Journal of Gastrointestinal Surgery

, Volume 12, Issue 6, pp 1005–1014 | Cite as

Positive VEGF Immunostaining Independently Predicts Poor Prognosis in Curatively Resected Gastric Cancer Patients: Results of a Study Assessing a Panel of Angiogenic Markers

  • Óscar Vidal
  • Antonio Soriano-Izquierdo
  • Manuel Pera
  • José I. Elizalde
  • Antonio Palacín
  • Antoni Castells
  • Josep M. Piqué
  • Alain Volant
  • Jean P. Metges


Angiopoietin-2 (Ang-2) and vascular endothelial growth factor (VEGF) contribute to gastric cancer aggressiveness by up-regulating the expression of proteases. We evaluated the expression and the prognostic significance of angiogenic factors and proteases in 148 patients with R0-resected gastric cancer. Expression of VEGF, Ang-2, cyclooxygenase-2 (COX-2), urokinase-type plasminogen activator (uPA) and its inhibitor PAI-1, matrix metalloproteinases (MMP)-1 and -9 were assayed by immunohistochemistry. After a mean of 63 ± 4 months, 81 out of 148 patients had died due to disease. The probability of being free of recurrence was 62, 48, and 42% at 2, 5, and 10 years, respectively. Single bivariate analysis identified VEGF, Ang-2, COX-2, PAI-1, and MMP-9 expression, along with several clinicopathological parameters (grade of curability, lymph node ratio, pTNM, pT, pN), as variables associated with both decreased disease-specific survival and recurrence. On multivariate analysis, after adjusting for significant clinical covariables, positive VEGF immunostaining was the primary prognostic factor, and no other tumor marker variable could add any significant improvement for the prediction, for both disease-specific survival (p = 0.001; HR, 3.27; 95% CI, 1.76 to 6.10) and tumor recurrence (p = 0.002; HR, 2.81; 95% CI, 1.48 to 5.35). Our study suggests that VEGF alone may be clinically useful for establishing therapeutic decisions in gastric cancer patients.


Gastric cancer Prognostic factors Angiogenesis VEGF 



We thank Llorenç Badiella from the Department of Statistics, Universitat Autonoma de Barcelona, for expert help in the statistical analysis and Dr. Alan Cameron and Dr. Joaquim Bellmunt for editorial comments.

This work was supported in part by research grants from the Fundació “la Caixa” (LC 02/126-00, from the Instituto de Salud Carlos III (RC03/02 and RC03/10), and from Fundación Científica de la Asociación Española Contra el Cáncer (Junta Provincial de Albacete).


  1. 1.
    Parkin DM, Bray F, Ferlay J, Pisani P. Global cancer statistics. 2002. CA Cancer J Clin 2005;55:74–108.PubMedCrossRefGoogle Scholar
  2. 2.
    Dicken BJ, Bigam DL, Cass C, Mackey JR, Joy AA, Hamilton SM. Gastric adenocarcinoma: review and considerations for future directions. Ann Surg 2005;241:27–39.PubMedGoogle Scholar
  3. 3.
    Maehara Y, Kakeji Y, Koga T, Emi Y, Baba H, Akazawa K, Sugimachi K. Therapeutic value of lymph node dissection and the clinical outcome for patients with gastric cancer. Surgery 2002;131:S85–S91.PubMedCrossRefGoogle Scholar
  4. 4.
    Cunningham D, Allum W, Stenning S, Thompson JN, Van de Velde CJH, Nicolson M, Scarffe H, Lofts FJ, Falk SJ, Iveson TJ, Smith DB, Langley, BVerma M, Weeden S, Chua YJ. Perioperative chemotherapy versus surgery alone for resectable gastroesophageal cancer. N Engl J Med 2006;355:11–20.PubMedCrossRefGoogle Scholar
  5. 5.
    Riley RD, Abrams KR, Sutton AJ, Lambert PC, Jones DR, Heney D, Burchill SA. Reporting of prognostic markers: current problems and development of guidelines for evidence-based practice in the future. Br J Cancer 2003;88:1191–1198.PubMedCrossRefGoogle Scholar
  6. 6.
    Folkman J. Angiogenesis in cancer, vascular rheumatoid and other diseases. Nature Med 1995;1:27–31.PubMedCrossRefGoogle Scholar
  7. 7.
    Carmeliet P. Angiogenesis in life, disease and medicine. Nature 2005;438:932–936.PubMedCrossRefGoogle Scholar
  8. 8.
    Hicklin DJ, Ellis LM. Role of the vascular endothelial growth factor pathway in tumor growth and angiogenesis. J Clin Oncol 2005;23:1011–1027.PubMedCrossRefGoogle Scholar
  9. 9.
    Tait CR, Jones PF. Angiopoietins in tumours: the angiogenic switch. J Pathol 2004;204:1–10.PubMedCrossRefGoogle Scholar
  10. 10.
    Kim KJ, Li B, Winer J, Armanini M, Gillett N, Phillips HS, Ferrara N. Inhibition of vascular endothelial growth factor-induced angiogenesis suppresses tumour growth in vivo. Nature 1993;362:841–844.PubMedCrossRefGoogle Scholar
  11. 11.
    Oliner J, Min H, Leal J, Yu D, Rao S, You E, Tang X, Kim H, Meyer S, Han SJ, Hawkins N, Rosenfeld R, Davy E, Graham K, Jacobsen F, Stevenson S, Ho J, Chen Q, Hartmann T, Michaels M, Kelley M, Li L, Sitney K, Martin F, Sun JR, Zhang N, Lu J, Estrada J, Kumar R, Coxon A, Kaufman S, Pretorius J, Scully S, Cattley R, Payton M, Coats S, Nguyen L, Desilva B, Ndifor A, Hayward I, Radinsky R, Boone T, Kendall R. Suppression of angiogenesis and tumor growth by selective inhibition of angiopoietin-2. Cancer Cell 2004;6:507–516.PubMedCrossRefGoogle Scholar
  12. 12.
    Bergers G, Coussens LM. Extrinsic regulators of epithelial tumor progression: metalloproteinases. Curr Opin Genet Dev 2000;10:120–127.PubMedCrossRefGoogle Scholar
  13. 13.
    Baba M, Konno H, Maruo Y, Tanaka T, Kanai T, Matsumoto K, Matsura M, Nishino N, Maruyama K, Nakamura S, Baba S. Relationship of p53 and vascular endothelial growth factor expression of clinicopathological factors in human scirrhous gastric cancer. Eur Surg Res 1998;30:130–137.PubMedCrossRefGoogle Scholar
  14. 14.
    Maeda K, Chung YS, Ogawa Y, Takatsuka S, Kang SM, Ogawa M, Sawada T, Sowa M. Prognostic value of vascular endothelial growth factor expression in gastric carcinoma. Cancer 1996;77:858–863.PubMedCrossRefGoogle Scholar
  15. 15.
    Maehara Y, Kabashima A, Koga T, Tokunaga E, Takeuchi H, Kakeji Y, Sugimachi K. Vascular invasion and potential for tumor angiogenesis and metastasis in gastric carcinoma. Surgery 2000;128:408–416.PubMedCrossRefGoogle Scholar
  16. 16.
    Fondevila C, Metges JP, Fuster J, Grau JJ, Palacin A, Castells A, Volant A, Pera M. p53 and VEGF expression are independent predictors of tumour recurrence and survival following curative resection of gastric cancer. Br J Cancer 2004;90:206–215.PubMedCrossRefGoogle Scholar
  17. 17.
    Etoh T, Inoue H, Tanaka S, Barnard GF, Kitano S, Mori M. Angiopoietin-2 is related to tumor angiogenesis in gastric carcinoma: possible in vivo regulation via induction of proteases. Cancer Res 2001;61:2145–2153.PubMedGoogle Scholar
  18. 18.
    Sun XD, Liu XE, Wu JM, Cai XJ, Mou YP, Li JD. Expression and significance of angiopoietin-2 in gastric cancer. World J Gastroenterol 2004;10:1382–1385.PubMedGoogle Scholar
  19. 19.
    Heiss MM, Babic R, Allgayer H, Gruetzner KU, Jauch KW, Loehrs U, Schildberg FW. Tumor-associated proteolysis and prognosis: new functional risk factors in gastric cancer defined by the urokinase-type plasminogen activator system. J Clin Oncol 1995;13:2084–2093.PubMedGoogle Scholar
  20. 20.
    Kaneko T, Konno H, Baba M, Tanaka T, Nakamura S. Urokinase-type plasminogen activator expression correlates with tumor angiogenesis and poor outcome in gastric cancer. Cancer Sci 2003;94:43–49.PubMedCrossRefGoogle Scholar
  21. 21.
    Greene FL, Page DL, Fleming ID, Fritz A, Balch CH, Haller DG, Morrow M, eds. AJCC Cancer Staging Manual. 6th ed. New York, NY: Springer-Verlag, 2002.Google Scholar
  22. 22.
    Japanese Gastric Cancer Association. Japanese Classification of Gastric Carcinoma-2nd English Edition. Gastric Cancer 1998;1:10–24.PubMedCrossRefGoogle Scholar
  23. 23.
    Grau JJ, Estape J, Fuster J, Filella X, Visa J, Teres J, Soler G, Albiol S, Garcia-Valdecasas JC, Grande L, Bombi JA, Bordas JM, Alcobendas F. Randomized trial of adjuvant chemotherapy with mitomycin plus ftorafur versus mitomycin alone in resected locally advanced gastric cancer. J Clin Oncol 1998;16:1036–1039.PubMedGoogle Scholar
  24. 24.
    Inoue K, Ozeki Y, Suganuma T, Sugiura Y, Tanaka S. Vascular endothelial growth factor expression in primary esophageal squamous cell carcinoma. Association with angiogenesis and tumor progression. Cancer 1997;79:206–213.PubMedCrossRefGoogle Scholar
  25. 25.
    Nakayama T, Yoshizaki A, Kawahara N, Ohtsuru A, Wen CY, Fukuda E, Nakashima M, Sekine I. Expression of Tie-1 and 2 receptors, and angiopoietin-1, 2 and 4 in gastric carcinoma; immunohistochemical analyses and correlation with clinicopathological factors. Histopathology 2004;44:232–239.PubMedCrossRefGoogle Scholar
  26. 26.
    Tatsuguchi A, Matsui K, Shinji Y, Gudis K, Tsukui T, Kishida T, Fukuda Y, Sugisaki Y, Tokunaga A, Tajiri T, Sakamoto C. Cyclooxygenase-2 expression correlates with angiogenesis and apoptosis in gastric cancer tissue. Hum Pathol 2004;35:488–495.PubMedCrossRefGoogle Scholar
  27. 27.
    Zhang S, Li L, Lin JY, Lin H. Imbalance between expression of matrix metalloproteinase-9 and tissue inhibitor of metalloproteinase-1 in invasiveness and metastasis of human gastric carcinoma. World J Gastroenterol 2003;9:899–904.PubMedGoogle Scholar
  28. 28.
    Vermeulen PB, Gasparini G, Fox SB, Colpaert C, Marson LP, Gion M, Belien JA, de Waal RM, Van Marck E, Magnani E, Weidner N, Harris AL, Dirix LY. Second international consensus on the methodology and criteria of evaluation of angiogenesis quantification in solid human tumours. Eur J Cancer 2002;38:1564–1579.PubMedCrossRefGoogle Scholar
  29. 29.
    Poon RT, Fan ST, Wong J. Clinical implications of circulating angiogenic factors in cancer patients. J Clin Oncol 2001;19:1207–1225.PubMedGoogle Scholar
  30. 30.
    Maeda K, Kang SM, Onoda N, Ogawa M, Kato Y, Sawada T, Chung KH. Vascular endothelial growth factor expression in preoperative biopsy specimens correlates with disease recurrence in patients with early gastric carcinoma. Cancer 1999;86:566–571.PubMedCrossRefGoogle Scholar
  31. 31.
    Saito H, Tsujitani S, Kondo A, Ikegushi M, Maeta M, Kaibara N. Expression of vascular endothelial growth factor correlates with hematogenous recurrence in gastric carcinoma. Surgery 1999;125:195–201.PubMedGoogle Scholar
  32. 32.
    Ichikura T, Tomimatsu S, Ohkura E, Mochizuki H. Prognostic significance of the expression of vascular endothelial growth factor (VEGF) and VEGF-C in gastric carcinoma. J Surg Oncol 2001;78:132–137.PubMedCrossRefGoogle Scholar
  33. 33.
    McCarty MF, Wey J, Stoeltzing O, Liu W, Fan F, Bucana C, Mansfield PF, Ryan AJ, Ellis LM. ZD6474, a vascular endothelial growth factor receptor tyrosine kinase inhibitor with additional activity against epidermal growth factor receptor tyrosine kinase, inhibits orthotopic growth and angiogenesis of gastric cancer. Mol Cancer Ther 2004;3:1041–1048.PubMedGoogle Scholar
  34. 34.
    Shah MA, Ramanathan RK, Ilson D, Randazzo J, Schwartz GK, Tse A, Tse A, D’Adamo D, Levner A, Capanu M, Kelsen DP. Final results of a multicenter phase II study of irinotecan (CPT), cisplatin (CIS), and bevacizumab (BEV) in patients with metastatic gastric or gastroesophageal (GEJ) adenocarcinoma (NCI #6447). J Clin Oncol 2006;24:183s.CrossRefGoogle Scholar
  35. 35.
    Wang J, Wu K, Zhang D, Tang H, Xie H, Hong L, Pan Y, Lan M, Hu S, Ning X, Fan D. Expressions and clinical significances of angiopoietin-1, -2 and Tie2 in human gastric cancer. Biochem Biophys Res Commun 2005;337:386–393.PubMedCrossRefGoogle Scholar
  36. 36.
    Chen CN, Sung CT, Lin MT, Lee PH, Chang KJ. Clinicopathologic association of cyclooxygenase 1 and cyclooxygenase 2 expression in gastric adenocarcinoma. Ann Surg 2001;233:183–188.PubMedCrossRefGoogle Scholar
  37. 37.
    Joo YE, Rew JS, Seo YH, Choi SK, Kim YJ, Park CS, Kim SJ. Cyclooxygenase-2 overexpression correlates with vascular endothelial growth factor expression and tumor angiogenesis in gastric cancer. J Clin Gastroenterol 2003;37:28–33.PubMedCrossRefGoogle Scholar
  38. 38.
    Mrena J, Wiksten JP, Thiel A, Kokkola A, Pohjola L, Lundin J, Ristimaki A, Haglund C. Cyclooxygenase-2 is an independent prognostic factor in gastric cancer and its expression is regulated by the messenger RNA stability factor HuR. Clin Cancer Res 2005;11:7362–7368.PubMedCrossRefGoogle Scholar
  39. 39.
    Andreasen PA, Kjoller L, Christensen L, Duffy MJ. The urokinase-type plasminogen activator system in cancer metastasis: a review. Int J Cancer 1997;72:1–22.PubMedCrossRefGoogle Scholar
  40. 40.
    Duffy MJ, Maguire TM, McDermott EW, O’Higgins N. Urokinase plasminogen activator: a prognostic marker in multiple types of cancer. J Surg Oncol 1999;71:130–135.PubMedCrossRefGoogle Scholar
  41. 41.
    Nekarda H, Schmitt M, Ulm K, Wenninger A, Vogelsang H, Becker K, Roder JD, Fink U, Siewert JR. Prognostic impact of urokinase-type plasminogen activator and its inhibitor PAI-1 in completely resected gastric cancer. Cancer Res 1994;54:2900–2907.PubMedGoogle Scholar
  42. 42.
    Okusa Y, Ichikura T, Mochizuki H. Prognostic impact of stromal cell-derived urokinase-type plasminogen activator in gastric carcinoma. Cancer 1999;85:1033–1038.PubMedCrossRefGoogle Scholar
  43. 43.
    Okusa Y, Ichikura T, Mochizuki H, Shinomiya N. Urokinase type plasminogen activator and its receptor regulate the invasive potential of gastric cancer cell lines. Int J Oncol 2000;17:1001–1005.PubMedGoogle Scholar

Copyright information

© The Society for Surgery of the Alimentary Tract 2007

Authors and Affiliations

  • Óscar Vidal
    • 1
  • Antonio Soriano-Izquierdo
    • 2
  • Manuel Pera
    • 1
    • 6
  • José I. Elizalde
    • 2
  • Antonio Palacín
    • 3
  • Antoni Castells
    • 2
  • Josep M. Piqué
    • 2
  • Alain Volant
    • 4
  • Jean P. Metges
    • 5
  1. 1.Department of Surgery, Institut de Malalties Digestives i Metabolisme, Hospital Clínic, Institut d’Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS)University of Barcelona Medical SchoolBarcelonaSpain
  2. 2.Department of Gastroenterology, Institut de Malalties Digestives i Metabolisme, Hospital Clínic, Institut d’Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), CIBERehdUniversity of Barcelona Medical SchoolBarcelonaSpain
  3. 3.Department of Pathology, Hospital ClínicUniversity of Barcelona Medical SchoolBarcelonaSpain
  4. 4.Department of PathologyCentre Hospitalier Universitaire Cavale Blanche et MorvanBrestFrance
  5. 5.Department of Medical OncologyCentre Hospitalier Universitaire Cavale Blanche et MorvanBrestFrance
  6. 6.Section of Gastrointestinal SurgeryHospital Universitario del MarBarcelonaSpain

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