inflammation and lung cancer risk qiuyin cai vanderbilt epidemiology center vanderbilt university

Inflammation and Lung Cancer Risk

Qiuyin Cai

Vanderbilt Epidemiology CenterVanderbilt University

OutlineOutline

• Inflammation and Cancer• Inflammation and Lung Cancer• Biomarkers• Arachidonic Acid Pathway

InflammationInflammation

• Inflammation: A protective tissue response to injury or destruction of tissues, which serves to destroy, dilute, or wall off both the injurious agent and the injured tissues. Inflammation is now recognized as a type of nonspecific immune response.

• The classical signs of acute inflammation are pain, heat, redness, swelling, and loss of function.

• Chronic inflammation prolonged and persistent inflammation marked chiefly by new connective tissue formation; it may be a continuation of an acute form or a prolonged low-grade form.

InflammationInflammation

Coussens & Werb: Nature. 420: 860-867, 2002

Inflammation PathwaysInflammation Pathways

Inflammation and CancerInflammation and Cancer• In 1863, Rudolf Virchow noted leucocytes in neoplastic tissues

• Lymphoreticular infiltrate reflected the origin of cancer at sites of chronic inflammation

• Non-infectious Agents• Asbestosis, silicosis: Lung cancer• Bronchitis: Lung cancer• Cystitis, bladder inflammation: Bladder cancer• IBD, Crohn’s disease, chronic ulcerative colitis: Colorectal cancer• Chronic pancreatitis: Pancreatic cancer• Reflux esophagitis/Barrett’s esophagus: esophageal cancer• Skin inflammation: Melanoma• Prostatitis: Prostate cancer• Pelvic inflammatory disease/tissue remodeling: Ovarian cancer

• Infectious agents• Viral infection

• HPV: Cervical cancer• HBV, HCV: Liver cancer• EBV: Lymphoma

• Bacteria• H Pylori: Stomach cancer• TB: Lung cancer

• Contributes to about 15-20% of cancer world-wide.

Chronic InflammationChronic Inflammation

• Many types of cancer, including lung cancer, are heavily infiltrated by different types of inflammatory cells, particularly the tumor-associated macrophages.

• These cells have ability to express a large variety of cytokines and growth factors

• Some of these cytokines and growth factors are known to function as regulators of tumor growth, metastasis, and angiogenesis.

Inflammation and cancerInflammation and cancer

de Visser et al: Nat Rev Cancer. 6: 24-37, 2006.

Lung Cancer Risk FactorsLung Cancer Risk Factors

• Cigarette Smoking• Environmental Tobacco Smoke (ETS)• Chronic lung diseases

• COPD• Chronic bronchitis• Tuberculosis

• Environmental exposures• Asbestos• Radon, Radiation• Air pollution (indoor & outdoor)

• All these cause inflammation in the lungs

Chronic InflammationChronic Inflammation

• A typical component in most lung disorders and lung infections is inflammation and activation of inflammatory cells with consequent free radical generation.

• Sustained cell proliferation in an inflammatory environment with abundant reactive free radicals and pro-malignant growth factors greatly potentiate and promote the development and progression of cancers.

• The inflammatory process itself may provide the prerequisite environment for the development of malignancy.

• In addition to infection by biological or physical agents, inflammation can be initiated by carcinogen-induced tissue injury.

Chronic Inflammation and Lung Cancer Risk: Possible MechanismsChronic Inflammation and Lung Cancer Risk: Possible Mechanisms

Pro-inflammatory Cytokines Inflammation

COX-2

ROS/RNS Production

Oxidative Stress

Oxidative DNA Damage

VEGF Angiogenesis

Lung Cancer

PGE2 Cell growth

Smoking, ETS Chronic lung diseases Chronic infection (bacteria, virus) Environmental pollutants

PGI2

PGH2 Arachidonic Acid

PGIS

Nitric oxide

Oncogene Tumor suppressor gene

PGES

Inhibition

Chronic Inflammation and Lung Cancer Risk: Possible MechanismsChronic Inflammation and Lung Cancer Risk: Possible Mechanisms

Hofseth and Ying: BBA. 1765: 74-84, 2006.

Lung Cancer BiomarkersLung Cancer Biomarkers

• Stage I and II lung cancer rarely causes symptoms

• Most lung cancer patients have advanced disease at diagnosis

• Early detection could potentially decrease lung cancer mortality by diagnosing the disease at an earlier and potentially more curable stage

• Biomarkers under evaluation:• Circulating DNA markers• Serum proteomic profiles• Gene methylation/mutations• Conventional sputum cytology

• Identifying biomarkers, especially using non-invasive methods, that may be useful in the detection of early malignant or even pre-malignant lesions are needed.

Biomarkers of InflammationBiomarkers of Inflammation

• Prostaglandin• C-reactive protein (CRP) • Cytokines:

• IL-1, IL-6, TNF-α and receptors

• Fibrinogen• Leukocyte count• Adhesion molecules: VCAM-1• Amyloid A

Arachidonic Acid PathwayArachidonic Acid Pathway

Winterhalder et al: Ann Oncol. 15: 185-196, 2004

Prostaglandin E2Prostaglandin E2

• The inflammation effects of PGH2 are largely mediated through PGE2.

• PGE2 increases cell proliferation, migration, angiogenesis, and immunosupression and decreases apoptosis.

• Overproduction of PGE2 and prostaglandin E synthase (PTGES) has been implicated in the pathogenesis of NSCLC.

• Suppression of the PGE2 receptor has been shown to inhibit the growth of lung carcinoma cell lines, and PGE2 augments the activation of the Ras signaling pathway in lung adenocarcinoma cells.

• Hidalgo et al (2002): case-control study (65 cases and 36 controls):

• Plasma PGE2 levels in NSCLC patients were elevated compared to normal controls.

• This study was limited by a small sample size and the use of post-diagnostic blood PGE2 levels as a marker.

Urinary Prostaglandin E2 Metabolite (PGE-M)Urinary Prostaglandin E2 Metabolite (PGE-M)

Murphey et al: Anal Biochem. 334:266-275, 2004

• The most accurate index of endogenous prostaglandins production in humans is the measurement of excreted urinary metabolites.

• PGE-M could be measured using a liquid chromatography /tandem mass spectrometric method.

• The measurement of urinary PGE-M provides the most accurate approach to assess the endogenous production of PGE2 in humans.

Urinary PGE-M in Normal SubjectsUrinary PGE-M in Normal Subjects


Fig 2: PGE-M in normal subjects post non-selective (ibuprofen) & selective COX-2 inhibition (rofecoxib)

A significant component of PGE2 production is COX-2 derived.

Urinary PGE-M in NSCLCUrinary PGE-M in NSCLC


A significant proportion of the excessive production of PGE2 in humans with NSCLC is COX-2 derived.

Shanghai Women’s Health Study (SWHS)Shanghai Women’s Health Study (SWHS)

• Population-based prospective cohort study (PI: Wei Zheng)

• Long-term epidemiological investigations of cancer and other chronic diseases

• Recruitment period: 3/1997-5/2000

• Approximately 75,000 women

• Biological samples: • Blood: 76%• Urine: 88%• DNA: 88%

Urinary PGE-M SWHS: Colorectal Cancer


Cai et al: J Clin Oncol. 24: 5010-5016, 2006



Table 3. Association of Baseline Urinary PGE-M Levels and Subsequent Risk of Colorectal Cancer

PGE-M (by quartiles)

Q1 Q2 Q3 Q4

P* for trend

All colorectal cancer (150 pairs)

Number of cases/controls 14/37 28/38 47/37 61/38

RR (95% CI) 1.0 (reference) 2.5 (1.1-5.8) 4.5 (1.9-10.9) 5.6 (2.4-13.5) < 0.001

Colon cancer (88 pairs)


RR (95% CI) 1.0 (reference) 2.1 (0.7-6.5) 4.8 (1.6-14.8) 4.9 (1.7-14.7) 0.009

Rectal cancer (62 pairs)


RR (95% CI) 1.0 (reference) 3.1 (0.8-11.6) 4.1 (1.0-17.3) 7.2 (1.7-30.7) 0.048

*Conditional logistic regression models were used to derive P-values for linear trends by modeling the log-transformed urinary PGE-M levels as continuous variable.

Cai et al: J Clin Oncol. 24: 5010-5016, 2006

Urinary PGE-M and Lung CancerUrinary PGE-M and Lung Cancer

Csiki et al: Clin Cancer Res. 11: 6634-6640, 2005

Correlation of Intratumoral PGE2 Levels and Urinary PGE-M in NSCLCCorrelation of Intratumoral PGE2 Levels and Urinary PGE-M in NSCLC

Csiki et al: Clin Cancer Res. 11: 6634-6640, 2005

Celecoxib inhibited intratumoral COX-2, reduced intratumoral PGE2 synthesis and resulted in a concomitant decrease in urine PGE-M levels.

Prostacyclin (PGI2)Prostacyclin (PGI2)• PGI2, another major PGH2 metabolite, may

differ from other bioactive prostaglandins and may exert cancer inhibitory effects on the development of lung cancer.

• Keith et al (2002) have shown that manipulation of PGI2 synthase (PTGIS) substantially reduces the occurrence of murine lung cancer.

• The non-specific inhibitory effect of NSAIDs on COX-2 enzymes may act as a double-edged sword, decreasing both pro-inflammatory prostaglandins (e.g. PGE2) and anti-inflammatory PGI2.

• This may explain some of the null associations found in epidemiological studies regarding NSAID use and lung cancer risk.

Urinary Prostacyclin Metabolite (PGI-M)Urinary Prostacyclin Metabolite (PGI-M)

• Because of the very short half-life of the active species, PGI2 synthesis in biological tissues can only be monitored by measuring PGI-M, the primary breakdown product of PGI2.

SWHS: Lung Cancer (82 cases and 82 controls)• Assayed by Cayman Chemical using EIA kit • Higher urinary PGI-M is associated with decreased lung cancer

risk.• Need to use a more accurate detecting method.

Biomarkers of InflammationBiomarkers of Inflammation

• Prostaglandin• C-reactive protein (CRP) • Cytokines:

• IL-1, IL-6, TNF-α and receptors

• Fibrinogen• Leukocyte count• Adhesion molecules: VCAM-1• Amyloid A

C-reactive Protein (CRP)C-reactive Protein (CRP)

• CRP is a nonspecific, but sensitive marker of systemic inflammation.

• As a downstream biomarker, CRP provides functional integration of overall upstream cytokine activation. • Produced in liver at the stimulation of pro-inflammatory

cytokines: • Interleukin-6 (IL-6)• Interleukin-1 (IL-1)• Tumor necrosis factor- (TNF-)

• CRP levels remain stable and measurable in serum samples stored for decades. • High within-person correlation in repeated measurements

(same r as for systolic blood pressure)

C-reactive Protein (CRP)C-reactive Protein (CRP)

• CRP has been shown in numerous epidemiological studies to be a robust and independent predictor of future cardiovascular events.

• CRP is accepted as a risk marker fro cardiovascular disease.

• Erlinger et al (2004) reported that plasma CRP concentrations were elevated among persons who subsequently developed colon cancer, suggesting that CRP may have etiological significance.

CRP and Lung CancerCRP and Lung Cancer• NSCLC patients with elevated CRP

concentrations had greater concentrations of IL-6, a pro-inflammatory cytokine.

• Sin et al (2006): Plasma CRP has excellent predictive powers in identifying participants with bronchial dysplastic lesions whose lesions progress to more advanced stages of dysplasia. • The baseline CRP levels in these participants were 64%

higher than those without progressive disease (p = 0.027).

CRP and Lung CancerCRP and Lung Cancer• Two small nested case-control studies reported positive

association of baseline CRP and lung cancer risk.

• Il’yasova et al, CEBP, 2005: Health Aging and Body Composition study (ages 70-79 years):

• 42 lung cancer patients: HR = 1.64 (95% CI: 1.20-2.24). • Additional adjustment for smoking reduced the HR estimates (HR: 1.54,

95% CI, 1.12-2.12).

• Trichopoulos et al, CEBP, 2006: Greek component of the EPIC study:• 72 lung cancer patients and 144 controls: OR = 1.31 (95% CI: 1.11-1.53). • When excluding lung cancer patients in the first year of follow-up, the OR

was 1.63 (95% CI: 1.25-2.14).

These studies were limited by small sample size and lack of information on acute inflammatory disease and medicine use.

These results support the hypothesis that inflammation is associated

with lung cancer.

CRP and Lung Cancer CRP and Lung Cancer

SWHS: 77 cases and 158 controls

Table 5. Association of baseline hsCRP with lung cancer risk

hsCRP # of Cases # of Controls OR (95% CI)

T1 (Low) 21 59 1.00 (reference)

T2 28 47 1.67 (0.85-3.32)

T3 (high) 28 52 1.51 (0.77-3.18)

Pro-inflammatory Cytokines and Lung Cancer RiskPro-inflammatory Cytokines and Lung Cancer Risk

• Il’yasova et al: CEBP, 2005. Health Aging and Body Composition Study

Markers N HR 95% CI

Log (IL-6) 42 1.43 0.91-2.26

Log (TNF-α) 39 1.67 0.79-3.55

Log (CRP) 42 1.64 1.20-2.24

NSAID use and Lung CancerNSAID use and Lung Cancer

Skriver et al: Int J Cancer. 117: 873-876, 2005

Genetic MarkersGenetic Markers

• Genetic polymorphisms of genes involved in prostaglandin synthases and PGE2 metabolism

PTGIS PolymorphismsPTGIS Polymorphisms

• Danish Diet, Cancer and Health Cohort: • 432 incident cases of lung cancer• 432 age and sex-matched controls• This cohort was established in 1993, and subjects were

enrolled between December 1993 and May 1997 in Copenhagen and Aarhus, Denmark.

• Population-based case-control study: • 159 cases of primary lung cancer recruited between 2002-

2005 in two lung cancer treatment centers in the county of North Jutland, Denmark.

• 444 age and sex-matched controls were randomly selected from the population of North Jutland County.

PTGIS PolymorphismsPTGIS Polymorphisms

Cases Controls N % N % OR 95% CI rs5629 G/G 363 63.6 480 56.3 1.00 reference G/T 177 31.0 313 36.7 0.73 0.55-0.96 T/T 31 5.4 59 6.9 0.72 0.42-1.25

rs5580 A/A 175 30.9 257 29.9 1.00 reference A/C 291 51.3 438 51.0 1.02 0.76-1.38 C/C 101 17.8 164 19.1 0.86 0.59-1.27

SummarySummary

• Inflammation plays an important role in lung carcinogenesis

• Urinary PGE-M and PGI-M and blood hsCRP may be useful biomarkers for lung cancer

• Genetic variations in genes involved in prostaglandin production may be associated with lung cancer risk

Future StudyFuture StudyVanderbilt Lung SPORE:

Lung Cancer Risk and Inflammation Pathways

Shanghai Women’s Health StudySouthern Community Cohort Study

Pro-inflammatory Cytokines

Inflammation (hsCRP, CRP gene)

Cox-2

Lung Cancer

PGE2 (PGE-M, 15-PGDH)

Cell growth

Smoking, ETS Chronic lung diseases Chronic infection Environmental pollutants

PGI2 (PGI-M)

Arachidonic Acid

PTGIS Nitric Oxide

PTGES

Inhibition

PGH2

Apoptosis

Angiogenesis

Invasiveness

Immunosuppression

AcknowledgementsAcknowledgements

• Vanderbilt University Medical Center

• Wei Zheng• Bill Blot• Xiao Ou Shu• Gong Yang• Wanqing Wen• Hui Cai• Regina Courtney• Qing Wang• Wande Guo• Ji-Rong Long

• Jason Morrow

• Kimberly Campbell

• Shanghai Cancer Institute• Yu-Tang Gao and his team

• NCI • Wong-Ho Chow• Bu-Tian Ji• Nathaniel Rothman

• Institute of Cancer Epidemiology, Danish Cancer Society

• Jorgen H. Olsen and his team

• International Epidemiology Institute

• Bill Blot and his team• Jon P. Fryzek

• Grant Supports• SWHS: NCI• Vanderbilt Lung SPORE: NCI

inflammation and lung cancer risk qiuyin cai vanderbilt epidemiology center vanderbilt university

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