International Journal of Nasopharyngeal Carcinoma (IJNPC) Vol. 01, No.

02, 2019 | 66-68

International Journal of
NASOPHARYNGEAL CARCINOMA
Journal homepage: ijnpc.usu.ac.id

OVEREXPRESSION OF VASCULAR ENDOTHELIAL GROWTH

FACTOR IN ADVANCED STAGE UNDIFFERENTIATED
NASOPHARYNGEAL CARCINOMA
Kadek Kris Aryana1
1
General Hospital of Parama Sidhi, Bali, Indonesia

Abstract Article Info

Introduction: Nasopharyngeal Carcinoma (NPC) is a malignancy that tends to diagnosed at an advanced stage with Keywords:
low survival and prognosis rate. One of the factors that may play a role in progressivity and metastasis of tumor is NPC, VEGF, stage, histopathology.
overexpression of vascular endothelial growth factor (VEGF), which is a key role in tumor angiogenesis.
Objective: This study aims to learn the expression of VEGF in NPC with Undifferentiated Carcinoma type and
to learn the association pf VEGF Expression with tumor stage of NPC *Corresponding author:
Method: This is a cross-sectional study performed in ENT-HNS Department of ENT-HNS of Udayana Address: Jl. Ahmad Yani No.196, Banyusari, Kec.
University/Sanglah Hospital. The sample was collected by consecutive nonprobability sampling, starting from Buleleng, Kab. Buleleng, Bali 81116, Indonesia.
January 2016. NPC patients underwent Histopathologic examination from a nasopharyngeal biopsy. The result
is Undifferentiated Carcinoma. VEGF expression analyzed by red-brown stained cytoplasm. Data were analyzed e-mail: krisaryana@gmail.com
by Spearman's Correlation Test Chi-Square test, and Paired Sample t-Test.
Result: VEGF positive Expression was found in 27 of 28 (96.4%) Undifferentiated Carcinoma type of NPC
cases. VEGF overexpression was found in 23 of 28 (82.4%) Undifferentiated Carcinoma type of NPC
cases.There is significant correlation found between tumor stage and VEGF expression (p<0.05).
Conclusion: From the research, it could conclude that there is significant correlation between tumor stage and
VEGF Expression.

1. INTRODUCTION Flt-1 and KDR expressions with clinical features and prognosis of NPC patients.
From 127 NPC specimens by immunohistochemical examination found a
Nasopharyngeal carcinoma (NPC) is a malignant tumor that is often found in positive value of VEGF 66.9%, Flt-1 90.6% and KDR 88.2%. It was concluded
the ENT-HNS section and ranks the highest of all malignancies in the head and neck that VEGF, Flt-1 and KDR are widely expressedon the NPC spesimen, and
area. In Indonesia, nasopharyngeal carcinoma ranks fourth of all malignancies after positively related with clinical features and prognosis of NPC patients. Some
cervical and breast cancer. Fachiroh's research in Yogyakarta stated that the research in India have been evaluated the correlation between VEGF
incidence of NPC patients was 3.9 people per 100,000 population [1]. expressions, EBV status and recurrence at NPC. This study found VEGF
The etiology of this malignancy involves 3 important factors, namely Epstein- overexpression 67% of 103 NPC patients. The results of the study explain that
Barr Virus (EBV), genetic determination, and environment [2]. The prognosis of VEGF expression patterns as markers tumor for early diagnosis of metastases in
patients with Nasopharyngeal Carcinoma (NPC) is determined by an early NPC and the presence of EBV related toincreased VEGF regulation [2].
diagnosis that is found NPC cases in stages I and II, and regional metastases have
not occurred. This situation is very difficult to achieve both in Indonesia and abroad.
From several studies in Indonesia and abroad, stage I and II only found between
3.8% -11.9%, compared with stage III and IV around 88.1%-96.2% [2].
Based on WHO, NPC can be classified into three types, namely:
Keratinizing Squamous Cell Carcinoma, Nonkeratinizing Squamous Cell
Carcinoma, and Basaloid Squamous Cell Carcinoma. Nonkeratinizing tumor
Cell Carcinoma includes a differentiated type (Differentiated Nonkeratinizing
Cell Carcinoma) and undifferentiated carcinoma. These tumors are generally
more radiosensitive and have strong relationships with EBV [1].
Angiogenesis is a very complex process, tightly regulated by proangiogenic
factors (VEGF) and antiangiogenic factors. VEGF plays an important role in
tumor angiogenesis. VEGF expression in tumor cells stimulated by hypoxia,
oncogene (race) and inactivation of tumor suppressor genes (p53) and by various
cytokines. Activation of the VEGF/VEGF axis the receptor (VEGFR) triggers a
signal network multiple that results in cell survival endothelial, mitogenesis,
migration, differentiation and vascular permeability and mobilization of cells
endothelial progenitor from bone marrow to peripheral circulation. The pathway
of VEGF can be seen on picture 1.
VEGF overexpression has been associated with tumor progression and poor
prognosis in various types of tumors. VEGF expression compared between tissue
samples taken from the normal nasopharynx, benign tumors of nasopharynx and
NPC, with VEGF expression values of 10%, 40%, and 80%. VEGF expression
increases in advanced NPC with a statistical comparison significant to an early Picture 1. VEGF signaling pathway to induce angiogenesis of tumour. [2]
stage of NPC (3). A study in China examine the correlation between VEGF,

Copyright © International Journal of Nasopharyngeal Carcinoma, Published by Talenta Publisher, ISSN: 2656-9027 e-ISSN: 2656-9035, DOI: 10.32734/ijnpc.v1i2.1142 66
International Journal of Nasopharyngeal Carcinoma (IJNPC) Vol. 01, No. 02, 2019 | 66-68

About 80% NPC with Undifferentiated Carcinoma type in Sanglah Table 2. Characteristics based on gender, age group, ethnicity, stage, and
Hospital who has received a complete radiochemotherapy treatment relapse VEGF expression
This is estimated to be related to the role of VEGF in the process of Characteristic n=28
angiogenesis of NPC. Therefore, researchers want aware of VEGF Sex
overexpression on NPC with Undifferentiated Carcinoma type, which is Male 19 (67.9%)
Female 9 (32.1%)
associated with progression and poor prognosis of the tumor [3]. Age (Mean ±SD=47.96±11.17)
1-15 0 (0%)
2. MATERIAL AND METHOD 16-30 1 (3.6%)
31-45 6 (21.4%)
46-60 17 (60.7%)
The Study conduct with descriptive analytical study (cross-sectional >60 4 (14.28%
study) which was carried out in the Anatomy Pathology section of Sanglah Stage of NPC
Stage I 0 (0%)
Hospital Denpasar. This research began on the 1st to the 31st of October Stage II 2 (7.1%)
2016. Independent variable is staging of NPC with undifferentiated Stage III 8 (28.6%)
Stage IV 18 (64.3%)
carcinoma type, and the dependent variable is VEGF Expression. VEGF Expression
The studied samples obtained from 28 pathological anatomical 0 1 (3.6%)
1 4 (14.3%)
results of patients affected by Undifferentiated Carcinoma type of NPC, 2 10 (35.7%)
which is based on history, ENT examination and histopathological 3 13 (46.4%)
biopsy result that meet inclusion and exclusion criteria. The inclusion
criteria are the Pathological Anatomy result of patients with If connected with Stage of NPC showed that the mean VEGF
Undifferentiated Carcinoma type of NPC in all range of age, who never expression at the initial stage (Stages I and II) were 8.15±5.89 and the mean
got treatment with radiation or chemotherapy. The exclusion criteria VEGF expression at an advanced stage (III and IV) are 59.20±29.75.
are People with NPC who are not a type of Undifferentiated Carcinoma Undifferentiated Carcinoma type with VEGF expression shows that in the
or NPC patients with Undifferentiated Carcinoma type with early stages (I and II) there was no over-expression of VEGF. There were
two early-stage cases, and each case had negative VEGF expression (0) and
histopathological results doubt. If the histopathological results of repeat
weak VEGF expression [1]. At an advanced stage (III and IV) found 26
biopsy remain doubtful. Determination of the minimum number of cases (92.9%) and from all of these cases, 23 cases had VEGF
samples based on observations before using the formula. The subject overexpression (2 and 3). Statistically, according to Pearson Chi-Square and
was taken using nonprobability consecutive sampling. Spearman correlation obtained significant results with a value of p<0.05.
The research material was tissue from the nasopharynx on NPC After Dependent t-test was also performed with significant results with a
patients who meet the inclusion criteria taken by biopsy. The tissue then value of t<0.05 This shows that there is a strong positive relationship
undergoes a histochemical examination to detect antigen on the tissue between VEGF overexpression and stage of Undifferentiated Carcinoma
by using certain antibody. From the histochemical examination, it could type of NPC - which is the higher stage of Undifferentiated Carcinoma type
measure the number of VEGF expressions in tumor cells and of NPC the VEGF expression will also be higher. Staging Relationship
categorized as follows. Description of Undifferentiated Carcinoma type of NPC with VEGF
overexpression is shown in table 3.
Table 1. VEGF expression on NPC patients
Table 3. Correlation of VEGF Expression with clinical stage of
Score Criteria Status undifferentiated carcinoma type of NPC
0 Negative
1 Weak (<10% tumor cell expression) No Overexpression VEGF Expression
2 Mild ( 10%-50% tumor cell expression) Stage Weak expression Overexpression Total Correlation
3 Strong (>50% tumor cell expression ) Overexpression (0 and 1) (2 and 3)
Early stage 2(7.1%)
2(100%) 0 r=0,001
The collected data analyzed by univariate and bivariate analysis. (I and II)
p=0,002
Advanced stage 26
Univariate analysis is initial data analysis. Descriptive analysis of this (III and IV)
3 (11.5%) 23 (88.5%)
(92.9%)
t=0,001
study includes the presentation of results and descriptive using descriptive
categories, namely in the form of distribution frequency and numerical 4. DISCUSSION
descriptive in the form of mean and standard deviation displayed are Age,
gender, stage and VEGF expression. Bivariate analysis is performed to Male patients make up 67.9% of NPC cases. this distribution is
see the relationship between one independent variable and one dependent consistent with previous findings indicating dominant male predisposition
variable. Data obtained will be presented in the form of tables and graphs. among NPC patients in North America, the Middle East/North Africa,
The data obtained is analyzed statistically for assessing the percentage of
Arctic, Southeast Asia, and China and East Asia [4]. The results of this study
VEGF expression in NPC patients’ immunohistochemically. To assess the
are almost the same as other studies on Ciptomangunkusumo hospital that
meaningful relationship, a chi-square test was carried out, Spearman
correlation test, and Paired sample t-test. found as much as 68.3% of the NPC patients are male, and most of them
(80.2%) are older than 30 years old [5]. High incidence in men may be due
3. RESULT to differences in life habits and work that cause man to be more in contact
with carcinogens that cause NPC. Habits life, such as smoking increases the
For this study, 28 consecutive patients with undifferentiated risk of NPC 2-6 times. Steam exposure, dust smoke, and chemical gas in the
carcinoma type of NPC were enrolled. In this case, NPC diagnosis was workplace also increase the risk of NPC 2-6 times [6].
confirmed by pathological examination of the biopsy using routine More than 80% of NPC patients are older than 30 years old. This
histochemical examination. Patient characteristic is summarized in table
finding follows the general age trend of NPC that starts to rise after 30.
2. The mean (±SD) age of the patients was 47.96±11.17 years, 19 patients
(67.9%) were male, and 9 patients (32.1%) were female. At presentation, Incidence peak in 31-60 years group, with 82.1 % of patients in this group.
92.9% of patients had an advanced stage of the disease, with 18 patients This peak concurs with many previous findings which found the peak in age
(64.3%) in stage IV and 8 patients (28.6%) in stage III. From the 31-50 years old in North Africa, the peak is around 50 years of age, in China,
histochemical examination, 27 cases (96.4%) show the expression of the majority of patients come in the fifth and sixth decades of life [7, 8].
VEGF; 23 cases have overexpression of VEGF (degree 2 and 3). NPC in Singapore peaks in age 41-50 years old [9].
At the initial stage, it was found that the average VEGF expression was
8.15±5.89 with a minimum expression of 0 and a maximum expression of 18,
whereas at the end of the stage the average VEGF expression was 59.20±29.75
with a minimum expression of 18 and expression maximal 96. These results are
similar to previous studies, which found that the average VEGF expression at the
initial and advanced stages was 7.56 and 65.20 [10]. The results of this study
showed considerable VEGF expression in NPC patients. In the literature
mentioned the potential pattern of VEGF expression as a tumor marker for early
diagnosis of the occurrence of metastases in NPC [11]. Immunohistochemical

67
International Journal of Nasopharyngeal Carcinoma (IJNPC) Vol. 01, No. 02, 2019 | 66-68

examination of VEGF and its receptors are reported to be related to clinical

features and prognosis of NPC patients [12]. Further research is needed to
ascertain the role of VEGF in the pathogenesis of NPC.
There is a significant correlation between the stage of Undifferentiated
Carcinoma type of NPC with the degree of VEGF expression, where the
value of p<0.005. Previous studies reported that VEGF overexpression
correlated significantly with advanced clinical stage, local recurrence and
distant metastases, and poor prognosis in NPC patients [13]. Previous
studies also reported a significant relationship between the degree of VEGF
expression and NPC stage. They also noted that VEGF detection in NPC
tissue might be useful for calculating limfe gland metastases and recurrence,
assessing clinical stage, and evaluating the prognosis of NPC [14, 15].

5. CONCLUSION

VEGF Overexpression was found in 96.4% of 28 cases of Undifferentiated

Carcinoma type of NPC. There is a significant correlation between VEGF
Expression in an advanced stage of undifferentiated carcinoma type of NPC.

REFERENCE

[1] Fachiroh J, Schouten T, Hariwiyanto B, Paramita DK, Harijadi A, Haryana SM,

et al. Molecular diversity of Epstein-Barr virus IgG and IgA antibody responses
in nasopharyngeal carcinoma: a comparison of Indonesian, Chinese, and
European subjects. The Journal of infectious diseases. 2004:53-62.
[2] K SA. Gambaran Kejadian KNF di RSUD Moewardi Surakarta 2007-
2009. 2010.
[3] Agulnik M, Siu L. State-of-the-art management of nasopharyngeal carcinoma:
current and future directions. British journal of cancer. 2005;92(5):799.
[4] Anghel I, Anghel A, Dumitru M, Soreanu C. Nasopharyngeal carcinoma--
analysis of risk factors and immunological markers. Chirurgia (Bucur).
2012;107(5):640-5.
[5] Jayalie VF, Paramitha MS, Jessica J, Liu CA, Ramadianto AS, Trimartani
T, et al. Profile of Nasopharyngeal Carcinoma in Dr. Cipto Mangunkusumo
National Hospital, 2010. eJournal Kedokteran Indonesia. 2017:156-62.
[6] Polesel J, Franceschi S, Talamini R, Negri E, Barzan L, Montella M, et al.
Tobacco smoking, alcohol drinking, and the risk of different histological
types of nasopharyngeal cancer in a low-risk population. Oral oncology.
2011;47(6):541-5.
[7] Adham M, Kurniawan AN, Muhtadi AI, Roezin A, Hermani B, Gondhowiardjo
S, et al. Nasopharyngeal carcinoma in Indonesia: epidemiology, incidence,
signs, and symptoms at presentation. Chinese journal of cancer. 2012;31(4):185.
[8] Ji X, Zhang W, Xie C, Wang B, Zhang G, Zhou F. Nasopharyngeal carcinoma
risk by histologic type in central China: impact of smoking, alcohol and family
history. International journal of cancer. 2011;129(3):724-32.
[9] Loh KS, Goh BC, Lu J, Hsieh W-S, Tan L. Familial nasopharyngeal
carcinoma in a cohort of 200 patients. Archives of Otolaryngology–Head
& Neck Surgery. 2006;132(1):82-5.
[10] Li Y-H, Hu C-F, Shao Q, Huang M-Y, Hou J-H, Xie D, et al. Elevated
expressions of survivin and VEGF protein are strong independent
predictors of survival in advanced nasopharyngeal carcinoma. Journal of
translational medicine. 2008;6(1):1.
[11] Lo AKF, Liu Y, Wang XH, Huang DP, Yuen PW, Wong YC, et al.
Alterations of biologic properties and gene expression in nasopharyngeal
epithelial cells by the Epstein-Barr virus–encoded latent membrane protein
1. Laboratory investigation. 2003;83(5):697.
[12] Kurnianda J, Hardianti MS, Harijadi T-HK, Purwanto I, Haryana SM,
Tjokronagoro M. Elevation of vascular endothelial growth factor in Indonesian
advanced stage nasopharyngeal carcinoma. Kobe J Med Sci. 2009;55(2):E36-E44.
[13] Farhat. Vascular Endothelial Growth Factor pada Karsinoma Nasofaring.
Majalah Kedokteran Nusantara. 2009;42(1):59-65.
[14] Hendarsih E, Oehadian A, Sumantri R, Supandiman I, Hernowo BS.
Perbedaan Ekspresi Vascular Endothelial Growth Factor dan Ekspresi
Tissue Factor Berdasarkan Respons Terapi Kemoradiasi Cisplatin pada
Penderita Karsinoma Nasofaring Stadium lanjut. Majalah Kedokteran
Bandung. 2015;47(1):49-54.
[15] Segawa Y, Oda Y, Yamamoto H, Shiratsuchi H, Hirakawa N, Komune S,
et al. Close correlation between CXCR4 and VEGF expression and their
prognostic implications in nasopharyngeal carcinoma. Oncology reports.
2009;21(5):1197-202.

68