Rom J Morphol Embryol 2018, 59(2):in press

RJME
REVIEW Romanian Journal of
Morphology & Embryology
http://www.rjme.ro/

Vascular endothelial growth factor (VEGF) – key factor in

normal and pathological angiogenesis
CARMEN STANCA MELINCOVICI1), ADINA BIANCA BOŞCA1), SERGIU ŞUŞMAN1,2), MARIANA MĂRGINEAN1),
CARINA MIHU3), MIHNEA ISTRATE3), IOANA-MARIA MOLDOVAN1), ALEXANDRA LIVIA ROMAN4),
CARMEN MIHAELA MIHU1)
1)
Discipline of Histology, Department of Morphological Sciences, “Iuliu Haţieganu” University of Medicine and Pharmacy,
Cluj-Napoca, Romania
2)
Department of Pathology, Imogen Research Center, Cluj-Napoca, Romania
3)
Medical Student, Faculty of Medicine, “Iuliu Haţieganu” University of Medicine and Pharmacy, Cluj-Napoca, Romania
4)
Discipline of Periodontology, Department of Oral Rehabilitation, Faculty of Dental Medicine, “Iuliu Haţieganu” University
of Medicine and Pharmacy, Cluj-Napoca, Romania

Abstract
Vascular endothelial growth factor (VEGF) represents a growth factor with important pro-angiogenic activity, having a mitogenic and an
anti-apoptotic effect on endothelial cells, increasing the vascular permeability, promoting cell migration, etc. Due to these effects, it actively
contributes in regulating the normal and pathological angiogenic processes. In humans, the VEGF family is composed of several members:
VEGF-A (which has different isoforms), VEGF-B, VEGF-C, VEGF-D, VEGF–E (viral VEGF), VEGF-F (snake venom VEGF), placenta growth
factor (PlGF), and, recently, to this family has been added endocrine gland-derived vascular endothelial growth factor (EG-VEGF). VEGF
binds to tyrosine kinase cell receptors (VEGFRs): VEGFR-1 [Fms-like tyrosine kinase 1 (Flt-1)], VEGFR-2 [kinase insert domain receptor
(KDR) in human; fetal liver kinase 1 (Flk-1) in mouse] and VEGFR-3 [Fms-like tyrosine kinase 4 (Flt-4)]. While VEGFR-1 and VEGFR-2 are
expressed predominantly on vascular endothelial cells, VEGFR-3 is expressed especially on lymphatic endothelial cells. VEGFR-2 has the
strongest pro-angiogenic activity and a higher tyrosine kinase activity than VEGFR-1. Endothelial cells also express co-receptors, such as
neuropilin-1 (NP-1) and neuropilin-2 (NP-2), which modulate tyrosine kinase receptor activity. Both VEGF and VEGFRs are expressed not
only on endothelial cells, but also on non-endothelial cells. This article aims to highlight the most recent data referring to the VEGF family and
its receptors, as well as its implications in the angiogenesis process. At present, blocking angiogenesis in cancer or in other pathological
processes, using anti-VEGF and anti-VEGFRs therapies, is considered to be extremely important.
Keywords: VEGF receptors, VEGF, isoforms, angiogenesis, anti-angiogenic therapy.

 Introduction process of formation and development of certain new

lymphatic vessels (lymphangiogenesis) [2].
Angiogenesis is an extremely complex process, The human VEGF gene, located on the 6p21.3
influenced by multiple factors, some of them acting as pro- chromosome, is part of the VEGF/platelet-derived growth
angiogenic agents, others as inhibitors of angiogenesis [1]. factor (PDGF) gene family, also called the cystine-knot
An extremely potent pro-angiogenic factor is vascular superfamily of growth factors [2, 12, 13]. From a struc-
endothelial growth factor (VEGF) and, for this reason, tural point of view, VEGF is a 40-kDa heterodimeric
there are numerous studies that demonstrated its impli- glycoprotein, which contains the cystine-knot motif,
cation in angiogenesis. characterized by the disposition of certain bisulfidic
During the embryonic period, the formation of new bridges in the protein structure [2, 12, 14]. Alongside
vessels occurs by the differentiation of endothelial cells VEGF, there are additional growth factors from the cystine-
from hemangioblasts (vasculogenesis) [2–5]. Later, after knot motif family: PDGF, nerve growth factor (NGF) and
birth, in certain physiological processes (menstrual cycle, transforming growth factor-beta (TGF-β) [14, 15].
pregnancy, wound healing and repair, etc.), new vascular In humans, the VEGF family includes several members
networks are formed by angiogenesis, based on preexisting that perform various functions: VEGF-A (which presents
vessels (neoangiogenesis) [1–3, 6–9]. several isoforms), VEGF-B, VEGF-C, VEGF-D, VEGF-E
At the same time, data suggests that VEGF plays an (viral VEGF, in parapoxvirus 1), VEGF-F (snake venom
important role in pathological angiogenesis, inducing VEGF) and the placenta growth factor (PlGF) [2, 16, 17].
the development and progression of certain pathological More recently, a new member has been added to this
conditions in the postnatal period, such as: tumor growth family, named the endocrine gland-derived vascular
and metastasis, macular degeneration, diabetic retino- endothelial growth factor (EG-VEGF) [17, 18].
pathy, inflammatory processes (e.g., rheumatoid arthritis),
ischemic processes (myocardial ischemia), preeclampsia,
 Short history
etc. [2, 4, 7–11].
At present, increased attention is focused on the In 1983, Senger et al. described a protein called

ISSN (print) 1220–0522 ISSN (online) 2066–8279

2 Carmen Stanca Melincovici et al.
vascular permeability factor (VPF), secreted by animal identified on myofibroblasts located in the connective
tumor cells (hamster, guinea, pig), which is responsible tissue of mouse myocardium, in the infarction areas [16].
for the increased permeability of the tumor blood vessels VEGFR-1 plays an important role in migration of
and the development of ascites associated with certain endothelial cells [12, 25], monocytes, macrophages, and
abdominal tumors [19]. hematopoietic stem cells [3, 12, 17, 27, 32], thus being
In 1989, Ferrara et al., from Genentech, independently, mainly involved in pathological angiogenesis in adult
isolated and described the VEGF protein, demonstrating life (tumors, inflammation, ischemia, preeclampsia, etc.)
its role in angiogenesis [20]. Subsequently, the two [12, 17, 32].
proteins, VPF and VEGF, turned out to have a similar VEGFR-1 has a 10 times higher affinity for VEGF
structure [21]. than VEGFR-2 and a lower tyrosine kinase activity [27,
Knowing that during carcinogenesis an important role 29, 33].
is played by tumor angiogenesis, the need to find certain Recent data on the biological role of VEGFR-1 in
angiogenesis inhibitors has become more stringent. vasculogenesis, during the embryonic development, is
Hence, in 1993, Ferrara et al. obtained an arrest in tumor contradictory [33]; most authors state that VEGFR-1
growth by blocking the angiogenesis with monoclonal anti- plays a role in endothelial cells differentiation and
VEGF antibodies [20, 22, 23]. Nowadays, anti-VEGF migration, but not in their proliferation [12, 25, 27].
targeted therapies are successfully used in cancer treatment. The inactivation of murine gene that encodes VEGFR-1
These results confirm the reports made since 1971 by (flt-1– null mutant mice or flt-1–/– mice), lead to embryonic
Judah Folkman, who advanced the idea that tumor death on days 8 or 9 of gestation, because, despite the fact
progression and growth depend on the tumor angiogenesis that the endothelial cells undergo differentiation, they
[20, 22, 23]. formed anarchic vascular channels; thus, the development
and organization of a functional and viable vascular
 VEGFR receptors system did not occur [4, 24, 25, 27, 32].
Consequently, according to these studies, VEGFR-1 is
VEGF binds to tyrosine kinase receptors, which present involved only in the differentiation of endothelial cells and
three domains: an extracellular domain for VEGF binding, is not actively involved in early stages of angiogenesis
a transmembrane domain and an intracellular domain during embryogenesis [4, 24, 25, 27, 32]. Molecular
with tyrosine kinase activity [2, 24, 25, 26]. VEGF, mechanisms referring to the involvement of the VEGFR-1
binding to the extracellular receptor domain, promotes the gene in vasculogenesis are not completely understood
activation of tyrosine kinase enzyme in the intracellular and there still are aspects that need to be clarified [25].
receptor domain, which phosphorylates the tyrosine It seems that VEGFR-1 inhibits the pro-angiogenic signals
residues, thus activating several intracellular signaling in the early development stage [26], preventing the binding
pathways [25]. of VEGF to VEGFR-2, which is expressed on the new
There are three types of VEGF receptors: VEGFR-1, formed endothelial cells (knowing that VEGFR-2 has a
VEGFR-2 and VEGFR-3 [2, 3, 12, 25]. Members of the stimulating effect on endothelial cells proliferation) [3,
VEGF family can also interact with other proteins, such 4, 26, 29].
as neuropilins [3, 25, 27–29], integrins [27–29], cadherins Some experiments have tried to determine which of
[27, 28], or heparan sulphate proteoglycans [3, 25, 27– the three domains of the VEGFR-1 receptors is involved
29]. Neuropilin-1 (NP-1) and neuropilin-2 (NP-2) co- in vasculogenesis or in pathological angiogenesis.
receptors are non-tyrosine kinase receptors and they Experimentally, in mice, the mutation of the VEGFR-1
selectively attach to certain VEGF subtypes or isoforms gene segment which encoded the intracellular domain with
(such as VEGF-A165) [3, 25]. Neuropilins enhance the tyrosine kinase activity (flt-1 TK–/– mice) has enabled
VEGFR-2 and VEGFR-3 functions, guiding the endothelial the differentiation of endothelial cells [4, 24, 26, 29],
cells migration in angiogenesis [3]. but not the migration of macrophages in pathological
VEGFR-1 and VEGFR-2 receptors are expressed conditions [4, 24, 29]. During all this time, the extra-
predominantly on vascular endothelial cells [2, 25, 26], but cellular domain and the transmembrane domain of the
can also be found on non-endothelial cells [16, 25, 26], receptor have remained unmodified [26, 34]. Hence, the
while VEGFR-3 is expressed especially on endothelial effect of VEGFR-1 on vasculogenesis is influenced by the
lymphatic cells [30]. extracellular and transmembrane domain of the VEGFR-1
[24, 26, 29].
VEGFR-1
According to the data presented above, the tyrosine
VEGFR-1 [Fms-like tyrosine kinase 1 (Flt-1)] is a kinase activity of the receptor does not influence the
member of the receptor tyrosine kinases family (RTKs), differentiation of endothelial cells during embryogenesis,
with a molecular weight of 180 kDa [12] and with high but plays an important role in pathological angiogenesis
receptiveness for VEGF-A [3, 4, 12, 13], VEGF-B [3, 4, [26, 29]. In the given context, experiments on mutant
12, 13], PlGF [3, 4, 12, 13] and VEGF-F [3, 13]. Besides mice that do not contain the tyrosine kinase region (flt-1
endothelial cells, there are other cells that can express TK–/– mice) have highlighted a lower rate of invasion and
VEGFR-1: inflammatory cells, monocytes/macrophage tumor metastasis and also a lower degree of inflammation
cells [3, 17, 25, 26], bone marrow-derived hematopoietic (e.g., in rheumatoid arthritis) compared with wild-type
progenitor cells [17, 31], trophoblastic cells [25], mesangial mice [4].
renal cells [25], tumor cells [25], vascular smooth muscle A soluble form of VEGFR-1 (sVEGFR-1 or sFlt-1),
cells (VSMCs) [17]. VEGFR-1 receptors have also been was obtained by alternative splicing of the VEGFR-1
 Vascular endothelial growth factor (VEGF) – key factor in normal and pathological angiogenesis 3
gene [3, 17, 27]. sVEGFR-1 does not contain neither the In exchange, the activation of VEGFR-1 is impor-
transmembrane, nor the intracellular domain of the tant in pathological angiogenesis (tumor growth and
VEGFR-1 receptor. Even though, it still shows affinity for progression, amplification of the inflammatory process,
VEGF, preventing its binding to VEGFR-2 [3, 17], thus preeclampsia, ischemia, atherosclerosis, etc.), by various
having an anti-angiogenic effect [4, 35]. The soluble form mechanisms: chemotaxis of inflammatory cells [4, 17,
of sVEGFR-1 (sFlt-1), with its negative role in angio- 27], secretion of inflammatory cytokines [4, 17, 27], the
genesis, is expressed during the embryonic development recruitment of medullary progenitor cells at the injury site
[27, 36]. Its presence in the corneal epithelium explains [27, 31], secretion of growth factors [e.g., hepatocyte
the absence of corneal vascularization [26, 35, 37]. growth factor (HGF), in the liver endothelial cells] [46,
sVEGFR-1 has affinity for VEGF-A and PlGF and, in 47], interaction with PlGF [4, 17, 27], and activation of
adults, increased serum levels of sVEGFR-1 are observed proteolytic enzymes (e.g., MMP-9) [27, 45].
in pathological angiogenesis (e.g., preeclampsia) [12, 26,
VEGFR-2
35, 36].
Postnatally, in pathological conditions, the interaction VEGFR-2 [kinase insert domain receptor (KDR) in
between VEGFR-1 and VEGFR-2 can be modified, human; fetal liver kinase 1 (Flk-1) in mouse], the predo-
VEGFR-1 having the same binding interface for VEGF minant receptor [8], is also a member of the tyrosine
and PlGF [4]. While PlGF binds only to VEGFR-1 [4, kinase receptor family, with a molecular weight of 200–
17], VEGF binds to both VEGFR-1 and VEGFR-2, still 230 kDa [12]. It shows greater affinity towards VEGF-A
having a 10 times higher affinity for VEGFR-1 [12]. and VEGF-E, and lower affinity for VEGF-C and VEGF-D
According to some authors, binding of PlGF to VEGFR-1 [3, 13].
stimulates endothelial cells to release VEGF, which will VEGFR-2 is expressed especially on endothelial cells
bind to VEGFR-2. Consequently, activation of VEGFR-2 of blood and lymphatic vessels [12], but it has also a weak
stimulates angiogenesis, migration and proliferation of expression in: hematopoietic cells [12, 25, 26], mega-
endothelial cells [3, 4, 38]. karyocytes [12, 25, 26], retinal progenitor cells [25, 26],
Hence, in pathological conditions, VEGFR-1 and neurons [26], osteoblasts [26] pancreatic ductal cells [26],
PlGF act synergistically, representing “key factors” in tumor cells [25, 33].
pathological angiogenesis, PlGF modulating the interaction VEGFR-2 is expressed in early embryonic life, at day
between VEGFR-1 and VEGFR-2 in this context [4, 17]. 7.5 of gestation, on hemangioblasts with mesodermic
In non-endothelial cells [monocytes, macrophages, origin, hence influencing their migration, differentiation
polymorphonuclears (PMN) leukocytes, hematopoietic into endothelial cells and the formation of vascular islands
stem cells, VSMCs] [27, 33], the activation of VEGFR-1 in the Yolk sac, with the initiation of vasculogenesis [3,
in pathological conditions (tumors, inflammation, ischemia, 26].
etc.) has an important role in chemotaxis and cell migration The inactivation of the murine gene that encodes
[27, 39, 40], due to the activation of different signaling VEGFR-2 in homozygotic animals (VEGFR-2-/-) leads to
pathways: phosphoinositide-3-kinase (PI3K)/protein kinase embryonic death on days 8–9, due to a failure of vascular
B (PKB/Akt) [4, 29, 41], mitogen-activated protein kinase island formation [25]. In this case, the differentiation
(MAPK)/extracellular signal-regulated kinase (ERK) of endothelial cells has not occurred, thus blocking the
pathway (p38-MAPK/ERK1/2) [4, 29, 33, 41]. The main development and organization of the vascular system [3,
activating factor of VEGFR-1 in inflammatory cells seems 25, 34]. In fact, several studies reported that VEGFR-2
to be PI3K [29, 41], and activating of other proteins (e.g., could also interfere with lymphangiogenesis by binding
Akt, p38, ERK1/2, etc.) also depends on PI3K [29, 41]. VEGF-C and VEGF-D, although the mechanisms involved
In pathological angiogenesis, the activation of tyrosine in this process are still being clarified [3]. Therefore,
kinase domain of VEGFR-1 promotes the inflammatory VEGFR-2 is essential for the normal course of vasculo-
cells migration and secretion of inflammatory cytokines genesis during the embryonic development [4, 17, 34].
[27, 39, 40], such as: tumor necrosis factor-alpha (TNF-α) VEGFR-2 presents the same domains as the other
[42, 43], interleukin-1beta (IL-1β) [42, 43], IL-6 [43], receptors in this family. Binding VEGF to the extra-
IL-8 [42, 43], monocyte chemoattractant protein-1 (MCP-1) cellular domain of VEGFR-2 causes the autophosphoryl-
[42, 43], macrophage inflammatory protein-1beta (MIP-1β) ation of tyrosine residues and the activation of certain
[42, 44]. signaling pathways (Figure 1), such as: phospholipase-Cγ
Hence, VEGFR-1 plays an important role in patho- (PLCγ)/protein kinase C (PKC) [4, 24, 29, 33] and Ras/
logical angiogenesis [4, 8]. It has been observed that in Raf/ERK/MAPK pathways [4, 12, 29], these signaling
certain types of solid tumors (breast cancer, lung, hepatic pathways being involved in proliferation of endothelial
carcinoma), activation of VEGFR-1 induced the secretion cells. Moreover, by the activation of the PI3K/Akt pathway
of proteolytic enzymes into the extracellular matrix (ECM) [4, 12, 33], VEGFR-2 plays a role in endothelial cell
[e.g., matrix metalloproteinase-9 (MMP-9)] [4, 45], which survival, playing an anti-apoptotic role. Also, it activates
favors tumor dissemination. certain integrins, which disrupt cell to cell cohesion and
In conclusion, VEGFR-1 is not actively involved in initiate cellular migration [3, 4, 12, 33]. In this context,
vasculogenesis during the embryonic period, since it it has been concluded that, by activating PI3K-kinase and
does not have a “mitogenic” effect on endothelial cells p38 MAPK pathways [27], adhesion molecules such as:
[4, 26]. It has a “negative role” in vasculogenesis, acting cadherins [vascular endothelial (VE)-cadherin] [27, 48, 49],
more like a “trap or decoy receptor” for VEGF [4], thus β-catenin [27, 50], occludins [27, 51] and connexin 43
making VEGF less accessible for VEGFR-2 [3, 4, 26]. [27], could form a complex with VEGFR-2, that weakens
4 Carmen Stanca Melincovici et al.
the intercellular junctions, destabilize the cytoskeleton of of Akt protein kinase, the formation of endothelial nitric
endothelial cells and induces the formation of endothelial oxide synthase (eNOS) and the production of nitric oxide
fenestrae [27]. Thus, the vascular permeability increases, (NO) is stimulated in endothelial cells, inducing vasodi-
favoring cell migration [3, 27]. Moreover, by the activation latation and increased vascular permeability [27].

Figure 1 – VEGF-A/VEGFR-2 signaling pathways. Targets of anti-angiogenic agents. VEGF binding on VEGFR-2 lead
to downstream signaling of the PLCγ/PKC, PI3K and MAPK signaling. VEGF(R): Vascular endothelial growth factor
(receptor); PLCγ: Phospholipase-Cγ; PKC: Protein kinase C; MEK: Mitogen-activated protein kinase kinase; ERK:
Extracellular signal-regulated kinase; DNA: Deoxyribonucleic acid; PI3K: Phosphoinositide-3-kinase; AKT/PKB:
Protein kinase B; eNOs: Endothelial nitric oxide synthase; MAPK: Mitogen-activated protein kinase.

During tumor neoangiogenesis, there are numerous It is considered that VEGFR-2 has the strongest pro-
paracrine interactions between endothelial cells and tumor angiogenic activity, thus blocking VEGFR-2 may have
cells [33, 52]. Binding VEGF to VEGFR-2 stimulates the useful clinical implications. VEGFR-2 has a stronger
secretion of von Willebrand factor (vWF) by endothelial tyrosine kinase activity than VEGFR-1, but a weaker
cells [33, 52]; the activation of endothelial cells is an affinity for VEGF (VEGF-A) [4, 20, 26].
essential event for tumor progression [52]. Through the alternative splicing of VEGFR-2 gene,
To conclude, VEGFR-2 is involved in vasculogenesis, a soluble form of VEGFR-2 was obtained (sVEGFR-2),
normal and pathological angiogenesis, acting through which has an affinity for VEGF-C, preventing its binding
different mechanisms, such as: migration of the heman- to VEGFR-3, thus impeding the proliferation of lymphatic
gioblasts towards the Yolk sac [25] and differentiation endothelial cells and blocking lymphangiogenesis [33, 55].
into endothelial cells [4, 12, 25], formation of vascular
VEGFR-3
tubes (tubulogenesis) [29], proliferation of endothelial cells
(mitogen effect) [4, 12], increase of vascular permeability VEGFR-3 [Fms-like tyrosine kinase 4 (Flt-4)] [2] also
[4, 12], migration of endothelial cells [4, 12], transmission belongs to the tyrosine kinase receptor family, having a
of signals which promote the endothelial cells survival, molecular weight of 195 kDa [12]. It plays an important
preventing their apoptosis [3, 8, 12, 53] and formation of role in the morphogenesis of the lymphatic vessel network
endothelial fenestrae [1, 12, 54]. In pathological processes, during embryonic development, also being involved in
VEGFR-2 is often involved in tumoral angiogenesis [33]. formation of new lymphatic vessels in the adult life [12].
 Vascular endothelial growth factor (VEGF) – key factor in normal and pathological angiogenesis 5
In this situation, lymphangiogenesis, or de novo formation and VEGFR-2 leads to the intensifying of platelet-activating
of lymph vessels from the pre-existing postcapillary factor (PAF) secretion by endothelial cells, promoting
venules (high endothelial venules), could occur in certain inflammation, increasing vascular permeability and migra-
pathological conditions, most frequently in inflammation tion of endothelial cells [33]. NP-1 can be also present in
or tumors [3, 33, 56]. VEGFR-3 has an affinity for VEGF-C other cells, such as neurons [3], smooth muscle cells [33]
and VEGF-D [3, 13, 33]. or tumor cells [3, 25, 65], being detected on the surface of
VEGFR-3 is expressed in the lymphatic endothelium tumor cells in breast cancer [3, 25], prostate, lung, pancreas
or in high endothelial venules [30], influencing the differ- or colon cancers [65], as well as in astrocytomas, glio-
entiation of lymphatic endothelial cells, tubulogenesis, blastomas, melanomas [65].
proliferation (mitogen effect), migration and survival NP-2 is expressed especially on endothelial cells in
of lymphatic endothelial cells [3, 33]. Expression of lymphatic vessels and veins [3, 64], enhancing the effects
VEGFR-3 has been observed in other cells, such as of VEGFR-3 [3], because of binding VEGF-C [2].
osteoblasts [57], macrophages [58], neural progenitors Neuropilins role in vasculogenesis has been experi-
[59], while its presence in tumor cells remains contro- mentally demonstrated on NP-1 null mice (Neuropilin-1–/–),
versial [60]. which led to death of mouse embryos through anomalies
Signaling pathways which activate lymphogenesis, of the vascular system [3].
especially during the embryonic development, are the
following: activation of MAPK extracellular signal-  Types of VEGF
regulated kinases (ERK1/2) through the PKC and Ras
pathways [24] (important pathways in cell proliferation), VEGF-A
as well as the PI3K–Akt/PKB pathway (involved especially VEGF-A, also called VEGF, is the most important
in survival of lymphatic endothelial cells) [3, 61]. and potent stimulator of angiogenesis, described for the
Expression of VEGFR-3 murine gene begins on day first time by Senger et al. as the VPF [19, 33].
8.5 of early intrauterine development, determining the VEGF-A plays an important role in vasculogenesis
differentiation of lymphatic endothelial cells and formation and neoangiogenesis, causing cell proliferation, apoptosis
of structures similar to lymph sacs, which will later undergo inhibition, increased vascular permeability, vasodilatation,
remodeling and extension, reorganizing themselves into recruitment of inflammatory cells to the injury site, etc.
a functional network of lymphatic vessels [3, 61]. The [4, 12, 16, 25, 29].
inactivation of this gene leads to mouse embryo death due VEGF is secreted not only by endothelial cells [1, 2,
to the absence of lymphatic vessels development and 12, 16], but also by other cells, in response to oxygen
massive edema [3, 62]. It is considered that, in adults, deprivation: tumor cells [1, 16], macrophages [1, 12, 16],
the onset of human hereditary primary lymphedema is platelets [16], keratinocytes [1, 16], kidney mesangial
linked to VEGFR-3 activity [62]. cells [1, 16], activated T-cells [1, 12, 16], leukocytes [2],
Binding of VEGF-C to VEGFR-3 is responsible for dendritic cells [66], retinal pigmentary epithelial cells [67],
most of the biological effects of VEGFR-3 [3]. The Müller cells in the retina [68], astrocytes [1], osteoblasts
discovery of a soluble form of VEGFR-3 (sVEGFR-3) [1], bronchial and alveolar epithelial cells [69], pericytes
and experiments on transgenic mice expressing this [70], VSMCs [71]. More recently, it has been found that
gene led to the conclusion that sVEGFR-3 inhibits the VEGF is expressed in the myofibroblasts located in the
development of lymphatic vessels and induces edema, myocardium, suggesting its implication in post-infarction
inhibiting the signals mediated by VEGF-C and VEGF-D tissue repair and remodeling [16].
[62]. Human VEGF-A contains eight exons separated by
It has been observed that tumors with lymph nodes seven introns [4] and, by alternative VEGF messenger
metastasis expressed high levels of VEGF-C or VEGF-D, ribonucleic acid (mRNA) splicing, creates different lengths
possibly by involvement of VEGFR-3 in migration of isoforms: VEGF121, VEGF145, VEGF148, VEGF162, VEGF165,
tumor cells through lymphatic vessels [24]. VEGF165b, VEGF183, VEGF189 and VEGF206 [2, 10, 12,
17, 25, 72]. These isoforms have different biological
Neuropilins
properties [17], depending on the structure and number
Neuropilins, NP-1 and NP-2, are transmembrane of amino acids contained, but also depending on their
receptors located on endothelial cells, which function as affinity for heparin and heparan-sulfate proteoglycans
co-receptors, modulating the activity of RTKs. Neuropilins (HSPGs) of the ECM [12, 32, 25]. Each isoform has a
selectively link to certain subtypes or isoforms of VEGF specific role in the differentiation and development of the
[2, 3, 63]. They have a low molecular weight of 120– vascular system [12].
135 kDa [33], and were initially identified as receptors All the isoforms have a common area, encoded by
for different types of semaphorins (class 3 semaphorins) exons 1–5 [2]. It is supposed that exons 6 and 7 (which
[3, 25, 63]. may be absent in some isoforms) are responsible for
NP-1 is expressed on endothelial cells in arteries [3, heparin affinity, while exon 8 (present in all isoforms)
25, 64] and has affinity especially for VEGF-A165 [3, ensures endothelial cells proliferation [72].
25, 33], but not for VEGF-A121 [3, 4, 25]. Some authors The most expressed VEGF-A proteins are the isoforms:
also describe affinity for PlGF-2 [25] or VEGF-B167 [33]. VEGF121, VEGF165 and VEGF189 [12, 32, 72]. Of these,
NP-1 enhances the activity of VEGFR-2 up to six times VEGF165 is the predominant isoform [12] and the most
[3, 33], influencing angiogenesis and the migration of active in vasculogenesis [10]. It does not contain amino
endothelial cells [25, 33]. The convergent effect of NP-1 acids encoded by exon 6, therefore having moderate
6 Carmen Stanca Melincovici et al.
affinity for heparin and HSPGs [10, 12, 13, 25, 32]. For the median cerebral artery in mice, followed by VEGF-B
this reason, most of VEGF165 remains bound to the cell administration, inhibited cortical neurons apoptosis and
surface [12, 13, 17, 25]. minimized the area of cerebral infarction [73].
VEGF121, without amino acids encoded by exons 6
Placenta growth factor
and 7, has no affinity for heparin or HSPGs, existing in
a free form [4, 10, 17, 25]. Placenta growth factor (PlGF) is also a growth factor
VEGF189 and VEGF206 are the longest isoforms, with of the VEGF family and was firstly identified in human
a strong affinity for heparin, being totally bound to ECM placental tissues [2, 17, 74–77]; it is implicated in the
structures and less on cell surface [12, 24, 25, 32]. It is trophoblast growth and differentiation, trophoblast invasion
considered that, for this reason, VEGF189 and VEGF206 and blastocyst implantation [2, 75–78]. Subsequently, PlGF
are less active than VEGF121 and VEGF165 [25]. was found in the uterine mucosa: in maternal stromal
Proteolytic enzymes (e.g., plasmin, urokinase) can decidual cells [74], uterine glandular and luminal epithelium
cleave the bond between VEGF and ECM elements, [75], glandular secretions, predecidual stromal cells in
consequently VEGF being released in a free, soluble form, the secretory phase of the uterine cycle [75], as well as
very active in the ECM [4, 12, 17, 25]. in the heart [2, 76], lungs [2, 76], skin (keratinocytes,
VEGF145, VEGF183, VEGF162 and VEGF165b isoforms dermal vessels endothelium) [76, 79].
are much less common; in particular, VEGF165b was found By alternative splicing of PlGF gene, four isoforms
to have an anti-angiogenic effect, inhibiting VEGF-A165 result: PlGF-1 (PlGF131), PlGF-2 (PlGF152), PlGF-3
[2, 4, 10, 12]. Other isoforms of the type VEGF-AXXXb (PlGF203) and PlGF-4 (PlGF224) [2, 76], which differ in
have been later described, e.g., VEGF-A121b [60], VEGF- molecular structure and biological properties. All isoforms
A183b [60], VEGF-A145b [60] and VEGF-A189b [66]; in vivo have affinity for VEGFR-1 [2, 17, 24], but PlGF-2 also
and in vitro studies have evidenced their anti-angiogenic binds to NP-1, NP-2 and heparin in the ECM [2, 12, 17,
role, especially for VEGF-A165b and VEGF-A121b [10]. 24, 76]. It has no direct mitogenic effect and does not
The strong pro-angiogenic effect of VEGF-A on increase vascular permeability [2], but, in pathological
embryonic vasculogenesis has been revealed by experi- conditions, it binds to VEGFR-1, displaces VEGF-A from
ments with heterozygotic VEGF-A gene knockout mice VEGFR-1 and allows the binding of VEGF-A to VEGFR-2,
(VEGF-A+/– mice) who died on days 10 or 11 of gestation, indirectly enhancing the effects of VEGF-A (increased
vascular permeability, cell migration and proliferation,
due to insufficient development of the vascular system
etc.) [2, 4, 17, 78, 80].
[1, 24].
To conclude, VEGFR-1 activation by binding PlGF
VEGF-A binds to VEGFR-1 and VEGFR-2 [1, 2, 24],
induces the indirect activation of VEGFR-2 [38, 78].
having a 10 times higher affinity for VEGFR-1 [12].
PlGF does not play an essential role in embryonic
VEGF165 binds to NP-1, NP-2 [2, 12, 24], as well as HSPGs
vasculogenesis, intervening rather in pathological angio-
of ECM [2, 24], while VEGF145 binds to NP-2 [12]. genesis (ischemia, inflammation, cancer), by a synergism
VEGF-B with VEGF-A [2, 12, 24, 78].
VEGF-B, discovered in 1995, is expressed in early VEGF-C
embryonic life; in adults, it is found in various tissues, VEGF-C is abundantly expressed in the embryonic
mainly in the myocardium, skeletal muscle and pancreas tissues, where the development of lymphatic vessels is
[12, 26, 33]. initiated (the jugular, perimetanephric, axillary areas)
Alternative gene splicing gives rise to two isoforms: [33], while in adults it is expressed in the heart, ovary,
▪ VEGF-B167, the predominant isoform, has a molecular placenta, intestine, thyroid, etc. [33].
weight of 21 kDa and binds to the cell surface or ECM It has a high affinity for VEGFR-3, which is expressed
elements. VEGF-B167 has affinity for VEGFR-1 [24, 26, on endothelial lymphatic cells, promoting lymphangio-
33] and interacts easily with NP-1 [26, 33]. genesis [24]. Certain authors also described a weak affinity
▪ VEGF-B186, with a molecular weight of 32 kDa, is for VEGFR-2, which explains its poor implication in
found in a free form, having affinity for VEGFR-1 [24, angiogenesis [2, 24]. Experimentally, in homozygotic
26, 33], and only if it undergoes proteolytic cleavage, it VEGF-C–/– mice, the development of lymphatic vessels
could interact with NP-1 [26, 33]. is altered since initial phases, the consequence being the
VEGF-B contributes to the development of the cardio- accumulation of interstitial fluid in the tissues, which
vascular system and the formation of the myocardium in may be sometimes lethal [24].
embryonic stages [12]. The role of VEGF-B in vasculo- Overexpression of VEGF-C correlates with a well-
genesis is not essential, VEGF-B–/– homozygotic mice developed network of lymphatic vessels, and the genic
being viable at birth, with only moderate defects of the transfer of human VEGF-C (phVEGF-C) could represent
cardiovascular system [24]. a new therapeutic strategy for the patients with lymph-
Current information on the role of VEGF-B as angio- edema [81].
genic factors in adult diseases is extremely controversial. Recent data suggests that VEGF-C also binds to NP-2,
At present, it is considered that, in adults, VEGF-B is more which acts as co-receptor for VEGFR-3, enhancing its
implicated in the survival of certain cell types, such as: activity [2, 82].
smooth muscle cells, endothelial cells, pericytes, neurons
VEGF-D
(motor neurons in the spinal cord, cortex or retina),
cardiomyocytes, rather than in angiogenesis [24, 73]. VEGF-D presents similar properties to VEGF-C [33],
Several experiments have revealed that the obstruction of also having a central role in lymphangiogenesis, but not
 Vascular endothelial growth factor (VEGF) – key factor in normal and pathological angiogenesis 7
an essential role in angiogenesis [2, 24, 33]. In the umbilical vein endothelial cells (HUVECs)], as well as in
embryo, it has high levels in the lung, where it is involved syncytiotrophoblasts, regulating trophoblast invasion and
in the development of lymphatic vessels [33]; in adults, formation of the maternal lacunae, during the placental
it is found in the heart, lungs, skeletal muscles, small growth [88, 91].
intestine [33]. It has affinity for VEGFR-3 and also for Very high serum levels of EG-VEGF were reported
NP-2 [82]. Experimentally, the VEGF-D gene inactivation in preeclampsia, being associated with early pregnancy
produces only a moderate atrophy of the lymphatic circu- loss [88, 90, 92].
lation, without other significant changes [2]. EG-VEGF binds to two receptor types, called pro-
kineticin receptor 1 (PROKR1) and 2 (PROKR2), which
VEGF-E (viral VEGF)
are intensely expressed in the first trimester of pregnancy
Orf virus is a parapoxvirus causing infections in goats [88, 91]. Several studies demonstrated that EG-VEGF,
and sheep, which may be transmitted to humans, producing when binding to PROKR1 mediated the proangiogenic
skin lesions of pustulous dermatitis type [24, 83], charac- effects, while PROKR2 mediates the increase in vascular
terized by local edema, vasodilatation, keratinocytes permeability [88].
and endothelial cells proliferation, as well as abundant
inflammatory infiltrate [33].  Stages of angiogenesis
VEGF-E contains viral proteins from different strains
of the Orf virus: VEGF-ENZ-2 (viral strain NZ-2) [12, 84], Angiogenesis, either in its early stages (vasculogenesis),
or when it starts from pre-existing vessels (neoangio-
VEGF-ENZ-7 (viral strain NZ-7) [12, 85], VEGF-ENZ-10
genesis), takes place under the synergistic activity of
(viral strain NZ-10) [12, 86], VEGF-ED1701 (viral strain
growth factors, VEGF playing a very important role [5].
D1701) [12, 87] and also VEGF-EVR 634 (viral strain VR
During development, VEGF induces the migration of
634 of pseudocowpox virus) [12, 86].
hemangioblasts into the blood islands and their differ-
The gene encoding VEGF-E protein (from viral strains
entiation into endothelial cells [4, 12, 25, 53]. After birth,
D1701, NZ-2 and NZ-7) is not found in the human genome
it ensures the proliferation and migration of endothelial
[83], but after viral infection, it could be incorporated in
cells [12, 25], induces tubulogenesis, increases vascular
the genome of the affected individuals, acting like a pro-
permeability [4, 12] and promotes endothelial cells survival
angiogenic factor [24].
(inhibiting apoptosis), etc. [5, 12, 16, 25, 53]. VEGF
VEGF-E significantly increases vascular permeability, also induces the appearance of fenestrations between the
similar to VEGF-A165, and also has mitogenic effect on endothelial cells of capillaries and venules [1, 12, 90], by
endothelial cells [85]. It has specific affinity for VEGFR-2, altering proteins in the intercellular junctions (occludin,
not for VEGFR-1 and VEGFR-3 [2, 12, 33, 83]. VE-cadherin/β-catenin), therefore increasing vascular
EG-VEGF permeability and facilitating endothelial cells migration,
vascular extravasation and metastasis [12, 25]. This
EG-VEGF, also called prokineticin 1 (PK1) [88], was process is also enabled by the secretion of matrix metallo-
described and characterized by LeCouter et al. [89]. It is proteinases (MMP-9, MMP-3, MMP-2), which decompose
located in the steroid hormone-producing endocrine glands the ECM and enhance cell migration [16, 33].
and placental tissues, where it is involved in physiological In pathological angiogenesis, VEGF promotes the
and pathological angiogenesis [18]. mobilization of inflammatory cells (macrophages, granulo-
EG-VEGF, expressed in the testis, adrenal gland, ovary, cytes, etc.) to the injury site, maintaining the local
placental tissues [18, 88–91], induces proliferation, growth, inflammatory process and inducing the synthesis of pro-
migration and survival of endothelial cells, tubulogenesis, angiogenic factors by endothelial cells [5, 93], platelets
increased vascular permeability and enables paracellular [93, 94, 95], smooth muscle cells [71, 93, 96, 97], inflam-
transport [18, 88–91]. matory cells [39–43, 98], fibroblasts [5, 93, 99] and tumor
Interestingly, the angiogenic effect of EG-VEGF is cells [95, 100].
exerted only on the endothelial cells located in the The major trigger inducing angiogenesis is hypoxia,
mentioned glands [89], with no effect on the endothelial but other factors may also be responsible: hypoglycemia,
cells with other locations, for example in cerebral vessels, hypertension, low pH, mechanical stress, chronic inflam-
aorta and cornea [90, 91]. mation, etc. [1, 8]. Hypoxic tissues release the hypoxia-
In the placenta, it is present in the fetal capillaries inducible factor-1 (HIF-1) [4, 99, 101, 102], which activates
inside the chorionic villi [human placental microvascular the transcription of pro-angiogenic factors, such as: VEGF
endothelial cells (HPECs)], and is intensely expressed [8, 99, 101, 103], basic fibroblast growth factor (bFGF,
in the first trimester of pregnancy (weeks 8–10) [91], FGF-2) [5, 95, 99, 103], PDGF-β [5, 93, 95], angio-
indicating its role in placental vessels development, but poietin-1 (Ang-1), angiopoietin-2 (Ang-2) [1, 8], TGF-β
also in materno–fetal exchanges, by increasing vascular [5], TNF-α, etc. [5, 95].
permeability and promoting paracellular transport [88, 91]. bFGF or FGF-2 was the first pro-angiogenic factor
The increased vascular permeability is because EG- described, with an important role in pathological angio-
VEGF induces the formation of fenestrae between fetal genesis, having a mitogenic effect on endothelial cells,
endothelial cells (HPECs); endothelial cells being normally increasing vascular permeability, being involved in
joined by occlusive junctions or adherens junctions [88, tubulogenesis, proteolytic decomposition of ECM [5,
91]. 104], etc. It also plays a role in fibroblast proliferation,
EG-VEGF was also found in endothelial cells that thus favoring granulation tissue formation and wound
line the umbilical blood vessels [macrovascular human healing [5, 104]. VEGF expression on endothelial cells
8 Carmen Stanca Melincovici et al.
could be stimulated by bFGF, both growth factors having vessels [8, 70, 101]. Initially, the newly formed vascular
a synergistic pro-angiogenic effect [5, 103, 104]. tubes do not have a lumen [8, 70].
Angiopoietins (Ang-1 and Ang-2) are pro-angiogenic The process is facilitated by the decomposition of
and vascular remodeling growth factors [5], both binding ECM, due to secretion and activation of matrix metallo-
to the same receptor, the Tie-2 receptor [5]. In normal adult proteinases (MMP-2, MMP-3, MMP-9) [16, 33] and
tissues, Ang-1 maintains the vessels integrity, increasing inhibition of tissue inhibitor of metalloproteinases-2
endothelial cells survival (antiapoptotic effect) and also (TIMP-2), induced by Ang-1 [8].
inhibits Ang-2 expression [5, 100]. Ang-2 may have a An important role in angiogenesis is played by
pro-angiogenic or anti-angiogenic effect, depending on membrane type-1 matrix metalloproteinase (MT1-MMP),
the presence of VEGF [5, 100, 103]. In the absence of a more recently described membrane protein group of
VEGF, Ang-2 promotes endothelial cells apoptosis, vessel metalloproteinases category, anchored on the cells surface,
regression and inhibits angiogenesis [100]. On the other with a lytic effect on the ECM molecules; it regulates
hand, in the presence of VEGF and HIF-1, Ang-2 acts as the expression of pro-angiogenic factors (e.g., VEGF) and
antagonist of Ang-1, destabilizes the interaction between controls cell migration [70, 106]. MT1-MMP may be
endothelial cells and the supporting cells, promoting expressed on endothelial cells or mural cells (pericytes,
vessel instability and formation of disorganized and VSMCs) [70, 107, 108], being involved in cell migration,
immature new blood vessels [5, 100]; it also induces tubulogenesis and cellular invasion [108]. At a more
the proliferation and migration of endothelial cells, thus advanced stage of neoangiogenesis, MT1-MMP may
favoring tissue neovascularization and pathological angio- activate the PDGF-β/PDGFR-β pathway, controlling the
genesis [5, 100, 103]. migration of pericytes and VSMCs and stabilization of
the newly formed vessels [106].
Under hypoxic conditions, the injured tissues and
Subsequently, during physiological angiogenesis, in
endothelial cells will release NO, which promotes vaso-
order to ensure stability of the new vessels, supporting
dilatation [70].
cells are recruited (pericytes in small vessels, VSMCs in
Increased VEGF secretion is also induced by other
large vessels) and cell fusion occurs. In a final stage, a
growth factors through paracrine mechanism [33, 104].
new basal membrane will be formed around the new
The integrity of blood vessels depends on the inter- vessels [8].
action between endothelial cells and other cells in the In pathological angiogenesis, the cells involved (ECs,
vascular wall, called supporting or mural cells (e.g., macrophages, T-lymphocytes, platelets, VSMCs, etc.)
pericytes, VSMCs) [11, 99, 105]. increase the release of proinflammatory cytokines [93, 105].
Pericytes (adventitial or perivascular cells) are The new vascular networks are anarchic, with tortuous,
associated with endothelial cells in small blood vessels dilated, abnormally structured vessels, with aberrant ECs
[70], both cell types being included in the same basal and weakly attached or even absent pericytes [8].
membrane [101]. Normally, pericytes ensure the support
for the endothelial cells, stabilize small vessels structure  Anti-VEGF therapies – therapeutic
and monitor endothelial cells survival [70, 99, 101, 105].
implications
Pericytes communicate with endothelial cells through gap
junctions [105], their activation promoting the proliferation Nowadays, a large number of studies aim to elucidate
of endothelial cells. Activated pericytes exhibit a great the role of anti-VEGF therapies in various diseases,
plasticity; they can differentiate into smooth muscle cells, especially cancer, ischemia, inflammation (e.g., rheumatoid
fibroblasts and adipocytes [70]. arthritis) or degenerative diseases.
The blood vessels formation includes several stages. The purpose of anti-VEGF medications is to inhibit
The initial stage starts with vasodilatation and alte- angiogenesis, either by blocking VEGF itself or its receptors
ration of the vascular structure, as a result of the pro- (VEGFRs).
angiogenic factors secreted by injured tissues (e.g., NO, A series of anti-VEGF agents have been approved by
VEGF, bFGF or FGF-2, PDGF-β, Ang-2, etc.), which United States Food and Drug Administration (US FDA)
act by both paracrine and autocrine mechanisms on the and are currently used in the treatment of certain tumor
endothelial and vascular mural cells [70, 103]. types or eye diseases.
The PDGF-β/PDGFR-β signaling pathway is very Since 2004, Bevacizumab/Avastin has been approved
important in pericyte recruitment and new blood vessel by the FDA and used as anti-VEGF therapy in renal [24],
formation and stabilization. PDGF-β is secreted by lung [109, 110, 111], colon [109, 112, 113], esophago-
endothelial cells and PDGFR-β is expressed on vascular gastric [114, 115], breast [3, 24, 116], cervical [117],
mural cells and endothelial cells. and ovarian cancer [118, 119], usually associated with
Under the action of these pro-angiogenic factors, chemotherapy. Other therapeutic strategies attempt to
endothelial cells (ECs) and mural cells are activated [70, block VEGFRs using drugs such as: Sorafenib or Sunitinib,
99], the effect being the proliferation of endothelial cells tested in phase III clinical trials as monotherapies or in
and their migration towards the ECM [70], where tubulo- association with chemotherapy for renal cancer [3, 24,
genesis will be initiated [8, 70]. VEGF released from the 109], gastrointestinal stromal tumors [3, 109], lung tumors
injured cells (pericytes, endothelial cells) will increase (non-small cell type) [109], breast tumors [109], colon
vascular permeability and allow extravasation of plasma [109], esophago-gastric adenocarcinoma [120] or hepato-
proteins into the ECM; where these proteins will serve as cellular carcinoma [24, 109].
provisional matrix for the migration of ECs and pericytes, Anti-angiogenic therapy has become very important
initiation of tubulogenesis and formation of new blood in eye diseases, drugs such as Ranibizumab, Pegaptanib/
 Vascular endothelial growth factor (VEGF) – key factor in normal and pathological angiogenesis 9
Macugen or Aflibercept being approved by the FDA and vement in overall survival (OS) and progression-free
successfully used for age-related macular degeneration survival (PFS), but these results were not always
[3], diabetic retinopathy (DR) and diabetic macular edema statistically significant (Table 1). This is probably because
(DME) [121, 122]. ECs have different locations and respond differently to
In ischemic processes, studies in large clinical trials these therapies, depending on the local microenvironment
attempt to stimulate angiogenesis by gene transfer of [11]. Additionally, long-term administration of anti-VEGF
pro-angiogenic molecules [3, 123]. therapy induced a decrease in efficacy and led to onset of
Even so, the use of anti-VEGF or anti-VEGFRs therapy therapy resistance [24]. Moreover, various negative side
in clinical trials did not always yield the expected results. effects have been described, including: hypertension,
Patients treated with anti-VEGF or anti-VEGFRs agents, proteinuria, renal dysfunctions, hemorrhage, thrombosis,
alone or associated with chemotherapy showed an impro- arrhythmia, etc. [24, 108–120, 124].
Table 1 – Clinical trials on anti-VEGF agents in cancer therapy
No. of
Cancer Median PFS Median OS
Reference patients Intervention P-value P-value
type [months] [months]
(n)
Stage IV
Zhao et al. Irinotecan (FOLFIRI) + Bevacizumab + Not Not
colorectal 122 PFS: 7.1 OS: 13.5
[112] Erlotinib reported reported
cancer
Stage IIIB/IV
Yamasaki Carboplatin + Paclitaxel + Not Not
non-small cell 33 PFS: 8.4 OS: 22.2
et al. [110] Bevacizumab reported reported
lung cancer
Arm A (n=103) Arm A Arm A
Extensive
Tiseo et al. Cisplatin + Etoposide PFS: 5.7 OS: 8.9
small-cell 204 0.03 0.011
[111] Arm B (n=101) Arm B Arm B
lung cancer
Cisplatin + Etoposide + Bevacizumab PFS: 6.7 OS: 9.8
Group I
Group I
Advanced Cisplatin + Paclitaxel or
Tewari et al. Not Not OS: 13.3
cervical 452 Topotecan + Paclitaxel 0.004
[117] reported reported
cancer Group II Group II
The same therapy + Bevacizumab OS: 17
FOLFIRI (Irinotecan + 5-Fluorouracil + FOLFIRI FOLFIRI
Metastatic
Cao et al. Leucovorin) PFS: 5.1 Not OS: 11.3 Not
colorectal 142
[113] FOLFIRI B reported FOLFIRI B reported
cancer FOLFIRI B (FOLFIRI + Bevacizumab)
PFS: 8.5 OS: 15.2
Group 1
Group 1 Group 1
Bevacizumab + Fluoropyrimidine–
Advanced PFS: 6.7 OS: 12.1
Ohtsu et al. Cisplatin
gastric 774 0.037 0.1
[114] Group 2
cancer Group 2 Group 2
Placebo + Fluoropyrimidine–
PFS: 5.3 OS: 10.1
Cisplatin
Group 1
Group 1 (n=764) OS: 44.6
0.85
Carboplatin + Paclitaxel Group 2
Newly OS: 45.5
Oza et al. diagnosed Not Not High-risk
1528
[118] ovarian reported reported subgroup
cancer Group 2 (n=764) Group 1
0.03
Chemotherapy + Bevacizumab OS: 34.5
Group 2
OS: 39.3
Ovarian Group 1 Group 1 Group 1
Perren et al. cancer Carboplatin + Paclitaxel PFS: 22.4 OS: 28.8 Not
1528 0.04
[119] (70% stage Group 2 Group 2 Group 2 reported
IIIC or IV) Chemotherapy + Bevacizumab PFS: 24.1 OS: 36.6
Group 1 (n=247) Group 1
Metastatic Single-agent chemotherapy PFS: 4.2
von Minckwitz Not Not
breast 494 Group 2 (n=247) 0.0068
et al. [116] Group 2 reported reported
cancer Single-agent chemotherapy +
PFS: 6.3
Bevacizumab
Advanced Group 1 Group 1
OS: 8.9
Moehler et al. esophago- FOLFIRI + Placebo PFS: 3.3
91 0.66 0.21
[120] gastric Group 2 Group 2
OS: 10.4
cancer FOLFIRI + Sunitinib PFS: 3.5
PFS: Progression-free survival; OS: Overall survival; FOLFIRI: Chemotherapy regimen – Folinic acid (Leucovorin) + 5-Fluorouracil (5-FU) +
Irinotecan (Camptosar).

 Conclusions genesis is involved in the progression of pathological

conditions, in the future more complex studies will be
The data presented in this article aimed to emphasize conducted, in large clinical trials, in order to identify
several important aspects regarding VEGF and its impli- targeted anti-angiogenic therapies with higher efficiency,
cations in the complex process of angiogenesis; but these long-term administration and minimal toxicity.
data are not exhaustive. Taking into account that angio-
10 Carmen Stanca Melincovici et al.
Conflict of interests [22] Ribatti D. Judah Folkman, a pioneer in the study of angio-
The authors declare that they have no conflict of genesis. Angiogenesis, 2008, 11(1):3–10.
[23] Ribatti D. Napoleone Ferrara and the saga of vascular
interests. endothelial growth factor. Endothelium, 2008, 15(1):1–8.
[24] Shibuya M. Vascular endothelial growth factor (VEGF) and its
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Corresponding author
Carina Mihu, Medical Student, Faculty of Medicine, “Iuliu Haţieganu” University of Medicine and Pharmacy, 4–6
Louis Pasteur Street, 400349 Cluj-Napoca, Romania; Phone +40750–774 404, e-mail: carina.mihu@umfcluj.ro

Received: November 22, 2017

Accepted: August 2, 2018