Cytokines as mediators and targets for cancer cachexia

The Molecular Mechanisms and Treatment of Cancer-Related Cachexia

Cancer cachexia is a multifactorial syndrome characterized by persistent skeletal muscle loss, with or without fat loss, which cannot be completely reversed by traditional nutritional support and leads to impaired organ function. Cachexia seriously reduces the quality of life of (QOL) patients, affects the therapeutic effect against cancers, increases the incidence of complications, and is an important cause of death for patients with advanced cancers. To date, no effective medical intervention has completely reversed cachexia, and no medication has been agreed upon. Here, we describe recent advances in the diagnosis, molecular mechanism and treatment of cancer-related cachexia.

Relationship between Anxiety and Fatigue in Leukemia Patients on Quality of Life with Nausea and Vomiting as an Intervening Factor

AIM: This study aims to identify anxiety and fatigue in children with leukemia on the quality of life. METHODS: Current research was implemented through a descriptive study with a cross-sectional design on children suffering from leukemia and undergoing a series of chemotherapy cycles. Through this design, the researcher measured the dependent variable, independent variable, and mediator variable at the same time with a sample of 82 people. Data collection was further done using PEDSQL 3 for cancer module. Meanwhile, the analysis used is path analysis which involves nausea and vomiting as a mediator. RESULTS: The results showed that the factor that had a direct relationship with the child’s quality of life was nausea and vomiting (p < 0.05) which was then analyzed using Sobel analysis resulting that nausea and vomiting were not a mediator of fatigue and anxiety. Therefore, it is necessary to pay attention to every nursing care practitioner to intervene in order to reduce anxiety and fatigue in children according to their condition. CONCLUSION: Anxiety and fatigue together have a relationship with nausea and vomiting in pediatric patients suffering from leukemia and undergoing chemotherapy. Nausea and vomiting have a significant direct relationship with quality of life. Anxiety and fatigue have a direct relationship with quality of life without being mediated by nausea and vomiting variables.

The Dichotomous Effect of Thiamine Supplementation on Tumorigenesis: A Systematic Review

The malignant neoplastic cell is characterized by its diverse metabolic changes. It occurs in order to maintain the high rate of proliferation. The possibility of new pharmacological targets has inserted tumor metabolism as a target for recent research, emphasizing the enzymatic activity of thiamin. This review aims to elucidate the behavior of thiamin against tumor development. This is a systematic review in which studies indexed in Pubmed, Scopus, SciELO and BVS were searched using the descriptors (Thiamin OR Vitamin B1) AND (Cancer OR Malignant neoplasia) AND (Tumor metabolism). Title and abstract were read. Duplicates, literary reviews, books, conference abstracts, editorials, and papers published prior to 2010 were eliminated. 23 records were included in this review. Low doses of thiamin have been shown to be enough to stimulate tumor growth. Another population studies has shown evidence of tumor regression after correction of vitamin B1 deficiency. There is an open path for the development of new research to better assess the influence of thiamin on cancer cells. Once the connections between thiamin and the metabolism of cancer cells are fully established, new opportunities for therapeutic intervention and dietary modification will appear to reduce the progression of the disease in patients with cancer.

Association between interleukin 6 polymorphisms (rs1800796, rs1800795, rs2069837, rs17147230, and rs1800797) and hepatocellular carcinoma susceptibility: a meta-analysis

Aim of the study

We reported the association between interleukin 6 polymorphisms (rs1800796, rs1800795, rs2069837, rs17147230, and rs1800797) and hepatocellular carcinoma (HCC) susceptibility in a meta-analysis.

Material and methods

The studies were retrieved by searching the search terms in Scopus, PubMed, Web of Science, and Cochrane Library databases until June 2020. The analyses were done by RevMan 5.3 software using odds ratios (ORs) and 95% confidence intervals (CIs) and the analysis of publication bias and sensitivity analyses were performed by CMA 2.0 software.

Results

Searching through the databases, 316 records were retrieved and finally 13 studies were analyzed in the present meta-analysis. For the rs1800797 polymorphism, there was an elevated risk of AA genotype (OR = 2.68, p = 0.03) in HCC patients compared to healthy controls. Also, there was an elevated risk of AA (OR = 3.06, p = 0.04) and GA (OR = 2.61, p = 0.005) genotypes in HCC patients compared to liver cirrhosis patients. For rs2069837 polymorphism, there was an elevated risk of GG genotype (OR = 2.25, p = 0.01) in HCC patients compared to healthy controls. For rs17147230, T allele (OR = 1.31, p = 0.03) and TT genotype (OR = 1.83, p = 0.02) had elevated risks in HCC patients compared to healthy controls.

Conclusions

The present meta-analysis confirmed that there was an elevated risk of the AA and GA genotypes of rs1800797 polymorphism and the GG genotype of rs2069837, and the T allele and TT genotype of rs17147230 in HCC.

Updates on the pathogenesis of advanced lung cancer-induced cachexia

Advanced lung cancer is becoming a chronic disease threatening human life and health. Cachexia has been recognized as the most common problem associated with advanced lung cancer. Lung cancer‐induced cachexia seriously affects patients’ quality of life. The present article summarizes the pathogenesis of advanced lung cancer‐induced cachexia from three aspects: anorexia, cytokines, and energy and metabolic abnormalities. In addition, the present article proposes corresponding nursing measures based on cachexia pathogenesis to improve the quality of life and survival rate of cachectic patients with advanced lung cancer by combining continuously advancing treatment regimens and effective nursing. The present article also provides references for healthcare professionals when administering related treatments and nursing care.

Effect of taurine on immune function in mice with T-cell lymphoma during chemotherapy

OBJECTIVE

To observe the effect of taurine on immune function in mice with T-cell lymphoma during chemotherapy.

METHODS

A total of 40 C57BL/6 mice were selected and randomly divided into 4 groups, namely model group, chemotherapy group, taurine group and chemotherapy + taurine group, each containing 10 mice. Hypodermic injection was adopted to inoculate EL-4 cells in order to establish model of T-cell lymphoma. When the tumor achieved the size of 1 cm³, intervention treatments were given to the groups respectively. Mice in model group received 0.2 mL of normal saline which was intraperitoneally injected on Days 1, 8 and 15 with 3 weeks as a cycle; mice in chemotherapy group were administered with 80 mg/kg body weight of gemcitabine which was also intraperitoneally injected on Days 1, 8 and 15 with 3 weeks as a cycle; mice in taurine group were administered with 80 mg/kg body weight of taurine intraperitoneally injected daily for consecutive 8 d; mice in chemotherapy + taurine group were treated in the same manner as the mice in taurine group and chemotherapy group. Five mice were sacrificed at 2 and 3 weeks after intervention respectively, and the tumor tissues were collected and weighted after removal of auxiliary tissue, then the tumor inhibition rate was calculated. The thymus and spleen of mice sacrificed at 3 weeks after intervention were collected and weighted, and thymus and spleen indexes were calculated. Enzyme linked immunosorbent assay was used to detect the serum levels of IL-4, IL-10, IL-12 and IFN-γ in mice of each group.

RESULTS

The tumor weights in chemotherapy group, taurine group and chemotherapy + taurine group after 2 and 3 weeks of treatment were significantly lower than that in model group (P < 0.05); the tumor weight in chemotherapy + taurine group after 2 and 3 weeks of treatment was significantly lower than that in chemotherapy group (P < 0.05); the tumor inhibition rate in chemotherapy + taurine group was significantly higher than that in chemotherapy group and taurine group (P < 0.05); the thymus and spleen indexes in taurine group and chemotherapy + taurine group were significantly higher than those in chemotherapy group and model group (P < 0.05); the thymus and spleen indexes in chemotherapy group were significantly lower than those in model group (P < 0.05); after 3 weeks of treatment, the serum levels of IL-4, IL-12 and IFN-γ in chemotherapy group, taurine group and chemotherapy + taurine group were significantly lower than those in model group (P < 0.05); the IL-4 level in taurine group and chemotherapy + taurine group was significantly lower than that in chemotherapy group (P < 0.05); the serum level of IL-10 in chemotherapy group and chemotherapy + taurine group was significantly higher than that in model group and taurine group (P < 0.05); the serum level of IFN-γ in taurine group and chemotherapy + taurine group was significantly lower than that in model group and chemotherapy group (P < 0.05); after treatment of 3 weeks, the serum levels of IL-4 and IL-10 in chemotherapy group, taurine group and chemotherapy + taurine group were significantly lower than those in model group (P < 0.05), and IL-12 level was significantly higher than that in model group (P < 0.05); the level of IFN-γ in taurine group and chemotherapy + taurine group was significantly higher than that in model group (P < 0.05), while the level of IFN-γ in chemotherapy group was significantly lower than that in the other 3 groups (P < 0.05).

CONCLUSIONS

Taurine can effectively enhance the immune function of mice with T-cell lymphoma during chemotherapy, reduce the toxicity of chemotherapy.

Cancer Cachexia and MicroRNAs

Cancer cachexia is a paraneoplastic syndrome compromising quality of life and survival, mainly characterized by involuntary weight loss, fatigue, and systemic inflammation. The syndrome is described as a result of tumor-host interactions characterized by an inflammatory response by the host to the presence of the tumor. Indeed, systemic inflammation is considered a pivotal feature in cachexia progression and maintenance. Cytokines are intimately related to chronic systemic inflammation and the mechanisms underlying the release of these factors are not totally elucidated, the etiology of cachexia being still not fully understood. Therefore, the understanding of cachexia-related mechanisms, as well as the establishment of markers for the syndrome, is very relevant. MicroRNAs (miRNAs) are a class of noncoding RNAs interfering with gene regulation. Different miRNA expression profiles are associated with different diseases and inflammatory processes. miRNAs modulate adipose and skeletal muscle tissue metabolism in cancer cachexia and also tumor and tissue derived inflammation. Therefore, we propose a possible role for miRNAs in the modulation of the host inflammatory response during cachexia. Moreover, the establishment of a robust body of evidence in regard to miRNAs and the mechanisms underlying cachexia is mandatory, and shall contribute to the improvement of its diagnosis and treatment.

Screening, evaluation, and management of cancer-related fatigue: Ready for implementation to practice?

Answer questions and earn CME/CNE Evidence regarding cancer-related fatigue (fatigue) has accumulated sufficiently such that recommendations for screening, evaluation, and/or management have been released recently by 4 leading cancer organizations. These evidence-based fatigue recommendations are available for clinicians, and some have patient versions; but barriers at the patient, clinician, and system levels hinder dissemination and implementation into practice. The underlying biologic mechanisms for this debilitating symptom have not been elucidated completely, hindering the development of mechanistically driven interventions. However, significant progress has been made toward methods for screening and comprehensively evaluating fatigue and other common symptoms using reliable and valid self-report measures. Limited data exist to support the use of any pharmacologic agent; however, several nonpharmacologic interventions have been shown to be effective in reducing fatigue in adults. Never before have evidence-based recommendations for fatigue management been disseminated by 4 premier cancer organizations (the National Comprehensive Cancer, the Oncology Nursing Society, the Canadian Partnership Against Cancer/Canadian Association of Psychosocial Oncology, and the American Society of Clinical Oncology). Clinicians may ask: Are we ready for implementation into practice? The reply: A variety of approaches to screening, evaluation, and management are ready for implementation. To reduce fatigue severity and distress and its impact on functioning, intensified collaborations and close partnerships between clinicians and researchers are needed, with an emphasis on system-wide efforts to disseminate and implement these evidence-based recommendations.

Clinical utility of the modified Glasgow prognostic score in patients with advanced head and neck cancer

BACKGROUND

The purpose of this study was to evaluate the prognostic potential of the modified Glasgow prognostic score (mGPS), known to reflect the degree of tumor-associated inflammation and cancer cachexia, in patients with advanced head and neck cancer.

METHODS

Patients with advanced head and neck cancer treated at the University of Tsukuba Hospital between January 2002 and December 2011 were retrospectively evaluated. They were categorized by their mGPS.

RESULTS

A total of 210 patients were enrolled in this study. Patients with an mGPS of 0 had better overall survival and disease-free survival than did those with an mGPS of 1 or 2. Multivariate analysis revealed that the mGPS was a significant risk factor for overall survival and disease-free survival.

CONCLUSIONS

Our results suggest that the mGPS is useful for predicting outcome in patients with advanced head and neck cancer and should be included in their routine clinical assessment.

Liver function tests may be useful tools for advanced cancer patient care: a preliminary single-center result

Accurate prognostication in advanced cancer may facilitate better palliative care. An objective marker may be more applicable and appropriate than a subjective evaluation by physicians. The aim of this study was to evaluate liver function tests as useful prognostic factors for survival in patients with advanced cancer. We recruited advanced cancer patients from January 2007 to December 2009. Data on age, sex, cancer diagnosis, site of metastases, clinical symptoms, and performance status were collected at the time of admission to the palliative care unit. Analyzed laboratory data were obtained on the Day 1 of admission to the palliative care unit. A total of 522 patients were enrolled; 322 (61.7%) of them were males. The mean age was 60.6 ± 13.2 years. Multiple logistic regression analysis adjusting for age and sex demonstrated aspartate transaminase (AST) > 80 IU/L [odds ratio (OR) = 2.01, p = 0.010] and alanine transaminase > 80 IU/L (OR = 1.89, p = 0.047) were independently significant prognostic factors of death within 14 days. AST > 80 IU/L (OR = 3.67, p = 0.017) and albumin < 3.0 g/dL (OR = 1.98, p = 0.048) were independently significant prognostic factors of death within 6 months. Liver function tests may be useful prognostic factors for patients in the palliative care unit, in addition to being useful for patients with hepatobiliary cancer or liver metastasis. These biochemical tests of liver function with cutoff values can easily be used in palliative care.

Proteomic profiling of the hypothalamus in a mouse model of cancer-induced anorexia-cachexia

BACKGROUND

Anorexia-cachexia is a common and severe cancer-related complication but the underlying mechanisms are largely unknown. Here, using a mouse model for tumour-induced anorexia-cachexia, we screened for proteins that are differentially expressed in the hypothalamus, the brain's metabolic control centre.

METHODS

The hypothalamus of tumour-bearing mice with implanted methylcholanthrene-induced sarcoma (MCG 101) displaying anorexia and their sham-implanted pair-fed or free-fed littermates was examined using two-dimensional electrophoresis (2-DE)-based comparative proteomics. Differentially expressed proteins were identified by liquid chromatography-tandem mass spectrometry.

RESULTS

The 2-DE data showed an increased expression of dynamin 1, hexokinase, pyruvate carboxylase, oxoglutarate dehydrogenase, and N-ethylmaleimide-sensitive factor in tumour-bearing mice, whereas heat-shock 70 kDa cognate protein, selenium-binding protein 1, and guanine nucleotide-binding protein Gα0 were downregulated. The expression of several of the identified proteins was similarly altered also in the caloric-restricted pair-fed mice, suggesting an involvement of these proteins in brain metabolic adaptation to restricted nutrient availability. However, the expression of dynamin 1, which is required for receptor internalisation, and of hexokinase, and pyruvate carboxylase were specifically changed in tumour-bearing mice with anorexia.

CONCLUSION

The identified differentially expressed proteins may be new candidate molecules involved in the pathophysiology of tumour-induced anorexia-cachexia.

Management of colorectal cancer patients after resection of liver metastases: can we offer a tailored treatment?

Surgical resection remains the only option of cure for patients with colorectal liver metastases, and no patient should be precluded from surgery. There is much controversy not only regarding the most appropriate therapeutic approach in the neoadjuvant setting but also after surgery is performed. Many patients will experience early relapses but others will be long survivors. We need to establish reliable prognostic and predictive factors to offer a tailored treatment. Several prognostic factors after metastasectomy have been identified: high C-reactive protein levels, a high neutrophil-lymphocyte ratio, elevated neutrophil count and low serum albumin are related to a worst outcome. Elevated CEA and Ki 67 levels, intrahepatic and perihepatic lymph node invasion are also some of the markers related to a worst outcome. In contrast, the administration of preoperative chemotherapy has been associated with a better prognosis after hepatectomy. The administration of adjuvant chemotherapy should be done taking in consideration these factors. Regarding predictive factors, determination of ERCC1, TS, TP and DPD and UGT1 polymorphisms assessment could be considered prior to chemotherapy administration. This would avoid treatment related toxicities and increase this population quality of life.

Pathophysiological role of hormones and cytokines in cancer cachexia

We investigated the role of fasting hormones and pro-inflammatory cytokines in cancer patients. Hormones (ghrelin, adiponectin, and leptin) and cytokines (TNF-α, IFN-γ, and IL-6) were measured by ELISA or RIA in lung cancer and colorectal cancer patients before the administration of cancer therapy, and measurements were repeated every 2 months for 6 months. From June 2006 to August 2008, 42 patients (19 with colorectal cancer and 23 with lung cancer) were enrolled. In total, 21 patients were included in the cachexia group and the others served as a comparison group. No significant difference in the initial adiponectin, ghrelin, TNF-α, IFN-γ, or IL-6 level was observed between groups, although leptin was significantly lower in cachectic patients than in the comparison group (15.3 ± 19.5 vs 80.9 ± 99.0 pg/mL, P = 0.007). During the follow-up, the patients who showed a > 5% weight gain had higher ghrelin levels after 6 months. Patients exhibiting elevated IL-6 levels typically showed a weight loss > 5% after 6 months. A blunted adiponectin or ghrelin response to weight loss may contribute to cancer cachexia and IL-6 may be responsible for inducing and maintaining cancer cachexia.

Body composition, symptoms, and survival in advanced cancer patients referred to a phase I service

Background

Body weight and body composition are relevant to the outcomes of cancer and antineoplastic therapy. However, their role in Phase I clinical trial patients is unknown.

Methods

We reviewed symptom burden, body composition, and survival in 104 patients with advanced cancer referred to a Phase I oncology service. Symptom burden was analyzed using the MD Anderson Symptom Assessment Inventory(MDASI); body composition was evaluated utilizing computerized tomography(CT) images. A body mass index (BMI)≥25 kg/m² was considered overweight. Sarcopenia, severe muscle depletion, was assessed using CT-based criteria.

Results

Most patients were overweight (n = 65, 63%); 53 patients were sarcopenic (51%), including 79% of patients with a BMI<25 kg/m² and 34% of those with BMI≥25 kg/m². Sarcopenic patients were older and less frequently African-American. Symptom burden did not differ among patients classified according to BMI and presence of sarcopenia. Median (95% confidence interval) survival (days) varied according to body composition: 215 (71–358) (BMI<25 kg/m²; sarcopenic), 271 (99–443) (BMI<25 kg/m²; non-sarcopenic), 484 (286–681) (BMI≥25 kg/m²; sarcopenic); 501 d (309–693) (BMI≥25 kg/m²; non-sarcopenic). Higher muscle index and gastrointestinal cancer diagnosis predicted longer survival in multivariate analysis after controlling for age, gender, performance status, and fat index.

Conclusions

Patients referred to a Phase I clinic had a high frequency of sarcopenia and a BMI≥25 kg/m², independent of symptom burden. Body composition variables were predictive of clinically relevant survival differences, which is potentially important in developing Phase I studies.

Adipose tissue inflammation and cancer cachexia: possible role of nuclear transcription factors

Cancer cachexia is a multifaceted syndrome whose aetiology is extremely complex and is directly related to poor patient prognosis and survival. Changes in lipid metabolism in cancer cachexia result in marked reduction of total fat mass, increased lipolysis, total oxidation of fatty acids, hyperlipidaemia, hypertriglyceridaemia, and hypercholesterolaemia. These changes are believed to be induced by inflammatory mediators, such as tumour necrosis factor-α (TNF-α) and other factors. Attention has recently been drawn to the current theory that cachexia is a chronic inflammatory state, mainly caused by the host's reaction to the tumour. Changes in expression of numerous inflammatory mediators, notably in white adipose tissue (WAT), may trigger several changes in WAT homeostasis. The inhibition of adipocyte differentiation by PPARγ is paralleled by the appearance of smaller adipocytes, which may partially account for the inhibitory effect of PPARγ on inflammatory gene expression. Furthermore, inflammatory modulation and/or inhibition seems to be dependent on the IKK/NF-κB pathway, suggesting that a possible interaction between NF-κB and PPARγ is required to modulate WAT inflammation induced by cancer cachexia. In this article, current literature on the possible mechanisms of NF-κB and PPARγ regulation of WAT cells during cancer cachexia are discussed. This review aims to assess the role of a possible interaction between NF-κB and PPARγ in the setting of cancer cachexia as well as its significant role as a potential modulator of chronic inflammation that could be explored therapeutically.

Prognostic value of an inflammation-based score in patients undergoing pre-operative chemotherapy followed by surgery for esophageal cancer

Recent studies have shown that the presence of systemic inflammation is associated with poor outcome in patients with malignancy. However, whether systemic inflammation affects the response to pre-operative therapy and survival of patients undergoing multimodal treatment for esophageal cancer is not clear. We studied 152 patients who underwent pre-operative chemotherapy followed by surgery for esophageal cancer. The correlation between various clinicopathological factors, including hematological markers of systemic inflammatory response, and survival or response to chemotherapy was examined. Among various hematological factors, leucocyte count, hemoglobin level, albumin level, neutrophil-lymphocyte ratio and CEA, but not serum concentration of C-reactive protein, were significantly associated with survival. Multivariate analysis revealed that the clinical response to chemotherapy, number of metastatic lymph nodes, operative complications and systemic inflammation score (SI score), comprising leucocyte count, albumin and hemoglobin levels, were independent prognostic factors, and identified the SI score as the most significant prognostic factor. There was no significant relationship between hematological markers of systemic inflammation, including the SI score, and the response to chemotherapy. In conclusion, in patients scheduled for chemotherapy followed by surgery for esophageal cancer, systemic inflammation, reflected by SI, predicts poor outcome, but not the response to chemotherapy.

Formoterol and cancer muscle wasting in rats: Effects on muscle force and total physical activity

Cancer cachexia occurs in the majority of cancer patients before death, and it is responsible for the death of 22% of cancer patients. One of the most relevant characteristics of cachexia is that of asthenia, which reflects significant muscle wasting noted in cachectic cancer patients The aim of the present study was to assess whether the β(2)-adrenergic agonist formoterol is associated with an improvement in physiological parameters such as grip force and total physical activity in cachetic rats. Administration of the β(2)-agonist formoterol (0.3 mg/kg for 7 days) in rats bearing Yoshida AH-130 ascites hepatoma tumors, a model which induces a strong loss of both body and muscle weight, resulted in a significant reversal of the muscle wasting process, as reflected by individual muscle weights. The anti-wasting effects of the drug were also observed in terms of total physical activity and grip force, thus resulting in an improvement in physical performance in cachectic tumor-bearing rats.

Nuclear magnetic resonance in conjunction with functional genomics suggests mitochondrial dysfunction in a murine model of cancer cachexia

Cancer patients commonly suffer from cachexia, a syndrome in which tumors induce metabolic changes in the host that lead to massive loss in skeletal muscle mass. Using a preclinical mouse model of cancer cachexia, we tested the hypothesis that tumor inoculation causes a reduction in ATP synthesis and genome-wide aberrant expression in skeletal muscle. Mice implanted with Lewis lung carcinomas were examined by in vivo³¹P nuclear magnetic resonance (NMR). We examined ATP synthesis rate and the expression of genes that play key-regulatory roles in skeletal muscle metabolism. Our in vivo NMR results showed reduced ATP synthesis rate in tumor-bearing (TB) mice relative to control (C) mice, and were cross-validated with whole genome transcriptome data showing atypical expression levels of skeletal muscle regulatory genes such as peroxisomal proliferator activator receptor γ coactivator 1 ß (PGC-1ß), a major regulator of mitochondrial biogenesis and, mitochondrial uncoupling protein 3 (UCP3). Aberrant pattern of gene expression was also associated with genes involved in inflammation and immune response, protein and lipid catabolism, mitochondrial biogenesis and uncoupling, and inadequate oxidative stress defenses, and these effects led to cachexia. Our findings suggest that reduced ATP synthesis is linked to mitochondrial dysfunction, ultimately leading to skeletal muscle wasting and thus advance our understanding of skeletal muscle dysfunction suffered by cancer patients. This study represents a new line of research that can support the development of novel therapeutics in the molecular medicine of skeletal muscle wasting. Such therapeutics would have wide-spread applications not only for cancer patients, but also for many individuals suffering from other chronic or endstage diseases that exhibit muscle wasting, a condition for which only marginally effective treatments are currently available.

The nutritional background of the host alters the disease course in a fish-myxosporean system

The aim of the present work was to determine if a practical plant protein-based diet containing vegetable oils (VO) as the major lipid source could alter the disease course when challenged with the myxosporean Enteromyxum leei, a wide-spread parasite in the Mediterranean basin causing heavy economic losses. Gilthead sea bream (Sparus aurata) fed for 9 months either a fish oil (FO) diet or a blend of VOs at 66% of replacement (66VO diet) were challenged by exposure to parasite-contaminated water effluent. All fish were periodically and non-lethally sampled to obtain biometrical data and to know their infection status. After 102 days of exposure, fish were euthanized and haematological, biometrical, histological, immunological, glutathione and anti-oxidant data were obtained from tissue, blood and serum samples. Anorexia appeared in both exposed groups, but feed intake reduction was higher in 66VO fish. The signs of disease (lower growth, condition factor, specific growth rate, haematocrit) as well as the disease course were worse in fish from 66VO group, with a higher prevalence and intensity of infection, a higher percentage of fish harbouring the parasite in the entire intestinal tract, and a faster establishment of the parasite. Parasite intensity of infection was negatively correlated with growth parameters and haematocrit in both groups, and with complement, lysozyme and hepatic total glutathione in 66VO fish.

Clinical outcomes of patients with breast cancer in a phase I clinic: the M. D. Anderson cancer center experience

PURPOSE

Patients with metastatic breast cancer (MBC) refractory to standard therapy have a poor prognosis. We assessed prognostic factors and clinical outcomes for patients with MBC referred to a phase I clinic focused primarily on targeted agents.

PATIENTS AND METHODS

We reviewed the medical records of sequential patients with MBC who presented to our phase I clinic between September 2004 and May 2008 to assess baseline patient characteristics, overall survival (OS), and clinical benefit.

RESULTS

A total of 92 patients were identified, with a median age of 53 years (range, 28-83 years). The median number of previous therapies was 5 (range, 1-16 therapies). Of 92 patients, 78 were eligible for and offered > or = 1 phase I clinical trial. With a median follow-up of 7.4 months, the median OS was 6.7 months (95% CI, 5.2-9.7). In multivariate analysis, independent factors predicting shorter survival were > or = 10 previous treatments (vs. < 10 previous treatments; hazard ratio [HR], 3.27; 95% CI, 1.37-7.81; P = .008), Eastern Cooperative Oncology Group (ECOG) performance status (PS) 2/3 (vs. 0/1; HR, 2.92; 95% CI, 1.28-6.66; P = .01), and albumin level < 3.5 g/dL (vs. > 3.5 g/dL; HR, 2.88; 95% CI, 1.41-5.89; P = .004).

CONCLUSION

Patients with locally advanced or metastatic breast cancer referred for our phase I studies had a median survival of 6.7 months. Heavily pretreated disease, poor ECOG PS, and/or low albumin levels were associated with significantly shorter survival in a multivariate analysis.

The inflammation-based modified Glasgow Prognostic Score in patients with vulvar cancer

OBJECTIVES

To evaluate the prognostic potential of the modified Glasgow Prognostic Score (mGPS), known to reflect the degree of tumor-associated inflammation and cachexia, in patients with vulvar cancer.

STUDY DESIGN

We included 93 consecutive patients with vulvar cancer into our study. As previously published, the pre-therapeutic mGPS was calculated as follows: patients with elevated C-reactive protein (CRP) serum levels (>10 mg/L) and hypoalbuminaemia (<35 g/L) were allocated a score of 2, patients with elevated CRP serum levels without hypoalbuminaemia were allocated a score of 1, patients with normal CRP serum levels with or without hypoalbuminaemia were allocated a score of 0. The mGPS was correlated with clinico-pathological parameters. The association between mGPS and prognosis was evaluated by univariate and multivariate survival analysis.

RESULTS

Mean (SD) pretreatment CRP and albumin serum levels were 9.5 (9.6) mg/L and 41.4 (5.3) g/L, respectively. mGPS was associated with tumor stage (p=0.01), but not with lymph node involvement (p=0.4), histological grade (p=0.8), and patients' age (p=0.7). In univariate analyses, mGPS (p=0.006, p=0.001), tumor stage (p<0.001, p<0.001), lymph node involvement (p<0.001, p<0.001), and patients' age (p=0.04, p=0.007), but not histological grade (p=0.1, p=0.3) and year of surgery (1995-2001 vs. 2002-2008, p=0.7, p=0.3) were associated with disease-free and overall survival, respectively. In a multivariate analysis, tumor stage (p=0.01, p=0.02) and lymph node involvement (p<0.001, p=0.001), but not mGPS (p=0.7, p=0.8), patients' age (p=0.6, p=0.4), histological grade (p=0.2, p=0.1), and year of surgery (p=0.4, p=0.8) were associated with disease-free and overall survival, respectively.

CONCLUSIONS

Despite being associated with prognosis in a univariate analysis, mGPS cannot be used as an independent inflammation-based predictor for survival in patients with vulvar cancer.

New insights into adipose tissue atrophy in cancer cachexia

Profound loss of adipose and other tissues is a hallmark of cancer cachexia, a debilitating condition associated with increased morbidity and mortality. Fat loss cannot be attributable to reduced appetite alone as it precedes the onset of anorexia and is much more severe in experimental models of cachexia than in food restriction. Morphological examination has shown marked remodelling of adipose tissue in cancer cachexia. It is characterised by the tissue containing shrunken adipocytes with a major reduction in cell size and increased fibrosis in the tissue matrix. The ultrastructure of 'slimmed' adipocytes has revealed severe delipidation and modifications in cell membrane conformation. Although the molecular mechanisms remain to be established, evidence suggests that altered adipocyte metabolism may lead to adipose atrophy in cancer cachexia. Increased lipolysis appears to be a key factor underlying fat loss, while inhibition of adipocyte development and lipid deposition may also contribute. Both tumour and host-derived factors are implicated in adipose atrophy. Zinc-alpha2-glycoprotein (ZAG), which is overexpressed by certain malignant tumours, has been identified as a novel adipokine. ZAG transcripts and protein expression in adipose tissue are up regulated in cancer cachexia but reduced with adipose tissue expansion in obesity. Studies in vitro demonstrate that recombinant ZAG stimulates lipolysis. ZAG may therefore act locally, as well as systemically, to promote lipid mobilisation in cancer cachexia. Further elucidation of ZAG function in adipose tissue may lead to novel targets for preventing adipose atrophy in malignancy.

Necdin is expressed in cachectic skeletal muscle to protect fibers from tumor-induced wasting

Skeletal muscles of subjects with advanced cancer undergo progressive wasting, referred to as cachexia. Cachexia is an important area for medical research because strategies proposed until now have yielded little benefit. We have recently identified necdin as a key player in fetal and postnatal physiological myogenesis and in muscle regeneration. Here we show that necdin is selectively expressed in muscles of cachetic mice and prove that its expression is causally linked to a protective response of the tissue against tumor-induced wasting, inhibition of myogenic differentiation and fiber regeneration. Necdin carries out this role mainly via interference with TNFalpha signaling at various levels, including regulation of expression of TNFR1 and p53, and regulation of the activity of caspase 3 and caspase 9. These data suggest that inhibition of muscle wasting using necdin is a feasible approach to treat cachexia in neoplastic patients.

Cachexia and aging: an update based on the Fourth International Cachexia Meeting

This manuscript highlights the new developments in the pathophysiology of anorexia, cachexia and sarcopenia, based on presentations given at the Fourth International Cachexia Meeting. It stresses the importance of these conditions in older persons.

Pathophysiology of cancer-related fatigue

Cancer-related fatigue (CRF) is influenced and modulated by a number of critical factors, and the mechanism that is both necessary and sufficient to induce development of severe fatigue in patients with cancer has not yet been identified. Specific research efforts to understand the factors that may contribute to CRF development have been made, including studies of the direct effects of tumor burden, the effects of cancer treatment, and other pathophysiologic and psychosocial conditions. Compelling new hypotheses regarding CRF pathophysiology have been proposed, such as the pro-inflammatory hypothesis, the serotonin hypothesis, the vagal-afferent-activation hypothesis, the anemia hypothesis, and the adenosine triphosphate hypothesis; some of these have been tested in both animal models and humans and some in animals only. Gaining an understanding of the specific mechanisms related to the development of fatigue in patients with cancer and survivors requires further investigation. Pathophysiologic research in CRF could be applied in the clinic to improve CRF diagnosis and to enable administration of mechanism-driven interventions. A targeted intervention study with CRF as a primary end point also would be useful.

Role of beta-adrenoceptor signaling in skeletal muscle: implications for muscle wasting and disease

The importance of beta-adrenergic signaling in the heart has been well documented, but it is only more recently that we have begun to understand the importance of this signaling pathway in skeletal muscle. There is considerable evidence regarding the stimulation of the beta-adrenergic system with beta-adrenoceptor agonists (beta-agonists). Although traditionally used for treating bronchospasm, it became apparent that some beta-agonists could increase skeletal muscle mass and decrease body fat. These so-called "repartitioning effects" proved desirable for the livestock industry trying to improve feed efficiency and meat quality. Studying beta-agonist effects on skeletal muscle has identified potential therapeutic applications for muscle wasting conditions such as sarcopenia, cancer cachexia, denervation, and neuromuscular diseases, aiming to attenuate (or potentially reverse) the muscle wasting and associated muscle weakness, and to enhance muscle growth and repair after injury. Some undesirable cardiovascular side effects of beta-agonists have so far limited their therapeutic potential. This review describes the physiological significance of beta-adrenergic signaling in skeletal muscle and examines the effects of beta-agonists on skeletal muscle structure and function. In addition, we examine the proposed beneficial effects of beta-agonist administration on skeletal muscle along with some of the less desirable cardiovascular effects. Understanding beta-adrenergic signaling in skeletal muscle is important for identifying new therapeutic targets and identifying novel approaches to attenuate the muscle wasting concomitant with many diseases.

Effects of glucocorticoids on weight change during the treatment of Wegener's granulomatosis

OBJECTIVE

Weight gain is a side effect of glucocorticoid (GC) use, but the natural history and health implications of changes in weight that occur during the treatment of inflammatory disease are not understood.

METHODS

We evaluated data from the Wegener's Granulomatosis Etanercept Trial. Patients were categorized according to clinical outcome at 1 year: remission (no disease flares), single flare, or multiple flares. Risk factors for gaining > or =10 kg were examined in multivariate models.

RESULTS

Weights at baseline and 1 year were available for 157 (93%) of the 168 patients analyzed. During year 1, the mean cumulative prednisone dosage in the multiple flares subgroup was 7.9 gm, compared with 6.0 gm and 3.9 gm in the single flare and remission subgroups, respectively (P < 0.001). Patients in these subgroups gained an average of 2.6 kg, 4.1 kg, and 5.8 kg, respectively (P = 0.005). Weight gain did not correlate with cumulative GC dose (R = 0.10, P = 0.25). Thirty-five patients (22.3%) gained and maintained > or =10 kg in the first year. New diagnosis of Wegener's granulomatosis at baseline was an independent predictor of gaining > or =10 kg at 1 year (odds ratio 19.7, 95% confidence interval 2.4-162.6, P = 0.006). Among the 78 patients in the remission subgroup, 40 sustained remissions through the 2-year time point. For these 40 patients, the mean weight gained at year 1 did not regress by the end of year 2, despite the absence of continued GC use.

CONCLUSION

Disease control was associated with lower cumulative GC doses but greater weight gain. More than one-fifth of patients gained >10 kg in the first year of treatment. The quantity of weight gained by patients during treatment has potential future health implications.

Acute-phase response proteins are related to cachexia and accelerated angiogenesis in gastroesophageal cancers

BACKGROUND

Accurate outcome prediction in gastroesophageal malignancies is challenging. Acute-phase response proteins (APRPs) have been claimed to be independent prognosticators, although the basis for their association with prognosis remains unexplained. We hypothesized that, similarly to pancreatic and lung cancers, changes in APRPs in gastroesophageal malignancies are associated with cachexia and accelerated angiogenesis.

METHODS

C-reactive protein (CRP), albumin and transferrin serum levels were evaluated and the Glasgow Prognostic Score (GPS) calculated. These data were compared with concentrations of circulating interleukin (IL)-1, IL-6 and IL-8, tumor necrosis factor-alpha (TNF-alpha), vascular endothelial growth factor (VEGF)-A, VEGF-C and midkine in 96 gastroesophageal cancer patients (49 with cachexia) and 42 healthy subjects.

RESULTS

Albumin and CRP levels were altered in the cancer patients, with further CRP elevation in those with cachexia. Transferrin was decreased only in the cachectic patients. The interrelationships between the APRPs were strengthened in cachexia and only then were APRPs correlated with the cytokines elevated in gastroesophageal cancer-related cachexia: IL-6, IL-8, VEGF-A and midkine. GPS corresponded well to transferrin, IL-1, IL-6, IL-8, TNF-alpha, VEGF-A and midkine concentrations.

CONCLUSIONS

Cachexia in gastroesophageal cancers is associated with changes in APRP concentrations. This, together with a direct relationship of APRPs with accelerated angiogenesis, may constitute a foundation for the association of APRPs and GPS with outcome in these malignancies.

Apoptosis signalling is essential and precedes protein degradation in wasting skeletal muscle during catabolic conditions

Activation of skeletal muscle proteolysis leads to wasting in many types of catabolic/chronic diseases. Protein breakdown is basically accomplished by the activation of the ubiquitin-proteasome system. Interestingly, several publications have shown that DNA fragmentation also occurs in skeletal muscle tissue during catabolism. The present review suggests that activation of apoptosis precedes protein breakdown associated with muscle wasting. In addition, the role of the different proteolytic systems and their relation with apoptosis is emphasized. Altogether, the data presented could be used for the design of new approaches for the treatment of muscle wasting diseases.

Effects of eicosapentaenoic and docosahexaenoic n-3 fatty acids from fish oil and preferential Cox-2 inhibition on systemic syndromes in patients with advanced lung cancer

Under the common denomination of Systemic Immune-Metabolic Syndrome (SIMS), we grouped many symptoms that share a similar pathophysiologic background. SIMS is the result of the dysfunctional interaction of tumor cells, stroma cells, and the immune system, leading to the release of cytokines and other systemic mediators such as eicosanoids. SIMS includes systemic syndromes such as paraneoplastic hemopathies, hypercalcemia, coagulopathies, fatigue, weakness, cachexia, chronic nausea, anorexia, and early satiety among others. Eicosapentaenoic and docosahexaenoic n-3 fatty acids from fish oil can help in the management of persistent chronic inflammatory states, but treatment's compliance is generally poor. Preferentially, Cox-2 inhibition can create a favorable pattern of cytokines by decreasing the production of certain eicosanoids, although their role in SIMS is unknown. The aim of this study was to test the hypothesis that by modulating systemic inflammation through an eicosanoid-targeted approach, some of the symptoms of the SIMS could be controlled. We exclusively evaluated 12 patients for compliance. Patients were assigned 1 of the 4 treatment groups (15-, 12-, 9-, or 6-g dose, fractionated every 8 h). For patients assigned to 15 and 12 doses, the overall compliance was very poor and unsatisfactory for patients receiving the 9-g dose. The maximum tolerable dose was calculated to be around 2 capsules tid (6 g of fish oil per day). A second cohort of 22 patients with advanced lung cancer and SIMS were randomly assigned to receive either fish oil, 2 g tid, plus placebo capsules bid (n = 12) or fish oil, 2 g tid, plus celecoxib 200 mg bid (n = 10). All patients in both groups received oral food supplementation. After 6 wk of treatment, patients receiving fish oil + placebo or fish oil + celecoxib showed significantly more appetite, less fatigue, and lower C-reactive protein (C-RP) values than their respective baselines values (P < 0.02 for all the comparisons). Additionally, patients in the fish oil + celecoxib group also improved their body weight and muscle strength compared to baseline values (P < 0.02 for all the comparisons). Comparing both groups, patients receiving fish oil + celecoxib showed significantly lower C-RP levels (P = 0.005, t-test), higher muscle strength (P = 0.002, t-test) and body weight (P = 0.05, t-test) than patients receiving fish oil + placebo. The addition of celecoxib improved the control of the acute phase protein response, total body weight, and muscle strength. Additionally, the consistent nutritional support used in our patients could have helped to maximize the pharmacological effects of fish oil and/or celecoxib. This study shows that by modulating the eicosanoid metabolism using a combination of n-3 fatty acids and cyclooxygenase-2 inhibitor, some of the signs and symptoms associated with a SIMS could be ameliorated.

Evaluation of an inflammation-based prognostic score in patients with advanced ovarian cancer

BACKGROUND

There is increasing evidence that the presence of an ongoing systemic inflammatory response is associated with poor outcome in patients with advanced cancer. The aim of this study was to validate whether an inflammation-based prognostic score (Glasgow Prognostic Score, GPS) is associated with survival in patients with advanced stage (stage III/IV) ovarian cancer.

PATIENTS AND METHODS

An audit was conducted of patients with a new diagnosis of stage III or IV ovarian cancer presenting to the West London Gynae-Oncology Centre between October 2003 and June 2006 (n=154). The GPS was constructed as follows: Patients with both an elevated C-reactive protein (>10 mg/l) and hypoalbuminaemia (<35 g/l) were allocated a score of 2. Patients in whom only one or none of these biochemical abnormalities was present were allocated a score of 1 or 0, respectively.

RESULTS

On univariate analysis GPS, histological type, ALP, performance status, primary surgery and ascites were predictors of overall survival. On multivariate a high GPS score, non-serous histology, high ALP and no initial surgery were independent predictors of worse overall survival in this population.

CONCLUSIONS

The presence of a systemic inflammatory response, as measured by the GPS, is an independent predictor of poor overall survival in patients with advanced ovarian cancer independent of treatment received.

Mechanisms of cancer-related fatigue

Cancer-related fatigue (CRF) is one of the most prevalent symptoms patients with cancer experience, both during and after treatment. CRF is pervasive and affects patients' quality of life considerably. It is important, therefore, to understand the underlying pathophysiology of CRF in order to develop useful strategies for prevention and treatment. At present, the etiology of CRF is poorly understood and the relative contributions of the neoplastic disease, various forms of cancer therapy, and comorbid conditions (e.g., anemia, cachexia, sleep disorders, depression) remain unclear. In any individual, the etiology of CRF probably involves the dysregulation of several physiological and biochemical systems. Mechanisms proposed as underlying CRF include 5-HT neurotransmitter dysregulation, vagal afferent activation, alterations in muscle and ATP metabolism, hypothalamic-pituitary-adrenal axis dysfunction, circadian rhythm disruption, and cytokine dysregulation. Currently, these hypotheses are largely based on evidence from other conditions in which fatigue is a characteristic, in particular chronic fatigue syndrome and exercise-induced fatigue. The mechanisms that lead to fatigue in these conditions provide a theoretical basis for future research into the complex etiology of this distressing and debilitating symptom. An understanding of relevant mechanisms may offer potential routes for its prevention and treatment in patients with cancer.Disclosure of potential conflicts of interest is found at the end of this article.

Novel treatments for cancer cachexia

Cancer cachexia is a debilitating and life-threatening syndrome characterised by anorexia, body weight loss, loss of adipose tissue and skeletal muscle, and accounts for > or = 20% of deaths in neoplastic patients. Cancer cachexia significantly impairs quality of life and response to antineoplastic therapies, increasing the morbidity and mortality of cancer patients. Muscle wasting is the most important phenotypic feature of cancer cachexia and the principle cause of function impairment, fatigue and respiratory complications, and is mainly related to a hyperactivation of muscle proteolytic pathways. Existing therapeutic strategies have proven to be only partially effective. In the last decade, the correction of anorexia, the inhibition of catabolic processes and the stimulation of anabolic pathways in muscle has been attempted pharmacologically, giving encouraging results in animal models and through preliminary clinical trials.

Cancer Cachexia Signaling Pathways Continue to Emerge Yet Much Still Points to the Proteasome: Fig. 1

Cachexia is a life-threatening consequence of cancer that diminishes both quality of life and survival. It is a syndrome that is characterized by extreme weight loss resulting mainly from the depletion of skeletal muscle. Research from the past decades investigating the mechanisms of tumor-induced muscle wasting has identified several key cachectic factors that act through the ubiquitin-dependent proteasome system. Signaling pathways that mediate the effects of these cachectic factors have also subsequently emerged. Here, we review some of these pathways specific to myostatin, nuclear factor kappaB, and the newly elucidated dystrophin glycoprotein complex. Although these molecules are likely to employ distinct modes of action, results suggest that they nevertheless maintain a link to the proteasome pathway. Therefore, although the proteasome remains a preferred choice for therapy, the continually emerging upstream signaling molecules serve as additional promising therapeutic targets for the treatment of tumor-induced muscle wasting.

Randomized phase 2 trial of anti-tumor necrosis factor therapy for cachexia in patients with early rheumatoid arthritis

BACKGROUND

Tumor necrosis factor (TNF) is an important mediator of cachexia, and its blockade prevents catabolism in animal models. However, little evidence shows that anti-TNF therapy is effective in treating cachexia in humans.

OBJECTIVE

The main aim of this study was to investigate the effect of etanercept, a synthetic soluble TNF receptor, on body composition in patients with early rheumatoid arthritis (RA).

DESIGN

Twenty-six patients were randomly assigned to 24 wk of treatment with etanercept or methotrexate; the latter is the first-line therapy for RA. Body composition, physical function, disease activity, systemic inflammation, and the circulating insulin-like growth factor (IGF) system were measured at baseline (week 0) and at follow-up (weeks 12 and 24). Twelve patients in each treatment group (9 F, 3 M) completed the study.

RESULTS

Overall, no important changes in body composition were observed, despite a transient increase in IGF-I at week 12 (P < 0.01). However, the secondary analysis of those patients (6/treatment group) who gained weight during follow-up showed a significant effect of etanercept on the composition of the weight gained: 44% of weight gained in the etanercept group was fat-free mass, as compared with only 14% in the methotrexate group (P = 0.04). Etanercept and methotrexate were equally effective in controlling the disease and improving physical function.

CONCLUSIONS

Anti-TNF therapy with etanercept is not superior to that with methotrexate for the treatment of rheumatoid cachexia over a period of 6 mo. However, TNF blockade seems to normalize the anabolic response to overfeeding and, if these findings are confirmed, may be useful in conditions characterized by anorexia and weight loss.