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Correlation with Vasculogenic Mimicry and Poor Prognosis

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Correlation with Vasculogenic Mimicry and Poor Prognosis Int J Clin Exp Pathol 2015;8(4):4033-4043 www.ijcep.com /ISSN:1936-2625/IJCEP0006586 Original Article Erythropoietin and erythropoietin receptor in hepatocellular carcinoma: correlation with vasculogenic mimicry and poor prognosis Zhihong Yang1,2*, Baocun Sun1,2,3*, Xiulan Zhao1,2*, Bing Shao1, Jindan An1, Qiang Gu1,2, Yong Wang1, Xueyi Dong1, Yanhui Zhang1,3, Zhiqiang Qiu1,3 1Department of Pathology, Tianjin Medical University, Tianjin 300070, China; 2Department of Pathology, General Hospital of Tianjin Medical University, Tianjin 300052, China; 3Department of Pathology, Cancer Hospital of Tianjin Medical University, Tianjin 300060, China. *Equal contributors. Received February 1, 2015; Accepted March 30, 2015; Epub April 1, 2015; Published April 15, 2015 Abstract: To evaluate erythropoietin (Epo) and erythropoietin receptor (EpoR) expression, its relationship with vas- culogenic mimicry (VM) and its prognostic value in human hepatocellular carcinoma (HCC), we examined Epo/EpoR expression and VM formation using immunohistochemistry and CD31/PAS (periodic acid-Schiff) double staining on 92 HCC specimens. The correlation between Epo/EpoR expression and VM formation was analyzed using two-tailed Chi-square test and Spearman correlation analysis. Survival curves were generated using Kaplan-Meier method. Multivariate analysis was performed using Cox regression model to assess the prognostic values. Results showed positive correlation between Epo/EpoR expression and VM formation (P < 0.05). Patients with Epo or EpoR expres- sion exhibited poorer overall survival (OS) than Epo-negative or EpoR-negative patients (P < 0.05). Epo-positive/VM- positive and EpoR-positive/VM-positive patients had the worst OS (P < 0.05). In multivariate survival analysis, age, Epo and EpoR were independent prognostic factors related to OS. These results will provide evidence for further re- search on HCC microcirculation patterns and also will provide new possible targets for HCC diagnosis and treatment. Keywords: Erythropoietin, erythropoietin receptor, vasculogenic mimicry, prognosis, hepatocellular carcinoma Introduction which describes the ability of highly aggressive uveal melanoma to form highly patterned vas- Hepatocellular carcinoma (HCC), the fifth most cular channels in vivo composed of a basement prevalent primary malignancies in worldwide, is membrane stained positive with periodic acid- the second leading cause of cancer death in Schiff (PAS) in the absence of endothelial cells China [1]. Both the incidence and mortality [7]. Up to now, many studies were performed rates of HCC have been steadily increasing in aiming at clarifying the underlying molecular recent years [2]. As an aggressive solid tumor, pathways of VM. its prognosis remains unsatisfactory despite significant advances in surgical techniques and Findings indicated erythropoietin (Epo) is a low- medical treatment [3]. High incidence of recur- molecular-weight glycoprotein hormone stimu- rence and metastasis contributed to the poor lator of erythropoiesis produced in the fetal prognosis of HCC [4, 5]. Adequate blood supply liver and subsequently in the adult kidney [8]. is the main cause of recurrence and metasta- Epo exerts its action through specific binding to sis. Unfortunately, because of complicated its cognate receptor (EpoR), a member of the blood supply pattern, therapeutic effect of anti- cytokine receptor superfamily, which is mainly angiogenesis on HCC patients was unsatisfac- expressed on erythroid colony-forming units [9]. tory. Besides angiogenesis, vasculogenic mim- Epo can triggers a chain of intracellular signal- icry (VM) and mosaic vessels which served as ing events, such as activation of the receptor- alternative pathways should be considered [6]. associated tyrosine kinase JAK2, phosphoryla- VM was first reported by Maniotis et al. in 1999, tion and nuclear translocation of STAT5, thus Erythropoietin and erythropoietin receptor in hepatocellular carcinoma promoting progenitor cell survival, proliferation our knowledge, this study is the first to report and differentiation [10]. Many studies indicated the correlation of Epo/EpoR expression and VM that the functions of Epo and EpoR are not and its clinical significance for HCC. strictly limited to erythroid or hematopoietic lin- eages. For instance, EpoR expression has been Materials and methods detected in umbilical cord and placental endo- thelial cell lines, and Epo was found to be capa- Patients ble of stimulating endothelial cell proliferation in vitro [11, 12]. In addition, many kinds of can- Tissue specimens were obtained from 92 cers, such as breast cancer, renal cancer, gas- patients who had undergone hepatectomy for tric cancer, hepatocellular carcinoma and cen- HCC in Tianjin Medical University Cancer Insti- tral nervous system tumors have shown Epo/ tute and Hospital from September 2000 to EpoR expression [13-17]. December 2004. The diagnoses of these sam- ples were independently verified by two pathol- There is increasing evidence suggesting a wider ogists. The data of clinicopathological parame- biological role for Epo/EpoR related to malig- ters were harvested from the patients’ clinical nant biological behavior of tumor, including records and pathological reports. We collected tumor angiogenesis [15]. Epo induces endothe- paraffin-embedded tumor tissue samples from lial cell proliferation and migration [11, 18]. patients who had not undergone therapy prior Tumor cells lining the VM networks express to tumor surgical operation. This study was multiple endothelial markers, and resemble approved by the Ethical Committee of Tianjin endothelial cell functions [19]. The expression Medical University prior to its initiation. of EpoR in tumor cell and vascular endothelium maybe imply that Epo/EpoR may affect the Immunohistochemistry and CD31/periodic tumor microenvironment, perhaps by stimulat- acid Schiff (PAS) double staining ing tumor angiogenesis and VM formation. Tissue sections (4 μm) were deparaffinized and Epo is a hypoxia responsive cytokine. Low oxy- hydrated following standard procedures. After gen tension increases activity of hypoxia-induc- immersing in 3% H2O2 for 30 min to eliminate ible factor (HIF) that binds to cis-acting DNA endogenous peroxidase, the sections were hypoxia response elements (HREs) to activate microwaved for antigen retrieval in 0.01 M sodi- EPO transcription [20]. Ribatti and others um citrate for 15 min. After blocking with 10% described erythropoietin as a pro-angiogenic goat serum for 30 min at room temperature, factor comparable to the classical pro-angio- the slides were incubated with a primary anti- genesis factors like vascular endothelial growth body overnight at 4°C and a homologous sec- factor (VEGF) and basic fibroblast growth factor ondary antibody for 1 h at room temperature in (bFGF) [21]. Our previous studies indicated that a humidified box. Then the sections were hypoxia condition, HIF and VEGF are particular- stained with freshly dispensed diaminobenzi- ly relevant in VM formation of tumors [22, 23]. dine solution (DAB) for observation under a So we hypothesize Epo/EpoR expression may microscope. In the process, the slides were all associated with VM formation. rinsed three times in phosphate-buffered saline (PBS) (pH 7.2) before each step, except Although Epo/EpoR involved in angiogenesis in for the procedure of serum blocking to incuba- HCC has been reported on previous study [16], tion with the primary antibody. After counter- the relationship between Epo/EpoR expression staining with hematoxylin or PAS, the slides and VM in HCC and the relevance of their co- were ready for microscopic examination. existence within clinical parameters remain unclear. In the current study, expression pat- In the current study, the primary antibodies to terns of Epo/EpoR and VM were examined by Epo and EpoR were purchased from Santa Cruz immunohistochemistry (IHC) on 92 samples of Biotechnology (Epo 1:50; EpoR 1:200, Santa human HCC samples. The correlation of Epo/ Cruz, CA, USA) and CD31 (Zhongshan Golden EpoR expression and VM and its relevance to Bridge Biotechnology Limited Company (Beijing, clinicopathologic parameters were explored. China). Positive control and negative control Prognostic roles of Epo/EpoR expression and were performed for each batch. For the nega- VM in human HCC were also evaluated using tive control, PBS was used instead of the pri- Cox regression and Kaplan-Meier analysis. To mary antibody. For the positive control, a fore- 4034 Int J Clin Exp Pathol 2015;8(4):4033-4043 Erythropoietin and erythropoietin receptor in hepatocellular carcinoma Figure 1. Epo/EpoR expression and VM formation in HCC specimens. A. Positive expression of Epo was a weak and diffuse cytoplasmic staining in the tumor cells. B. Negative expression of Epo in HCC. C. Positive expression of EpoR was brown granules staining in the cytoplasms/membrane of the tumor cells. D. Negative expression of EpoR in HCC. E. VM formation in HCC tissue (black arrows indicate VM channels formed by tumor cells; yellow arrows indi- cate typical blood vessels with brown CD31+ staining). F. Epo/EpoR-positive expression directly correlated with VM formation in HCC samples. gone positively expressed tissue section was cells, 1 for less than 30% positive cells, 2 for used. The results were evaluated following the less than 60% positive cells, and 3 for more method described by Bittner et al [24]. The per- than 60% positive cells. The intensity was also centage and the intensity of the positive
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