Predictive and Prognostic Significance of Vascular
Endothelial Growth Factor (VEGF) and Response to VAD
Protocol of Chemotherapy In Multiple Myeloma Patients
Ashraf
M. El Hefni, Huda F. Ebian
Ashraf M. El Hefni, Hematology/Oncology unit, Internal
Medicine Department, Faculty of Medicine, Zagazig University
Huda F. Ebian, Hematology &Oncology unit, Clinical Pathology
Department, Faculty of Medicine, Zagazig University
Correspondence to: Ashraf M. El Hefni, MD, Hematology &
Oncology unit, Internal Medicine Department, Faculty of Medicine, Zagazig
University
Email: Elhefny70@zu.edu.eg
Telephone: +201005766415
Fax:
+20552330211
Received: February 23,
2015 Revised: April 16, 2015
Accepted: April 21, 2015
Published online: July 6, 2015
ABSTRACT
Angiogenesis
played a crucial role in the pathogenesis of hematological malignancies
including multiple myeloma.
Aim: This study aimed
to assess angiogenesis activators such as vascular endothelial growth factor
and its soluble receptor-2 in blood plasma of multiple myeloma patients and
response to VAD protocol of therapy
Patients and methods: fifty six patients with multiple
myeloma were enrolled in our study, there age range (45-65) with median 53
years old, forty one were males and rest were females, routine hematological
and biochemical tests, serum monoclonal protein concentration and/or urinary
light chain excretion and beta 2-microglobulin were performed at the beginning
of treatment and four months after
VAD chemotherapy with serial measurements of vascular endothelial growth factor
(VEGF) and its soluble receptor-2 in the peripheral blood plasma of patients at diagnosis and after
treatment by VAD protocol of chemotherapy.
Results: There was
significant decrement of vascular endothelial growth factor and its soluble
receptor-2 levels in the plasma of patients who achieved complete or very good
partial response (p=0.01 and p=0.04 respectively),also a
significance association between vascular endothelial growth factor, its
soluble receptor and other bad prognostic factors such as stage, high B2
macroglobulin level in multiple myeloma patients ,and when multi analysis was
applied a high significant association were observed reflecting an independent
risk of vascular endothelial growth factor, or its soluble receptor-2, ten
myeloma patients (17.8%) showed complete response, while twenty seven (48.2%)
patients showed either very good or partial response and rest patient showed no
response with tolerated toxicity according to WHO criteria of toxicity and the
median time to progression for responders was 22.5 months while 95% confidence
interval (CI) was 1.71-3.09.
Conclusion: Vascular
endothelial growth factor and its soluble receptor -2 had a prognostic and
predictive utility in responded multiple myeloma patient indicating that the
rate of angiogenesis was decreased after successful treatment and might open a
future direction for target therapy
© 2015 ACT. All
rights reserved.
Key words: Multiple myeloma; Vascular endothelial growth factor;
Chemotherapy; Angiogenesis
El Hefni AM, Ebian HF. Predictive and Prognostic
Significance of Vascular Endothelial Growth Factor (VEGF) and Response to VAD
Protocol of Chemotherapy In Multiple Myeloma Patients. International
Journal of Hematology Research 2015; 1(2): 70-73 Available from: URL:
http://www.ghrnet.org/index.php/ijhr/article/view/1082
INTRODUCTION
Angiogenesis was defined as the formation of new blood vessels from
pre-existing ones and played a crucial role in the pathophysiology of solid
tumors and hematological malignancies, in the past decade, several groups had
demonstrated a significantly elevated angiogenic activity in the bone marrow of
patients with various hematological malignancies such as multiple myeloma,
myelodysplastic syndromes, acute myeloid leukemia and B cell chronic
lymphocytic leukemia[1,2].
Multiple
myeloma was characterized by proliferation of malignant plasma cells that
accumulate in the bone marrow and often produce a monoclonal immunoglobulin and
it was the first hematological malignancy in which increased angiogenesis rate
was detected and its activators as vascular endothelial growth factor played a
role in myeloma pathogenesis and had shown to stimulate the proliferation of
malignant plasma cells as well as nonmalignant stromal cells through activation
of different type of receptors of tis factors[3,4].
Vascular endothelial
growth factor (VEGF) was an important positive regulator of angiogenesis and
the biological activity of it was mediated by different receptors of tyrosine
kinase activity, vascular endothelial growth factor receptor -1(fms-like
tyrosine kinase1 - FLT-1) and vascular endothelial growth factor receptor-2
(kinase domain receptor ) both receptors had a high affinity for factor, and
were expressed on vascular endothelial cells as well as on malignant cells and
receptor -2 had 1,356 amino acids in humans and can be separated into 4 regions
the extra cellular ligand-binding domain, transmembrane domain, tyrosine kinase domain, and
downstream carboxy terminal region
also it is the major positive signal transducer for both physiological
and pathological angiogenesis[5,6].
The aim of
this study was to evaluate the levels of vascular endothelial growth factor and
its soluble receptor 2 in the platelet-poor blood plasma of myeloma patients at
diagnosis and after treatment by four courses of VAD protocol of chemotherapy.
Patients
and methods
This study had been carried out at inpatient and outpatient clinic of
hematology/ oncology unit of internal medicine department, clinical pathology
department, faculty of medicine, zagazig university and zagazig insurance
hospital in period between January 2011 and Jully 2014, fifty six patients with
multiple myeloma were enrolled in the study and there age range (45-65) with median 53
years old, forty one were males and rest were females, routine hematological and
biochemical tests, serum monoclonal protein concentration and/or urinary light
chain excretion and ¦Â2-microglobulin were performed at the beginning of of treatment and 3-4 months after VAD
chemotherapy. Bone marrow aspirate and/or bone marrow biopsy were performed
before the first course of treatment and after administration of the fourth
course of treatment, all patient were entered in a study received VAD bolus
protocol of chemotherapy after approval of local board committee and it
consisted of vincristine 0.4 mg i.v., doxorubicin 9 mg/m2 i.v. and
dexamethasone 40 mg per oral daily for four consecutive days for three to four
months then reevaluated and categorized according to response criteria ,
Response
Criteria
Response to treatment was documented according to to International
Myeloma Working Group.Complet response(CR)requires negative immunfixation on
the serum and urine and less than 5%plasma cell in bone marrow. Very good
partial response (VGPR) was defined as reduction of serum of monoclonal (M)
protein by at least 90% and urine M protein level less than100 mg per 24 hour.
Partial response (PR) was defined as decrease in serum M protein by 50% to 90%
and urine M protein level less than 200 mg per 24 hour.insufficient response
(IR) as decrease in M-protein by less than 50%[7].
Method of assay
After giving written informed consent to the study, patients had bone
marrow aspiration from either the sternum or iliac crest, peripheral venous
blood sample was taken on the same day. All samples were immediately mixed with
EDTA and centrifuged at 3,800 rpm for 15 min at room temperature to give plasma
poor platelet sample. Vascular endothelial growth factor (VEGF) measurements
were done using ELISA kits according to the manufacturers¡¯ instructions. The
following ELISA kits were used: human VEGF (R&D systems, Minneapolis (USA).
For each patient, level of vascular endothelial growth factor (VEGF) and its
soluble receptor-2(sVEGFR-2) were measured at diagnosis and at the time of
maximum treatment response, four months after treatment[8].
Statistical
analysis
Data was analyzed using IBM SPSS advanced statistics version 20 (SPSS
Inc., Chicago, IL). Numerical data of scores were expressed as mean and
standard deviation or median and range as appropriate. Chi-square test
(Fisher¡¯s exact test) was used to examine the relation between qualitative
variables. For not normally distributed quantitative data, comparison between
two groups was done using Mann-Whitney test (non-parametric t-test).
Spearman-rho method was used to test correlation between numerical variables.
Survival analysis was done using Kaplan-Meier method and comparison between two
survival curves was done using log-rank test. Cox-regression method was used to
test the relation between numerical variables and survival. Odds ratio (OR)
with it 95% confidence interval (CI) were used for risk estimation. P value
less than0.05 was significant
RESULTS
The fifty six multiple myeloma patients had evaluated by plasma samples
taken at diagnosis and after four courses of therapy and patient¡¯s characteristics
were shown in Table 1.
Vascular
endothelial growth factor (VEGF).Vascular endothelial growth factor receptor-2
(VEGFR-2), Lactate dehydrogenase (LDH), Immunoglobulin G (Ig G).
The plasma
level of vascular endothelial growth factor as well as its soluble receptors
were decreased significantly in responded patient either complete response (CR)
or very good and partial response patients (p=0.019, p=0.043
respectively) while there was not any significant reduction in Non-responded
patients for chemotherapy table 2.
When multi
variant cox analysis was applied to detect the significance association between
vascular endothelial growth factor, its soluble receptor and other bad
prognostic factors in multiple myeloma patient ,a high significant association
were detected reflecting
independent risk of vascular endothelial growth factor, or soluble receptor
table 3.
All myeloma
patients are treated by VAD bolus protocol, ten patient (17.8%) showed complete
response, while twenty seven (48.2%) patients showed either very good or
partial response and rest patient showed no response with tolerated toxicity
according to WHO criteria of toxicity (Tables 1 and 4).
The median
time to progression for responded patients was 22.5 months (95% confidence
interval 1.71-3.09) by VAD bolus protocol (Figure 1).
DISCUSSIONS
Vascular endothelial growth factor (VEGF) considered a major regulator
for angiogenesis and it had five tyrosine kinase receptors and activation of
these receptors regulate either physiological or pathological angiogenesis
according to its pathway, vascular endothelial growth factor receptor -2 had
strong tyrosine kinase activity, and transduced the major signals for
angiogenesis. However, unlike other representative tyrosine kinase receptors
which used the Ras pathway and this soluble receptor 2 mostly used the
Phospholipase-C¦Ã-Protein kinase- C pathway to activate MAP-kinase and DNA
synthesis so this receptor had a direct signal transducer for pathological
angiogenesis including cancer and diabetic retinopathy by itself and the
signaling appeared to be critical targets for the suppression of these diseases[9,10].
Vascular
endothelial growth factor (VEGF) was an important positive regulator of
angiogenesis and the biological activity of it was mediated by different
receptors of tyrosine kinase activity[11].
In multiple
myeloma, vascular endothelial growth factor was produced by malignant plasma
cells and stimulates the proliferation of endothelial cells, also at the same
time, vascular endothelial growth factor had secreted by endothelial cells in
the tumor microenvironment it acted in an autocrine and paracrine way on both
endothelial and myeloma cells, so there was a reciprocal stimulation between
endothelial cells and myeloma cells to produce it[12].
A significant
increment in plasma level of vascular endothelial growth factor and its soluble
receptor -2 in myeloma patients at diagnosis before starting chemotherapy
protocol with significant decrement in there plasma levels after four courses
of VAD protocol of therapy in responded patients and this was consistent with
same data observed by Mileskhin et al. who reported that high levels of vascular endothelial growth factor were
associated with response rate in patients treated chemotherapy[13,16].
Anther
contradictory results were detected by Cibeira and collaborators who noticed
that there was not a significant correlation between response rate and vascular
endothelial growth factor level or
its receptor-2[14,15] and this might attributed to different in
selection criteria of patients or method of assessment as the concentrations of angiogenesis
factors in the plasma rather than in the serum because platelets contain significant
concentrations of these cytokines, released during during preparation of serum[6,17].
Vascular
endothelial growth factor and its soluble receptor -2 in myeloma patients had
associated with other poor prognostic factors and both of them had independent
risk factors with a predictive value due to significant decrement in there
plasma level after four courses of VAD protocol of therapy in responded
patients reflecting decrement of angiogenesis rate in myeloma patients after
therapy[16].
The aim of
front-line therapy for multiple myeloma was to substantially decrease tumor
burden and the degree of disease reduction is associated with improved outcome,
including prolonged progression-free survival (PFS) and overall survival (OS)[17].
The introduction of immune
modulatory drugs and proteasome inhibitors had significantly improved survival
of myeloma patients and increasing evidence suggested that these agents also
improve outcome of the disease more than traditional protocols[18].
But in certain situation VAD protocol still used in our country
VAD regimen
was introduced many years ago and was shown to be the first effective salvage
treatment for multiple myeloma that was resistant to alkylating agents and this
combination of vincristine and doxorubicin with intermittent high-dose
dexamethasone (VAD) had high response rate in treatment for multiple myeloma
with tolerated toxicity[19,20].
Our study
observed that the VAD bolus regimen was effective in patients less or more than
60 years of age and thirty seven (66%) patients showed response rate and this
consistent with the data of Segeren et al. study in which administered
vincristine and doxorubicin as a rapid i.v. infusion in a large cohort of
previously untreated patients ¡Ü60 years of age and observed a 67%
objective response rate[21], and well tolerated toxicity
without observation of grad four
myelosuppression or other toxicity according to WHO criteria with median time
to progression for responders was 22.5 months, also the similar results were observed
in study of Demopoulos et al[22].
Conclusion
Vascular endothelial growth factor and its soluble receptor -2 had a
prognostic and predictive utility in responded multiple myeloma patient
indicating that the rate of angiogenesis was decreased after successful
treatment and it could be used as a target therapy together with its soluble
receptor-2 in the future, also VAD protocol was effective and well tolerated
regimen for treatment multiple myeloma patients
CONFLICT OF INTERESTS
The authors have no conflicts of interest to declare.
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