25/07/2025
Mechanisms of Drug Resistance in Anti-Angiogenic Therapy👇
✅Anti-angiogenic therapy, designed to target and inhibit the formation of new blood vessels in tumors, faces significant challenges due to the development of drug resistance. This resistance can be either intrinsic (where patients are non-responsive from the beginning) or acquired (where initially responsive patients eventually stop benefiting from the treatment). Several mechanisms contribute to both types of resistance:
✅1. Compensatory Upregulation of Alternative Pro-Angiogenic Factors
After prolonged exposure to anti-angiogenic therapy, tumors often adapt by increasing the production of alternative pro-angiogenic factors. These factors can bypass the blockade of the primary angiogenic pathways. Key factors involved include:
bFGF (basic Fibroblast Growth Factor)
PDGF (Platelet-Derived Growth Factor)
PlGF (Placental Growth Factor)
These molecules promote angiogenesis by stimulating the formation of new blood vessels, allowing tumors to continue growing and spreading even in the presence of anti-angiogenic drugs.
✅2. Recruitment of Bone Marrow-Derived Endothelial Progenitor Cells (EPCs)
In response to anti-angiogenic therapy, tumors can recruit bone marrow-derived endothelial progenitor cells (EPCs) to support neovascularization. These progenitor cells are capable of differentiating into endothelial cells, contributing to the formation of new blood vessels and enhancing tumor vascularization despite the inhibition of traditional angiogenic pathways.
Mechanism: EPCs migrate to the tumor site, bypassing the need for endothelial cell proliferation from pre-existing vessels.
✅3. Increased Pericyte Coverage
The presence of pericytes, which are contractile cells that wrap around endothelial cells, is essential for maintaining the stability and integrity of blood vessels. In response to anti-angiogenic therapy, tumors may increase pericyte coverage around blood vessels, thereby enhancing the stability of newly formed vasculature. This helps protect blood vessels from the effects of therapy and prevents vessel regression.
Effect: Stable vessels are less likely to collapse under the influence of anti-angiogenic drugs, promoting continued blood supply to the tumor.
✅4. Autophagy and Tumor Survival in Hypoxic Environments
Autophagy, a cellular process by which cells degrade and recycle their own components, is a critical survival mechanism for tumor cells, especially in hypoxic conditions (low oxygen levels). Under anti-angiogenic therapy, the tumor microenvironment becomes more hypoxic due to reduced blood flow. In response, tumor cells may increase autophagy to adapt and survive in the oxygen-deprived environment, thus contributing to therapy resistance.
Effect: Autophagy allows tumor cells to survive under adverse conditions where normal cells would perish, making them less susceptible to anti-angiogenic treatments.
✅5. Increased Tumor Invasiveness and Metastasis
As tumors progress, they may increase their invasiveness, allowing tumor cells to invade distant tissues and metastasize through the blood and lymphatic circulation. This process is often facilitated by the acquisition of drug resistance, enabling tumor cells to escape localized inhibition and spread to other areas.
Effect: Anti-angiogenic therapy may not stop the metastatic spread, as tumor cells can bypass vascular dependency by traveling through alternate routes like the lymphatic system or blood vessels.
✅6. Genetic Mutations
Genetic mutations in key signaling pathways involved in angiogenesis and tumor growth can render the tumor resistant to anti-angiogenic therapies. For example, mutations in VEGFR (vascular endothelial growth factor receptor) or downstream signaling molecules may prevent the drug from effectively blocking angiogenesis.
Effect: Tumors with genetic alterations in angiogenic pathways can continue to produce and utilize alternative angiogenesis mechanisms even in the presence of targeted therapies.
✅7. Vessel Mimicry, Vessel Co-Option, and Intussusception
Vessel Mimicry: Tumor cells themselves can form vessel-like structures around existing blood vessels to provide nutrient and oxygen supply. This process bypasses the need for normal angiogenesis and enables the tumor to maintain its blood supply.
Vessel Co-option: Tumor cells may hijack existing normal blood vessels, using them for their own growth and survival, even in the presence of anti-angiogenic drugs.
Intussusception: This process involves the splitting of existing blood vessels into two, often through endothelial cell reorganization. It allows for the formation of new vessels without the need for typical endothelial sprouting.
Effect: These alternative mechanisms of vascularization help tumors overcome anti-angiogenic treatments by creating new blood vessels that are not reliant on the blocked angiogenic pathways.
💡Liu, ZL., Chen, HH., Zheng, LL. et al. Angiogenic signaling pathways and anti-angiogenic therapy for cancer. Sig Transduct Target Ther 8, 198 (2023).