Overexpression of VEGFA mediated by HIF-1 is associated with higher rate of spread through air spaces in resected lung adenocarcinomas

Background: Spread through air spaces (STAS), a newly identified pattern of invasion in lung adenocarcinomas (LACs), is an unfavorable prognostic factor for patients with LAC, but the molecular characteristics and mechanisms underlying STAS have not been adequately explored.Methods: In total, 650 pathologically confirmed invasive LAC patients who underwent curative resection between December 2019 and April 2020 were reviewed. Disease-free survival (DFS) and overall survival (OS) were analyzed using the log-rank test and the Cox proportional hazards model. A comparative deep sequencing analysis was conducted to explore the molecular characteristics underlying STAS. Vascular endothelial growth factor A (VEGFA) expression was evaluated by immunoblotting and immunohistochemical analysis using fresh tumor tissue and tissue microarray.Results: STAS was more prevalent in patients with a smoking history (p < 0.001), high pathological TNM stage (p < 0.001), lymphovascular invasion (p < 0.001), visceral pleural invasion (p < 0.001) and micropapillary/solid histological subtypes (p < 0.001). STAS-negative patients had better DFS (p < 0.001) and OS (p = 0.003) compared to STAS-positive patients with invasive LACs, especially in the lymph node-negative population (p < 0.001). After RNA-sequencing analysis, hypoxia-inducible factor-1 (HIF-1) signaling was enriched and appeared to be strongly correlated with STAS, and more STAS-positive individuals were detected in the higher VEGFA-expressing group (p = 0.042).Conclusions: We demonstrated that STAS was an independent prognostic marker of poor clinical outcome, especially in lymph node-negative patients, and that higher VEGFA expression mediated by HIF-1 signaling was associated with an increased STAS rate.