B, VEGF-C, and VEGF-D in the adenoma-carcinoma sequence during colorectal cancer progression. J Pathol 2003;200:183–194.
41.
Kawakami M, Furuhata T, Kimura Y, Yamaguchi K, Hata F, Sasaki K, Hirata K: Expression analysis of vascular endothelial growth factors and their relationships to lymph node metastasis in human colorectal cancer. J Exp Clin Cancer Res 2003;22:229–237.
42.
Stacker SA, Achen MG, Jussila L, Baldwin ME, Alitalo K: Lymphangiogenesis and cancer metastasis. Nat Rev Cancer 2002;2:573–583.
43.
Duff SE, Li C, Jeziorska M, Kumar S, Saunders MP, Sherlock D, O’Dwyer ST, Jayson GC: Vascular endothelial growth factors C and D and lymphangiogenesis in gastrointestinal tract malignancy. Br J Cancer 2003;89:426–430.
44.
Karkkainen MJ, Petrova TV: Vascular endothelial growth factor receptors in the regulation of angiogenesis and lymphangiogenesis. Oncogene 2000;19:5598–5605.
45.
Veikkola T, Karkkainen M, Claesson-Welsh L, Alitalo K: Regulation of angiogenesis via vascular endothelial growth factor receptors. Cancer Res 2000;60:203–212.
46.
Juttner S, Wissmann C, Jons T, Vieth M, Hertel J, Gretschel S, Schlag PM, Kemmner W, Hocker M: Vascular endothelial growth factor-D and its receptor VEGFR-3: two novel independent prognostic markers in gastric adenocarcinoma. J Clin Oncol 2006;24:228–240.
47.
Onogawa S, Kitadai Y, Tanaka S, Kuwai T, Kimura S, Chayama K: Expression of VEGF-C and VEGF-D at the invasive edge correlates with lymph node metastasis and prognosis of patients with colorectal carcinoma. Cancer Sci 2004;95:32–39.
48.
Weigand M, Hantel P, Kreienberg R, Waltenberger J: Autocrine vascular endothelial growth factor signalling in breast cancer. Evidence from cell lines and primary breast cancer cultures in vitro. Angiogenesis 2005;8:197–204.
49.
Kulke MH, Lenz HJ, Meropol NJ, Posey J, Ryan DP, Picus J, Bergsland E, Stuart K, Tye L, Huang X, Li JZ, Baum CM, Fuchs CS: Activity of sunitinib in patients with advanced neuroendocrine tumors. J Clin Oncol 2008;26:3403–3410.
50.
Roskoski R Jr: Vascular endothelial growth factor (VEGF) signaling in tumor progression. Crit Rev Oncol Hematol 2007;62:179–213.
51.
Lee S, Chen TT, Barber CL, Jordan MC, Murdock J, Desai S, Ferrara N, Nagy A, Roos KP, Iruela-Arispe ML: Autocrine VEGF signaling is required for vascular homeostasis. Cell 2007;130:691–703.
52.
Folkman J: Angiogenesis. Annu Rev Med 2006;57:1–18.
53.
Zetter BR: Angiogenesis and tumor metastasis. Annu Rev Med 1998;49:407–424.
54.
Poncet G, Villaume K, Walter T, Pourreyron C, Theillaumas A, Lepinasse F, Hervieu V, Cordier-Bussat M, Scoazec JY, Roche C: Angiogenesis and tumor progression in neuroendocrine digestive tumors. J Surg Res 2009;154:68–77.
55.
Takahashi Y, Kishima-Fukasawa Y, Kobayashi N, Sano T, Kosuge T, Nimura Y, Kanai Y, Hiraoka N: Prognostic value of tumor architecture, tumor-associated vascular characteristics, and expression of angiogenic molecules in pancreatic endocrine tumors. Clin Cancer Res 2007;13:187–196.
56.
Sundar SS, Ganesan TS: Role of lymphangiogenesis in cancer. J Clin Oncol 2007;25:4298–4307.
57.
Choi JH, Oh YH, Park YW, Baik HK, Lee YY, Kim IS: Correlation of vascular endothelial growth factor-D expression and VEGFR-3-positive vessel density with lymph node metastasis in gastric carcinoma. J Korean Med Sci 2008;23:592–597.
58.
Gu Y, Qi X, Guo S: Lymphangiogenesis induced by VEGF-C and VEGF-D promotes metastasis and a poor outcome in breast carcinoma: a retrospective study of 61 cases. Clin Exp Metastasis 2008;25:717–725.
59.
Zhang B, Zhao WH, Zhou WY, Yu WS, Yu JM, Li S: Expression of vascular endothelial growth factors-C and -D correlate with evidence of lymphangiogenesis and angiogenesis in pancreatic adenocarcinoma. Cancer Detect Prev 2007;31:436–442.
60.
Voland P, Besig S, Rad R, Braun T, Baur DM, Perren A, Langer R, Hofler H, Prinz C: Correlation of matrix metalloproteinases and tissue inhibitors of matrix metalloproteinase expression in ileal carcinoids, lymph nodes and liver metastasis with prognosis and survival. Neuroendocrinology 2009;89:66–78.
61.
Kulke MH, Freed E, Chiang DY, Philips J, Zahrieh D, Glickman JN, Shivdasani RA: High-resolution analysis of genetic alterations in small bowel carcinoid tumors reveals areas of recurrent amplification and loss. Genes Chromosomes Cancer 2008;47:591–603.
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