[Skip to Content]
Access to paid content on this site is currently suspended due to excessive activity being detected from your IP address 54.161.241.199. Please contact the publisher to request reinstatement.
[Skip to Content Landing]
Download PDF
Figure 1.
Recurrent tumors (A) show significantly more inflammatory cell infiltration and higher microvascular density than nonrecurrent tumors (B) (hematoxylin-eosin, original magnification ×20).

Recurrent tumors (A) show significantly more inflammatory cell infiltration and higher microvascular density than nonrecurrent tumors (B) (hematoxylin-eosin, original magnification ×20).

Figure 2.
Under immunoperoxidase staining, recurrent tumors (A) stain more intensely for vascular endothelial growth factor C than do nonrecurrent tumors (B) (original magnification ×20); recurrent tumors (C) stain less intensely for pigment epithelium–derived factor than do nonrecurrent tumors (D) (original magnification ×10). Brown discoloration is considered positive staining.

Under immunoperoxidase staining, recurrent tumors (A) stain more intensely for vascular endothelial growth factor C than do nonrecurrent tumors (B) (original magnification ×20); recurrent tumors (C) stain less intensely for pigment epithelium–derived factor than do nonrecurrent tumors (D) (original magnification ×10). Brown discoloration is considered positive staining.

Figure 3.
Salivary glands show positive staining with vascular endothelial growth factor primarily in endothelial cells (A) but no significant staining for pigment epithelium–derived factor (B) (vascular endothelial growth factor and pigment epithelium–derived factor immunoperoxidase staining, original magnification ×20, where brown discoloration is considered positive staining).

Salivary glands show positive staining with vascular endothelial growth factor primarily in endothelial cells (A) but no significant staining for pigment epithelium–derived factor (B) (vascular endothelial growth factor and pigment epithelium–derived factor immunoperoxidase staining, original magnification ×20, where brown discoloration is considered positive staining).

Table 1. 
Demographic and Tumor Location Data in Patients With Lymphangioma
Demographic and Tumor Location Data in Patients With Lymphangioma
Table 2. 
Histopathologic Characteristics of Lymphangioma Specimens*
Histopathologic Characteristics of Lymphangioma Specimens*
Table 3. 
Immunohistochemical Staining Results for Lymphangioma Specimens*
Immunohistochemical Staining Results for Lymphangioma Specimens*
1.
Redenbacher  E De Ranula Sublingual, Speciali, Cum Casa Congenita.  Munich, Germany: Monachii Lindauer; 1828
2.
Landing  BHFarber  S Tumors of the cardiovascular system.  In: Landing  BH, Farber  S, eds. Atlas of Tumor Pathology. Washington, DC: Armed Forces Institute of Pathology; 1956:124-138
3.
Bill  AH  JrSumner  DS A unified concept of lymphangioma and cystic hygroma. Surg Gynecol Obstet 1965;12079- 86
PubMed
4.
Williams  HB Embryology and classification of lymphatic abnormalities.  In: Williams  HB, ed. Symposium on Vascular Malformations and Melanotic Lesions. St Louis, Mo: Mosby; 1983:175-185
5.
Smith  RJBurke  DKSato  YPoust  RIKimura  KBauman  NM OK-432 therapy for lymphangiomas. Arch Otolaryngol Head Neck Surg 1996;1221195- 1199
PubMedArticle
6.
Batsakis  JG Tumors of the Head and Neck: Clinical and Pathological Considerations. 2nd ed. Baltimore, Md: Williams & Wilkins; 1979:301-304
7.
Emery  PJBailey  CMEvans  JN Cystic hygroma of the head and neck: a review of 37 cases. J Laryngol Otol 1984;98613- 619
PubMedArticle
8.
Reinhardt  MANelson  SCSencer  SFBostrom  BCKurachek  SCNesbit  ME Treatment of childhood lymphangiomas with interferon-alpha. J Pediatr Hematol Oncol 1997;19232- 236
PubMedArticle
9.
Fageeh  NManoukian  JTewfik  TSchloss  MWilliams  HBGaskin  D Mangagement of head and neck lymphatic malformations in children. J Otolaryngol 1997;26253- 258
PubMed
10.
Enzinger  FMWeiss  SW Tumors of lymph vessels.  In: Enzinger  FM, Weiss  SW, eds. Soft Tissue Tumors. St Louis, Mo: Mosby-Year Book; 1995:679-688
11.
Folkman  J Angiogenesis in cancer, vascular, rheumatoid and other disease. Nat Med 1995;127- 31
PubMedArticle
12.
Folkman  J New perspectives in clinical oncology from angiogenesis research. Eur J Cancer 1996;32A2534- 2539
PubMedArticle
13.
Salven  PHeikkila  PAnttonen  AKajanti  MJoensuu  H Vascular endothelial growth factor in squamous cell head and neck carcinoma: expression and prognostic significance. Mod Pathol 1997;101128- 1133
PubMed
14.
Jia  YTLi  ZXHe  YTLiang  WYang  HCMa  HJ Expression of vascular endothelial growth factor-C and the relationship between lymphangiogenesis and lymphatic metastasis in colorectal cancer. World J Gastroenterol 2004;103261- 3263
PubMed
15.
Nishida  NYano  HKomai  KNishida  TKamura  TKojiro  M Vascular endothelial growth factor C and vascular endothelial growth factor receptor 2 are related closely to the prognosis of patients with ovarian carcinoma. Cancer 2004;1011364- 1374
PubMedArticle
16.
Zeng  YOpeskin  KBaldwin  ME  et al.  Expression of vascular endothelial growth factor receptor-3 by lymphatic endothelial cells is associated with lymph node metastasis in prostate cancer. Clin Cancer Res 2004;105137- 5144Article
17.
Tanigaki  YNagashima  YKitamura  YMatsuda  HMikami  YTsukuda  M The expression of vascular endothelial growth factor-A and -C, and receptor 1 and 3: correlation with lymph node metastasis and prognosis in tongue squamous cell carcinoma. Int J Mol Med 2004;14389- 395
PubMed
18.
Ogawa  ETakenaka  KYanagihara  K  et al.  Clinical significance of VEGF-C status in tumour cells and stromal macrophages in non-small cell lung cancer patients. Br J Cancer 2004;91498- 503
PubMedArticle
19.
Rowe  RWTomoda  MStrebel  FRJenkins  GNStephens  LCBull  JM The natural progression of microvasculature in primary tumor and lymph node metastases in a breast cancer model: relationship between microvessel density, vascular endothelial growth factor expression, and metastatic invasion. Cancer Biol Ther 2004;3408- 414
PubMedArticle
20.
Ferrara  N Vascular endothelial growth factor: basic science and clinical progress. Endocr Rev 2004;25581- 611
PubMedArticle
21.
Fenton  BMPaoni  SFDing  I Pathophysiological effects of vascular endothelial growth factor receptor-2 blocking antibody plus fractionated radiotherapy on murine mammary tumors. Cancer Res 2004;645712- 5719
PubMedArticle
22.
Penland  SKGoldberg  RM Combining anti-VEGF approaches with oxaliplatin in advanced colorectal cancer. Clin Colorectal Cancer 2004;4(suppl 2)S74- S80
PubMedArticle
23.
Dawson  DWVolpert  OVGillis  P  et al.  Pigment epithelium-derived factor: a potent inhibitor of angiogenesis. Science 1999;285245- 248
PubMedArticle
24.
Uehara  HMiyamoto  MKato  K  et al.  Expression of pigment epithelium-derived factor decreases liver metastasis and correlates with favorable prognosis for patients with ductal pancreatic adenocarcinoma. Cancer Res 2004;643533- 3537
PubMedArticle
25.
Garcia  MFernandez-Garcia  NIRivas  V  et al.  Inhibition of xenografted human melanoma growth and prevention of metastasis development by dual antiangiogenic/antitumor activities of pigment epithelium-derived factor. Cancer Res 2004;645632- 5642
PubMedArticle
26.
Abramson  LPStellmach  VDoll  JACornwell  MArensman  RMCrawford  SE Wilms’ tumor growth is suppressed by antiangiogenic pigment epithelium-derived factor in a xenograft model. J Pediatr Surg 2003;38336- 342
PubMedArticle
27.
Miyagishi  DOhno-Matsui  KAmagasa  TMorita  I Regulation of the expression of pigment epithelium-derived factor, an anti-angiogenic factor in human oral squamous cell carcinoma cell lines. Cancer Lett 2003;19677- 85
PubMedArticle
28.
Alberdi  EAymerich  MSBecerra  SP Binding of pigment epithelium-derived factor (PEDF) to retinoblastoma cells and cerebellar granule neurons: evidence for a PEDF receptor. J Biol Chem 1999;27431605- 31612
PubMedArticle
29.
Maddalozzo  JHughes  CAHuang  LMu  YLudemann  JCrawford  S High angiogenic activity in cells isolated from cystic hygroma: role of bFGF. Arch Otolaryngol Head Neck Surg 1999;12545- 48
PubMedArticle
30.
Huang  HYHo  CCHuang  PHHsu  SM Co-expression of VEGF-C and its receptors, VEGFR-2 and VEGFR-3, in endothelial cells of lymphangioma: implication of autocrine or paracrine regulation of lymphangioma. Lab Invest 2001;811729- 1734
PubMedArticle
31.
Cohen  SRThompson  JW Lymphangiomas of the larynx in infants and children: a survey of pediatric lymphangioma. Ann Otol Rhinol Laryngol Suppl 1986;1271- 20
PubMed
32.
Orvidas  LJKasperbauer  JL Pediatric lymphangiomas of the head and neck. Ann Otol Rhinol Laryngol 2000;109411- 421
PubMed
33.
Kukk  ELymboussaki  ATaira  S  et al.  VEGF-C receptor binding and pattern of expression with VEGFR-3 suggests a role in lymphatic vascular development. Development 1996;1223829- 3837
PubMed
34.
Partanen  TAAlitalo  KMiettinen  M Lack of lymphatic vascular specificity of vascular endothelial growth factor receptor 3 in 185 vascular tumors. Cancer 1999;862406- 2412
PubMedArticle
35.
Cursiefen  CSchlotzer-Schrehardt  UBreiteneder-Geleff  SHolbach  LM Orbital lymphangioma with positive immunohistochemistry of lymphatic endothelial markers (vascular endothelial growth factor receptor 3 and podoplanin). Graefes Arch Clin Exp Ophthalmol 2001;239628- 632
PubMedArticle
36.
Ricciardelli  EJRichardson  MA Cervicofacial cystic hygroma. Patterns of recurrence and management of the difficult case. Arch Otolaryngol Head Neck Surg 1991;117546- 553
PubMedArticle
Original Article
November 2005

Altered Pigment Epithelium–Derived Factor and Vascular Endothelial Growth Factor Levels in Lymphangioma Pathogenesis and Clinical Recurrence

Author Affiliations

Author Affiliations: Departments of Otolaryngology–Head and Neck Surgery (Drs Sidle, Maddalozzo, and Meier) and Pathology (Ms Cornwell and Drs Stellmach and Crawford), Northwestern University Feinberg School of Medicine, and Division of Pediatric Otolaryngology, Children’s Memorial Hospital (Dr Maddalozzo), Chicago, Ill.

Arch Otolaryngol Head Neck Surg. 2005;131(11):990-995. doi:10.1001/archotol.131.11.990
Abstract

Objective  To determine the role of angiogenesis in the clinical behavior and pathogenesis of lymphangioma tumors.

Design  A retrospective study. Median follow-up period was 44.5 months.

Setting  Children's Memorial Hospital, Chicago, Ill.

Patients  Tumor specimens from 12 pediatric patients who underwent surgical excision of cervicofacial lymphangioma were examined for expression of angiogenic inducer vascular endothelial growth factor (VEGF) and angiogenic inhibitor pigment epithelium–derived factor (PEDF) using immunohistochemical analysis. Specimens were divided into recurrent and nonrecurrent tumors based on clinical information.

Main Outcome Measures  Staining patterns of VEGF and PEDF were evaluated in lymphangioma specimens. Staining patterns were then compared in both recurrent and nonrecurrent groups and graded in a blinded fashion. Histological evidence of increased angiogenesis including microvascular density, stromal fibrosis, and inflammation were graded in each group and correlated with recurrence.

Results  Lymphangioma specimens demonstrated histological evidence of increased angiogenic activity including multiple areas of increased VEGF staining combined with little PEDF staining. Sex, age at onset, or tumor location did not correlate with recurrence. Furthermore, recurrent specimens had increased histological evidence of angiogenesis as well as increased VEGF and decreased PEDF activity compared with nonrecurrent lesions.

Conclusions  Lymphangiomas exhibit tumorlike pathogenesis owing to the high expression of angiogenic inducers compared with the low expression of inhibitors. Recurrence may be influenced by this imbalance of angiogenic mediators. Further research with antiangiogenic therapy using agents such as PEDF analogues or anti-VEGF receptor antibodies is indicated because they may stabilize or suppress the growth of these neoplasms.

The pathogenesis and classification of lymphatic malformations has been debated since they were first described by Redenbacher1 in 1828. Landing and Farber2 in 1956 initially classified them into the following 3 entities: lymphangioma simplex, cavernous lymphangioma, and cystic lymphangioma (cystic hygroma). However, these categories tend to overlap. A unified concept then developed that declared that the previously described lymphangiomas are variations of a single entity, and their classification is determined by their location in the head and neck.3 Current classification by Williams4 separates lymphatic malformations into the following 4 categories: (1) lymphangioma, subdivided into cavernous and simplex; (2) cystic hygroma; (3) lymphedema (Milroy disease); and (4) lymphangiectasia. Furthermore, Smith et al5 clinically describe the lymphatic malformations as macrocystic or microcystic depending on their appearance with contrast cystography. Because there is no significant histological difference between the types of lymphatic malformations, in the present study we describe both cystic hygromas and lymphangiomas and make no distinction between them.6

The classification of lymphangiomas is controversial and has been difficult owing to their rare occurrence and incomplete knowledge about their pathogenesis. Approximately 90% of lymphangiomas occur in the head and neck region. As they slowly grow and progress, they can cause symptoms of dysphagia, airway obstruction, and gross disfigurement. Infection and inflammation also commonly occur. Surgical excision is the most widely accepted primary therapy for treatment of lymphangiomas.7 However, complete excision is often not possible and recurrence is frequent. Other forms of therapy have been investigated including OK-432 (a hemolytic streptococcal preparation), interferon alfa, bleomycin, laser therapy, and radiation with variable results.5,810

Currently, most researchers believe lymphangiomas to be congenital malformations of the lymphatic system. They are characterized histologically by a proliferation of blood vessels and lymphatics with intervening fibrous tissue and lymphoid aggregates. Some researchers have argued that they are true neoplasms resulting from transformed lymphatic endothelial and/or stromal cells.10 Likely, lymphangiomas have characteristics of both in their pathogenesis. In the tumor model of lymphangioma pathogenesis, a dysregulation of angiogenesis may contribute to lymphangioma growth and progression. This is supported histologically by the increase in microvascular density (MVD) exhibited in lymphangiomas, which is the hallmark of angiogenesis.

Angiogenesis, the induction of new capillaries from preexisting vessels, is a key event in several biological processes ranging from wound healing to the formation of benign and malignant neoplasms. Angiogenesis is regulated by a delicate balance between angiogenic inducers and naturally occurring inhibitors. Tumor growth and progression is favored when inducers of angiogenesis, such as basic fibroblast growth factor and vascular endothelial growth factor (VEGF), predominate locally or systemically.1113 Expression of VEGF and its receptors (VEGFR-2 and VEGFR-3) have extensively been correlated with malignant behavior, metastasis, and worsened prognosis in many different tumor types including colorectal cancer, prostate cancer, head and neck squamous cell cancer, breast cancer, ovarian cancer, and lung cancer.1419 In addition, anti-VEGF receptor antibodies have been demonstrated to decrease tumor growth, decrease angiogenesis, and increase hypoxia in preclinical studies.20,21 Clinically, they also have been shown to increase patient survival when combined with chemotherapy.22

Much less is known about the role of angiogenic inhibitors in disease processes. Pigment epithelium–derived factor (PEDF) has been discovered to be a potent inhibitor of angiogenesis.23 Also, PEDF expression has been isolated in many different tumor types. In contrast to VEGF, PEDF expression has been correlated with an inhibition of tumor growth, a decrease in metastasis, and a favorable prognosis.2427 Previous studies have suggested the presence of a PEDF receptor on retinoblastoma cells; however, the identity of this receptor remains elusive.28

In lymphangioma, angiogenic activity has been shown to be, in part, due to elevated levels of potent angiogenic inducer, basic fibroblastic growth factor.29 Although VEGF has been implicated in the regulation of lymphangioma growth, PEDF has not been previously studied in lymphangioma.30 A proposed model for the pathogenesis of lymphangiomas suggests that they are in part neoplastic, and growth or recurrence of these lesions depends on an imbalance of angiogenic mediators.

METHODS

After obtaining institutional review board approval, tumor specimens from 12 pediatric patients who underwent surgical excision of cervicofacial lymphangioma at the Children’s Memorial Hospital in Chicago, Ill, were examined for expression of the angiogenic factors VEGF and PEDF using immunohistochemical analysis. The clinical records of the 12 patients were also retrospectively reviewed for demographic data, site of lesion, sex of the patient, age at onset, and presence of recurrence. Only tumor specimens from patients in whom curative resections were attempted were used in the study. Specimens were divided into recurrent and nonrecurrent tumors.

Paraffin blocks were available for examination for the 12 tumor specimens. All of the paraffin blocks examined in this study were from the primary resection of tumor. Sections were examined for histological markers that might distinguish recurrent from nonrecurrent lesions. Histological factors evaluated included vessel density, fibrosis, and inflammation (lymphocyte aggregation). Microvascular density, stromal fibrosis, and lymphocyte aggregation were graded on a 0 to 3 scale (0 = none; 1 = focal; 2 = multifocal; and 3 = diffuse) in 4 high-power fields per slide.

Expression of the angiogenic factors was analyzed by immunohistochemical analysis using slides that were incubated with monoclonal human IgG antibodies to VEGF-C (SC-507; Santa Cruz Biotechnology, Santa Cruz, Calif) at a dilution of 1:200 or PEDF (generated by the authors)23 at a dilution of 1:75 through an immunoperoxidase staining method. In brief, 3-μm sections were deparaffinized in xylene and rehydrated in graded ethanol solutions. Endogenous peroxidase activity was quenched with 3% hydrogen peroxide in methanol. Sections were blocked with 10% normal equine serum for 20 minutes, rinsed with phosphate-buffered saline, and incubated for 30 minutes or with phosphate-buffered saline as a negative control. The sections were next rinsed and incubated for 30 minutes with biotin-conjugated equine anti-mouse and anti-rabbit antibody (Vector Laboratories, Burlingame, Calif) at a dilution of 1:50. An avidin-biotin complex (ABC elite; Vector Laboratories) was applied for 30 minutes. All incubations took place in a humidified chamber at 37°C. Sections were rinsed a final time with phosphate-buffered saline and neutralized with buffered sodium acetate. Then 3,3′-diaminobenzidine (DAB) reagent was applied to produce a permanent color change. The slides were counterstained with hematoxylin-eosin, mounted, and evaluated by light microscopy. The Vectastain Universal Elite ABC Kit (Vector Laboratories) and the Biogenex (San Ramon, Calif) Liquid DAB Kit were used for staining. Our pathologist (S.E.C.) and senior author (D.M.S.) examined each slide to determine the intensity and pattern of VEGF and PEDF expression. This was done in a blinded fashion with negligible variability between the 2 observers. Staining intensity was scored on a similar 0 to 3 scale as described for histological characteristics (0 = none; 1 = light; 2 = moderate; and 3 = heavy). Because the pattern of staining was focal, specific areas within the tissue specimen were graded based on the staining intensity in that particular area. In particular, vascular smooth muscle, endothelial cells, inflammatory cells, and surrounding matrix were graded. By adding the scores of each of the 4 graded areas, a total score of VEGF and PEDF staining pattern for each specimen was established. Endothelial cell–positive staining for VEGF and PEDF was the internal positive control within tumor specimens. Because of the differing tissues surrounding the tumor in each specimen, no uniform negative control specimen could be evaluated. These data were then correlated with clinical recurrence of disease.

Statistical analysis was performed using the Mann-Whitney rank sum test with statistical significance defined as P<.05. Data, unless otherwise specified, are reported as mean ± SEM.

RESULTS

The demographics of each patient, primary site of tumor, recurrence, and age at first resection are given in Table 1. The study group included 7 boys and 5 girls with a mean age of 2.6 years. There were 10 cervical and 2 facial lymphangiomas. At a median follow up of 44.5 months, 5 patients were disease free, whereas 7 patients had recurrence of disease.

All tumor specimens displayed histological characteristics of lymphangiomas. Histopathologic data for each tumor specimen are presented in Table 2. Tumor specimens demonstrated increased MVD, stromal fibrosis, and lymphoid aggregates, whereas surrounding tissue did not exhibit these characteristics. In total, 9 tumor specimens showed high MVD (≥2.0 or ≥3.0), including all of the recurrent tumors. Recurrent tumors demonstrated significantly higher MVD than did nonrecurrent tumors (2.7 ± 0.18 vs 1.4 ± 0.25; P = .01). Also, recurrent tumor specimens displayed a significant increase in lymphoid aggregation (2.4 ± 0.20 vs 0.8 ± 0.20; P = .003) and more fibrosis; however, fibrosis did not reach statistical significance (2.0 ± 0.38 vs 1.6 ± 0.25; P = .53). Figure 1 shows hematoxylin-eosin–stained slides where recurrent tumor (Figure 1A) has higher MVD, interstitial fibrosis, and inflammatory reaction than does nonrecurrent tumor (Figure 1B).

The results of immunohistochemical staining and examination are presented in Table 3. Because VEGF and PEDF localized differently to various tissues within each specimen, the slides were graded based on the following 4 different areas: vascular smooth muscle, inflammatory cells, endothelial cells, and surrounding matrix. The scores from each of these areas were then added for each specimen for a possible total score of 12. As a group, the recurrent tumor specimens showed significantly more intense VEGF staining than did nonrecurrent specimens (9.6 ± 0.72 vs 6.4 ± 0.81; P = .048). Also, nonrecurrent tumor specimens significantly stained more intensely to PEDF than did recurrent specimens (5.8 ± 1.74 vs 1.9 ± 0.34; P = .03). Specimen 5, a nonrecurrent lesion, demonstrated the highest PEDF score, but no unique clinical or pathologic aspects were determined. Figure 2 demonstrates that recurrent tumors (Figure 2C and D) have increased VEGF and decreased PEDF staining compared with nonrecurrent tumors (Figure 2A and B). Figure 3 demonstrates that salivary ductal tissue stains intensely for VEGF but little for PEDF. Sex of the patient, location of the primary tumor, and age at presentation did not correlate with recurrence (P>.05).

COMMENT

Lymphangiomas of the cervical and facial regions pose a very difficult problem to the pediatric head and neck surgeon. They present at birth or within the first 2 years of life in 80% to 90% of patients.31 The current treatment of choice for head and neck lymphangiomas remains surgical resection with preservation of all important neurovascular structures.32 It is often difficult to obtain surgical margins, and the subsequent high recurrence rates seen with these tumors has led some clinicians to pursue other treatment modalities with variable results.5,810

The etiology of lymphangiomas is not well understood. They are defined histologically by a benign proliferation of blood vessels and dilated lymphatic channels intervened with areas of fibrosis and lymphoid aggregates. The channels are lined by flattened, elongated endothelial cells creating “staghorn vessels,” which are characteristic of lymphatic spaces (Figure 2). High angiogenic activity has been demonstrated in cells isolated from lymphangiomas. The senior author’s group previously has shown high levels of angiogenic inducer, basic fibroblast growth factor, and lower levels of naturally occurring angiogenic inhibitor, thrombospondin-1.29 Not all the angiogenic activity could be relieved by a blocking antibody to basic fibroblast growth factor. Therefore, other angiogenic mediators such as VEGF were thought to play a role.

Investigators have suggested that VEGF induces lymphangiogenesis and VEGF-C appears to be the first angiogenic mediator that is specific for the lymphatic system.30,33 VEGFR-3, the receptor for VEGF-C, is localized primarily to lymphatics in normal tissue but can also be localized to the proliferating endothelium of vascular tumors and anywhere neovascularization is occurring.34 Other studies have demonstrated the presence of this receptor in lymphatic malformations and vascular tumors of the head and neck.29,30,35 Also, VEGF has been implicated as an angiogenic mediator in many different tumor types, and its expression is correlated with malignant behavior, metastasis, and prognosis.1419 Similar to these other tumor types, we demonstrated significantly high levels of VEGF protein in lymphangioma, which was correlated with recurrence. Of note, lymphoid infiltrates may promote angiogenesis because VEGF localizes to this cell population within tumor specimens.

Our data also demonstrate the novel finding of PEDF expression in lymphangiomas. In many tumor types, PEDF expression has been studied and, opposite to that of VEGF, has been correlated with an inhibition of tumor growth, a decrease in metastasis, and a favorable prognosis.2427 In the present study, PEDF expression in lymphangioma correlated with a decrease in recurrence. This study also demonstrated a higher rate of recurrence in tumors that had a high MVD, the hallmark of angiogenesis, and increased lymphocytic infiltration. A known potent inhibitor of angiogenesis, PEDF likely plays a part in the delicate balance that keeps these tumors in check because lymphangioma specimens with the highest MVD had the lowest PEDF staining.

An interesting finding was that the endothelium in salivary tissue stained intensely to VEGF, an angiogenic inducer (Figure 3). These same structures did not appear to produce any significant amount of PEDF, an angiogenic inhibitor. In addition, stratified squamous epithelium also stains strongly for VEGF. The higher recurrence rates noted by other authors in lesions of the suprahyoid areas are likely in close proximity to both salivary tissue and oral/pharyngeal mucosa.31,36 Local recurrence in these locations may be facilitated by high local levels of VEGF, which appears to be secreted by these tissues.

CONCLUSIONS

These data support our conclusion that lymphangioma has a tumorlike pathogenesis and is dependent on angiogenesis to support its growth. As demonstrated in other tumors, the dysregulation of angiogenesis by loss of naturally occurring inhibitors may be the underlying mechanisms of growth and proliferation. An imbalance of VEGF and PEDF may also increase the risk of recurrence after surgical resection.

Identification of the mechanism of action for these and other angiogenesis markers in lymphangioma would aid in our understanding of the pathophysiologic features of these tumors. In turn, this knowledge may open new avenues of therapy using antiangiogenic agents. If an imbalance between angiogenic inducers and inhibitors is the underlying mechanisms of their growth and proliferation, then restoring the balance through therapy with angiogenic inhibitors such as PEDF analogues or anti-VEGF receptor antibodies may be of some use in treating these tumors, and further investigation is warranted.

Back to top
Article Information

Correspondence: John Maddalozzo, MD, Pediatric Otolaryngology, Children’s Memorial Hospital, 2300 Children’s Plaza, Box 25, Chicago, IL 60614 (jpmaddalozzo@childrensmemorial.org).

Submitted for Publication: February 23, 2005; final revision received June 29, 2005; accepted July 7, 2005.

Financial Disclosure: None.

Previous Presentation: This study was presented at the American Society of Pediatric Otolaryngology section of the 2003 Combined Otolaryngological Spring Meetings; May 5, 2003; Nashville, Tenn.

References
1.
Redenbacher  E De Ranula Sublingual, Speciali, Cum Casa Congenita.  Munich, Germany: Monachii Lindauer; 1828
2.
Landing  BHFarber  S Tumors of the cardiovascular system.  In: Landing  BH, Farber  S, eds. Atlas of Tumor Pathology. Washington, DC: Armed Forces Institute of Pathology; 1956:124-138
3.
Bill  AH  JrSumner  DS A unified concept of lymphangioma and cystic hygroma. Surg Gynecol Obstet 1965;12079- 86
PubMed
4.
Williams  HB Embryology and classification of lymphatic abnormalities.  In: Williams  HB, ed. Symposium on Vascular Malformations and Melanotic Lesions. St Louis, Mo: Mosby; 1983:175-185
5.
Smith  RJBurke  DKSato  YPoust  RIKimura  KBauman  NM OK-432 therapy for lymphangiomas. Arch Otolaryngol Head Neck Surg 1996;1221195- 1199
PubMedArticle
6.
Batsakis  JG Tumors of the Head and Neck: Clinical and Pathological Considerations. 2nd ed. Baltimore, Md: Williams & Wilkins; 1979:301-304
7.
Emery  PJBailey  CMEvans  JN Cystic hygroma of the head and neck: a review of 37 cases. J Laryngol Otol 1984;98613- 619
PubMedArticle
8.
Reinhardt  MANelson  SCSencer  SFBostrom  BCKurachek  SCNesbit  ME Treatment of childhood lymphangiomas with interferon-alpha. J Pediatr Hematol Oncol 1997;19232- 236
PubMedArticle
9.
Fageeh  NManoukian  JTewfik  TSchloss  MWilliams  HBGaskin  D Mangagement of head and neck lymphatic malformations in children. J Otolaryngol 1997;26253- 258
PubMed
10.
Enzinger  FMWeiss  SW Tumors of lymph vessels.  In: Enzinger  FM, Weiss  SW, eds. Soft Tissue Tumors. St Louis, Mo: Mosby-Year Book; 1995:679-688
11.
Folkman  J Angiogenesis in cancer, vascular, rheumatoid and other disease. Nat Med 1995;127- 31
PubMedArticle
12.
Folkman  J New perspectives in clinical oncology from angiogenesis research. Eur J Cancer 1996;32A2534- 2539
PubMedArticle
13.
Salven  PHeikkila  PAnttonen  AKajanti  MJoensuu  H Vascular endothelial growth factor in squamous cell head and neck carcinoma: expression and prognostic significance. Mod Pathol 1997;101128- 1133
PubMed
14.
Jia  YTLi  ZXHe  YTLiang  WYang  HCMa  HJ Expression of vascular endothelial growth factor-C and the relationship between lymphangiogenesis and lymphatic metastasis in colorectal cancer. World J Gastroenterol 2004;103261- 3263
PubMed
15.
Nishida  NYano  HKomai  KNishida  TKamura  TKojiro  M Vascular endothelial growth factor C and vascular endothelial growth factor receptor 2 are related closely to the prognosis of patients with ovarian carcinoma. Cancer 2004;1011364- 1374
PubMedArticle
16.
Zeng  YOpeskin  KBaldwin  ME  et al.  Expression of vascular endothelial growth factor receptor-3 by lymphatic endothelial cells is associated with lymph node metastasis in prostate cancer. Clin Cancer Res 2004;105137- 5144Article
17.
Tanigaki  YNagashima  YKitamura  YMatsuda  HMikami  YTsukuda  M The expression of vascular endothelial growth factor-A and -C, and receptor 1 and 3: correlation with lymph node metastasis and prognosis in tongue squamous cell carcinoma. Int J Mol Med 2004;14389- 395
PubMed
18.
Ogawa  ETakenaka  KYanagihara  K  et al.  Clinical significance of VEGF-C status in tumour cells and stromal macrophages in non-small cell lung cancer patients. Br J Cancer 2004;91498- 503
PubMedArticle
19.
Rowe  RWTomoda  MStrebel  FRJenkins  GNStephens  LCBull  JM The natural progression of microvasculature in primary tumor and lymph node metastases in a breast cancer model: relationship between microvessel density, vascular endothelial growth factor expression, and metastatic invasion. Cancer Biol Ther 2004;3408- 414
PubMedArticle
20.
Ferrara  N Vascular endothelial growth factor: basic science and clinical progress. Endocr Rev 2004;25581- 611
PubMedArticle
21.
Fenton  BMPaoni  SFDing  I Pathophysiological effects of vascular endothelial growth factor receptor-2 blocking antibody plus fractionated radiotherapy on murine mammary tumors. Cancer Res 2004;645712- 5719
PubMedArticle
22.
Penland  SKGoldberg  RM Combining anti-VEGF approaches with oxaliplatin in advanced colorectal cancer. Clin Colorectal Cancer 2004;4(suppl 2)S74- S80
PubMedArticle
23.
Dawson  DWVolpert  OVGillis  P  et al.  Pigment epithelium-derived factor: a potent inhibitor of angiogenesis. Science 1999;285245- 248
PubMedArticle
24.
Uehara  HMiyamoto  MKato  K  et al.  Expression of pigment epithelium-derived factor decreases liver metastasis and correlates with favorable prognosis for patients with ductal pancreatic adenocarcinoma. Cancer Res 2004;643533- 3537
PubMedArticle
25.
Garcia  MFernandez-Garcia  NIRivas  V  et al.  Inhibition of xenografted human melanoma growth and prevention of metastasis development by dual antiangiogenic/antitumor activities of pigment epithelium-derived factor. Cancer Res 2004;645632- 5642
PubMedArticle
26.
Abramson  LPStellmach  VDoll  JACornwell  MArensman  RMCrawford  SE Wilms’ tumor growth is suppressed by antiangiogenic pigment epithelium-derived factor in a xenograft model. J Pediatr Surg 2003;38336- 342
PubMedArticle
27.
Miyagishi  DOhno-Matsui  KAmagasa  TMorita  I Regulation of the expression of pigment epithelium-derived factor, an anti-angiogenic factor in human oral squamous cell carcinoma cell lines. Cancer Lett 2003;19677- 85
PubMedArticle
28.
Alberdi  EAymerich  MSBecerra  SP Binding of pigment epithelium-derived factor (PEDF) to retinoblastoma cells and cerebellar granule neurons: evidence for a PEDF receptor. J Biol Chem 1999;27431605- 31612
PubMedArticle
29.
Maddalozzo  JHughes  CAHuang  LMu  YLudemann  JCrawford  S High angiogenic activity in cells isolated from cystic hygroma: role of bFGF. Arch Otolaryngol Head Neck Surg 1999;12545- 48
PubMedArticle
30.
Huang  HYHo  CCHuang  PHHsu  SM Co-expression of VEGF-C and its receptors, VEGFR-2 and VEGFR-3, in endothelial cells of lymphangioma: implication of autocrine or paracrine regulation of lymphangioma. Lab Invest 2001;811729- 1734
PubMedArticle
31.
Cohen  SRThompson  JW Lymphangiomas of the larynx in infants and children: a survey of pediatric lymphangioma. Ann Otol Rhinol Laryngol Suppl 1986;1271- 20
PubMed
32.
Orvidas  LJKasperbauer  JL Pediatric lymphangiomas of the head and neck. Ann Otol Rhinol Laryngol 2000;109411- 421
PubMed
33.
Kukk  ELymboussaki  ATaira  S  et al.  VEGF-C receptor binding and pattern of expression with VEGFR-3 suggests a role in lymphatic vascular development. Development 1996;1223829- 3837
PubMed
34.
Partanen  TAAlitalo  KMiettinen  M Lack of lymphatic vascular specificity of vascular endothelial growth factor receptor 3 in 185 vascular tumors. Cancer 1999;862406- 2412
PubMedArticle
35.
Cursiefen  CSchlotzer-Schrehardt  UBreiteneder-Geleff  SHolbach  LM Orbital lymphangioma with positive immunohistochemistry of lymphatic endothelial markers (vascular endothelial growth factor receptor 3 and podoplanin). Graefes Arch Clin Exp Ophthalmol 2001;239628- 632
PubMedArticle
36.
Ricciardelli  EJRichardson  MA Cervicofacial cystic hygroma. Patterns of recurrence and management of the difficult case. Arch Otolaryngol Head Neck Surg 1991;117546- 553
PubMedArticle
×