Angiogenesis in Adipose Tissue

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Editor
Yihai Cao
Department of Microbiology
Tumor and Cell Biology (MTC)
Karolinska Institute
Stockholm, Sweden
Department of Medicine
and Health Sciences
Linköping University
Linköping, Sweden

ISBN 978-1-4614-8068-6 ISBN 978-1-4614-8069-3 (eBook)

DOI 10.1007/978-1-4614-8069-3
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Preface

The concept of therapeutic antiangiogenesis was proposed by Judah Folkman 40

years ago. Although this theory was initially hypothesized for cancer therapy by
blocking tumor angiogenesis, the same principle may also apply for treatment of
other angiogenesis-dependent nonmalignant diseases. Today, antiangiogenic drugs
have successfully been used for treatment of various cancers and age-related macu-
lar disease in human patients. The clinical success of antiangiogenic therapy crys-
tallizes more than 40-year extensive preclinical and clinical findings of angiogenesis
research. It has also paved new avenues for therapeutic extensions to other areas
including obesity and metabolic disorders.
Obesity and its related metabolic diseases pose the biggest threat to global human
health. Unfortunately, pharmacological intervention of obesity by effective drugs is
not available and development of such effective drugs is an inevitable urgent task
for prevention and treatment of the fast growing obese population in both developed
and developing countries. The original experimental evidence that expansion of the
adipose tissue is dependent on angiogenesis was provided in mouse obese models,
in which treatment of obese animals with antiangiogenic agents significantly pre-
vented obese development. These findings resemble the antitumor effect of angio-
genesis inhibitors. As angiogenesis is essentially required for almost all tissue
growth and expansion, the preclinical findings of antiobesity effect by angiogenesis
inhibitors are probably not surprising.
White adipose tissue (WAT) and brown adipose tissue (BAT) exhibit opposing
metabolic effects, as the former stores excessive energy and latter flames the stored
energy to become heat. Storage of excessive lipids in WAT and energy consumption
in BAT seem to be dependent on appropriate vascular functions, which are tightly
controlled by the number and structure of microvessels in the adipose tissues. Thus,
blood vessels might play dual roles in modulation of adipose tissue growth or regres-
sion, depending on its relation to the metabolic status of the adipose tissue.
Emerging experimental evidence shows that the adipose vascular system is not
merely a pipe-like structure that supplies oxygen and nutrients for adipocytes.
Blood vessels in the adipose tissue may also serve as a reservoir of stem cells that
under certain conditions differentiate into preadipocytes and adipocytes. In fact,

v
vi Preface

both vascular endothelial cells and perivascular cells have been reported to have
stem cell features, which allow them to trans-differentiate into adipocytes.
Additionally, blood vessels in the adipose tissue provide other cell types including
stromal cells and inflammatory cells that significantly modulate adipocyte func-
tions. Similar to tumors, various cell types in the adipose tissue produce multiple
angiogenic factors and cytokines that often collaboratively modulate adipogenesis.
Emerging evidence suggests that a complex interplay exists between these angio-
genic factors and cytokines.
This is the first book focusing on discussion of complex roles of the adipose
vasculature in modulation of adipogenesis, obesity, and metabolism. Although most
of these findings are based on preclinical animal models, the same mechanism most
likely exists in humans. I express my deepest appreciation to all coauthors and other
experts who have significantly contributed to the development of this exciting field
and to this comprehensive book covering most aspects of the adipocyte-vascular
interface. I also apologize that many other interesting aspects related to this topic
may not be covered due to the space limit of this book.

Stockholm, Sweden Yihai Cao, M.D., Ph.D

Contents

Part I Historical Review of Angiogenesis

1 Angiogenesis in Diseases and Therapy .................................................. 3

Yihai Cao

Part II Spatiotemporal Relation of Adipocytes

and Vascular Cells During Development

2 Adipose Stem Cells.................................................................................. 19

Carolyn Algire, Dasa Medrikova, and Stephan Herzig
3 Stromal Vascular Cells............................................................................ 41
Sahohime Matsumoto and Ichiro Manabe
4 Vascular Adipose Complex ..................................................................... 53
J. Michael Sorrell

Part III Adipose Vasculature

5 Blood Vessels in White and Brown Adipose Tissues ............................ 77

Sharon Lim, Jennifer Honek, and Yihai Cao
6 Lymphatic System in Adipose Tissues ................................................... 103
Bernhard Nausch, Sonia Rehal, and Pierre-Yves von der Weid
7 Origin of Adipocyte Precursors from Adipose
Vascular Endothelium ............................................................................ 131
Andrea Frontini, Silvia Corvera, and Saverio Cinti
8 Vascular and Endothelial Regeneration................................................ 157
Louis Casteilla, Patrick Laharrague, and V. Planat-Benard

vii
viii Contents

Part IV Angiogenic Factors and Adipokines in Adipose Tissue

9 Role of NPY in Brown Adipocytes and Obesity ................................... 169

Sheng Bi
10 Leptin, Adiponectin, and Other Adipokines in Regulation
of Adipose Tissue Angiogenesis .............................................................. 187
Ebba Brakenhielm and Yihai Cao

Part V Regulation of Adipose Angiogenesis by Inflammatory Cells

11 Immune Cells in Adipose Tissue: Key Players

in Metabolic Disorders ........................................................................... 231
Fanny Volat and Anne Bouloumié
12 Adipose Tissue Hypoxia in Regulation of Angiogenesis
and Obesity .............................................................................................. 247
Zoi Michailidou and Jonathan R. Seckl

Part VI Mouse Models to Study Adipose Angiogenesis

13 Adipose Angiogenesis Models in Animals and Methodology .............. 265

Jennifer Honek, Sharon Lim, and Yihai Cao
14 Mouse Genetic Models in Studying Adipose Angiogenesis ................. 297
Ilse Scroyen and H. Roger Lijnen

Part VII Adipose Tissue Facilitates Tumor Angiogenesis and Growth

15 Adipose Tissue-Derived Progenitor Cells and Cancer ........................ 321

Chieh Tseng and Mikhail G. Kolonin
16 Adipose-Derived Endothelial Precursor Cells Supporting
Tumor Growth ......................................................................................... 339
Patrizia Mancuso, Ines Martin-Padura, and Francesco Bertolini

Part VIII Engineering of Vascularized Adipose Tissue

17 Successful Angiogenesis as Key to Engineered Adipose Tissue .......... 351

Paul Severin Wiggenhauser and Jan-Thorsten Schantz

Index ................................................................................................................. 371

 Part I
Historical Review of Angiogenesis
Chapter 1
Angiogenesis in Diseases and Therapy

Yihai Cao

Abstract Angiogenesis research has become an increasingly attractive field in

biomedicine for academic and pharmaceutical scientists because of its broad
involvement in various human diseases, including the most common and lethal dis-
eases such as cancer, obesity, cardiovascular diseases, chronic inflammation, and
ophthalmological diseases. Although the initiation of angiogenesis can be triggered
by distinct and overlapping angiogenic factors and cytokines in different diseases, a
common fundamental mechanism that underlies the angiogenic process exists under
various pathological settings. Targeting pathological angiogenesis has provided an
effective therapeutic approach of treatment of certain human diseases. For example,
anti-vascular endothelial growth factor (anti-VEGF) drugs show markedly benefi-
cial effects in vision improvement in patients with wet type of age-related macular
degeneration (AMD). Similar anti-VEGF drugs in combination with chemotherapy
have also successfully been developed for treatment of various cancers in human
patients. Paradoxically, promoting neovascularization has also been therapeutically
implied for treatment of ischemic diseases such as ischemic myocardium and
chronic leg ischemia. However, proangiogenic therapy-based approaches have not
been demonstrated to be beneficial in rigorous clinical trials. Would modulation of
angiogenesis offer a new therapeutic approach for treatment of obesity and its
related metabolic disorders? In some mouse disease models, administration of
generic antiangiogenic agents has provided supportive evidence although such an
approach needs validation in humans.

Keywords Angiogenesis • Disease therapy • Obesity • Diabetes • Cancer • Targeted

therapy • Neovascularization

Y. Cao, M.D., Ph.D. (*)

Department of Microbiology, Tumor and Cell Biology (MTC), Karolinska Institute,
171 77 Stockholm, Sweden
Department of Medicine and Health Sciences, Linköping University,
581 85 Linköping, Sweden
e-mail: [email protected]

Y. Cao (ed.), Angiogenesis in Adipose Tissue, DOI 10.1007/978-1-4614-8069-3_1, 3

© Springer Science+Business Media New York 2013
4 Y. Cao

1.1 Process of Angiogenesis

Blood vessel formation and growth are achieved via several processes including
vasculogenesis, angiogenesis, and intussusception (Carmeliet and Jain 2000; Cao
2009a; Folkman 1996). While vasculogenesis is essential for the formation of the
first vascular structure including primitive cardinal endothelium and aorta during
early stages of embryogenesis (Risau and Flamme 1995), angiogenesis is the key
process of neovascularization that employs vessel sprouting from the preexisting
vasculature (Yancopoulos et al. 1998). It is believed that endothelial cells in quies-
cent vasculatures respond to angiogenic signals to proliferate, migrate, and eventu-
ally form tubular-like structures. In adults, vasculatures in most tissues remain
quiescent and the dormant nature of these blood vessels suggests the existence of
negative regulators that prevent vessel growth. In support of this notion, numerous
endogenous angiogenesis inhibitors have been identified in both healthy and patho-
logical tissues (Cao 2001; O’Reilly et al. 1994, 1997; Nyberg et al. 2005). The ini-
tiation of an angiogenic phenotype requires high levels of angiogenic stimuli to
override negative regulators, tipping the balance toward vascular spouting (Cao
2004). Indeed, high levels of angiogenic factors including vascular endothelial
growth factor (VEGF), fibroblast growth factor (FGF), platelet-derived growth fac-
tor (PDGF), angiopoietins, and hepatocyte growth factor (HGF) are often found in
tissues that undergo neovascularization (Cao et al. 2009). These angiogenic driving
factors are especially expressed at high levels in tumors and other pathological tis-
sues that encounter tissue ischemia.
In response to angiogenic signals, endothelial cells have to break down the base-
ment membrane to migrate and proliferate, leading to an organized and directed
growth cone. This process is controlled by several signaling systems in which the
interplay between VEGF and Notch signaling systems is primarily essential to
ensure the formation of an optimal vascular network (Cao et al. 2009; Benedito
et al. 2012; Sawamiphak et al. 2010; Tammela et al. 2008; Hellstrom et al. 2007;
Siekmann and Lawson 2007; Ridgway et al. 2006; Noguera-Troise et al. 2006).
In the presence of VEGF, inhibition of the Notch signaling pathway results in exces-
sive formation of endothelial cell tips and vascular networks. The Dll4-triggered
Notch signaling prevents the undirected tip formation in the angiogenic growth
cone, leading to the directed growth of angiogenic vessels (Hellstrom et al. 2007;
Siekmann and Lawson 2007; Ridgway et al. 2006; Noguera-Troise et al. 2006)
(Fig. 1.1). Concomitant to the vascular sprouting process, angiogenic vessels recruit
peri-vascular cells or mural cells, i.e., pericytes and vascular smooth muscle cells,
to remodel and stabilize the nascent vasculature (Gerhardt et al. 2003). Peri-vascular
coverage also prevents the excessive and undirected sprouting from blood vessels.
In pathological tissues, blood vessels exhibit several abnormalities that distin-
guish them from healthy vasculatures. For example, in tumor tissues vasculatures
usually appear as disorganized and tortuous primitive vascular networks that are
highly leaky (Cao 2005, 2009a) (Figs. 1.1 and 1.2) One of the key reasons why
tumor vessels possess these pathological features is that VEGF expression levels are
high in the tumor microenvironment. Genetic alterations in tumor cells often lead to
1 Angiogenesis in Diseases and Therapy 5

Fig. 1.1 Role of Notch signaling in the formation of a vascular network. Suppression of Notch
signaling using DAPT (middle) results in the formation of a disorganized vascular network as
compared to the vector tumor (left). Overexpression of Dll4 triggers Notch signaling and thereby
prevents undirected tip formation resulting in a more normalized vascular structure (right; green:
GFP-labelled tumor cells; red: CD31-positive endothelial cells)

Fig. 1.2 Tumor tissue vasculatures are commonly disorganized and leaky. Tumor vessels were
detected using the endothelial marker CD31 (red color). Perfusion with 70 kDa lysine-fixable
rhodamine dextran (green color) results in extravasation of a large percentage of dextran indicating
the high permeability and leakiness of the tumor vessels (white arrowheads: extravasated
dextran)

elevated levels of VEGF expression (Konishi et al. 2000; Sager 1989). Additionally,
infiltration of other cell types such as stromal fibroblasts and inflammatory cells also
significantly contributes to VEGF production (Dong et al. 2004; Crawford et al.
2009; Inoue et al. 2002). It is known that the tumor cells and the tumor microenviron-
ment are exposed to tissue hypoxia that substantially upregulates VEGF expression
via transcriptional activation of the hypoxia-inducible factor 1α (HIF-1α) system
(Makino et al. 2001; Maxwell et al. 1999; Carmeliet et al. 1998; Maltepe et al. 1997;
Mukhopadhyay et al. 1995; Millauer et al. 1994; Shweiki et al. 1992). VEGF is also
a potent vascular permeability factor that stimulates vascular leakiness (Dvorak et al.
1985; Senger et al. 1983). VEGF-induced angiogenesis and vascular permeability
are mediated mainly via the VEGFR-2-triggered signaling pathway (Eriksson et al.
6 Y. Cao

2003; Cao 2009b). Based on its broad and pivotal role in tumor angiogenesis, VEGF
and its receptor signaling pathways have become attractive targets for anticancer
drug development (Hurwitz et al. 2004; Motzer et al. 2007; Escudier et al. 2007).
In fact, today’s most commonly used antiangiogenic drugs used in cancer patients
are based on inhibition of the VEGF signaling system (see below).

1.2 Adipose Angiogenesis

Among all tissues, adipose tissues are extraordinarily hypervascularized, and per-
haps brown adipose tissue (BAT) is the most vascularized tissue in the body
(Rupnick et al. 2002; Lim et al. 2012; Xue et al. 2010; Cao 2007, 2010a; Brakenhielm
and Cao 2008; Brakenhielm et al. 2004). In both white adipose tissue (WAT) and
BAT, each adipocyte is engulfed with microvessels that nourish and communicate
with adipocytes (Rupnick et al. 2002; Lim et al. 2012; Xue et al. 2010; Cao 2007,
2010a; Brakenhielm and Cao 2008; Brakenhielm et al. 2004). Unlike most other
tissues in the body, adipose tissues, especially WAT, undergo constant expansion
and shrinkage during the entire adulthood (Cao 2007, 2010a). Adipose plasticity
also demands adipose vascular changes that growth and regression relentlessly
occur in order to cope with the adipose metabolic demand. Existence of high
microvessel density in WAT and BAT suggests that adipocytes and probably other
cell types in the adipose microenvironment produce angiogenic factors to maintain
vascular homeostasis. In addition to production of a range of classical angiogenic
factors, adipocytes produce several adipokines including leptin, adiponectin, resis-
tin, and visfatin that modulate angiogenesis and vascular functions (Cao 2007).
Adipose tissues also produce endogenous angiogenesis inhibitors that may involve
in maintenance of vascular homeostasis and vascular regression (Cao 2007).
Although both WAT and BAT are highly vascularized tissues, the vasculature in
these tissues may display opposing functions. In expanding WAT, the switch of an
angiogenic phenotype could potentially facilitate energy deposition, whereas the
same angiogenic phenotype may facilitate energy consumption in metabolically
active BAT (Cao 2010a). In metabolically active adipose tissues, microvessels also
play essential role in removing metabolic products. Bulky recent data demonstrate
that vascular cells are the important source of supplying adipose precursor cells that
can differentiate into adipocytes (Kahn 2008; Gupta et al. 2012; Tran et al. 2012).
Thus, blood vessels in the adipose tissue do not merely provide nutrients and oxy-
gen for adipocytes but also serve as a reservoir of stem cells.

1.3 Angiogenesis in Metabolic Diseases

Angiogenesis has been associated with development of metabolic diseases includ-

ing type II diabetes and cancer (Folkman 1971; Smith et al. 1999; Gariano and
Gardner 2005). Obesity-associated diabetic mellitus is a major worldwide
1 Angiogenesis in Diseases and Therapy 7

metabolic disease and its prevalence is constantly increasing. A substantial number

of diabetic patients eventually develop complications affecting multiple organs and
tissues. Proliferative diabetic retinopathy (PDR) and diabetic macular edema (DME)
are the two most common and severe retinal complications that are sight threatening
in diabetic patients (Smith et al. 1999; Gariano and Gardner 2005). Interestingly,
pathological angiogenesis and vascular dysfunctions are the primary cause for
development of these diabetic complications (Hellstrom et al. 2007; Takeda et al.
2009; Ferrara and Alitalo 1999). In particular, the ischemia-induced VEGF expres-
sion has causally been linked to the development and progression of these retinal
complications. As VEGF displays both angiogenic and vascular permeability effects
on blood vessels, this factor is considered as a crucial target for therapeutic develop-
ment of effective drugs. Early clinical assessments of anti-VEGF drugs in PDR
patients have demonstrated some clinical benefits (Boras et al. 2011; Kakkassery
et al. 2010; Nicholson and Schachat 2010).
In addition to retinal complications, diabetic patients often suffer from kidney
complications in association with tissue hypoxia. Vascular dysfunction-induced
hypoxia induces HIF-1α expression, which is modulated by prolylhydrylases
(PHDs) (Miyata and de Strihou 2010). The vascular changes in diabetic kidney
include reduction of the total number of peritubular capillaries by mechanisms of
reduction of angiotensin II and nitric oxide, anemia, and high oxygen consumption
(Carmeliet and Jain 2011; Manalo et al. 2011; Yu et al. 2012; Schodel et al. 2009;
Nangaku 2009). Targeting PHDs have been implied for the treatment of diabetic
nephropathy although clinical benefits based on this type of approached need future
validation.
Opposing to hypervascularization in retinopathy and nephropathy, impaired
angiogenesis often presents in legs of diabetic patients, leading to development of
chronic ulcers. In this case, promoting, but not inhibiting, angiogenesis offers an
alternative attractive approach for therapy. In fact, topical delivery of proangiogenic
factors such as PDGF-BB has currently been used for treatment of chronic diabetic
ulcers (Mulder et al. 2009; Steed 2006). Thus, targeting angiogenesis based on
opposing principles has been used for treatment of various diabetes-associated clin-
ical complications.

1.4 Antiangiogenic Cancer Therapy

The original concept that tumor growth is dependent on angiogenesis and inhibition
of tumor angiogenesis would be a novel approach for cancer therapy was proposed
by Dr. Judah Folkman 41 years ago (Folkman 1971). In most preclinical experimen-
tal settings, inhibition of tumor angiogenesis has produced remarkable effects on
suppression of tumor growth (Cao et al. 2011; Cao and Langer 2010). Based on
these exciting findings in preclinical animal models, the antiangiogenic principle
has become an important and attractive approach for both pharmaceutical industry
and academic scientists for development of cancer drugs.
8 Y. Cao

There are two classes of angiogenesis inhibitors, broad-spectrum endogenous

angiogenesis inhibitors and angiogenic factor antagonists (Cao 2009a; Folkman
2006, 2007). Endogenous angiogenesis inhibitors are those biological molecules
that naturally exist in our body. For example, angiostatin, endostatin, and thrombo-
spondin-1 are all endogenous angiogenesis inhibitors that display physiological and
pathological functions by regulation of angiogenesis and vascular homeostasis
(O’Reilly et al. 1994, 1997; Dameron et al. 1994). It has been proposed that endog-
enous angiogenesis inhibitors are often expressed at high levels to prevent vessel
growth. In tumors, this endogenous angiogenesis inhibitor-dominant situation can
be altered by overproduction of angiogenic factors, tipping toward an angiogenic
phenotype. Endogenous angiogenesis inhibitors and many generic antiangiogenic
agents usually block endothelial cell proliferation and migration via undefined and
broad signaling pathways (Cao 2001; Folkman 2007). They often inhibit endothe-
lial cell growth independent from the source of angiogenic stimuli. Angiogenic fac-
tor antagonists and angiogenic signaling pathway inhibitors usually specifically
block one or several signaling systems required for endothelial cell growth or vas-
cular functions. For example, bevacizumab and ramucirumab specifically block
VEGF- and VEGFR-2-triggered signaling systems (Hurwitz et al. 2004; Garon
et al. 2012; Krupitskaya and Wakelee 2009), respectively, whereas sunitinib,
sorafenib, and pazopanib target a broad spectrum of tyrosine kinases including
VEGF receptors (Motzer et al. 2007; Escudier et al. 2007; Xu et al. 2011).
The first marketed antiangiogenic drug, bevacizumab, for the treatment of cancer
disease was approved by the US FDA in 2004 (Hurwitz et al. 2004). Bevacizumab
as a neutralizing antibody specifically blocks VEGF and thus it is a monospecific
drug. Initially, bevacizumab was approved for treatment of advanced and metastatic
colorectal cancers in combination with the standard chemotherapy (Hurwitz et al.
2004). Unlike in mouse tumor models, administration of bevacizumab alone in can-
cer patients has not yielded statistical survival improvement. Why would anti-VEGF
monotherapy be effective in mouse tumor models, but ineffective in human patients?
What are the differences between mouse tumor models and human cancer patients?
These critical issues remain currently unresolved (Cao 2011). Antiangiogenic drug-
based combination therapy containing chemotherapeutics produced therapeutic
benefits compared with chemotherapy alone although the survival benefits in most
cancer types remain modest (Kerbel 2008). Antiangiogenic therapy is currently
being used as one of the key components in the frontline and standard therapy for
treatment of several cancer types including colorectal cancer, lung cancer, renal cell
carcinoma, and gastrointestinal cancers (Hurwitz et al. 2004; Friedman et al. 2009;
Ignoffo 2004; Miklos 2012; Mountzios and Pentheroudakis 2012; Sculier et al.
2007; Sharieff 2004; Sonpavde 2003; Tol et al. 2008).
Several mechanistic rationales have been proposed to explain the therapeutic
benefit based on combination therapy. Vascular normalization is one of the attrac-
tive hypotheses that explain the possible mechanism underlying antiangiogenic
therapy (Jain 2005). Tumor vasculatures often appear as disorganized primitive vas-
cular networks that are highly leaky. The key reason why these tumor vessels are
highly disorganized, tortuous, and leaky is that tumors often produce VEGF at high
1 Angiogenesis in Diseases and Therapy 9

levels and VEGF induces vascular leakage and disorganization. Anti-VEGF drugs
can significantly improve the structure of tumor vessels, leading to a normalized
phenotype. The anti-VEGF-induced vascular normalization significantly improves
the leaky features and blood perfusion that, in the presence of chemotherapeutics,
improve drug delivery (Batchelor et al. 2007). Thus, anti-VEGF drug-induced vas-
cular normalization may significantly modulate chemotherapy-based therapeutic
efficacy. However, a recent study in human cancer patients does not support these
preclinical findings (Van der Veldt et al. 2012).
Another interesting hypothesis of explicating the mechanism underlying the
combination of antiangiogenic drugs with chemotherapy is that antiangiogenic
agents might increase tolerance of chemotoxicity. It has been shown, in mouse
tumor models, that tumor-derived VEGF significantly impairs the bone marrow
function by suppression of hematopoiesis (Xue et al. 2008; Zhang et al. 2011). It is
known that most chemotherapeutics also inhibit hematopoiesis in the bone marrow.
Chemotherapy treatment of high VEGF-producing tumors resulted in severe sup-
pression of bone marrow hematopoiesis, leading to early death of tumor-bearing
mice (Zhang et al. 2011). However, treatment of these tumor-bearing mice with
anti-VEGF drugs prior to chemotherapy led to a significant increase of survival by
improving bone marrow hematopoiesis (Zhang et al. 2011). Given the fact that a
substantial number of cancer patients die of chemotherapy-related toxicity, these
findings imply that increasing tolerance of chemotoxicity could potentially provide
an attractive mechanism explaining combination therapy.
Cancer is not a local disease, but a systemic disorder that affects functions of
multiple tissues and organs. In addition to metastasis, cancer patients, especially at
the advanced stage of diseases, often develop various degrees of systemic symp-
toms, manifesting cancer cachexia and paraneoplastic syndrome. In a mouse tumor
model, it has been shown that tumor-derived VEGF enters the circulation and affects
functions of multiple tissues and organs (Xue et al. 2008). Interestingly, anti-VEGF
drugs at a low dose can significantly improve survivals of these tumor-bearing mice
without affecting tumor growth (Xue et al. 2008). These findings demonstrate that
off-tumor targets could potentially be beneficial sites of antiangiogenic drugs. These
preclinical findings warrant clinical validation.
Clinical experiences with antiangiogenic drugs in cancer patients show that these
drugs also produce broad adverse effects by affecting multiple tissue and organ
systems (des Guetz et al. 2011; Hapani et al. 2009; Launay-Vacher and Deray 2009;
Randall and Monk 2010; Zhu et al. 2007). Commonly seen clinical adverse effects
include hypertension, proteinuria, hemorrhages, and gastrointestinal perforation
(des Guetz et al. 2011; Hapani et al. 2009; Launay-Vacher and Deray 2009; Randall
and Monk 2010; Zhu et al. 2007). In some rare cases, severe cardiovascular compli-
cations can occur and cause sudden death (des Guetz et al. 2011). Since these drugs
are given to cancer patients via the systemic delivery route and VEGF displays
broad physiological functions, the systemic impact of these drugs is not totally
unexpected. One of the key and urgently unresolved issues related to clinical prac-
tice of antiangiogenic drugs is to define reliable biomarkers that distinguish nonre-
sponsive patient population from the likely responsive population (Cao et al. 2011;
10 Y. Cao

Cao and Langer 2010). Unfortunately, such a reliable biomarker is currently lacking
during clinical practice. Noticeably, cancer patients also develop resistance to anti-
angiogenic drugs (Cao et al. 2009). Although the mechanism underlying the resis-
tance is not completely understood, it is believed that multiple mechanisms are
involved in development of antiangiogenic drug resistance.
While antiangiogenic drugs during clinical practice have encountered many
unpredictable obstacles, survival improvements by currently available antiangio-
genic drugs in combination with chemotherapy seen in various cancers are encourag-
ing for development of future more effective drugs. Many unresolved challenging
issues including understanding the fundamental mechanism of their actions, defining
reliable biomarkers, overcoming drug resistance, minimizing adverse effects, opti-
mizing combinations with chemotherapeutics, and long-lasting therapy have also
offered tremendous opportunities for future intensive research in this important area.

1.5 Antiangiogenic Therapy in Ophthalmological Diseases

Several angiogenesis-related ophthalmological diseases including the wet type age-

related macular degeneration (AMD) and diabetic retinopathy are the most common
reasons of causing blindness in adult humans (Gariano and Gardner 2005; Boras
et al. 2011; Kakkassery et al. 2010; Nicholson and Schachat 2010; Miyata and de
Strihou 2010). The onset and progression of these retinal disorders are tightly asso-
ciated with vascular abnormalities, manifesting excessive neovascularization and
vascular leakiness as two major pathological features. VEGF is the key angiogenic
factor that induces angiogenesis and vascular permeability under these pathological
conditions. Thus, inhibition of VEGF and its signaling pathways offers an attractive
and novel therapeutic approach for treatment of these ocular diseases.
In 2004, the US FDA approved the first anti-VEGF drug, pegaptanib (macugen,
an anti-VEGF aptamer), for treatment of wet AMD in human patients (Gragoudas
et al. 2004). Subsequently, the FDA authority approved ranibizumab (Stone 2006;
Brown et al. 2006; Rosenfeld et al. 2006; Steinbrook 2006) (lucentis, a Fab frag-
ment of anti-VEGF monoclonal antibody) for treatment of wet type of AMD. Unlike
anti-VEGF drugs in oncology applications, anti-VEGF drugs have been used as
monotherapy for treatment of AMD and have shown very robust effects in improve-
ment of vision. It has been noticed that anti-vascular edema is one of the major
mechanisms underlying clinical benefits. Bevacizumab, as a parental molecule of
ranibizumab, has also been used as an off-label anti-VEGF drug for treatment of
AMD (Martin and Maguire 2011). Today, anti-VEGF drugs are the most commonly
used effective drugs for treatment of the wet type of AMD. Additionally, anti-VEGF
drugs as monotherapy have also entered clinical trials for treatment of diabetic reti-
nopathy and early clinical phase evaluation shows beneficial effects for this indica-
tion (Zechmeister-Koss and Huic 2012). Thus, anti-VEGF drugs have revolutionized
clinical management of these otherwise untreatable eye diseases.
1 Angiogenesis in Diseases and Therapy 11

1.6 Cardiovascular Diseases

In paradox to antiangiogenic therapy for treatment of cancer and ophthalmological

disorders, promoting angiogenesis has also been implemented for treatment of dis-
eases (Powell et al. 2008; Khurana et al. 2005; Simons 2005). It was originally
hypothesized that stimulation of angiogenesis would be clinically beneficial for
treatment of ischemia-related diseases including ischemic myocardium and chronic
leg ischemia. This concept remains undisputed and has been proved in various pre-
clinical models by delivery of proangiogenic factors to the ischemic tissues.
However, clinical translation of this concept and preclinical findings remain largely
disappointing and unfulfilled promises (Powell et al. 2008; Khurana et al. 2005;
Simons 2005). Several rigorous clinical trials using various proangiogenic factors
including VEGF and FGF have not demonstrated clinical benefits for treatment of
these ischemic disorders (Powell et al. 2008; Khurana et al. 2005; Simons 2005).
It is not known why human patients responded differently from animal models. One
of the possibilities to explain clinical failure is that these trials have been performed
as monotherapy by delivering a single proangiogenic factor to the pathological site.
For improvement of vascular functions in ischemic muscle tissues, it is desirable to
establish collateral vascular networks rather than primitive vessels without appro-
priate functions. The arterial vessel wall consists of two cell types: endothelial cells
and vascular smooth muscle cells. These cellular composition features suggest that
a combination of arteriogenic and angiogenic factors should be considered for ther-
apeutic development (Cao 2010b). In supporting this view, a combination of arterio-
genic factor such as PDGF-BB and angiogenic factor FGF or VEGF has produced
improved therapeutic benefits relative to their monotherapy (Zhang et al. 2009; Cao
et al. 2003, 2008; Nissen et al. 2007; Lu et al. 2007; Cao and Liu 2007; Richardson
et al. 2001). To date, combination therapy-based approaches have not been assessed
in human trials.

1.7 Conclusions and Perspectives

Angiogenesis is essentially involved in development of most common and lethal

human diseases. Understanding the fundamental mechanism of the angiogenic pro-
cess and functions of key regulators under pathological conditions provides tremen-
dous opportunities for therapeutic intervention. Clinical successes in oncology and
ophthalmology areas have laid the cornerstone for future drug development for
treatment of various angiogenesis-dependent diseases. Although the intensive basic
research on angiogenesis has provided invaluable clues for clinical implications,
clinical practice with antiangiogenic drugs has raised many unexpected issues that
do not seem to match or even be against principles seen in various animal models.
This is particularly true in the area of antiangiogenic cancer therapy. The only way
to resolve these clinically related issues is to understand the fundamental
12 Y. Cao

mechanisms of vascular functions in modulating tumor growth and invasion in

human patients. This task demands intimate collaborations between basic scientists
and clinical oncologists. Improvement of therapeutic efficacy of current existing
antiangiogenic drugs and future development of more effective drugs remain chal-
lenging. It is anticipated that antiangiogenic therapy will be further expanded in
treatment of many more human diseases and will become one of the most important
therapeutic approaches for improvement of quality of life and survival.

Acknowledgements The author thanks Sharon Lim, Patrik Andersson for the artwork and Dr.
Jeannette Söderberg for critical reading. The author’s laboratory is supported through research
grants from the Swedish Research Council, the Swedish Cancer Foundation, the Karolinska
Institute Foundation, the Karolinska Institute distinguished professor award, the Tianjin Natural
Science Foundation (CMM-Tianjin, No. 09ZCZDSF04400) for international collaboration
between Tianjin Medical University and Karolinska Institutet, the Torsten Söderbergs foundation,
the European Union Integrated Project of Metoxia (Project no. 222741), and the European
Research Council (ERC) advanced grant ANGIOFAT (Project no 250021).

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