Open Access Open Badges Research article

Increased serum sTRAIL levels were correlated with survival in bevacizumab-treated metastatic colon cancer

Atil Bisgin1*, Aysegul Kargi2, Arzu D Yalcin3, Cigdem Aydin1, Deniz Ekinci2, Burhan Savas2 and Salih Sanlioglu1

Author Affiliations

1 Human Gene and Cell Therapy Center of Akdeniz University Hospitals and Clinics, Department of Medical Genetics, Antalya, Turkey

2 Department of Medical Oncology, Akdeniz University Faculty of Medicine, Antalya, Turkey

3 Allergy and Clinical Immunology Unit, Antalya Education and Training Hospital, Antalya, Turkey

For all author emails, please log on.

BMC Cancer 2012, 12:58  doi:10.1186/1471-2407-12-58

The electronic version of this article is the complete one and can be found online at:

Received:10 May 2011
Accepted:7 February 2012
Published:7 February 2012

© 2012 Bisgin et al; licensee BioMed Central Ltd.

This is an Open Access article distributed under the terms of the Creative Commons Attribution License (, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.



Colorectal cancer is the third most common cancer and the third leading cause of cancer-related death. Bevacizumab is a humanized monoclonal antibody developed against vascular endothelial growth factor (VEGF) for the treatment of metastatic cancer. The parameters of RECIST (Response Evaluation Criteria for Solid Tumors) are not adequate to detect important treatment effects and response. Our goal was to evaluate the possibility of using sTRAIL (serum-soluble TNF-related apoptosis-inducing ligand) and VEGF as markers of treatment efficacy and prognosis in patients with metastatic colon cancer.


sTRAIL and VEGF levels were measured by ELISA in the sera of 16 bevacizumab-treated metastatic colon cancer patients and 10 presumably healthy age-matched controls. The measurements were taken before and after treatment for comparison purposes.


Elevated levels of sTRAIL were found in seven out of 16 patients after bevacizumab treatment. Although these patients had a median survival time of 20.6 months, the remaining bevacizumab-treated patients who did not show an increase in sTRAIL had a median survival time of 9.4 months. As expected, serum VEGF levels were decreased in all patients who received bevacizumab therapy and showed no correlation between serum VEGF levels and patient survival (data not shown).


Serum sTRAIL levels might be a useful predictor of prognosis in metastatic colon cancer, in the early evaluation stages following bevacizumab treatment.


Colorectal cancer is the third most common cancer and the second leading cause of cancer-related death [1]. Overall, the 5-year survival rate is <10% for stage IV cancer [2]. The cure rate with surgery alone is very low and chemotherapy and radiotherapy are usually needed in patients with untreated metastatic colon cancer. The development of colorectal cancer is characterized by a sequence of events during which normal colonic epithelium gradually transforms to carcinoma tissue, in most cases, via the development of colorectal adenomas [3]. This sequence of events is driven by an accumulation of molecular (epi)genetic alterations causing progressive disorders in cell growth, differentiation and apoptosis [4,5]. Apoptosis, or programmed cell death, plays an important role in the development and maintenance of tissue homeostasis but also represents an effective mechanism by which abnormal cells, such as tumor cells, can be eliminated [6-8]. Abnormalities in apoptotic function or resistance to apoptosis have been identified as important events in the pathogenesis of colorectal cancer and its resistance to chemotherapeutic drugs and radiotherapy [9,10].

In recent years, bevacizumab, a novel humanized monoclonal antibody directed against vascular endothelial growth factor (VEGF) has found widespread clinical use as an angiogenesis inhibitor for certain types of metastatic cancers [11]. Treatment with bevacizumab with/without the combination of other chemotherapeutic agents inhibits VEGF receptor activation and vascular permeability, which eventually lead to tumor cell apoptosis [12,13]. Apoptosis can be induced passively, through the lack of essential survival signals, or actively, through the ligand-induced trimerization of specific death receptors of the tumor necrosis factor (TNF) receptor family, such as Fas, the TNF receptor, or TRAIL (TNF-related apoptosis-inducing ligand) receptor [14].

TRAIL (APO-2 ligand) is a transmembrane (type II) glycoprotein that also belongs to the TNF superfamily. The extracellular domain of TRAIL is homologous to that of other family members and shows a homotrimeric subunit structure. Like TNF and Fas ligand (FASL), TRAIL also exists physiologically in a biologically active soluble homotrimeric form, serum-soluble TRAIL; sTRAIL [15]. Several recent studies have indicated that sTRAIL is involved in the pathophysiology of different disease states such as cancer, viral infections, autoimmune diseases and inflammation, and defective apoptosis due to its interaction with its ligand preventing signaling for apoptosis may contribute to these diseases [16-21].

Several studies have shown that both the membrane-bound TRAIL and sTRAIL can induce apoptosis in a wide variety of tumor types by activating death receptors [22-24]. sTRAIL is also used as a positive marker for apoptosis [25]. However, it has been observed that the cytotoxic effects of antiangiogenic agents are increased in clinical phase II and III studies when these agents are combined with TRAIL-related therapies [26-28]. Another study with human glioblastoma cells has indicated that TRAIL inhibits angiogenesis stimulated by VEGF expression [29].

However, recently used RECIST parameters (Response Evaluation Criteria for Solid Tumors; responders vs. non-responders) are not adequate to document the differences in treatment response [30]. Therefore, there is a need for a sensitive, specific and reliable serum marker to monitor the therapeutic response.

The purpose of our study was to evaluate the possible use of sTRAIL as a marker for bevacizumab treatment efficacy at the cell apoptosis-linked step.


The amount of released sTRAIL and VEGF was measured by ELISA in the serum of 16 metastatic colon cancer patients with liver metastases, who also received bevacizumab therapy, and 10 age- and sex-matched healthy control individuals who did not receive the treatment. Serum samples were obtained before bevacizumab-based chemotherapy regimens and 3 months after. Serum samples were kept between 2 and 8°C, centrifuged at 10,000 rpm for 10 min, and then frozen at -81°C until assayed.

ELISA was done using the Diaclone sTRAIL ELISA kit (Gen-Probe, Besancon, France) according to the manufacturer's instructions. Statistical analyses were performed using SPSS for Windows version 13.0 (SPSS Inc., Chicago, IL, USA). Group comparisons were made using the independent samples t test. Progression-free survival (PFS) was defined as the period from the beginning of chemotherapy until documented progression or death from any cause. Overall survival (OS) was defined as the period from the first day of treatment until the date of last follow-up or death.

Written informed consent relating to the Declaration of Helsinki was obtained from all patients. The study was approved by Akdeniz University Local Committee on Ethics.


The baseline clinical characteristics of the patients are summarized in Table 1. The serum sTRAIL concentrations before therapy were similar to those of the controls (Figure 1). Serum sTRAIL levels in metastatic colorectal cancer (MCRC) patients before bevacizumab-based chemotherapy and healthy controls were 1.12 ± 0.04 ng/ml and 1.17 ± 0.08 ng/ml, respectively. After bevacizumab treatment, seven out of 16 patients' post-treatment sTRAIL ratios were significantly increased as shown in Figure 2.

Table 1. Colon cancer patients versus healthy individuals.

thumbnailFigure 1. Serum sTRAIL levels. No difference between two groups (P = 0.50) before bevacizumab treatment: 1.12 ± 0.04 ng/ml in metastatic colon cancer patients and 1.17 ± 0.08 ng/ml in healthy control individuals.

thumbnailFigure 2. Serum sTRAIL levels after treatment. Elevated levels of sTRAIL were found in seven out of 16 metastatic colon cancer patients whose serum sTRAIL concentrations were similar to those of healthy age- and sex-matched control individuals (n = 10) before bevacizumab therapy, as seen in Figure 1. These increases were significant compared with pretreatment measurements (P < 0.001). The increase or decrease in the serum levels were shown as percentage change in serum sTRAIL.

Nine patients had progressive diseases, resulting in an overall response rate (56.2%). Median overall survival was 9.4 ± 0.9 months in non-responders. Interestingly, these nine patients were the same ones who showed no increase in sTRAIL levels after bevacizumab treatment. Therefore, we wanted to know whether there was any correlation between sTRAIL levels and overall survival rates. Our study demonstrated that elevated sTRAIL levels after bevacizumab treatment were significantly associated with increased median overall survival of up to 20.6 months (Table 2).

Table 2. Change in serum sTRAIL levels and association with survival.

Not surprisingly, the serum VEGF levels were decreased in all patients who received bevacizumab therapy (data not shown). Serum VEGF levels in MCRC patients before bevacizumab-based chemotherapy were 211 ± 189 ng/ml, and 3 months after treatment, they decreased to 117 ± 18.9 ng/ml, similar to healthy controls (119.5 ± 35.1 ng/ml).

Discussion and conclusions

MCRC is mainly treated with combination of bevacizumab and irinotecan or oxaliplatin-based chemotherapy. The role of TRAIL and another apoptotic marker FAS/FASL systems in CRC patients treated with chemotherapeutic agents has been discussed previously [31-33]. The use of sTRAIL is a novel concept for which few data exist. We evaluated sTRAIL ratio as a marker of chemotherapeutic responsiveness in MCRC patients. This is believed to be the first study in which changes in levels of sTRAIL after bevacizumab treatment have been estimated in overall survival of MCRC patients.

In this study, we compare the levels of sTRAIL in responders versus non-responders to bevacizumab therapy. In responding patients, sTRAIL level increased, but the level decreased or was unchanged in non-responders. This significant change may be a result of the effect of bevacizumab on cancer cells via apoptosis. Another study has found that, although there was no significant difference between sTRAIL, soluble death receptor (sDR)4 and sDR5 levels in MCRC patients before and after treatment, significant correlations were observed between post-treatment sFASL and sDR4, post-treatment sFAS and sTRAIL, post-treatment sTRAIL and sFAS/sFASL ratio, and post-treatment sFASL and sDR5 [34]. This controversy may also have been due to the patients enrolled in the study. Although we chose newly diagnosed patients who had bevacizumab as first-line treatment, in the other study, patients were mostly treated with bevacizumab-based chemotherapy in the second-line setting after failure of oxaliplatin-based chemotherapy.

There have been many studies that have focused on identifying biomarkers for prediction of bevacizumab efficacy. The most obvious protein biomarker to select for testing bevacizumab efficacy is VEGF, but no studies have yet found changes in VEGF concentrations during therapy to have consistent predictive value [35]. One study has found that circulating levels of intercellular adhesion molecule (ICAM)-1 to be at least potentially predictive of survival benefit. Other studies have suggested that neutropenia might have a negative effect on bevacizumab efficacy. There have also been other studies that have concluded that polymorphisms in the VEGF pathway may have predictive value [36,37]. However, although several candidate biomarkers have already been described, including tumor and plasma VEGF, circulating E-selectin, ICAM-1 and vascular cell adhesion molecule-1, much more work is needed to determine the most effective biomarkers and thus to select the patients that are most likely to benefit from bevacizumab therapy [36].

As a conclusion, our study gave a different perspective on MCRC and bevacizumab treatment efficacy in relation to apoptosis and serum sTRAIL levels. The present data highlight the potential importance of sTRAIL in this setting. Further study with a larger patient population and longer duration is warranted to clarify its value.

Competing interests

The authors declare that they have no competing interests.

Authors' contributions

AB carried out the immunoassays, participated in the design and execution of the study and drafted the manuscript. AK followed up the patients and carried out the survival analysis. ADY performed the statistical analysis and participated in its coordination. CA assisted AB with immunoassays. DE carried out VEGF immunoassays and blood sampling. BS followed up the patients and participated in the study design. SS participated in study design and coordination. All authors read and approved the final manuscript.


This study was supported by the Akdeniz University Scientific Research Project Administration Division and Health Science Institute.


  1. Valentini V, Coco C, Gambacorta MA, Barba MC, Meldolesi E: Evidence and research perspectives for surgeons in the European Rectal Cancer Consensus Conference (EURECA-CC2).

    Acta Chir Iugosl 2010, 57(3):9-16. PubMed Abstract | Publisher Full Text OpenURL

  2. Palmer G, Holm T: Survival in locally advanced rectal cancer can be improved. Optimal management with centralized investigation and treatment.

    Lakartidningen 2010, 107(35):2014-2017.


    PubMed Abstract OpenURL

  3. Jass JR, Whitehall VL, Young J, et al.: Emerging concepts in colorectal neoplasia.

    Gastroenterology 2002, 123:862-876. PubMed Abstract | Publisher Full Text OpenURL

  4. Giardiello FM, Hamilton SR, Krush AJ, et al.: Treatment of colonic and rectal adenomas with sulindac in familial adenomatous polyposis.

    N Engl J Med 1993, 328:1313-1316. PubMed Abstract | Publisher Full Text OpenURL

  5. Nugent KP, Farmer KC, Spigelman AD, et al.: Randomized controlled trial of the effect of sulindac on duodenal and rectal polyposis and cell proliferation in patients with familial adenomatous polyposis.

    Br J Surg 1993, 80:1618-1619. PubMed Abstract | Publisher Full Text OpenURL

  6. Winde G, Schmid KW, Brandt B, et al.: Clinical and genomic influence of sulindac on rectal mucosa in familial adenomatous polyposis.

    Dis Colon Rectum 1997, 40:1156-1168. PubMed Abstract | Publisher Full Text OpenURL

  7. Steinbach G, Lynch PM, Phillips RK, et al.: The effect of celecoxib, a cyclooxygenase-2 inhibitor, in familial adenomatous polyposis.

    N Engl J Med 2000, 342:1946-1952. PubMed Abstract | Publisher Full Text OpenURL

  8. Ashkenazi A, Dixit VM: Apoptosis control by death and decoy receptors.

    Curr Opin Cell Biol 1999, 11:255-2601. PubMed Abstract | Publisher Full Text OpenURL

  9. Rijcken FE, Hollema H, van der Sluis T, Boersma-van Ek W, Kleibeuker JH: Sulindac increases epithelial cell proliferative activity in the proximal colon of HNPCC patients.

    Eur J Gastroenterol Hepatol 2005, 17:A56-A57. OpenURL

  10. Reed JC: Apoptosis-targeted therapies of cancer.

    Cancer Cell 2003, 3:17-22. PubMed Abstract | Publisher Full Text OpenURL

  11. Ranieri G, Patruno R, Ruggieri E, Montemurro S, Valerio P, Ribatti D: Vascular endothelial growth factor (VEGF) as a target of bevacizumab in cancer: from the biology to the clinic.

    Curr Med Chem 2006, 13(16):1845-1857. PubMed Abstract | Publisher Full Text OpenURL

  12. Puthillath A, Patel A, Fakih MG: Targeted therapies in the management of colorectal carcinoma: role of bevacizumab.

    Onco Targets Ther 2009, 2:1-15. PubMed Abstract | PubMed Central Full Text OpenURL

  13. Jenab-Wolcott J, Giantonio BJ: Bevacizumab: current indications and future development for management of solid tumors.

    Expert Opin Biol Ther 2009, 9(4):507-517. PubMed Abstract | Publisher Full Text OpenURL

  14. Opferman JT, Korsmeyer SJ: Apoptosis in the development and maintenance of the immune system.

    Nat Immunol 2003, 4(5):410-415.


    PubMed Abstract | Publisher Full Text OpenURL

  15. Holland PM: Targeting Apo2L/TRAIL receptors by soluble Apo2L/TRAIL.

    Cancer Lett 2011.

    [Epub ahead of print] 10.1016/j.canlet.2010.11.001


  16. Wandinger KP, Lünemann JD, Wengert O, Bellmann-Strobl J, Aktas O, Weber A, Grundström E, Ehrlich S, Wernecke KD, Volk HD, Zipp F: TNF-related apoptosis inducing ligand (TRAIL) as a potential response marker for interferon-beta treatment in multiple sclerosis.

    Lancet 2003, 361(9374):2036-2043. PubMed Abstract | Publisher Full Text OpenURL

  17. Han LH, Sun WS, Ma CH, Zhang LN, Liu SX, Zhang Q, Gao LF, Chen YH: Detection of soluble TRAIL in HBV infected patients and its clinical implications.

    World J Gastroenterol 2002, 8(6):1077-1080. PubMed Abstract | Publisher Full Text OpenURL

  18. Liabakk NB, Sundan A, Torp S, Aukrust P, Frøland SS, Espevik T: Development, characterization and use of monoclonal antibodies against sTRAIL: measurement of sTRAIL by ELISA.

    J Immunol Methods 2002, 259(1-2):119-128. PubMed Abstract | Publisher Full Text OpenURL

  19. Lub-de Hooge MN, de Vries EG, de Jong S, Bijl M: Soluble TRAIL concentrations are raised in patients with systemic lupus erythematosus.

    Ann Rheum Dis 2005, 64(6):854-858.

    Epub 2004 Nov 25

    PubMed Abstract | Publisher Full Text | PubMed Central Full Text OpenURL

  20. Bisgin A, Terzioglu E, Aydin C, Yoldas B, Yazisiz V, Balci N, Bagci H, Gorczynski RM, Akdis CA, Sanlioglu S: TRAIL death receptor-4, decoy receptor-1 and decoy receptor-2 expression on CD8+ T cells correlate with the disease severity in patients with rheumatoid arthritis.

    BMC Musculoskelet Disord 2010, 11:192. PubMed Abstract | BioMed Central Full Text | PubMed Central Full Text OpenURL

  21. Aydin C, Sanlioglu AD, Bisgin A, Yoldas B, Dertsiz L, Karacay B, Griffith TS, Sanlioglu S: NF-κB targeting by way of IKK inhibition sensitizes lung cancer cells to adenovirus delivery of TRAIL.

    BMC Cancer 2010, 10:584. PubMed Abstract | BioMed Central Full Text | PubMed Central Full Text OpenURL

  22. Shi J, Zheng D, Liu Y, Sham MH, Tam P, Farzaneh F, Xu R: Overexpression of soluble TRAIL induces apoptosis in human lung adenocarcinoma and inhibits growth of tumor xenografts in nude mice.

    Cancer Res 2005, 65(5):1687-92.

    Erratum in: Cancer Res. 2005 May 1;65(9):3966

    PubMed Abstract | Publisher Full Text OpenURL

  23. Sanlioglu AD, Dirice E, Elpek O, Korcum AF, Ozdogan M, Suleymanlar I, Balci MK, Griffith TS, Sanlioglu S: High TRAIL death receptor 4 and decoy receptor 2 expression correlates with significant cell death in pancreatic ductal adenocarcinoma patients.

    Pancreas 2009, 38(2):154-160. PubMed Abstract | Publisher Full Text OpenURL

  24. Koksal IT, Sanlioglu AD, Karacay B, Griffith TS, Sanlioglu S: Tumor necrosis factor-related apoptosis inducing ligand-R4 decoy receptor expression is correlated with high Gleason scores, prostate-specific antigen recurrence, and decreased survival in patients with prostate carcinoma.

    Urol Oncol 2008, 26(2):158-165.

    Epub 2007 Nov 19

    PubMed Abstract | Publisher Full Text OpenURL

  25. Aukrust P, et al.:

    J Infect Dis. 1994, 169:420-424. PubMed Abstract | Publisher Full Text OpenURL

  26. Ding W, Cai T, Zhu H, Wu R, Tu C, Yang L, Lu W, He Q, Yang B: Synergistic antitumor effect of TRAIL in combination with sunitinib in vitro and in vivo.

    Cancer Lett 2010, 293:158-166.

    Epub 2010 Feb 6

    PubMed Abstract | Publisher Full Text OpenURL

  27. Ren B, Song K, Parangi S, Jin T, Ye M, Humphreys R, Duquette M, Zhang X, Benhaga N, Lawler J, Khosravi-Far R: A double hit to kill tumor and endothelial cells by TRAIL and antiangiogenic 3TSR.

    Cancer Res 2009, 69(9):3856-3865.

    Epub 2009 Apr 14

    PubMed Abstract | Publisher Full Text | PubMed Central Full Text OpenURL

  28. Plastaras JP, Kozak KR: A one, two punch for liver cancer: anti-angiogenesis with a death receptor agonist.

    Cancer Biol Ther 2009, 8(5):463-464.

    Epub 2009 Mar 23

    PubMed Abstract | Publisher Full Text OpenURL

  29. Cantarella G, Risuglia N, Dell'eva R, Lempereur L, Albini A, Pennisi G, Scoto GM, Noonan DN, Bernardini R: TRAIL inhibits angiogenesis stimulated by VEGF expression in human glioblastoma cells.

    Br J Cancer 2006, 94(10):1428-1435. PubMed Abstract | Publisher Full Text | PubMed Central Full Text OpenURL

  30. Trillet-Lenoir V, et al.: Assessment of tumour response to chemotherapy for metastatic colorectal cancer: accuracy of the RECIST criteria.

    Br J Radiol 2002, 75(899):903-908. PubMed Abstract | Publisher Full Text OpenURL

  31. Nadal C, Maurel J, Gallego R, Castells A, Longarón R, Marmol M, Sanz S, Molina R, Martin-Richard M, Gascón P: FAS/FAS ligand ratio: a marker of oxaliplatin-based intrinsic and acquired resistance in advanced colorectal cancer.

    Clin Cancer Res 2005, 11:4770-4774. PubMed Abstract | Publisher Full Text OpenURL

  32. van Geelen CM, Westra JL, de Vries EG, Boersma-van Ek W, Zwart N, Hollema H, Boezen HM, Mulder NH, Plukker JT, de Jong S, Kleibeuker JH, Koornstra JJ: Prognostic significance of tumor necrosis factor-related apoptosis-inducing ligand and its receptors in adjuvantly treated stage III colon cancer patients.

    J Clin Oncol 2006, 24:4998-5004. PubMed Abstract | Publisher Full Text OpenURL

  33. Granci V, Bibeau F, Kramar A, Boissière-Michot F, Thézénas S, Thirion A, Gongora C, Martineau P, Del Rio M, Ychou M: Prognostic significance of TRAIL-R1 and TRAIL-R3 expression in metastatic colorectal carcinomas.

    Eur J Cancer 2008, 44:2312-2318. PubMed Abstract | Publisher Full Text OpenURL

  34. Yildiz R, Benekli M, Buyukberber S, Kaya AO, Ozturk B, Yaman E, Berk V, Coskun U, Yamac D, Sancak B, Uner A: The effect of bevacizumab on serum soluble FAS/FASL and TRAIL and its receptors (DR4 and DR5) in metastatic colorectal cancer.

    J Cancer Res Clin Oncol 2010, 136(10):1471-1476.

    Epub 2010 Feb 13

    PubMed Abstract | Publisher Full Text OpenURL

  35. Jubb AM, Harris AH: Biomarkers to predict the clinical efficacy of bevacizumab in cancer.

    Lancet Oncol 2010, 11:1172-1183. PubMed Abstract | Publisher Full Text OpenURL

  36. Yang SX: Bevacizumab and breast cancer: current therapeutic progress and future perspectives.

    Expert Rev Anticancer Ther 2009, 9(12):1715-1725. PubMed Abstract | Publisher Full Text | PubMed Central Full Text OpenURL

  37. Beatty GL, Giantonio BJ: Bevacizumab and oxaliplatin-based chemotherapy in metastatic colorectal cancer.

    Expert Rev Anticancer Ther 2008, 8(5):683-688. PubMed Abstract | Publisher Full Text OpenURL

Pre-publication history

The pre-publication history for this paper can be accessed here: