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BMC Cancer
Published in: BMC Cancer 1/2019

Open Access 01-12-2019 | Breast Cancer | Research article

Activation of the hypoxia pathway in breast cancer tissue and patient survival are inversely associated with tumor ascorbate levels

Authors: Elizabeth J. Campbell, Gabi U. Dachs, Helen R. Morrin, Valerie C. Davey, Bridget A. Robinson, Margreet C. M. Vissers

Published in: BMC Cancer | Issue 1/2019

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Abstract

Background

The transcription factor hypoxia inducible factor (HIF) -1 drives tumor growth and metastasis and is associated with poor prognosis in breast cancer. Ascorbate can moderate HIF-1 activity in vitro and is associated with HIF pathway activation in a number of cancer types, but whether tissue ascorbate levels influence the HIF pathway in breast cancer is unknown. In this study we investigated the association between tumor ascorbate levels and HIF-1 activation and patient survival in human breast cancer.

Methods

In a retrospective analysis of human breast cancer tissue, we analysed primary tumor and adjacent uninvolved tissue from 52 women with invasive ductal carcinoma. We measured HIF-1α, HIF-1 gene targets CAIX, BNIP-3 and VEGF, and ascorbate content. Patient clinical outcomes were evaluated against these parameters.

Results

HIF-1 pathway proteins were upregulated in tumor tissue and increased HIF-1 activation was associated with higher tumor grade and stage, with increased vascular invasion and necrosis, and with decreased disease-free and disease-specific survival. Grade 1 tumors had higher ascorbate levels than did grade 2 or 3 tumors. Higher ascorbate levels were associated with less tumor necrosis, with lower HIF-1 pathway activity and with increased disease-free and disease-specific survival.

Conclusions

Our findings indicate that there is a direct correlation between intracellular ascorbate levels, activation of the HIF-1 pathway and patient survival in breast cancer. This is consistent with the known capacity of ascorbate to stimulate the activity of the regulatory HIF hydroxylases and suggests that optimisation of tumor ascorbate could have clinical benefit via modulation of the hypoxic response.
Literature
1.
Semenza GL. HIF-1: upstream and downstream of cancer metabolism. Curr Opin Genet Dev. 2010;20(1):51–6.PubMedCrossRef
2.
Semenza GL. The hypoxic tumor microenvironment: a driving force for breast cancer progression. Biochim Biophys Acta. 2016;1863(3):382–91.PubMedCrossRef
3.
Ratcliffe PJ. Oxygen sensing and hypoxia signalling pathways in animals: the implications of physiology for cancer. J Physiol. 2013;591(Pt 8):2027–42.PubMedPubMedCentralCrossRef
4.
Semenza GL. Regulation of the breast cancer stem cell phenotype by hypoxia-inducible factors. Clin Sci (Lond). 2015;129(12):1037–45.CrossRef
5.
Deb S, Johansson I, Byrne D, Nilsson C, Investigators K, Constable L, Fjallskog ML, Dobrovic A, Hedenfalk I, Fox SB. Nuclear HIF1A expression is strongly prognostic in sporadic but not familial male breast cancer. Mod Pathol. 2014;27(9):1223–30.PubMedCrossRef
6.
Li M, Xiao D, Zhang J, Qu H, Yang Y, Yan Y, Liu X, Wang J, Liu L, Wang J, et al. Expression of LPA2 is associated with poor prognosis in human breast cancer and regulates HIF-1alpha expression and breast cancer cell growth. Oncol Rep. 2016;36(6):3479–87.PubMedCrossRef
7.
Schoning JP, Monteiro M, Gu W. Drug resistance and cancer stem cells: the shared but distinct roles of hypoxia-inducible factors HIF1alpha and HIF2alpha. Clin Exp Pharmacol Physiol. 2017;44(2):153–61.PubMedCrossRef
8.
Vleugel MM, Greijer AE, Shvarts A, van der Groep P, van Berkel M, Aarbodem Y, van Tinteren H, Harris AL, van Diest PJ, van der Wall E. Differential prognostic impact of hypoxia induced and diffuse HIF-1alpha expression in invasive breast cancer. J Clin Pathol. 2005;58(2):172–7.PubMedPubMedCentralCrossRef
9.
Zhang H, Wong CC, Wei H, Gilkes DM, Korangath P, Chaturvedi P, Schito L, Chen J, Krishnamachary B, Winnard PT Jr, et al. HIF-1-dependent expression of angiopoietin-like 4 and L1CAM mediates vascular metastasis of hypoxic breast cancer cells to the lungs. Oncogene. 2012;31(14):1757–70.PubMedCrossRef
10.
Cao D, Hou M, Guan YS, Jiang M, Yang Y, Gou HF. Expression of HIF-1alpha and VEGF in colorectal cancer: association with clinical outcomes and prognostic implications. BMC Cancer. 2009;9:432.PubMedPubMedCentralCrossRef
11.
Volinia S, Galasso M, Sana ME, Wise TF, Palatini J, Huebner K, Croce CM. Breast cancer signatures for invasiveness and prognosis defined by deep sequencing of microRNA. Proc Natl Acad Sci U S A. 2012;109(8):3024–9.PubMedPubMedCentralCrossRef
12.
Wang T, Gilkes DM, Takano N, Xiang L, Luo W, Bishop CJ, Chaturvedi P, Green JJ, Semenza GL. Hypoxia-inducible factors and RAB22A mediate formation of microvesicles that stimulate breast cancer invasion and metastasis. Proc Natl Acad Sci U S A. 2014;111(31):E3234–42.PubMedPubMedCentralCrossRef
13.
Wang W, He YF, Sun QK, Wang Y, Han XH, Peng DF, Yao YW, Ji CS, Hu B. Hypoxia-inducible factor 1alpha in breast cancer prognosis. Clin Chim Acta. 2014;428:32–7.PubMedCrossRef
14.
Generali D, Berruti A, Brizzi MP, Campo L, Bonardi S, Wigfield S, Bersiga A, Allevi G, Milani M, Aguggini S, et al. Hypoxia-inducible factor-1alpha expression predicts a poor response to primary chemoendocrine therapy and disease-free survival in primary human breast cancer. Clin Cancer Res. 2006;12(15):4562–8.PubMedCrossRef
15.
Gilkes DM, Bajpai S, Wong CC, Chaturvedi P, Hubbi ME, Wirtz D, Semenza GL. Procollagen lysyl hydroxylase 2 is essential for hypoxia-induced breast cancer metastasis. Mol Cancer Res. 2013;11(5):456–66.PubMedPubMedCentralCrossRef
16.
17.
Landazuri MO, Vara-Vega A, Viton M, Cuevas Y, del Peso L. Analysis of HIF-prolyl hydroxylases binding to substrates. Biochem Biophys Res Commun. 2006;351(2):313–20.PubMedCrossRef
18.
Peet D, Linke S. Regulation of HIF: asparaginyl hydroxylation. Novartis Found Symp. 2006;272:37–49 discussion 49–53, 131–140.PubMed
19.
Stolze IP, Mole DR, Ratcliffe PJ. Regulation of HIF: prolyl hydroxylases. Novartis Found Symp. 2006;272:15–25 discussion 25-36.PubMed
20.
Smirnova NA, Hushpulian DM, Speer RE, Gaisina IN, Ratan RR, Gazaryan IG. Catalytic mechanism and substrate specificity of HIF prolyl hydroxylases. Biochemistry Biokhimiia. 2012;77(10):1108–19.PubMedCrossRef
21.
Chowdhury R, Candela-Lena JI, Chan MC, Greenald DJ, Yeoh KK, Tian YM, McDonough MA, Tumber A, Rose NR, Conejo-Garcia A, et al. Selective small molecule probes for the hypoxia inducible factor (HIF) prolyl hydroxylases. ACS Chem Biol. 2013;8(7):1488–96.PubMedCrossRef
22.
Kuiper C, Vissers MC. Ascorbate as a co-factor for Fe- and 2-oxoglutarate dependent dioxygenases: physiological activity in tumor growth and progression. Front Oncol. 2014;4:359.PubMedPubMedCentral
23.
Flashman E, Davies SL, Yeoh KK, Schofield CJ. Investigating the dependence of the hypoxia-inducible factor hydroxylases (factor inhibiting HIF and prolyl hydroxylase domain 2) on ascorbate and other reducing agents. Biochem J. 2010;427(1):135–42.PubMedCrossRef
24.
Yeoh KK, Chan MC, Thalhammer A, Demetriades M, Chowdhury R, Tian YM, Stolze I, McNeill LA, Lee MK, Woon EC, et al. Dual-action inhibitors of HIF prolyl hydroxylases that induce binding of a second iron ion. Org Biomol Chem. 2013;11(5):732–45.PubMedCrossRef
25.
Kuiper C, Dachs GU, Currie MJ, Vissers MC. Intracellular ascorbate enhances hypoxia-inducible factor (HIF)-hydroxylase activity and preferentially suppresses the HIF-1 transcriptional response. Free Radic Biol Med. 2014;69:308–17.PubMedCrossRef
26.
Kuiper C, Dachs GU, Munn D, Currie MJ, Robinson BA, Pearson JF, Vissers MC. Increased tumor ascorbate is associated with extended disease-free survival and decreased hypoxia-inducible factor-1 activation in human colorectal cancer. Front Oncol. 2014;4:10.PubMedPubMedCentral
27.
Kuiper C, Molenaar IG, Dachs GU, Currie MJ, Sykes PH, Vissers MC. Low ascorbate levels are associated with increased hypoxia-inducible factor-1 activity and an aggressive tumor phenotype in endometrial cancer. Cancer Res. 2010;70(14):5749–58.PubMedCrossRef
28.
Knowles HJ, Raval RR, Harris AL, Ratcliffe PJ. Effect of ascorbate on the activity of hypoxia-inducible factor in cancer cells. Cancer Res. 2003;63(8):1764–8.PubMed
29.
Campbell EJ, Vissers MC, Bozonet S, Dyer A, Robinson BA, Dachs GU. Restoring physiological levels of ascorbate slows tumor growth and moderates HIF-1 pathway activity in Gulo(−/−) mice. Cancer Med. 2015;4(2):303–14.PubMedCrossRef
30.
Campbell EJ, Vissers MC, Dachs GU. Ascorbate availability affects tumor implantation-take rate and increases tumor rejection in Gulo−/− mice. Hypoxia. 2016;4:41–52.PubMedPubMedCentral
31.
Vissers MC, Gunningham SP, Morrison MJ, Dachs GU, Currie MJ. Modulation of hypoxia-inducible factor-1 alpha in cultured primary cells by intracellular ascorbate. Free Radic Biol Med. 2007;42(6):765–72.PubMedCrossRef
32.
Campbell EJ, Vissers MC, Wohlrab C, Hicks KO, Strother RM, Bozonet SM, Robinson BA, Dachs GU. Pharmacokinetic and anti-cancer properties of high dose ascorbate in solid tumours of ascorbate-dependent mice. Free Radic Biol Med. 2016;99:451–62.PubMedCrossRef
33.
Wohlrab C, Vissers MCM, Phillips E, Morrin H, Robinson BA, Dachs GU. The association between ascorbate and the hypoxia-inducible factors in human renal cell carcinoma requires a functional Von Hippel-Lindau protein. Front Oncol. 2018;8:574.PubMedPubMedCentralCrossRef
34.
Jozwiak P, Krzeslak A, Wieczorek M, Lipinska A. Effect of glucose on GLUT1-dependent intracellular ascorbate accumulation and viability of thyroid Cancer cells. Nutr Cancer. 2015;67(8):1333–41.PubMedCrossRef
35.
Fitzmaurice C, Allen C, Barber RM, Barregard L, Bhutta ZA, Brenner H, Dicker DJ, Chimed-Orchir O, Dandona R, Dandona L, et al. Global, regional, and National Cancer Incidence, mortality, years of life lost, years lived with disability, and disability-adjusted life-years for 32 Cancer groups, 1990 to 2015: a systematic analysis for the global burden of disease study. JAMA Oncol. 2017;3(4):524–48.PubMedCrossRef
36.
Nechuta S, Lu W, Chen Z, Zheng Y, Gu K, Cai H, Zheng W, Shu XO. Vitamin supplement use during breast cancer treatment and survival: a prospective cohort study. Cancer Epidemiol Biomark Prev. 2011;20(2):262–71.CrossRef
37.
Greenlee H, Hershman DL, Jacobson JS. Use of antioxidant supplements during breast cancer treatment: a comprehensive review. Breast Cancer Res Treat. 2009;115(3):437–52.PubMedCrossRef
38.
Greenlee H, Kwan ML, Ergas IJ, Sherman KJ, Krathwohl SE, Bonnell C, Lee MM, Kushi LH. Complementary and alternative therapy use before and after breast cancer diagnosis: the pathways study. Breast Cancer Res Treat. 2009;117(3):653–65.PubMedPubMedCentralCrossRef
39.
40.
McEligot AJ, Largent J, Ziogas A, Peel D, Anton-Culver H. Dietary fat, fiber, vegetable, and micronutrients are associated with overall survival in postmenopausal women diagnosed with breast cancer. Nutr Cancer. 2006;55(2):132–40.PubMedCrossRef
41.
Poole EM, Shu X, Caan BJ, Flatt SW, Holmes MD, Lu W, Kwan ML, Nechuta SJ, Pierce JP, Chen WY. Postdiagnosis supplement use and breast cancer prognosis in the after breast Cancer pooling project. Breast Cancer Res Treat. 2013;139(2):529–37.PubMedPubMedCentralCrossRef
42.
Rohan TE, Hiller JE, McMichael AJ. Dietary factors and survival from breast cancer. Nutr Cancer. 1993;20(2):167–77.PubMedCrossRef
43.
Larsson SC, Akesson A, Bergkvist L, Wolk A. Multivitamin use and breast cancer incidence in a prospective cohort of Swedish women. Am J Clin Nutr. 2010;91(5):1268–72.PubMedCrossRef
44.
Cui Y, Shikany JM, Liu S, Shagufta Y, Rohan TE. Selected antioxidants and risk of hormone receptor-defined invasive breast cancers among postmenopausal women in the Women's Health Initiative observational study. Am J Clin Nutr. 2008;87(4):1009–18.PubMedPubMedCentralCrossRef
45.
Harris HR, Orsini N, Wolk A. Vitamin C and survival among women with breast cancer: a meta-analysis. Eur J Cancer. 2014;50(7):1223–31.PubMedCrossRef
46.
Chen Z, Ai L, Mboge MY, Tu C, McKenna R, Brown KD, Heldermon CD, Frost SC. Differential expression and function of CAIX and CAXII in breast cancer: a comparison between tumorgraft models and cells. PLoS One. 2018;13(7):e0199476.PubMedPubMedCentralCrossRef
47.
Ivanova L, Zandberga E, Silina K, Kalnina Z, Abols A, Endzelins E, Vendina I, Romanchikova N, Hegmane A, Trapencieris P, et al. Prognostic relevance of carbonic anhydrase IX expression is distinct in various subtypes of breast cancer and its silencing suppresses self-renewal capacity of breast cancer cells. Cancer Chemother Pharmacol. 2015;75(2):235–46.PubMedCrossRef
48.
Samanta D, Gilkes DM, Chaturvedi P, Xiang L, Semenza GL. Hypoxia-inducible factors are required for chemotherapy resistance of breast cancer stem cells. Proc Natl Acad Sci U S A. 2014;111(50):E5429–38.PubMedPubMedCentralCrossRef
49.
Harrison H, Rogerson L, Gregson HJ, Brennan KR, Clarke RB, Landberg G. Contrasting hypoxic effects on breast cancer stem cell hierarchy is dependent on ER-alpha status. Cancer Res. 2013;73(4):1420–33.PubMedCrossRef
50.
51.
Ozer A, Bruick RK. Non-heme dioxygenases: cellular sensors and regulators jelly rolled into one? Nat Chem Biol. 2007;3(3):144–53.PubMedCrossRef
52.
Hirsila M, Koivunen P, Xu L, Seeley T, Kivirikko KI, Myllyharju J. Effect of desferrioxamine and metals on the hydroxylases in the oxygen sensing pathway. FASEB J. 2005;19(10):1308–10.PubMedCrossRef
53.
Koivunen P, Hirsila M, Gunzler V, Kivirikko KI, Myllyharju J. Catalytic properties of the asparaginyl hydroxylase (FIH) in the oxygen sensing pathway are distinct from those of its prolyl 4-hydroxylases. J Biol Chem. 2004;279(11):9899–904.PubMedCrossRef
54.
Kuiper C, Vissers MC, Hicks KO. Pharmacokinetic modeling of ascorbate diffusion through normal and tumor tissue. Free Radic Biol Med. 2014;77C:340–52.CrossRef
55.
Savini I, Rossi A, Pierro C, Avigliano L, Catani MV. SVCT1 and SVCT2: key proteins for vitamin C uptake. Amino Acids. 2008;34(3):347–55.PubMedCrossRef
56.
May JM. The SLC23 family of ascorbate transporters: ensuring that you get and keep your daily dose of vitamin C. Br J Pharmacol. 2011;164(7):1793–801.PubMedPubMedCentralCrossRef
57.
58.
Nualart F, Mack L, Garcia A, Cisternas P, Bongarzone ER, Heitzer M, Jara N, Martinez F, Ferrada L, Espinoza F, et al. Vitamin C transporters, recycling and the bystander effect in the nervous system: SVCT2 versus gluts. J Stem Cell Res Ther. 2014;4(5):209.PubMedPubMedCentralCrossRef
59.
Hong SW, Lee SH, Moon JH, Hwang JJ, Kim DE, Ko E, Kim HS, Cho IJ, Kang JS, Kim DJ, et al. SVCT-2 in breast cancer acts as an indicator for L-ascorbate treatment. Oncogene. 2013;32(12):1508–17.PubMedCrossRef
60.
Badid N, Ahmed FZ, Merzouk H, Belbraouet S, Mokhtari N, Merzouk SA, Benhabib R, Hamzaoui D, Narce M. Oxidant/antioxidant status, lipids and hormonal profile in overweight women with breast cancer. Pathol Oncol Res. 2010;16(2):159–67.PubMedCrossRef
61.
Nagamma T, Baxi J, Singh PP. Status of oxidative stress and antioxidant levels in smokers with breast cancer from western Nepal. Asian Pac J Cancer Prev. 2014;15(21):9467–70.PubMedCrossRef
62.
Shah FD, Patel JB, Shukla SN, Shah PM, Patel PS. Evaluation of plasma non-enzymatic antioxidants in breast cancer etiology. Asian Pac J Cancer Prev. 2009;10(1):91–6.PubMed
63.
Gerber M, Richardson S, Salkeld R, Chappuis P. Antioxidants in female breast cancer patients. Cancer Investig. 1991;9(4):421–8.CrossRef
64.
Ramaswamy G, Krishnamoorthy L. Serum carotene, vitamin a, and vitamin C levels in breast cancer and cancer of the uterine cervix. Nutr Cancer. 1996;25(2):173–7.PubMedCrossRef
65.
Frei B, Birlouez-Aragon I, Lykkesfeldt J. Authors’ perspective: what is the optimum intake of vitamin C in humans? Crit Rev Food Sci Nutr. 2012;52(9):815–29.PubMedCrossRef
66.
Levine M, Conry-Cantilena C, Wang Y, Welch RW, Washko PW, Dhariwal KR, Park JB, Lazarev A, Graumlich JF, King J, et al. Vitamin C pharmacokinetics in healthy volunteers: evidence for a recommended dietary allowance. Proc Natl Acad Sci U S A. 1996;93(8):3704–9.PubMedPubMedCentralCrossRef
67.
Carr AC, Frei B. Toward a new recommended dietary allowance for vitamin C based on antioxidant and health effects in humans. Am J Clin Nutr. 1999;69(6):1086–107.PubMedCrossRef
68.
Carr AC, Bozonet SM, Pullar JM, Simcock JW, Vissers MC. Human skeletal muscle ascorbate is highly responsive to changes in vitamin C intake and plasma concentrations. Am J Clin Nutr. 2013;97(4):800–7.PubMedPubMedCentralCrossRef
69.
Padayatty SJ, Sun H, Wang Y, Riordan HD, Hewitt SM, Katz A, Wesley RA, Levine M. Vitamin C pharmacokinetics: implications for oral and intravenous use. Ann Intern Med. 2004;140(7):533–7.PubMedCrossRef
70.
Chen Q, Espey MG, Sun AY, Lee JH, Krishna MC, Shacter E, Choyke PL, Pooput C, Kirk KL, Buettner GR, et al. Ascorbate in pharmacologic concentrations selectively generates ascorbate radical and hydrogen peroxide in extracellular fluid in vivo. Proc Natl Acad Sci U S A. 2007;104(21):8749–54.PubMedPubMedCentralCrossRef
71.
Welsh JL, Wagner BA, van't Erve TJ, Zehr PS, Berg DJ, Halfdanarson TR, Yee NS, Bodeker KL, Du J, Roberts LJ 2nd, et al. Pharmacological ascorbate with gemcitabine for the control of metastatic and node-positive pancreatic cancer (PACMAN): results from a phase I clinical trial. Cancer Chemother Pharmacol. 2013;71(3):765–75.PubMedPubMedCentralCrossRef
72.
Cieslak JA, Sibenaller ZA, Walsh SA, Ponto LL, Du J, Sunderland JJ, Cullen JJ. Fluorine-18-labeled thymidine positron emission tomography (FLT-PET) as an index of cell proliferation after pharmacological ascorbate-based therapy. Radiat Res. 2016;185(1):31–8.PubMedCrossRef
73.
Galea MH, Blamey RW, Elston CE, Ellis IO: The Nottingham Prognostic Index in primary breast cancer. Breast Cancer Research and Treatment. 1992;22(3):207–219.
74.
Kurshumliu F, Gashi-Luci L, Kadare S, Alimehmeti M, Gozalan U: Classification of patients with breast cancer according to Nottingham prognostic index highlights significant differences in immunohistochemical marker expression. World Journal of Surgical Oncology/ 2014;12:243.
Metadata
Title
Activation of the hypoxia pathway in breast cancer tissue and patient survival are inversely associated with tumor ascorbate levels
Authors
Elizabeth J. Campbell
Gabi U. Dachs
Helen R. Morrin
Valerie C. Davey
Bridget A. Robinson
Margreet C. M. Vissers
Publication date
01-12-2019
Publisher
BioMed Central
Published in
BMC Cancer / Issue 1/2019
Electronic ISSN: 1471-2407
DOI
https://doi.org/10.1186/s12885-019-5503-x

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