Prognostic significance of vascular endothelial cell growth factors -A, -C and -D in breast cancer and their relationship with angio- and lymphangiogenesis

Abstract

Vascular endothelial cell growth factors (VEGF)-A, -C and -D have potent angio and lymphangiogenic functions in experimental models, although their role in the progression of human breast cancer is unclear. The aims of the current study were to examine the relationship between the expression of the aforementioned growth factors with the angio and lymphangiogenic characteristics of breast cancer, and to assess their suitability as potential prognostic factors. Paraffin-embedded sections of 177 primary invasive breast cancer, with complete clinical follow-up information for 10 years, were stained for VEGF-A, -C, -D, podoplanin and CD34 using standard immunohistochemical approaches. The expression of the growth factors was correlated with clinicopathological criteria and patients' survival. Lymph vessel density (LVD) and microvessel density (MVD) were assessed and correlated with expression of the growth factors. Vascular endothelial cell growth factor-A, -C and -D were highly expressed in 40, 37 and 42% of specimens, respectively. High expression of VEGF-A and - C, but not of -D, was associated with a higher LVD (P=0.013 and P=0.014, respectively), a higher MVD (P<0.001 and P=0.002, respectively), the presence of lymph node metastasis (P<0.001 and P<0.001, respectively), distant metastasis (P=0.010 and P=0.008, respectively) and a shorter Overall Survival (P=0.029 and 0.028, respectively). In conclusion, breast cancers that express high levels of VEGF-A and -C are characterised by a poor prognosis, likely through the induction of angio and lymphangiogenesis. Examination of expression of VEGF-A and -C in breast cancer may be beneficial in the identification of a subset of tumours that have a higher probability of recurrence and metastatic spread.

Figure 1

(A) Peritumoural area of a breast carcinoma section stained with VEGF-A showing positive staining in the endothelial cells (red arrow) and in the macrophages (green arrow), × 400. (B) Grade-III infiltrating breast carcinoma showing heterogeneous staining intensity for VEGF-A in the same specimen; tumour sheets with weak staining intensity on the left and others with strong staining intensity on the right, × 200. (C) VEGF-C-stained tumour section showing strong positive staining in the tumour-associated macrophages (red arrow) and in the tumour cells, × 400. (D) Grade-II infiltrating breast carcinoma showing strong positive staining with VEGF-D, × 100.

Figure 2

(A) Infiltrating duct carcinoma of the breast stained with podoplanin showing multiple lymphatics at the peritumoural area with a lymphatic invasion in one of the vessels (arrow), × 200. (B) Infiltrating duct carcinoma of the breast stained with CD34 showing high MVD, × 200.

Figure 3

Box plots showing relationships between expression of VEGF-A and -C with MVD and LVD, with the middle line in each box representing the median value.

Figure 4

Associations between expression of VEGF-A and -C with patient prognosis using Kaplan–Meier method. High expression of VEGF-A is significantly associated with decreased OS (A). High expression of VEGF-C is significantly associated with decreased OS (B) and DFI (C). Comparison between survival in four groups: group A (low expression of both VEGF-A and VEGF-C, group B; (high expression VEGF-A), group C; (high expression of VEGF-C) and group D; (high expression of both VEGF-A and VEGF-C) showing that group D has the worst prognosis.