ANTICANCER RESEARCH 37 : 4371-4378 (2017) doi:10.21873/anticanres.11831

Comparison of Different Muscle-Relaxant Anesthetics on Growth, Migration and Invasion of Gastric Cancer Cells AIHUA JIANG 1* , HUISHAN ZHAO 1* , XIAOFEI LIU 1, MINGWEI YU 1, JIAN CHEN 1 and WEN G. JIANG 2

1Affiliated Yantai Yuhuangding Hospital of Qingdao University, Yantai, P.R. China; 2Cardiff-China Medical Research Collaborative, Cardiff University School of Medicine, Cardiff, U.K.

Abstract. Background/Aim: Muscle relaxants, also known treatment for GC includes radiotherapy, routine surgery, as neuromuscular blocking agents, can block nerve hormone therapy and biotherapy. However, when tumors impulses to the muscles and are always used in surgery for progress there is a risk that not all of the tumor tissue is general anesthesia. However, the effect of muscle-relaxant surgically removed (3, 4). Anesthetics are administered to anesthetics on cell activity in gastric cancer is currently facilitate surgery. Some factors including anesthetic unknown. The present study aimed to examine and techniques and anesthetic drugs may affect the activity of compare the role of three different muscle-relaxant residual tumor cells after surgery and facilitate cancer anesthetics in gastric cancer cells. Materials and Methods: recurrence and/or metastasis (5). Gastric cancer cells (SGC7901 and BGC 823) were Tumor metastasis is the spread of cells from the primary treated with a different dose of muscle-relaxant tumor to new locations in the body, through the circulatory anesthetics, Rocuronium bromide (Rb), Vecuronium and lymphatic system, and is considered the main cause of bromide (Vb) and Cisatracurium Besilate (CB). Using in cancer-related death. Metastatic tumor cells show different vitro models, the effects on gastric cancer cell invasion, genomic and epigenetic profiles generally associated with growth and migration of various anesthetics were aggressive traits. The analgesia technique and the anesthetic subsequently investigated. Results: We found that Rb agents used during surgical tumor resection have been increased the growth, invasion and migration of gastric determined as pathogenic factors for cancer recurrence/ cancer cells SGC7901 and BGC823. However, Vb and CB, metastasis. Thus, anesthesiologists take enormous as relatively mitigative anesthetics, did not significantly responsibility in decreasing metastasis/recurrence rate of affect gastric cancer cell malignant phenotype at their cancer, both during the perioperative period and postoperative regular blood concentration. Conclusion: Our results are analgesia period. There is evidence to suggest that anesthetics important in selecting the type and dose of anesthetic used may potentially have a role in tumor metastasis (6-8). A better for surgery of gastric cancer patients. An understanding of understanding of the mechanisms of metastatic disease and the effect of muscle-relaxant anesthetics and their impact identification of regulators of metastasis, including how on tumor metastasis is critical, since it provides insight metastatic tumor cells invade and grow in the local into the appropriate anesthetic strategy that could improve microenvironment, would enable the treatment and long-term survival in some patients with gastric cancer. development of metastatic prevention strategies. Gastric cancer (GC) is a highly lethal malignancy The effect of anesthetics on cancer metastasis has been worldwide, particular in developing countries, which makes unveiled gradually. Some anesthetics were considered an it a key public health problem (1, 2). The conventional important factor in cancer metastasis. Recently, a review summarized the effect of anesthesia on tumor metastasis, including anesthetic and analgesic techniques (5), suggesting that anesthetics are a non-negligible issue in *These Authors contributed equally to this study. clinical practice. Propofol was investigated in several kinds of cancers and in gastric cancer has been shown to have an Correspondence to: Prof. Wen G. Jiang, Cardiff-China Medical inhibitory role in the growth and survival of gastric cancer Research Collaborative, Cardiff University School of Medicine, cells through up-regulating ING3 (9). In another study Heath Park, Cardiff CF14 4XN, U.K. Tel: +44 2920687065, e-mail: [email protected] propofol inhibited proliferation and apoptosis by regulating microRNA-451 and MMP-2 expression (10). Propofol has Key Words: Anesthetics, migration, breast cancer, invasion, Rb, Vb, also been shown to have an effect on the metastasis of CB. other cancer cells such as ovarian (11), lung (12) and

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Figure 1 . Chemical structures of Rb (A), Vb (B) and CB (C).

prostate cancer (13). Increasing numbers of reports on clinical dosages used by the anesthesiologist for which Rb, Vb and procaine have suggested that low dosage of procaine CB were 0.6 mg/kg, 0.1 mg/kg and 0.2 mg/kg respectively. Dilution suppressed the proliferation of lung cancer cells, however ranges were as follows: Rb - 8/80 μg/ml, Vb - .5/15 μg/ml and CB - 2.5/25 μg/ml. this did not appear with higher doses (14). Procaine has also been seen to affect osteosarcoma cells, by inhibiting In vitro cell growth assays. For each cell line 3,000 cells/200 μl/well their migration and growth possibly through inducing cell were added to a 96-well plate (BEAVER, Suzhou, China) and apoptosis (15). Muscle relaxants, including Rocuronium incubated for 1 to 5 days (1, 3, 4 and 5 days respectively). After bromide (Rb), Vecuronium bromide (Vb) and Cisatracurium incubation, culture medium was removed and replaced with 100 μl Besilate (CB), act as effective anesthetics by blocking the of 10% CCK-8 (Cell Counting Kit-8, Dojindo, Japan). Absorbance nerve impulses to the muscles, and thus are generally used of the solution was determined using a spectrophotometer (Thermo in surgery for general anesthesia. Currently there is little Fisher Scientific) at a wavelength of 450 nm. research on the effect of muscle relaxants on tumor In vitro cell scratch assay. Cells were seeded into 12-well plates and metastasis. Last year, our team concentrated on muscle cultured overnight to allow the formation of a confluent monolayer. relaxants’ impact on breast cancer metastasis. Interestingly, Subsequently an artificial wound in the monolayer was created by we found that Rb promoted breast cancer cell growth, using a 200- μl pipette tip to scratch a wound. The cell monolayer migration and invasion, but Vb did not (16). In this study, was washed twice with PBS to remove floating cells. Migration of we investigated how muscle relaxants affect the activity of cells, monitored by the closing of the artificial wound space was gastric cancer cells. recorded every 6 h using an inverted microscope over a period up to 24 h. The sizes of the wounds were subsequently analyzed using Image J software. Materials and Methods In vitro cell adhesion assay. Six-well plates were pre-coated with 5 Cell culture. Gastric cancer cells SGC7901 and BGC 823 were μg/100 μl/well Matrigel (BD Matrigel™ Basement Membrane obtained from China Centre for Type Culture Collection (Shanghai, Matrix, Corning, Tewksbury MA, USA) diluted in serum free media China). These two wild-type cancer cells were routinely cultured in and dried to form an artificial basement membrane. Following RPMI-1640 (Life Technologies Corporation, USA) supplemented rehydration with serum-free media for 40 min, 20,000 cells/200 μl with 10% foetal calf serum (FCS; PAA Laboratories, Somerset, were added into each well. After 4 min incubation culture medium UK), penicillin and streptomycin (Sigma-Aldrich Inc, Poole, Dorset, was removed and the wells were washed with PBS to remove any UK)), in an incubator at 37.0˚C, 5% CO 2 and 95% humidity. non-adherent cells. Adherent cells were fixed with 4% formalin for Muscle relaxants for anesthesia. Three kinds of muscle relaxant 30 min. After washing each well twice with PBS, adherent cells were anesthetics, Rb, Vb and CB, were purchased from Sigma (Sigma- stained with 0.5% crystal violet. Crystal violet staining was dissolved Aldrich, Dorset, UK). They were all dissolved in PBS and stored at with 10% acetic acid and measured using a spectrophotometer 4˚C until use. The doses used during experiments were based on the (Thermo Fisher Scientific) at a wavelength of 540 nm.

4372 Jiang et al : Muscle-relaxant Anesthetics and Gastric Cancer

Figure 2. Effects of Rb, Vb and CB on growth of gastric cancer cells in vitro. Rb increased the proliferation of SGC7901 (A) and BGC823(B) in vitro. Vb had no significant effect on the growth of SGC7901 (C) and BGC823 (D) cells. CB hardly stimulated the growth of SGC7901 (E) and BGC823(F) in vitro, but overdose could result in partial cell death (*p<0.05, **p<0.01 vs. control with no treatment).

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Figure 3. The effect of Rb, Vb and CB on migration of gastric cancer cells in vitro. A: Rb promoted the migration of SGC7901 (A) and BGC823 (B). Vb had no effect on the migration of SGC7901(C) and BGC823 (D) at the regular blood concentration in vitro, but facilitated the migration at tenfold blood concentration. CB hardly affected SGC7901 (E) and BGC823 (F) migration in vitro.

4374 Jiang et al : Muscle-relaxant Anesthetics and Gastric Cancer

Figure 4. The effect of Rb, Vb and CB on adhesion of gastric cancer cells. Rb increased the adhesion of SGC7901 (A) at tenfold blood concentration in vitro. Rb and Vb affected the adhesion of BGC823 (B) and reached statistical significance. Representative data of adhesion assay for SGC7901 and BGC823 cells treated with different concentration of muscle-relaxant anesthetics for 40 min (C).

In vitro cell invasion assay. Transwell chambers (8- μm pore size) Rb promoted gastric cancer cell growth. When compared to polycarbonate filter inserts (6.5 mm diameter) (Becton Dickinson and the untreated control group Rb resulted in a significant increase Company, Oxford, UK), were coated with 50 μg Matrigel/100 μl/insert in gastric cancer cell growth, in SGC7901 ( p< 0.05) (Figure (BD Matrigel™ Basement Membrane Matrix) and air-dried. Following p< rehydration, 20,000 cells/200 μl were seeded into inserts with 5% 2A) and BGC823 cells 0.05) (Figure 2B), when treated with foetal calf serum and 1 ml with 10% foetal calf serum medium in regular blood concentration and a tenfold blood concentration, bottom well. After 48 h, the cells that invaded through the Matrigel though a concentration dependent effect was not observed. were fixed, stained, and quantified as described previously (17). When SGC7901(Figure 2C) and BGC823 cells (Figure 2D) were cultured with Vb (1.5 μg/ml and 15 μg/ml), high Statistical analysis. Statistical analysis was performed using Minitab concentration Vb marginally promoted cell proliferation, whilst statistical software package (version 14) and Graphpad. Differences low concentration had no effect. CB did not result in a were considered to be statistically significant at p< 0.05. significant change on the growth of gastric cancer cells, but the Results tenfold concentration did (Figure 2E and 2F).

Chemical structures of muscle relaxant anesthetics Differing effects of Rb, Vb and CB on the migration of Rocuronium bromide (Rb), Vecuronium bromide (Vb) and gastric cancer cells in vitro. The scratch wounding assay Cisatracurium Besilate (CB). Clinically, Rb (C 32 H53 BrN 2O4), showed that Rb facilitated the movement of SGC7901 Vb (C 34 H57 BrN 204) and CB (C 65 H82 N2O18 S2) are widely (Figure 3A) and BGC823 (Figure 3B) cells compared to the used to induce and maintain anesthesia in patients undergoing untreated control both at 8 μg/ml and 80 μg/ml and reached gastric cancer resection surgery. The chemical structures of Rb statistical significance ( p< 0.05). This increase in SGC7901 (Figure 1A), Vb (Figure 1B) and CB (Figure 1C) are shown gastric cancer cell migration was also oberved when treated in Figure 1. with Vb (Figure 3C), however this did not reach statistical

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Figure 5. The effect of Rb, Vb and CB on invasion of gastric cancer cells in vitro. Rb and tenfold blood concentration Vb induced the invasion of SGC7901 (A) and BGC823 (B) in vitro. Representative data of transwell assay for SGC7901 and BGC823 cells treated with different concentrations of muscle-relaxant anesthetics for 48 h (C).

significance. This trend was not observed in BGC823 gastric Figure 5C displays the representative figures and data of the cancer cells (Figure 3D). High CB concentration could also invasion assays for SGC7901 and BGC823 cells treated with increase cell migration. different concentrations of muscle-relaxant anesthetics for 48h.

Rb and Vb inceased the adhesion of gastric cancer cells . Both Discussion in SGC7901 (Figure 4A) and BGC823 cell lines (Figure 4B), Rb and Vb promoted cell adhesion in a concentration- Anesthetics are unavoidable for patients with gastric cancer dependent manner. CB had no significant effect on the who receive surgical treatment. Gastric cancer patients often adhesive properties of gastric cancer cells. Representative data show high sensitivity to some anesthetics; however, the from the adhesion assay in SGC7901 and BGC823 cells mechanism by which these anaethetics affect tumor treated with different concentration muscle-relaxant metastasis remains poorly understood. Muscle-relaxant anesthetics for 40 min are shown in Figure 4C. anesthetics are widely used in the induction and maintenance of anesthesia as adjunctive drugs for patients undergoing Comparison between Rb, Vb and CB with the control group gastric cancer surgery. In the present study, we focused on (no treatment) on the invasion in vitro. In order to explore the the effect of Rb, Vb and CB on gastric cancer cell function effect of Rb, Vb and CB on gastric cancer cell invasion, we in vitro . We attempted to discover the most appropriate used an established in vitro technique. Rb significantly anesthetics that exert the least pro-metastatic effects on increased the invasive potential of SGC7901 and BGC823 cells gastric cancer cells. but CB did not (Figure 5A and B). Invasion did not change Recently, accumulating clinical evidence suggested that upon treatment with Vb at a regular blood concentration, both anesthetics and the technology of anesthesia influenced however a tenfold blood concentration facilitated cell invasion. the efficacy of patients undergoing surgery for various

4376 Jiang et al : Muscle-relaxant Anesthetics and Gastric Cancer cancers (18-20). The impact of multiple anesthetics on tumor Acknowledgements metastasis was gradually brought to light. For example, propofol inhibited the migratory ability of cervical carcinoma The Authors would like to thank Cancer Research Wales for supporting this study. They also thank Dr Jane Lane and Dr Sioned cells by altering cellular morphology (21). A report regarding Owen for proof reading the manuscript. lidocaine indicated that lidocaine supressed the migration and invasion of TRPV6-expressing cancer cells through References downregulating TRPV6 (22). Anaesthetic techniques act as vital parts of surgery treatment, as it might affect the serum 1 Siegel R, Ma J, Zou Z and Jemal A: Cancer statistics, 2014. CA environment in a way which subsequently influences cancer Cancer J Clin 64 : 9-29, 2014. cell biology, and therefore tumor metastasis (23). 2 Ferlay J, Soerjomataram I, Dikshit R, Eser S, Mathers C, Rebelo M, Parkin DM, Forman D and Bray F: Cancer incidence and Research into Rb and Vb mainly refers to its effects on mortality worldwide: sources, methods and major patterns in neurones (24-26), but wider effects have not been GLOBOCAN 2012. Int J Cancer 136 : E359-386, 2015. investigated in vitro . Thus, it is important to study the effect 3 Porter PL: Global trends in breast cancer incidence and of muscle-relaxant anesthetics, especially Rb, Vb or CB, on mortality. Salud publica de Mexico 51(Suppl 2) : s141-146, 2009. tumor metastasis both in vitro and in vivo . Interestingly, their 4 Gluck S and Mamounas T: Improving outcomes in early-stage impact on the partial malignant phenotype of breast cancer breast cancer. Oncology 24 : 1-15, 2010. cells has been previously reported (16). In continuation to 5 Vahabi S and Eatemadi A: Effects of anesthetic and analgesic our previous studies, we explored the effect of Rb, Vb and techniques on cancer metastasis. Biomed Pharmacother 87 : 1-7, 2017. CB on gastric cancer cell activity. We found that Rb 6 Tazawa K, Koutsogiannaki S, Chamberlain M and Yuki K: The increased the gastric cancer cell malignant phenotype effect of different anesthetics on tumor cytotoxicity by natural including growth, invasion and migration. Certainly, Rb has killer cells. Toxicol Lett 266 : 23-31, 2017. the advantage of operating quickly. In summary, Rb is not 7 Deng F, Ouyang M, Wang X, Yao X, Chen Y, Tao T, Sun X, Xu recommended to be used in patients with cancer, considering L, Tang J and Zhao L: Differential role of intravenous survival prognosis and recurrence. Vb and CB rarely affected anesthetics in colorectal cancer progression: implications for cell growth and activity at a regular blood concentration, yet clinical application. 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Therefore, Pharmacol Sci 20 : 4791-4795, 2016. through further study, we would investigate the effect of 15 Ying B, Huang H, Li H, Song M, Wu S and Ying H: Procaine anesthetics on cancer metastasis when treated with several inhibits proliferation and migration and promotes cell apoptosis in osteosarcoma cells by upregulation of microRNA-133b. anesthetics at the same time. Accumulated evidence over Oncol Res, 2017. doi: 10.3727/096504017X14878518291077. these years has provided an insight into the importance of [Epub ahead of print] the most proper anesthetics for different diseases in 16 Jiang A, Zhao H, Cai J and Jiang WG: Possible effect of muscle- attenuating tumor metastasis, thereby having a favorable relaxant anaesthetics on invasion, adhesion and migration of long-term outcome. breast cancer cells. Anticancer Res 36 : 1259-1265, 2016.

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