Introduction
About 1.2 million new cases of lung cancer occur annually worldwide. Approximately 35 % of patients with non-small cell lung cancer (NSCLC) are diagnosed with stage III disease [
1]. Of the stage III subgroup, only about 20 % of patients can be treated with surgery; the majority of patients may choose radiotherapy (RT) for local treatment, and meta-analysis indicates that combined chemotherapy and radiotherapy (CCRT) has become the standard of care for this group of patients, with good outcomes [
2]. Specifically, among patients who underwent CCRT with a standard dose of radiation (> 60 Gy), the complete remission rate ranged from 10 to 60 %, with a 5-year survival rate of 5–23 % [
3]. Patients surviving for 6–12 months had a statistically significantly increased survival rate when the intrathoracic tumor was controlled. Patients treated with 50–60 Gy showing tumor control had a 3-year survival rate of 22 %, compared with 10 % for patients with intrathoracic failure [
4], suggesting that local intrathoracic control may be predictive of patient survival. Therefore, it is important to enhance the radiosensitivity of lung cancer cells, which may affect local control and subsequent survival. In this study, we attempted to analyze the environmental changes after RT that increase the likelihood of the resistance of cancer cells to RT.
Blood and lymphatic vascular system development and maintenance are coupled through multiple growth factors and receptors expressed on blood and lymphatic endothelial cells (BECs and LECs, respectively). Vascular endothelial growth factors A and C (VEGF-A and VEGF-C, respectively) are two major growth factors that promote endothelial cell proliferation, migration, and induction of permeability. VEGF-C binding to VEGF receptor 3 (VEGFR-3) induces LEC proliferation and lymphatic vascular hyperplasia [
5,
6]. VEGF-C can also bind to VEGFR-2, eliciting a response that is similar to that induced by VEGF-A but less potent [
7].
The expression of VEGF-C and VEGFR-3 in lung cancer tumor cells was significantly associated with more advanced regional lymph node metastasis [
8‐
10]. Previous studies also demonstrated that radiation not only induced angiogenesis but also caused lymphangiogenesis [
11]. For example, Nathanson et al. reported that subtherapeutic hyperthermia or radiation increased lymphatic flow from tumors, which was associated with an increase in metastasis of melanoma [
12]. Talmadge et al. also showed that sublethal dose irradiation activated genes or signal pathways that induced functional changes that increased the survival or metastasis of cancer cells [
13]. Moreover, radiation of tumor cells induced vascular or microenvironment changes that enhanced capillary invasion capacity [
14,
15]. In the present study, we investigated the mechanism and consequences of irradiation-induced VEGF-C expression in lung cancer cells.
Materials and methods
Lung cancer cells
The human lung cell lines A549 and H1299 were obtained from the American Type Culture Collection (Manassas, Va.) and were maintained in Dulbecco’s modified Eagle medium (DMEM) or RPMI supplemented with nonessential amino acids, l-glutamine, a twofold vitamin solution, sodium pyruvate, 10 % fetal bovine serum, penicillin, and streptomycin. Cells were cultured at 37 °C in a humidified atmosphere of 5 % CO2 and 95 % air.
Establishment of lung cancer xenografts and irradiation
Male SCID mice (5–6 weeks old) were obtained from the National Taiwan University Animal Center, Taipei, Taiwan. To establish the xenografts, 1 × 106 A549 cells were injected subcutaneously into the right hind limb. At 10 days postimplantation, mice were immobilized in a customized harness that exposed the right hind leg. The remainder of the body was shielded by five times the half-value thickness of lead. A cobalt-60 unit was used to irradiate the primary tumor with 25 or 50 Gy (5-Gy or 10-Gy daily fractions, at a dose rate of 1 Gy/min).
On postimplantation day 9, tumor volumes were calculated every 3 days using a standard formula: width2 × length/2. Tumors were harvested at the time of sacrifice 14 days after completion of the radiotherapy and fixed in 10 % neutral buffered formalin and processed for immunohistochemical evaluations. All mice were group-housed under a fixed light–dark cycle (12 h of light and 12 h of darkness) with ad libitum access to sterilized food and water. All experimental procedures were performed in accordance with protocols approved by the Committee of Experimental Animal Management at the College of Medicine, National Taiwan University.
Immunohistochemistry analysis
All tissues were fixed in 10 % neutral buffered formalin and embedded in paraffin using standard protocols. Immunohistochemistry (IHC) analysis was performed on a single representative block from each case. Tissue sections (5 μm) were dewaxed, and antigen retrieval was performed in a citrate buffer (pH 6) using an electric pressure cooker set at 120 °C for 5 min as previously described (Choi et al. 2005). Sections were incubated for 5 min in 3 % hydrogen peroxide to quench endogenous tissue peroxidase. The sections were incubated in antibodies specific for the lymphatic endothelial marker, D2-40 antibodies (1:200 dilution; Biocompare, San Francisco, Calif.), for 60 min at room temperature. After washing unbound primary antibody, sections were treated with biotinylated secondary antibodies followed by avidin coupled to biotinylated HRP at room temperature according to the manufacturer’s instructions (DAKO, Carpinteria, Calif.). Immunohistochemical reactions were developed with diaminobenzidine as the chromogenic peroxidase substrate. Sections were counterstained with hematoxylin. Specificity was verified by negative control reactions that did not contain primary antibodies as well as by appropriate cytoplasmic reactions for each antigen in positive control tissues.
Microlymphatic vessel density assessment
Immunohistochemical reactions for D2-40 were analyzed at low magnification (× 40), and lymphatic vessels were counted in five representative high-magnification (× 400; 0.152 mm2; 0.44-mm diameter) fields. Single immunoreactive lymphatic endothelial cells, or lymphatic endothelial cell clusters separate from other microlymphatic vessels, were counted as individual microlymphatic vessels. The mean visual microlymphatic vessel density (MLVD) for D2-40 was calculated.
Culture of HUVECs and LECs
Human umbilical vein endothelial cells (HUVECs) were purchased from the Food Industry Research and Development Institute and cultured in M199 medium (Life Technologies, Carlsbad, Calif.) supplemented with 20 % fetal bovine serum, endothelial cell growth supplement (Millipore, Billerica, Mass.), heparin, l-glutamine, penicillin, and streptomycin. Human lymphatic endothelial cell (LECs) were isolated from human lymph nodes (ScienCell, Carlsbad, Calif.) and cultured in endothelial cell medium (ScienCell). The cells were cultured at 37 °C in a humidified atmosphere of 5 % CO2 and 95 % air.
Irradiation protocol
Cell culture plates were irradiated with different doses of radiation (0–10 Gy) using a cobalt-60 unit. The source–skin distance technique was set at 80 cm at the bottom of the flask. The dose rate was 1 Gy/min. Dosimetry was performed with an ionization chamber.
Western blot analysis
After cells were treated with various radiation doses and drugs, total protein was collected at different times. Protein was extracted using Mammalian Protein Extraction Reagent (M-PER; Pierce, Rockford, Ill.). An equal amount of protein from each cell line was loaded per lane and separated on a 10 % sodium dodecyl sulfate (SDS)–Tris glycine polyacrylamide gel electrophoresis (PAGE) gel. Gels were transferred onto nitrocellulose membranes (Novex, San Diego, Calif.) and blocked overnight by incubating with 1 × Tris-buffered saline containing 0.1 % Tween and 5 % nonfat dry milk. Membranes were probed with antibodies against phospho-Akt (p-Akt; Cell Signaling, Beverly, Mass.), phospho-mTOR (p-mTOR; Novus International, St. Louis, Mo.), phospho-eIF4E (p-4EBP), phospho–p70 ribosomal protein S6 kinases (p-p70S6K; Cell Signaling), phospho–eukaryotic translation initiation factor 4E (p-eIF4E; Cell Signaling), VEGF-C (Zymed Laboratories, South San Francisco, Calif.), Akt, mTOR, 4EBP, eIF4E, and actin (all from Chemicon International, Temecula, Calif.). Bound antibodies were then detected using the appropriate peroxidase-coupled secondary antibodies, followed by incubation with an enhanced chemiluminescence detection system (ECL; Boehringer Mannheim, Mannheim, Germany).
Enzyme-linked immunosorbent assay to detect secreted VEGF-C
Cell culture supernatant was collected after culturing A549 cells in completed culture medium for 24 h after irradiation. VEGF-C secretion was measured in the cell culture supernatant using a commercial enzyme-linked immunosorbent assay (ELISA) kit (R&D Systems, Minneapolis, Minn.) according to the manufacturer’s protocol. Color intensity was measured by a plate reader at 450 nm. Data represent the average of three different assays.
Reverse transcription–polymerase chain reaction
Reverse transcription (RT) of RNA was performed in a final reaction volume of 20 µl containing 5 µg of total RNA in Moloney murine leukemia virus (MMLV) reverse transcriptase buffer that contained 10 mM dithiothreitol, dNTPs (2.5 mM each), 1 mM (dT) primer, and 200 U of MMLV reverse transcriptase (Promega, Madison, Wis.). The reaction mixture was incubated at 37 °C for 2 h, and was terminated by heating at 70 °C for 10 min. A portion of the reaction mixture was then amplified by PCR with the following primer pairs: VEGF-C, sense 5′-CAGTTACGGTCTGTGTCCAGTGTAG-3′ and antisense 5′-GGACACACATGGAGGTTTAA-3′; β-actin, sense 5′- ATCCGCAAAGACCTGTACGC-3′ and antisense 5′-TGTGTGGACTTGGGAGAGGA-3′. A total of 30 cycles were performed. The products were separated on 2 % agarose gels, stained with 1 mg/ml ethidium bromide, and visualized using a UVP GDS-7900 digital imaging system. The results were confirmed by conducting at least three independent experiments.
Transfection of small interfering RNA
Small interfering RNA (siRNA) duplexes specific for VEGF-C or Akt were purchased from Santa Cruz Biotechnology (Santa Cruz, Calif.); control siRNAs with sequences that do not target any gene product were obtained from Invitrogen (Carlsbad, Calif.). Cells were transfected with 25 nM VEGF-C siRNA, Akt siRNA, or control siRNA in serum-free Opti-MEM using the oligofectamine method (Invitrogen) for 1 h at 37 °C. After changing the culture medium, cells were cultured for 24 h at 37 °C prior to further experiments.
A549 (1 × 105 cells) cells expressing control or VEGF-C siRNA were cultured in a 6-cm dish overnight, washed two times with PBS, and then incubated in medium before exposure to 5-Gy irradiation. Conditioned medium (CM) was harvested at 24 h after irradiation. The origin of CM was designated as the following: (1) non-irradiated A549 CM, (2) irradiated A549 CM, (3) irradiated VEGF-C-siRNA A549 CM, and (4) irradiated control-siRNA A549 CM.
Cell proliferation assay
Cells were cultured in 96-well plates at a density of 5,000 cells/well. The quantity of viable cells was estimated by a colorimetric assay using 3-(4,5-dimethylthiazol-2-yl)-2,5-diphenyltetrazolium bromide (MTT). MTT (10 µl of 5 mg/ml solution, Sigma, Germany) was added to each well and incubated for 4 h at 37 °C. The cells were then treated with 40 µl/well dimethyl sulfoxide (DMSO) and incubated for 60 min at 37 °C. The absorbance of each well was determined in an ELISA plate reader using an activation wavelength of 570 nm and a reference wavelength of 630 nm. The percentage of viable cells was determined by comparison with untreated control cells.
Statistical analysis
All data presented are the mean ± standard deviation of experiments repeated three or more times. A paired t-test was used to evaluate statistically significant differences between indicated groups in specified tests; p values < 0.05 were considered statistically significant.
Discussion
Tumor cells can produce multiple growth factors to create a microenvironment conducive for BEC and LEC growth. Tumor cell progression and metastasis may benefit from cross-talk between tumor cells, VECs, and LECs [
17,
18]. Radiation has antiangiogenic as well as antilymphogenic effects by damaging cell membranes, DNA, and endothelial cells, resulting in apoptosis. However, radiation also has proangiogenic and prolymphogenic effects either through direct mechanisms or through signals that are released by irradiated cancer cells and the tumor microenvironment. Recent studies also demonstrated a close association between radiosensitivity, proangiogenic growth factors, and endothelial cell survival; VEGFR inhibitors enhance the therapeutic efficacy of irradiation in NSCLC by hindering the repair of sublethal radiation damage [
19].
In the current study, radiation increased VEGF-C expression in a dose-dependent manner over time. Furthermore, CM from irradiated A549 cells enhanced proliferation of HUVECs and LECs, which was ameliorated in irradiated A549 cells expressing VEGF-C siRNA, suggesting that VEGF-C may play an important role in the angiogenic or lymphogenic effect of radiation in lung cancer. These results were consistent with those of other studies, which reported that radiation can both stimulate and inhibit angiogenesis through regulation of the proangiogenic and antiangiogenic balance [
20,
21]. For example, Sonveaux et al. [
20] found that irradiation stimulated migration and tubulogenesis of HUVECs accompanied by up-regulation of endothelial nitric oxide synthase (eNOS). In human tumor samples, the clinical relevance of irradiation-induced angiogenic growth factor expression has been observed [
21]. For example, in a study of rectal cancer patients receiving neoadjuvant RT followed by surgery, a significant increase in VEGF expression was observed in postradiation specimens compared with primary tumor samples [
21]. Therefore, radiation might induce a defense mechanism against radiation damage through the activation of a potential proangiogenic reaction. Most studies demonstrated radiation-induced VEGF-A expression but the novel finding in our study is VEGF-C over-expression after irradiation in lung cancer cells.
Several studies have demonstrated that radiation can activate various signaling pathways, including the PI3K, MAPK, JNK, and NF-κB signaling pathways [
22,
23]. The PI3K/Akt/mTOR signaling pathway is involved in tumorigenesis, translation of proteins for cell cycle progression, and lung cancer cell proliferation [
24,
25]. In addition to killing tumor cells, radiation could induce radioprotective signaling. Several studies analyzing the mechanism of radioresistance have demonstrated that it may be associated with activation of the PI3K/Akt/mTOR pathway [
26,
27]. Sunavala-Dossabhoy et al. [
26] observed that radiation increased the expression of a radioprotective protein, Tousled-like kinase 1B (TLK1B), which was preceded by an increase in p-Akt and p-4EBP. Irradiation also induced phosphorylation of Akt and mTOR in a breast cancer cell line, which was attenuated by mTOR and PI3K inhibitors. These findings suggest that the mTOR inhibitor attenuates radiation-induced Akt/mTOR prosurvival signaling and enhances the cytotoxic effects of radiation in breast cancer cells [
27]. Moreover, Dionysopoulos et al. [
28] demonstrated that clinicopathological parameters as well as high mTOR and CCND1 mRNA expression were associated with poor patient outcome in localized laryngeal cancer. The present study further supported that radiation can induce phosphorylation of Akt, mTOR, 4EBP, and eIF4E, indicating that the PI3K/Akt/mTOR/eIF4E signaling pathway can be activated by irradiation.
mTOR, p38, and JNK play important roles in the up-regulation of VEGF-C expression, and inhibition of mTOR by rapamycin has an anti-lymphangiogenic effect, which inhibited lymphatic metastasis [
29]. Also, activation of the PI3k/Akt signaling pathway up-regulated VEGF-C expression [
30]. These observations were supported by the present study, which found down-regulation of radiation-induced VEGF-C expression after inhibition of PI3K/AKT by LY294002, suppression of mTOR signaling by rapamycin, and expression of AKT siRNA. Moreover, our study observed that radiation-induced VEGF-C expression was at the translational level but not the transcriptional level. The result is similar to the finding of Morfoisse et al. [
31]
. They demonstrated that transcription-independent but translation-dependent up-regulation of VEGF-C in hypoxia stimulates lymphangiogenesis in tumors.