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| ORIGINAL ARTICLE |
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| Year : 2015 | Volume
: 11
| Issue : 5 | Page : 44-48 |
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Expression of cyclooxygenase-2, vascular endothelial growth factor, and epidermal growth factor receptor in Chinese patients with esophageal squamous cell carcinoma
Yong Cui, Chang Dong, Bing-Qun Wu, Xin-Chun Duan, Guan Shi, Min Gong, Tian-You Wang
Department of Thoracic Surgery, Beijing Friendship Hospital, Capital Medical University, Beijing, China
| Date of Web Publication | 31-Aug-2015 |
Correspondence Address:
Dr. Chang Dong
Department of Thoracic Surgery, Beijing Friendship Hospital, Capital Medical University, Yongan Street, Xicheng District, Beijing
China
 Source of Support: None, Conflict of Interest: None  | Check |
DOI: 10.4103/0973-1482.163838
Background: Esophageal squamous cell carcinoma (ESCC) is a frequently occurring cancer with poor prognosis despite combined therapeutic strategies. The aim of the current study was to elucidate a further finding on the clinicopathologic significance of immunohistochemical expression of cyclooxygenase-2 (COX-2), vascular endothelial growth factor (VEGF), and epidermal growth factor receptor (EGFR) in Chinese patients with ESCC.
Methods: Formalin-fixed paraffin-embedded surgically resected tumor samples were obtained from 140 randomly selected Chinese patients with ESCC. Sections were immunohistochemically stained for COX-2, VEGF, and EGFR. The correlations between clinicopathological features and the high expression of COX-2, VEGF, and EGFR were analyzed using the Statistical Package for the Social Sciences 19.0 software (IBM Inc., Chicago, IL, USA).
Results: In the present study, high expression of COX-2, EGFR, and VEGF was found in 64.3%, 62.1%, and 65.0%, respectively. Results showed that COX-2 overexpression was significantly correlated with degree of differentiation (P = 0.000), and lymph node metastasis (negative/positive, P = 0.002). EGFR and VEGF overexpression was significantly correlated with a differentiated degree, T stage, N stage, and tumor, node, metastases stage.
Conclusion: High expression of COX-2, EGFR, and VEGF is an unfavorable prognostic factor in ESCC, and could be used as a poor prognosis indicator for the ESCC patients. Targeting therapy to these three targets should be considered to the combined treatment in ESCC. Keywords: Cyclooxygenase-2, epidermal growth factor receptor, esophageal neoplasms, vascular endothelial growth factor
How to cite this article:
Cui Y, Dong C, Wu BQ, Duan XC, Shi G, Gong M, Wang TY. Expression of cyclooxygenase-2, vascular endothelial growth factor, and epidermal growth factor receptor in Chinese patients with esophageal squamous cell carcinoma. J Can Res Ther 2015;11, Suppl S1:44-8 |
How to cite this URL:
Cui Y, Dong C, Wu BQ, Duan XC, Shi G, Gong M, Wang TY. Expression of cyclooxygenase-2, vascular endothelial growth factor, and epidermal growth factor receptor in Chinese patients with esophageal squamous cell carcinoma. J Can Res Ther [serial online] 2015 [cited 2022 Mar 5];11:44-8. Available from: https://www.cancerjournal.net/text.asp?2015/11/5/44/163838 |
| > Introduction | |  |
Esophageal cancer is the sixth leading cause of cancer death worldwide now. Esophageal cancer is a growing epidemic with approximately 460,000 new diagnosis and 380,000 deaths annually worldwide. [1],[2] More than half of the cases are in China. Although the recent rise in the incidence of esophageal cancer has predominantly been caused by an increase in adenocarcinomas, the majority of cases worldwide are still esophageal squamous cell carcinomas (ESCC). Furthermore, more than 90% of esophageal cancer is squamous cancer in China.
For patients with the loco-regional disease, surgical resection is the best treatment option for cure. [3] However, most of these patients will be diagnosed at a late stage; with approximately 50% of patients have advanced unresectable or metastatic cancer. With advances in surgical techniques and treatment, the prognosis of esophageal cancer has slowly improved over the past decades. However, the 5-year overall survival (OS) rate (17%) remains poor, even in comparison with the dismal survival rates (4%) from the 1970s. [4],[5] Moreover, OS after resection is relatively poor with 5-year survival rates of around 35%, because of early tumor recurrence and early occurrence of metastatic disease. [6]
Clearly, additional strategies are needed to improve treatment options. Over the past decade, the field of drug development has been transformed into direct treatment at specific molecular targets. With the increasing knowledge on molecular carcinogenesis, therapies have been developed directed against biological characteristics of tumors. In this way, selective destruction of tumor cells can be accomplished, possibly leading to increased efficiency and specificity with a reduction in toxicity of the therapy. Moreover, it allows for therapy tailored to the patient's individual tumor. In order to guide targeted therapy, analysis of the expression of these molecular markers is essential and is part of the routine histopathologic examination in some kind of cancers. [7]
However, the difficult decision is which target to select and for what population. The aims of the present study were therefore to determine the frequency of the immunohistochemical expression of three targets (cyclooxygenase-2 [COX-2], vascular endothelial growth factor [VEGF], and epidermal growth factor receptor [EGFR]) which are for currently available molecular therapies and to explore their correlations with clinicopathological features in Chinese patients with ESCC.
| > Methods | | |
Patients and samples
Specimens of ESCC were gathered from 140 patients who had been treated by esophageal resection, two field lymph node dissection, and reconstruction of the digestive tract in Beijing Friendship Hospital, Capital Medical University between 2010 and 2013. This study enrolled 106 men and 34 women, median age of 62 years (ranged 38-75 years). Pathological features were presented according to the 7 th edition of the Union for International Cancer Control/American Joint Committee on Cancer tumor, node, metastases (TNM) staging system.
Immunohistochemical staining
Tissue specimens were processed using conventional procedures for paraffin embedding, cut into 4 μm sections, and mounted onto poly-l-lysine-coated slides. Sections were dewaxed in xylene and rehydrated in a descending series of alcohols. They were then blocked for endogenous peroxidase with 30 mL/L H 2 O 2 in methanol and nonspecific antibody binding with normal rabbit serum.
The slides were incubated overnight at 4°C with the monoclonal antibodies, that is, with the monoclonal antibody against EGFR (clone H11, diluted 1:200, Dako, Glostrup, Denmark), VEGF (clone VG1, diluted 1:50, Dako, Glostrup, Denmark), and COX-2 (clone CX-294, diluted 1:100, Dako, Glostrup, Denmark). The samples were visualized by the EnVision method (Dako) according to the manufacturer's instructions. Lung squamous cell carcinoma strongly expressing EGFR, VEGF, and COX-2 was used as a positive control. For the negative control, sections were similarly treated but without the primary antibody. Expressions of COX-2, VEGF, and EGFR were semi-quantitatively determined according to the percentage of positive cancer cells. Staining intensity was classified as four grades: none (0), weak (1), moderate (2), and strong (3). The percentage of positive cancer cells was classified as four grades: 0 (0%), 1 (1-10%), 2 (11-49%), and 3 (50-100%). Grades 0 and 1 were considered as low expression, and grades 2 and 3 were considered as high expression.
Statistical analysis
The Chi-square test was used for statistical analysis of categorized data. For quantitative data, t-tests were used. All statistical analyses were performed using Statistical Package for the Social Sciences 19.0 software (IBM Inc., Chicago, IL, USA), and statistical significance was defined as a P < 0.05.
| > Results | | |
Expression of cyclooxygenase-2, epidermal growth factor receptor, and vascular endothelial growth factor
In the current series, COX-2 high expression [Figure 1]a was observed in 90 of 140 patients (64.3%), whereas negative or weak expression [Figure 1]d was noted in 50 patients (35.7%). COX-2 immunoreactivity was characteristically cytoplasmic and granular [Figure 1]a. EGFR expression was mainly seen in the cell membrane of tumor cells [Figure 1]b. EGFR high expression was observed in 87 of 140 patients (62.1%), whereas negative or weak expression [Figure 1]e was noted in 53 patients (37.9%). VEGF expression was primarily detected in the cytoplasm or cell membranes of the tumor cells [Figure 1]c. The vascular endothelial cells within the carcinomas were weakly stained. VEGF high expression was observed in 91 of 140 patients (65.0%), whereas negative or weak expression [Figure 1]f was noted in 49 patients (35.0%). | Figure 1: Expression of cyclooxygenase-2, epidermal growth factor receptor, and vascular endothelial growth factor. Immunohistochemically, staining of high and low expression of cyclooxygenase-2 (a and d), epidermal growth factor receptor (b and e), and vascular endothelial growth factor (c and f)
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High expression of cyclooxygenase-2, epidermal growth factor receptor, and vascular endothelial growth factor in association with clinicopathological features
The correlation between the patterns of expression and clinicopathological factors is listed in [Table 1]. In the present study, results showed that COX-2, EGFR, and VEGF overexpression were significantly correlated with the degree of differentiation and lymph node metastasis. The patients with a poor differentiation and lymph node metastasis had significantly high expression. Meanwhile, EGFR or VEGF overexpression was significantly correlated with T stage and TNM stage. However, the expression of COX-2, EGFR, and VEGF did not have any significant correlation with the gender of the patients and length of the tumor. | Table 1: Correlation between clinical/pathological characteristics and COX-2, EGFR, and VEGF in 140 cases of resected ESCC (Chi-square test or Fisher's exact test)
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| > Discussion | | |
Esophageal cancer is the eighth most common malignancy worldwide, and the fourth most common malignancy in China. [8] ESCC is the predominant type of esophageal cancer and is characterized by a high mortality in China. For most of the patients, systemic and lymph node metastasis is the major cause for failure of treatment. [9] This emphasizes the need for new systemic therapies. Over the past decade, the study of drug development has been transformed with the identification of and ability to direct treatment at specific molecular targets which are thought to have a critical role in the proliferation, invasion, and metastasis of a specific cancer cell. However, it is still difficult to decide which target(s) to select and for what population. Therefore, we have performed an immunohistochemical study on a validated ESCC in Chinese patients. We investigated the expression of three identified targets which therapeutic agents have been developed, namely, COX-2, EGFR, and VEGF. Their correlations with clinicopathological features were explored.
Cyclooxygenase-2
COX-2, a rate-limiting enzyme in the conversion of arachidonic acid to prostaglandins, participates in the regulation of cellular processes including angiogenesis, proliferation, and apoptosis. [10],[11] The biological behavior of ESCCs may be different in patients from different areas, and different causes may result in various biological behaviors of cancer cells and exhibition of different levels of COX-2 expression. COX-2 was detected immunoreactivity in 78.0-98.6% of esophageal adenocarcinomas, [12],[13] and in 38.7-91.0% of ESCCs. [13],[14] In this study, COX-2 overexpression was identified in 64.3% of ESCCs. The result showed that COX-2 overexpression was significantly correlated with lymph node metastasis and poor differentiated degree. COX-2 overexpression could be an unfavorable prognostic factor in ESCC. Although the role of COX-2 in ESCC progression has not been elucidated, it is possible that overexpression of COX-2 leads to high levels of prostaglandins in tumors. Prostaglandins produced by COX-2 may subsequently facilitate tumor progression by acting as differentiation and growth factors, or as immunosuppressors. The administration of selective COX-2 inhibitors might be advantageous in ESCC patients.
Epidermal growth factor receptor
EGFR is a tyrosine kinase (TK) that has an extracellular ligand-binding domain, transmembrane region, and transduction module consisting of a TK motif and several autophosphorylation sites. The EGFR signal pathway plays an important role in various tumorigenic processes, including cell cycle progression, angiogenesis, and metastasis, as well as protection from apoptosis. [15] Studies show that overexpression of EGFR occurs in 30-90% of ESCC and correlates with poor prognosis, and has relation to the depth of tumor invasion. [16],[17],[18] One meta-analysis consisted of 13 papers including 1150 cases of ESCC, which results showed that the positive rate of EGFR was 62.8% of ESCC, and overexpression of EGFR had correlation with the T stage, vascular invasion, and OS, but no relation to histological grading, lymphatic metastasis, and clinical stages was found. [19] A former meta-analysis included nine articles, including 802 cases of ESCC. Its results showed that EGFR positive expression rate was 61.8%, and EGFR was closely related to not only T staging and prognosis, but also the differentiation and lymph node metastasis. [20] In our study, 62.1% of ESCCs were high expression for EGFR, which is comparable with other reports. [19] This study showed high expression of EGFR in ESCC which increased TNM stage, the depth of tumor invasion, lymph node metastasis, and poor differentiation. Therefore, theoretically, anti-EGFR targeted therapy has potential application value. It has been reported that compared with chemotherapy alone, cetuximab plus chemotherapy could more obviously improve the curative effect for metastatic ESCC. [21] In a phase II study, five of nine advanced esophageal cancer patients treated with gefitinib (a tyrosine kinase inhibitor) in second-line had stable disease. [22]
Vascular endothelial growth factor
VEGF has been shown to be a powerful mediator of tumor angiogenesis by stimulating the proliferation and migration of endothelial cells. [23],[24],[25] VEGF increases vessel permeability, which subsequently leads to the migration and organization of endothelial and tumor cells and promotes cancer cell invasion into the circulation. [26] Most studies have shown that VEGF is associated with the aggressive characteristics of ESCC. VEGF expression has been significantly correlated with the presence of lymph node metastasis in patients with ESCC. [27],[28] Other investigators have found that a high VEGF level was significantly associated with advanced stage disease and a high frequency of distant metastases, as well as a poorer survival. [28],[29] While some other studies have reported no significant association between VEGF expression and clinical/pathological factors in patients with esophageal cancer. [30],[31],[32] In this study, VEGF high expression was detected in 65.0% of ESCCs, which is in the range of 24-93% as reported in the literature. [24] The results of this study showed that similar to high expression of EGFR, high expression of VEGF in ESCC, which increased TNM stage, the depth of tumor invasion, lymph node metastasis, and poor differentiation. This proportion of patients may benefit from bevacizumab therapy. Bevacizumab, a humanized monoclonal antibody directed against VEGF, has significantly improved the survival of patients with advanced nonsmall cell lung cancer or colorectal cancer when given in combination with conventional chemotherapy. [33],[34],[35]
In this study, we also found a significant correlation between the expression of COX-2, EGFR, and VEGF, evidence in support of the hypothesis that the activation of VEGF may induce angiogenetic effects of COX-2. [36],[37] An in vitro study showed that COX-inhibiting substances resulted in significant reduction in VEGF-A and VEGF-C expression. [38]
| > Conclusion | | |
This study showed COX-2, EGFR, and VEGF are high expressions in the ESCCs. Meanwhile, we were able to show those high expressions were correlated with some clinical/pathological characteristics which might indicate a poor prognosis. The results indicate that COX-2, EGFR, and VEGF might be useful factors in targeted therapy for ESCCs.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
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[Figure 1]
[Table 1]
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