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Blasko F, Horvathova L. The relationship between the tumor and its innervation: historical, methodical, morphological, and functional assessments - A minireview. Endocr Regul 2024; 58:68-82. [PMID: 38563296 DOI: 10.2478/enr-2024-0008] [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] [Indexed: 04/04/2024] Open
Abstract
The acceptance of the tumor as a non-isolated structure within the organism has opened a space for the study of a wide spectrum of potential direct and indirect interactions, not only between the tumor tissue and its vicinity, but also between the tumor and its macroenvironment, including the nervous system. Although several lines of evidence have implicated the nervous system in tumor growth and progression, for many years, researchers believed that tumors lacked innervation and the notion of indirect neuro-neoplastic interactions via other systems (e.g., immune, or endocrine) predominated. The original idea that tumors are supplied not only by blood and lymphatic vessels, but also autonomic and sensory nerves that may influence cancer progression, is not a recent phenomenon. Although in the past, mainly due to the insufficiently sensitive methodological approaches, opinions regarding the presence of nerves in tumors were inconsistent. However, data from the last decade have shown that tumors are able to stimulate the formation of their own innervation by processes called neo-neurogenesis and neo-axonogenesis. It has also been shown that tumor infiltrating nerves are not a passive, but active components of the tumor microenvironment and their presence in the tumor tissue is associated with an aggressive tumor phenotype and correlates with poor prognosis. The aim of the present review was to 1) summarize the available knowledge regarding the course of tumor innervation, 2) present the potential mechanisms and pathways for the possible induction of new nerve fibers into the tumor microenvironment, and 3) highlight the functional significance/consequences of the nerves infiltrating the tumors.
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Affiliation(s)
- Filip Blasko
- Institute of Experimental Endocrinology, Biomedical Research Center, Slovak Academy of Sciences, Bratislava, Slovakia
- Institute of Physiology, Faculty of Medicine, Comenius University Bratislava, Bratislava, Slovakia
| | - Lubica Horvathova
- Institute of Experimental Endocrinology, Biomedical Research Center, Slovak Academy of Sciences, Bratislava, Slovakia
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Valiati FE, Feiten JG, Géa LP, Silveira ÉDM, Scotton E, Caldieraro MA, Salum GA, Kauer-Sant’Anna M. Inflammation and damage-associated molecular patterns in major psychiatric disorders. TRENDS IN PSYCHIATRY AND PSYCHOTHERAPY 2022; 45:e20220576. [PMID: 36527709 PMCID: PMC10640887 DOI: 10.47626/2237-6089-2022-0576] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/30/2022] [Accepted: 12/01/2022] [Indexed: 11/14/2023]
Abstract
BACKGROUND Emerging evidence indicates that inflammation plays an important role as a mechanism underlying mental disorders. However, most of the research on inflammatory mechanisms focuses on serum levels of interleukins and very few studies have investigated molecules that initiate and expand innate immune pathways such as damage-associated molecular patterns (DAMPs). OBJECTIVES This study investigated the levels of DAMPs among patients diagnosed with major depressive disorder (MDD), bipolar disorder (BD) I and II, schizophrenia (SCZ), and generalized anxiety disorder (GAD). We quantified serum levels of heat shock proteins (HSPs) 70 and 60 and of S100 calcium-binding protein B (S100B). METHODS Serum levels of HSP70, HSP60, and S100B were assessed in a sample of participants with psychiatric disorders (n = 191) and a control group (CT) (n = 59) using enzyme-linked immunosorbent assay (ELISA). RESULTS Serum HSP70 concentrations were significantly higher in the MDD group compared to the CT, SCZ, and BD groups. The GAD group had higher concentrations of HSP70 than the SCZ group. Exploring associations with medications, lithium (p = 0.003) and clozapine (p = 0.028) were associated with lower HSP70 levels. Approximately 64% of the sample had DAMPs levels below the limits of detection indicated by the respective ELISA kit. CONCLUSION This was the first study to assess DAMPs levels in a transdiagnostic sample. Our preliminary findings suggest that HSP70 may be associated with MDD pathophysiology. Medications such as lithium and clozapine were associated with lower HSP70 levels in BD and SCZ groups, respectively. Therefore, it is worth mentioning that all participants were medicated and many psychotropic drugs exert an anti-inflammatory effect, possibly reducing the signs of inflammation.
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Affiliation(s)
- Fernanda Endler Valiati
- Laboratório de Psiquiatria MolecularCentro de Pesquisa ClínicaHospital de Clínicas de Porto AlegrePorto AlegreRSBrazil Laboratório de Psiquiatria Molecular, Centro de Pesquisa Experimental (CPE) and Centro de Pesquisa Clínica (CPC), Hospital de Clínicas de Porto Alegre (HCPA), Porto Alegre, RS, Brazil.
- Departamento de BioquímicaInstituto de Ciências Básicas da SaúdeUniversidade Federal do Rio Grande do SulPorto AlegreRSBrazil Departamento de Bioquímica, Instituto de Ciências Básicas da Saúde, Universidade Federal do Rio Grande do Sul (UFRGS), Porto Alegre, RS, Brazil.
| | - Jacson Gabriel Feiten
- Laboratório de Psiquiatria MolecularCentro de Pesquisa ClínicaHospital de Clínicas de Porto AlegrePorto AlegreRSBrazil Laboratório de Psiquiatria Molecular, Centro de Pesquisa Experimental (CPE) and Centro de Pesquisa Clínica (CPC), Hospital de Clínicas de Porto Alegre (HCPA), Porto Alegre, RS, Brazil.
- Departamento de PsiquiatriaFaculdade de MedicinaUFRGSPorto AlegreRSBrazil Programa de Pós-Graduação em Psiquiatria e Ciências do Comportamento, Departamento de Psiquiatria, Faculdade de Medicina, UFRGS, Porto Alegre, RS, Brazil.
| | - Luiza Paul Géa
- Laboratório de Psiquiatria MolecularCentro de Pesquisa ClínicaHospital de Clínicas de Porto AlegrePorto AlegreRSBrazil Laboratório de Psiquiatria Molecular, Centro de Pesquisa Experimental (CPE) and Centro de Pesquisa Clínica (CPC), Hospital de Clínicas de Porto Alegre (HCPA), Porto Alegre, RS, Brazil.
| | - Érico de Moura Silveira
- Laboratório de Psiquiatria MolecularCentro de Pesquisa ClínicaHospital de Clínicas de Porto AlegrePorto AlegreRSBrazil Laboratório de Psiquiatria Molecular, Centro de Pesquisa Experimental (CPE) and Centro de Pesquisa Clínica (CPC), Hospital de Clínicas de Porto Alegre (HCPA), Porto Alegre, RS, Brazil.
| | - Ellen Scotton
- Laboratório de Psiquiatria MolecularCentro de Pesquisa ClínicaHospital de Clínicas de Porto AlegrePorto AlegreRSBrazil Laboratório de Psiquiatria Molecular, Centro de Pesquisa Experimental (CPE) and Centro de Pesquisa Clínica (CPC), Hospital de Clínicas de Porto Alegre (HCPA), Porto Alegre, RS, Brazil.
- Programa de Pós-Graduação em Farmacologia e TerapêuticaUFRGSPorto AlegreRSBrazil Programa de Pós-Graduação em Farmacologia e Terapêutica, UFRGS, Porto Alegre, RS, Brazil.
| | - Marco Antonio Caldieraro
- Laboratório de Psiquiatria MolecularCentro de Pesquisa ClínicaHospital de Clínicas de Porto AlegrePorto AlegreRSBrazil Laboratório de Psiquiatria Molecular, Centro de Pesquisa Experimental (CPE) and Centro de Pesquisa Clínica (CPC), Hospital de Clínicas de Porto Alegre (HCPA), Porto Alegre, RS, Brazil.
- Departamento de PsiquiatriaFaculdade de MedicinaUFRGSPorto AlegreRSBrazil Programa de Pós-Graduação em Psiquiatria e Ciências do Comportamento, Departamento de Psiquiatria, Faculdade de Medicina, UFRGS, Porto Alegre, RS, Brazil.
| | - Giovanni Abrahão Salum
- Departamento de PsiquiatriaFaculdade de MedicinaUFRGSPorto AlegreRSBrazil Programa de Pós-Graduação em Psiquiatria e Ciências do Comportamento, Departamento de Psiquiatria, Faculdade de Medicina, UFRGS, Porto Alegre, RS, Brazil.
| | - Marcia Kauer-Sant’Anna
- Laboratório de Psiquiatria MolecularCentro de Pesquisa ClínicaHospital de Clínicas de Porto AlegrePorto AlegreRSBrazil Laboratório de Psiquiatria Molecular, Centro de Pesquisa Experimental (CPE) and Centro de Pesquisa Clínica (CPC), Hospital de Clínicas de Porto Alegre (HCPA), Porto Alegre, RS, Brazil.
- Departamento de BioquímicaInstituto de Ciências Básicas da SaúdeUniversidade Federal do Rio Grande do SulPorto AlegreRSBrazil Departamento de Bioquímica, Instituto de Ciências Básicas da Saúde, Universidade Federal do Rio Grande do Sul (UFRGS), Porto Alegre, RS, Brazil.
- Departamento de PsiquiatriaFaculdade de MedicinaUFRGSPorto AlegreRSBrazil Programa de Pós-Graduação em Psiquiatria e Ciências do Comportamento, Departamento de Psiquiatria, Faculdade de Medicina, UFRGS, Porto Alegre, RS, Brazil.
- Instituto Nacional de Ciência e Tecnologia Translacional em MedicinaPorto AlegreRSBrazil Instituto Nacional de Ciência e Tecnologia Translacional em Medicina (INCT-TM), Porto Alegre, RS, Brazil.
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Khan WA, Alsamghan AS, Khan MWA. Endometrial cancer patients have high affinity antibodies for estrogen metabolite-receptor aggregate: A potential biomarker for EC. J Obstet Gynaecol Res 2020; 46:2115-2125. [PMID: 32761720 DOI: 10.1111/jog.14413] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2020] [Revised: 06/26/2020] [Accepted: 07/10/2020] [Indexed: 12/29/2022]
Abstract
AIM Elevated levels of 16α-hydroxyestrone (16α-OHE1 ) have been described in endometrial cancer (EC) and estrogen receptors (ER) expressed in endometrial tissue, but research on their combined role is lacking. We aimed to investigate the affinity and binding specificity of EC antibodies against the 16α-OHE1 -ERα aggregate in the serum of EC patients. Specificities of EC antibodies were also evaluated according to various clinical characteristics found in these cancer patients. METHODS The binding specificity and affinity of EC antibodies against 16α-OHE1 -ERα in the serum of 120 EC patients were evaluated by direct binding and competition ELISA and quantitative precipitation titration. Binding of EC antibodies was also determined according to various clinical characteristics in EC patients through competition ELISA. RESULTS Antibodies from EC patients demonstrated high recognition of 16α-OHE1 -ERα compared to ERα (P < 0.05) or 16α-OHE1 (P < 0.001). The relative affinity of EC IgG was 1.49 × 10-7 M, 1.34 × 10-6 M and 1.13 × 10-6 M for 16α-OHE1 -ERα, ERα and 16α-OHE1 , respectively. Several factors, such as obesity, postmenopausal status, use of hormonal therapy, ER and progesterone receptor (PR) status, low 2-OHE1 /16α-OHE1 ratio, chemotherapy and hypertension, augment the production of antibodies against 16α-OHE1 -ERα in EC patients. CONCLUSION 16α-OHE1 -ERα is a high-affinity antigen for EC antibodies in the serum of EC patients and might function as a biomarker for this disease. Furthermore, several factors enhanced the production of antibodies against 16α-OHE1 -ERα in the sera of these EC patients.
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Affiliation(s)
- Wahid Ali Khan
- Department of Clinical Biochemistry, College of Medicine, King Khalid University, Abha, KSA
| | - Awad Saeed Alsamghan
- Department of Family and Community Medicine, College of Medicine, King Khalid University, Abha, KSA
| | - Mohd Wajid Ali Khan
- Department of Clinical Laboratory Science, College of Applied Medical Science, University of Hail, Hail, KSA.,Molecular Diagnostic and Personalised Therapeutics Unit, University of Hail, Hail, KSA
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Franklin TC, Xu C, Duman RS. Depression and sterile inflammation: Essential role of danger associated molecular patterns. Brain Behav Immun 2018; 72:2-13. [PMID: 29102801 DOI: 10.1016/j.bbi.2017.10.025] [Citation(s) in RCA: 122] [Impact Index Per Article: 20.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/21/2017] [Revised: 10/14/2017] [Accepted: 10/31/2017] [Indexed: 12/12/2022] Open
Abstract
Stress is a major risk factor for psychiatric disorder including major depressive disorder (MDD) and can induce inflammation, which is known to be dysregulated in depression. Several clinical and pre-clinical studies have demonstrated a strong association between depressive symptoms and the expression of factors that increase inflammation. Conversely, administration of anti-inflammatory agents has been shown to ameliorate depressive symptoms, demonstrating the importance of inflammation as a mediator of depression. Although it is clear that inflammation plays a role in the pathophysiology of depression, the mechanism by which inflammation is activated in mood disorders remains unclear. To address this issue, studies have investigated the role of pattern recognition receptor (PRR) activation in stress-induced inflammation and mood disorders. However, the identification of the endogenous factors, referred to as danger-associated molecular patterns (DAMP) that activate these receptors remains understudied. Here we review the role of DAMPs in depression and highlight the clinical evidence for elevation of DAMP signaling in MDD patients and in pre-clinical animal stress models of depression.
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Affiliation(s)
- Tina C Franklin
- Laboratory of Molecular Psychiatry, Center for Genes and Behavior, Department of Psychiatry, Yale University School of Medicine, New Haven, CT 06508, USA
| | - Chelsea Xu
- Laboratory of Molecular Psychiatry, Center for Genes and Behavior, Department of Psychiatry, Yale University School of Medicine, New Haven, CT 06508, USA
| | - Ronald S Duman
- Laboratory of Molecular Psychiatry, Center for Genes and Behavior, Department of Psychiatry, Yale University School of Medicine, New Haven, CT 06508, USA.
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Wohleb ES, Franklin T, Iwata M, Duman RS. Integrating neuroimmune systems in the neurobiology of depression. Nat Rev Neurosci 2016; 17:497-511. [PMID: 27277867 DOI: 10.1038/nrn.2016.69] [Citation(s) in RCA: 402] [Impact Index Per Article: 50.3] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Data from clinical and preclinical studies indicate that immune dysregulation, specifically of inflammatory processes, is associated with symptoms of major depressive disorder (MDD). In particular, increased levels of circulating pro-inflammatory cytokines and concomitant activation of brain-resident microglia can lead to depressive behavioural symptoms. Repeated exposure to psychological stress has a profound impact on peripheral immune responses and perturbs the function of brain microglia, which may contribute to neurobiological changes underlying MDD. Here, we review these findings and discuss ongoing studies examining neuroimmune mechanisms that influence neuronal activity as well as synaptic plasticity. Interventions targeting immune-related cellular and molecular pathways may benefit subsets of MDD patients with immune dysregulation.
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Affiliation(s)
- Eric S Wohleb
- Departments of Psychiatry and Neurobiology, Yale University School of Medicine, New Haven, Connecticut 06519, USA
| | - Tina Franklin
- Departments of Psychiatry and Neurobiology, Yale University School of Medicine, New Haven, Connecticut 06519, USA
| | - Masaaki Iwata
- Division of Neuropsychiatry, Department of Brain and Neurosciences, Tottori University Faculty of Medicine, 86 Nishi-cho, Yonago, Tottori 683-8503, Japan
| | - Ronald S Duman
- Departments of Psychiatry and Neurobiology, Yale University School of Medicine, New Haven, Connecticut 06519, USA
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Telepak LC, Jensen SE, Dodd SM, Morgan LS, Pereira DB. Psychosocial factors and mortality in women with early stage endometrial cancer. Br J Health Psychol 2014; 19:737-50. [PMID: 24152380 PMCID: PMC4061273 DOI: 10.1111/bjhp.12070] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2013] [Revised: 03/09/2013] [Indexed: 01/06/2023]
Abstract
OBJECTIVES Psychosocial factors have previously been linked with survival and mortality in cancer populations. Little evidence is available about the relationship between these factors and outcomes in gynaecologic cancer populations, particularly endometrial cancer, the fourth most common cancer among women. This study examined the relationship between several psychosocial factors prior to surgical resection and risk of all-cause mortality in women with endometrial cancer. DESIGN The study utilized a non-experimental, longitudinal design. METHODS Participants were 87 women (Mage = 60.69 years, SDage = 9.12 years) who were diagnosed with T1N0-T3N2 endometrial cancer and subsequently underwent surgery. Participants provided psychosocial data immediately prior to surgery. Survival statuses 4-5 years post-diagnoses were abstracted via medical record review. Cox regression was employed for the survival analysis. RESULTS Of the 87 women in this sample, 21 women died during the 4- to 5-year follow-up. Adjusting for age, presence of regional disease and medical comorbidity severity (known biomedical prognostic factors), greater use of an active coping style prior to surgery was significantly associated with a lower probability of all-cause mortality, hazard ratio (HR) = 0.78, p = .04. Life stress, depressive symptoms, use of self-distraction coping, receipt of emotional support and endometrial cancer quality of life prior to surgery were not significantly associated with all-cause mortality 4-5 years following diagnosis. CONCLUSIONS Greater use of active coping prior to surgery for suspected endometrial cancer is associated with lower probability of all-cause mortality 4-5 years post-surgery. Future research should attempt to replicate these relationships in a larger and more representative sample and examine potential behavioural and neuroendocrine/immune mediators of this relationship. STATEMENT OF CONTRIBUTION What is already known on this subject? Psychosocial factors have previously been linked with clinical outcomes in a variety of cancer populations. With regards to gynecologic cancer, the majority of the research has been conducted in ovarian cancer and examines the protective role of social support in mortality outcomes. What does this study add? Demonstrates association between active coping during perioperative period and 5 year survival. Demonstrates psychosocial-survival relationship exists independent of biobehavioral factors.
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Affiliation(s)
- Laura C. Telepak
- Department of Clinical and Health Psychology, University of Florida, Gainesville, Florida, USA
| | - Sally E. Jensen
- Division of Organ Transplantation, Departments of Medical Social Sciences and Surgery, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Stacy M. Dodd
- Department of Behavioral Medicine, Palo Alto Health Care System, Palo Alto, California, USA
| | - Linda S. Morgan
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, University of Florida, Gainesville, Florida, USA
| | - Deidre B. Pereira
- Department of Clinical and Health Psychology, University of Florida, Gainesville, Florida, USA
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Depressive symptoms and cortisol variability prior to surgery for suspected endometrial cancer. Psychoneuroendocrinology 2013; 38:241-9. [PMID: 22762895 PMCID: PMC3473116 DOI: 10.1016/j.psyneuen.2012.06.001] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/30/2011] [Revised: 05/17/2012] [Accepted: 06/05/2012] [Indexed: 11/23/2022]
Abstract
Endometrial cancer (EC) is the most common type of gynecologic cancer affecting women; however, very little research has examined relationships between psychological factors and hypothalamic-pituitary-adrenal (HPA) axis dysregulation in this population. The current study examined relations between depressive/anxious symptoms and salivary cortisol diurnal rhythm and variability in women undergoing surgery for suspected endometrial cancer. Depressive and anxious symptoms were measured prior to surgery using the Structured Interview Guide for the Hamilton Depression Inventory (SIGH-AD). Saliva was collected four times a day for the 3 days prior to surgery and then assayed by ELISA to obtain cortisol concentrations. Cortisol slopes and intraindividual variability were then calculated across subjects. Relations between depressive/anxious symptoms and cortisol indices were examined using multilevel modeling and linear regression analyses. Participants were 82 women with nonmetastatic endometrial cancer. Anxious symptoms were not associated with either cortisol slope or intraindividual variability, and depressive symptoms were unrelated to cortisol slope. However, after controlling for presence of poorer prognosis cancer subtypes, greater depressive symptoms (excluding symptoms possibly/definitely due to health/treatment factors) in the week preceding surgery were significantly related to greater cortisol intraindividual variability (β=.214; p<.05). These results suggest that depressive symptoms prior to surgery for suspected endometrial cancer are related to greater cortisol intraindividual variability, which is suggestive of more erratic HPA axis arousal. Future research should examine whether mood symptoms may be associated with compromised health outcomes via erratic HPA axis arousal in this population.
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Dhabhar FS, Saul AN, Holmes TH, Daugherty C, Neri E, Tillie JM, Kusewitt D, Oberyszyn TM. High-anxious individuals show increased chronic stress burden, decreased protective immunity, and increased cancer progression in a mouse model of squamous cell carcinoma. PLoS One 2012; 7:e33069. [PMID: 22558071 PMCID: PMC3338811 DOI: 10.1371/journal.pone.0033069] [Citation(s) in RCA: 50] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2011] [Accepted: 02/03/2012] [Indexed: 12/30/2022] Open
Abstract
In spite of widespread anecdotal and scientific evidence much remains to be understood about the long-suspected connection between psychological factors and susceptibility to cancer. The skin is the most common site of cancer, accounting for nearly half of all cancers in the US, with approximately 2-3 million cases of non-melanoma cancers occurring each year worldwide. We hypothesized that a high-anxious, stress-prone behavioral phenotype would result in a higher chronic stress burden, lower protective-immunity, and increased progression of the immuno-responsive skin cancer, squamous cell carcinoma. SKH1 mice were phenotyped as high- or low-anxious at baseline, and subsequently exposed to ultraviolet-B light (1 minimal erythemal dose (MED), 3 times/week, 10-weeks). The significant strengths of this cancer model are that it uses a normal, immunocompetent, outbred strain, without surgery/injection of exogenous tumor cells/cell lines, and produces lesions that resemble human tumors. Tumors were counted weekly (primary outcome), and tissues collected during early and late phases of tumor development. Chemokine/cytokine gene-expression was quantified by PCR, tumor-infiltrating helper (Th), cytolytic (CTL), and regulatory (Treg) T cells by immunohistochemistry, lymph node T and B cells by flow cytometry, adrenal and plasma corticosterone and tissue vascular-endothelial-growth-factor (VEGF) by ELISA. High-anxious mice showed a higher tumor burden during all phases of tumor development. They also showed: higher corticosterone levels (indicating greater chronic stress burden), increased CCL22 expression and Treg infiltration (increased tumor-recruited immuno-suppression), lower CTACK/CCL27, IL-12, and IFN-γ gene-expression and lower numbers of tumor infiltrating Th and CTLs (suppressed protective immunity), and higher VEGF concentrations (increased tumor angiogenesis/invasion/metastasis). These results suggest that the deleterious effects of high trait anxiety could be: exacerbated by life-stressors, accentuated by the stress of cancer diagnosis/treatment, and mediate increased tumor progression and/or metastasis. Therefore, it may be beneficial to investigate the use of chemotherapy-compatible anxiolytic treatments immediately following cancer diagnosis, and during cancer treatment/survivorship.
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Affiliation(s)
- Firdaus S Dhabhar
- Department of Psychiatry & Behavioral Sciences, Stanford University, Stanford, California, United States of America.
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