Morphine stimulates cancer progression and mast cell activation and impairs survival in transgenic mice with breast cancer J. Nguyen, K. Luk, D. Vang,

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Morphine stimulates cancer progression and mast cell activation and impairs survival in transgenic mice with breast cancer J. Nguyen, K. Luk, D. Vang, W. Soto, L. Vincent, S. Robiner, R. Saavedra, Y. Li, P. Gupta, K. Gupta British Journal of Anaesthesia Volume 113, Pages i4-i13 (July 2014) DOI: 10.1093/bja/aeu090 Copyright © 2014 The Author(s) Terms and Conditions

Fig 1 Influence of morphine on cancer outcomes in C3TAG mice. Tumour burden (weight and number per mouse) and survival of mice after treatments are shown. (a and b) Six-week-old mice were treated for 7 weeks. n=4 for PBS and 5 for MS. (c and d) Three-month-old mice were treated for 7 weeks with, either PBS, MS, NAL, or MS and NAL. n=6 per treatment. (e) Three-month-old mice with palpable mammary tumours were injected with either MS or PBS until they became moribund (considered end of survival). n=40 for PBS and 17 for morphine. The Kaplan–Meier curve for survival is shown. MS, morphine; NAL, naloxone; PBS, phosphate-buffered saline. British Journal of Anaesthesia 2014 113, i4-i13DOI: (10.1093/bja/aeu090) Copyright © 2014 The Author(s) Terms and Conditions

Fig 2 Higher MOR expression in growing tumours drives morphine-induced angiogenesis and lymphangiogenesis. (a) Cryosections of large and small tumours showing MOR-ir (green), vasculature (CD31-ir, red), and nuclei (DAPI, blue). Bottom row shows co-localization of MOR-ir with vasculature (yellow). Magnification ×1000; scale bar, 50 µm. (b). Three-month-old mice were treated with morphine or PBS for 7 weeks. Immunostaining of tumour sections co-stained for lymphatic vessel endothelium (LYVE-1, green), blood vessels (CD31, red), and cell nuclei (DAPI, blue) is shown. Magnification ×100; scale bar, 500 µm. Each image in (a) and (b) represents six different tumours. British Journal of Anaesthesia 2014 113, i4-i13DOI: (10.1093/bja/aeu090) Copyright © 2014 The Author(s) Terms and Conditions

Fig 3 Influence of morphine on mast cell activation in tumours of C3TAG mice. Three-month-old mice were treated with PBS or morphine for 7 weeks. (a) Toluidine blue-stained tumour sections showing intense degranulation in morphine-treated mouse tumour sections. Magnification ×900; scale bar, 200 µm. n=10 per image. (b) Number of mast cells enumerated using Toluidine blue staining is shown as mean (sem) from 10 different tumours. (c) Tumours sections were co-stained with mast cell markers FcεR1 (red) and c-Kit (blue), and CD31 (red, blood vessels). Intense mast cell degranulation is observed in the morphine group. Mast cells are closely associated with the vasculature (magenta) or are in close proximity to the vasculature. Magnification ×1200; scale bar, 20 µm. (d and e) Tryptase and β-hexosaminidase, markers of mast cell activation, were analysed in tumour lysates by ELISA. Each bar shows mean (sem) from 7 to 8 different tumours. British Journal of Anaesthesia 2014 113, i4-i13DOI: (10.1093/bja/aeu090) Copyright © 2014 The Author(s) Terms and Conditions

Fig 4 Morphine stimulates cytokine release in the tumours. Three-month-old mice were treated with PBS or morphine for 7 weeks. The concentrations of GM-CSF, RANTES, or IL-6 in tumour lysates were determined using ELISA assays. Each bar represents mean (sem) values from 5 to 8 different tumours. British Journal of Anaesthesia 2014 113, i4-i13DOI: (10.1093/bja/aeu090) Copyright © 2014 The Author(s) Terms and Conditions

Fig 5 Morphine stimulates SP release in the tumours. Three-month-old mice were treated with PBS or morphine for 7 weeks. (a) Tumour sections immunostained for CD31 (blood vessels, green), c-Kit (mast cells, red), and SP (blue) are shown. Lane 4 shows the co-localization of SP with mast cells on and near the vasculature (white). Each image in each row is from the same field of view. Magnification ×1000; scale bar, 25 µm. n=6 for each image. (b) SP concentration in whole tumour lysates determine by ELISA is shown as the mean (sem) from 7 different tumours. SP, substance P. British Journal of Anaesthesia 2014 113, i4-i13DOI: (10.1093/bja/aeu090) Copyright © 2014 The Author(s) Terms and Conditions

Fig 6 Model showing how morphine may stimulate a vicious cycle of SP release, pain, and inflammation. Morphine treatment stimulates mast cell activation in the tumours. Degranulating mast cells then release SP and tryptase, which may enhance peripheral/intra-tumoural nerve activation leading to pain. Activated nerve fibres may release more SP in turn, thus increasing neuro-inflammation and driving a vicious cycle of mast cell activation, inflammation, disease progression, and pain. British Journal of Anaesthesia 2014 113, i4-i13DOI: (10.1093/bja/aeu090) Copyright © 2014 The Author(s) Terms and Conditions