ANGIOGENESIS

Even with all the genetic abnormalities discussed above, solid

tumors cannot enlarge beyond 1 to 2 mm in diameter unless
they are vascularized. Like normal tissues, tumors require
delivery of oxygen and nutrients and removal of waste
products; presumably the 1- to 2-mm zone represents the
maximal distance across which oxygen, nutrients, and waste
can diffuse from blood vessels. Cancer cells can stimulate neoangiogenesis,
during which new vessels sprout from previously
existing capillaries, or, in some cases, vasculogenesis, in
which endothelial cells are recruited from the bone marrow
(Chapter 3). Tumor vasculature is abnormal, however. The
vessels are leaky and dilated, and have a haphazard pattern of
connection. Neovascularization has a dual effect on tumor
growth: perfusion supplies needed nutrients and oxygen, and
newly formed endothelial cells stimulate the growth of adjacent
tumor cells by secreting growth factors, such as insulinlike
growth factors (IGFs), PDGF, and granulocyte-macrophage
colony-stimulating factor. Angiogenesis is required not only
for continued tumor growth but also for access to the vasculature
and hence for metastasis. Angiogenesis is thus a necessary
biologic correlate of malignancy.104
How do growing tumors develop a blood supply? The
emerging paradigm is that tumor angiogenesis is controlled
by the balance between angiogenesis promoters and inhibitors.
Early in their growth, most human tumors do not induce
angiogenesis. They remain small or in situ, possibly for years,
until the angiogenic switch terminates this stage of vascular
quiescence.105 The molecular basis of the angiogenic switch
involves increased production of angiogenic factors and/or
loss of angiogenic inhibitors. These factors may be produced
directly by the tumor cells themselves or by infl ammatory cells
(e.g., macrophages) or other stromal cells associated with the
tumors. Proteases, either elaborated by the tumor cells directly
or from stromal cells in response to the tumor, are also involved
in regulating the balance between angiogenic and anti-angiogenic
factors. Many proteases can release the proangiogenic
basic fi broblast growth factors (bFGF) stored in the ECM;
conversely, three potent angiogenesis inhibitorsangiostatin,
endostatin, and vasculostatinare produced by proteolytic
cleavage of plasminogen, collagen, and transthyretin, respectively.
The angiogenic switch is controlled by several physiologic
stimuli, such as hypoxia. Relative lack of oxygen stimulates
HIF1, an oxygen-sensitive transcription factor mentioned
above, which then activates transcription of a variety of proangiogenic
cytokines, such as VEGF and bFGF. These factors
create an angiogenic gradient that stimulates the proliferation
of endothelial cells and guides the growth of new vessels
toward the tumor. VEGF also increases the expression of
ligands that activate the Notch signaling pathway, which plays
a crucial role in regulating the branching and density of the
new vessels (Chapter 3). Both pro- and anti-angiogenic factors
are regulated by many other genes frequently mutated in
cancer. For example, in normal cells, p53 can stimulate expression
of anti-angiogenic molecules such as thrombospondin-1,
and repress expression of pro-angiogenic molecules such as
VEGF. Thus, loss of p53 in tumor cells not only removes the
cell cycle checkpoints listed above but also provides a more
permissive environment for angiogenesis. The transcription

of VEGF is also infl uenced by signals from the RAS-MAP

kinase pathway, and mutations of RAS or MYC up-regulate
the production of VEGF. The mechanisms whereby bFGF,
VEGF, and the Notch pathway work together to coordinate
angiogenesis were discussed in Chapter 3. bFGF and VEGF are
commonly expressed in a wide variety of tumor cells, and
elevated levels can be detected in the serum and urine of a
signifi cant fraction of cancer patients. Indeed, an anti-VEGF
monoclonal antibody, bevacizumab, has recently been
approved for use in the treatment of multiple cancers.106
Another emerging strategy involves the use of antibodies that
inhibit Notch activation. These antibodies cause new vessels
to be so malformed that they cannot deliver blood to the
tumor effectively.107,108