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Pedersini R, Schivardi G, Laini L, Zamparini M, Bonalumi A, di Mauro P, Bosio S, Amoroso V, Villa N, Alberti A, Di Meo N, Gonano C, Zanini B, Laganà M, Ippolito G, Rinaudo L, Farina D, Castellano M, Cappelli C, Simoncini EL, Cosentini D, Berruti A. Changes in body composition in early breast cancer patients treated with aromatase inhibitors. J Endocrinol Invest 2024:10.1007/s40618-024-02401-7. [PMID: 38856966 DOI: 10.1007/s40618-024-02401-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/16/2023] [Accepted: 05/20/2024] [Indexed: 06/11/2024]
Abstract
PURPOSE The aim of the study was to analyze the modification of total and regional body composition in early breast cancer patients treated with aromatase inhibitors (AIs). METHODS This is a prospective, single-center, observational, longitudinal study. Four-hundred and twenty-eight patients treated with adjuvant aromatase inhibitors were enrolled at the Medical Oncology and Breast Unit of Spedali Civili Hospital in Brescia from September 2014 to June 2022. Several body composition parameters including total and regional fat and lean body mass were investigated with dual-energy X-ray absorptiometry (DXA) scan at baseline and after 18 months of treatment with aromatase inhibitors. RESULTS A significant increase in fat body mass (mean + 7.2%, 95% confidence interval [CI]: 5.5;8.9%) and a reduction in lean body mass (mean -3.1%, 95% CI -3.9; -2.4) were documented in this population. The changes in fat and lean body mass varied considerably according to different body districts ranging between + 3.2% to + 10.9% and from-1.3% to -3.9%, respectively. CONCLUSION Aromatase inhibitor adjuvant therapy in early breast cancer is associated with changes in body composition, with a wide variability among different body districts, leading to a risk of sarcopenic obesity. Supervised physical exercise that focuses on single body parts that may display detrimental variations may be beneficial for AIs treated patients.
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Affiliation(s)
- R Pedersini
- Medical Oncology Department, ASST Spedali Civili of Brescia, Piazzale Spedali Civili 1, 20123, Brescia, Italy
- SSVD Breast Unit, ASST Spedali Civili of Brescia, Brescia, Italy
| | - G Schivardi
- Medical Oncology Department, ASST Spedali Civili of Brescia, Piazzale Spedali Civili 1, 20123, Brescia, Italy.
| | - L Laini
- Medical Oncology Department, ASST Spedali Civili of Brescia, Piazzale Spedali Civili 1, 20123, Brescia, Italy
| | - M Zamparini
- Medical Oncology Department, ASST Spedali Civili of Brescia, Piazzale Spedali Civili 1, 20123, Brescia, Italy
| | - A Bonalumi
- Medical Oncology Department, ASST Spedali Civili of Brescia, Piazzale Spedali Civili 1, 20123, Brescia, Italy
| | - P di Mauro
- Medical Oncology Department, ASST Spedali Civili of Brescia, Piazzale Spedali Civili 1, 20123, Brescia, Italy
| | - S Bosio
- SSVD Breast Unit, ASST Spedali Civili of Brescia, Brescia, Italy
| | - V Amoroso
- Medical Oncology Department, ASST Spedali Civili of Brescia, Piazzale Spedali Civili 1, 20123, Brescia, Italy
| | - N Villa
- Medical Oncology Department, ASST Spedali Civili of Brescia, Piazzale Spedali Civili 1, 20123, Brescia, Italy
| | - A Alberti
- Medical Oncology Department, ASST Spedali Civili of Brescia, Piazzale Spedali Civili 1, 20123, Brescia, Italy
| | - N Di Meo
- Department of Medical and Surgical Specialties, Radiological Sciences and Public Health, Medical Oncology, University of Brescia, ASST Spedali Civili, Brescia, Italy
| | - C Gonano
- Medical Oncology Department, ASST Spedali Civili of Brescia, Piazzale Spedali Civili 1, 20123, Brescia, Italy
| | - B Zanini
- Department of Clinical and Experimental Sciences, University of Brescia, Brescia, Italy
| | - M Laganà
- Medical Oncology Department, ASST Spedali Civili of Brescia, Piazzale Spedali Civili 1, 20123, Brescia, Italy
| | - G Ippolito
- Medical Oncology Department, ASST Spedali Civili of Brescia, Piazzale Spedali Civili 1, 20123, Brescia, Italy
| | - L Rinaudo
- Tecnologie Avanzate Srl, Turin, Italy
| | - D Farina
- Department of Medical and Surgical Specialties, Radiological Sciences and Public Health, Medical Oncology, University of Brescia, ASST Spedali Civili, Brescia, Italy
| | - M Castellano
- Department of Internal Medicine and Endocrinology, University of Brescia, ASST Spedali Civili, Brescia, Italy
| | - C Cappelli
- Department of Internal Medicine and Endocrinology, University of Brescia, ASST Spedali Civili, Brescia, Italy
| | - E L Simoncini
- SSVD Breast Unit, ASST Spedali Civili of Brescia, Brescia, Italy
| | - D Cosentini
- Medical Oncology Department, ASST Spedali Civili of Brescia, Piazzale Spedali Civili 1, 20123, Brescia, Italy
| | - A Berruti
- Medical Oncology Department, ASST Spedali Civili of Brescia, Piazzale Spedali Civili 1, 20123, Brescia, Italy
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Thomas NS, Scalzo RL, Wellberg EA. Diabetes mellitus in breast cancer survivors: metabolic effects of endocrine therapy. Nat Rev Endocrinol 2024; 20:16-26. [PMID: 37783846 DOI: 10.1038/s41574-023-00899-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 09/01/2023] [Indexed: 10/04/2023]
Abstract
Breast cancer is the most common invasive malignancy in the world, with millions of survivors living today. Type 2 diabetes mellitus (T2DM) is also a globally prevalent disease that is a widely studied risk factor for breast cancer. Most breast tumours express the oestrogen receptor and are treated with systemic therapies designed to disrupt oestrogen-dependent signalling. Since the advent of targeted endocrine therapy six decades ago, the mortality from breast cancer has steadily declined; however, during the past decade, an elevated risk of T2DM after breast cancer treatment has been reported, particularly for those who received endocrine therapy. In this Review, we highlight key events in the history of endocrine therapies, beginning with the development of tamoxifen. We also summarize the sequence of reported adverse metabolic effects, which include dyslipidaemia, hepatic steatosis and impaired glucose tolerance. We discuss the limitations of determining a causal role for breast cancer treatments in T2DM development from epidemiological data and describe informative preclinical studies that suggest complex mechanisms through which endocrine therapy might drive T2DM risk and progression. We also reinforce the life-saving benefits of endocrine therapy and highlight the need for better predictive biomarkers of T2DM risk and preventive strategies for the growing population of breast cancer survivors.
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Affiliation(s)
- Nisha S Thomas
- Department of Pathology, University of Oklahoma Health Sciences Center, Oklahoma City, OK, USA
- Stephenson Cancer Center, Oklahoma City, OK, USA
- Harold Hamm Diabetes Center, Oklahoma City, OK, USA
| | - Rebecca L Scalzo
- Division of Endocrinology, Metabolism and Diabetes, Department of Medicine, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
- Rocky Mountain Regional VA Medical Center, Aurora, CO, USA
| | - Elizabeth A Wellberg
- Department of Pathology, University of Oklahoma Health Sciences Center, Oklahoma City, OK, USA.
- Stephenson Cancer Center, Oklahoma City, OK, USA.
- Harold Hamm Diabetes Center, Oklahoma City, OK, USA.
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3
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Cheung YMM, Hoermann R, Van K, Wu D, Healy J, Chao M, White S, Yeo B, Zajac J, Grossmann M. Effects of aromatase inhibitor therapy on visceral adipose tissue area and cardiometabolic health in postmenopausal women with early and locally advanced breast cancer. Clin Endocrinol (Oxf) 2023; 98:190-201. [PMID: 36271726 DOI: 10.1111/cen.14839] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/19/2022] [Revised: 10/20/2022] [Accepted: 10/21/2022] [Indexed: 01/04/2023]
Abstract
OBJECTIVE Aromatase inhibitor (AI) therapy provides oncological benefits in postmenopausal women with oestrogen receptor-positive breast cancer. However, AI treatment has been associated with increased cardiovascular risk. In nonbreast cancer populations, experimentally induced low oestrogen states and natural transition to menopause have been associated with increases in visceral adipose tissue (VAT), a known surrogate marker for cardiometabolic risk. Given that AI treatment blocks oestradiol production, we hypothesized that AI treatment would increase VAT. METHODS We conducted a prospective 12-month cohort study of 52 postmenopausal women newly initiating AI treatment (median age: 64.5 years) and 52 women with breast pathology not requiring endocrine therapy (median age: 63.5 years). VAT area and other body composition parameters were measured at baseline, 6 months and 12 months using dual X-ray absorptiometry. Other risk markers of cardiometabolic health were also assessed. RESULTS In women initiating AI treatment, there was no statistically significant difference in VAT area after 12 months when compared to controls, with a mean adjusted difference of -5.00 cm2 (-16.9, 6.91), p = .55. Moreover, changes in total fat mass, lean mass, subcutaneous adipose tissue area, hepatic steatosis and measures in endothelial function were also not statistically different between groups after 12 months. Findings were similar after adjustments for activity levels and coronavirus disease 2019 lockdown duration. CONCLUSIONS These data provide reassurance that over the initial 12 months of AI therapy, AI treatment is not associated with metabolically adverse changes in body composition, hepatic steatosis or vascular reactivity. The impact of extended AI therapy on cardiometabolic health requires further study.
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Affiliation(s)
- Yee-Ming M Cheung
- Department of Medicine, Austin Health, The University of Melbourne, Heidelberg, Victoria, Australia
- Department of Endocrinology, Austin Health, Heidelberg, Victoria, Australia
| | - Rudolf Hoermann
- Department of Medicine, Austin Health, The University of Melbourne, Heidelberg, Victoria, Australia
| | - Karen Van
- Department of Endocrinology, Austin Health, Heidelberg, Victoria, Australia
| | - Damian Wu
- Department of Medicine, Austin Health, The University of Melbourne, Heidelberg, Victoria, Australia
| | - Jenny Healy
- Department of Medicine, Austin Health, The University of Melbourne, Heidelberg, Victoria, Australia
| | - Michael Chao
- Olivia Newton-John Cancer Wellness and Research Centre, Heidelberg, Victoria, Australia
| | - Shane White
- Olivia Newton-John Cancer Wellness and Research Centre, Heidelberg, Victoria, Australia
- Department of Medical Oncology, Austin Health, Heidelberg, Victoria, Australia
| | - Belinda Yeo
- Olivia Newton-John Cancer Wellness and Research Centre, Heidelberg, Victoria, Australia
- Department of Medical Oncology, Austin Health, Heidelberg, Victoria, Australia
| | - Jeffrey Zajac
- Department of Medicine, Austin Health, The University of Melbourne, Heidelberg, Victoria, Australia
- Department of Endocrinology, Austin Health, Heidelberg, Victoria, Australia
| | - Mathis Grossmann
- Department of Medicine, Austin Health, The University of Melbourne, Heidelberg, Victoria, Australia
- Department of Endocrinology, Austin Health, Heidelberg, Victoria, Australia
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4
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Poltronieri TS, Pérsico RS, Falcetta FS, Viana LV. Changes in Body Adiposity in Women Undergoing Breast Cancer Treatment: A Scoping Review. Nutr Cancer 2022; 74:3431-3445. [DOI: 10.1080/01635581.2022.2081341] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Affiliation(s)
- Taiara S. Poltronieri
- Graduate Program in Medical Sciences, Endocrinology, Faculdade de Medicina, Universidade Federal do Rio Grande do Sul, Porto Alegre, Rio Grande do Sul, Brazil
- Hospital de Clinicas de Porto Alegre, Porto Alegre, Rio Grande do Sul, Brazil
| | - Raquel S. Pérsico
- Graduate Program in Medical Sciences, Endocrinology, Faculdade de Medicina, Universidade Federal do Rio Grande do Sul, Porto Alegre, Rio Grande do Sul, Brazil
- Hospital de Clinicas de Porto Alegre, Porto Alegre, Rio Grande do Sul, Brazil
| | - Frederico S. Falcetta
- Graduate Program in Medical Sciences, Endocrinology, Faculdade de Medicina, Universidade Federal do Rio Grande do Sul, Porto Alegre, Rio Grande do Sul, Brazil
- Hospital de Clinicas de Porto Alegre, Porto Alegre, Rio Grande do Sul, Brazil
| | - Luciana V. Viana
- Graduate Program in Medical Sciences, Endocrinology, Faculdade de Medicina, Universidade Federal do Rio Grande do Sul, Porto Alegre, Rio Grande do Sul, Brazil
- Hospital de Clinicas de Porto Alegre, Porto Alegre, Rio Grande do Sul, Brazil
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5
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Scalzo RL, Foright RM, Hull SE, Knaub LA, Johnson-Murguia S, Kinanee F, Kaplan J, Houck JA, Johnson G, Sharp RR, Gillen AE, Jones KL, Zhang AMY, Johnson JD, MacLean PS, Reusch JEB, Wright-Hobart S, Wellberg EA. Breast Cancer Endocrine Therapy Promotes Weight Gain With Distinct Adipose Tissue Effects in Lean and Obese Female Mice. Endocrinology 2021; 162:bqab174. [PMID: 34410380 PMCID: PMC8455348 DOI: 10.1210/endocr/bqab174] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/24/2021] [Indexed: 12/19/2022]
Abstract
Breast cancer survivors treated with tamoxifen and aromatase inhibitors report weight gain and have an elevated risk of type 2 diabetes, especially if they have obesity. These patient experiences are inconsistent with, preclinical studies using high doses of tamoxifen which reported acute weight loss. We investigated the impact of breast cancer endocrine therapies in a preclinical model of obesity and in a small group of breast adipose tissue samples from women taking tamoxifen to understand the clinical findings. Mature female mice were housed at thermoneutrality and fed either a low-fat/low-sucrose (LFLS) or a high-fat/high-sucrose (HFHS) diet. Consistent with the high expression of Esr1 observed in mesenchymal stem cells from adipose tissue, endocrine therapy was associated with adipose accumulation and more preadipocytes compared with estrogen-treated control mice but resulted in fewer adipocyte progenitors only in the context of HFHS. Analysis of subcutaneous adipose stromal cells revealed diet- and treatment-dependent effects of endocrine therapies on various cell types and genes, illustrating the complexity of adipose tissue estrogen receptor signaling. Breast cancer therapies supported adipocyte hypertrophy and associated with hepatic steatosis, hyperinsulinemia, and glucose intolerance, particularly in obese females. Current tamoxifen use associated with larger breast adipocyte diameter only in women with obesity. Our translational studies suggest that endocrine therapies may disrupt adipocyte progenitors and support adipocyte hypertrophy, potentially leading to ectopic lipid deposition that may be linked to a greater type 2 diabetes risk. Monitoring glucose tolerance and potential interventions that target insulin action should be considered for some women receiving life-saving endocrine therapies for breast cancer.
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Affiliation(s)
- Rebecca L Scalzo
- Division of Endocrinology, Metabolism & Diabetes, Department of Medicine; University of Colorado Anschutz Medical Campus, Aurora, CO 80045, USA
- Center for Women’s Health Research; University of Colorado Anschutz Medical Campus, Aurora, CO 80045, USA
- Rocky Mountain Regional VA Medical Center, Aurora, CO 80045, USA
| | - Rebecca M Foright
- Department of Anatomy and Cell Biology, University of Kansas Medical Center, Kansas City, KS 66160, USA
| | - Sara E Hull
- Division of Endocrinology, Metabolism & Diabetes, Department of Medicine; University of Colorado Anschutz Medical Campus, Aurora, CO 80045, USA
| | - Leslie A Knaub
- Division of Endocrinology, Metabolism & Diabetes, Department of Medicine; University of Colorado Anschutz Medical Campus, Aurora, CO 80045, USA
| | - Stevi Johnson-Murguia
- Department of Pathology, University of Oklahoma Health Sciences Center, Stephenson Cancer Center, Harold Hamm Diabetes Research Center, Oklahoma City, OK 73104, USA
| | - Fotobari Kinanee
- Department of Pathology, University of Colorado Anschutz Medical Campus, Aurora, CO 80045, USA
| | - Jeffrey Kaplan
- Department of Pathology, University of Colorado Anschutz Medical Campus, Aurora, CO 80045, USA
| | - Julie A Houck
- Division of Endocrinology, Metabolism & Diabetes, Department of Medicine; University of Colorado Anschutz Medical Campus, Aurora, CO 80045, USA
| | - Ginger Johnson
- Division of Endocrinology, Metabolism & Diabetes, Department of Medicine; University of Colorado Anschutz Medical Campus, Aurora, CO 80045, USA
| | - Rachel R Sharp
- Department of Cell Biology, University of Oklahoma Health Sciences Center, Stephenson Cancer Center, Harold Hamm Diabetes Research Center, Oklahoma City, OK 73104, USA
| | - Austin E Gillen
- Division of Hematology, Department of Medicine, University of Colorado Anschutz Medical Campus, Aurora, CO 80045, USA
| | - Kenneth L Jones
- Department of Cell Biology, University of Oklahoma Health Sciences Center, Stephenson Cancer Center, Harold Hamm Diabetes Research Center, Oklahoma City, OK 73104, USA
| | - Anni M Y Zhang
- Diabetes Research Group, Life Sciences Institute, Department of Cellular and Physiological Sciences, Faculty of Medicine, University of British Columbia, Vancouver, BC, Canada
| | - James D Johnson
- Diabetes Research Group, Life Sciences Institute, Department of Cellular and Physiological Sciences, Faculty of Medicine, University of British Columbia, Vancouver, BC, Canada
| | - Paul S MacLean
- Division of Endocrinology, Metabolism & Diabetes, Department of Medicine; University of Colorado Anschutz Medical Campus, Aurora, CO 80045, USA
- Center for Women’s Health Research; University of Colorado Anschutz Medical Campus, Aurora, CO 80045, USA
- Department of Pathology, University of Colorado Anschutz Medical Campus, Aurora, CO 80045, USA
| | - Jane E B Reusch
- Division of Endocrinology, Metabolism & Diabetes, Department of Medicine; University of Colorado Anschutz Medical Campus, Aurora, CO 80045, USA
- Center for Women’s Health Research; University of Colorado Anschutz Medical Campus, Aurora, CO 80045, USA
- Rocky Mountain Regional VA Medical Center, Aurora, CO 80045, USA
| | - Sabrina Wright-Hobart
- Department of Pathology, University of Colorado Anschutz Medical Campus, Aurora, CO 80045, USA
| | - Elizabeth A Wellberg
- Center for Women’s Health Research; University of Colorado Anschutz Medical Campus, Aurora, CO 80045, USA
- Department of Pathology, University of Oklahoma Health Sciences Center, Stephenson Cancer Center, Harold Hamm Diabetes Research Center, Oklahoma City, OK 73104, USA
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Estrada-Meza J, Videlo J, Bron C, Saint-Béat C, Silva M, Duboeuf F, Peyruchaud O, Rajas F, Mithieux G, Gautier-Stein A. Tamoxifen Treatment in the Neonatal Period Affects Glucose Homeostasis in Adult Mice in a Sex-Dependent Manner. Endocrinology 2021; 162:6277101. [PMID: 33999998 DOI: 10.1210/endocr/bqab098] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/15/2021] [Indexed: 12/11/2022]
Abstract
Tamoxifen is a selective estrogen receptor modulator used to activate the CREERT2 recombinase, allowing tissue-specific and temporal control of the somatic mutagenesis to generate transgenic mice. Studies integrating development and metabolism require a genetic modification induced by a neonatal tamoxifen administration. Here, we investigate the effects of a neonatal tamoxifen administration on energy homeostasis in adult male and female C57BL/6J mice. C57BL/6J male and female mouse pups received a single injection of tamoxifen 1 day after birth (NTT) and were fed a high-fat/high-sucrose diet at 6 weeks of age. We measured weight, body composition, glucose and insulin tolerance, basal metabolism, and tibia length and weight in adult mice. The neonatal tamoxifen administration exerted long-term, sex-dependent effects on energy homeostasis. NTT female mice became overweight and developed impaired glucose control in comparison to vehicle-treated littermates. NTT females exhibited 60% increased fat mass, increased food intake, decreased physical activity and energy expenditure, impaired glucose and insulin tolerance, and fasting hyperglycemia and hyperinsulinemia. In contrast, NTT male mice exhibited a modest amelioration of glucose and insulin tolerance and long-term decreased lean mass linked to decreased bone weight. These results suggest that the neonatal tamoxifen administration exerted a marked and sex-dependent influence on adult energy homeostasis and bone weight and must therefore be used with caution for the development of transgenic mouse models regarding studies on energy homeostasis and bone biology.
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Affiliation(s)
- Judith Estrada-Meza
- Université Claude Bernard Lyon 1, Université de Lyon, INSERM UMR-S1213, Lyon, France
| | - Jasmine Videlo
- Université Claude Bernard Lyon 1, Université de Lyon, INSERM UMR-S1213, Lyon, France
| | - Clara Bron
- Université Claude Bernard Lyon 1, Université de Lyon, INSERM UMR-S1213, Lyon, France
| | - Cécile Saint-Béat
- Université Claude Bernard Lyon 1, Université de Lyon, INSERM UMR-S1213, Lyon, France
| | - Marine Silva
- Université Claude Bernard Lyon 1, Université de Lyon, INSERM UMR-S1213, Lyon, France
| | - François Duboeuf
- Université Claude Bernard Lyon 1, Université de Lyon, INSERM UMR-S1033, Lyon, France
| | - Olivier Peyruchaud
- Université Claude Bernard Lyon 1, Université de Lyon, INSERM UMR-S1033, Lyon, France
| | - Fabienne Rajas
- Université Claude Bernard Lyon 1, Université de Lyon, INSERM UMR-S1213, Lyon, France
| | - Gilles Mithieux
- Université Claude Bernard Lyon 1, Université de Lyon, INSERM UMR-S1213, Lyon, France
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Lee TJ, Cho JM, Jo T, Han WY, Maldonado AA, Eom JS, Kim EK. Volumetric changes of the pedicled transverse rectus abdominis musculocutaneous flap and the contralateral native breast during long-term follow-up. ARCHIVES OF AESTHETIC PLASTIC SURGERY 2019. [DOI: 10.14730/aaps.2019.01690] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
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8
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Cheung YM, Ramchand SK, Yeo B, Grossmann M. Cardiometabolic Effects of Endocrine Treatment of Estrogen Receptor-Positive Early Breast Cancer. J Endocr Soc 2019; 3:1283-1301. [PMID: 31259291 PMCID: PMC6595530 DOI: 10.1210/js.2019-00096] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/09/2019] [Accepted: 05/01/2019] [Indexed: 12/15/2022] Open
Abstract
Estrogen receptor-positive early breast cancer is common and has a relatively good prognosis. It shares risk factors with cardiovascular disease, and cardiovascular disease is an important competing cause of mortality. Adjuvant endocrine therapy with aromatase inhibitors (requiring concomitant ovarian suppression in premenopausal women) or selective estrogen receptor modulators (usually tamoxifen) exert oncologic benefits by respectively inhibiting estradiol synthesis or breast estrogen receptor signaling. Aromatase inhibitors cause systemic estradiol depletion. Tamoxifen has mixed agonistic/antagonistic effects in a tissue-dependent fashion. Given that estrogens modulate cardiometabolic risk, a review of the effects of endocrine therapy on cardiometabolic outcomes is pertinent. The current, but limited, evidence suggests that tamoxifen treatment, although associated with increases in body fat, hepatic steatosis, serum triglycerides, and diabetes risk, modestly reduces low-density lipoprotein cholesterol and lipoprotein(a) and may have favorable effects on markers of subclinical atherosclerosis. Tamoxifen is associated with either no effect on, or a reduction in, cardiovascular events, and it is associated with an increase in venous thromboembolic events. Aromatase inhibitors, although fewer studies are available and often confounded by comparison with tamoxifen, have not been consistently associated with adverse changes in cardiometabolic risk factors or increases in cardiovascular events. Further clinical trials designed to evaluate cardiometabolic outcomes are needed to more accurately determine the effects of endocrine therapy on cardiovascular risks, to inform individualized decisions regarding choice and duration of endocrine therapy, and to implement evidence-based strategies to mitigate cardiometabolic risks. In the meantime, although breast cancer-specific evidence for benefit of lifestyle measures is available and recommended routinely, proactive monitoring and treatment of cardiovascular risk factors should follow general population recommendations.
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Affiliation(s)
- Yee-Ming Cheung
- Department of Endocrinology, Austin Health, Heidelberg, Victoria, Australia
- Department of Medicine, Austin Health, University of Melbourne, Heidelberg, Victoria Australia
| | - Sabashini K Ramchand
- Department of Endocrinology, Austin Health, Heidelberg, Victoria, Australia
- Department of Medicine, Austin Health, University of Melbourne, Heidelberg, Victoria Australia
| | - Belinda Yeo
- Department of Medical Oncology, Austin Health, Heidelberg, Victoria, Australia
- Olivia Newton-John Cancer Research Institute, Heidelberg, Victoria, Australia
| | - Mathis Grossmann
- Department of Endocrinology, Austin Health, Heidelberg, Victoria, Australia
- Department of Medicine, Austin Health, University of Melbourne, Heidelberg, Victoria Australia
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9
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Cho E, Zhang Y, Pruznak A, Kim HM. Effect of tamoxifen on fatty degeneration and atrophy of rotator cuff muscles in chronic rotator cuff tear: An animal model study. J Orthop Res 2015; 33:1846-53. [PMID: 26121952 DOI: 10.1002/jor.22964] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/09/2015] [Accepted: 06/03/2015] [Indexed: 02/04/2023]
Abstract
Fatty degeneration of the rotator cuff muscles is an irreversible change resulting from chronic rotator cuff tear and is associated with poor clinical outcomes following rotator cuff repair. We evaluated the effect of Tamoxifen, a competitive estrogen receptor inhibitor, on fatty degeneration using a mouse model for chronic rotator cuff tear. Sixteen adult mice were divided into two diet groups (Tamoxifen vs. Regular) and subjected to surgical creation of a large rotator cuff tear and suprascapular nerve transection in their left shoulder with the right shoulder serving as a control. The rotator cuff muscles were harvested at 16 weeks and subjected to histology and RT-PCR for adipogenic and myogenic markers. Histology showed substantially decreased atrophy and endomysial inflammation in Tamoxifen group, but no significant differences in the amount of intramuscular adipocytes and lipid droplets compared to the Regular group. With RT-PCR, the operated shoulders showed significant upregulation of myogenin and PPAR-γ, and downregulation of myostatin compared to the nonsurgical shoulder. No significant differences of gene expression were found between the two diet groups. Our study demonstrated that tamoxifen diet leads to decreased muscle atrophy and inflammatory changes following chronic rotator cuff tear, but has no apparent effect on adipogenesis.
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Affiliation(s)
- Edward Cho
- Department of Orthopaedics and Rehabilitation, Penn State College of Medicine, Hershey, Pennsylvania
| | - Yue Zhang
- Department of Orthopaedics and Rehabilitation, Penn State College of Medicine, Hershey, Pennsylvania
| | - Anne Pruznak
- Cellular and Molecular Physiology, Penn State College of Medicine, Hershey, Pennsylvania
| | - H Mike Kim
- Department of Orthopaedics and Rehabilitation, Penn State College of Medicine, Hershey, Pennsylvania
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10
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Ye R, Wang QA, Tao C, Vishvanath L, Shao M, McDonald JG, Gupta RK, Scherer PE. Impact of tamoxifen on adipocyte lineage tracing: Inducer of adipogenesis and prolonged nuclear translocation of Cre recombinase. Mol Metab 2015; 4:771-8. [PMID: 26629402 PMCID: PMC4632120 DOI: 10.1016/j.molmet.2015.08.004] [Citation(s) in RCA: 95] [Impact Index Per Article: 10.6] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/05/2015] [Revised: 08/13/2015] [Accepted: 08/20/2015] [Indexed: 12/18/2022] Open
Abstract
Background The selective estrogen receptor modulator tamoxifen, in combination with the Cre-ERT2 fusion protein, has been one of the mainstream methods to induce genetic recombination and has found widespread application in lineage tracing studies. Methods & results Here, we report that tamoxifen exposure at widely used concentrations remains detectable by mass-spectrometric analysis in adipose tissue after a washout period of 10 days. Surprisingly, its ability to maintain nuclear translocation of the Cre-ERT2 protein is preserved beyond 2 months of washout. Tamoxifen treatment acutely leads to transient lipoatrophy, followed by de novo adipogenesis that reconstitutes the original fat mass. In addition, we find a “synthetically lethal” phenotype for adipocytes when tamoxifen treatment is combined with adipocyte-specific loss-of-function mutants, such as an adipocyte-specific PPARγ knockout. This is observed to a lesser extent when alternative inducible approaches are employed. Conclusions These findings highlight the potential for tamoxifen-induced adipogenesis, and the associated drawbacks of the use of tamoxifen in lineage tracing studies, explaining the discrepancy in lineage tracing results from different systems with temporal control of gene targeting. Tamoxifen treatment induces acute fat loss and de novo adipogenesis in mice. PPARγ knockout exacerbates tamoxifen-induced lipoatrophy. Tamoxifen-driven Cre-ERT2 nuclear translocation lasts beyond two months in adipose. De novo adipogenesis upon cold exposure is confirmed with the mTmG reporter.
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Affiliation(s)
- Risheng Ye
- Touchstone Diabetes Center, Department of Internal Medicine, The University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Qiong A. Wang
- Touchstone Diabetes Center, Department of Internal Medicine, The University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Caroline Tao
- Touchstone Diabetes Center, Department of Internal Medicine, The University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Lavanya Vishvanath
- Touchstone Diabetes Center, Department of Internal Medicine, The University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Mengle Shao
- Touchstone Diabetes Center, Department of Internal Medicine, The University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Jeffery G. McDonald
- Department of Molecular Genetics, The University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Rana K. Gupta
- Touchstone Diabetes Center, Department of Internal Medicine, The University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Philipp E. Scherer
- Touchstone Diabetes Center, Department of Internal Medicine, The University of Texas Southwestern Medical Center, Dallas, TX, USA
- Department of Cell Biology, The University of Texas Southwestern Medical Center, Dallas, TX, USA
- Corresponding author.
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11
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Sheean PM, Hoskins K, Stolley M. Body composition changes in females treated for breast cancer: a review of the evidence. Breast Cancer Res Treat 2012; 135:663-80. [PMID: 22903689 PMCID: PMC3444142 DOI: 10.1007/s10549-012-2200-8] [Citation(s) in RCA: 70] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2012] [Accepted: 08/07/2012] [Indexed: 01/02/2023]
Abstract
Body composition changes cannot be precisely captured using body weight or body mass index measures. Therefore, the primary purpose of this review was to characterize the patterns of body composition change in females treated for breast cancer including only studies that utilize imaging technologies to quantify adipose tissue and lean body mass (LBM). We reviewed PubMed for studies published between 1971 and 2012 involving females diagnosed with breast cancer where computed axial tomography , dual-energy X-ray absorptiometry, or magnetic resonance imaging were employed for body composition assessment. Of the initial 440 studies, 106 papers were evaluated and 36 papers met all eligibility criteria (15 observational and 21 intervention trials). Results of these studies revealed that body weight did not consistently increase. Importantly, studies also showed that body weight did not accurately depict changes in lean or adipose tissues. Further findings included that sarcopenic obesity as a consequence of breast cancer treatment was not definitive, as menopausal status may be a substantial moderator of body composition. Overall, the behavioral interventions did not exhibit consistent or profound effects on body composition outcomes; approximately half showed favorable influence on adiposity while the effects on LBM were not apparent. The use of tamoxifen had a clear negative impact on body composition. The majority of studies were conducted in predominantly white survivors, highlighting the need for trials in minority populations. Collectively, these studies were limited by age, race, and/or menopause status matched control groups, overall size, and statistical power. Very few studies simultaneously collected diet and exercise data-two potential factors that impact body composition. Future breast cancer trials should prioritize precise body composition methodologies to elucidate how these changes impact recurrence, prognosis, and mortality, and to provide clinicians with appropriate advice regarding lifestyle recommendations in this growing sector of the population.
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Affiliation(s)
- Patricia M Sheean
- Institute for Health Research and Policy, University of Illinois at Chicago, M/C 275, 1747 West Roosevelt Road, Chicago, IL 60608, USA.
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12
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Byerley LO, Lee SH, Redmann S, Culberson C, Clemens M, Lively MO. Evidence for a novel serum factor distinct from zinc alpha-2 glycoprotein that promotes body fat loss early in the development of cachexia. Nutr Cancer 2010; 62:484-94. [PMID: 20432169 DOI: 10.1080/01635580903441220] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
We provide evidence that a factor other than the previously identified lipid mobilizing factor, zinc alpha-2 glycoprotein, promotes lipolysis in the MCA-induced sarcoma-bearing cachexia model. Cachexia is characterized by progressive loss of adipose tissue and skeletal muscle without a concurrent increase in food intake to restore lost tissue stores. We compared tumor-bearing ad lib fed (TB) animals to nontumor bearing ad lib fed (NTB) animals or nontumor-bearing pair-fed (PF) animals at various time points throughout development of tumor derived cachexia. Prior to cachexia, the TB animals lost more than 10 +/- 0.7% of their body fat before losing protein mass and decreasing their food intake. Fat loss occurred because adipocyte size, not number, was reduced. Increased turnover of palmitate and significantly higher serum triglyceride levels prior to cachexia were further indicators of an early loss of lipid from the adipocytes. Yet, circulating levels of norepinephrine, epinephrine, TNF-alpha, and zinc alpha-2 glycoprotein were not increased prior to the loss of fat mass. We provide evidence for a serum factor(s), other than zinc alpha-2 glycoprotein, that stimulates release of glycerol from 3T3-L1 adipocytes and promotes the loss of stored adipose lipid prior to the loss of lean body mass in this model.
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Affiliation(s)
- Lauri O Byerley
- University of North Carolina at Charlotte, Charlotte, North Carolina, USA.
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13
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Knobf MT, Insogna K, DiPietro L, Fennie C, Thompson AS. An aerobic weight-loaded pilot exercise intervention for breast cancer survivors: bone remodeling and body composition outcomes. Biol Res Nurs 2008; 10:34-43. [PMID: 18705153 PMCID: PMC3540790 DOI: 10.1177/1099800408320579] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
OBJECTIVE Weight gain and bone loss are commonly reported in breast cancer survivors. The purpose of this pilot study is to assess feasibility and explore the effect of an aerobic weight-loaded exercise intervention on bone remodeling, weight, and body composition. DESIGN A one-group pre-posttest design was used to test a 16-24-week supervised walking exercise intervention among women within 2 years of menopause. Through Weeks 1-4, time and weight were progressively increased. By Week 5 and through the end of the intervention, a waist belt was loaded with 5 lb and participants spent 45 min on the treadmill 3 times/week. Bone remodeling was measured by serum biomarkers (N-terminal propeptides of type I collagen [NTX] and serum osteocalcin). Dual-energy absorptiometry scans assessed body composition. Data were collected at baseline and 16 and 24 weeks. RESULTS The majority of the 26 participants were married, well educated, and employed, with a mean age of 51.3 years (SD = 6.2). The high adherence (M = 88.2%, SD = 6.8) demonstrated feasibility. There were no significant changes in serum osteocalcin (p = .67), serum NTX (p = .31), lean muscle mass (p = .08), or percent fat mass for the group as a whole (p = .14), but fat mass increased for women on adjuvant endocrine therapy (p = .04). The women maintained their weight. CONCLUSIONS This novel exercise intervention for breast cancer survivors was feasible, and women otherwise at high risk for weight gain and bone loss maintained their weight and bone mass.
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Affiliation(s)
- M Tish Knobf
- Yale University School of Nursing, 100 Church Street South, New Haven, CT 06536, USA.
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14
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Gil KM, Frasure HE, Hopkins MP, Jenison EL, von Gruenigen VE. Body weight and composition changes in ovarian cancer patients during adjuvant chemotherapy. Gynecol Oncol 2006; 103:247-52. [PMID: 16690107 DOI: 10.1016/j.ygyno.2006.03.005] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2005] [Revised: 02/28/2006] [Accepted: 03/01/2006] [Indexed: 11/20/2022]
Abstract
OBJECTIVE To prospectively examine body weight changes in women with newly diagnosed ovarian cancer receiving surgery and adjuvant chemotherapy. Body composition was examined in a subset of these women. METHODS Body weight (BW) and body composition, using bioelectrical impedance (RJL Systems Inc.), were prospectively measured pre- and post-operatively, and at 3, 6, and 12 months. RESULTS Mean age of 42 women was 59 years and did not differ by stage of disease. Nine women with early stage disease did not receive adjuvant chemotherapy. Mean BW of 33 patients receiving chemotherapy decreased from the pre- to post-operative visit and then returned to baseline levels by 12 months (F = 8.70, P = 0.003). Nine patients who did not receive chemotherapy demonstrated a similar pattern (F = 7.0, P = 0.002). Women receiving chemotherapy with stage I/II cancer had a 2.8 +/- 2.0 kg weight gain over the year, and women with stage III/IV cancer had a 1.5 +/- 1.5 kg weight loss (t = 1.72, P = 0.096). A subset of women with stage I/II (n = 6) and stage III/IV (n = 6) ovarian cancer receiving chemotherapy had body composition measured at three time points. Absolute body fat changes paralleled changes in BW (F = 9.95, P = 0.002). CONCLUSIONS Our study is the first prospective evaluation of body weight and composition in women undergoing surgery and chemotherapy for ovarian cancer. These results demonstrate that women undergoing surgery for ovarian cancer lost weight following surgery and regained it slowly over the following year. Further investigations of weight changes during adjuvant chemotherapy are indicated to assess potential changes in different stages of disease.
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Affiliation(s)
- Karen M Gil
- Department of Obstetrics and Gynecology, Akron General Medical Center, 224 West Exchange Street, Akron, OH 44302, USA.
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15
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Fouladiun M, Körner U, Bosaeus I, Daneryd P, Hyltander A, Lundholm KG. Body composition and time course changes in regional distribution of fat and lean tissue in unselected cancer patients on palliative care—Correlations with food intake, metabolism, exercise capacity, and hormones. Cancer 2005; 103:2189-98. [PMID: 15822132 DOI: 10.1002/cncr.21013] [Citation(s) in RCA: 217] [Impact Index Per Article: 11.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
BACKGROUND Several investigations that yielded different results in terms of net changes in body composition of weight-losing cancer patients have been reported that employed a variety of methods based on fundamentally different technology. Most of those reports were cross-sectional, whereas to the authors' knowledge there is sparse information available on longitudinal follow-up measurements in relation to other independent methods for the assessment of metabolism and performance. METHODS For the current report, the authors evaluated time course changes in body composition (dual-energy X-ray absorptiometry) with measurements of whole body and regional distribution of fat and lean tissue in relation to food and dietary intake, host metabolism (indirect calorimetry), maximum exercise capacity (walking test), and circulating hormones in cancer patients who were receiving palliative care during 4-62 months of follow-up. The entire cohort comprised 311 patients, ages 68 years +/- 3 years who were diagnosed with solid gastrointestinal tumors (84 colorectal tumors, 74 pancreatic tumors, 73 upper gastrointestinal tumors, 51 liver-biliary tumors, 3 breast tumors, 5 melanomas, and 21 other tumor types). RESULTS Decreased body weight was explained by loss of body fat, preferentially from the trunk, followed by leg tissue and arm tissue, respectively. Lean tissue (fat-free mass) was lost from arm tissue, whereas trunk and leg tissue compartments increased, all concomitant with declines in serum albumin, increased systemic inflammation (C-reactive protein, erythrocyte sedimentation rate), increased serum insulin, and elevated daily caloric intake; whereas serum insulin-like growth factor 1 (IGF-1), resting energy expenditure, and maximum exercise capacity remained unchanged in the same patients. Serum albumin levels (P < 0.001), whole body fat (P < 0.02), and caloric intake (P < 0.001) predicted survival, whereas lean tissue mass did not. Daily intake of fat and carbohydrate was more important for predicting survival than protein intake. Survival also was predicted by serum IGF-1, insulin, leptin, and ghrelin levels (P < 0.02 - P < 0.001). Serum insulin, leptin, and ghrelin (total) levels predicted body fat (P < 0.001), whereas IGF-1 and thyroid hormone levels (T3, free T3) predicted lean tissue mass (P < 0.01). Systemic inflammation primarily explained variation in lean tissue and secondarily explained loss in body fat. Depletion of lean arm tissue was related most to short survival compared with the depletion of lean leg and trunk tissue. CONCLUSIONS The current results demonstrated that body fat was lost more rapidly than lean tissue in progressive cancer cachexia, a phenomenon that was related highly to alterations in the levels of circulating classic hormones and food intake, including both caloric amount and diet composition. The results showed importance in the planning of efficient palliative treatment for cancer patients.
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Affiliation(s)
- Marita Fouladiun
- Surgical Metabolic Research Laboratory at Lundberg Laboratory for Cancer Research, Göteborg, Sweden
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16
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Ferrer-Lorente R, García-Peláez B, Fernández-López JA, Remesar X, Alemany M. Tamoxifen does not prevent the mobilization of body lipids elicited by oleoyl-estrone. Steroids 2004; 69:661-5. [PMID: 15465111 DOI: 10.1016/j.steroids.2004.06.001] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/23/2004] [Revised: 06/01/2004] [Accepted: 06/06/2004] [Indexed: 01/11/2023]
Abstract
Oleoyl-estrone is a powerful, slimming adipose tissue-derived signal that has biological effects widely opposed to those of its estrone moiety. The present experiment was designed to determine whether oleoyl-estrone effects on body energy are mediated by the estrogen receptor, blocked with the antagonist tamoxifen. Male Wistar rats were given daily oral doses of 10 micromol/kg d of oleoyl-estrone in oil containing 0 or 0.40 mg/kg d of tamoxifen. The data were compared with controls receiving only oil or 50 nmol/kg d of free estrone. After 10 days, the rats were killed, and their body composition and plasma metabolites and hormones were analyzed. Rats receiving estrone increased their body energy and lipid content compared with controls. Both groups of oleoyl-estrone-treated rats lost body weight, energy, and lipid; the losses in the rats receiving tamoxifen alone were less marked than in those receiving oleoyl-estrone. No significant changes in plasma glucose or triacylglycerols were observed. The patterns of change of estrone sulphate, estradiol, and oleoyl-estrone were consistent with a noticeable hydrolysis of oleoyl-estrone. The lack of differences in the fat mass in oleoyl-estrone-treated rats irrespective of the presence of tamoxifen suggested that the estrogenic pathway was not responsible for the slimming effects observed. Thus, it can be concluded that oleoyl-estrone effects are not mediated through its conversion to estrone or estradiol acting through the estrogen receptor. Tamoxifen partly mimicked the slimming effects of oleoyl-estrone; this could be speculatively explained by tamoxifen acting through the oleoyl-estrone signalling pathway.
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Affiliation(s)
- Raquel Ferrer-Lorente
- Department of Nutrition and Food Science, Faculty of Biology, University of Barcelona. Av. Diagonal 645, 08028 Barcelona, Spain
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Albanese CV, Diessel E, Genant HK. Clinical applications of body composition measurements using DXA. J Clin Densitom 2003; 6:75-85. [PMID: 12794229 DOI: 10.1385/jcd:6:2:75] [Citation(s) in RCA: 180] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/26/2002] [Accepted: 01/29/2003] [Indexed: 01/05/2023]
Abstract
Dual-energy X-ray absorptiometry (DXA) scanning was primarily developed for the diagnosis of osteoporosis and was initially applied to studies of the clinically important sites of the lumbar spine, femoral neck, and forearm. The rapid adoption of DXA has led to the development of different, competing generations of equipment. Improvements have been achieved through advances in X-ray generation and detection technology, modification of data acquisition protocols, and implementation of more sophisticated image analysis algorithms. As a result, DXA has been extended to allow the study of the total skeleton and its regional parts, as well as soft-tissue composition measurement. The three major components of the body: fat mass, lean mass, and bone mineral mass, can now be easily measured using a single whole body DXA scan with high precision and low scanning time. The comprehensive view of body composition provided by DXA makes it an attractive technique for a variety of clinical applications such as the prevention of cardiovascular and metabolic diseases, clinical management of different chronic diseases, and monitoring of the impact of treatment regimens on body tissues. In this article we review the contribution DXA has made to the understanding of body composition in clinical studies in adults.
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Affiliation(s)
- Carlina V Albanese
- Osteoporosis and Bone Pathology Unit of Study, Institute of Radiology, University of Rome La Sapienza, Viale Regina Elena, 326, 00161 Rome, Italy.
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18
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Abstracts of Original Communications. Proc Nutr Soc 2001. [DOI: 10.1017/s0029665101000027] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
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