Tehran University Medical Journal

Horizons of personalized medicine in breast cancer treatment: review article

Mohammad Hossein Modarressi

Breast cancer that is caused by the accumulation of genetic and epigenetic alterations, is one of the main causes of death resulted from cancer. Various therapeutic approaches have been introduced for this cancer and the traditional diagnosis and treatment is based on the prognosis estimation using cancer anatomic features (TNM system) and clinical results, but studies show different responses of these treatments and recurrence after those in some patients. This diversity is resulted by the differences in biological and molecular characteristics. So genomic and molecular studies became more important and the role of targeted treatment based on an individual's genome was highlighted. Today, the progression in personalized medicine using specific individual genome profile has been possible. The ultimate goal of such studies, in the setting of the personalized medicine, is providing markers which can be used to risk assessment of progressing disease. This new science cause great development in the treatment of breast cancer by recognition of specific markers and application of targeted therapy. Trastuzumab and tamoxifen are the most common monoclonal antibodies applied in these patients depends on their biological and molecular profile. The good response to tamoxifen is seen only in patients with estrogen receptor (ER+) which inhibits the binding of estrogen to its receptor. Defect in the metabolizer enzyme of tamoxifen (CYP2D6), which convert it to the active forms, results in the increased risk of recurrence after treatment. Fulvestrant is another monoclonal antibody which its effect is similar to tamoxifen. Trastuzumab suppresses the cell growth by binding inhibition of epidermal growth factor to HER2 receptors. In the metastatic form of disease, the patients may show resistance to trastuzumab, so lapatinib is suitable alternative in these cases. Pertuzumab combination with trastuzumab and chemotherapy with taxane blocks the dimerization of HER2 with another form of HER receptors. The application of personalized medicine in triple negative phenotype is limited due to the lack of appropriate targets and biomarkers, it makes necessary to do further studies. The aim of this review was to describing the different aspects of personalized medicine and introducing the most important biomarkers and targets in the treatment of breast cancer.

In vitro selective growth inhibition of breast adenocarcinoma cell lines by Pseudomonas sp. UW4 metabolites

Leila Rouhi

Background: Breast cancer is a malignant proliferation of epithelial cells that lining the ducts or lobules of the breast. It is the second common cancer, after lung cancer in women. Since growth inhibition is an important strategy in cancer treatment, many attempts are in program to find new apoptotic inducer agents. Today there is some reports about effect of metabolites of Pseudomonas on cancer cells, hence, metabolites of Pseudomonas sp. UW4, were isolated and anti-cancer and anti-microbial activity of these metabolites was studied.

Methods: This experimental study was performed in cellular and developmental biology of Shahrekord Islamic Azad University from April 2015 to August 2015. Anti-microbial activity of metabolites of Pseudomonas sp. UW4 was tested against a pathogenic bacteria, including Escherichia coli, Bacillus cereus and Staphylococcus aureus. For anti-cancer activity, in this study SKBR3 cells and normal fibroblast cells (HU-02) were cultured in DMEM medium with 10% fetal bovine serum (FBS). The cells were treated by various concentrations of these metabolites 5, 10, 15 and 20 mg/ml for 24, 48 and 72 h. Cell viability was assessed by MTS assay. Cells were seeded at 5×10³ cells/ml in 96 well plates and incubated for 24 hr. Then metabolites of bacteria were added, after indicated times MTS (20 µl) was added and the absorbance was measured at 492 nm using ELISA plate reader.

Results: Pseudomonas sp. UW4 was able to produce antimicrobial metabolites against Staphylococcus aureus. Metabolites decreases the viability of SKBR3 cell line in a time and dose dependent manner, so that the most effective concentration of this substance was 20 mg/ml and 72 h after treatment (P< 0.01). While Pseudomonas sp. UW4 in various concentrations had no significant effect on normal fibroblast cells (P= 0.24).

Conclusion: Bioactive compounds produced by of Pseudomonas sp. UW4 could be used for elimination of infections and treatment of breast cancer SK-BR3.

Measurement of APRIL serum levels as a tumor marker for diagnosis of pancreatic cancer

Amin Hassanzadeh Nemati

Background: Members of the tumor necrosis factor (TNF) superfamily of ligands and their receptors (TNFR) are critical regulators of the adaptive immune system. A proliferation inducing ligand (APRIL) is a member of tumor necrosis factor superfamily. APRIL was identified via database mining in 1998 by Hahne, et al. APRIL allows tumor cells to proliferate at a reasonable rate even in low serum. APRIL is abundantly expressed in many tumor cells and tumor tissues. Increasing level of APRIL expression related to replacement of -Arg-Lys-Arg-Arg- motif by -Ala-Lys-Arg-Ala- between amino acids 101-104 and thus abrogated APRIL processing. Previous studies have shown a correlation between APRIL expression with some autoimmune disease, breast cancer, stomach cancer, esophagus cancer and colorectal cancer. Herein, we explore correlation between serum APRIL with pancreatic cancer.

Methods: Our study is performed in digestive disease research institute (DDRI) of the Shariati Hospital in Tehran City and affiliated Hospital of Tehran University of Medical Sciences. In this study, concentrations of serum APRIL in sera (30 pancreatic cancer patients and 30 healthy controls) from November 2011 to November 2013 collected and level of a proliferation inducing ligand measured by ELISA technique. In this study used from SPSS software, version 22 (IBM SPSS, Armonk, NY, USA) to perform statistical data analysis.

Results: The case group measurement results compared with control groups results according to some characteristics such as age, smoking and, diabetes. ELISA analysis of APRIL measurements show that mean serum APRIL level of pancreatic cancer patients (7 ng/ml) was significantly higher than control group (5 ng/ml). The p-value of this study was 0.003.

Conclusion: Our results indicate that serum APRIL, as a potential biomarker, has a positive diagnosis and prognosis value for pancreatic cancer.

Study of chemical composition and characteristics of Centurea cyanus extract on colon cancer cell line and analysis of apoptosis gene expression

Shoreh Zare Karizi

Background: Centaurea cyanus is an endemic and well-known herbal medicine in Iran, is an annual flowering plant in the family of Asteraceae. The flowers are the part used in modern herbal medicine and are considered to have tonic, stimulant and emmenagogue properties, with action similar to that of blessed thistle. The aim this study was to investigate the phytochemical constituents of C. cyanus extract, its antioxidant, anti-tumor and anti-bacterial activities.

Methods: This experimental study was conducted from June to January of 2015 in Islamic Azad University of Varamin, Iran. At first, the phytochemical components of C. cyanus extract was analyzed using gas chromatography–mass spectrometry (GC-MS) method. Subsequently, the antibacterial potential of the extract was evaluated against 4 pathogenic bacteria including Staphylococcus aureus, Streptococcus pyogenes, Psedomonas aeroginosa and Klebsiella pnemoniae via minimum inhibitory concentration (MIC) mathod. Moreover, the anti-oxidant and anti-tumor activities of extract on colon cancer cell line (HT29) were investigate using DPPH and MTT colorimetric methods, respectively. Finally, the Bax and Bcl2 apoptosis gene expression level was analyzed by quantitative Real-time PCR technique.

Results: GC-MS analysis of C. cyanus extract was shown 19 major components and the most frequent component was belonged to n-Hexadecanoic acid (36.4%) and Linoleic acid (19.3%). The maximum antibacterial activity of extract was observed on S. aureus and P. aeroginosa isolates. The antioxidant activity of the extract was 0.109±0.07 mg/ml. Moreover, the MTT results show that extract had IC50= 26.04±0.45 on HT29 cell line. The Real-time PCR results showed the expression level of Bax and Bcl2 was significantly increased and decreased respectively in colon cancer cell line (2.63±0.54 (P< 0.05), 0.38±0.72 (P< 0.05)).

Conclusion: The results of this study show that the extract had significant anti-bacterial and anti-cancer effects and it appear that the extract has potential uses for pharmaceutical industries.

The role of para aortic lymphadenectomy in early stage of ovarian cancer

Mansoureh Mottaghi

Background: Surgical staging is the standard treatment of ovarian cancer. Pelvic and para-aortic lymphadenectomy is the important part of the surgery. The aim of this study was to evaluate the effect of para aortic lymph node dissection in early stage of patients with ovarian cancer.

Methods: This descriptive cross-sectional cohort study was performed on all stage I of ovarian cancer patients admitted in department of gynecology oncology of Ghaem Hospital, Mashhad University of Medical Sciences in November 2012 to March 2014. Every patient with clinical early stage of ovarian cancer candidate to surgical treatment selected. All cases underwent surgical staging surgery with concurrent systematic pelvic and para-aortic lymphadenectomy. In laparotomy after identification of left and right iliac artery, all lymph nodes have been properly exposed and dissected as a part of a staging laparotomy. The dissection was continued up to the nodal tissues surrounding the aorta, and inferior vena cava, until inferior mesenteric artery lymphadenectomy level. The procedure performed only by gynecologist oncologist. In addition, we assessed other parameters such as operation time, estimated blood loss, associated mortality and morbidity and vascular injuries. Finally, the effect of para aortic lymph node dissection in early stage of ovarian cancer evaluated.

Results: Among a total of 57 ovarian cancer patients, 27 of them apparent stage I disease cases were selected. Surgical staging surgery with concurrent systematic pelvic and para-aortic lymphadenectomy was carried for all of them. Positive para-aortic lymph node was found only in one case. The average number removed para-aortic lymph nodes in the pelvis was 9 and in para aortic was 7, respectively. In addition, 20 minutes increase in total length of operation time was observed duo to para-aortic lymphadenectomy. Also the rate increase in intra-abdominal hemorrhage rate was estimated 60 ml.

Conclusion: Lymph node dissection will produce a significant benefit in accurate and complete surgical staging. Staging surgery in addition to systematic pelvic and para aortic lymph adenoctomy in early stage ovarian cancer is preferred in gynecologic oncology centers.

The evaluation of the resuscitation results and its associated factors

Shokrollah Sadredini

Background: Cardiopulmonary resuscitation, commonly well-known as CPR, is an emergency technique that includes chest compression often with artificial ventilation in an exertion to manually preserve complete brain task until additional measures are taken to return spontaneous blood circulation and breathing in a person who is in cardiac arrest. According to the International Liaison Committee on Resuscitation Guidelines, CPR includes chest compressions for adults between 5 cm (2.0 in) and 6 cm (2.4 in) deep and at a rate of at least 100 to 120 per minute. Cardiopulmonary resuscitation is aimed to reverse vital organs as like as heart, lungs and for subsistence of patients. Several researches showed that different factors affect the resuscitation results. The current study was designed to assess the results of resuscitation and its association factors.

Methods: This retrospective, descriptive and analytic study was carried out in Baharloo Hospital, Tehran, Iran during March 2014 and February 2015. In current work, all resuscitated patients were imported and patients with uncompleted files and died before entrance to hospital were excluded. The data was obtained from medical records units, office files unit and the unit of quality improvement. Data were analyzed by use of SPSS version 22 (Armonk, NY, USA) software and Chi-square test and Student’s t-test.

Results: From 891 patients, 813 cases were entered the study that 498 (61.3%) were male and 315 (38.7%) were female. 41.1% of resuscitation were successful and 58/9% were unsuccessful. The mean and standard deviation time of resuscitation was 28.80 and 12.6 minutes; the most frequent primary diagnosis was cardiovascular disease. In this study there was a significant difference between age and duration of the resuscitation with successful resuscitation (P= 0.02) but, in the variables of ward and resuscitation team were not significant (P> 0.05).

Conclusion: The results of this study showed that resuscitation in younger group, short duration of resuscitation and patients without heart diseases are more successful.

Risk factors of nonalcoholic fatty liver disease: a case-control study

Khairollah Asadollahi

Background: Considering the high incidence and prevalence of nonalcoholic fatty liver disease (NAFLD) in the Iranian society and the limited number of studies to investigate its associated risk factors, the current study was designed to identify any relevant risk factor of this disease.

Methods: The present case-control study was performed among 150 nonalcoholic fatty liver disease patients and 150 normal liver participants who attended to gastroenterology clinics in Ilam city, Iran during 2014-2015. All demographic data, clinical trials and health behaviors associated with lifestyle such as nutritional status, smoking, physical activities were collected and compared between two groups.

Results: Among a total of 300 participants in the current study, the male female ratio was 46.54% and the mean±standard deviation of all participants was 42.13±12.15 years. The mean values of total cholesterol, triglycerides (TG), low density lipoprotein (LDL), alanine transaminase (ALT), aspartate aminotransferase (AST) and alkaline phosphatase (ALP) were significantly higher in cases than controls group (P< 0.0001). A significant relationship was revealed between positive familial history, marriage, and low physical activities with NAFLD (P< 0.05). In the patient's group, consumption of red meat was significantly higher and dairy intake was significantly lower compared to the control group (P< 0.05). Using the multivariate logistic regression analysis, the adjusted odds ratio for variables of waist circumference, triglyceride, ALT and body mass index (BMI) were statistically significant [1.11, (1.04-1.18); 2.58, (1.01-6.67); 5.34, (1.84-15.52) and 7.28,) 1.89-27.99) respectively] (P< 0.05). Also, a significant association was observed among the variables of ALT, AST and BMI with the severity grade of NAFLD (P< 0.05).

Conclusion: The results of this study showed that waist circumference, BMI, serum level of ALT and TG concentrations can predict the occurrence of non-alcoholic fatty liver disease. BMI, ALT, and AST seem to be associated with the ultrasonography staging of liver in NAFLD. Therefore, these parameters could be used to predict the ultrasonography staging of liver in these patients.

Clinical outcome of tracheal extubatedcardiac surgery patients who did not meet protocol driven laboratory criteria for extubation

Khosro Barkhordari

Background: We retrospectively compared the clinical outcome of post-cardiac surgery tracheal extubation between patients extubated with a lower than normal pH and patients extubated according to our routine institutional protocol. Our main goal was to clarify that strict adherence to the current criteria is dispensable.

Methods: In this retrospective cohort study, we recruited 256 patients who met our study criteria and divided them into the exposed group (n= 95) and the control group (n= 161). The inclusion criteria consisted of coronary artery bypass grafting alone and age> 18 years. The exclusion criteria comprised the use of corticosteroids in the preceding 2 weeks, Serum creatinine (SCr)> 2 mg/dL, uncontrolled diabetes, liver dysfunction, Glasgow coma scale <13, and acetazolamide and sodium bicarbonate use. The arterial blood gas (ABG) characteristics before and 6 hours after extubation, extubation failure rate, length of stay in the in ICU, length of stay in the hospital and mortality were compared between the two groups.

Results: In the control group, the males outnumbered the females and the ejection fraction was higher relative to that in the exposure group (P= 0.01 and P= 0.02, respectively). There were more patients with chronic obstructive pulmonary disease in the exposure group (P< 0.005) and also the euroSCORE was higher (P< 0.002). There were no significant differences between the groups regarding the ABG values at the time of ICU admission. Significantly higher levels of FiO₂ and PaCO₂ (P< 0.001 for both) as well as lower HCO3 and pH (P< 0.001 for both) were observed in the exposure group immediately before extubation. Following extubation, there was a significant increase in pH and a significant reduction in FiO₂ need in the exposure group (P< 0.001 for both). The extubation failure rate, length of stay in the in ICU, length of stay in the hospital, and mortality rate were not different between the 2 groups.

Conclusion: The patients with a lower than normal pH, tracheal extubated at the discretion of the ICU anesthesiologist did not have a clinical outcome worse than that of the patients extubated in accordance with our routine institutional protocol.

Total antioxidant capacity, lipid peroxidation and uric acid of saliva in smokers and non-smokers: a comparative study

Atena Shiva

Background: Smoking is a harmful habit and saliva is the first fluid that is exposed to cigarette smoke as a source of oxidant and peroxidant agent. Salivary antioxidant system plays an important role in its anti-cancer potential. Uric acid has a role as antioxidant in the body and could increase plasma antioxidant capacity and has a specific role as inhibitor on radicals and peroxidant agent. Therefore, the aim of this study was to evaluate indicators of oxidative stress or malondialdehyde (MDA) as an important parameter of lipid peroxidation and total antioxidants capacity in smokers and non-smoking persons.

Methods: In this case-control study which was conducted in clinical biochemistry labratory, Mazandaran University of Medical Sciences on Spring 2016. The sample on salivary fluids was collected by spitting method in tubs from 50 smokers (cases group) and nonsmokers (controls group) after all night fasting. As soon as saliva was collected, at the first step total whole salivary fluids were centrifuged and the superior parts were transferred in a tub and stored at -80 ℃ until analyzed. Total antioxidant capacity (TCA) of their saliva was evaluated by Ferric reducing ability of plasma (FRAP) method, lipid peroxidation parameter (MDA) with thiobarbituric acid (TBARS) and uric acid by calorimetry (uricase) methods. The data were analyzed via SPSS software and independent t-test was used to compare the two groups.

Results: Indicators of oxidative stress, in the case group was 1.17±0.29 nmol/ml significantly higher than compared to control group with 0.91±0.16 nmol/ml. TCA in the case group was 220.66±39.68 μmol/l compared to control group 272.26±40.64 μmol/l was significantly lower (P< 0.05).

Conclusion: The result of this study indicates that smoking can reduce total antioxidant capacity and increase lipid peroxidation parameters. In addition, duration of cigarette using has destructive effects on body that it can lead to several diseases. The important thing is to keep trying to quit smoking. For smokers who are willing to quit, it would be recommend that smokers be managed with a combination of behavioral support and pharmacologic therapy.

Reactive oxygen species generation as marker of platelet activation in PRP derived platelet concentrates during storage: brief report

Ehteramolsadat Hosseini

Background: Platelet storage is complicated by deleterious changes that cause progressive structural and functional damages, so-called platelet storage lesion (PSL). PSL is commonly manifested by augmented platelet activation which is also associated with the increased levels of reactive oxygen species (ROS). Whether ROS generation increases during the storage of platelet concentrates and whether it will be correlated with P-selectin expression as a valid marker of platelet activation was investigated in this study.

Methods: In our experimental study, six PRP-platelet concentrates were randomly obtained from Iranian Blood Transfusion Organization (IBTO). All the platelet products met the standard quality assessment based on AABB guidelines. Washed platelets were subjected to flow cytometry analysis for the evaluation of P-selectin expression and intracellular ROS production using DHR 123 in day 0, 1, 3 and 5 after storage. Statistical data were analyzed by Kruskal-Wallis test with Dunn’s multiple comparison test. For correlations, linear regression analysis was applied. P values of less than 0.05 were considered to be significant.

Results: Platelets ROS generation significantly increased from day 0 to day 5 of storage (P= 0.0002). This observed gradual increase was also directly correlated with the increasing levels of P-selectin expression during platelet storage (r= 0.72, P= 0.0001).

Conclusion: Our study showed significant increases in ROS generation during the storage of platelet concentrates correlated with the increments of P-selectin expression as an important marker of platelet activation. This finding suggests that the analysis of ROS generation can also be considered a marker of platelet activation during storage. However, whether ROS generation first induces platelet activation or platelet activation during storage triggers ROS generation is still remain to be determined.