The Combined Treatment with Ketogenic Diet and Metformin Slows Tumor Growth in Two Mouse Models of Triple Negative Breast Cancer.

BACKGROUND: Many tumors contain hypoxic microenvironments caused by inefficient tumor vascularization. Hypoxic tumors have been shown to resist conventional cancer therapies. Hypoxic cancer cells rely on glucose to meet their energetic and anabolic needs to fuel uncontrolled proliferation and metastasis. This glucose dependency is linked to a metabolic shift in response to hypoxic conditions. METHODS: To leverage the glucose dependency of hypoxic tumor cells, we assessed the effects of a controlled reduction in systemic glucose by combining dietary carbohydrate restriction, using a ketogenic diet, with gluconeogenesis inhibition, using metformin, on two mouse models of triple-negative breast cancer (TNBC). RESULTS: We confirmed that MET - 1 breast cancer cells require abnormally high glucose concentrations to survive in a hypoxic environment in vitro. Then, we showed that, compared to a ketogenic diet or metformin alone, animals treated with the combination regimen showed significantly lower tumor burden, higher tumor latency and slower tumor growth. As a result, lowering systemic glucose by this combined dietary and pharmacologic approach improved overall survival in our mouse model by 31 days, which is approximately equivalent to 3 human years. CONCLUSION: This is the first preclinical study to demonstrate that reducing systemic glucose by combining a ketogenic diet and metformin significantly inhibits tumor proliferation and increases overall survival. Our findings suggest a possible treatment for a broad range of hypoxic and glycolytic tumor types, one that can also augment existing treatment options to improve patient outcomes.

Alterations in cGMP, soluble guanylate cyclase, phosphodiesterase 5, and B-type natriuretic peptide induced by chronic increased pulmonary blood flow in lambs.

OBJECTIVE: The objective of the study was to determine alterations in cGMP, soluble guanylate cyclase (sGC), phosphodiesterase type 5 (PDE5), and B-type natriuretic peptide (BNP), in an animal model of a congenital cardiac defect with increased pulmonary blood flow. DESIGN: Prospective, comparative, experimental study. SUBJECTS: Lambs, from birth until 8 weeks of age. METHODOLOGY: Late gestation fetal lambs underwent in utero placement of an 8 mm aortopulmonary vascular graft (shunt). In shunted and normal age-matched control lambs, at 2, 4, and 8 weeks of age, cGMP and BNP levels were measured, and sGC subunit and PDE5 protein expression were determined by Western blot analysis and immunohistochemistry. RESULTS: In shunted lambs, tissue and plasma cGMP levels were greater than normal throughout the 8-week study period (P < 0.05). sGCalpha protein was greater at 2 and 4 weeks (P < 0.05), and sGCbeta and PDE5 protein were greater at 4 weeks in shunted lambs (P < 0.05). Plasma BNP levels did not change in normal lambs but increased in shunted lambs by 8 weeks of age (P < 0.05). BNP levels were greater in shunted lambs than normal at 4 and 8 weeks (P < 0.05). CONCLUSIONS: Alterations in sGC subunit protein expression during the first post-natal month, and increased BNP levels during the second post-natal month contribute to elevations in plasma and lung tissue cGMP in lambs with increased pulmonary blood flow.

Lung antioxidant enzymes are regulated by development and increased pulmonary blood flow.

Increasing data suggest that oxidative stress, due to an increased production of reactive oxygen species and/or a decrease in antioxidants, is involved in the pathophysiology of pulmonary hypertension. Several antioxidant systems regulate the presence of oxidant species in vivo, and of primary interest are the superoxide dismutases (SOD) and catalase. However, little is known about the expression of antioxidant enzymes during the development of pulmonary hypertension. This study uses our lamb model of increased postnatal pulmonary blood flow, secondary to in utero aortopulmonary graft placement (shunt lambs), to investigate the expression patterns as well as activities of antioxidant enzymes during the early development of pulmonary hypertension. Protein levels of catalase, SOD1, SOD2, and SOD3 were evaluated by Western blot, and the activities of catalase and SOD were also quantified. In control lambs, protein expression and activities of catalase and SOD2 increased postnatally (P < 0.05). However, SOD1 and SOD3 protein levels did not change. In shunt lambs, catalase, SOD1, and SOD2 protein levels all increased over the first 8 wk of life (P < 0.05). However, SOD3 did not change. This was associated with an increase in the activities of catalase and SOD2 (P < 0.05). Compared with control lambs, catalase and SOD2 protein levels were decreased in 2-wk-old shunt lambs and this was associated with increased levels of hydrogen peroxide (H(2)O(2)) and superoxide (P < 0.05). Developmentally superoxide but not H(2)O(2) levels significantly increased in both shunt and control lambs with levels being significantly higher in shunt compared with control lambs at 2 and 4 but not 8 wk. These data suggest that the antioxidant enzyme systems are dynamically regulated postnatally, and this regulation is altered during the development of pulmonary hypertension secondary to increased pulmonary blood flow. An increased understanding of these alterations may have important therapeutic implications for the treatment of pulmonary hypertension secondary to increased pulmonary blood flow.

Fibroblast growth factor-2 expression is altered in lambs with increased pulmonary blood flow and pulmonary hypertension.

A lamb model of pulmonary hypertension, developed by inserting an aortopulmonary vascular graft (shunt), displays vascular remodeling and increased pulmonary blood flow characteristic of children with congenital heart disease. The purpose of this study was to determine whether expression of fibroblast growth factor-2 (FGF-2), a smooth muscle cell mitogen, is altered in shunt lambs. FGF-2 mRNA and protein levels were increased in lung tissue extracts from shunt lambs at 4 wk of age relative to age-matched controls (p < 0.05). FGF-2 protein levels were also increased in the pulmonary arteries and serum of shunt lambs (p < 0.05). Pulmonary arterial smooth muscle cells (PASMC) and endothelial cells (PAEC) were isolated from 4 wk-old lambs and subjected to cyclic stretch and laminar shear stress to mimic increased pulmonary blood flow. Stretch and shear increased FGF-2 promoter activity, and intracellular and extracellular FGF-2 protein levels in both cell types (p < 0.05). Exogenous FGF-2 stimulated PASMC proliferation at levels detected in the extracellular medium of sheared cells (p < 0.05). Elevated FGF-2 signaling by PASMC and PAEC exposed to increased pulmonary blood flow may play a role in the pulmonary vascular remodeling associated with the shunt model of pulmonary hypertension secondary to congenital heart disease.

Increased oxidative stress in lambs with increased pulmonary blood flow and pulmonary hypertension: role of NADPH oxidase and endothelial NO synthase.

Although oxidative stress is known to contribute to endothelial dysfunction-associated systemic vascular disorders, its role in pulmonary vascular disorders is less clear. Our previous studies, using isolated pulmonary arteries taken from lambs with surgically created heart defect and increased pulmonary blood flow (Shunt), have suggested a role for reactive oxygen species (ROS) in the endothelial dysfunction of pulmonary hypertension, but in vivo data are lacking. Thus the initial objective of this study was to determine whether Shunt lambs had elevated levels of ROS generation and whether this was associated with alterations in antioxidant capacity. Our results indicate that superoxide, but not hydrogen peroxide, levels were significantly elevated in Shunt lambs. In addition, we found that the increase in superoxide generation was not associated with alterations in antioxidant enzyme expression or activity. These data suggested that there is an increase in superoxide generation rather than a decrease in scavenging capacity in the lung. Thus we next examined the expression of various subunits of the NADPH oxidase complex as a potential source of the superoxide production. Results indicated that the expression of Rac1 and p47(phox) is increased in Shunt lambs. We also found that the NADPH oxidase inhibitor diphenyliodonium (DPI) significantly reduced dihydroethidium (DHE) oxidation in lung sections prepared from Shunt but not Control lambs. As DPI can also inhibit endothelial nitric oxide synthase (eNOS) superoxide generation, we repeated this experiment using a more specific NADPH oxidase inhibitor (apocynin) and an inhibitor of NOS (3-ethylisothiourea). Our results indicated that both inhibitors significantly reduced DHE oxidation in lung sections prepared from Shunt but not Control lambs. To further investigate the mechanism by which eNOS becomes uncoupled in Shunt lambs, we evaluated the levels of dihydrobiopterin (BH(2)) and tetrahydrobiopterin (BH(4)) in lung tissues of Shunt and Control lambs. Our data indicated that although BH(4) levels were unchanged, BH(2) levels were significantly increased. Finally, we demonstrated that the addition of BH(2) produced an increase in superoxide generation from purified, recombinant eNOS. In conclusion our data demonstrate that the development of pulmonary hypertension in Shunt lambs is associated with increases in oxidative stress that are not explained by decreases in antioxidant expression or activity. Rather, the observed increase in oxidative stress is due, at least in part, to increased expression and activity of the NADPH oxidase complex and uncoupled eNOS due to elevated levels of BH(2).

Nitric oxide-endothelin-1 interactions after surgically induced acute increases in pulmonary blood flow in intact lambs.

Several congenital heart defects require surgery that acutely increases pulmonary blood flow (PBF). This can lead to dynamic alterations in postoperative pulmonary vascular resistance (PVR) and can contribute to morbidity and mortality. Thus the objective of this study was to determine the role of nitric oxide (NO), endothelin (ET)-1, and their interactions in the alterations of PVR after surgically induced increases in PBF. Twenty lambs underwent placement of an aortopulmonary vascular graft. Lambs were instrumented to measure vascular pressures and PBF and studied for 4 h. Before and after shunt opening, lambs received an infusion of saline (n = 9), tezosentan, an ETA- and ETB -receptor antagonist (n = 6), or Nomega-nitro-L-arginine (L-NNA), a NO synthase (NOS) inhibitor (n = 5). In control lambs, shunt opening increased PBF by 117.8% and decreased PVR by 40.7% (P < 0.05) by 15 min, without further changes thereafter. Plasma ET-1 levels increased 17.6% (P < 0.05), and total NOS activity decreased 61.1% (P < 0.05) at 4 h. ET-receptor blockade (tezosentan) prevented the plateau of PBF and PVR, such that PBF was increased and PVR was decreased compared with controls at 3 and 4 h (P < 0.05). These changes were associated with an increase in total NOS activity (+61.4%; P < 0.05) at 4 h. NOS inhibition (L-NNA) after shunt placement prevented the sustained decrease in PVR seen in control lambs. In these lambs, PVR decreased by 15 min (P < 0.05) but returned to baseline by 2 h. Together, these data suggest that surgically induced increases in PBF are limited by vasoconstriction, at least in part by an ET-receptor-mediated decrease in lung NOS activity. Thus NO appears to be important in maintaining a reduction in PVR after acutely increased PBF.

Inhaled nitric oxide induced NOS inhibition and rebound pulmonary hypertension: a role for superoxide and peroxynitrite in the intact lamb.

Previous in vivo studies indicate that inhaled nitric oxide (NO) decreases nitric oxide synthase (NOS) activity and that this decrease is associated with significant increases in pulmonary vascular resistance (PVR) upon the acute withdrawal of inhaled NO (rebound pulmonary hypertension). In vitro studies suggest that superoxide and peroxynitrite production during inhaled NO therapy may mediate these effects, but in vivo data are lacking. The objective of this study was to determine the role of superoxide in the decrease in NOS activity and rebound pulmonary hypertension associated with inhaled NO therapy in vivo. In control lambs, 24 h of inhaled NO (40 ppm) decreased NOS activity by 40% (P<0.05) and increased endothelin-1 levels by 64% (P<0.05). Withdrawal of NO resulted in an acute increase in PVR (60.7%, P<0.05). Associated with these changes, superoxide and peroxynitrite levels increased more than twofold (P<0.05) following 24 h of inhaled NO therapy. However, in lambs treated with polyethylene glycol-conjugated superoxide dismutase (PEG-SOD) during inhaled NO therapy, there was no change in NOS activity, no increase in superoxide or peroxynitrite levels, and no increase in PVR upon the withdrawal of inhaled NO. In addition, endothelial NOS nitration was 18-fold higher (P<0.05) in control lambs than in PEG-SOD-treated lambs following 24 h of inhaled NO. These data suggest that superoxide and peroxynitrite participate in the decrease in NOS activity and rebound pulmonary hypertension associated with inhaled NO therapy. Reactive oxygen species scavenging may be a useful therapeutic strategy to ameliorate alterations in endogenous NO signaling during inhaled NO therapy.

Cyclic stretch increases VEGF expression in pulmonary arterial smooth muscle cells via TGF-beta1 and reactive oxygen species: a requirement for NAD(P)H oxidase.

Our previous studies have indicated that transforming growth factor (TGF)-beta1 and VEGF expression are increased in the smooth muscle cell (SMC) layer of the pulmonary vessels of lambs with pulmonary hypertension secondary to increased pulmonary blood flow. Furthermore, we found that TGF-beta1 expression increased before VEGF. Because of the increased blood flow in the shunt lambs, the SMC in the pulmonary vessels are exposed to increased levels of the mechanical force, cyclic stretch. Thus, in this study, using primary cultures of pulmonary arterial SMC isolated from pulmonary arteries of 4-wk-old lambs, we investigated the role of cyclic stretch in the apparent coordinated regulation of TGF-beta1 and VEGF. Our results demonstrated that cyclic stretch induced a significant increase in VEGF expression both at the mRNA and protein levels (P < 0.05). The increased VEGF mRNA was preceded by both an increased expression and secretion of TGF-beta1 and an increase in reactive oxygen species (ROS) generation. In addition, a neutralizing antibody against TGF-beta1 abolished the cyclic stretch-dependent increases in both superoxide generation and VEGF expression. Our data also demonstrated that cyclic stretch activated an NAD(P)H oxidase that was TGF-beta1 dependent and that NAD(P)H oxidase inhibitors abolished the cyclic stretch-dependent increase in VEGF expression. Therefore, our results indicate that cyclic stretch upregulates VEGF expression via the TGF-beta1-dependent activation of NAD(P)H oxidase and increased generation of ROS.

Improving the results of small-bore vascular graft testing in rabbits: a technical primer.

Appropriate models to evaluate the in vivo behavior of small-diameter grafts are varied. To evaluate the behavior of small-diameter, bovine-derived grafts in the arterial circulation, we chose the rabbit abdominal aorta model. In the development of our procedure, we evaluated several models published in the literature, with unsatisfactory results. The high incidence of postoperative mortality and morbidity led us to modify published methods to incorporate cautious surgical technique and mild systemic hypothermia with cross-clamp times shorter than 30 min, as well as perioperative administration of agents with metabolic, rheologic, and neuroprotective properties. These modifications enabled us to achieve 100% operative survival with a very low incidence of postoperative paralysis. The presented model will be used for further evaluation of small-diameter grafts in our laboratory.

Cyclic stretch increases VEGF expression in pulmonary arterial smooth muscle cells via TGF-1 and reactive oxygen species: a requirement for NAD(P)H oxidase.

We have previously shown that TGF-1 and VEGF expression are increased in the smooth muscle cell (SMC) layer of the pulmonary vessels of lambs with pulmonary hypertension secondary to increased pulmonary blood flow. Further we found that TGF-1 expression increased prior to VEGF. Due to the increased blood flow in these lambs the SMC in the pulmonary vessels are exposed to increased levels of cyclic stretch. Thus, using primary cultures of pulmonary arterial SMCs (PASMCs) isolated from 4 week-old lambs, we investigated the role of cyclic stretch in the apparent coordinated regulation of TGF-1 and VEGF. Our results demonstrated that cyclic stretch induced a significant increase in VEGF expression both at the mRNA and protein preceded by an increase in expression and secretion of TGF-1 and an increase in reactive oxygen species (ROS) generation. In addition, a neutralizing TGF-1 antibody abolished the cyclic stretch-dependent increase in ROS and VEGF expression. Further, we found that cyclic stretch activated an NAD(P)H oxidase in a TGF-1 dependent manner that when inhibited abolished the cyclic stretch-dependent increase in VEGF expression. Our results indicate that cyclic stretch up-regulates VEGF expression via the TGF-1 dependent activation of NAD(P)H oxidase and increased generation of ROS.

Cellular expression of PCNA and procollagen in vital and ethanol-treated autologous pericardial implants in sheep.

BACKGROUND AND AIMS OF THE STUDY: Cardiovascular surgeries involving repair or reconstruction of heart valve leaflets with vital autologous pericardium have shown detrimental healing outcomes, mainly fibrosis with retraction. It is proposed that cells intrinsic to the pericardial implants may contribute to this fibrosis by becoming activated to proliferate and synthesize type I collagen. METHODS: Vital and ethanol-treated autologous pericardium were implanted as rectangular flaps bisecting the lumen in the descending aorta of sheep to simulate a heart valve leaflet. Implants recovered at 5, 10, 15, and 30 days were evaluated immunohistologically for expression of PCNA and procollagen. RESULTS: In ethanol-treated pericardium, concentrations of activated cells shifted from the fibrin layers on the periphery of implants at days 5 and 10 to cells internal to the implant at days 15 and 30. In contrast, concentrations of activated cells in vital pericardium shifted from cells within the implants at days 5 and 10 to the fibrin deposits overlaying the implants at days 15 and 30. CONCLUSION: Different distributional patterns of activated cells were observed between vital and ethanol-treated pericardial flap implants. These different patterns may be important in understanding the cause of the detrimental healing outcome observed with vital autologous pericardial flap implants.

An in vitro model of pericardial tissue healing.

INTRODUCTION: A previous study in our laboratory showed that a flap of fresh autologous pericardium bisecting the aorta of sheep retracted and became fibrotic. Histologic analyses suggested that activated cells within the pericardium contributed to the retraction of the implant. Here we report the development of an in vitro model to investigate the effects of serum on cellular proliferation and cell-mediated tissue contraction. METHODS: Sections of living and ethanol-treated sheep pericardium were incubated with 0.5%, 5%, 10%, 20%, and 50% serum in medium for up to 8 days and evaluated for cellular proliferation and tissue contraction. These serum-stimulated events were further evaluated in the presence of Mitomycin C, Cytochalasin B and D, Aphidicolin, AraC, and Cycloheximide. RESULTS: Cellular proliferation and cell-mediated tissue contraction were induced by serum in a dose-dependent manner. Expression of PCNA was suppressed in the presence of Cytochalasin B, Cytochalasin D, Aphidicolin, and AraC. Tissue contraction was prevented by Cycloheximide. Mitomycin C inhibited both proliferation and tissue contraction. Ethanol-treated tissue, which was absent of living cells, did not respond to stimulation with serum. CONCLUSIONS: An in vitro model was developed to study the responses of cells within pericardial tissues to stimulation by serum. In this model, serum induced cellular proliferation and tissue contraction. Different chemical inhibitors independently modulated these serum-stimulated events. Pre-existing cells within pericardial tissues might respond to stimulus through differential pathways. This model may help to develop methods to make autologous pericardium a clinically useful biomaterial.

Serum components stimulate pericardial tissue contraction.

BACKGROUND AND AIMS OF THE STUDY: Previous experiments have demonstrated the retraction and fibrosis of vital autologous pericardial flap implants in the descending aorta of sheep. An in-vitro model of pericardial tissue contraction was developed that showed healing reactions similar to those observed in the fresh in-vivo flap. Here, the component(s) of serum that stimulate tissue contraction were partially characterized. The molecular weight range and stability (heat and protease resistance) of the serum component(s) are described. Tissue contraction also requires de-novo protein synthesis. METHODS: Sections (1 cm2) of sheep pericardium were incubated with fractionated, heat-treated, or protease-treated fetal bovine serum for 14 days. In addition, SDS-PAGE protein profiles were generated using tissues incubated with and without cycloheximide for up to 12 days. RESULTS: Tissue contraction was observed in molecular weight serum fractions > or =5 kDa, as well as in samples incubated with heat and protease-treated serum. SDS-PAGE showed the appearance of a protein band after day 4 during the process of tissue contraction that was absent in samples incubated with cycloheximide. CONCLUSION: Serum fractions > or =5 kDa stimulated protein synthesis and pericardial tissue contraction. The active component(s) was shown to be heat stable, but partially sensitive to protease. The addition of cycloheximide to the culture medium, shown previously to prevent pericardial tissue contraction, inhibited de-novo synthesis of the protein that appeared during the process of tissue contraction.