Antioxidants, Cytokines and Markers of Oxidative Stress in Lung Cancer

200 Pages·2010·3.02 MB·English

MARIKA CROHNS
Antioxidants, Cytokines and Markers of
Oxidative Stress in Lung Cancer
Associations with adverse events, response and survival
ACADEMIC DISSERTATION
To be presented, with the permission of
the Faculty of Medicine of the University of Tampere,
for public discussion in the Jarmo Visakorpi Auditorium,
of the Arvo Building, Lääkärinkatu 1, Tampere,
on March 19th, 2010, at 12 o’clock.
UNIVERSITY OF TAMPERE

MARIKA CROHNS
Antioxidants, Cytokines and Markers of
Oxidative Stress in Lung Cancer
Associations with adverse events, response and survival
Acta Universitatis Tamperensis 1501
Tampere University Press
Tampere 2010
ACADEMIC DISSERTATION
University of Tampere, Medical School
Tampere University Hospital, Department of Oncology
Finland
Supervised by Reviewed by
Professor Pirkko Kellokumpu-Lehtinen Professor Henrik Riska
University of Tampere University of Helsinki
Finland Finland
Professor Hannu Alho Professor Ylermi Soini
University of Helsinki University of Kuopio
Finland Finland
Distribution Tel. [phone]
Bookshop TAJU Fax [phone]
P.O. Box 617 [email protected]
33014 University of Tampere www.uta.fi/taju
Finland http://granum.uta.fi
Cover design by
Juha Siro
Acta Universitatis Tamperensis 1501 Acta Electronica Universitatis Tamperensis 938
ISBN 978-951-44-7997-7 (print) ISBN 978-951-44-7998-4 (pdf)
ISSN-L 1455-1616 ISSN 1456-954X
ISSN 1455-1616 http://acta.uta.fi
Tampereen Yliopistopaino Oy – Juvenes Print
Tampere 2010
To my family
“Everything that we see is a shadow cast by that which we do not see”
Martin Luther King, Jr.

Contents
LIST OF ORIGINAL COMMUNICATIONS ...........................................................9
ABBREVIATIONS ..................................................................................................11
ABSTRACT .............................................................................................................13
TIIVISTELMÄ ........................................................................................................15
1. INTRODUCTION ............................................................................................17
2. REVIEW OF THE LITERATURE ...................................................................19
2.1 Free radicals and oxidative stress ......................................................................19
2.2 Antioxidant defense system ...............................................................................21
2.2.1 Vitamin C (ascorbic acid) .......................................................................23
2.2.2 Vitamin E (tocopherol) ...........................................................................23
2.2.3 Urate (uric acid) .....................................................................................24
2.2.4 Thiols and glutathione (GSH) ................................................................24
2.3 Antioxidants in the respiratory tract ..................................................................27
2.4 Lipid peroxidation .............................................................................................28
2.5 Protein oxidation ................................................................................................29
2.6 Oxidative damage to DNA ................................................................................29
2.6.1 Repair of oxidative damage to DNA ......................................................30
2.7 Nitrosative stress ................................................................................................31
2.8 Free radicals and formation of cancer ...............................................................31
2.9 Cytokines ...........................................................................................................32
2.9.1 Interleukins .............................................................................................33
2.9.2 Vascular endothelial growth factor (VEGF) ...........................................34
2.10 Previous studies on the effect of cytokines and oxidative stress in cancer .......34
2.11 Studies during radiotherapy ...............................................................................38
2.12 Studies during chemotherapy ............................................................................40
2.13 Exhaled hydrocarbon studies .............................................................................42
2.14 Previous studies on associations with adverse events and response..................42
2.15 Previous studies on associations with survival ..................................................43
3. OXIDANT EFFECTS OF RADIOTHERAPY ................................................45
4. LUNG CANCER ..............................................................................................47
4.1 Epidemiology of lung cancer .............................................................................47
4.2 Etiology of lung cancer ......................................................................................47
4.3 Classification of lung cancer ..............................................................................48
4.4 Staging of lung cancer .......................................................................................49
4.5 Features of lung cancer ......................................................................................51
4.6 Symptoms and diagnosis of lung cancer ...........................................................52
4.7 Evaluation of performance status ......................................................................52
4.8 Treatment of non-small cell lung cancer ...........................................................53
4.8.1 Stage I–II disease ...................................................................................54
4.8.2 Stage III disease .....................................................................................54
4.8.2.1 Stage III A ................................................................................54
4.8.2.2 Stage III B ................................................................................55
4.8.3 Stage IV disease .....................................................................................55
4.9 Treatment of small cell lung cancer ...................................................................55
4.9.1 Limited disease .......................................................................................56
4.9.2 Extensive disease ....................................................................................56
4.10 Radiotherapy ......................................................................................................56
4.11 Radiation pneumonitis .......................................................................................58
4.12 Chemotherapy ....................................................................................................58
4.12.1 Adriamycin .............................................................................................59
4.12.2 Vincristine ..............................................................................................59
4.12.3 Cyclophosphamide .................................................................................60
4.12.4 Biological treatment of lung cancer .......................................................60
5. AIMS OF THE STUDY ...................................................................................63
6. MATERIAL AND METHODS ........................................................................65
6.1 Lung cancer patients ..........................................................................................65
6.2 Control group .....................................................................................................66
6.3 Pretreatment evaluation and follow-up of lung cancer patients ........................67
6.3.1 Baseline questionnaire ............................................................................67
6.3.2 Criteria for smoking ...............................................................................67
6.4 Treatments .........................................................................................................68
6.4.1 Radiotherapy ..........................................................................................68
6.4.2 Chemotherapy ........................................................................................68
6.5 Evaluation of performance status, adverse events and clinical response .........69
6.5.1 Definitions for response .........................................................................69
6.5.2 Ethical considerations ............................................................................70
6.6 Schedule of study procedures ............................................................................70
6.6.1 Bronchoscopy and bronchoalveolar lavage (BAL) ................................72
6.6.2 Collection of urine and blood samples ...................................................72
6.6.3 Markers of oxidative damage to DNA (study I) .....................................73
6.6.4 Antioxidant bronchoalveolar lavage (BAL) study (study II) .................73
6.6.5 Chemotherapy study (study III) .............................................................74
6.6.6 Exhaled pentane study (study IV) ..........................................................74
6.6.7 Cytokine study (study V) .......................................................................74
6.7 Measurement methods .......................................................................................75
6.7.1 BAL and plasma ascorbic acid ...............................................................75
6.7.2 BAL and serum urate..............................................................................75
6.7.3 BAL and plasma protein thiols ...............................................................75
6.7.4 BAL and plasma NOx and nitrite ...........................................................76
6.7.5 BAL and serum cytokines ......................................................................76
6.7.6 BAL fluid cell counts..............................................................................76
6.7.7 Plasma glutathione .................................................................................77
6.7.8 Plasma alpha-tocopherol and gamma-tocopherol ..................................77
6.7.9 Serum vitamin E .....................................................................................77
6.7.10 Serum TRAP ..........................................................................................77
6.7.11 Serum proteins ........................................................................................78
6.7.12 Serum protein oxidation .........................................................................78
6.7.13 Serum TBARS ........................................................................................78
6.7.14 Serum conjugated dienes ........................................................................78
6.7.15 Urinary 8-oxoGua and 8-oxodG ............................................................79
6.7.16 Nuclear 8-oxodG ....................................................................................79
6.7.17 Exhaled pentane .....................................................................................80
6.8 Statistics .............................................................................................................81
6.8.1 Primary and secondary variables ............................................................81
6.8.2 Group comparisons ................................................................................81
6.8.3 Within-patient changes during treatment ...............................................81
6.8.4 The effect of demographic characteristics ..............................................82
6.8.5 Baseline levels of primary and secondary variables vs. adverse
events, response to treatment and survival .............................................82
7. RESULTS .........................................................................................................83
7.1 Study subjects demographics .............................................................................83
7.2 Occurrence of adverse events ............................................................................83
7.3 Response to treatment ........................................................................................84
7.4 Survival ..............................................................................................................85
7.5 Markers of oxidative damage to DNA (study I) ................................................85
7.5.1 Baseline situation ...................................................................................85
7.5.2 Radiotherapy treatment ..........................................................................88
7.5.3 Chemotherapy treatment ........................................................................88
7.6 Antioxidant BAL study (study II) ......................................................................89
7.7 Chemotherapy study (study III) .........................................................................92
7.8 Exhaled pentane study (study IV)......................................................................94
7.9 Cytokine study (study V) ...................................................................................96
7.10 Associations with subjects´ demographics ........................................................98
7.11 Associations with stage of disease ...................................................................100
7.12 Associations with other laboratory measurements ..........................................101
7.13 Associations with adverse events ....................................................................102
7.14 Associations with response to treatment .........................................................102
7.15 Associations with overall survival ...................................................................103
8. DISCUSSION .................................................................................................105
8.1 Markers of oxidative damage to DNA (study I) ..............................................105
8.2 Antioxidant BAL study (study II) ....................................................................107
8.3 Chemotherapy study (study III) .......................................................................109
8.4 Exhaled pentane study (study IV)....................................................................110
8.5 Cytokine study (study V) .................................................................................112
8.6 Associations with overall survival ...................................................................113
8.7 Comments on study subjects ...........................................................................114
8.8 Comments on methodology .............................................................................115
8.9 Comments on the results of the study ..............................................................117
9. CONCLUSIONS ............................................................................................119
ACKNOWLEDGEMENTS ...................................................................................121
REFERENCES ......................................................................................................123
APPENDIX ............................................................................................................143
ORIGINAL COMMUNICATIONS .......................................................................149