The clinical relevance of serum vascular endothelial growth factor (VEGF) in correlation to circulating tumor cells and other serum biomarkers in patients with metastatic breast cancer
VEGF is one of the most important angiogenesis-stimulating cytokines and has been previously shown to be overexpressed in several solid cancers. The aim of the present study was to assess the clinical relevance of serum VEGF (sVEGF) in a large cohort of metastatic breast cancer patients and to explore the relationship between sVEGF and other blood-based biomarkers.
Two hundred fifty-three patients with metastatic breast cancer were enrolled in this prospective, multicentre study. Blood samples were collected before start of first-line or later-line treatment. sVEGF was quantified by a commercially available ELISA. Circulating tumor cells (CTCs) were detected using CellSearch and other biomarkers (EGFR, HER2, RAS p21, TIMP1, CAIX) by ELISA.
Levels of sVEGF were determined in all patients, with a median concentration of 231 pg/ml. After a median follow-up of 19 months, median overall survival (OS) was 10.2 months in patients with sVEGF levels above the upper quartile (i.e. 367 pg/ml), while median OS has not been reached in patients with sVEGF < 367 pg/ml (p < 0.001). Median progression-free survival (PFS) was 4.8 months for patients with sVEGF ≥ 367 pg/ml versus 9.1 months with sVEGF levels < 367 pg/ml (p < 0.001). Patients with sVEGF levels ≥ 367 pg/ml and ≥ 5 CTCs had the shortest OS, while those with sVEGF < 367 pg/ml and non-elevated CTCs had the longest OS. CTCs, grading, line of therapy and RAS p21 were independent predictors of OS. sVEGF, line of therapy and CTCs were independent predictors of PFS in the multivariate analysis.
Metastatic breast cancer patients with elevated levels of sVEGF have significantly worse clinical outcome. This finding supports the biological role of VEGF in breast cancer. Trial registration: Current Controlled Trials ISRCTN59722891 (DETECT).
KeywordsBreast cancer VEGF Circulating tumor cell Survival Biomarker
TF, WJ, BA, PAF, SKB, KP, BR, SR, EFS, AH and VM designed and conducted the study. MBP analyzed and interpreted the data, performed statistical analysis and prepared the manuscript. TF, IW, PAF and VM analyzed and interpreted the data and were major contributors in writing the manuscript. All authors read and approved the final manuscript.
The DETECT study was supported by a research grant from Roche Pharma AG, Germany and by Adnagen AG, Germany. ELISA kits were provided at no cost by Oncogene Science. The funding agencies had no role in study design or collection, analysis and interpretation of data or in the writing of the manuscript.
Compliance with Ethical Standards
Conflict of interest
Wolfgang Janni received a research grant from Roche. Bahriye Aktas has served as a consultant/advisor for Roche, Pfizer and Novartis. Klaus Pantel has served as a consultant/advisor for Agena Bioscience. Sabine Kasimir-Bauer has served as a consultant/advisor for Qiagen. Peter A. Fasching has served as a consultant/advisor for Amgen, Novartis, Roche, Pfizer, Teva and Puma Celgene and received a research grant from Novartis. Brigitte Rack has received honoraria or research grants from Novartis, Roche, Pfizer, Janssen Diagnostics, Astra Zeneca, Novartis, Lilly, Chugai and Sanofi. Malgorzata Banys-Paluchowski, Isabell Witzel, Sabine Riethdorf, Andreas Hartkopf, Erich-Franz Solomayer, Tanja Fehm and Volkmar Müller declare that they have no conflicts of interest.
All procedures performed in this study were in accordance with the ethical standard of the institutional and national research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards. The study was approved by the local ethical committees of participation institutions.
Informed consent was obtained from all individual participants included in the study.
- 6.Eppenberger U, Kueng W, Schlaeppi JM, Roesel JL, Benz C, Mueller H, Matter A, Zuber M, Luescher K, Litschgi M, Schmitt M, Foekens JA, Eppenberger-Castori S (1998) Markers of tumor angiogenesis and proteolysis independently define high- and low-risk subsets of node-negative breast cancer patients. J Clin Oncol 16:3129–3136. https://doi.org/10.1200/JCO.19184.108.40.20629 CrossRefPubMedGoogle Scholar
- 8.Manders P, Beex LV, Tjan-Heijnen VC, Geurts-Moespot J, Van Tienoven TH, Foekens JA, Sweep CG (2002) The prognostic value of vascular endothelial growth factor in 574 node-negative breast cancer patients who did not receive adjuvant systemic therapy. Br J Cancer 87:772–778. https://doi.org/10.1038/sj.bjc.6600555 CrossRefPubMedPubMedCentralGoogle Scholar
- 9.Linardou H, Kalogeras KT, Kronenwett R, Kouvatseas G, Wirtz RM, Zagouri F, Gogas H, Christodoulou C, Koutras AK, Samantas E, Pectasides D, Bafaloukos D, Fountzilas G (2012) The prognostic and predictive value of mRNA expression of vascular endothelial growth factor family members in breast cancer: a study in primary tumors of high-risk early breast cancer patients participating in a randomized Hellenic Cooperative Oncology Group trial. Breast Cancer Res 14:R145. https://doi.org/10.1186/bcr3354 CrossRefPubMedPubMedCentralGoogle Scholar
- 12.Pivot X, Schneeweiss A, Verma S, Thomssen C, Passos-Coelho JL, Benedetti G, Ciruelos E, von Moos R, Chang HT, Duenne AA, Miles DW (2011) Efficacy and safety of bevacizumab in combination with docetaxel for the first-line treatment of elderly patients with locally recurrent or metastatic breast cancer: results from AVADO. Eur J Cancer 47:2387–2395. https://doi.org/10.1016/j.ejca.2011.06.018 CrossRefPubMedGoogle Scholar
- 14.Gligorov J, Doval D, Bines J, Alba E, Cortes P, Pierga JY, Gupta V, Costa R, Srock S, de Ducla S, Freudensprung U, Mustacchi G (2014) Maintenance capecitabine and bevacizumab versus bevacizumab alone after initial first-line bevacizumab and docetaxel for patients with HER2-negative metastatic breast cancer (IMELDA): a randomised, open-label, phase 3 trial. Lancet Oncol 15:1351–1360. https://doi.org/10.1016/S1470-2045(14)70444-9 CrossRefPubMedGoogle Scholar
- 15.Baselga J, Zamagni C, Gomez P, Bermejo B, Nagai S, Melichar B, Chan A, Mangel L, Bergh J, Costa FP, Gomez HL, Gradishar W, Hudis C, Rapoport B, Roche H, Maeda P, Huang L, Zhang J, Schwartzberg LS (2014) A phase III randomized, double-blind, trial comparing sorafenib plus capecitabine versus placebo plus capecitabine in the treatment of locally advanced breast cancer (ESMO 2014). Ann Oncol 25:1–41CrossRefGoogle Scholar
- 16.Schwartzberg LS, Tauer KW, Hermann RC, Makari-Judson G, Isaacs C, Beck JT, Kaklamani V, Stepanski EJ, Rugo HS, Wang W, Bell-McGuinn K, Kirshner JJ, Eisenberg P, Emanuelson R, Keaton M, Levine E, Medgyesy DC, Qamar R, Starr A, Ro SK, Lokker NA, Hudis CA (2013) Sorafenib or placebo with either gemcitabine or capecitabine in patients with HER-2-negative advanced breast cancer that progressed during or after bevacizumab. Clin Cancer Res 19:2745–2754. https://doi.org/10.1158/1078-0432.CCR-12-3177 CrossRefPubMedGoogle Scholar
- 17.Bergh J, Bondarenko IM, Lichinitser MR, Liljegren A, Greil R, Voytko NL, Makhson AN, Cortes J, Lortholary A, Bischoff J, Chan A, Delaloge S, Huang X, Kern KA, Giorgetti C (2012) First-line treatment of advanced breast cancer with sunitinib in combination with docetaxel versus docetaxel alone: results of a prospective, randomized phase III study. J Clin Oncol 30:921–929. https://doi.org/10.1200/JCO.2011.35.7376 CrossRefPubMedGoogle Scholar
- 19.Adams J, Carder PJ, Downey S, Forbes MA, MacLennan K, Allgar V, Kaufman S, Hallam S, Bicknell R, Walker JJ, Cairnduff F, Selby PJ, Perren TJ, Lansdown M, Banks RE (2000) Vascular endothelial growth factor (VEGF) in breast cancer: comparison of plasma, serum, and tissue VEGF and microvessel density and effects of tamoxifen. Cancer Res 60:2898–2905PubMedGoogle Scholar
- 21.Banys-Paluchowski M, Witzel I, Riethdorf S, Rack B, Janni W, Fasching PA, Solomayer EF, Aktas B, Kasimir-Bauer S, Pantel K, Fehm T, Muller V (2017) Clinical Relevance of Serum HER2 and Circulating Tumor Cell Detection in Metastatic Breast Cancer Patients. Anticancer Res 37:3117–3128. https://doi.org/10.21873/anticanres.11669 CrossRefPubMedGoogle Scholar
- 22.Banys-Paluchowski M, Witzel I, Riethdorf S, Rack B, Janni W, Fasching PA, Solomayer EF, Aktas B, Kasimir-Bauer S, Pantel K, Fehm T, Muller V (2017) Evaluation of serum epidermal growth factor receptor (EGFR) in correlation to circulating tumor cells in patients with metastatic breast cancer. Sci Rep 7:17307. https://doi.org/10.1038/s41598-017-17514-8 CrossRefPubMedPubMedCentralGoogle Scholar
- 24.Muller V, Riethdorf S, Rack B, Janni W, Fasching PA, Solomayer E, Aktas B, Kasimir-Bauer S, Zeitz J, Pantel K, Fehm T (2011) Prospective evaluation of serum tissue inhibitor of metalloproteinase 1 and carbonic anhydrase IX in correlation to circulating tumor cells in patients with metastatic breast cancer. Breast Cancer Res 13:R71. https://doi.org/10.1186/bcr2916 CrossRefPubMedPubMedCentralGoogle Scholar
- 26.Gianni L, Romieu GH, Lichinitser M, Serrano SV, Mansutti M, Pivot X, Mariani P, Andre F, Chan A, Lipatov O, Chan S, Wardley A, Greil R, Moore N, Prot S, Pallaud C, Semiglazov V (2013) AVEREL: a randomized phase III Trial evaluating bevacizumab in combination with docetaxel and trastuzumab as first-line therapy for HER2-positive locally recurrent/metastatic breast cancer. J Clin Oncol 31:1719–1725. https://doi.org/10.1200/JCO.2012.44.7912 CrossRefPubMedGoogle Scholar
- 27.Miles DW, de Haas SL, Dirix LY, Romieu G, Chan A, Pivot X, Tomczak P, Provencher L, Cortes J, Delmar PR, Scherer SJ (2013) Biomarker results from the AVADO phase 3 trial of first-line bevacizumab plus docetaxel for HER2-negative metastatic breast cancer. Br J Cancer 108:1052–1060. https://doi.org/10.1038/bjc.2013.69 CrossRefPubMedPubMedCentralGoogle Scholar
- 28.Miles D, Cameron D, Bondarenko I, Manzyuk L, Alcedo JC, Lopez RI, Im SA, Canon JL, Shparyk Y, Yardley DA, Masuda N, Ro J, Denduluri N, Hubeaux S, Quah C, Bais C, O’Shaughnessy J (2017) Bevacizumab plus paclitaxel versus placebo plus paclitaxel as first-line therapy for HER2-negative metastatic breast cancer (MERiDiAN): A double-blind placebo-controlled randomised phase III trial with prospective biomarker evaluation. Eur J Cancer 70:146–155. https://doi.org/10.1016/j.ejca.2016.09.024 CrossRefPubMedGoogle Scholar
- 29.Kwon KA, Kim SH, Oh SY, Lee S, Han JY, Kim KH, Goh RY, Choi HJ, Park KJ, Roh MS, Kim HJ, Kwon HC, Lee JH (2010) Clinical significance of preoperative serum vascular endothelial growth factor, interleukin-6, and C-reactive protein level in colorectal cancer. BMC Cancer 10:203. https://doi.org/10.1186/1471-2407-10-203 CrossRefPubMedPubMedCentralGoogle Scholar
- 36.Iovino F, Ferraraccio F, Orditura M, Antoniol G, Morgillo F, Cascone T, Diadema MR, Aurilio G, Santabarbara G, Ruggiero R, Belli C, Irlandese E, Fasano M, Ciardiello F, Procaccini E, Lo Schiavo F, Catalano G, De Vita F (2008) Serum vascular endothelial growth factor (VEGF) levels correlate with tumor VEGF and p53 overexpression in endocrine positive primary breast cancer. Cancer Invest 26:250–255. https://doi.org/10.1080/07357900701560612 CrossRefPubMedGoogle Scholar
- 37.Mueller MD, Vigne JL, Minchenko A, Lebovic DI, Leitman DC, Taylor RN (2000) Regulation of vascular endothelial growth factor (VEGF) gene transcription by estrogen receptors alpha and beta. Proc Natl Acad Sci U S A 97:10972–10977. https://doi.org/10.1073/pnas.200377097 CrossRefPubMedPubMedCentralGoogle Scholar
- 40.Addison CL, Pond GR, Cochrane B, Zhao H, Chia SK, Levine MN, Clemons M (2015) Correlation of baseline biomarkers with clinical outcomes and response to fulvestrant with vandetanib or placebo in patients with bone predominant metastatic breast cancer: An OCOG ZAMBONEY sub-study. J Bone Oncol 4:47–53. https://doi.org/10.1016/j.jbo.2015.04.001 CrossRefPubMedPubMedCentralGoogle Scholar
- 41.Bachelot T, Ray-Coquard I, Menetrier-Caux C, Rastkha M, Duc A, Blay JY (2003) Prognostic value of serum levels of interleukin 6 and of serum and plasma levels of vascular endothelial growth factor in hormone-refractory metastatic breast cancer patients. Br J Cancer 88:1721–1726. https://doi.org/10.1038/sj.bjc.6600956 CrossRefPubMedPubMedCentralGoogle Scholar
- 42.Rocca A, Cancello G, Bagnardi V, Sandri MT, Torrisi R, Zorzino L, Viale G, Pietri E, Veronesi P, Dellapasqua S, Ferrucci F, Luini A, Johansson H, Ghisini R, Goldhirsch A, Colleoni M (2009) Perioperative serum VEGF and extracellular domains of EGFR and HER2 in early breast cancer. Anticancer Res 29:5111–5119PubMedGoogle Scholar
- 43.Lam SW, Nota NM, Jager A, Bos MM, van den Bosch J, van der Velden AM, Portielje JE, Honkoop AH, van Tinteren H, Boven E (2016) Angiogenesis- and hypoxia-associated proteins as early indicators of the outcome in patients with metastatic breast cancer given first-line bevacizumab-based therapy. Clin Cancer Res 22:1611–1620. https://doi.org/10.1158/1078-0432.ccr-15-1005 CrossRefPubMedGoogle Scholar
- 44.Pectasides D, Papaxoinis G, Kotoula V, Fountzilas H, Korantzis I, Koutras A, Dimopoulos AM, Papakostas P, Aravantinos G, Varthalitis I, Kosmidis P, Skarlos D, Bournakis E, Bafaloukos D, Kalofonos HP, Kalogeras KT, Fountzilas G (2012) Expression of angiogenic markers in the peripheral blood of docetaxel-treated advanced breast cancer patients: a Hellenic Cooperative Oncology Group (HeCOG) study. Oncol Rep 27:216–224. https://doi.org/10.3892/or.2011.1504 CrossRefPubMedGoogle Scholar
- 45.Burstein HJ, Chen YH, Parker LM, Savoie J, Younger J, Kuter I, Ryan PD, Garber JE, Chen H, Campos SM, Shulman LN, Harris LN, Gelman R, Winer EP (2008) VEGF as a marker for outcome among advanced breast cancer patients receiving anti-VEGF therapy with bevacizumab and vinorelbine chemotherapy. Clin Cancer Res 14:7871–7877. https://doi.org/10.1158/1078-0432.CCR-08-0593 CrossRefPubMedGoogle Scholar
- 48.Kallergi G, Markomanolaki H, Giannoukaraki V, Papadaki MA, Strati A, Lianidou ES, Georgoulias V, Mavroudis D, Agelaki S (2009) Hypoxia-inducible factor-1alpha and vascular endothelial growth factor expression in circulating tumor cells of breast cancer patients. Breast Cancer Res 11:R84. https://doi.org/10.1186/bcr2452 CrossRefPubMedPubMedCentralGoogle Scholar
- 49.Skerenova M, Mikulova V, Capoun O, Zima T, Tesarova P (2017) Circulating tumor cells and serum levels of MMP-2, MMP-9 and VEGF as markers of the metastatic process in patients with high risk of metastatic progression. Biomed Pap Med Fac Univ Palacky Olomouc Czech Repub 161:272–280. https://doi.org/10.5507/bp.2017.022 CrossRefPubMedGoogle Scholar
- 50.Vilsmaier T, Rack B, Janni W, Jeschke U, Weissenbacher T, Group SS (2016) Angiogenic cytokines and their influence on circulating tumour cells in sera of patients with the primary diagnosis of breast cancer before treatment. BMC Cancer 16:547. https://doi.org/10.1186/s12885-016-2612-7 CrossRefPubMedPubMedCentralGoogle Scholar
- 51.Pineda E, Salud A, Vila-Navarro E, Safont MJ, Llorente B, Aparicio J, Vera R, Escudero P, Casado E, Bosch C, Bohn U, Perez-Carrion R, Carmona A, Ayuso JR, Ripolles T, Bouzas R, Gironella M, Garcia-Albeniz X, Feliu J, Maurel J (2017) Dynamic soluble changes in sVEGFR1, HGF, and VEGF promote chemotherapy and bevacizumab resistance: A prospective translational study in the BECOX (GEMCAD 09 – 01) trial. Tumour Biol. https://doi.org/10.1177/1010428317705509 CrossRefPubMedGoogle Scholar
- 54.Wu WC, Lien R, Liao PJ, Wang NK, Chen YP, Chao AN, Chen KJ, Chen TL, Hwang YS, Lai CC (2015) Serum levels of vascular endothelial growth factor and related factors after intravitreous bevacizumab injection for retinopathy of prematurity. JAMA Ophthalmol 133:391–397. https://doi.org/10.1001/jamaophthalmol.2014.5373 CrossRefPubMedGoogle Scholar
- 55.Davidovic SP, Nikolic SV, Curic NJ, Latinovic SL, Draskovic DO, Cabarkapa VS, Stosic ZZ (2012) Changes of serum VEGF concentration after intravitreal injection of Avastin in treatment of diabetic retinopathy. Eur J Ophthalmol 22:792–798. https://doi.org/10.5301/ejo.5000118 CrossRefPubMedGoogle Scholar
- 56.Muller V, Witzel I, Pantel K, Krenkel S, Luck HJ, Neumann R, Keller T, Dittmer J, Janicke F, Thomssen C (2006) Prognostic and predictive impact of soluble epidermal growth factor receptor (sEGFR) protein in the serum of patients treated with chemotherapy for metastatic breast cancer. Anticancer Res 26:1479–1487PubMedGoogle Scholar
- 57.Souder C, Leitzel K, Ali SM, Demers L, Evans DB, Chaudri-Ross HA, Hackl W, Hamer P, Carney W, Lipton A (2006) Serum epidermal growth factor receptor/HER-2 predicts poor survival in patients with metastatic breast cancer. Cancer 107:2337–2345. https://doi.org/10.1002/cncr.22255 CrossRefPubMedGoogle Scholar
- 58.Witzel I, Loibl S, von Minckwitz G, Eidtmann H, Fehm T, Khandan F, Schmatloch S, Hauschild M, Bischoff J, Fasching PA, Mau C, Schem C, Rack B, Meinhold-Heerlein I, Liedtke C, Karn T, Huober J, Zu Eulenburg C, Issa-Nummer Y, Untch M, Muller V (2012) Predictive value of HER2 serum levels in patients treated with lapatinib or trastuzumab: a translational project in the neoadjuvant GeparQuinto trial. Br J Cancer 107:956–960. https://doi.org/10.1038/bjc.2012.353 CrossRefPubMedPubMedCentralGoogle Scholar
- 59.Kozlowski M, Laudanski W, Mroczko B, Szmitkowski M, Milewski R, Lapuc G (2013) Serum tissue inhibitor of metalloproteinase 1 (TIMP-1) and vascular endothelial growth factor A (VEGF-A) are associated with prognosis in esophageal cancer patients. Adv Med Sci 58:227–234. https://doi.org/10.2478/ams-2013-0017 CrossRefPubMedGoogle Scholar
- 65.Falchook GS, Naing A, Hong DS, Zinner R, Fu S, Piha-Paul SA, Tsimberidou AM, Morgan-Linnell SK, Jiang Y, Bastida C, Wheler JJ, Kurzrock R (2013) Dual EGFR inhibition in combination with anti-VEGF treatment: a phase I clinical trial in non-small cell lung cancer. Oncotarget 4:118–127. https://doi.org/10.18632/oncotarget.763 CrossRefPubMedPubMedCentralGoogle Scholar