Tumor Biology

, Volume 37, Issue 4, pp 5063–5074 | Cite as

DLL4 as a predictor of pelvic lymph node metastasis and a novel prognostic biomarker in patients with early-stage cervical cancer

  • Shanshan Yang
  • YunDuo Liu
  • BaiRong Xia
  • Jiangpeng Deng
  • TianBo Liu
  • Qi Li
  • YanPing Yang
  • YaoXian Wang
  • XiaoMing Ning
  • YunYan ZhangEmail author
  • Min XiaoEmail author
Original Article


Delta-like ligand 4 (DLL4), one of the five Notch signaling ligands in mammals, has an important function in proliferation, invasion, metastasis, progression, and angiogenesis of malignancies. This study aimed to investigate DLL4 expression level in early-stage cervical carcinoma and to evaluate its clinical significance. We used fresh frozen and paraffin-embedded cervical cancer tissues to analyze DLL4 expression and its clinical significance. DLL4 expression at both mRNA and protein levels in cervical cancer tissues was significantly higher than that in normal cervical tissues. High DLL4 protein level was clearly correlated with high International Federation of Gynecology and Obstetrics (FIGO) stage (P = 0.044), lymphovascular space involvement (LVSI) (P = 0.015), pelvic lymph node metastasis (PLNM) (P = 0.001), and recurrence (P < 0.001). Univariate and multivariate logistic regression analyses demonstrated that DLL4 overexpression was strongly associated with lymph node metastasis (odds ratio, 2.790; 95 % CI, 1.344–5.791; P = 0.006). Moreover, survival analysis revealed that DLL4 expression was an independent factor of unfavorable overall survival (hazard ratio, 2.130; 95 % CI, 1.108–4.097; P = 0.023) and disease-free survival (hazard ratio, 1.965; 95 % CI, 1.085–3.560; P = 0.026) in patients with cervical cancer. Overall, our data indicate that high DLL4 expression predicts pelvic lymph node metastasis and poor survival in cervical cancer. Therefore, DLL4 may be a potential clinical diagnostic marker for patients with early-stage cervical cancer.


Delta-like ligand 4 Cervical cancer Pelvic lymph node metastasis Prognosis 



The authors thank all the people and patients who had participated in this study. This work is supported by the Post Doctoral Fund of Heilongjiang Province (No. LBH-Z14171), the Health and Family Planning Commission of Heilongjiang Provincial (No. 2014-363), the National Natural Science Foundation of China (No. 81372786), and the HaiYan Foundation of Affiliated Tumor Hospital of Harbin Medical University (No. JJQN2014-07).

Compliance with ethical standards

Conflicts of interest



  1. 1.
    Torre LA, Bray F, Siegel RL, Ferlay J, Lortet-Tieulent J, Jemal A. Global cancer statistics, 2012. CA Cancer J Clin. 2015;65(2):87–108.CrossRefPubMedGoogle Scholar
  2. 2.
    Siegel RL, Miller KD, Jemal A. Cancer statistics, 2015. CA Cancer J Clin. 2015;65(1):5–29.CrossRefPubMedGoogle Scholar
  3. 3.
    Siegel R, Naishadham D, Jemal A. Cancer statistics, 2013. CA Cancer J Clin. 2013;63(1):11–30.CrossRefPubMedGoogle Scholar
  4. 4.
    Macdonald OK, Chen J, Dodson M, Lee CM, Gaffney DK. Prognostic significance of histology and positive lymph node involvement following radical hysterectomy in carcinoma of the cervix. Am J Clin Oncol. 2009;32(4):411–6.CrossRefPubMedGoogle Scholar
  5. 5.
    Carmeliet P. Mechanisms of angiogenesis and arteriogenesis. Nat Med. 2000;6(4):389–95.CrossRefPubMedGoogle Scholar
  6. 6.
    Kerbel RS. Tumor angiogenesis. N Engl J Med. 2008;358(19):2039–49.CrossRefPubMedPubMedCentralGoogle Scholar
  7. 7.
    Yeh TS, Wu CW, Hsu KW, Liao WJ, Yang MC, Li AF, et al. The activated Notch1 signal pathway is associated with gastric cancer progression through cyclooxygenase-2. Cancer Res. 2009;69(12):5039–48.CrossRefPubMedGoogle Scholar
  8. 8.
    Artavanis-Tsakonas S, Rand MD, Lake RJ. Notch signaling: cell fate control and signal integration in development. Science. 1999;284(5415):770–6.CrossRefPubMedGoogle Scholar
  9. 9.
    Iso T, Hamamori Y, Kedes L. Notch signaling in vascular development. Arterioscler Thromb Vasc Biol. 2003;23(4):543–53.CrossRefPubMedGoogle Scholar
  10. 10.
    Gale NW, Dominguez MG, Noguera I, Pan L, Hughes V, Valenzuela DM, et al. Haploinsufficiency of delta-like 4 ligand results in embryonic lethality due to major defects in arterial and vascular development. Proc Natl Acad Sci U S A. 2004;101(45):15949–54.CrossRefPubMedPubMedCentralGoogle Scholar
  11. 11.
    Shawber CJ, Kitajewski J. Notch function in the vasculature: insights from zebrafish, mouse and man. Bioessays. 2004;26(3):225–34.CrossRefPubMedGoogle Scholar
  12. 12.
    Shutter JR, Scully S, Fan W, Richards WG, Kitajewski J, Deblandre GA, et al. Dll4, a novel Notch ligand expressed in arterial endothelium. Genes Dev. 2000;14(11):1313–8.PubMedPubMedCentralGoogle Scholar
  13. 13.
    Lv W, Chen L, Zhou DH, Wei B. Influence of specific blocking of the delta-like ligand 4/notch signal transduction pathway on the biological behavior of human umbilical vein endothelial cells. Cancer Biother Radiopharm. 2010;25(4):449–54.CrossRefPubMedGoogle Scholar
  14. 14.
    Mailhos C, Modlich U, Lewis J, Harris A, Bicknell R, Ish-Horowicz D. Delta4, an endothelial specific notch ligand expressed at sites of physiological and tumor angiogenesis. Differentiation. 2001;69(2–3):135–44.CrossRefPubMedGoogle Scholar
  15. 15.
    Li JL, Sainson RC, Oon CE, Turley H, Leek R, Sheldon H, et al. DLL4-Notch signaling mediates tumor resistance to anti-VEGF therapy in vivo. Cancer Res. 2011;71(18):6073–83.CrossRefPubMedGoogle Scholar
  16. 16.
    Xiao M, Yang S, Ning X, Huang Y. Aberrant expression of delta-like ligand 4 contributes significantly to axillary lymph node metastasis and predicts postoperative outcome in breast cancer. Hum Pathol. 2014;45(11):2302–10.CrossRefPubMedGoogle Scholar
  17. 17.
    Hu GH, Liu H, Lai P, Guo ZF, Xu L, Yao XD, et al. Delta-like ligand 4 (Dll4) predicts the prognosis of clear cell renal cell carcinoma, and anti-Dll4 suppresses tumor growth in vivo. Int J Clin Exp Pathol. 2014;7(5):2143–52.PubMedPubMedCentralGoogle Scholar
  18. 18.
    Kontomanolis E, Panteliadou M, Giatromanolaki A, Pouliliou S, Efremidou E, Limberis V, et al. Delta-like ligand 4 (DLL4) in the plasma and neoplastic tissues from breast cancer patients: correlation with metastasis. Med Oncol. 2014;31(5):945.CrossRefPubMedGoogle Scholar
  19. 19.
    Chen HT, Cai QC, Zheng JM, Man XH, Jiang H, Song B, et al. High expression of delta-like ligand 4 predicts poor prognosis after curative resection for pancreatic cancer. Ann Surg Oncol. 2012;19 Suppl 3:S464–74.CrossRefPubMedGoogle Scholar
  20. 20.
    Hu W, Lu C, Dong HH, Huang J, Shen DY, Stone RL, et al. Biological roles of the Delta family Notch ligand Dll4 in tumor and endothelial cells in ovarian cancer. Cancer Res. 2011;71(18):6030–9.CrossRefPubMedPubMedCentralGoogle Scholar
  21. 21.
    Pecorelli S. Revised FIGO staging for carcinoma of the vulva, cervix, and endometrium. Int J Gynaecol Obstet. 2009;105(2):103–4.CrossRefPubMedGoogle Scholar
  22. 22.
    Tavassoeli FA, Devilee P. WHO classification of tumours, pathology and genetics: tumours of the breast and female genital organs. France: IARC:Lyon; 2003.Google Scholar
  23. 23.
    Benedet JL, Bender H, Jones 3rd H, Ngan HY, Pecorelli S. FIGO staging classifications and clinical practice guidelines in the management of gynecologic cancers. FIGO Committee on Gynecologic Oncology. Int J Gynaecol Obstet. 2000;70(2):209–62.CrossRefPubMedGoogle Scholar
  24. 24.
    Livak KJ, Schmittgen TD. Analysis of relative gene expression data using real-time quantitative PCR and the 2(−Delta Delta C(T)) Method. Methods. 2001;25(4):402–8.CrossRefPubMedGoogle Scholar
  25. 25.
    Donnem T, Andersen S, Al-Shibli K, Al-Saad S, Busund LT, Bremnes RM. Prognostic impact of Notch ligands and receptors in nonsmall cell lung cancer: coexpression of Notch-1 and vascular endothelial growth factor-A predicts poor survival. Cancer. 2010;116(24):5676–85.CrossRefPubMedGoogle Scholar
  26. 26.
    Bolos V, Grego-Bessa J, de la Pompa JL. Notch signaling in development and cancer. Endocr Rev. 2007;28(3):339–63.CrossRefPubMedGoogle Scholar
  27. 27.
    Mazur PK, Einwachter H, Lee M, Sipos B, Nakhai H, Rad R, et al. Notch2 is required for progression of pancreatic intraepithelial neoplasia and development of pancreatic ductal adenocarcinoma. Proc Natl Acad Sci U S A. 2010;107(30):13438–43.CrossRefPubMedPubMedCentralGoogle Scholar
  28. 28.
    Dufraine J, Funahashi Y, Kitajewski J. Notch signaling regulates tumor angiogenesis by diverse mechanisms. Oncogene. 2008;27(38):5132–7.CrossRefPubMedPubMedCentralGoogle Scholar
  29. 29.
    Benedito R, Roca C, Sorensen I, Adams S, Gossler A, Fruttiger M, et al. The notch ligands Dll4 and Jagged1 have opposing effects on angiogenesis. Cell. 2009;137(6):1124–35.CrossRefPubMedGoogle Scholar
  30. 30.
    Rao PK, Dorsch M, Chickering T, Zheng G, Jiang C, Goodearl A, et al. Isolation and characterization of the notch ligand delta4. Exp Cell Res. 2000;260(2):379–86.CrossRefPubMedGoogle Scholar
  31. 31.
    Patel NS, Li JL, Generali D, Poulsom R, Cranston DW, Harris AL. Up-regulation of delta-like 4 ligand in human tumor vasculature and the role of basal expression in endothelial cell function. Cancer Res. 2005;65(19):8690–7.CrossRefPubMedGoogle Scholar
  32. 32.
    Williams CK, Li JL, Murga M, Harris AL, Tosato G. Up-regulation of the Notch ligand Delta-like 4 inhibits VEGF-induced endothelial cell function. Blood. 2006;107(3):931–9.CrossRefPubMedPubMedCentralGoogle Scholar
  33. 33.
    Noguera-Troise I, Daly C, Papadopoulos NJ, Coetzee S, Boland P, Gale NW, et al. Blockade of Dll4 inhibits tumour growth by promoting non-productive angiogenesis. Novartis Found Symp. 2007;283:106–20. discussion 21–5, 238–241.CrossRefPubMedGoogle Scholar
  34. 34.
    Li GG, Li L, Li C, Ye LY, Li XW, Liu DR, et al. Influence of up-regulation of Notch ligand DLL4 on biological behaviors of human gastric cancer cells. World J Gastroenterol. 2013;19(28):4486–94.CrossRefPubMedPubMedCentralGoogle Scholar
  35. 35.
    Jubb AM, Soilleux EJ, Turley H, Steers G, Parker A, Low I, et al. Expression of vascular notch ligand delta-like 4 and inflammatory markers in breast cancer. Am J Pathol. 2010;176(4):2019–28.CrossRefPubMedPubMedCentralGoogle Scholar
  36. 36.
    Jubb AM, Turley H, Moeller HC, Steers G, Han C, Li JL, et al. Expression of delta-like ligand 4 (Dll4) and markers of hypoxia in colon cancer. Br J Cancer. 2009;101(10):1749–57.CrossRefPubMedPubMedCentralGoogle Scholar
  37. 37.
    Zhang JX, Cai MB, Wang XP, Duan LP, Shao Q, Tong ZT, et al. Elevated DLL4 expression is correlated with VEGF and predicts poor prognosis of nasopharyngeal carcinoma. Med Oncol. 2013;30(1):390.CrossRefPubMedGoogle Scholar
  38. 38.
    Patel NS, Dobbie MS, Rochester M, Steers G, Poulsom R, Le Monnier K, et al. Up-regulation of endothelial delta-like 4 expression correlates with vessel maturation in bladder cancer. Clin Cancer Res. 2006;12(16):4836–44.CrossRefPubMedGoogle Scholar
  39. 39.
    Qiu XX, Chen L, Wang CH, Lin ZX, Zhou CF, Liu SY, et al. High delta-like ligand 4 (DLL4) is correlated with peritumoral brain edema and predicts poor prognosis in primary glioblastoma. Medicine (Baltimore). 2014;93(8), e57.CrossRefGoogle Scholar
  40. 40.
    Stacker SA, Achen MG, Jussila L, Baldwin ME, Alitalo K. Lymphangiogenesis and cancer metastasis. Nat Rev Cancer. 2002;2(8):573–83.CrossRefPubMedGoogle Scholar
  41. 41.
    Selman TJ, Mann C, Zamora J, Appleyard TL, Khan K. Diagnostic accuracy of tests for lymph node status in primary cervical cancer: a systematic review and meta-analysis. Cmaj. 2008;178(7):855–62.CrossRefPubMedPubMedCentralGoogle Scholar
  42. 42.
    Noordhuis MG, Fehrmann RS, Wisman GB, Nijhuis ER, van Zanden JJ, Moerland PD, et al. Involvement of the TGF-beta and beta-catenin pathways in pelvic lymph node metastasis in early-stage cervical cancer. Clin Cancer Res. 2011;17(6):1317–30.CrossRefPubMedGoogle Scholar
  43. 43.
    NCCN (National Comprehensive Cancer Network) clinical practice guidelines in oncology: cervical cancer (2015.V1).Google Scholar
  44. 44.
    Ishigami S, Arigami T, Uenosono Y, Okumura H, Kurahara H, Uchikado Y, et al. Clinical implications of DLL4 expression in gastric cancer. J Exp Clin Cancer Res. 2013;32:46.CrossRefPubMedPubMedCentralGoogle Scholar

Copyright information

© International Society of Oncology and BioMarkers (ISOBM) 2015

Authors and Affiliations

  • Shanshan Yang
    • 1
  • YunDuo Liu
    • 2
  • BaiRong Xia
    • 2
  • Jiangpeng Deng
    • 3
  • TianBo Liu
    • 2
  • Qi Li
    • 1
  • YanPing Yang
    • 1
  • YaoXian Wang
    • 1
  • XiaoMing Ning
    • 4
  • YunYan Zhang
    • 1
    Email author
  • Min Xiao
    • 5
    Email author
  1. 1.Department of Gynecological RadiotherapyThe Affiliated Tumor Hospital of Harbin Medical UniversityHarbinChina
  2. 2.Department of GynecologyThe Affiliated Tumor Hospital of Harbin Medical UniversityHarbinChina
  3. 3.Department of OncologyDazhou Central Hospital of Sichuan ProvinceDazhouChina
  4. 4.Department of PathologyThe Affiliated Tumor Hospital of Harbin Medical UniversityHarbinChina
  5. 5.Department of Breast SurgeryThe Affiliated Tumor Hospital of Harbin Medical UniversityHarbinChina

Personalised recommendations