Mechanisms of Cancer Cachexia

Anorexia Nervosa in vivo cytokine production: a systematic review

INTRODUCTION

The underlying psychobiology that contributes to Anorexia Nervosa (AN) onset and disease progression remains unclear. New research is emerging suggesting a possible link between inflammation and a variety of mental illnesses. Alterations of cytokines may play a role in the pathogenesis of AN. Some studies have found differences in the cytokine profile of those with AN compared to healthy controls, but results are heterogeneous. The aim of this work was to systematically review existing studies investigating in-vivo cytokine production in those with AN before and after weight restoration compared to controls.

METHODS

A comprehensive literature search of four electronic databases (PubMed, PsychInfo, EMBASE and CINAH) was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) guidelines to identify human in-vivo studies investigating the relationship between AN and cytokine production. Data extracted from included studies related to population characteristics (e.g. age, gender, mean mBMI/%IBW), cytokine measurement and relevant findings. Confounding factors (e.g. smoking status, co-morbid mental illness, menstruation status) were also collected.

RESULTS

36 studies were eligible for this systematic review of which the majority were conducted in Europe (77.8%) and involved female subjects (97.2%). Those with AN ranged in age from 13 to 47 years and had an illness duration of 3 months to 24 years. 15 candidate cytokines and 3 receptors were identified (TNF-alpha, IL-6, IL-1B, CRP, IL-2, IL-7, IL-10, IFN-γ, TNF-R2, IL-1 α, IL-15, TNF-R1, IL-17, IL-18, TGF-B1, IL-12, IL-6R and TGF-B2) exploring in-vivo levels in patients with AN and comparing to controls. TNF-alpha and IL-6 were the most extensively studied with IL-6 being significantly elevated in 4 out of 8 (50%) of longitudinal studies when comparing AN patients at baseline compared to post weight restoration. Following weight restoration, there was no difference in IL-6 levels when comparing to HC in 7 of 8 (87.5%) longitudinal studies examined.

CONCLUSIONS

The most promising cytokine potentially involved in the pathogenesis of AN appears to be IL-6, and possibly TNF-alpha pathways. The heterogeneity of clinical and methodology factors impedes the generalizability of results. Future studies may wish to address these methodological shortcomings as alterations in cytokine levels in AN could act as therapeutic targets assisting with weight restoration and psychopathology and may offer diagnostic potential.

Suporte nutricional pediátrico

O objetivo deste trabalho é avaliar os efeitos do suporte nutricional sobre o estado nutricional de pacientes pediátricos hipercatabólicos, e analisar os efeitos da utilização de produtos de suporte enteral de adultos em pacientes pediátricos. Foram avaliados dois pacientes pediátricos, ambos do sexo masculino com 4 e 5 anos. Apesar de suporte nutricional empregado haver permitido a manutenção dos pacientes em Balanço Nitrogenado Positivo, garantindo-lhes, uma evolução favorável que se reflete na melhora da concentração de proteínas séricas, o que só foi possível com a identificação da Taxa de Catabolismo Protéico, não recomendamos dietas enterais de adulto para crianças imunodeprimidas face ao risco de contaminação das formulas, o que pode proporcionar infecções oportunistas.

Spinal Metastatic Disease: A Review of the Role of the Multidisciplinary Team

Historically, a simple approach centered on palliation was applicable to the majority of patients with metastatic spinal disease. With advances in diagnosis and treatment, a more complicated algorithm has devolved requiring a multidisciplinary approach with institutional commitment and support. We performed a database review including pertinent articles exploring the multidisciplinary management of spinal metastatic disease. The wide variation in clinical presentation and tumor response to treatment necessitates a multidisciplinary approach that integrates the diagnosis and treatment of the cancer, symptom management, and rehabilitation for optimal care of patients with spinal metastases. Advances in the field of radiology have led to earlier and more focused diagnosis of spinal metastasis and acts to guide therapy. Advances in surgical techniques, neurophysiologic monitoring, and anesthetic expertise have allowed surgeons to perform more extensive procedures leading to improved outcomes and reduced morbidity. Radiation oncology input that is essential as external beam radiation therapy can provide significant pain relief. Non-operative measures may include bisphosphonate infusions, management of complications (e.g. hypercalcemia of malignancy), monoclonal antibody infusions, and chemotherapy if indicated in the treatment of the primary malignancy. Input from psychology services is necessary to address the biopsychosocial ramifications of spinal metastasis. Allied health professionals in the form of physiotherapists, social workers, and dieticians also contribute in maximizing patients' quality of life and well-being.

Nutrition Intervention in Cancer

Nutrition intervention supports the patient with malnutrition secondary to cancer and its treatment and has been used in the primary and secondary prevention of common forms of cancer. During the emotional stress of dealing with cancer at any stage, patients derive increased quality of life and a sense of control over their lives as the result of receiving supportive advice on diet and lifestyle. Therefore, the use of nutrition intervention in cancer patients is justified in the absence of absolute proof of efficacy as long as it is done safely and with the consent of the cancer patient.

Duodenal stenting followed by systemic chemotherapy for patients with pancreatic cancer and gastric outlet obstruction

OBJECTIVES

Endoscopic duodenal stenting has recently been proposed as a substitute for surgical gastrojejunostomy for the treatment of gastric outlet obstruction. We aimed to evaluate the efficacy and safety of duodenal stenting followed by systemic chemotherapy for patients with advanced pancreatic cancer with gastric outlet obstruction.

METHODS

This was a single-center, retrospective cohort study, conducted at an academic medical center, of 71 patients with advanced pancreatic cancer and gastric outlet obstruction (mean age: 67.6 years; range: 31-92 years) who underwent duodenal stenting with or without subsequent chemotherapy. Overall survival, duration of oral intake of foods, the rate of introduction of chemotherapy, progression-free survival, and adverse events were evaluated.

RESULTS

Stent placement was technically successful in 69 (97%) patients. Thirty-six (51%) patients were treated with chemotherapy: 17 with gemcitabine alone, 15 with S-1 alone, 3 with FOLFIRINOX, and 1 with paclitaxel. Median progression-free survival and overall survival after chemotherapy were 2.6 months (95% confidence interval: 1.3-3.9 months) and 4.7 months (95% confidence interval: 2.6-6.8 months), respectively. Cases of grade 3 anemia were frequently observed during chemotherapies following duodenal stenting (32%). Tumor stage, performance status, neutrophil-to-lymphocyte ratio, and introduction of chemotherapy were independent prognostic factors for survival (hazard ratios of 3.73, 2.21, 2.69, and 1.85 with p-values of <0.001, 0.010, <0.001, and 0.045, respectively).

CONCLUSIONS

The findings of this study suggest that endoscopic duodenal stenting is an advantageous treatment in advanced pancreatic cancer patients with gastric outlet obstruction regarding its safety and smooth conduction of subsequent chemotherapies.

Potential prognostic significance of a new proteomic profile in patients with advanced pancreatic adenocarcinoma

OBJECTIVES

Seven-signal proteomic approach has recently been developed as a new proteomic profile measured by matrix-assisted laser desorption/ionization mass spectrometry. The aim of this study was to evaluate prognostic significance of this proteomic value in patients with pancreatic adenocarcinoma.

METHODS

Blood samples from the patients with pancreatic adenocarcinoma were prospectively collected before treatments including surgical resection and systemic chemotherapies. The seven-signal proteomic profiles of the samples were measured, and the prognostic significance of the proteomic value was evaluated through comparison with other existing prognostic markers.

RESULTS

Cut-off value of the proteomic profiles at 52 stratified overall prognosis of the patients (6.5 months vs. 10.9 months with the values ≥52 vs. <52, p = 0.020). In subgroup analyses of inoperable cases with carcinoembryonic antigen level of <5 ng/ml or performance status of 0-1, the proteomic value at 52 stratified their prognosis (p = 0.002 and p = 0.006, respectively).

CONCLUSIONS

The new seven-signal proteomics showed useful prognostic significance for patients with pancreatic adenocarcinoma. Further studies with a large sample size would be required to evaluate whether this proteomic approach possibly complements the existing parameters, such as carcinoembryonic antigen and performance status.

Inflammation based regulation of cancer cachexia

Cancer cachexia, consisting of significant skeletal muscle wasting independent of nutritional intake, is a major concern for patients with solid tumors that affects surgical, therapeutic, and quality of life outcomes. This review summarizes the clinical implications, background of inflammatory cytokines, and the origin and sources of procachectic factors including TNF-α, IL-6, IL-1, INF-γ, and PIF. Molecular mechanisms and pathways are described to elucidate the link between the immune response caused by the presence of the tumor and the final result of skeletal muscle wasting.

Altered glutamine metabolism and therapeutic opportunities for lung cancer

Disordered cancer metabolism was described almost a century ago as an abnormal adaptation of cancer cells to glucose utilization especially in hypoxic conditions; the so-called Warburg effect. Greater research interest in this area in the past two decades has led to the recognition of the critical coupling of specific malignant phenotypes such as increased proliferation and resistance to programmed cell death (apoptosis) with altered metabolic handling of key molecules that are essential for normal cellular metabolism. The altered glucose metabolism frequently encountered in cancer cells has already been exploited for cancer diagnosis and treatment. The role of other glycolytic pathway intermediates and alternative pathways for energy generation and macromolecular synthesis in cancer cells has only become recognized more recently. Especially, the important role of altered glutamine metabolism in the malignant behavior of cancer cells and the potential exploitation of this cellular adaptation for therapeutic targeting has now emerged as an important area of cancer research. Expectedly, attempts to exploit this understanding for diagnostic and therapeutic ends are running apace with the elucidation of the complex metabolic alterations that accompany neoplastic transformation. Because lung cancer is a leading cause of cancer death with limited curative therapy options, careful elucidation of the mechanism and consequences of disordered cancer metabolism in lung cancer is warranted. This review provides a concise, systematic overview of the current understanding of the role of altered glutamine metabolism in cancer, and how these findings intersect with current and future approaches to lung cancer management.

Development and formative evaluation of a web-based self-management exercise and diet intervention program with tailored motivation and action planning for cancer survivors

Background

Most dietary and exercise interventions developed to date for cancer survivors have employed intensive clinic-based face-to-face counseling sessions. However, when the clinic-based face-to-face intervention ends, the participants cannot receive feedback from the experts, and the motivation for regular exercise and diet practices decreases. One way to overcome the shortcomings of clinic-based face-to-face intervention is to employ the Internet to this end. To maximize effectiveness when providing Web-based interventions, action planning should be able to start at the right time, education should be tailored to motivational readiness, and self-efficacy should be enhanced at appropriate intervals.

Objective

The aim of this study was to develop a Web-based self-management diet and exercise intervention program with the aid of the transtheoretical model (TTM) and to conduct formative evaluations.

Methods

The Web-based self-management exercise and diet intervention program was developed employing a 5-phase system development life-cycle (SDLC) method. The 5 phases were 1) identification of user requirements, 2) system design, 3) system development, 4) system evaluation, and 5) system application. An expert group composed of 3 content experts, a Web developer, and 2 Web designers, evaluated the usability and accuracy of the content. The program was evaluated by 30 breast cancer survivors for perceived ease of use.

Results

The Web-based self-managed exercise and diet intervention program contained 5 components differing in screen layout. These components are introduction, assessment, education (tailored information provision), action planning (goal setting, scheduling, keeping a diary), and automatic feedback. Education, action planning, and automatic feedback were tailored to each participant through the assessment. The processes of change, self-efficacy, and decisional balance, which are the principal strategies encouraging behavioral change according to the TTM theory, were reflected in the education, and self-efficacy was also reflected in the automatic feedback. After iterative testing by experts on problems that arose in terms of usability and content accuracy during system operation, the perceived ease of use of the program was evaluated by 29 breast cancer survivors. The end users rated the program as being easy to understand and use (a total usability score of 81.3 points). In addition, program feasibility was evaluated using the percentage of patients (27/30, 90%) who consistently used the program.

Conclusions

The use of Internet technology allowed immediate and easy access to interventions, real-time monitoring of progress, online education, tailored action planning, and tailored short message services using mobile phones.

Tumour necrosis factor alpha and oxidative stress as maintaining factors in the evolution of anorexia nervosa

OBJECTIVE

Aim of the study was to evaluate tumour necrosis factor α (TNF-α) axis and oxidative status in patients with anorexia nervosa (AN) seeking a possible correlation with both nutritional status and evolution of the disease.

SUBJECTS AND METHODS

Thirty-nine consecutive women with AN and an age-matched healthy control group were studied. Patients were 26±9 yr, with a body mass index (BMI) of 13.9±2 kg/m(2). TNF-α, its receptors TNF-R55 and TNF-R75, and oxidative status markers (selenium, ascorbic/ dehydroascorbic acid, retinol, α-tocopherol, selenium-dependent gluthatione peroxidase, reduced/oxidated gluthatione) were measured. A correlation with both nutritional indexes (body weight, BMI, albumin, prealbumin, transferrin, lymphocyte count) and disease duration was investigated. Pearson's correlation and unpaired Student's t-test were used to compare patients and controls.

RESULTS

TNF-α and oxidative status markers were significantly higher in patients than controls and TNF-α was directly related to dehydroascorbic acid (p<0.05). Both TNF-R55 and TNF-R75 were higher in patients with duration of disease longer than one year as compared to controls and patients with shorter duration. Receptors inversely correlated with BMI (p<0.05 and p<0.01) and directly with disease duration (p<0.05). Inverse correlation between disease duration and BMI was present (p<0.01).

CONCLUSIONS

The study showed activation of TNF-α axis and oxidative stress in AN patients, as well as correlation between the two systems. Due to the correlation between TNF receptors and both BMI and disease duration, a possible role of pro-inflammatory cytokines in the evolution of the eating disorder is suggested.

Interleukin-1α Polymorphism -889C/T Related to Obesity in Korean Taeumin Women

Interleukin-1 (IL-1), a cytokine produced predominantly by cells from the macrophage lineage, can affect multiple neuroendocrine and metabolic functions. IL-1α production by cultured peripheral blood mononuclear cells from an obese group was significantly elevated in comparison to a control group. The aim of this study was to investigate whether the IL-1α polymorphism and Sasang constitution, a major branch in Korean traditional medicine, were related to obesity. Genotyping was done in 182 healthy females with a marked variation in body mass index (BMI) by a PCR-restriction fragment length polymorphism assay. The T allele was associated with decreased BMI (p = 0.020). In a subgroup with BMI values ranging from 27 ~ 29 kg/m2, the frequency of the T allele was significantly decreased (p = 0.004, odds ratio, OR = 0.141 compared to a subgroup with a BMI values less than 25 Kg/m2). In addition, in Taeumin female subjects, the frequency of the IL-1α T allele was markedly decreased in a subgroup with BMI values in the range of 27 ~ 29 kg/m2compared to a lean group with BMI values less than 25 kg/m2(p = 0.004, OR = 0.139). In Korean women, an association was found between -889C/T polymorphism in the regulatory region of the IL-1α gene and BMI values. In addition, an association was found among IL-1α polymorphism, obesity, and the Sasang constitution.

An intermediate dose of LCMV clone 13 causes prolonged morbidity that is maintained by CD4+ T cells

Wasting is a sign of various underlying disorders and is a common feature of cancer, sepsis, and AIDS. We have developed an in vivo model to study the various stages of wasting following infection of mice with lymphocytic choriomeningitis virus cl-13. Using this model we have identified four distinct stages of wasting and have discovered that all stages occur in the different groups of mice regardless of whether the virus is cleared or persists. However, the degree and extent of wasting vary between groups of mice, depending upon the dose of virus administered. Blocking IFNγ or TNFα, which are believed to take part in the wasting process, did not affect the wasting state. Finally, we found that CD4+ T cells control the maintenance stage of wasting. We believe this model will be useful in studying the regulation of wasting during a persistent viral infection, hopefully leading to improved therapies to ameliorate the disorder.

Cachexia, malnutrition, the refeeding syndrome, and lessons from Goldilocks

Cachexia has plagued clinicians for centuries. Although all cachexia is related to malnutrition, cachexia associated with malignant diseases differs from starvation cachexia in that it is more recalcitrant to nutritional therapy. All cachexia responds to judicious nutritional support; however, cancer cachexia worsens autonomously as the disease advances and cannot be arrested or reversed by any known form of nutrition, hormonal, or pharmacologic therapy. Cachexia must be treated cautiously to avoid overfeeding syndrome, which may result in serious or dangerous complications or death.

Lipids changes in liver cancer

Liver is one of the most important organs in energy metabolism. Most plasma apolipoproteins and endogenous lipids and lipoproteins are synthesized in the liver. It depends on the integrity of liver cellular function, which ensures homeostasis of lipid and lipoprotein metabolism. When liver cancer occurs, these processes are impaired and the plasma lipid and lipoprotein patterns may be changed. Liver cancer is the fifth common malignant tumor worldwide, and is closely related to the infections of hepatitis B virus (HBV) and hepatitis C virus (HCV). HBV and HCV infections are quite common in China and other Southeast Asian countries. In addition, liver cancer is often followed by a procession of chronic hepatitis or cirrhosis, so that hepatic function is damaged obviously on these bases, which may significantly influence lipid and lipoprotein metabolism in vivo. In this review we summarize the clinical significance of lipid and lipoprotein metabolism under liver cancer.

Impact of TNF-α and IL-6 Levels on Development of Cachexia in Newly Diagnosed NSCLC Patients

OBJECTIVES

We investigated the role of cytokines tumor necrosis factor-alpha (TNF-alpha) and interleukin-6 (IL-6) in cachexia development in newly diagnosed nonsmall cell lung cancer (NSCLC) patients.

METHODS

: We evaluated 44 (M/F:41/3) NSCLC patients and 12 (M/F:10/2) age matched healthy smokers. NSCLC cases with a weight loss of > or =10% consisted the cachectic group (n:23, M/F:21/2) and the ones with <10% weight loss consisted the noncachectic group (n:21, M/F:19/2).

RESULTS

Body mass index (BMI) of cachectics was significantly lower than that of noncachectics (21.0 +/- 2.9 versus 24.5 +/- 3.6, P = 0.02) and controls (21.0 +/- 2.9 versus 25.5 +/- 2.6, P = 0.01). Serum TNF-alpha level did not differ between cachectic and noncachectics (37.3 +/- 39.1 and 51.6 +/- 84.2 pg/mL, respectively). However, it was significantly higher in NSCLC patients compared with controls (44.1 +/- 64.3 and 15.1 +/- 14.3 pg/mL, P = 0.03). Serum IL-6 level was not different between 3 groups (6.4 +/- 4.1, 8.9 +/- 16.3, and 4.1 +/- 3.5 pg/mL, respectively) but it correlated significantly with TNF-alpha (r = 0.4, P = 0.006) and BMI (r = -0.3, P = 0.03). Erythrocyte sedimentation rate (ESR) correlated significantly with TNF-alpha (r = 0.4, P = 0.003) and BMI (r = -0.3, P = 0.03). Among 44 cases, survival of 12 and 17 patients was recorded in cachectics and noncachectics, with no statistical difference (12.2 +/- 3.7 and 11.2 +/- 1.0 months, respectively).

CONCLUSIONS

TNF-alpha and IL-6 levels did not differ significantly between cachectics and noncachectics. However, significant correlations between IL-6, BMI, and TNF-alpha suggested that these cytokines acted as cofactors in weight loss. Survival was neither influenced by BMI, nor the cytokine levels in the present study. The significant correlation of ESR with TNF-alpha suggested that ESR could provide valuable clue for considerable weight loss in the follow-up of NSCLC patients.

The tumor microenvironment in the post-PAGET era

The research area of tumor microenvironment is considered, at present, to be an important factor in tumorigenesis and especially in tumor progression. The present mini review is focused on three principles characterizing the nature of the tumor microenvironment. We first discuss the regulatory functions of the tumor microenvironment and the complexity of the combinatorial signaling pathways operating in it. We then address the aspect that the tumor microenvironment incorporates both pro and anti malignancy factors and that a balance between these factors regulates tumor progression. Thirdly we provide evidence that the non-tumor cells in the tumor microenvironment and their products may be different from those of their counterparts residing in non-tumor microenvironments. The conclusion of this mini review is that the tumor microenvironment, by exerting regulatory functions and selective pressures drives cancer cells into one of several molecular evolution pathways thereby determining and shaping their malignancy phenotype.

Prevention of Cancer Cachexia by a Novel Nuclear Factor κB Inhibitor in Prostate Cancer

PURPOSE

To investigate the association between serum interleukin-6 (IL-6) and cachexia in patients with prostate cancer and the inhibitory effect of a new nuclear factor kappaB (NF-kappaB) inhibitor, dehydroxymethylepoxyquinomicin (DHMEQ), on IL-6 production and cachexia in an animal model of hormone-refractory prostate cancer.

EXPERIMENTAL DESIGN

The association between serum IL-6 levels and variables of cachexia was evaluated in 98 patients with prostate cancer. The inhibitory effects of DHMEQ on IL-6 secretion and cachexia were investigated in in vitro and in vivo studies using JCA-1 cells derived from human prostate cancer.

RESULTS

Serum IL-6 levels were significantly elevated and cachexia developed in JCA-1 tumor-bearing mice as well as in prostate cancer patients with progressive disease. IL-6 secretion was significantly inhibited in JCA-1 cells exposed to DHMEQ. Intraperitoneal administration of DHMEQ (8 mg/kg) to tumor-bearing mice produced a significant amelioration of the reduction in body weight, epididymal fat weight, gastrocnemius muscle weight, hematocrit, and serum levels of triglyceride and albumin when compared with administration of DMSO or no treatment. DHMEQ caused a significant decrease of serum IL-6 level in JCA-1 tumor-bearing mice (all P < 0.05).

CONCLUSIONS

These results suggested an association between serum IL-6 and cachexia in patients with prostate cancer and in JCA-1 tumor-bearing mice and that a new NF-kappaB inhibitor, DHMEQ, could prevent the development of cachexia in JCA-1 tumor-bearing mice presumably through the inhibition of IL-6 secretion. DHMEQ seems to show promise as a novel and unique anticachectic agent in hormone-refractory prostate cancer.

The Relationship Between a Urinary Cachectic Factor and Weight Loss in Advanced Cancer Patients

A 24K glycoprotein, the proteolysis-inducing factor (PIF), has been identified in mice and humans with cancer cachexia. Clinical cross-sectional studies found an association between the presence of PIF in urine and tumors of patients and weight loss. For the first time, we report results from a longitudinal study establishing the relationship between a urinary PIF pattern and persistent weight loss. Over time, cancer patients positive for the PIF pattern experienced weight loss, whereas those with a negative test gained weight.

Management of paraneoplastic syndromes in lung cancer

Paraneoplastic syndromes are common complications of lung cancer. Although most frequently associated with advanced disease, paraneoplastic syndromes may also occur at early stages. Occasionally, the paraneoplastic syndrome may be the presenting symptom of lung cancer. For most paraneoplastic syndromes, the best treatment is to treat the underlying malignancy. However, in many cases, treatment of moderate efficacy or urgent therapy is required. Specific recommendations for the management of the most common paraneoplastic syndromes, including cachexia, hypercalcemia, and hyponatremia, are provided.

Treatment with ursodeoxycholic acid is associated with weight gain in patients with primary biliary cirrhosis

BACKGROUND

Ursodeoxycholic acid (UDCA) is the established treatment of primary biliary cirrhosis (PBC) and is a safe and well-tolerated medication. Nevertheless, patients often anecdotally complain of weight gain while on this drug.

GOALS

We compared weight changes in patients treated with UDCA and those on placebo to characterize this potential side effect.

STUDY

One-hundred eighty patients with PBC who were enrolled into a randomized, controlled trial received either UDCA (13-15 mg/kg/d) or an identical placebo. Changes from baseline weight were calculated at 12, 24, 36, and 48 months. Other markers of disease activity, including liver biochemistries, serum lipids, histologic stage, and Mayo Risk Score were evaluated in both groups.

RESULTS

The proportion of patients who gained weight during the first 12 months of therapy was significantly greater in the UDCA than placebo group (67/86 [78%] versus 43/73 [57%] respectively, P = 0.005). Patients in the UDCA group gained an average of 3.6 +/- 6.5% kg (2.2 +/- 5.1 kg) which was significantly greater than the average of 0.6 +/- 6.9% kg (0.6 +/- 4.9 kg) gained in the placebo group (P = 0.04). The biggest change in weight occurred in the first 12 months of treatment (P < 0.001); after this, weight was maintained for the 4-year duration of treatment. There was no significant correlation between initial body mass index (BMI) and weight change or changes in disease activity and weight.

CONCLUSION

UDCA treatment in patients with PBC is associated with a significant weight gain that occurs in the first 12 months of treatment, persists for the duration of treatment, and occurs independent of baseline BMI. Discussions with PBC patients beginning UDCA treatment should include the beneficial effects this medication has on disease outcome, but should also mention weight gain as a possible side effect.

Mechanisms mediating metabolic abnormalities in the livers of Ehrlich ascites tumor-bearing mice

Previously we reported that intermittent intraperitoneal administration of ornithine decarboxylase-inducing factor (ODC factor), interleukin 1alpha (IL-1alpha), and tumor-necrosis factor-alpha (TNF-alpha) to normal mice induced biological changes in the hosts which included changes in the pattern of expression of pyruvate kinase (PK) isozymes in the liver and hypertrophy of the spleen. In the study reported here, we investigated the chronic and combined effects of these factors on hepatic enzymes using alzet microosmotic pumps implanted in the subcutis of the backs or abdominal cavities of mice. Continuous administration of ODC factor and recombinant human IL-1alpha (rhIL-1alpha) reduced the activity of L-type PK, which is a glycolysis-related enzyme in the liver, and induced the activity of M2-type PK, a known marker of liver dedifferentiation. Serine dehydratase (SDH) and tyrosine aminotransferase (TAT), enzymes associated with amino acid metabolism, were not significantly influenced at the examined concentration. The simultaneous continuous infusion of ODC factor and rhIL-1alpha or rhTNF-alpha caused alterations in the patterns of expression of PK isozyme activity profiles and reduced overall PK activity. SDH and TAT activities were also significantly induced. Moreover, mice treated with these combined factors displayed many other metabolic changes normally associated with cancer cachexia. These findings suggest that the tumor-derived ODC factor and cytokines such as IL-1alpha and TNF-alpha might function synergistically in the metabolic perturbations observed in Ehrlich ascites tumor bearers.

Molecular-based therapeutic approaches in treatment of anorexia of aging and cancer cachexia

Loss of appetite, or anorexia, has profound implications for older persons, altering social interactions, reducing quality of life, and leading to weight loss with grave health consequences. Two conditions associated with anorexia considered in this article are the multidetermined anorexia of aging and the wasting syndrome termed cachexia induced by cancer. Nutritional interventions may have some benefit in the former, but are of limited value in the latter. Emerging studies at the molecular level relating to appetite regulation and energy balance may offer new approaches to arrest progressive weight loss in the anorexia of aging and cancer cachexia.

Glucose and glycogen catabolism in perfused livers of Walker-256 tumor-bearing rats and the response to hormones

The alterations in hepatic glucose and glycogen catabolism were evaluated in rats bearing the Walker-256 tumor. Food intake was monitored concomitantly with measurements of the in vivo hepatic glycogen levels. Glycogenolysis, glycolysis and oxygen uptake were measured in the isolated perfused liver. The hepatic glucose phosphorylating capacity was measured in the high-speed supernatant fraction of liver homogenates. Food intake was 21.4% reduced in tumor-bearing rats; the glycogen levels were decreased by 63.6%. Initial basal rates of glucose release (glycogenolysis) and lactate+pyruvate production from endogenous glycogen (glycolysis) in the perfused liver were not changed by the tumor-bearing state, resulting in a higher relative rate of glycogen breakdown (% of glycogen degradation per unit time). In absolute terms stimulation of glycogen mobilization by glucagon or norepinephrine was smaller in the tumor-bearing state. The percentage of extra glycogen degradation per unit time caused by both hormones, however, was practically the same in the control and in the tumor-bearing state. The hepatic glucose phosphorylating capacity was reduced from 3.92+/-0.39 nmolmin(-1)(mgprotein)(-1) in normal rats to 2.61+/-0.23 nmolmin(-1)(mgprotein)(-1) in livers from tumor-bearing rats. Glycolysis from exogenous glucose (20 mM) in perfused livers was diminished from 0.136+/-0.023 &mgr;molmin(-1)(gliver)(-1) in normal rats to 0.046+/-0.008 &mgr;molmin(-1)(gliver)(-1) in tumor-bearing rats. It can be concluded that livers from rats bearing the Walker-256 tumor are less able to transform glucose and accumulate glycogen while possessing a greater tendency of releasing glucose from the glycogen stores.

Evolving routines: preventing fatigue associated with lung and colorectal cancer

Some individuals with cancer develop fatigue whereas others do not. To begin the development of a biobehavioral model that could explain this phenomenon, the authors interviewed 29 individuals with lung and colorectal cancer before, during, and after treatment and obtained evaluable data for 18. Blood samples and body weight were obtained at the time of each interview. A three-stage process, evolving routines, and an adaptive behavioral mode labeled gliding characterized those who reported little or no fatigue, even when hemoglobin levels were low. Three other nonadaptive behavioral modes (inertia, disorganization, and overexertion) characterized those who reported fatigue. Individuals with similar disease and treatment profiles seldom demonstrated the same behavioral or biological response patterns.

The skewing to Th1 induced by lentinan is directed through the distinctive cytokine production by macrophages with elevated intracellular glutathione content

In vivo lentinan (LNT)-elicited peritoneal macrophages (Mps) showed the reduced release of prostaglandins (PGs), IL-10 and IL-6, while it endowed Mps with the elevated capability to produce IL-12 and nitric oxide (NO) upon in vitro triggering, due to the elevated intracellular glutathione (GSH) content in Mps. Deprivation of intracellular GSH completely ablated the production of IL-12. Conversely, lipopolysaccharide (LPS) induced peritoneal Mps with the reduced intracellular GSH content and the reciprocal profile of mediator production. Mps with the elevated intracelluar GSH is arbitrarily termed as reductive Mp (RMp) and that with reduced amount as oxidative Mp (OMp). OMp was converted to RMp when GSH was replenished with glutathione monoethylester (GSH-OEt). The IL-2 administration in combination with LNT exerted the synergistic induction of RMp, resulting in synergistic augmentation of IL-12, NO and reduction of IL-6 production. It was also confirmed that CD4+T cells derived of LNT-administered mice showed augmented IFN-gamma and reduced IL-4 production upon in vitro anti-CD3 stimulation. Taken together it is concluded that skewing of Th1/Th2 balance to Th1 by a beta-(1-3)-glucan, LNT, is directed through the distinctive production of IL-12 versus IL-6, IL-10 and prostaglandin E2 (PGE2) by Mps, depending on intracellular GSH redox status. To the efficient tumor immunotherapy, it may be one of the critical elements to induce a reductive form of Mps in tumor stromal tissues to maintain Th1 response.

Hypothalamic dopaminergic receptor expressions in anorexia of tumor-bearing rats

Our past microdialysis studies in ventromedial hypothalamic nucleus (VMN) and lateral hypothalamic area (LHA) of changes in dopamine concentrations in response to changes in food intake [characterized as feeding pattern (changes in meal number and size)] in anorexia of cancer show abnormal presynaptic dopaminergic neurotransmission. To determine postsynaptic receptor status, studies were done in tumor-bearing (TB) and non-tumor-bearing (NTB) free-feeding control rats while continuously measuring their food intake via a rat eater meter. When TB rats developed anorexia, TB and control rats were killed, and postsynaptic D(1)- and D(2)-receptor mRNA expression in LHA and VMN were measured via RT-PCR. At anorexia, food intake decreased initially by a decrease in meal number, whereas a concurrent increase in meal size occurred for 24 h in an attempt to maintain food intake constant. Then meal size also decreased. At this time, D(1)- and D(2)-receptor mRNA expressions in LHA and VMN of TB vs. controls were significantly upregulated. Verification of D(1)- or D(2)-receptor changes to changes in meal number and size at anorexia was made by injection of intra-VMN or -LHA dopaminergic receptor antagonists. Intra-VMN D(1)-receptor antagonist (SCH-23390) in TB rats decreased food intake mainly via a decrease in meal size. Intra-VMN D(2)-receptor antagonist (sulpiride) in TB rats increased food intake via an increase in meal number and in NTB free-feeding rats by an increase in meal size. Intra-LHA D(1)-receptor antagonist in TB rats had no effect on food intake or feeding pattern. Intra-LHA D(2)-receptor antagonist in TB and in NTB free-feeding rats increased food intake via an increase in meal number. Our data provide evidence that postsynaptic dopaminergic receptor subtypes in the hypothalamus are involved in the regulation of meal size, meal number, and thus food intake in anorectic TB rats.

Heterogeneous response of adipose tissue to cancer cachexia

Cancer cachexia causes disruption of lipid metabolism. Since it has been well established that the various adipose tissue depots demonstrate different responses to stimuli, we assessed the effect of cachexia on some biochemical and morphological parameters of adipocytes obtained from the mesenteric (MES), retroperitoneal (RPAT), and epididymal (EAT) adipose tissues of rats bearing Walker 256 carcinosarcoma, compared with controls. Relative weight and total fat content of tissues did not differ between tumor-bearing rats and controls, but fatty acid composition was modified by cachexia. Adipocyte dimensions were increased in MES and RPAT from tumor-bearing rats, but not in EAT, in relation to control. Ultrastructural alterations were observed in the adipocytes of tumor-bearing rat RPAT (membrane projections) and EAT (nuclear bodies).

Gender differences in tumor-induced anorectic feeding pattern in Fischer-344 rats

Gender differences of feeding pattern in normal male and female rats are well recognized. Differences in gender-related feeding patterns have also been established following a variety of experimental manipulations, such as hypothalamic lesions, nicotine infusion, and total parenteral nutrition administration. Anorexia is a common feature during tumor growth. The present study examined whether the feeding indices constituting the feeding patterns differed with the development of cancer anorexia in male and female rats. Sixteen male and 15 female Fischer-344 rats had their food intake (FI) and feeding indices, meal number (MN) and meal size (MZ), continuously measured by a computerized rat eater meter. Viable methylcholanthrene (MCA) sarcoma cells (10(6)) were inoculated subcutaneously in 10 male (M-TB) and 8 female (F-TB) Fischer rats, while the rest were controls and received an equal volume of vehicle. Tumor-bearing (TB) rats became anorectic by Day 18, when the weight of the tumor was approximately 8% of the total body weight (BW). A notable decrease in BW was observed in both M-TB and F-TB. A decrease in FI resulted from different feeding indices between male and female rats. In male rats, lower FI was due to a decrease in both MN and MZ. In female rats, lower FI was solely due to a decrease in MN. The data show that gender differences in feeding patterns, which are an external manifestation of biochemical changes in the brain, occur following development of cancer-related anorexia suggesting that besides other factors, cancer anorexia is also influenced by sex-related hormones.

Inhibin and p27 interact to regulate gonadal tumorigenesis

Tumor suppressors function as antiproliferative signaling proteins, and defects in these genes lead to uncontrolled cell proliferation and cancer. For example, absence of the tumor suppressor p27(Kip1), a cyclin-dependent kinase inhibitor (CKI), results in increased body size, hyperplasia of several organs including the testes, and cancer in mice. Similarly, lack of inhibins, alpha/beta heterodimeric members of the transforming growth factor-beta (TGFbeta) superfamily, causes testicular and ovarian tumors of the granulosa/Sertoli cell lineage beginning at 4 weeks of age and adrenal tumors in gonadectomized mice. Neither the cell cycle alterations in the absence of inhibin nor the cause of the increased testis size in the p27 knockout mice is known. To study the molecular (cell cycle) changes that result from absence of inhibins, we analyzed the regulation of cell cycle proteins in gonadal tumors derived from inhibin alpha knockout mice (Inha(-/-)). Northern blot analyses demonstrate that cyclin-dependent kinase 4 (Cdk4) and cyclin D2 mRNA levels are elevated, and immunohistochemistry shows that p27 protein levels are decreased in both ovarian and testicular tumors from Inha(-/-) mice. These findings suggest that increased Cdk4/cyclin D2 (positive) activity and decreased p27 (negative) activity is causal for gonadal tumor formation. To test this hypothesis, we generated double mutant mice lacking both p27 and inhibin alpha to determine whether the tumor suppressors p27 and inhibin have additive suppressor activity in the gonads. Like Inha(-/-) mice, p27(-/-)Inha(-/-) mice demonstrate elevated serum activin levels, ovarian and testicular tumors, and a resultant lethal cachexia-like syndrome. However, whereas 95% of the Inha(-/-) female mice die by 18 weeks of age, 100% of the p27(-/-)Inha(-/-) female mice are dead by 8 weeks. Similarly, 95% of the Inha(-/-) single mutant males die by 13 weeks while 100% of the p27(-/-)Inha(-/-) male mice die by 10 weeks. Moreover, tumor foci in p27(-/-)Inha(-/-) mice can be observed as early as 2 weeks of age in males and as early as 4 weeks in females. These findings demonstrate that absence of both inhibin and p27 in mice causes earlier development of ovarian and testicular tumors and earlier death compared with absence of inhibin alone.

Feeding behavior during sialodacryoadenitis viral infection in rats

Sialodacryoadenitis (SDA) is a highly contagious common viral infection in rats, akin to mumps in humans. Anorexia occurs during such viral infection. But the pattern of the decrease in food intake (a decrease in either meal size and meal number or both) during spontaneous viral infection has not been previously characterized. We observed the onset of anorexia and an abnormal feeding pattern during an opportunistic SDA viral infection in our rat colony. We thus studied seven male rats. Before the viral infection there was a positive association between food intake and meal number (P<.05). After infection food intake decreased by 68%. This occurred via a significant decrease in meal size (by 69%) (P<.05); and a nonsignificant decrease in meal number (P=.71). This pattern of decreased food intake is similar to that occurring during indomethacin-induced ulcerative ileitis, where we previously measured an increase in plasma tumor-necrosis factor (TNF)-alpha. Anorexia in response to bacterial lipopolysaccharide administration, which is also linked to plasma TNF-alpha, is however, caused only via a decrease in meal number. The differences in the decrease in the feeding pattern between the SDA viral and a bacterial infection suggest that factors other than TNF-alpha alone play a significant role in the mechanism of anorexia during a viral infection.

Effect of cytokines on hypothalamic neuropeptide Y release in vitro

Studies involving altered energy balance states in rodents have demonstrated that hypothalamic neuropeptide Y (NPY) activity is strongly activated in states of negative energy balance, such as periods of dietary restriction or starvation. However, in cancer cachexia, when there is a significant reduction in body weight as a result of appetite loss, leading to loss in fat and lean tissue mass, there is no augmentation in the activity of the hypothalamic NPY system. Therefore, we have examined whether cytokines, interleukin (IL)-1, IL-1beta, IL-6, and tumor-necrosis factor-alpha (TNF-alpha; cachectin), which are elevated in cancer patients, can attenuate NPY release from hypothalamic slices in vitro. None of the cytokines altered either the basal or stimulated NPY release from the hypothalamic slices. However, we were able to measure a significant reduction in potassium-stimulated NPY release (-60%) by using the nonselective voltage-dependent calcium channel blocker NiCl (30 microM) without any effect on basal release, as a positive control. Therefore, we suggest that the failure to activate the hypothalamic NPY system in states of cancer cachexia cannot be attributed to a cytokine-induced reduction in neurotransmitter release.

Use of recombinant human soluble TNF receptor in anorectic tumor-bearing rats

With progression of tumor growth, rats demonstrate anorexia and reduced food intake, a function of meal number and meal size. Tumor necrosis factor-alpha (TNF-alpha), a recognized anorectic agent, reacts with two different receptors (type I: 55 kDa; type II: 75 kDa). We used a dimeric, pegylated 55-kDa TNF receptor construct to test its effects on food intake, meal number, and meal size, which were continuously measured with a rat eater meter in 16 Fischer 344 male rats injected with 10(6) viable methylcholanthrene cells. When anorexia developed, rats received a subcutaneous injection of either 0.25 mg/kg body wt of soluble TNF receptor construct (study) or vehicle (tumor-bearing control). Before TNF inhibitor injection, no differences were observed in food intake, meal number, or meal size between the two groups. After the TNF inhibitor injection, study vs. control rats significantly improved food intake as a result of an increase in meal number and meal size. Rats also showed a significant improvement in body weight. These data suggest that TNF-alpha, in addition to other cytokines, contributes to the anorexia of tumor growth, probably mediated via the hypothalamus.

Plasma amino acid concentrations in patients with acute myelogenous leukemia

Changes in plasma-free amino acid (PFAA) concentrations in the presence of solid tumors have been widely described. Conversely, the PFAA profile in patients with acute leukemias is less well defined. The aim of the present study was to clarify whether the PFAA profile is altered in patients with acute myeloid leukemia (AML), whether the profile differs from the PFAA profile of solid tumors, and whether it may predict outcome of AML. Fasting PFAA were measured in 40 untreated, normally nourished patients with AML (17 males, 23 females), ages 22-78 y, with white blood cell (WBC) counts ranging from 1.08 to 276.5 x 10(3)/cm2, and in 24 healthy volunteers. Plasma concentrations (mu mol/L, mean +/- SE) of glutamic acid (GLU), free tryptophan (FTRP), ornithine (ORN), and glycine (GLY) were significantly higher in AML (GLU: 90.2 +/- 6.1 versus 37 +/- 8; FTRP: 7.0 +/- 0.6 versus 4.8 +/- 0.3, P < 0.005; ORN: 108.7 +/- 5.8 versus 78 +/- 6, P < 0.001; GLY: 295.0 +/- 14.8 versus 239 +/- 9, P < 0.01), whereas serine (SER), methionine (MET), and taurine (TAU) were significantly lower in AML than in controls (SER: 109.0 +/- 5.8 versus 130 +/- 4, P < 0.03; MET: 25.5 +/- 1.3 versus 33 +/- 3, P < 0.03; TAU: 46.5 +/- 3.5 versus 81 +/- 2, P < 0.001), and tended to be even lower in patients who had not responded to chemotherapy or had relapsed within 18 mo of enrollment. Such changes were unrelated to age, sex, and WBC count. Changes in PFAA that occur in AML are only in part similar to those observed in solid tumors. The reduction of TAU appears to be a typical feature of AML and might be secondary to the deficiency of its precursors SER and MET. Further studies are under way aimed at clarifying whether PFAA might predict prognosis in AML, whether PFAA is normalized by remission induction, and if its correction may be of any benefit for patients with hematologic malignancies.

Interventional nutrition for the cancer patient

Dogs and cats with cancer have significant alterations in carbohydrate, protein, and fat metabolism, which can result in cancer cachexia and subsequently can decrease quality of life, reduce response to therapy, and shorten survival time. Nutritional modulation may be beneficial in the treatment of cancer patients to reverse these metabolic alterations. There is evidence that foods relatively low in simple carbohydrates with moderate amounts of high-quality protein, fiber, and fat (especially fats of the omega-3 fatty acid series) are beneficial for pets with cancer. In addition, certain supplemental nutrients may have potential to reduce the risk of developing cancer, or the growth and metastases of established malignant disease. Nutritional intervention can be a powerful tool for controlling malignant disease and for reducing toxicity associated with chemotherapy and radiation therapy.

The effect of Walker-256 tumour development upon Kupffer cell metabolism

The liver plays a central role in the establishment and maintenance of the cachectic state in rats bearing extra-hepatic tumours. Kupffer cells, which as macrophages, show a strong relationship between metabolism and function could be involved in the alterations observed in the disruption of many functions of the organ as a whole. To assess whether the metabolic/functional pattern of Kupffer cells was altered by cachexia we have investigated the utilization of glucose, glutamine and palmitate by the cells from tumour-bearing and control rats. We have found an enhanced utilization of the three substrates by the cells from tumour-bearing rats as compared with controls, which was related to greater energy production through the Krebs cycle and enhanced production of precursors for the synthesis of the many substances the cells secrete when activated. The use of palmitate as substrate was also augmented in these cells, in the opposition to the observation in stimulated peritoneal macrophages. The availability of palmitate however, was not associated with a reduction of glucose or glutamine consumption. The cycle of interconversion, free fatty acids/triacyglycerol in Kupffer cells from tumour-bearing rats was also found to be increased, as was hydrogen peroxide production. Taken together the results suggest an increased utilization of substrates for both energy production and for synthetic processes (e.g. NADPH for hydrogen peroxide production).

C-reactive protein as an outcome predictor for maintenance hemodialysis patients

BACKGROUND

The possible association between inflammatory processes and other outcome measures in ESRD patients led us to measure the blood C-reactive protein (CRP) concentration in a large sample of hemodialysis patients, and to evaluate its statistical relationship with other common laboratory measures and patient survival. This was performed in a prospective, observational analysis with mortality as the principal outcome measure.

METHODS

One thousand fifty-four routine blood samples, collected from as many patients during June and July 1995 (one sample per patient), were randomly selected for measurement of CRP, prealbumin, and other routine laboratory measures. Six months after the initial blood tests, patient survival was determined: Logistic regression analysis was the primary statistical tool used to evaluate laboratory associations with odds of death. Bivariate regression and correlation analyses were performed using all available data.

RESULTS

The distribution of CRP values was skewed; approximately 35% of the values exceeded the upper limit of the laboratory's reference range. Serum albumin and prealbumin concentrations both correlated with the serum creatinine concentration (r = 0.378 and r = 0.347, respectively; P's < 0.001), and were inversely associated with the CRP (r = -0.254 and r = -0.354, respectively; P's < 0.001). CRP was also inversely associated with blood hemoglobin concentrations (r = -0.235; P < 0.001). Using multiple regression analysis to further explore these relationships, the serum creatinine concentration was inversely associated with CRP (r = -0.140; P < 0.001). However, after adjustment for the linkage of the serum creatinine with the serum albumin concentration (r = -0.378; P < 0.001), no relationship with creatinine was observed. Before and after adjustment for serum albumin and prealbumin concentration, the ferritin concentration correlated directly with CRP (r = 0.148; P < 0.001). Ferritin was inversely and highly correlated with total iron binding capacity (r = -0.516; P < 0.001). Independent associations of hemoglobin with albumin (t = 7.16; P < 0.001), prealbumin (t = 2.39; P = 0.017), and CRP (t = -4.27; P < 0.001) were observed. Also, the dose of erythropoietin was directly associated with the CRP concentration, before (r = 0.081, P = 0.009) and after (t = 2.03, P = 0.042) adjustment for the serum albumin and iron concentrations. CRP correlated directly with neutrophil (r = 0.318; P < 0.001) and platelet counts (r = 0.180; P < 0.001), but was weakly and inversely correlated with the lymphocyte count (r = -0.071; P = 0.04). A logistic regression analysis performed using the laboratory variables revealed a strong, independent, and inverse relationships between the serum albumin and creatinine concentrations, total lymphocyte count, and the odds risk of death. In this model, no significant relationship was observed between the odds risk of death and CRP.

CONCLUSIONS

The data presented herein suggest that: (1) strong predictable associations exist among laboratory proxies for malnutrition, anemia, and the acute phase reaction, and (2) the pathobiology implied by these laboratory abnormalities influence patients' mortal risk primarily through depletion of vital body proteins, not inflammation.

The effect of clenbuterol and recombinant erythropoietin on tumor growth and the anemia caused by the Walker 256 carcinosarcoma

In patients with advanced cancer, anemia is a common complication indicative of a poor prognosis. Attempts to alleviate this have met with mixed success and interventions including erythropoietin often fail to elicit an appropriate response. We have used rats implanted with the Walker 256 carcinosarcoma as a model of non-responsive anemia. This study demonstrates that the provision of recombinant erythropoietin in the presence of clenbuterol, a beta2 agonist, attenuates both the cancer induced anemia and the growth of the tumor in this model. We hypothesize that this treatment relieves the tumor induced inhibition of hematopoiesis, which allows for not only an increase in hematocrit but an increased immunosurveillance resulting in tumor suppression.