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Clinical Relevance of +936 C>T VEGFA and c.233C>T bFGF Polymorphisms in Chronic Lymphocytic Leukemia. Genes (Basel) 2020; 11:genes11060686. [PMID: 32585853 PMCID: PMC7349122 DOI: 10.3390/genes11060686] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2020] [Revised: 06/14/2020] [Accepted: 06/19/2020] [Indexed: 12/21/2022] Open
Abstract
Angiogenesis process contributes to the pathogenesis of B-cell chronic lymphocytic leukemia (B-CLL) being the levels of VEGFA and bFGF higher in patients than in healthy controls. Our aim was to evaluate the implication of angiogenesis factors genetic variants in the predisposition to B-CLL and their association with clinical factors and survival. We performed a population-based case-control study in 224 Spanish B-CLL patients and 476 healthy randomly selected controls to evaluate susceptibility to developing B-CLL. Six polymorphisms were evaluated: rs1109324, rs1547651, rs3025039 (+936 C>T), rs833052 of the VEGFA gene, rs1449683 (c.233C>T) of the bFGF gene and (−710 C>T) of the VEGFR1 gene. The association between clinical parameters and patient outcome was analyzed. Carriers of the CT/TT variants of rs3025039 showed a significant protective effect against developing B-CLL. The CT/TT variants of rs1449683 show a tendency towards the development of the disease and the same variants associated significantly with higher genetic risk and with reduced disease free survival. Moreover, the association persisted in the early-stage disease subgroup. Our study provides evidence of the protective effect of the T/- rs3025039 VEGFA variant against B-CLL development and the association of CT/TT variants of the rs1449683 bFGF gene with genetic risk and an adverse survival.
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Urganci BE, Acikbas I, Er FR. Investigation of Immunovascular Polymorphisms and Intersections in Psoriasis. Indian J Dermatol 2019; 64:187-191. [PMID: 31148856 PMCID: PMC6537683 DOI: 10.4103/ijd.ijd_422_18] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/03/2022] Open
Abstract
Background: Psoriasis is a chronic, inflammatory skin disease. The etiology of the disease is unknown. It is a polygenic and multifactorial disease, which interacts with genetic and environmental factors. Genetic factors (polymorphism/mutation) can alter the immune system and normal physiologically functioning keratinocytes to pathological or predisposition levels. Aims: We aimed to investigate psoriasis at a different and novel window by searching for vascular and immunological variations and intersections in psoriasis. We investigated the main vascular and hypoxic controlling factors, which are vascular endothelial growth factor (VEGF) and hypoxia inducible factor 1 alpha (HIF-1α), as well as immunological and serotonergic factors, such as TNF-α, IL-10, and 5HT2A, which could connect each other to the pathogenesis of psoriasis. Subjects and Methods: Nine single nucleotide polymorphisms (SNPs) in five genes were genotyped by mini-array format in 300 subjects: VEGF (rs2010963, rs833061, and rs1570360), HIF-1α (rs11549465), TNF-α (rs361525, rs1799964, and rs1800629), IL-10 (rs1800896), and 5HT2A (rs6311). Results: An association was found between rs1800629 (TNF-α) and Type I psoriasis, and rs833061 (VEGF) and Type II psoriasis. Haplotype analysis suggests that the coexistence of the polymorphisms rs1799964 (TNF-α), rs2010963 (VEGF), rs833061 (VEGF), and rs6311 (5HT2A) may be a protective factor for psoriasis. Conclusion: Our results suggest that the vascular component of the studied vasculo-immunologic variation is more relevant in the pathogenesis of psoriasis.
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Affiliation(s)
- Buket Er Urganci
- Department of Medical Biology, Medical Faculty, Pamukkale University, Denizli, Turkey
| | - Ibrahim Acikbas
- Department of Medical Biology, Medical Faculty, Pamukkale University, Denizli, Turkey
| | - F Rezzan Er
- Department of Dermatology, Denizli State Hospital, Denizli, Turkey
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Song Y, Hu J, Chen Q, Guo J, Zou Y, Zhang W, Chen X, Hu W, Huang P. Association between vascular endothelial growth factor rs699947 polymorphism and the risk of three major urologic neoplasms (bladder cancer, prostate cancer, and renal cell carcinoma): A meta-analysis involving 11,204 subjects. Gene 2018; 679:241-252. [PMID: 30195633 DOI: 10.1016/j.gene.2018.09.005] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2018] [Revised: 08/25/2018] [Accepted: 09/05/2018] [Indexed: 12/26/2022]
Abstract
BACKGROUND The relationship between vascular endothelial growth factor (VEGF) gene variant rs699947 polymorphism and urologic neoplasms risk was studied extensively in recent years. The VEGF gene plays a key role in angiogenesis of urologic neoplasms, but some conclusions are still inconclusive. The aim of this study was to determine whether this polymorphism is a risk factor for susceptibility to urologic neoplasms by conducting a meta-analysis. METHODS We performed a meta-analysis of 15 different publications from the PubMed, Embase and Medline databases, to better assess the association between VEGF rs699947 polymorphism and urologic neoplasms risk. Odds ratios (ORs) and 95% confidence intervals (CIs) were evaluated using random or fixed effects models. RESULTS By pooling all eligible studies, we found that the VEGF rs699947 polymorphism was not associated with overall urologic neoplasms. However, subgroup analysis based on cancer types demonstrated that significantly increased association was found between VEGF rs699947 polymorphism and the risk of bladder cancer (BCa) under heterozygous genetic model (OR = 1.48, 95%CI = 1.17-1.89). And rs699947 polymorphism was also identified an increased risk of renal cell carcinoma (RCC) under dominant, recessive, homozygous, heterozygous and allelic contrast genetic models, while no association was observed in prostate cancer (PCa). In addition, in subgroup analysis by ethnicity, we found rs699947 polymorphism was associated with Asian population under dominant, homozygous, heterozygous and allelic contrast genetic models. No evidence of publication bias was found (Begg's test, P = 0.855; Egger's test, P = 0.590). CONCLUSIONS In summary, our study showed evidence that the VEGF rs699947 polymorphism was obviously associated with an increased risk of bladder cancer and renal cell carcinoma, particularly in Asian population, while no significant association was observed in overall urologic neoplasms. Future studies with larger sample sizes are warranted to further evaluate these associations in more details.
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Affiliation(s)
- Yuxuan Song
- The First Clinical Medical School, Nanchang University, Nanchang, Jiangxi 330006, China; Department of Urology, Tianjin Medical University General Hospital, Tianjin 300052, China; Department of Urology, The First Affiliated Hospital of Nanchang University, Nanchang, Jiangxi 330006, China
| | - Jieping Hu
- The First Clinical Medical School, Nanchang University, Nanchang, Jiangxi 330006, China; Department of Urology, The First Affiliated Hospital of Nanchang University, Nanchang, Jiangxi 330006, China
| | - Qingke Chen
- The First Clinical Medical School, Nanchang University, Nanchang, Jiangxi 330006, China; Department of Urology, The First Affiliated Hospital of Nanchang University, Nanchang, Jiangxi 330006, China
| | - Jia Guo
- The First Clinical Medical School, Nanchang University, Nanchang, Jiangxi 330006, China
| | - Yixuan Zou
- Grade 2016, Queen Mary Institute, Nanchang University, Nanchang, Jiangxi 330000, China
| | - Wen Zhang
- Grade 2017, School of Public Health, Nanchang University, Nanchang 330031, China
| | - Xiaolong Chen
- Department of Epidemiology, School of Public Health, Nanchang University, Nanchang 330006, China
| | - Wang Hu
- Department of Epidemiology, School of Public Health, Nanchang University, Nanchang 330006, China
| | - Peng Huang
- Department of Epidemiology, School of Public Health, Nanchang University, Nanchang 330006, China; Jiangxi Province Key Laboratory of Preventive Medicine, School of Public Health, Nanchang University, Nanchang 330006, China.
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Zidi S, Stayoussef M, Gazouani E, Mezlini A, Yacoubi-Loueslati B, Almawi WY. Relationship of common vascular endothelial growth factor polymorphisms and haplotypes with the risk of cervical cancer in Tunisians. Cytokine 2015; 74:108-12. [DOI: 10.1016/j.cyto.2014.11.009] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2014] [Revised: 11/08/2014] [Accepted: 11/10/2014] [Indexed: 01/31/2023]
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Clinical relevance of vascular endothelial growth factor type A (VEGFA) and VEGF receptor type 2 (VEGFR2) gene polymorphism in chronic lymphocytic leukemia. Blood Cells Mol Dis 2015; 54:139-43. [DOI: 10.1016/j.bcmd.2014.11.022] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2014] [Accepted: 11/14/2014] [Indexed: 01/20/2023]
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Qi M, Huang X, Zhou L, Zhang J. Four polymorphisms of VEGF (+405C>G, -460T>C, -2578C>A, and -1154G>A) in susceptibility to psoriasis: a meta-analysis. DNA Cell Biol 2014; 33:234-44. [PMID: 24678886 DOI: 10.1089/dna.2013.2252] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
The contribution of genetic polymorphisms in the vascular endothelial growth factor (VEGF) gene to psoriasis risk is a controversial topic. The aim of this meta-analysis was to investigate large-scale evidence to determine the degree to which four common VEGF polymorphisms (+405C>G [dbSNP: rs2010963], -460T>C [dbSNP: rs833061], -2578C>A [dbSNP: rs699947], and -1154G>A [dbSNP: rs1570360]) are associated with susceptibility to psoriasis. A literature search of PubMed, Embase, Web of Science, Chinese National Knowledge Infrastructure, and Chinese Biomedical Literature Database was conducted to identify all eligible studies published before September 15, 2013. The principal outcome measure for evaluating the strength of the association was crude odds ratios (ORs) along with their corresponding 95% confidence intervals (95% CIs). Two thousand five hundred thirty-one patients and 2670 controls from nine case-control studies detailing a possible association between the VEGF genotypes and psoriasis risk were selected. Our meta-analysis provides evidence that two independent alleles +405G and -460C may be a protective factor for psoriasis in Asians, whereas the -1154A allele had a slight but statistically significant preventive effect on the development of psoriasis in Caucasians. The -2578C>A polymorphism, however, did not correlate with any significant difference between patients and healthy controls, even when the groups were stratified by ethnicity. Results from the meta-analysis do support the hypothesis that single-nucleotide polymorphism markers at +405C>G, -460C>T, and -1154G>A of the VEGF gene may serve as biological markers of psoriasis. Future studies should investigate interactions among multiple genotypes and environmental exposures to identify the role of proangiogenic markers in psoriasis and to delineate the underlying mechanisms of psoriasis.
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Affiliation(s)
- Min Qi
- 1 Department of Cosmetic and Plastic Surgery, Xiangya Hospital, Central South University , Changsha, China
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Tan X, Xian L, Chen X, Shi L, Wang Y, Guo J, Liang G, Zhao Z, Chen M. Association between ERCC2 Lys751Gln polymorphism and lung cancer risk: a meta-analysis involving 23,370 subjects. Twin Res Hum Genet 2014; 17:99-107. [PMID: 24556168 DOI: 10.1017/thg.2014.4] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
Recent studies report a correlation between excision repair cross-complementing group 2 (ERCC2) Lys751Gln polymorphism and an increased risk of lung cancer, but results are controversial and inconclusive. Thus, we conducted a comprehensive meta-analysis in order to assess the correlation between them. Our study uses an odds ratio (OR) with a 95% confidence interval (95% CI) to evaluate the strength of the association; we also performed Begg's funnel plot and the Egger's test to assess the publication bias of previous articles. Finally, our meta-analysis is comprised of 28 full studies, including 23,370 subjects (10,242 cases and 13,128 controls). Our overall research shows that ERCC2 Lys751Gln polymorphism carries an increased risk of developing lung cancer (C vs. A: OR = 1.160, 95% CI = 1.081-1.245, p = .000; CC vs. AA: OR = 1.252, 95% CI = 1.130-1.388, p = .000; CA vs. AA: OR = 1.152, 95% CI = 1.060-1.252, p = .001; CC+CA vs. AA: OR = 1.186, 95% CI = 1.089-1.292, p = .000; CC vs. CA+AA: OR = 1.196, 95% CI = 1.087-1.316, p = .000). In ethnic subgroup analyses, we find a significant risk among Caucasians (C vs. A: OR = 1.106, 95% CI = 1.048-1.166, p = .000; CC vs. AA: OR = 1.233, 95% CI = 1.103-1.378, p = .000; CC+CA vs. AA: OR = 1.113, 95% CI = 1.033-1.199, p = .005; CC vs. CA+AA: OR = 1.185, 95% CI = 1.069-1.313, p = .001) and among Asians under two genetic models (CA vs. AA: OR = 1.265, 95% CI = 1.034-1.549, p = .023; CC+CA vs. AA: OR = 1.252, 95% CI = 1.015-1.544, p = .036). These results were confirmed by similar findings, demonstrated by stratified analyses in study design and histological typing. This meta-analysis indicates that ERCC2 Lys751Gln polymorphism may lead to an increased susceptibility to lung cancer risk among Caucasians and Asians.
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Affiliation(s)
- Xiang Tan
- Department of Cardiothoracic Surgery, First Affiliated Hospital, Guangxi Medical University, Nanning, Guangxi, China
| | - Lei Xian
- Department of Cardiothoracic Surgery, First Affiliated Hospital, Guangxi Medical University, Nanning, Guangxi, China
| | - Xinyu Chen
- Department of Oncology, First Affiliated Hospital, Guangxi Medical University, Nanning, Guangxi, China
| | - Lijun Shi
- Department of Oncology, Cancer Affiliated Hospital, Guangxi Medical University, Nanning, Guangxi, China
| | - Yongyong Wang
- Department of Cardiothoracic Surgery, First Affiliated Hospital, Guangxi Medical University, Nanning, Guangxi, China
| | - Jianji Guo
- Department of Cardiothoracic Surgery, First Affiliated Hospital, Guangxi Medical University, Nanning, Guangxi, China
| | - Guanbiao Liang
- Department of Cardiothoracic Surgery, First Affiliated Hospital, Guangxi Medical University, Nanning, Guangxi, China
| | - Zhenqing Zhao
- Department of Cardiothoracic Surgery, First Affiliated Hospital, Guangxi Medical University, Nanning, Guangxi, China
| | - Mingwu Chen
- Department of Cardiothoracic Surgery, First Affiliated Hospital, Guangxi Medical University, Nanning, Guangxi, China
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VEGF +405G/C (rs2010963) polymorphisms and digestive system cancer risk: a meta-analysis. Tumour Biol 2014; 35:4977-82. [PMID: 24474253 DOI: 10.1007/s13277-014-1655-0] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2013] [Accepted: 01/13/2014] [Indexed: 02/08/2023] Open
Abstract
Vascular endothelial growth factor (VEGF) polymorphisms, specifically +405G/C (rs2010963), reportedly influence the risk for various digestive cancers. However, the consequences of these polymorphisms remain controversial and ambiguous. Therefore, we performed a meta-analysis of 11 studies with VEGF +405G/C genotyping on 2,862 patients and 3,028 controls using the random effects model. We obtained a pooled odds ratio (OR) of 1.04 (95% confidence interval (CI) = 0.86-1.26) for the recessive genetic model, 1.07 (95% CI = 0.81-1.42) for the dominant genetic model, 1.09 (95% CI = 0.81-1.47) for the homozygote comparison, and 1.03 (95% CI = 0.83-1.27) for the heterozygote comparison. In the subgroup analysis of the recessive model, the OR was 1.20 (95% CI = 1.02-1.40) in colorectal cancer. These results show that VEGF +405G/C polymorphisms are unlikely to be a major determinant of susceptibility to digestive cancer. Furthermore, the subgroup analysis of recessive model indicates that VEGF +405G/C polymorphisms increase the risk for colorectal cancer.
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Associations between vascular endothelial growth factor polymorphisms and prostate cancer risk: a meta-analysis. Tumour Biol 2013; 35:1307-11. [DOI: 10.1007/s13277-013-1173-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2013] [Accepted: 09/02/2013] [Indexed: 12/22/2022] Open
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Vascular endothelial growth factor (VEGF) gene polymorphisms and risk of head and neck cancer: a meta-analysis involving 2,444 individuals. Mol Biol Rep 2013; 40:5987-92. [DOI: 10.1007/s11033-013-2708-y] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2013] [Accepted: 09/14/2013] [Indexed: 10/26/2022]
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Slattery ML, Lundgreen A, Wolff RK. VEGFA, FLT1, KDR and colorectal cancer: assessment of disease risk, tumor molecular phenotype, and survival. Mol Carcinog 2013; 53 Suppl 1:E140-50. [PMID: 23794399 DOI: 10.1002/mc.22058] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2012] [Revised: 05/15/2013] [Accepted: 05/21/2013] [Indexed: 01/10/2023]
Abstract
Angiogenesis is essential for tumor progression. Vascular endothelial growth factor (VEGFA) and its receptors 1 (FLT1) and 2 (KDR), have been identified as major mediators of this process. We hypothesized that genetic variation in FLT1 (38 SNPs), KDR (22 SNPS), and VEGFA (11 SNPs) would be associated with colon and rectal cancer development and survival. Data from a case-control study of 1555 colon cancer cases and 1956 controls and 754 rectal cancer cases and 959 controls were used. An adaptive rank truncation product (ARTP), based on 10,000 permutations, was used to determine the statistical significance of the candidate genes and angiogenesis pathway. Based on ARTP results, FLT1 was significantly associated with risk of colon cancer (P(ARTP) = 0.045) and VEGFA was significantly associated with rectal cancer (P(ARTP) = 0.036). After stratifying by tumor molecular subtype, SNP associations observed for colon cancer were: VEGFA rs2010963 with CIMP+ colon tumors; FLT1 rs4771249 and rs7987649 with TP53; FLT1 rs3751397, rs7337610, rs7987649, and rs9513008 and KDR rs10020464, rs11941492, and rs12498529 with MSI+ and CIMP+/KRAS2-mutated tumors. FLT1 rs2296189 and rs600640 were associated with CIMP+ rectal tumors and FLT1 rs7983774 was associated with TP53-mutated rectal tumors. Four SNPs in FLT1 were associated with colon cancer survival while three SNPs in KDR were associated with survival after diagnosis with rectal cancer. Aspirin/NSAID use, smoking cigarettes, and BMI modified the associations. These findings suggest the importance of inflammation and angiogenesis in the etiology of colorectal cancer and that genetic and lifestyle factors may be targets for modulating disease risk.
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Affiliation(s)
- Martha L Slattery
- Department of Internal Medicine, University of Utah Health Sciences Center, Salt Lake City, Utah
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Association of vascular endothelial growth factor (VEGF) gene polymorphism and increased serum VEGF concentration with pancreatic adenocarcinoma. Pancreatology 2013; 13:267-72. [PMID: 23719599 DOI: 10.1016/j.pan.2013.02.006] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/02/2013] [Revised: 02/05/2013] [Accepted: 02/20/2013] [Indexed: 12/11/2022]
Abstract
UNLABELLED BACKGROUND &AIM: Pancreatic cancer is related to high mortality rate. The vascular endothelial growth factor (VEGF) has a strong influence in tumor-related angiogenesis having association with the grade of angiogenesis and the prognosis of different solid tumors including pancreatic cancer. The present study was aimed to analyze the genotype and haplotype distribution of VEGF gene single nucleotide polymorphisms (SNPs), -460T/C, +405G/C, +936C/T, in patients with pancreatic adenocarcinoma from South India, and the effect of these SNPs on serum VEGF level. METHODS Total 80 patients with pancreatic adenocarcinoma and 87 controls were recruited. The genotype of VEGF gene polymorphisms was determined in both patients and controls using polymerase chain reaction-restriction fragment length polymorphism method. The serum VEGF protein was estimated by standard enzyme-linked immunosorbent assay. RESULTS The genotype, +405G/G of VEGF gene showed a significant association with the patients with pancreatic adenocarcinoma (P = 0.012, Odds ratio: 2.133), whereas no significant difference was found in the genotype distribution of SNPs, -460C/T and +936C/T between patient and control groups (P > 0.05). Serum VEGF level was found to be significantly high in patients (1315.10 pg/Ml, SD ± 230.79) when compared to controls (591.35 pg/mL, SD ± 92.48) (P < 0.0001), which showed a strong genotype-phenotype correlation between genotype +405G/G and serum VEGF level. Further, the haplotype C-G-T showed a strong association with the disease, and no specific haplotype was associated with increased serum VEGF level. CONCLUSION The polymorphism, +405G/C but not -460T/C and +936C/T, of VEGF gene is strongly associated with pancreatic adenocarcinoma, and this SNP has significant influence on serum VEGF level.
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quốc Lu’o’ng KV, Nguyễn LTH. The roles of beta-adrenergic receptors in tumorigenesis and the possible use of beta-adrenergic blockers for cancer treatment: possible genetic and cell-signaling mechanisms. Cancer Manag Res 2012; 4:431-45. [PMID: 23293538 PMCID: PMC3534394 DOI: 10.2147/cmar.s39153] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
Cancer is the leading cause of death in the USA, and the incidence of cancer increases dramatically with age. Beta-adrenergic blockers appear to have a beneficial clinical effect in cancer patients. In this paper, we review the evidence of an association between β-adrenergic blockade and cancer. Genetic studies have provided the opportunity to determine which proteins link β-adrenergic blockade to cancer pathology. In particular, this link involves the major histocompatibility complex class II molecules, the renin-angiotensin system, transcription factor nuclear factor-kappa-light-chain-enhancer of activated B cells, poly(ADP-ribose) polymerase-1, vascular endothelial growth factor, and the reduced form of nicotinamide adenine dinucleotide phosphate oxidase. Beta-adrenergic blockers also exert anticancer effects through non-genomic factors, including matrix metalloproteinase, mitogen-activated protein kinase pathways, prostaglandins, cyclooxygenase-2, oxidative stress, and nitric oxide synthase. In conclusion, β-adrenergic blockade may play a beneficial role in cancer treatment. Additional investigations that examine β-adrenergic blockers as cancer therapeutics are required to further elucidate this role.
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