The efficacy of angiogenesis inhibitors in cancer is limited by resistance mechanisms that are poorly understood. Notably, instead of through the induction of angiogenesis, tumor vascularization can occur through the nonangiogenic mechanism of vessel co-option. Here we show that vessel co-option is associated with a poor response to the anti-angiogenic agent bevacizumab in patients with colorectal cancer liver metastases. Moreover, we find that vessel co-option is also prevalent in human breast cancer liver metastases, a setting in which results with anti-angiogenic therapy have been disappointing. In preclinical mechanistic studies, we found that cancer cell motility mediated by the actin-related protein 2/3 complex (Arp2/3) is required for vessel co-option in liver metastases in vivo and that, in this setting, combined inhibition of angiogenesis and vessel co-option is more effective than the inhibition of angiogenesis alone. Vessel co-option is therefore a clinically relevant mechanism of resistance to anti-angiogenic therapy and combined inhibition of angiogenesis and vessel co-option might be a warranted therapeutic strategy.

Access optionsAccess options

Rent or Buy article

Get time limited or full article access on ReadCube.


All prices are NET prices.


  1. 1.

    , , & Discovery and development of bevacizumab, an anti-VEGF antibody for treating cancer. Nat. Rev. Drug Discov. 3, 391–400 (2004).

  2. 2.

    Tumor angiogenesis. N. Engl. J. Med. 358, 2039–2049 (2008).

  3. 3.

    et al. Bevacizumab plus irinotecan, fluorouracil, and leucovorin for metastatic colorectal cancer. N. Engl. J. Med. 350, 2335–2342 (2004).

  4. 4.

    et al. Bevacizumab plus capecitabine versus capecitabine alone in elderly patients with previously untreated metastatic colorectal cancer (AVEX): an open-label, randomised phase 3 trial. Lancet Oncol. 14, 1077–1085 (2013).

  5. 5.

    & Antiangiogenic therapy: impact on invasion, disease progression, and metastasis. Nat. Rev. Clin. Oncol. 8, 210–221 (2011).

  6. 6.

    & Anti-angiogenic therapy for cancer: current progress, unresolved questions and future directions. Angiogenesis 17, 471–494 (2014).

  7. 7.

    et al. Angiogenesis in primary lung cancer and lung secondaries. Eur. J. Cancer 32A, 2494–2500 (1996).

  8. 8.

    et al. Liver metastases from colorectal adenocarcinomas grow in three patterns with different angiogenesis and desmoplasia. J. Pathol. 195, 336–342 (2001).

  9. 9.

    , , , & Alternative vascularization mechanisms in cancer: Pathology and therapeutic implications. Am. J. Pathol. 170, 1–15 (2007).

  10. 10.

    et al. Vessel co-option in primary human tumors and metastases: an obstacle to effective anti-angiogenic treatment? Cancer Med. 2, 427–436 (2013).

  11. 11.

    , , & Antiangiogenic therapy in oncology: current status and future directions. Lancet 388, 518–529 (2016).

  12. 12.

    et al. Selection for hepatic resection of colorectal liver metastases: expert consensus statement. HPB (Oxford) 15, 91–103 (2013).

  13. 13.

    et al. The multifaceted role of the microenvironment in liver metastasis: biology and clinical implications. Cancer Res. 73, 2031–2043 (2013).

  14. 14.

    et al. Breast adenocarcinoma liver metastases, in contrast to colorectal cancer liver metastases, display a non-angiogenic growth pattern that preserves the stroma and lacks hypoxia. Br. J. Cancer 90, 1429–1436 (2004).

  15. 15.

    et al. Bevacizumab, capecitabine, and oxaliplatin as neoadjuvant therapy for patients with potentially curable metastatic colorectal cancer. J. Clin. Oncol. 26, 1830–1835 (2008).

  16. 16.

    et al. Perioperative chemotherapy with bevacizumab and liver resection for colorectal cancer liver metastasis. HPB 12, 37–42 (2010).

  17. 17.

    et al. A multicentre study of capecitabine, oxaliplatin plus bevacizumab as perioperative treatment of patients with poor-risk colorectal liver-only metastases not selected for upfront resection. Ann. Oncol. 22, 2042–2048 (2011).

  18. 18.

    et al. Association of computed tomography morphologic criteria with pathologic response and survival in patients treated with bevacizumab for colorectal liver metastases. J. Am. Med. Assoc. 302, 2338–2344 (2009).

  19. 19.

    et al. Optimal morphologic response to preoperative chemotherapy: an alternate outcome end point before resection of hepatic colorectal metastases. J. Clin. Oncol. 30, 4566–4572 (2012).

  20. 20.

    et al. CT findings of response and recurrence, independent of change in tumor size, in colorectal liver metastasis treated with bevacizumab. AJR Am. J. Roentgenol. 197, W1060–W1066 (2011).

  21. 21.

    et al. The histological growth pattern of colorectal cancer liver metastases has prognostic value. Clin. Exp. Metastasis 29, 541–549 (2012).

  22. 22.

    , & Nucleating actin for invasion. Nat. Rev. Cancer 11, 177–187 (2011).

  23. 23.

    et al. Involvement of Arp2/3 complex in the process of colorectal carcinogenesis. Mod. Pathol. 17, 461–467 (2004).

  24. 24.

    et al. Correlation between liver metastasis of the colocalization of actin-related protein 2 and 3 complex and WAVE2 in colorectal carcinoma. Cancer Sci. 98, 992–999 (2007).

  25. 25.

    et al. Synergistic activity of the SRC family kinase inhibitor dasatinib and oxaliplatin in colon carcinoma cells is mediated by oxidative stress. Cancer Res. 69, 3842–3849 (2009).

  26. 26.

    et al. The potential of 5-fluorocytosine/cytosine deaminase enzyme prodrug gene therapy in an intrahepatic colon cancer model. Gene Ther. 9, 844–849 (2002).

  27. 27.

    et al. Therapeutic targeting of Id2 reduces growth of human colorectal carcinoma in the murine liver. Oncogene 27, 7192–7200 (2008).

  28. 28.

    et al. Cross-species vascular endothelial growth factor (VEGF)-blocking antibodies completely inhibit the growth of human tumor xenografts and measure the contribution of stromal VEGF. J. Biol. Chem. 281, 951–961 (2006).

  29. 29.

    et al. Randomized phase III trial of capecitabine compared with bevacizumab plus capecitabine in patients with previously treated metastatic breast cancer. J. Clin. Oncol. 23, 792–799 (2005).

  30. 30.

    et al. Paclitaxel plus bevacizumab versus paclitaxel alone for metastatic breast cancer. N. Engl. J. Med. 357, 2666–2676 (2007).

  31. 31.

    et al. Phase III study of bevacizumab plus docetaxel compared with placebo plus docetaxel for the first-line treatment of human epidermal growth factor receptor 2-negative metastatic breast cancer. J. Clin. Oncol. 28, 3239–3247 (2010).

  32. 32.

    et al. RIBBON-1: randomized, double-blind, placebo-controlled, phase III trial of chemotherapy with or without bevacizumab for first-line treatment of human epidermal growth factor receptor 2-negative, locally recurrent or metastatic breast cancer. J. Clin. Oncol. 29, 1252–1260 (2011).

  33. 33.

    et al. RIBBON-2: a randomized, double-blind, placebo-controlled, phase III trial evaluating the efficacy and safety of bevacizumab in combination with chemotherapy for second-line treatment of human epidermal growth factor receptor 2-negative metastatic breast cancer. J. Clin. Oncol. 29, 4286–4293 (2011).

  34. 34.

    , & Angiogenesis is redundant for tumour growth in lymph node metastases. Histopathology 38, 466–470 (2001).

  35. 35.

    et al. Investigation of the lack of angiogenesis in the formation of lymph node metastases. J. Natl. Cancer Inst. 107, djv155 (2015).

  36. 36.

    et al. Cutaneous breast cancer deposits show distinct growth patterns with different degrees of angiogenesis, hypoxia and fibrin deposition. Histopathology 42, 530–540 (2003).

  37. 37.

    Breast Cancer Progression Working Party. Evidence for novel nonangiogenic pathway in breast-cancer metastasis. Lancet 355, 1787–1788 (2000).

  38. 38.

    et al. Mechanism of tumour vascularization in experimental lung metastases. J. Pathol. 235, 384–396 (2015).

  39. 39.

    , , & The vascular basement membrane as “soil” in brain metastasis. PLoS One 4, e5857 (2009).

  40. 40.

    et al. Lack of angiogenesis in experimental brain metastases. J. Neuropathol. Exp. Neurol. 70, 979–991 (2011).

  41. 41.

    et al. Serpins promote cancer cell survival and vascular co-option in brain metastasis. Cell 156, 1002–1016 (2014).

  42. 42.

    et al. Biomarkers of response and resistance to antiangiogenic therapy. Nat. Rev. Clin. Oncol. 6, 327–338 (2009).

  43. 43.

    , , & Perilesional enhancement of hepatic metastases: correlation between MR imaging and histopathologic findings-initial observations. Radiology 215, 89–94 (2000).

  44. 44.

    et al. Co-option of liver vessels and not sprouting angiogenesis drives acquired sorafenib resistance in hepatocellular carcinoma. J. Natl. Cancer Inst. 108, djw030 (2016).

  45. 45.

    et al. Anti-VEGF antibody treatment of glioblastoma prolongs survival but results in increased vascular cooption. Neoplasia 2, 306–314 (2000).

  46. 46.

    et al. Vascular endothelial growth factor-A(165) induces progression of melanoma brain metastases without induction of sprouting angiogenesis. Cancer Res. 62, 341–345 (2002).

  47. 47.

    et al. Antiangiogenic therapy of cerebral melanoma metastases results in sustained tumor progression via vessel co-option. Clin. Cancer Res. 10, 6222–6230 (2004).

  48. 48.

    et al. Antiangiogenic therapy elicits malignant progression of tumors to increased local invasion and distant metastasis. Cancer Cell 15, 220–231 (2009).

  49. 49.

    et al. Tumor invasion after treatment of glioblastoma with bevacizumab: radiographic and pathologic correlation in humans and mice. Neuro-oncol. 12, 233–242 (2010).

  50. 50.

    et al. VEGF inhibits tumor cell invasion and mesenchymal transition through a MET/VEGFR2 complex. Cancer Cell 22, 21–35 (2012).

  51. 51.

    et al. Suppression of tumor invasion and metastasis by concurrent inhibition of c-Met and VEGF signaling in pancreatic neuroendocrine tumors. Cancer Discov. 2, 270–287 (2012).

  52. 52.

    et al. EphrinB2 repression through ZEB2 mediates tumour invasion and anti-angiogenic resistance. Nat. Commun. 7, 12329 (2016).

  53. 53.

    & Statistical methods for assessing agreement between two methods of clinical measurement. Lancet 1, 307–310 (1986).

  54. 54.

    et al. Bevacizumab improves pathologic response and protects against hepatic injury in patients treated with oxaliplatin-based chemotherapy for colorectal liver metastases. Cancer 110, 2761–2767 (2007).

  55. 55.

    , , , & Infarct-like necrosis: a distinct form of necrosis seen in colorectal carcinoma liver metastases treated with perioperative chemotherapy. Am. J. Surg. Pathol. 36, 570–576 (2012).

  56. 56.

    et al. Personalizing the treatment of women with early breast cancer: highlights of the St Gallen International Expert Consensus on the Primary Therapy of Early Breast Cancer 2013. Ann. Oncol. 24, 2206–2223 (2013).

  57. 57.

    et al. American Society of Clinical Oncology/College of American Pathologists guideline recommendations for immunohistochemical testing of estrogen and progesterone receptors in breast cancer (unabridged version). Arch. Pathol. Lab. Med. 134, e48–e72 (2010).

  58. 58.

    et al. Recommendations for human epidermal growth factor receptor 2 testing in breast cancer: American Society of Clinical Oncology/College of American Pathologists clinical practice guideline update. J. Clin. Oncol. 31, 3997–4013 (2013).

  59. 59.

    , , & Essential role for endocytosis in the growth factor-stimulated activation of ERK1/2 in endothelial cells. J. Biol. Chem. 288, 7467–7480 (2013).

  60. 60.

    & Proportional hazards tests and diagnostics based on weighted residuals. Biometrika 81, 515–526 (1994).

Download references


The study was supported by Breakthrough Breast Cancer (which recently merged with the Breast Cancer Campaign to form Breast Cancer Now), NHS funding to the NIHR Biomedical Research Centre at RM/ICR (London), the Liver Disease Biobank (Montreal) and De Stichting tegen Kanker (Antwerp). We thank I. Hart, K. Hodivala-Dilke, C. Isacke, R. Kerbel, A. Tutt and the members of the Liver Metastasis Research Network for their critical comments on the work. We thank Genentech for providing B20-4.1.1, S. Petrillo for assistance with the Liver Disease Biobank, J. Campbell for advice on statistical analysis and M. Balazsi for assistance with digital pathology. For their technical assistance, we thank the staff of the ICR Biological Services Unit and the staff of the Breast Cancer Now Histopathology Core Facility.

Author information

Author notes

    • Sophia Frentzas
    • , Eve Simoneau
    • , Victoria L Bridgeman
    • , Peter B Vermeulen
    •  & Shane Foo

    These authors contributed equally to this work.

    • David Cunningham
    • , Peter Metrakos
    •  & Andrew R Reynolds

    Co-senior authors.


  1. Tumour Biology Team, The Breast Cancer Now Toby Robins Research Centre, The Institute of Cancer Research, London, UK.

    • Sophia Frentzas
    • , Victoria L Bridgeman
    • , Peter B Vermeulen
    • , Shane Foo
    • , Eleftherios Kostaras
    • , Mark R Nathan
    • , Tracy J Berg
    •  & Andrew R Reynolds
  2. The Royal Marsden Hospital, London, UK.

    • Sophia Frentzas
    • , Andrew Wotherspoon
    • , Clare Peckitt
    • , Zak Eltahir
    • , Gina Brown
    •  & David Cunningham
  3. McGill University Health Centre, Royal Victoria Hospital–Glen Site, Montreal, Quebec, Canada.

    • Eve Simoneau
    • , Zu-hua Gao
    • , Yu Shi
    • , Ayat Salman
    • , Anthoula Lazaris
    • , Alla Khashper
    •  & Peter Metrakos
  4. Translational Cancer Research Unit, Gasthuiszusters Antwerpen Hospitals St. Augustinus, Antwerp, Belgium.

    • Peter B Vermeulen
    • , Gert Van den Eynden
    • , Hanna Nyström
    • , Steven Van Laere
    •  & Luc Dirix
  5. Breast Cancer Now Histopathology Core Facility, The Royal Marsden Hospital, London, UK.

    • Frances Daley
  6. Lineberger Comprehensive Cancer Center, University of North Carolina, Chapel Hill, North Carolina, USA.

    • Xianming Tan
  7. Breast Cancer Now Unit, Guy's Hospital, King's College London School of Medicine, London, UK.

    • Patrycja Gazinska
  8. Cancer Genomics Center the Netherlands–Hubrecht Institute–Royal Netherlands Academy of Arts and Sciences & University Medical Centre Utrecht, Utrecht, the Netherlands.

    • Laila Ritsma
    •  & Jacco van Rheenen
  9. Department of Surgical and Perioperative Sciences, Umeå University, Umeå, Sweden.

    • Hanna Nyström
    •  & Malin Sund
  10. University of Texas MD Anderson Cancer Center, Houston, Texas, USA.

    • Evelyne Loyer


  1. Search for Sophia Frentzas in:

  2. Search for Eve Simoneau in:

  3. Search for Victoria L Bridgeman in:

  4. Search for Peter B Vermeulen in:

  5. Search for Shane Foo in:

  6. Search for Eleftherios Kostaras in:

  7. Search for Mark R Nathan in:

  8. Search for Andrew Wotherspoon in:

  9. Search for Zu-hua Gao in:

  10. Search for Yu Shi in:

  11. Search for Gert Van den Eynden in:

  12. Search for Frances Daley in:

  13. Search for Clare Peckitt in:

  14. Search for Xianming Tan in:

  15. Search for Ayat Salman in:

  16. Search for Anthoula Lazaris in:

  17. Search for Patrycja Gazinska in:

  18. Search for Tracy J Berg in:

  19. Search for Zak Eltahir in:

  20. Search for Laila Ritsma in:

  21. Search for Jacco van Rheenen in:

  22. Search for Alla Khashper in:

  23. Search for Gina Brown in:

  24. Search for Hanna Nyström in:

  25. Search for Malin Sund in:

  26. Search for Steven Van Laere in:

  27. Search for Evelyne Loyer in:

  28. Search for Luc Dirix in:

  29. Search for David Cunningham in:

  30. Search for Peter Metrakos in:

  31. Search for Andrew R Reynolds in:


S. Frentzas, E.S., V.L.B., P.B.V. and S. Foo performed experiments, collected data, analysed data, provided input on the study design and assisted with interpretation of the data; P.B.V., A.W., Z.G., Y.S. and G.V.D.E. performed histopathological analysis of tissue specimens; E.K., M.R.N., F.D., P.G., T.J.B. and Z.E. provided essential technical assistance with experiments; C.P. and X.T. performed statistical analysis on clinical data; A.S. and A.L. assisted with the retrieval of tissue specimens and the associated clinical data; L.R., J.V.R. and S.V.L. shared unpublished data that were crucial to the successful execution of the study and provided critical comments on the manuscript; A.K., G.B., E.L., H.N. and M.S. provided expert assistance with the analysis of clinical data and critical comments on the manuscript; L.D., D.C. and P.M. provided tissue specimens for the study and critical comments on the design of the study and the writing of the manuscript; A.R.R. conceived of and designed the study, supervised the research and wrote the manuscript.

Competing interests

The authors declare no competing financial interests.

Corresponding authors

Correspondence to David Cunningham or Peter Metrakos or Andrew R Reynolds.

Supplementary information

PDF files

  1. 1.

    Supplementary Text, Figures and Tables

    Supplementary Figures 1–17 and Supplementary Tables 1–13

About this article

Publication history






Further reading