Depressive symptoms and cytokine levels in Serum and Tumor Tissue in patients with an Astrocytoma: a pilot study

MISSING IMAGE

Material Information

Title:
Depressive symptoms and cytokine levels in Serum and Tumor Tissue in patients with an Astrocytoma: a pilot study
Physical Description:
Mixed Material
Language:
English
Creator:
Starkweather, Angela R.
Sherwood, Paula
Lyon, Debra E.
Bovbjerg, Dana H.
Broaddus, William C.
Elswick. R K Jr.
Sturgill, Jamie
Publisher:
Bio-Med Central ( BMC Research Notes)
Publication Date:

Notes

Abstract:
Background: Preoperative depressive symptoms are associated with poor outcomes in patients with an astrocytoma. Cytokines are associated with depressive symptoms in the general population and are important mediators of tumor growth and progression. The aims of this study were to: (1) characterize depressive symptoms, other treatment-related symptoms and biological mediators; and (2) determine whether preoperative depressive symptoms were associated with the selected biological mediators. Methods: A prospective, exploratory study was carried out among 22 patients with a high-grade astrocytoma. Self-report questionnaires and peripheral blood samples were collected on the day of surgery. Tumor tissue was collected intraoperatively. Self-report questionnaires were assessed at 3, 6, 9, and 12-months postoperatively. Results: In circulation, serum IL-8 was inversely correlated with depressive symptoms while IL-17 measured in tumor tissue supernatant was inversely correlated with depressive symptoms. Depressive symptoms showed a significant increase at 12 months from baseline levels and were positively associated with treatment-related symptoms at 3 months and symptom distress at 12 months post-surgery. Conclusions: In this pilot study, depressive symptoms were negatively associated with IL-8 in serum and IL-17 in tumor tissue. The changes among depressive symptoms, treatment-related symptoms and symptom distress highlight the need for multi-faceted symptom management strategies over the treatment trajectory in this patient population.
General Note:
Starkweather et al. BMC Research Notes 2014, 7:423 http://www.biomedcentral.com/1756-0500/7/423; Pages 1-7
General Note:
doi:10.1186/1756-0500-7-423 Cite this article as: Starkweather et al.: Depressive symptoms and cytokine levels in Serum and Tumor Tissue in patients with an Astrocytoma: a pilot study. BMC Research Notes 2014 7:423.

Record Information

Source Institution:
University of Florida
Holding Location:
University of Florida
Rights Management:
© 2014 Starkweather et al.; licensee BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/4.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly credited. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.
System ID:
AA00026951:00001


This item is only available as the following downloads:


Full Text

PAGE 1

RESEARCHARTICLEOpenAccessDepressivesymptomsandcytokinelevelsin SerumandTumorTissueinpatientswithan Astrocytoma:apilotstudyAngelaRStarkweather1*,PaulaSherwood2,DebraELyon3,DanaHBovbjerg4,WilliamCBroaddus5, RKElswickJr6andJamieSturgill6AbstractBackground: Preoperativedepressivesymptomsareassociatedwithpooroutcomesinpatientswithan astrocytoma.Cytokinesareassociatedwithdepressivesymptomsinthegeneralpopulationandareimportant mediatorsoftumorgrowthandprogression. Theaimsofthisstudywereto:(1)characterizedepressivesymptoms,othertreatment-relatedsymptomsandbiological mediators;and(2)determinewhetherpreoperativedepressivesymptomswereassociatedwiththeselectedbiological mediators. Methods: Aprospective,exploratorystud ywascarriedoutamong22patientswithahigh-gradeastrocytoma. Self-reportquestionnairesandperipheralbloodsample swerecollectedonthedayofsurgery.Tumortissuewas collectedintraoperatively.Self-rep ortquestionnaireswereassessedat3,6 ,9,and12-monthspostoperatively. Results: Incirculation,serumIL-8wasinverselycorrelate dwithdepressivesymptomswhileIL-17measuredin tumortissuesupernatantwasinverselycorrelatedwit hdepressivesymptoms.Depressivesymptomsshoweda significantincreaseat12monthsfro mbaselinelevelsandwerepositively associatedwithtreatment-related symptomsat3monthsandsymptomdistressat12monthspost-surgery. Conclusions: Inthispilotstudy,depressivesymptomswerenegativelyassociatedwithIL-8inserumandIL-17 intumortissue.Thechangesamongdepressivesymptoms,treatment-relatedsymptomsandsymptomdistresshighlight theneedformulti-facetedsymptommanagementstrategies overthetreatmenttrajectoryinthispatientpopulation.BackgroundItisestimatedthat24,620peoplewillbediagnosedwith aprimarymalignantbrainorcentralnervoussystem tumorthisyearintheUnitedStates[1].Atrocytomas arethemostcommonprimarymalignantbraintumor (PMBT)inadults[2].Althoughadvancesinsurgery, radiation,andchemotherapyhaveimprovedlengthof survivalinpatientswithanastrocytoma[3],mortality remainshighwhichunderscorestheneedtobetter understandhowotherfactorsaffectthediseasetrajectory.Depressivesymptomsareastrongprognosticindicatorofpooroutcomeinpatientswithanastrocytoma [4,5]andseveralstudieshavereportedanassociation withreducedqualityoflifeandsurvivaltimeregardless oftreatmenttypeordegreeoftumorresection[6-9]. Whilethesefindingssuggestthattheremaybecommon biologicalmechanismsunderlyingtheinfluenceofdepressivesymptomsontumorprogressionandresistance totreatment,particularlyforanastrocytoma[10-12], therehavebeennostudiesthathavesimultaneously examinedthesefactors.Therefore,theaimofthisprospective,exploratorystudywastocharacterizedepressive symptoms,othertreatment-relatedsymptomsandbiologicalmediatorsthatareknowntoinfluenceastrocytoma growthandprogression.Asecondaryaimwastodeterminewhetherpreoperativedepressivesymptomswere associatedwiththeselectedbiologicalmediators. *Correspondence: astarkweathe@vcu.edu1DepartmentofAdultHealthandNursingSystems,VirginiaCommonwealth UniversitySchoolofNursing,1100EastLeighStreet,P.O.Box980567, Richmond,VA23298,USA Fulllistofauthorinformationisavailableattheendofthearticle 2014Starkweatheretal.;licenseeBioMedCentralLtd.ThisisanOpenAccessarticledistributedunderthetermsofthe CreativeCommonsAttributionLicense(http://creativecommons.org/licenses/by/4.0),whichpermitsunrestricteduse, distribution,andreproductioninanymedium,providedtheoriginalworkisproperlycredited.TheCreativeCommonsPublic DomainDedicationwaiver(http://creativecommons.org/publicdomain/zero/1.0/)appliestothedatamadeavailableinthis article,unlessotherwisestated.Starkweather etal.BMCResearchNotes 2014, 7 :423 http://www.biomedcentral.com/1756-0500/7/423

PAGE 2

DepressiveSymptomsandtheTumorMicroenvironmentInflammationhaslongbeenregardedasaphysiological mechanismassociatedwithdepressivesymptoms.Evidenceinsupportofthisrelationshiphasbeendemonstratedbystudiesthathaveobserveddepressivebehavior followingadministrationofproinflammatorycytokines [particularlyinterleukin(IL)-1,IL-6,andtumornecrosis factor-alpha(TNF)],eithercentrally(inthebrain)or peripherallyinanimalsandhumans[13-15].Morespecifically,IL-1,IL-6,andTNFhavebeenshowntoplaya roleintheetiologyofdepressionbyreducingthesynthesis ofserotonininthebrain,stimulatinghypothalamicand preopticnoradrenergicneurotransmission,andinhibiting glucocorticoidreceptorfunctioningtherebyleadingto hypothalamic-pituitary-adrenocortical(HPA)axisdyregulation[16]. Inthecentralnervoussystem,astrocytesarethemajor glialcellpopulationandactasimmunocompetentcells; thatis,theyorchestratelocalimmuneresponses[17,18]. Partofthelethalityassociatedwithastrocytomas,aswell asothergliomas,isduetotheinfluenceofanimmunosuppressivetumormicroenvironmentwhichallowsthe tumorcellstoevadeimmunesurveillance.Cytokinesplay amajorroleinthisprocess,alongwithotherproteinsincludingvascularendothelialgrowthfactor(VEGF),matrix metallopreoteinases(MMPs)andglialfibrillaryacidicprotein(GFAP)[19,20]thatpromoteangiogenesisandtumor growth[21,22].Inthetumormicroenvironment,cytokines maysupporttumorgrowth,inhibitit,orplayadualfunction[23].Thosewhichhavebeenfoundtosuppresstumor growthincludeIL-2,IL-12,IL-13andIFN(gamma,beta andalpha)whileIL-4,IL-6,IL-8andIL-10predominantly contributetotumorgrowth[24].Thus,cytokineshave beenimplicatedincontributingtotheinvasivenessand vascularizationoftumorcellsandimmunosuppression withinthetumormicroenvironmentaswellastheinitiationandpersistenceofdepressivesymptoms[25,26]. Todate,nostudieshavesimultaneouslycharacterized depressivesymptomsandthelocalandsystemiclevels ofthesebiologicalmediatorsinpatientswithanastrocytoma.Notingthehighreportedrateofdepressivesymptomsinpatientswithanastrocytoma,thedetrimental effectsonqualityoflife,andcompellingdatathatsuggests sharedmechanismsunderlyingdepressivesymptomsand tumorprogression[27,28],weconductedadescriptive correlationalstudyinpatientswithanastrocytomawho wereundergoingtumorresection.ResultsSampledemographicsTherewereatotalof22patientswithameanageof 45.7years(SD18.09)whometinclusioncriteriaand wereenrolled.Ofthese,therewere9women(41%)and 13men(59%)ofwhom30%werediagnosedwithaprimary(denovo)gradeIIIastrocytomaand70%witha primary(denovo)gradeIVastrocytoma.Lifetimehistory ofdepressionwaspositivefor7participants(30%)with theremainingparticipantsreportingthattheyhadnever receivedadiagnosisortreatmentfordepression.DepressivesymptomsAsseeninTable1,therewasastatisticallysignificantincreaseinthelevelofdepressivesymptomsbetweenbaselineandthe12monthfollowupassessment( P <.02).The meanBeckDepressionInventoryversionII(BDI-II)score atthetimeofsurgerywas11.68(SD,1.7),indicating minimaldepressivesymptoms.ThemeanBDI-IIscore increasedto16.66(SD,2.37)at3monthsaftertumor resection,slightlydecreasedto15.07(SD,1.84)and14.21 (SD,1.35)at6and9monthspost-tumorresection respectively,andincreasedto18.63(SD,1.48)at12months post-tumorresection.PerceivedStressLevelsofperceivedstressincreasedfrombaselineto thefollow-upperiodat3,6,9,and12-monthspostoperatively,however,therewerenosignificantdifferencesbetweenthescoresovertimeandnosignificant associationwithdepressivesymptoms.Treatment-relatedsymptomsTherewasastatisticallysignificantriseintheM.D. AndersonSymptomInventory(MDASI)Coresymptoms betweenbaselineandthe3monthfollow-upappointment( P <.003).However,therewerenosignificantchanges intheM.D.AndersonSymptomInventoryBrainTumor Table1SymptomscoresovertimeTime Pre-surgery (N=22) 3mpost-surgery (N=21) 6mpost-surgery (N=20) 9mpost-surgery (N=19) 12mpost-surgery (N=19) BDI-II11.681.7016.662.3715.071.8414.211.3518.631.48 MDASICore2.110.333.030.272.200.182.070.122.590.20 MDASIBT1.250.251.680.281.250.161.160.171.850.25 MDASIInterference3.140.554.520.374.040.424.350.374.610.31Valuesgivenaremeanstandarderrors.Abbreviations: m Months, BDI-II BeckDepressionInventoryversionII, MDASICore M.D.AndersonSymptomInventory, MDASIBT M.D.AndersonSymptomInventory-BrainTumorModule.Starkweather etal.BMCResearchNotes 2014, 7 :423 Page2of7 http://www.biomedcentral.com/1756-0500/7/423

PAGE 3

Module(MDASIBT)score.TheMDASIInterferencescore increasedsignificantlybetweenbaselineandthe12month follow-upassessment( P <.002).BaselinedepressivesymptomswereassociatedwiththeMDASICoresymptoms ( P <.01)andinterferencescores( P <.002).BiologicalfactorsThebiologicaldatafromserumandbraintumorsupernatantfromtissueacquiredatthetimeofsurgeryispresentedinFigure1andFigure2.Spearmancorrelations wereperformedtoinvestigatethepossibilityofarelationshipbetweenbiologicalmediatorsintheserumand tumortissue,aswellasbetweendepressivesymptoms andbiologicalmediators.Therewerenosignificantassociationsbetweentheserumandbraintumorlevels.Of theserumcytokinelevels,IL-8wassignificantlynegativelycorrelatedwithdepressivesymptoms(Spearman ’ = .70, P <.0004)whileIL-17wastheonlytumortissue cytokineassociatedwithdepressivesymptoms(Spearman ’ = .50, P <.03).DiscussionAccordingtothecut-offscoresoftheBeckDepression InventoryversionII(BDI-II),depressivesymptomwere minimalatbaselinebutshowedastatisticallysignificant increaseat12monthsfrombaselinelevels.Therewas alsoasignificantriseintreatment-relatedsymptomsat 3monthsfollowingtumorresectionaswellasasignificantincreaseinsymptomdistress(interferencescore)at 12months.Theseresultsaresimilartothosereported byLitofskyetal.[7]inwhichdepressivesymptomsincreasedoverthefirst6-monthsfollowingtumorresection,however,intheirstudytheMF-36MentalHealth scorewasusedtoquantifydepressivesymptomsand treatment-relatedsymptomswerenotmeasured.Asystematicreviewofstudiesevaluatingdepressioninglioma patientsconcludedthatdepressivesymptoms,regardless ofthemeasureused,tendtoincreaseinfrequencyand severityovertimeaftertumorresection[29].Thepresent studyenhancesunderstandingaboutdepressivesymptoms byidentifyingatime-relatedcourseinwhichthereisa simultaneousriseintheseverityoftreatment-related symptomsat3monthsaftertumorresectionaswellasan increaseinsymptomdistressat12months. Theassociationbetweendepressivesymptomsand treatment-relatedsymptomsisnotsurprisingasprevious studieshaveobservedthatdepressivesymptomstendto co-occurwithtreatment-relatedsymptoms,including cognitiveimpairment,sleepdisturbancesandpaininpatientswithabraintumor[29,30].Previousstudieshave alsoreportedanassociationamongdepressivesymptomsanddecreasedphysicalfunctioning,qualityoflife andsurvivalinpatientswithbraincancer[6-9].Mainio etal.[31]reportedthatincreasedseverityofdepression inpatientswithabraintumoraftertumorresectionwas associatedwithalowerfunctionalstatusasindicatedby theKarnofskyPerformanceScale.Depressiondefinedas aBDIscoreof10orgreaterpredictedshortersurvivalin patientswithlow-gradeglioma[8].Inaretrospectivereviewof1052patientswithmalignantastrocytomaundergoingtumorresection,apreoperativeclinicaldiagnosisof depressionwasapredictorofshortersurvival[6].Theresultsofthepresentstudydemonstratethatdepressive symptomsandsymptomdistresssimultaneouslyincrease at12monthspost-tumorresection.Thisfindingsuggests thatdepressivesymptomsaremorelikelytooccurwhen treatment-relatedsymptomsbegintonegativelyimpact dailyfunctioning. Manyoftheperipheralcytokineswereelevatedatthe timeofsurgery.Ofparticularinterestweretheelevated levelsofIL-6andTNFassustainedelevationsofthese cytokineshavebeenassociatedwith “ sicknessbehavior ” however,thelevelsofthesecytokineswerenotassociatedwithdepressivesymptomsinthissample.Incontrast,serumlevelsofIL-8wereinverselyassociatedwith depressivesymptoms.Althoughinthetumormicroenvironment,IL-8haschemotactic,tumorigenicand proangiogenicpropertiesandhasbeenshowntoinduce infiltrationoftumor-associatedmacrophages(TAMs) 0 50 100 150 200 250 300 350 400 450 Serum (pg/dL) Tumor (pg/dL) Figure1 Cytokinelevelsinserumandbraintumortissue. 0 200 400 600 800 1000 1200 1400 1600 1800 VEGFTNF-GFAPMMP-2MMP-9 Serum (pg/dL) Tumor (pg/dL) Figure2 Additionalbiologicalfactorsinserumandtumortissue. Starkweather etal.BMCResearchNotes 2014, 7 :423 Page3of7 http://www.biomedcentral.com/1756-0500/7/423

PAGE 4

[17,32],thepresentfindingsuggestsapossiblederegulationofperipheralneutrophilactivationassociatedwith depressivesymptoms. Thisstudydidnotfindanassociationbetweenplasma andtumorlevelsoftheselectedcytokines.Incontrast,a studybySamarasetal.[33]foundthatlevelsofIL-6and IL-10inastrocyticneoplasmsandperipheralbloodwere highlycorrelatedandthattheprincipalIL-6positivecell typewastheneoplasticastrocyte,whereasmicroglial cellsandmacrophageswerethemajorsourceofIL-10. Oneofthemostintriguingfindingsofthispilotstudy wastheinverserelationshipbetweendepressivesymptomsandbraintumorIL-17levels.Itwasrecently reportedthatIL-17expressionwithintumortissuewas associatedwithprogression-freesurvivalinpatientswith anastrocytoma[34].Inthatstudy,theauthorsconcludedthathighlevelsofIL-17expressionintumortissuesmaybeagoodprognosticmarkerforpatientswith gradeIVastrocytoma.IL-17isaCD4Tcell-derivedproinflammatorycytokinethatmayenhancetumorsuppressionbysignalingTh17cellsintothebraintissue.Th17 cellshaveenhancedmigratorycapabilitiesintotheCNS becauseoftheirabilitytopenetratethebloodbrainbarrier[34].However,duetomethodologicaldifferences betweenstudies(ie.measurementofIL-17expression vs.levelofIL-17intumortissuesupernatant)thesignificanceofthepresentfindingremainsunclearandno causalinferencescanbemadebasedonthedesignof thestudy.FurtherinvestigationsarenecessarytoexaminetherelationshipbetweenIL-17intumortissueand depressivesymptomsinalargersampleofpatientsand toexaminetheinfluenceonpatientoutcomes.LimitationsThisexploratorystudywasdesignedtoexploretherelationshipsamongdepressivesymptomsandtheselected biologicalfactors.Mostpatientsinthestudyreported minimaltomoderatelevelsofdepressivesymptoms. Sincethestudydidnotincludeapsychologicalexaminationtodifferentiateparticipantswithmajordepression disorder(MDD),thestudyfindingscannotbegeneralizedtopatientswithMDD.However,itcanbeargued thatevensubsyndromalMDDisassociatedwithsignificantmorbidityinindividualswithcancer.Inthis context,thestudyfindingswarrantfurtherinvestigation.ConclusionsInthissampleofpatientswithagradeIIIorIVastrocytoma,depressivesymptomsvariedoverthetreatment trajectorywithasignificantincreaseat12months.Depressivesymptomsweresignificantlyassociatedwith treatment-relatedsymptomsat3monthspost-operative andsymptomdistressat12monthspostoperative.These findingssuggestthatdepressivesymptomsaremore likelytooccurwhentreatment-relatedsymptomsincreaseorwhentheybegintonegativelyimpactdaily functioning.Asmanyaspectsofdepressivesymptoms overlapwithtreatment-relatedsymptoms,includingcognitiveimpairmentandsleepdisturbances,theresults suggestthatmulti-facetedsymptommanagementstrategiesmaybebeneficialduringthepostoperativeperiod. SerumlevelofIL-8andtumortissuelevelofIL-17were negativelyassociatedwithdepressivesymptoms,however,furtherresearchisnecessaryinordertodetermine whetherthesefindingscanbereplicatedinalarger sample.MethodsThisstudyusedaprospectiv e,exploratory,repeatedmeasuresdesigntocharacterizedepressivesymptoms, treatment-relatedsymptomsa ndpro-andanti-inflammatory cytokines(aswellasMMP-2,MMP-9,andGFAP)intumor tissueandinbloodatthetimeoftumorresection.Patient reportedsymptomswerealsoassessedat3,6,9,and 12-monthspostoperatively.Thefollow-uptimepoints wereselectedbasedonthenormalcourseofpatients aftertumorresection,whichincludesstartingchemotherapyandradiation,prognosticevaluationsofthetumor responsetotreatment,andcontinuedsurveillance.ParticipantsandproceduresThisstudywasapprovedbytheInstitutionalReview Board(IRB)ofVirginiaCommonwealthUniversity,a largeurbanuniversityhealthsysteminthemid-Atlantic regionthatservedasthestudysiteforrecruitmentand datacollectedprocesses.Thestudywasconductedin accordancewiththeDepartmentofHealthandHuman Services ’ policyforprotectionofhumanresearchsubjects. EligiblepatientswerereferredandscreenedbyresearchcollaboratorsintheDepartmentofNeurological Surgery.Informedconsentwasobtainedfromeachparticipant.Inclusioncriteriaincludedmalesandfemales 18yearsorolder,withclinicaldiagnosisofamalignant astrocytoma(GradeIIIorIV)whowerescheduledfor tumorresection.Inaddition,participantshadtobefluentinEnglishandwithouthistoryofimmune-related diseaseorpreviouscancerdiagnosis.Patientswereineligibleiftheywereunabletoprovideinformedconsent duetoalteredcognitivestatusasevidencedbyaMiniMentalStatusExaminationscoreof23orlower(0 – 23) oriftheywerecurrentlytakingananxiolyticorantidepressantmedication.Subjectswhoenrolledinthestudy butweresubsequentlystartedonananti-depressantduringthepostoperativeperiodwerenotfollowedandtheir datawasnotusedintheanalyses.Recruitmentanddata collectiontookplacebetweenDecember2010and December2012.Starkweather etal.BMCResearchNotes 2014, 7 :423 Page4of7 http://www.biomedcentral.com/1756-0500/7/423

PAGE 5

Afterinformedconsentwasobtained,participants wereaskedtocompletethestudyquestionnairesina privateroom.Whenaparticipantwasfoundtobeatrisk forseveredepression( 20ontheBDI-II)orverbalized difficultydealingwithdepressivesymptoms,theirphysicianwasnotifiedasexplainedintheinformedconsent. Followingcompletionofthequestionnaires,abloodspecimenwascollectedadheringtoastandardvenipuncture protocolfromanantecubitalsiteonthedayofsurgery. Bloodspecimenswereimmediatelytransportedoniceto thelaboratoryforprocessing. Aspartofstandardcareforthetreatmentofanastrocytoma,alloftheparticipantsunderwentagrosstotal resection,whichhasbeenassociatedwithlongersurvival andimprovedneurologicalfunction[35].Tissuespecimensacquiredduringthesurgerywereimmediately packedoniceandtransportedtothelaboratoryforprocessing.Surgerywasfollowedbyinvolved-fieldradiotherapyrangingfromatotaldoseof54to60Gyand adjuvantchemotherapywithtemozolomide.Measures DemographicsDemographicandclinicalcharacteristicsofstudyparticipants(e,g.,age,gender,raceandethnicity,lifetimehistoryofdepression)wererecordedatbaselineforeach participant.Lifetimehistoryofdepressionwasquantified byaskingthepatientwhethertheyhadeverreceiveda diagnosisorbeentreatedfordepression.Ifthepatient answeredaffirmativelytoeitherdiagnosisortreatment, apositivelifetimehistoryofdepressionwasrecorded. Agewasincludedasacontinuousvariableinanalyses, whilegenderandlifetimehistoryofdepressionwere dichotomous.DepressivesymptomsDepressivesymptomsweremeasuredusingthe Beck DepressionInventoryversionII (BDI-II).TheBDI-IIis a21-itemself-reportinstr umentintendedtoassessthe existenceandseverityofsymptomsofdepressionas listedintheAmericanPsychiatricAssociation ’ s Diagnostic andStatisticalManualofMentalDisordersFourthEdition (DSM-IV;1994)[36].Thereisafour-pointscalefor eachitemrangingfrom0to3.Ontwoitems(16and18) therearesevenoptionstoindicateeitheranincreaseor decreaseofappetiteandsleep.Summingthe21itemsprovidesatotalBDI-IIscorethatisusedtoprovideacategoricalratingofsymptomseverity(0to13indicatesminimal symptomsofdepression,14to19mildsymptoms,20to 28moderatesymptoms,and29to63severesymptoms). Thetotalscorewasusedintheanalysestodeterminethe relationshipsbetweendepressivesymptomsandbiological factors.ValidityfortheBDI-IIhasbeenwellestablishedin patientswithaPMBT[29].PerceivedStressThePerceivedStressScale(PSS)isthemostwidelyused psychologicalinstrumentformeasuringtheperception ofstress.PSSisabrief10-itemscalemeasuringthedegree towhichexperiencesareappraisedasuncontrollable[37]. Individualsratetheirresponsesusinga5-pointLikert scale.Atotalscoreisprovidedbyaddingtheresponses together,withahigherscoreindicatingahigherlevelof perceivedstress.InternalconsistencyofthePSSranges from0.75-0.86andtest-retestreliabilityis0.85[38].Treatment-relatedsymptomsThe M.D.AndersonSymptomInventory-BrainTumorModule (MDASI-BTM)wasusedtome asuretreatment-related symptoms.TheMDASI-BTMmeasuressixsymptomconstructs,includingaffective,co gnitive,focalneurological deficits,treatment-related symptoms,general/diseaserelatedsymptoms,andgastrointestinalsymptoms[39]. TheMDASI-BTMisa22-item instrumentconsisting of11-pointscales(0 – 10)foreachitem.Participants areaskedtoindicatethepresenceandseverityofeach symptominthelast24hours,with0being “ not present ” and10being “ asbadasyoucanimagine ” Itemsofthecoresymptoms(Core=13items)and braintumormodulesymptomitems(BT=9items)are summedanddividedbythenumberofitemsineach categorytoprovideameancoresymptomscoreand meanbraintumormodulescore.Interference(SD=6 items)measureshowmuchsymptomshaveinterfered withdifferentaspectsofapatient ’ slifeinthelast 24hours,includinginterferenceingeneralactivity, mood,work,relationswithotherpeople,walking,and enjoymentoflife.Themeanoftheinterferenceitems isusedasameasureofoverallsymptomdistress.Total Core,BT,andInterferencescoreswereusedinthe statisticalanalyses.ThesixconstructsoftheMDASIBTMhavebeenshowntobesensitivetodiseaseseverity,treatmentstatus,and diseaseprogression[39].BiologicalfactorsLevelsofpro-andanti-inflammatorycytokines,MMP-2, MMP-9andGFAPweremeasuredinserumandtumor specimenstakenatthetimeofsurgicalresection.Blood sampleswerecollectedviavenipunctureusinga10mL serumseparatorvacutainer,immediatelyplacedonice anddeliveredtothelaboratoryforprocessing.Allspecimenswerealiquotedimmediately,frozen,andstoredin a 80Cfreezeruntilbatchprocessing.Tumortissue specimenswerecollectedatthetimeofbiopsy/resection intraoperativelyaspartofnormalclinicalprocedures. Noalterationsinthesurgerywererequiredforthisaspectofdatacollection.A1.51.5.0.5cmstripoftumor specimenwascutfromthetumorcenterandplacedina sterilecontaineraspreviouslydescribedbySamarasStarkweather etal.BMCResearchNotes 2014, 7 :423 Page5of7 http://www.biomedcentral.com/1756-0500/7/423

PAGE 6

etal.[33].Thetissuefragmentsweretransported directlytothelaboratorybyaresearchteammember. Underareverse-flowhoodeachspecimenwascutinto threeequalstripsandeachstripwasplacedinacryovial thatwassnapfrozeninliquidN2andstoredina 80C freezeruntilbatchprocessing.Atthetimeofanalysis, eachspecimenwasthawedunderareverse-flowhood andchoppedinto1mm2piecesusingcrossedscalpels. Thetissuefragmentswereimmediatelyplacedina universaltubecontaining1.5mLofcelllysisbuffer (Bio-Rad;Hercules,CA).Thetissuewasdisruptedby drawingthesamplesupanddownthroughapipette tip20timesfollowedbyorbitalagitationfor20minutes at300rpmand4C.Thesampleswerethencentrifugedat4500 g for15minutesat4C.ThetissuesupernatantwascollectedforcytokineanalysisusingaBio-Plex instrumentfollowingthemanufacturer ’ sinstructions. Cytokines,GFAP,MMP-2andMMP-9weremeasured inserumandtumorsupernatantusingtheHuman17plexpanelthatincludesinterleukin(IL)1beta(IL-1), IL-1RA,IL-2,IL-4,IL-5,IL-6,IL-7,IL-8,IL-10,IL12p70,IL-13,IL-15,IL-17,VEGF,andTNF;andstandardizedELISAkits(Biovendor,Candler,NC).Analysis wasconductedusingtheBio-Plex(Bio-Rad;Hercules, CA).Allsampleswererunintriplicateandthedatawas expressedasthemeanstandarderror.Theassays accuratelymeasurecytokinevaluesintherangeof 1 – 2,500pg/ml,areprecise(intra-assayCV<10%,interassayCV<15%),andshowlessthan1%cross-reactivity withothermolecules.StatisticalanalysesMeansandstandarddeviationsofthedemographicdata wereusedtodescribethesample.Thedistributionsof thebiologicaldataweregraphicallyinspectedandarepresentedasthemeanstandarderror(SE).Studentt-tests wereusedtoevaluatedifferencesinthepatient-reported symptomscoresovertimeandPearsoncorrelationcoefficientswereusedtoassessrelationshipsbetweendepressivesymptomscoresandtreatment-relatedsymptoms. Althoughthereiscontroversyregardingwhethertologtransformcytokinedatatocreatenormaldistributions, thisapproachmaynotbeideallysuitedforidentifying clinicallyimportantlevelsofthebiologicalfactorsmeasured.Thus,Spearmanrankcorrelationswereperformed forthenonparametriccytokinedata.Duetothevariance inserumcytokinelevels,thelevelofsignificancewasset atP<.001.AllanalyseswereconductedusingSigmaPlot (SystatSoftware,Inc.,SanJose,CA).Apoweranalysiswas calculatedusingastudythatreportedsignificantdifferencesindepressivesymptomsamongpatientswitha braintumor[6]andsuggestedaminimumof20subjects wereneededtoobtain90%powerorgreateratP<.05 significancelevel.Competinginterests Theauthorsdeclarethattheynocompetinginterests. Authors ’ contributions ARSandPSconceivedofthestudyandparticipatedinitsdesign.ARS carriedouttheclinicalresearchanddraftedthemanuscript.PS,DEL,and DHBparticipatedinthedesignofthestudyandcoordinationandhelped todraftthemanuscript.RKEandJScarriedouttheimmunoassaysand performedthestatisticalanalysis.WCBparticipatedinthedesignofthe study,facilitatedrecruitmentandcollectedtissuesamples.Allauthorsread andapprovedthefinalmanuscript. Acknowledgements WewouldliketothanktheAmericanNursesFoundationandOncology NursesFoundation/AmericanBrainTumorFoundation(Starkweather,PI)for supportingthecollection,processingandanalysisofthebiologicalsamples. Thefollowingauthorsarecurrentlyreceivingresearchfundingfromthe NationalInstitutesofHealth:ARS(R01NR013932;#P30NR011403;Grap,PI); PS(R01CA118711,R01NR004339,R01NR011044,R01NR0131170);DEL(R01 NR012667);DHB(R01CA129557,R01CA131148,R21CA165146,P30 CA047904);RKE(#P30NR011403;Grap,PI). Authordetails1DepartmentofAdultHealthandNursingSystems,VirginiaCommonwealth UniversitySchoolofNursing,1100EastLeighStreet,P.O.Box980567, Richmond,VA23298,USA.2SchoolofNursing,SchoolofMedicine,University ofPittsburghCancerInstitute,UniversityofPittsburgh,336VictoriaBuilding, 3500VictoriaStreet,Pittsburgh,Pennsylvania15261,USA.3Collegeof Nursing,UniversityofFlorida,1225CenterDrive,Gainesville,FL32611,USA.4SchoolofMedicine,GraduateSchoolofPublicHealth,SchoolofArtsand Sciences,UniversityofPittsburghCancerInstitute,UniversityofPittsburgh, HillmanCancerCenter,CooperPavilion,Suite140,Pittsburgh,Pennsylvania, USA.5DepartmentofNeurosurgery,VirginiaCommonwealthUniversity HealthSystems,Richmond,Virginia,USA.6VirginiaCommonwealthUniversity SchoolofNursing,1100EastLeighStreet,P.O.Box980567,Richmond,VA 23298,USA. Received:20March2014Accepted:30June2014 Published:4July2014 References1.CentralBrainTumorRegistryoftheUnitedStates(CBTRUS): Primarybrain tumorsintheUnitedStates:Factsheet. Hinsdale,IL:CBTRUS;2013. 2.AmericanCancerSociety: Cancerfactsandfigures,2013. Atlanta:ACS;2013. 3.LawrenceYR,MishraMV,Werner-WasikM,AndrewsDW,ShowalterTN,Glass J,ShenX,SymonZ,DickerAP: Improvingprognosisofglioblastomain the21stcentury:whohasbenefitedmost? Cancer 2012, 118: 4228 – 4234. 4.HjerlK,AndersenEW,KeidingN,MouridsenHT,MortensenPB,JorgensenT: Depressionasaprognosticfactorforbreastcancermortality. Psychosom 2003, 44: 24 – 30. 5.NakayaN,Saito-NakayaK,AkizukiN,YoshikawaE,KobayakawaM,FujimoriM, NagaiK,NishiwakiY,FukudoS,TsubonoY,UchitomiY: Depressionand survivalinpatientwithnon-smallcelllungcanceraftercurativeresection: apreliminarystudy. CancerSci 2006, 97: 199 – 205. 6.GathinjiM,McGirtMJ,AttenelloFJ,ChaichanaKL,ThanK,OliviA,WeingartJD, BremH,Quinones-HinojosaA: Associationofpreoperativedepressionand survivalafterresectionofmalignantbrainastrocytoma. SurgNeurol 2009, 71: 299 – 303. 7.LitofskyNS,FaraceE,AndersonFJr,MeyersCA,HuangW,LawsERJr, GliomaOutcomesProjectInvestigators: Depressioninpatientswithhigh-grade glioma:resultsoftheGliomaOutcomesProject. Neurosurg 2004, 54: 358 – 366. 8.MainioA,HakkoH,TimonenM,NiemelaA,KoivukangasJ,RasanenP: Depressioninrelationtosurvivalamongneurosurgicalpatientswitha primarybraintumor:a5-yearfollow-upstudy. Neurosurg 2005, 56: 1234 – 1241. 9.MainioA,TuunanenS,HakkoH,NiemelaA,KoivukangasJ,RasanenP: Decreasedqualityoflifeanddepressionaspredictorsofshortersurvival amongpatientswithlow-gradegliomas:afollowupfrom1990to2003. EurArchPsychiatryClinNeurosci 2006, 256: 516 – 521. 10.SoodAK,LutgendorfSK: Stressinfluencesonanoikis. CancPrevRes 2011, 4: 481 – 485.Starkweather etal.BMCResearchNotes 2014, 7 :423 Page6of7 http://www.biomedcentral.com/1756-0500/7/423

PAGE 7

11.SharmaA,GreenmanJ,SharpDM,WalkerLG,MonsonJR: Vascular endothelialgrowthfactorandpsychosocialfactorsincolorectalcancer. Psychooncol 2008, 17: 66 – 73. 12.YangEV,KimSJ,DonovanEL,ChenM,GrossAC,WebsterMarketonJI, BarskySH,GlaserR: NorepinephrineupregulatesV EGF,IL-8,andIL-6expression inhumanmelanomatumorcelllines:Implicationsforstress-related enhancementoftumorprogression. BrainBehavImmun 2009, 23: 67 – 75. 13.DantzerR,KelleyKW: Twentyyearsofresearchoncytokine-inducedsickness behavior. BrainBehavImmun 2007, 21: 153 – 160. 14.WilsonDR,WariseL: Cytokinesandtheirroleindepression. Perspect PsychiatrCare 2008, 44: 285 – 289. 15.LoftisJM,HuckansM,MorascoBJ: Neuroimmunemechanismsof cytokine-induceddepression:cur renttheoriesandnoveltreatment strategies. NeurobiolDis 2010, 37: 519 – 533. 16.EyreH,BauneBT: Neuroplasticchangesindepression:aroleforthe immunesystem. Psychoneuroendocrinol 2012, 37: 1397 – 1416. 17.ZhuVF,YangJ,LeBrunDG,LiM: Understandingtheroleofcytokinesin glioblastomamultiformepathogenesis. CancerLett 2012, 316: 139 – 150. 18.DongY,BenvenisteEN: Immunefunctionofastrocytes. Glia 2001, 36: 180 – 190. 19.BrommelandT,RosengranL,FridlundS,HennigR,IsaksenV: Serumlevels ofglialfibrillaryacidicproteincorrelatetotumourvolumeofhigh-grade gliomas. ActaNeurologScand 2007, 116: 380 – 384. 20.KorzhevskiiDE,OtellinVA,Grigor ’ evIP: Glialfibrillaryacidicproteinin astrocytesinthehumanneocortex. NeurosciBehavPhysiol 2005, 35: 789 – 792. 21.LutgendorfSK,SoodAK: Biobehavioralfactorsandcancerprogression: Physiologicalpathwaysandmechanisms. PsychosomMed 2011,73: 724 – 730. 22.SicaA,AllavenaP,MantovaniA: Cancerrelatedinflammation:the macrophageconnection. CancerLett 2008, 267: 204 – 215. 23.KumarR,KamdarD,MaddenL,HillsC,CrooksD,O ’ BrienD,GreenmanJ: Th1/Th2cytokineimbalanceinmeningioma,anaplasticastrocytomaand glioblastomamultiformepatients. OncolRep 2006, 15: 1513 – 1516. 24.ZisakisA,PiperiC,ThemistocleousMS,KorkolopoulouP,BoviatsisEI,SakasDE, PatsourisE,LeaRW,KalofoutisA: Comparativeanalaysisofperipheraland localizedcytokinesecretioninglioblastomapatients. Cytokine 2007, 39: 99 – 105. 25.YangEV,SoodAK,ChemM,LiY,EubankTD,MarshCB,JewellS,FlavahanNA, MorrisonC,YehPE,LemeshowS,GlasterR: Norepinephrineup-regulatesthe expressionofvascularendotheliagrowthfactor,matrixmetalloproteinase MMP-2,andMMP-9innasopharyngealcarcinomatumorcells. CancerRes 2006, 66: 10357 – 10364. 26.DavisS,ThomasA,PerryR,OakleyA,KalariaRN,O ’ BrienJT: Glialfibrillary acidicproteininlatelifemajordepressivedisorder:an immunocytochemicalstudy. JNeurolNeurosurgPsych 2002, 73: 556 – 560. 27.McCainNL,GrayDP,WalterJM,RobinsJ: Implementingacomprehensive approachtothestudyofhealthdynamicsusingthe psychoneuroimmunologyparadigm. AdvNursSci 2005, 28: 320 – 332. 28.StarkweatherAR,SherwoodP,LyonDE,McCainNL,BovbjergD,BroaddusWC: Abiobehavioralperspectiveondepressivesymptomsinpatientswitha cerebralastrocytoma. JNeurosciNurs 2011, 43 (1) : 17 – 28. 29.RooneyAG,CarsonA,GrantR: Depressionincerebralgliomapatients: asystematicreviewofobservationalstudies. JNatlCancerInst 2011, 103: 61 – 76. 30.FoxS,LyonD,FaraceE: Symptomclustersinpatientswithhigh-grade glioma. JNursScholarsh 2007, 39: 61 – 67. 31.MainioA,HakkoH,NiemalaA,KoivukangasJ,RasanenP: Depressionand functionaloutcomeinpatientswithbraintumors:Apopulation-based1-year follow-upstudy. JNeurosurg 2005, 103: 841 –847. 32.HongTM,TengLJ,ShunCT,PengMC,TsaiJC: Inducedinterleukin-8 expressioningliomasbytumorassociatedmacrophages. JNeurooncol 2009, 93: 289 – 301. 33.SamarasV,PiperiC,KorkolopoulouP,ZisakisA,LevidouG,Themistocleous MS,BoviatsisEI,SakasDE,LeaRW,KalofoutisA,PatsourisE: Applicationof theELISPOTmethodforcomparativeanalysisofinterleukin(IL)-6and IL-10secretioninperipheralbloodofpatientswithastroglialtumors. MolCellBiochem 2007, 304: 343 – 351. 34.CiuX,XuZ,ZhaoZ,SuiD,RenX,HuangQ,QinJ,HaoL,WangZ,ShenL, LinS: AnalysisofCD137LandIL-17expressionintumortissueasprognostic indicatorsforglioblastoma. InterJBiolSci 2013, 9: 134 – 141. 35.BrownPD,MaurerMJ,RummansTA,PollockBE,BallmanKV,SloanJA, BoeveBF,ArusellRM,ClarkMM,BucknerJC: Aprospectivestudyofquality oflifeinadultswithnewlydiagnosedhigh-gradegliomas:Theimpactof theextentofresectiononqualityoflifeandsurvival. Neurosurg 2005, 57: 495 – 504. 36.BeckAT,SteerRA,BrownGK: ManualfortheBeckDepressionInventory-II. SanAntonio,TX:PsychologicalCorporation;1996. 37.CohenS: Perceivedstressscale. MindGarden:PaloAlto,CA;1994. 38.CohenS,KamarchT,MermelsteinR: Aglobalmeasureofperceivedstress. JHealthSocialBehav 1983, 24: 385 – 396. 39.ArmstrongTS,MendozaT,GningI,CocoC,CohenMZ,EriksenL,HsuMA, GilbertMR,CleelandC: ValidationoftheM.D.AndersonSymptom InventoryBrainTumorModule(MDASI-BT). JNeuro-Oncol 2006, 80: 27 – 35.doi:10.1186/1756-0500-7-423 Citethisarticleas: Starkweather etal. : Depressivesymptomsand cytokinelevelsinSerumandTumorTissueinpatientswithan Astrocytoma:apilotstudy. BMCResearchNotes 2014 7 :423. Submit your next manuscript to BioMed Central and take full advantage of: € Convenient online submission € Thorough peer review € No space constraints or color “gure charges € Immediate publication on acceptance € Inclusion in PubMed, CAS, Scopus and Google Scholar € Research which is freely available for redistribution Submit your manuscript at www.biomedcentral.com/submit Starkweather etal.BMCResearchNotes 2014, 7 :423 Page7of7 http://www.biomedcentral.com/1756-0500/7/423