Stress-induced Norepinephrine Downregulates CCL2 in Macrophages to Suppress Tumor Growth in a Model of Malignant Melanoma.

Psychological stressors have been implicated in the progression of various tumor types. We investigated a role for stress in tumor immune cell chemotaxis in the B16F10 mouse model of malignant melanoma. We exposed female mice to 6-hour periods of restraint stress (RST) for 7 days, then implanted B16F10 malignant melanoma tumor cells and continued the RST paradigm for 14 additional days. We determined serum corticosterone and liver catecholamine concentrations in these mice. To evaluate the tumor microenvironment, we performed IHC and examined cytokine expression profiles using ELISA-based analysis of tumor homogenates. We found that tumors in mice subjected to RST grew significantly slower, had reduced tumor C-C motif ligand 2 (CCL2), and contained fewer F4/80-positive macrophages than tumors from unstressed mice. We observed a concomitant increase in norepinephrine among the RST mice. An in vitro assay confirmed that norepinephrine downregulates CCL2 production in both mouse and human macrophages, and that pretreatment with the pan-ß-adrenergic receptor inhibitor nadolol rescues this activity. Furthermore, RST had no effect on tumor growth in transgenic CCL2-deficient mice. This study suggests that stress reduces malignant melanoma by reducing recruitment of tumor-promoting macrophages by CCL2.

The impact of adrenergic signaling in skin cancer progression: possible repurposing of ß-blockers for treatment of skin cancer.

Studies suggest that psychosocial factors can impact cancer progression. Parallel work in the fields of psychoneuroimmunology and developmental neuroscience have led to the implication of catecholamine hormones (norepinephrine and epinephrine) and their receptors (the ß-adrenergic receptors; ß-ARs) in regulating cancer progression. In this review we discuss studies that describe the effects of psychological stress as mediated by factors including the catecholamines norepinephrine and epinephrine on various aspects of tumor progression including proliferation, angiogenesis, and metastasis. We discuss the role of ß-ARs in facilitating these effects and the potential use of ß-blockers in adjuvant cancer therapy.

Use of ß-blockers and mortality following ovarian cancer diagnosis: a population-based cohort study.

BACKGROUND: Experimental data suggest that catecholamine hormones are involved in stimulating the aggressiveness of ovarian cancer, but few population-based studies have examined this association. We therefore conducted a population-based cohort study to examine whether ß-blockers affect mortality following ovarian cancer diagnosis. METHODS: We used the Danish Cancer Registry to identify all patients diagnosed with ovarian cancer in northern Denmark between 1999 and 2010 (n=6,626). Data on medication use, comorbidity, and survival were obtained from medical databases. According to the last redeemed prescription before diagnosis, ß-blocker use was categorized as current (within ≤90 days), previous (>90 days) or never. We used Cox proportional hazards regression to calculate hazard ratios (HRs) for all-cause mortality with 95% confidence intervals (CIs) adjusting for confounding factors. RESULTS: Among the ovarian cancer patients, 373 (5.6%) were current, 87 (1.3%) previous, and 6,166 (93.1%) were nonusers of ß-blockers. Median duration of use was 19.0 months among current users and 43.0 months among previous users. Median follow-up was 2.55 years (IQR: 0.81-9.23). Nonusers and current users of ß-blockers had similar comorbidity burden whereas previous users had moderate comorbidity more frequently. Compared with nonusers, the adjusted HR was 1.17 (95% CI: 1.02-1.34) for current users and 1.18 (95% CI: 0.90-1.55) for previous users. Secondary analyses stratifying by cancer stage and duration of ß-blocker use supported the overall results. CONCLUSIONS: We found no evidence that ß-blocker use was associated with decreased mortality following ovarian cancer diagnosis.

Basal cell carcinoma: stressful life events and the tumor environment.

CONTEXT: Child emotional maltreatment can result in lasting immune dysregulation that may be heightened in the context of more recent life stress. Basal cell carcinoma (BCC) is the most common skin cancer, and the immune system plays a prominent role in tumor appearance and progression. OBJECTIVE: To address associations among recent severe life events, childhood parental emotional maltreatment, depression, and messenger RNA (mRNA) coding for immune markers associated with BCC tumor progression and regression. DESIGN: We collected information about early parent-child experiences, severe life events in the past year as assessed by the Life Events and Difficulties Schedule, depression, and mRNA for immune markers associated with BCC tumor progression and regression from patients with BCC tumors. SETTING: University medical center. PARTICIPANTS: Ninety-one patients with BCC (ages, 23-92 years) who had a previous BCC tumor. MAIN OUTCOME MEASURES: The expression of 4 BCC tumor mRNA markers (CD25, CD3ε, intercellular adhesion molecule 1, and CD68) that have been linked to BCC tumor progression and regression were assessed in BCC tumor biopsy specimens. RESULTS: Both maternal and paternal emotional maltreatment interacted with the occurrence of severe life events to predict the local immune response to the tumor (adjusted P = .009 and P = .03, respectively). Among BCC patients who had experienced a severe life event within the past year, those who were emotionally maltreated by their mothers (P = .007) or fathers (P = .02) as children had a poorer immune response to the BCC tumor. Emotional maltreatment was unrelated to BCC immune responses among those who did not experience a severe life event. Depressive symptoms were not associated with the local tumor immune response. CONCLUSIONS: Troubled early parent-child relationships, in combination with a severe life event in the past year, predicted immune responses to a BCC tumor. The immunoreactivity observed in BCCs and the surrounding stroma reflects an anti-tumor-specific immune response that can be altered by stress.

Tumor site immune markers associated with risk for subsequent basal cell carcinomas.

BACKGROUND: Basal cell carcinoma (BCC) tumors are the most common skin cancer and are highly immunogenic. OBJECTIVE: The goal of this study was to assess how immune-cell related gene expression in an initial BCC tumor biopsy was related to the appearance of subsequent BCC tumors. MATERIALS AND METHODS: Levels of mRNA for CD3ε (a T-cell receptor marker), CD25 (the alpha chain of the interleukin (IL)-2 receptor expressed on activated T-cells and B-cells), CD68 (a marker for monocytes/macrophages), the cell surface glycoprotein intercellular adhesion molecule-1 (ICAM-1), the cytokine interferon-γ (IFN-γ) and the anti-inflammatory cytokine IL-10 were measured in BCC tumor biopsies from 138 patients using real-time PCR. RESULTS: The median follow-up was 26.6 months, and 61% of subjects were free of new BCCs two years post-initial biopsy. Patients with low CD3ε CD25, CD68, and ICAM-1 mRNA levels had significantly shorter times before new tumors were detected (p = 0.03, p = 0.02, p = 0.003, and p = 0.08, respectively). Furthermore, older age diminished the association of mRNA levels with the appearance of subsequent tumors. CONCLUSIONS: Our results show that levels of CD3ε, CD25, CD68, and ICAM-1 mRNA in BCC biopsies may predict risk for new BCC tumors.

ß-Blockers and survival among Danish patients with malignant melanoma: a population-based cohort study.

BACKGROUND: To study whether use of ß-blockers increases survival in patients with malignant melanoma because experimental data suggest that catecholamine hormones may be involved in stimulating the aggressiveness of malignant melanoma. METHODS: A total of 4,179 patients diagnosed with malignant melanoma in Denmark with a median follow-up of 4.9 years and identified in the Danish Cancer Registry participated. Data on ß-blocker use, comorbidity, and survival were obtained from medical and administrative databases. Cox proportional hazards models were used to estimate HRs for all-cause mortality with 95% CIs with adjustment for prognostic factors. RESULTS: A total of 372 (8.9%) patients with malignant melanoma were treated with ß-blockers within 90 days of melanoma diagnosis. The median ß-blocker duration for exposure within 90 days of melanoma diagnosis, more than 90 days, and no prior exposure was 7.6, 1.4, and 0 years, respectively. The patients receiving ß-blockers were older, had more comorbidities, and more cardiovascular and psychotropic drug user than the patients receiving no ß-blockers prior to melanoma diagnosis. After adjustment for age and comorbidity index, the HR for melanoma death was 0.87 (95% CI: 0.64-1.20) and for all-cause mortality was 0.81 (95% CI: 0.67-0.97). CONCLUSION: Increased survival time of patients with melanoma receiving ß-blockers suggests that this class of drugs may hold promise in treatment strategy for these patients. IMPACT: The observations described here suggest that catecholamines may retard melanoma progression and that ß-blockers may have unrecognized potential as a therapeutic intervention for melanoma.

Glucocorticoids activate Epstein Barr virus lytic replication through the upregulation of immediate early BZLF1 gene expression.

Psychological stress-associated immune dysregulation has been shown to disrupt the steady-state expression and reactivate latent herpes viruses. One such virus is the Epstein Barr virus (EBV), which is associated with several human malignancies. EBV infects >90% of people living in North America and persists for life in latently infected cells. Although several studies have shown that glucocorticoids (GCs) can directly induce reactivation of the latent virus, the mechanism of stress hormone involvement in the control of EBV gene expression is not well understood. In this study, we tested the hypothesis that GCs can induce the latent EBV genome to lytically replicate through the induction of the EBV immediate early gene BZLF1 which encodes the lytic transactivator protein ZEBRA. We show a dose-dependent upregulation of BZLF1 mRNA expression by hydrocortisone (HC) and dexamethasone (Dex) in Daudi cells, an EBV genome positive Burkitt's lymphoma cell line, and Dex-induction of the early gene products BLLF3 (encoding for the EBV dUTPase) and BALF5 (encoding for the EBV DNA polymerase). We show that Daudi cells express glucocorticoid receptors (GR) that mediate Dex-dependent upregulation of BZLF1 mRNA levels. This effect was inhibited by both the glucocorticoid receptor antagonist RU486 and by cycloheximide. The results suggest that GCs, in addition to inducing stress-related immune dysregulation, can mediate latent EBV reactivation through the induction of the BZLF1 gene.

Norepinephrine upregulates VEGF, IL-8, and IL-6 expression in human melanoma tumor cell lines: implications for stress-related enhancement of tumor progression.

Studies suggest that stress can be a co-factor for the initiation and progression of cancer. The catecholamine stress hormone, norepinephrine (NE), may influence tumor progression by modulating the expression of factors implicated in angiogenesis and metastasis. The goal of this study was to examine the influence of NE on the expression of VEGF, IL-8, and IL-6 by the human melanoma cell lines, C8161, 1174MEL, and Me18105. Cells were treated with NE and levels of VEGF, IL-8, and IL-6 were measured using ELISA and real-time PCR. The expression of beta-adrenergic receptors (beta-ARs) mRNA and protein were also assessed. Finally, immunohistochemistry was utilized to examine the presence of beta1- and beta2-AR in primary and metastatic human melanoma biopsies. We show that NE treatment upregulated production of VEGF, IL-8, and IL-6 in C8161 cells and to a lesser extent 1174MEL and Me18105 cells. The upregulation was associated with induced gene expression. The effect on C8161 cells was mediated by both beta1- and beta2-ARs. Furthermore, 18 of 20 melanoma biopsies examined expressed beta2-AR while 14 of 20 melanoma biopsies expressed beta1-AR. Our data support the hypothesis that NE can stimulate the aggressive potential of melanoma tumor cells, in part, by inducing the production VEGF, IL-8, and IL-6. This line of research further suggests that interventions targeting components of the activated sympathetic-adrenal medullary (SAM) axis, or the utilization of beta-AR blocking agents, may represent new strategies for slowing down the progression of malignant disease and improving cancer patients' quality of life.

Multiple pathways for Epstein-Barr virus episome loss from nasopharyngeal carcinoma.

Epstein-Barr virus (EBV) is the prototypical example for episomal persistence of genetic information. Yet, little is known about how this viral episome is lost. Episome loss occurs naturally in nasopharyngeal carcinoma (NPC) upon explantation into culture. Using whole-genome profiling, we found evidence for 2 different pathways of episome loss: (i) rapid loss of the entire episome or (ii) successive mutation/deletion of the episome until at least 1 essential cis-element is destroyed. This second phenotype was seen in a clone of HONE-1 NPC cells that maintains the EBV episome for prolonged time in culture. The conceptual insights provided by our quantitative analysis should aid our understanding of mammalian episomes, as well as lead to designs to cure latent viral infection.

Catecholamines can mediate stress-related effects on tumor progression.

Studies have implicated behavior as a factor that can influence several aspects of health and have described the complex bidirectional interactions among the CNS, the endocrine system and the immune system that are involved. There is evidence that psychological factors can affect the incidence and progression of some cancers in humans. The hypothesis that stress could be a cofactor is supported by data obtained from animal models. Catecholamines, norepinephrine in particular, have been shown to directly affect various aspects of tumor development that is separate from the well-characterized effects on the cellular immune response to immunogenic tumors. Studies have shown that norepinephrine can directly affect tumor cell behavior and gene expression, further suggesting another mechanism for stress-related modulation of tumor progression. This line of research further suggests that interventions targeting components of the activated sympathetic-adrenal-medullary axis, or the utilization of ß-adrenergic receptor-blocking agents, may represent new strategies for slowing down the progression of malignant disease and improving cancer patients' quality of life.

VEGF is differentially regulated in multiple myeloma-derived cell lines by norepinephrine.

Evidence from human and animal studies support the hypothesis that psychological stress can be a co-factor for the initiation and progression of cancer. Recent work from our laboratory and others have shown that the catecholamine hormone, norepinephrine (NE), may influence tumor progression of some solid epithelial tumors including nasopharyngeal carcinoma (NPC) and ovarian cancer by modulating the expression of proangiogenic and pro-metastatic factors, such as vascular endothelial growth factor (VEGF). In this study, we determined whether NE can likewise modulate the expression of VEGF in a lymphoid tumor, multiple myeloma (MM), a cancer of plasma cells. Three MM-derived cell lines, NCI-H929, MM-M1, and FLAM-76, were studied. The presence of beta1- and beta2-adrenergic receptors (ARs) was assessed using Western blotting. Cells were treated with 0, 1, and 10 microM NE for 1, 3, 6, and 24h and the levels of VEGF in culture supernatants were measured by ELISA. Immunoblots of cell lysates revealed the presence of beta1- and beta2-ARs in all three MM-derived cell lines. However, these MM-derived cell lines exhibited varying degrees of NE-dependent regulation of VEGF expression with FLAM-76 (the only IL-6-dependent cell line among the three) exhibiting the most significant stimulation, followed by MM-M1 cells and then NCI-H929. The data suggest that the ability of NE to regulate the expression of VEGF is not limited to solid epithelial tumors and suggests a possible regulatory role of catecholamine stress hormones in MM progression.

Norepinephrine up-regulates the expression of vascular endothelial growth factor, matrix metalloproteinase (MMP)-2, and MMP-9 in nasopharyngeal carcinoma tumor cells.

Recent studies using ovarian cancer cells have shown that the catecholamine hormones norepinephrine (norepi) and epinephrine (epi) may influence cancer progression by modulating the expression of matrix metalloproteinases (MMP) and vascular endothelial growth factor (VEGF). The purpose of this study is to determine if the stress hormone norepi can influence the expression of MMP-2, MMP-9, and VEGF in nasopharyngeal carcinoma (NPC) tumors by using three NPC tumor cell lines. The NPC cell lines HONE-1, HNE-1, and CNE-1 were treated with norepi. The effects of norepi on MMP-2, MMP-9, and VEGF synthesis were measured by ELISA; functional MMP activity was measured by the invasive potential of the cells using a membrane invasion culture system whereas functional activity of VEGF was analyzed using a human umbilical vein endothelial cell tube formation assay. Norepi treatment increased MMP-2, MMP-9, and VEGF levels in culture supernatants of HONE-1 cells, which could be inhibited by the beta-blocker propranolol. Norepi induced the invasiveness of all NPC cell lines in a dose-dependent manner, which was blocked by CMT-3, an MMP inhibitor, and propranolol. Norepi stimulated the release of functional angiogenic VEGF by HONE-1 cells as well. Finally, HONE-1 cells were shown to express beta-adrenergic receptors as did seven of seven NPC biopsies examined. The data suggest that catecholamine hormones produced by the sympathetic-adrenal medullary axis may affect NPC tumor progression, in part, through modulation of key angiogenic cytokines.

EBV-encoded dUTPase induces immune dysregulation: Implications for the pathophysiology of EBV-associated disease.

Epstein-Barr virus (EBV) encodes for several enzymes that are involved in viral DNA replication. There is evidence that some viral proteins, by themselves, can induce immune dysregulation that may contribute to the pathophysiology of the virus infection. In this study, we focused on the EBV-encoded deoxyuridine triphosphate nucleotidohydrolase (dUTPase) and present the first evidence that the dUTPase is able to induce immune dysregulation in vitro as demonstrated by the inhibition of the replication of stimulated peripheral blood mononuclear cells (PBMCs) and the upregulation of several proinflammatory cytokines including TNF-alpha, IL-1beta, IL-8, IL-6, and IL-10 produced by unstimulated PBMCs treated with purified EBV-encoded dUTPase. Depletion of CD14-positive cells (monocytes) eliminated the cytokine profile induced by EBV dUTPase treatment. The data support the hypothesis that at least one protein of the EBV early antigen complex can induce immune dysregulation and may be involved in the pathophysiology of EBV-associated disease.

Effects of exogenous FGF-1 treatment on regeneration of the lens and the neural retina in the newt, Notophthalmus viridescens.

Experiments were designed to compare the effects of recombinant newt fibroblast growth factor-1 (rnFGF-1) and recombinant human glial growth factor (rhGGF) on lens and retina regeneration in the eyes of adult newts. Both eyes were retinectomized and lentectomized. Beginning 3 days after the operation, one eye was given either 0.1 microg of rnFGF-1 or 0.1 microg of rhGGF in 1 microl of phosphate-buffered saline (PBS) per injection, three per week. Contralateral operated eyes served as controls and were treated with PBS alone or were not injected. In eyes that were not injected, injected with PBS alone, or with PBS containing rhGGF, regeneration of both the retina and the lens proceeded normally as described in the literature. In these control eyes, the entire retinal pigmented epithelium (RPE) depigmented/dedifferentiated and a retina rudiment formed from which a new retina regenerated by the end of the experiment at day 41 post-operation. Likewise, only a small area of dorsal iris depigmented/dedifferentiated and formed a lens vesicle from which a lens subsequently regenerated. The vitreous remained relatively free of loose cells. In eyes given rnFGF-1, the RPE depigmented/dedifferentiated and formed what appeared to be a retina rudiment but a new retina did not regenerate. Instead, vesicles were seen associated with the retina rudiment. In eyes given rnFGF-1, both the dorsal iris and ventral iris depigmented/dedifferentiated and lens regeneration occurred but the new lenses had abnormal fiber cells and the lens epithelium was very thin or absent. In addition, ectopic lenses usually regenerated in rnFGF-1-treated eyes. An abundance of loose cells were present in the vitreous of rnFGF-1-treated eyes associated largely with the RPE and the dorsal and ventral irises. The results are consistent with the view that the timely expression of FGFs is involved in the depigmentation/dedifferentiation of the RPE and dorsal iris and is necessary for proper regeneration of the lens and neural retina. Continued presence of FGF results in continued and excessive dedifferentiation, resulting in the lack of retina regeneration and abnormal lens regeneration.

Stress-associated changes in the steady-state expression of latent Epstein-Barr virus: implications for chronic fatigue syndrome and cancer.

Antibodies to several Epstein-Barr virus (EBV)-encoded enzymes are observed in patients with different EBV-associated diseases. The reason for these antibody patterns and the role these proteins might play in the pathophysiology of disease, separate from their role in virus replication, is unknown. In this series of studies, we found that purified EBV deoxyuridine triphosphate nucleotidohydrolase (dUTPase) can inhibit the replication of human peripheral blood mononuclear cells in vitro and upregulate the production of TNF-alpha, IL-1beta, IL-6, IL-8, and IL-10. It also enhanced the ability of natural killer cells to lyse target cells. The EBV dUTPase also significantly inhibited the replication of mitogen-stimulated lymphocytes and the synthesis of IFN-gamma by cells isolated from lymph nodes and spleens obtained from mice inoculated with the protein. It also produced sickness behaviors known to be induced by some of the cytokines that were studied in the in vitro experiments. These symptoms include an increase in body temperature, a decrease in body mass and in physical activity. The data provide a new perspective on how an early nonstructural EBV-encoded protein can cause immune dysregulation and produce clinical symptoms observed in patients with chronic fatigue syndrome (CFS) separate from its role in virus replication and may serve as a new approach to help identify one of the etiological agents for CFS. The data also provide additional insight into the pathophysiology of EBV infection, inflammation, and cancer.

Stress-related modulation of matrix metalloproteinase expression.

Matrix metalloproteinases (MMPs) and the tissue inhibitors of metalloproteinases (TIMPs), whose expression can be controlled by cytokines, play a role in extracellular matrix remodeling in physiological and pathological processes. Using a blister chamber wound model on UV-B-exposed human forearm skin, we examined whether stress or mood-associated neuroendocrine alteration is sufficient to modulate MMP and TIMP expression. We did not find evidence that depressive symptoms were reliably associated with modulation of either MMP or TIMP expression. However, we did find that activation of the hypothalamic-pituitary-adrenal (HPA) and sympathetic-adrenal medullary (SAM) axes can modulate levels of MMPs. A positive association between plasma norepinephrine levels and MMP-2 protein levels, and a negative correlation between plasma cortisol levels and MMP-2 levels were found. The data suggest that activation of the HPA and SAM axes, even in individuals within the normal range of depressive symptoms, could mediate MMP levels and wound healing in blister wounds.

Stress-induced immunomodulation and the implications for health.

There are complex bi-directional interactions among the central nervous system (CNS), the endocrine system, and the immune system. Although the mechanisms of this bi-directional communication is not yet fully understood, studies in the field of psychoneuroimmunology (PNI) have shown that stress, through the hypothalamic-pituitary-adrenal (HPA) and the sympathetic-adrenal medullary (SAM) axes, can result in the dysregulation of the immune system. In this review, we discuss human studies and animal models, which focuses on psychological stress emphasizing the implications of these effects on wound healing and infectious diseases.

Stress-associated immunomodulation and its implications for responses to vaccination.

The rapidly growing field of psychoneuroimmunology involves the elucidation of the complex interactions between the CNS, the endocrine system and the immune system and its effects on health. Although the mechanisms involved in this bidirectional communication is not yet fully understood, studies in psychoneuroimmunology have shown that stress, through the hypothalamic-pituitary-adrenal and the sympathetic-adrenal-medullary axes, can induce modulation of the immune system. In this review, we discuss human studies and animal models, which focus on psychological stress and its effects on the immune response to vaccination, emphasizing the implications of these effects on health.