Rationale and Objectives
To evaluate the correlation between enhancement parameters of multiphase contrast-enhanced computed tomography (CT) and immunohistochemical activities of vascular endothelial growth factor (VEGF), VEGF receptors, and CD34 in hepatocellular carcinoma (HCC).
Materials and Methods
Twenty-seven patients underwent curative resection for HCC with no preoperative treatment. We defined several CT enhancement parameters by measuring attenuation values of tumor, liver parenchyma, and aorta. The stored tissue blocks were assayed for immunohistochemical activities of VEGF, two VEGF receptors (Flt-1, Flk-1), and CD34, which were correlated with the enhancement parameters of multiphase contrast-enhanced CT.
Results
The VEGF activities in HCC showed moderate positive correlation with phase difference in portal phase, delayed enhancement (DE), tumor-blood ratio, blood pool index, and tumor-parenchyma ratio in arterial phase. The Flk-1 activities in HCC showed moderate positive correlation only with DE. CD34 activity in HCC showed positive correlation with most of the CT parameters except for DE.
Conclusion
Our study showed that several CT enhancement parameters representing mainly delayed enhancement features were well correlated with VEGF activity in HCC, and might be valuable indicators for assessing angiogenic activity in HCC.
Angiogenesis plays an important role in tumor growth and metastasis, and neovasculature facilitates shedding of tumor cells into surrounding blood vessels ( ). Growing tumors produce several angiogenic factors that stimulate endothelial cells and facilitate the formation of neovessels. Among the many angiogenic growth factors, vascular endothelial growth factor (VEGF) has been recognized as one of the most potent and effective factors ( ). VEGF expression by tumors is closely related to tumor progression and prognosis and metastasis ( ). There are currently two well-known VEGF receptors: Flt-1 and Flk-1. Flt-1 is also called VEGFR-1, and Flk-1 is also called VEGFR-2 or KDR. The expression of VEGF receptor also correlates with vascularity, metastasis, and proliferative activities of tumors ( ). Thus it stands to reason that VEGF receptors must play a role in regulating VEGF functions in the cancer microenvironment.
Hepatocellular carcinoma (HCC) is a hypervascular tumor characterized by its blood supply mainly from arterial sources ( ), and a high propensity for venous invasion. Expression of proangiogenic factors such as VEGF is known to be associated with the development of HCC ( ). CD34, a glycosylated transmembrane protein, is preferentially expressed on the surface of regenerating or migrating endothelial cells ( ), and has been investigated for localization of endothelial cells in HCC ( ). Several studies have suggested that CD34 may be a more sensitive and specific marker than other endothelial cell markers for microvessels in HCC ( ).
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Materials and methods
Patients
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Determination of CT Parameters
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Table 1
Summary of CT Enhancement Parameters
CT Enhancement Parameter Definition CE CEA CT value in arterial phase – CT value in precontrast phase CEP CT value in portal phase – CT value in precontrast phase RE REA (CEA/CT value in precontrast phase) × 100 (%) REP (CEP/CT value in precontrast phase) × 100 (%) PD PDA (Tumoral CT value – parenchymal CT value) in arterial phase PDP (Tumoral CT value – parenchymal CT value) in portal phase DE Tumoral CT value in portal phase – tumoral CT value in arterial phase TBR(Tumoral peak CT value – tumoral CT value in precontrast phase)(Aortic peak CT value – aortic CT value in precontrast phase)×100(%) (Tumoral peak CT value – tumoral CT value in precontrast phase)
(Aortic peak CT value – aortic CT value in precontrast phase)
×
100
(
%
) BP (Tumoral CEP/parenchymal CEP) × 100 (%) Tumor-parenchyma ratio in arterial phase (TPA) (Tumoral CEA/parenchymal CEA) × 100 (%)
CT: computed tomography; CE: contrast-enhancement index; CEA: contrast-enhancement index in arterial phase; CEP: contrast-enhancement index in portal phase; RE: relative enhancement ratio; REA: relative enhancement ratio in arterial phase; REP: relative enhancement ratio in portal phase; PD: phase difference; PDA: phase difference in arterial phase; PDP: phase difference in portal phase.
Each of CE, RE, and PD is divided into two categories according to the phase that CT attenuation values are taken in. Labels are attached with A for arterial phase and P for portal phase. CE and RE can be measured separately in HCC and hepatic parenchyma.
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Immunohistochemical Analysis
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Statistical Analysis
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Results
Tumor Size/Grade and Angiogenic Activities in HCC
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Table 2
Summary of Correlations Between Tumor Size/Grade and Immunohistochemical Activities in HCC ⁎
VEGF of HCC Flt-1 of HCC Flk-1 of HCC CD34 of HCC_r__P__r__P__r__P__r__P_ Tumor size −0.29 .15 −0.38 .051 0.20 .32 0.35 .076 Tumor grade −0.17 .39 −0.091 .65 −0.061 .76 0.35 .071
HCC: hepatocellular carcinoma; VEGF: vascular endothelial growth factor; r : correlation coefficient.
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CT Findings and Angiogenic Activities in HCC
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Table 3
Summary of the Mean Values of CE and RE for HCC and for the Liver
CEA (Hu) CEP (Hu) REA (%) REP (%) HCC 46.16 ± 25.35 69.05 ± 27.38 108.86 ± 61.49 164.19 ± 68.19 Liver 12.27 ± 10.85 58.85 ± 17.00 22.53 ± 20.98 107.03 ± 35.09
CE: contrast-enhancement index; Hu: Hounsfield unit; CEA: contrast-enhancement index in arterial phase; CEP: contrast-enhancement index in portal phase; REA: relative enhancement ratio in arterial phase; REP: relative enhancement ratio in portal phase; HCC: hepatocellular carcinoma.
Table 4
Summary of Correlations Between CT Parameters and Immunohistochemical Activities in HCC
VEGF of HCC Flt-1 of HCC Flk-1 of HCC CD34 of HCC_r__P__r__P__r__P__r__P_ CEA 0.031 .88 −0.065 .75 −0.15 .44 0.61 .001 CEP 0.28 .15 −0.17 .39 0.1 .61 0.64 .001 REA 0.071 .73 −0.058 .78 −0.15 .45 0.6 .001 REP 0.26 .19 −0.24 .22 0.058 .76 0.57 .002 PDA 0.23 .26 −0.029 .89 −0.66 .74 0.57 .002 PDP 0.43 .023 −0.12 0.54 0.24 .24 0.43 .026 DE 0.39 .047 −0.27 .18 0.4 .036 0.13 .51 TBR 0.45 .02 −0.14 .48 0.17 .39 0.54 .003 BP 0.47 .013 −0.15 .45 0.19 .34 0.4 .037 TPA 0.39 .047 −0.029 .89 −0.067 .74 0.16 .42
CT: computed tomography; VEGF: vascular endothelial growth factor; HCC: hepatocellular carcinoma; CEA: contrast-enhancement index in arterial phase; CEP: contrast-enhancement index in portal phase; REA: relative enhancement ratio in arterial phase; REP: relative enhancement ratio in portal phase; PDA: phase difference in arterial phase; PDP: phase difference in portal phase; TBR: tumor-blood ratio; TPA: tumor-parenchyma ratio in arterial phase; r : correlation coefficient.
Most CT parameters representing delayed enhancement feature are moderately correlated with VEGF activities of HCC. All CT parameters except DE are correlated with CD34 activities of HCC.
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CT Findings and Angiogenic Activities in Liver Parenchyma
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Table 5
Summary of Correlation Between CT Parameters and Immunohistochemical Activities in Liver Parenchyma
VEGF of Liver Flt-1 of Liver Flk-1 of Liver CD34 of Liver_r__P__r__P__r__P__r__P_ CEA −0.28 .16 −0.26 .20 −0.28 .16 0.064 .75 CEP −0.60 .001 −0.45 .018 −0.49 .010 −0.079 .70 REA −0.28 .16 −0.26 .20 −0.26 .19 0.039 .85 REP −0.54 .004 −0.44 .023 −0.45 .019 −0.059 .77
See Table 4 for abbreviations.
CEP and REP representing enhancement feature in portal phase are negatively correlated with VEGF, Flt-1, and Flk-1 except CD34.
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Discussion
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