京都大学 / 0048 / 新制・課程博士 / 博士(医学) / 甲第19601号 / 医博第4108号 / 新制||医||1014(附属図書館) / 32637 / 京都大学大学院医学研究科医学専攻 / (主査)教授 岩井 一宏, 教授 柳田 素子, 教授 山下 潤 / 学位規則第4条第1項該当 / Doctor of Medical Science / Kyoto University / DFAM

No description available.

Cancer cachexia is a debilitating, paraneoplastic syndrome commonly associated with late stage malignancy. It is estimated that ~25% of cancer-related deaths are due directly to complications arising from cachexia (Barton, 2001). Cachexia manifests as severe body wasting, primarily due to the loss of skeletal muscle mass. This study tested the hypothesis that muscle atrophy associated with cancer cachexia could be attenuated by using a unilateral, functional overload (FO) model applied concurrently with tumor development. To accomplish this, Morris hepatoma MH-7777 cells were implanted in adult female, Buffalo rats (n = 12) and allowed to incubate for 6 weeks. FO surgeries (n = 12) were performed five days prior to MH-7777 cell implantation. Over the course of six weeks, healthy, age, sex and strain-matched, vehicle-injected rats (n = 12) gained ~5% of body weight compared to tumor-bearing rats that lost ~6% of body weight when adjusted for tumor mass. Tumor-bearing animals experienced significant atrophy to gastrocnemius, tibialis anterior, extensor digitorum longus, plantaris and diaphragm muscles. FO successfully reversed plantaris muscle atrophy in cachectic, tumor-bearing rats (n=5). FO plantaris masses were ~24% larger than contralateral controls. However, this hypertrophic response was not as great as FO plantaris muscles from healthy, sham-operated controls (~44% larger than contralateral controls, n=5). FO plantaris muscles from tumor-bearing rats had ~1.5 fold increase in myonuclei/fiber ratios compared those of sham-operated, tumor-bearing controls (n = 6). Therefore, cancer cachexia did not prevent myonuclear accretion necessary for skeletal muscle hypertrophy. Little data exists on adaptations to myosin heavy chain (MHC) isoforms in cachectic skeletal muscle. Plantaris muscles from tumor-bearing rats displayed decreased percentages of MHC type I compared to plantaris muscles from vehicle-injected controls (7% vs. 3%, respectively). However, FO plantaris muscles from tumor-bearing rats had an increased percentage of MHC type I and decreased percentage of MHC type IIb compared to sham-operated tumor-bearing rats, adaptations commonly seen in trained muscles. Therefore, cancer cachexia did not prevent the capability of skeletal muscle to respond normally to hypertrophic stimuli. This study also attempted to characterize a mechanism responsible for the hypertrophic response, increased myonuclei/fiber ratio and transition toward a slower MHC profile in FO plantaris muscles from tumor-bearing rats. Recently, the Ca2+/calmodulin-dependent protein phosphatase, calcineurin, has been suggested as a critical factor regulating skeletal muscle growth and fiber-type dependent gene expression (Chin, 1998; Wu, 2000; Olson, 2000; Otis, 2001). The protein content of the catalytic subunit (CaNa) and the regulatory subunit (CaNb) of calcineurin were unchanged in plantaris muscles from tumor-bearing animals compared to healthy controls. Furthermore, total and specific (normalized to CaNa protein content) calcineurin phosphatase activity were not altered in any group. Therefore, calcineurin activity did not appear to be associated with the regulation of the morphological and physiological response of hypertrophying plantaris muscles in cachectic, tumor-bearing rats. Overall, this study indicated that atrophied plantaris muscles from tumor-bearing animals have a reduced capacity to hypertrophy potentially due to a decreased myonuclei/fiber ratio. Furthermore, it is unlikely that changes to mass and MHC isoform expression are associated with calcineurin phosphatase activity. / Ph. D.

No description available.

Thesis (MNutr (Interdisciplinary Health Sciences. Human Nutrition))--University of Stellenbosch, 2006. / Background At least 40 - 80% of all cancer patients develop some degree of clinical malnutrition and cachexia. The complex and multi-factorial nature of cancer cachexia and the inability of conventional nutrition intervention to reverse or attenuate the effects of this syndrome have driven investigators to consider new therapies and approaches to manage the syndrome of cancer cachexia including eicosapentaenoic acid (EPA), an n-3 fatty acid of fish oil origin. Objectives The aim of this study was to review Phase I, Phase II and Phase III (RCT) trials investigating the safety and efficacy of n-3 supplementation in the treatment of cancer cachexia in adult patients with unresectable solid tumours, with special reference to weight loss, body composition, appetite, dietary intake, energy expenditure, functional status, acute phase response and quality of life. Adverse effects associated with EPA supplementation were also reviewed. Methodology and data collection The major databases were systematically searched for studies that met the inclusion criteria using a structured keyword search strategy or various combinations of these keywords. Relevancy of studies was assessed by two independent reviewers according to pre-determined inclusion and exclusion criteria. Quality was assessed by two independent reviewers using the Jadad scale. Data extraction was performed by the principal reviewer and one of the independent reviewers, and investigators of the included studies were contacted where further information was required. Meta-analysis was not appropriate due to heterogeneity of the data. However, where possible, the paired t-test was used for analysis of the data. Descriptive or non-quantitative analysis of the tabulated data provided a summary of the characteristics of the included studies enabling comparisons to be made between interventions and outcomes within the specified population. Results The search resulted in a total of 1408 citations, of which only 16 studies met the inclusion and exclusion criteria. Of these, only 4 studies were of a good quality. Although the reported data was incomplete and variable, the combined analyses suggested that the effect of EPA supplementation on weight, fat mass, dietary intake, energy expenditure, and acute phase response was not significant. Interestingly there appeared to be a significant increase increased or decreased? in lean body mass (p<0.05). There was little or no data to draw any conclusions regarding the effect of supplementation on appetite and quality of life. Conclusion Despite several limitations in this review, the data collected and analysed are suggestive of the beneficial effects of EPA supplementation, but there remains a significant lack of substantial evidence and conclusive statistical analysis to confirm that EPA supplementation is a safe and effective method of intervention in the management of patients with cancer cachexia.

No description available.

A caquexia associada ao câncer é uma síndrome multifatorial e multiorgão de etiologia desconhecida caracterizada por profunda perda de massa corporal. Assim, o presente estudo investigou o processo inflamatório sistêmico e no tecido adiposo subcutâneo e testou a hipótese de atenuação da inflamação pelo TF crônico em pacientes com caquexia associada ao câncer e controles. Pacientes foram distribuídos em seis grupos: Controles (Control SED e TR), portadores de tumor gastrintestinal sem caquexia (WSC SED e TR) e portadores de tumor gastrintestinal com caquexia (CC SED e TR). Observamos cessação da perda de massa corporal e ganho cardiorrespiratório (incremento de 209%) entres os pacientes caquéticos treinados e redução de colesterol total no CC TR, de LDL no CC SED e de HDL no CC SED e CC TR. O TF foi capaz de aumentar a concentração de HDL ao longo da intervenção (de 34,83 ± 4,74 mg/dL para 57,0 ± 3,42 mg/dL). Não encontramos diferenças entre as células imunitárias infiltradas no TASC dos pacientes avaliados. Esse é o primeiro estudo, de nosso conhecimento, que demonstra que o exercício físico realizado de forma crônica é capaz de reduzir a inflamação em pacientes com câncer caquéticos, atenuando os sintomas da síndrome. / Cancer cachexia is a multifactorial and multiorgan systemic syndrome with an unknown aetiology and characterized by a profound weight loss. Therefore, this study aimed to investigate the inflammation process in a systemic context and in the subcutaneous adipose tissue (SAT) and to evaluated the possible anti-inflammatory effects of the aerobic exercise in subjects with cancer cachexia. Patients were separated in six groups: Control (sedentary SED and trained TR), weight-stable patients with gastrointestinal cancer (WSC SED and TR) and patients with gastrointestinal cancer and cachexia (CC SED and TR). Cessation of weight loss and cardiorespiratory gain wre observed in the CCTR group and a reduction of total cholesterol in the CCTR group decreased in LDL in the CC SED group and HDL in the CC SED and CC TR groups. Physical exercise was able to increase serum HDL during the intervention. No differences were found in the immune cells infiltrating in the patients sAT (macrophages and MDSC). Inflammatory mediators changed by cachexia were modulated by ET. To our knowledge, this is the first study to demonstrate a reduction of inflammation and cachexia symptoms in cancer patients.

A desnutrição freqüentemente está presente em pacientes com insuficiência cardíaca (IC), podendo trazer aumento de complicações e mortalidade. O objetivo do estudo foi o de avaliar o estado nutricional de pacientes portadores de IC refratária, aguardando a realização de transplante cardíaco. Avaliação nutricional foi realizada utilizando-se da avaliação subjetiva global, avaliação antropométrica completa [índice de massa corpórea (IMC), circunferência do braço (CB), prega cutânea tricipital (PCT), circunferência muscular do braço (CMB) e área gordurosa do braço (AGB)], avaliação laboratorial e realização de anamnese alimentar em dois momentos: no momento de admissão na fila de transplante (1a avaliação) e 4 meses após (2a avaliação). Na 1ª avaliação foram estudados 56 pacientes, idade média de 46±12 anos, 67,8% homens, 33,9% com miocardiopatia chagásica. Análise de dados antropométricos revelou com base no IMC: 73,2% eutróficos e 5,3% com baixo peso; CMB: 66% apresentavam depleção. Houve correlação negativa e significativa entre IMC e fator de necrose tumoral (r= - 0,305; p= 0,022). Análise laboratorial demonstrou: baseado na albumina, 50% dos pacientes apresentavam-se com algum grau de depleção, na transferrina 40% e na contagem de linfócitos 80%. Houve correlação negativa e significativa entre albumina e interleucina-6 (r = - 0,464; p< 0,001), transferrina e interleucina-6 (r= -0,269; p= 0,047) e contagem de linfócitos e interleucina-6 (r= - 0,394; p=0,003). Na 2ª avaliação 18 pacientes foram estudados. Não foram observadas diferenças significativas entre as duas avaliações quanto aos parâmetros estudados. Com base na realização da anamnese alimentar os pacientes atingiram aproximadamente 85% e 84% de suas necessidades calóricas na 1ª e 2ª avaliações, e com relação à ingestão protéica, tanto na 1ª como na 2ª avaliação mais de 70% dos pacientes apresentaram consumo adequado de proteínas. Foi observado consumo abaixo das necessidades nutricionais de cálcio, potássio, magnésio, zinco, folato e vitamina E. Quanto ao sódio verificamos um consumo acima do recomendado. Foram transplantados 14 pacientes com idade de 44 ± 21 anos, 57,1% do sexo masculino, quatro pacientes morreram no pós operatório. Não houve diferenças significativas quanto aos dados antropométricos, laboratoriais, de adequação alimentar e idade entre o grupo de transplantados que sobreviveram (n=9) comparados com os que faleceram (n=4). Concluímos que a desnutrição é comum em pacientes com IC grave aguardando transplante cardíaco. A avaliação nutricional baseada no IMC não mostrou ser um bom método, necessitando ser complementada com as medidas de CB, CMB, PCT e AGB. A avaliação laboratorial permitiu a detecção de comprometimento nutricional. A participação das citocinas inflamatórias no processo de desnutrição foi evidenciada em nossa população. Portanto, a avaliação nutricional completa deve fazer parte do atendimento em pacientes com IC crônica, particularmente aqueles com IC refratária à espera por um transplante cardíaco / Malnutrition is frequently present in patients with heart failure (HF) and is associated with an increase in morbidity and mortality. The objective of this study was to evaluate nutritional status of patients with refractory HF waiting for cardiac transplantation. Nutritional evaluation was done with the use of subjective global assessment, complete anthropometric measurements (body mass index (BMI), mid-arm circumference (MAC), triceps skinfold thickness (TSF), mid-arm muscle circumference (MAMC) and arm fat area), laboratory evaluation and food intake assessment in two moments: at the admission to the cardiac transplantation waiting list (1st evaluation) and after 4 months (2nd evaluation). On the 1st evaluation, we studied 56 patients, mean age 46±12 years, 67.8% were men, and 33.9% had Chagas disease. Analyzing anthropometric measurements, we found that, based on BMI 73.2% of patients were normal and 5.3% had underweight; MAMC revealed 66% with depletion. There was a negative and significant correlation between BMI and tumor necrosis factor-a (r= - 0.305; p<0.022). Laboratory evaluation showed that based on albumin levels, 50% of patients had some degree of depletion, based on transferrin 40% and on lymphocyte count 80%. There were negative and significant correlations between albumin and interleukin-6 (r= - 0.464; p<0.001), transferrin and interleukin-6 (r= -0.269; p<0.047) and lymphocyte count and interleukin-6 (r= -0.394; p<0.003). On the 2nd evaluation 18 patients were studied. There were no significant differences in the studied parameters between the 1st and 2nd evaluations. Based on the food intake assessment, percentage of adequacy of calories intake was 85% and 84% on 1st and 2nd evaluations, and more than 70% of patients had adequate protein intake on both evaluations. Low intake of calcium, potassium, magnesium, zinc, folate and vitamin E was detected. Daily sodium intake was found to be above the recommended levels. Fourteen patients were submitted to cardiac transplantation, mean age 44±21 years, 57.1% were men. Four patients died in post operative period. No relation was observed between anthropometric, laboratory, alimentary adequacy and age variables between patients transplanted that survive (n=9) and that died (n=4). We concluded that malnutrition is common in patients with refractory HF listed for cardiac transplantation. Nutritional assessment based on BMI did not show to be a good index to detect nutritional disorders and need to be used together with MAC, TSF, MAMC and arm fat area. Laboratory evaluation permitted the detection of compromised nutritional status. The participation of inflammatory cytokines in the process of malnutrition was evidenced in our population. Therefore, a complete nutritional evaluation should be part of routine care of patients with chronic HF, particularly in those with refractory HF waiting for cardiac transplantation

A caquexia associada ao câncer, cujo o sintoma mais notável é a severa e rápida perda de peso, afeta cerca de 80% dos pacientes com câncer avaçado e constitui causa direta de morte em 22 a 40% dos casos. Estudos recentes têm mostrado que os mediadores inflamatórios têm um papel importante no desenvolvimento de caquexia, hoje em dia considerada como uma doença inflamatória crónica. Um possível contribuinte é o tecido adiposo branco (TAB) que sofre diversas alterações, como por exemplo, reorganização morfológica e aumento da lipólise, liberando assim ácidos graxos livres (AGL), que por sua vez, podem acentuar a produção de citocinas pró-inflamatórias. O objetivo do presente estudo foi analisar a expressão gênica de citocinas pró-inflamatórias no TAB e estabelecer se os ácidos graxos que são liberados pelos adipócitos na vigência da caquexia deflagram e/ou contribuem para inflamação local e sistêmica. O estudo envolveu 122 pacientes divididos em 3 grupos: controle (N), câncer sem caquexia (WSC) e câncer com caquexia (CC). O grupo CC foi composto por pacientes com uma perda de peso não intencional superior a 5% nos últimos 12 meses e atendeu a no mínimo três dos cinco critérios utilizados para a classificação da caquexia e o grupo WSC foi composta por pacientes em tratamento para o câncer, sem declarar a perda de peso> 5% nos últimos 12 meses. O tecido adiposo subcutâneo (TASC) apresentou aumento da expressão gênica de TNF- e uma tendência do aumento para a expressão gênica de CCL-2 no CC comparado ao N, enquanto o conteúdo de RNAm da IL-10 diminuiu no mesmo grupo. Sugerimos que o TASC enconta-se inflamado nos pacientes com caquexia associado ao câncer e um possível ativador da secreção de proteínas pró-inflamatórias nesse tecido poderia ser a maior presença de acidos graxos livres. / The cachexia associated with cancer, whose most notable symptom is severe and rapid weight loss, affecting about 80% of patients with cancer and avacado is the direct cause of death in 22 to 40% of cases. Recent studies have shown that inflammatory mediators play an important role in the development of cachexia, nowadays considered as a chronic inflammatory disease. A possible contributory is white adipose tissue (TAB) that undergoes various changes, such as morphological reorganization and increased lipolysis, thereby releasing free fatty acids (AGL), which in turn, can enhance the production of pro-inflammatory cytokines. The aim of this study was to analyse the gene expression of proinflammatory cytokines in the TAB and establish whether the fatty acids are released by fat cells in the presence of cachexia trigger and / or contribute to local and systemic inflammation. The study involved 122 patients divided into 3 groups: control (N) without cancer cachexia (WSC) and cancer cachexia (CC). The CC group consisted of patients with a loss of unintentional weight more than 5% in the last 12 months and met at least three of the five criteria used for classification of cachexia and the WSC group was composed of patients on treatment for cancer without declaring weight loss> 5% in the last 12 months. The subcutaneous adipose tissue (TASC) showed an increase in TNF- and increase the tendency of gene expression for CCL-2 gene expression in the CC as compared to N, while the mRNA content of IL-10 decreased in the same group. We suggest that the TASC is ignited in patients with cachexia associated with cancer and possible activator of secretion of proinflammatory proteins that fabric could be increased presence of free fatty acids.

A caquexia do câncer é uma síndrome multifatorial cuja principal característica é a atrofia do músculo esquelético, resultando na progressiva incapacidade funcional do paciente. Essa síndrome está diretamente associada a uma redução da tolerância ao esforço físico e uma menor sobrevida em pacientes com câncer. O tratamento farmacológico para a caquexia ainda é muito limitado, possivelmente devido à característica multifatorial dessa síndrome. Nesse sentido, as evidências indicam que uma abordagem multimodal é necessária para atenuar a caquexia, incluindo estratégias não-farmacológicas como o treinamento físico. Contudo, os mecanismos envolvidos nos efeitos terapêuticos do treinamento físico sobre a caquexia do câncer ainda foram pouco explorados. Portanto, esse estudo teve como objetivo central avaliar os efeitos do treinamento físico aeróbio sobre a disfunção do metabolismo energético e a atrofia muscular em modelos experimentais de caquexia do câncer, além de explorar os mecanismos envolvidos nos possíveis efeitos terapêuticos do treinamento físico. Para isso, inicialmente padronizamos um modelo de caquexia em ratos utilizando injeção de células tumorais Walker 256 na medula óssea. Esse modelo apresentou consistente crescimento tumoral e atrofia muscular. Avaliamos sobre esse modelo os efeitos de dois protocolos diferentes de treinamento físico aeróbio, a saber: treinamento físico aeróbio contínuo em intensidade moderada (MIT, do inglês moderate intensity training) e o treinamento físico intervalado em alta intensidade (HIIT, do inglês high-intensity interval training). Embora não tenham sido observados efeitos sobre o crescimento tumoral, o MIT e o HIIT melhoraram a capacidade aeróbia e aumentaram a sobrevida dos animais, sugerindo que o treinamento físico aeróbio induz efeitos benéficos durante a progressão da caquexia do câncer. De fato, o HIIT normalizou marcadores de estresse oxidativo e reestabeleceu a função do músculo esquelético. Com o intuito de explorar mecanismos responsáveis por esses benefícios, realizamos uma análise proteômica de larga escala no músculo esquelético de ratos controle, do modelo Walker e do modelo Walker submetido ao HIIT. Nessa análise identificamos a COP9 signalosome complex subunit 2/Thyroid receptor interacting protein 15 (COPS2/TRIP15) como uma das principais proteínas alteradas, estando o seu conteúdo reduzido no músculo esquelético de ratos com caquexia e normalizado após a realização do HIIT. Resultados similares foram observados em outro modelo experimental de câncer (B16F10 em camundongos) submetido ou não ao HIIT. Na próxima etapa buscamos avaliar se a COPS2/TRIP15 poderia apresentar um papel terapêutico no músculo esquelético. Para isso, realizamos a superexpressão dessa proteína em miotubos primários de camundongos. Os miotubos foram incubados com meio de cultura previamente condicionado em células tumorais por 48 horas para induzir disfunção do metabolismo e perda de conteúdo proteico. Contudo, a superexpressão da COPS2/TRIP15 nos miotubos não foi suficiente para impedir os efeitos induzidos pelo meio condicionado. Em suma, essa tese de doutorado demonstrou que o HIIT foi capaz de atenuar a intolerância ao esforço físico e normalizar o conteúdo de COPS2/TRIP15 no músculo esquelético em diferentes modelos experimentais de caquexia do câncer. Esses resultados pré-clínicos abrem perspectivas de avaliar os efeitos do HIIT em pacientes com caquexia do câncer. Novos experimentos são necessários para entender a função da COPS2/TRIP15 no músculo esquelético durante a progressão da caquexia / Cancer cachexia is a multifactorial syndrome characterized by skeletal muscle wasting, resulting in a functional impairment. This syndrome is associated with exercise intolerance and early mortality in cancer patients. Pharmacological treatment is still limited, perhaps due to the multifactorial characteristics of this syndrome. In this sense, evidences indicate that a multimodal approach is necessary to counteract cachexia, including non-pharmacological strategies, such as exercise training. However, little is known regarding the mechanisms underlying the potential therapeutic effects of exercise training on cancer cachexia. Therefore, the current study aimed to evaluate the effects of aerobic exercise training on metabolic impairment and skeletal muscle wasting in cancer cachexia experimental models. Additionally, we aimed to explore mechanisms involving the potential therapeutic effects of exercise training. For doing that, we first standardized a cancer cachexia rat model by injecting Walker 256 tumor cells in the bone marrow. This model displayed consistent tumor growth, skeletal muscle wasting and good reproducibility. By using this experimental model, we assessed the effects of two different aerobic exercise training protocols: moderate intensity training (MIT) and high-intensity interval training (HIIT). Even though tumor growth was not affected, both MIT and HIIT improved aerobic capacity and survival. Moreover, HIIT reestablished the skeletal muscle function and normalized oxidative stress markers. To further explore mechanisms underlying such benefits, we applied a proteomics screening in the skeletal muscle of 1) control rats, 2) rats with cancer cachexia and 3) rats with cancer cachexia submitted to HIIT. In this analysis, we identified COP9 signalosome complex subunit 2/Thyroid receptor interacting protein 15 (COPS2/TRIP15) as one of the most regulated proteins, showing lower content in the skeletal muscle during cancer cachexia progression, which was normalized after HIIT. Similar results were observed for B16F10 model in mice submitted or not to HIIT. We further assessed whether COPS2/TRIP15 could present a therapeutic role in the skeletal muscle. For doing that, we overexpressed this protein in primary mouse myotubes using an adenovirus. Cell culture media taken from tumor cells were incubated in the myotubes to induce metabolism impairment and loss of protein content. However, COPS2/TRIP15 overexpression was not sufficient to mitigate deleterious effects induced by the conditioned media. In summary, the current PhD thesis demonstrated that HIIT mitigated exercise intolerance and normalized COPS2/TRIP15 protein content in the skeletal muscle of different cancer cachexia experimental models. These pre-clinical data open perspectives to evaluate HIIT effects in cancer cachexia patients. New experiments are necessary to explore the role of COPS2/TRIP15 during cancer cachexia progression