Heart failure remains a leading cause of morbidity and mortality worldwide, with limited progress in the development of novel therapies. It has been demonstrated that tumor growth improves cardiac function and reduces myocardial fibrosis in mouse models of heart failure. It is clear that cancer cell implantation is not a possible therapeutic strategy for heart failure. Therefore, we further studied the underlying mechanism involved, with the objective of demonstrating its broad therapeutic applicability. We show that a single intravenous injection of serum from tumor-bearing mice rapidly augments left-ventricular fractional shortening and suppresses fibrosis in the heart, diaphragm, and skeletal muscles. Cytokine profiling identified IFNγ and TNFα as essential mediators secreted downstream of natural killer (NK) cell activation. Purified recombinant IFNγ and TNFα mimic the serum effect, polarizing cardiac and skeletal macrophages toward an anti-inflammatory, reparative state. We further show that macrophage depletion abrogates the observed beneficial effect, confirming their critical role. Our findings define a novel NK cell–macrophage cytokine axis that reverses cardiac dysfunction and fibrosis in pressure-overload (transverse aortic constriction) and ATF3-transgenic heart failure models. Together, these findings define a novel host-tumor microenvironment response through cytokine secretion, which leads to cardiac repair and dissolution of fibrosis. This work presents a novel therapeutic strategy for harnessing innate immune cells in the treatment of heart failure and fibrotic disease.

The dynamic relationship between heart failure and cancer poses a dual challenge. While cardiac remodeling can promote cancer growth and metastasis, tumor development can ameliorate cardiac dysfunction and suppress fibrosis. However, the precise mechanism through which cancer influences the heart and fibrosis is yet to be uncovered. To further explore the interaction between heart failure and cancer, we used the MDX mouse model, which suffers from cardiac fibrosis and cardiac dysfunction. A previous study from our lab demonstrated that tumor growth improves cardiac dysfunction and dampens fibrosis in the heart and diaphragm muscles of MDX mice. We used breast Polyoma middle T (PyMT) and Lewis lung carcinoma (LLC) cancer cell lines that developed into large tumors. To explore whether the aggressiveness of the cancer cell line is crucial for the beneficial phenotype, we employed a PyMT breast cancer cell line lacking integrin β1, representing a less aggressive cell line compared to the original PyMT cells. In addition, we examined immortalized and primary MEF cells. The injection of integrin β1 KO PyMT cancer cells and Mouse Embryo Fibroblasts cells (MEF) resulted in the improvement of cardiac function and decreased fibrosis in the heart, diaphragm, and skeletal muscles of MDX mice. Collectively, our data demonstrate that the cancer line aggressiveness as well as primary MEF cells are sufficient to impose the beneficial phenotype. These discoveries present potential novel clinical therapeutic approaches with beneficial outcome for patients with fibrotic diseases and cardiac dysfunction that do not require tumor growth.

Abstract Ovarian carcinosarcoma (OCS) is a rare and extremely lethal gynecological cancer, accounting for less than 1% of all ovarian cancers, and harboring an unfavorable prognosis compared to the common subtype. There are no efficient treatments available, highlighting the need for a reliable pre-clinical model as a tool to study this disease. Our goal was to generate a genetically engineered mouse model (GEMM) of OCS, carrying relevant genetic alterations, in order to study OCS pathogenesis. To generate the model, we used a Cre-Lox system for targeted knockout of three relevant tumor suppressor genes: Trp53, Brca2 and Pten. Mice in our model also carry a Lox-stop-Lox-TdTomato transgene, which results in fluorescent TdTomato protein expression in all recombined cells. Gene knockout in our model was achieved via injections of adenoviral particles coding for CRE recombinase into the ovarian bursa. Female mice in our model developed tumors arising from the ovary with an admixture of malignant epithelial and stromal elements, successfully mimicking human OCS. Tumors often metastasized to the abdominal cavity and at times generated ascites. The tumors showed patchy staining for PAX8, ER, Cytokeratin and Vimentin, further confirming their resemblance to human OCS. Mice harboring homozygous deletions of all three tumor suppressor genes developed tumors rapidly, first imaged 7 weeks after induction, and euthanized at a humane end point 11-14 weeks after CRE injection (average 11.4±0.95 weeks). This rapid timeline, together with high Ki-67 expression, suggest that tumor development in our model mimics the highly aggressive nature of the human disease. Interestingly, homozygous deletion of Trp53 and Pten and heterozygous deletion of Brca2 did not significantly alter time to tumor formation or tumor morphology, compared to the original model, suggesting that homozygous deletion of Brca2 is not essential or OCS development in our model. On the other hand, heterozygous deletion of either Trp53 or Pten, maintaining homozygous deletion of the other alleles, significantly delayed tumor formation and reduced tumor penetration, suggesting that Trp53 and Pten play a significant role in this model. Finally, harvesting mouse ovaries at very early time points, prior to tumor development, showed early pre-malignant lesions emerging from the ovarian surface epithelium, implicating ovarian surface epithelial cells as a potential OCS cell of origin of in our model. In conclusion, we have developed a reproducible model of OCS arising from the ovarian surface epithelium, correctly mimicking human disease in terms of clinical course, morphology, and tumor markers. This novel pre-clinical model, together with the mouse OCS cell lines we have generated from the model, will allow studies of disease pathogenesis, development of early detection and prevention tools, and studies of new OCS treatments. Citation Format: Einav Bangiev-Girsh, Amir Basis, Paul Zannou, Inna Naroditsky, Asaf Aizic, Ami Aronheim, Liron Berger, Ruth Perets. A novel genetically engineered mouse model of ovarian carcinosarcoma [abstract]. In: Proceedings of the AACR Special Conference on Ovarian Cancer; 2023 Oct 5-7; Boston, Massachusetts. Philadelphia (PA): AACR; Cancer Res 2024;84(5 Suppl_2):Abstract nr A067.

Cardiovascular diseases (CVD) and cancer are the top deadly diseases in the world. Both CVD and cancer have common risk factors; therefore, with the advances in treatment and life span, both diseases may occur simultaneously in patients. It is becoming evident that CVD and cancer are highly connected, establishing a novel discipline known as cardio-oncology. This includes the cardiomyocyte death following any anti-tumor therapy known as cardiotoxicity as well the intricate interplay between heart failure and cancer. Recent studies, using various mouse models, showed that heart failure promotes tumor growth and metastasis spread. Indeed, patients with heart failure were found to be at higher risk of developing malignant diseases. While the effect of heart failure on cancer is well established, little is known regarding the effect of tumors on heart failure. A recent study from our lab has demonstrated that tumor growth and metastasis ameliorate cardiac remodeling in a pressure-overload mouse model. Nevertheless, this study was inconclusive regarding whether tumor growth solely suppresses cardiac remodeling or is able to reverse existing heart failure outcomes as well. Here, we used a regulable transgenic mouse model for cardiac hypertrophy and fibrosis. Cancer cell implantation suppressed cardiac dysfunction and fibrosis as shown using echocardiography, qRT-PCR and fibrosis staining. In addition, tumor growth resulted in an M1 to M2 macrophage switch, which is correlated with cardiac repair. Macrophage depletion using clodronate liposomes completely abrogated the tumors' beneficial effect. This study highly suggests that harnessing tumor paradigms may lead to the development of novel therapeutic strategies for CVDs and fibrosis.

Heart failure and cancer are the deadliest diseases worldwide. Murine models for cardiac remodeling and heart failure demonstrate that cardiac dysfunction promotes cancer progression and metastasis spread. Yet, no information is available on whether and how tumor progression affects cardiac remodeling. Here, we examined cardiac remodeling following transverse aortic constriction (TAC) in the presence or absence of proliferating cancer cells. We show that tumor-bearing mice, of two different cancer cell lines, display reduced cardiac hypertrophy, lower fibrosis and improved cardiac contractile function following pressure overload induced by TAC surgery. Integrative analysis of qRT-PCR, flow cytometry and immunofluorescence identified tumor-dependent M1-to-M2 polarization in the cardiac macrophage population as a mediator of the beneficial tumor effect on the heart. Importantly, tumor-bearing mice lacking functional macrophages fail to improve cardiac function and display sustained fibrosis.

Heart failure and cancer are currently the deadliest diseases in the Western world, posing the most pressing clinical challenges that remain unmet today. Both conditions share similar risk factors, including age, genetics, lifestyle, chronic inflammation, stress, and more. Furthermore, medications that are being used to counteract cancer frequently result in cardiotoxicity and the spontaneous emergence of heart failure. Thus, heart failure and cancer display an intimate connection and share similarities. Recent studies show that cardiac remodeling and heart failure promote cancer progression and metastasis. Using three different mouse models for heart failure revealed that the communication between the remodeled heart and the tumor is facilitated through multiple secreted factors. Among these factors, Periostin was consistently found to be elevated in all models and was shown to be required in vitro. Yet, whether Periostin is necessary for tumor promotion in vivo is unknown. Towards this end, we examined tumor promotion in mice lacking Periostin following transverse aortic constriction (TAC). Despite the loss of Periostin, tumor growth was promoted in the TAC-operated mice. This likely occurred due to increased levels of various cytokines and growth factors in Periostin KO mice. Many of these factors are potential ligands of Integrin receptors. Therefore, we next studied the role of Integrin receptors in the tumor-promotion phenotype following heart failure. We generated cancer cells with an Integrin β1 loss of function mutation and examined tumor growth in the presence and absence of heart failure. Integrin β1 KO cancer cells fail to display cardiac-remodeling-dependent tumor-promotion. Interestingly, a previous study showed that renal cell carcinoma cells (Renca) fail to be promoted following a myocardial infarction. Consistently, we show that Renca cells do not respond to secreted factors derived from the failing heart both in vitro and in vivo. Interestingly, Renca cells display low basal mRNA levels of Integrin β1 which may explain the inability of heart failure to promote their growth. The findings may have significant clinical relevance to cardio–oncology patients who suffer from cancers with high levels of Integrin β1. Chemotherapy leading to cardiotoxicity in these patients may generate a vicious cycle with poor prognosis.

The interplay between heart failure and cancer represents a double-edged sword. Whereas cardiac remodeling promotes cancer progression, tumor growth suppresses cardiac hypertrophy and reduces fibrosis deposition. Whether these two opposing interactions are connected awaits to be determined. In addition, it is not known whether cancer affects solely the heart, or if other organs are affected as well. To explore the dual interaction between heart failure and cancer, we studied the human genetic disease Duchenne Muscular Dystrophy (DMD) using the MDX mouse model. We analyzed fibrosis and cardiac function as well as molecular parameters by multiple methods in the heart, diaphragm, lungs, skeletal muscles, and tumors derived from MDX and control mice. Surprisingly, cardiac dysfunction in MDX mice failed to promote murine cancer cell growth. In contrast, tumor-bearing MDX mice displayed reduced fibrosis in the heart and skeletal and diaphragm muscles, resulting in improved cardiac function. The latter is at least partially mediated via M2 macrophage recruitment to the heart and diaphragm muscles. Collectively, our data support the notion that the effect of heart failure on tumor promotion is independent of the improved cardiac function in tumor-bearing mice. Reduced fibrosis in tumor-bearing MDX mice stems from the suppression of new fibrosis synthesis and the removal of existing fibrosis. These findings offer potential therapeutic strategies for DMD patients, fibrotic diseases, and cardiac dysfunction.

Abstract Heart failure and cancer are known to share common risk factors. Nevertheless, until recently, these two were considered separate diseases. Nevertheless, it appears that heart failure and cancer are more connected than initially anticipated. The interplay between heart failure and cancer represents a double-edged sword. While Cardiac remodeling promotes cancer progression, tumor growth suppresses cardiac hypertrophy and reduces fibrosis deposition. Whether these two opposing interactions are connected is currently unknown. In addition, the experimental setup used was unable to distinguish whether tumor growth suppresses de novo fibrosis synthesis or is capable of dissolving existing fibrosis as well. Here we studied a clinically relevant human disease, Duchenne Muscular Dystrophy (DMD), using MDX mouse as a model for a fibrotic disease in multiple organs. Duchenne patients suffer from fibrosis of the skeletal, cardiac, and diaphragm muscles leading to cardiomyopathy, and respiratory failure with no cure. To study the mutual interaction between heart failure and cancer, we implanted murine cancer cells in MDX mice and monitored tumor growth, cardiac function, and fibrosis. Surprisingly, cardiac dysfunction failed to promote cancer progression in MDX mice. In contrast, MDX tumor-bearing mice displayed reduced fibrosis in the lungs, heart and diaphragm muscles resulting in an improvement of cardiac contractile function. The latter is at least partially mediated via macrophage polarization towards M2 in the heart and diaphragm muscles. Collectively, our data support the notion that tumor promotion due to heart failure is an independent of cardiac dysfunction amelioration by tumor growth. Additionally, these results suggest that the reduced overall fibrosis in tumor-bearing MDX mice represents suppression of de novo fibrosis deposition as well as dissolving existing fibrosis in the heart and diaphragm muscles. Harnessing tumor paradigms may provide novel therapeutic strategies for DMD patients, human fibrotic diseases, and cardiac dysfunction.

Supplementary Data from Cardiac Dysfunction Promotes Cancer Progression via Multiple Secreted Factors

Heart failure and cancer are the leading cause of deaths worldwide. The diseases share common risk factors, survival pathways and death signals. Recent studies suggest that these diseases are highly connected and affect each other outcome. Murine models for cardiac remodeling and heart failure including: myocardial infraction, pressure overload, cardiac hypertrophy, and chronic hypertension promotes cancer progression and metastasis spread. In addition, heart failure patients have increased risk to develop cancer. Nevertheless, no information is available whether and how tumor progression affects cardiac remodeling. Here we examined cardiac remodeling processes in the presence and absence of tumor. We show that tumor-bearing mice display reduced cardiac hypertrophy, lower fibrosis, and improved cardiac contractile function. While the adaptive immune system is not involved, we found that innate immune cells play a major role. We identified that the cardiac macrophage population undergoes tumor dependent M1 to M2 polarization. Importantly, tumor-bearing mice lacking functional macrophages fail to improve cardiac function and display sustained fibrosis. This is the first study showing the double-edged sword interaction between cancer and heart failure. While heart failure promotes tumor growth, cancer improves cardiac outcome. Harnessing cancer paradigms that are involved in the tumor to heart beneficial outcome may provide novel therapeutics strategies for cardiovascular diseases.

AbstractHeart failure and cancer are the leading cause of deaths worldwide. While heart failure and cancer have been considered separate diseases, it is becoming evident that they are highly connected and affect each other's outcomes. Recent studies using experimental mouse models have suggested that heart failure promotes tumor progression. The mouse models used involve major irreversible surgery. Here, we induced heart hypertrophy via expression of activating transcription factor 3 (ATF3) in cardiomyocytes, followed by cancer cells’ implantation. Tumors developing in ATF3-transgenic mice grew larger and displayed a more highly metastatic phenotype compared with tumors in wild-type mice. To address whether ATF3 expression or the cardiac outcome are necessary for tumor progression, ATF3 expression was turned off after cardiac hypertrophy development followed by cancer cell implantation. The tumor promotion phenotype and the enhancement of metastatic properties were preserved, suggesting that the failing heart per se is sufficient to promote tumor progression. Serum derived from ATF3-transgenic mice enhanced cancer cell proliferation and increased cancer cell metastatic properties in vitro. Using a cytokine array panel, multiple factors responsible for promoting tumor cell proliferation and the metastatic phenotype were identified. Interestingly, the failing heart and the tumor separately and simultaneously contributed to higher levels of these factors in the serum as well as other tissues and organs. These data suggest the existence of intimate cross-talk between the hypertrophied heart and the tumor that is mediated by secreted factors, leading to cancer promotion and disease deterioration.Significance:This work highlights the importance of early diagnosis and treatment of heart failure prior to reaching the irreversible stage that can exacerbate cancer progression.

Cardiovascular diseases and cancer are the leading cause of death worldwide. The two diseases share high co-prevalence and affect each other's outcomes. Recent studies suggest that heart failure promotes cancer progression, although the question of whether cardiac remodeling in the absence of cardiac contractile dysfunction promotes cancer progression remains unanswered. Here, we aimed to examine whether mild cardiac remodeling can promote tumor growth. We used low-phenylephrine (PE)-dose-infused in mice, together with breast cancer cells (polyoma middle T, PyMT), implanted in the mammary fat pad. Although cardiac remodeling, hypertrophy and fibrosis gene hallmarks were identified, echocardiography indicated no apparent loss of cardiac function. Nevertheless, in PE-infused mouse models, PyMT-cell-derived tumors grew larger and displayed increased cell proliferation. Consistently, serum derived from PE-infused mice resulted in increased cancer cell proliferation in vitro. ELISA and gene expression analysis identified periostin, fibronectin and CTGF as cardiac- and tumor-secreted factors that are highly abundant in PE-infused mice serum as compared with non-infused mice. Collectively, a low dose of PE infusion without the deterioration of cardiac function is sufficient to promote cancer progression. Hence, early detection and treatment of hypertension in healthy and cancer patients would be beneficial for improved outcomes.

BACKGROUND:Activating transcription 3 (ATF3) is a member of the basic leucine zipper family of transcription factors. ATF3 is an immediate early gene expressed following various cellular stresses. ATF3 acts through binding to cyclic AMP response elements found in the promoters of key regulatory proteins that determine cell fate. In the heart, multiple cardiac stresses result in chronic ATF3 expression. Transgenic mice with ATF3 expression in cardiomyocytes clearly demonstrate that ATF3 serves a leading role in heart hypertrophy, cardiac fibrosis, cardiac dysfunction and death. In contrast, the use of ATF3 whole body knockout mice resulted non-conclusive results. The heart is composed of various cell types such as cardiomyocytes, fibroblasts, endothelial and immune cells. The question that we addressed in this study is whether ablation of ATF3 in unique cell types in the heart results in diverse cardiac phenotypes.METHODS:ATF3-flox mice were crossed with αMHC and Postn specific promoters directing CRE expression and thus ATF3 ablation in cardiomyocytes and myofibroblast cells. Mice were challenged with transverse aortic constriction (TAC) for eight weeks and heart function, ventricle weight, hypertrophic markers, fibrosis markers and ATF3 expression were assessed by qRT-PCR.RESULTS:The results of the study show that ATF3 deletion in cardiomyocytes followed by TAC resulted in reduced heart growth and dampened fibrosis response while ATF3 ablation in myofibroblasts displayed a reduced hypertrophic gene program.CONCLUSIONS:TAC-operation results in increased ATF3 expression in both myofibroblasts and cardiomyocytes that promotes a hypertrophic program and fibrotic cardiac growth, respectively.

BACKGROUND The coronavirus disease-2019 (COVID-19) pandemic forced drastic changes in all layers of life. Social distancing and lockdown drove the educational system to uncharted territories at an accelerated pace, leaving educators little time to adjust. OBJECTIVES To describe changes in teaching during the first phase of the COVID-19 pandemic. METHODS We described the steps implemented at the Technion-Israel Institute of Technology Faculty of Medicine during the initial 4 months of the COVID-19 pandemic to preserve teaching and the academic ecosystem. RESULTS Several established methodologies, such as the flipped classroom and active learning, demonstrated effectiveness. In addition, we used creative methods to teach clinical medicine during the ban on bedside teaching and modified community engagement activities to meet COVID-19 induced community needs. CONCLUSIONS The challenges and the lessons learned from teaching during the COVID-19 pandemic prompted us to adjust our teaching methods and curriculum using multiple online teaching methods and promoting self-learning. It also provided invaluable insights on our pedagogy and the teaching of medicine in the future with emphasis on students and faculty being part of the changes and adjustments in curriculum and teaching methods. However, personal interactions are essential to medical school education, as are laboratories, group simulations, and bedside teaching.

Abstract Cardiac hypertrophy and cancer are the leading cause of deaths worldwide. While heart failure and cancer have been considered separate diseases, it is becoming evident that they are highly connected and affect each other's outcome. Recent studies using mouse models mimicking myocardial infraction and aortic stenosis were shown to promote cancer progression. These two mouse models involve major irreversible surgeries. Here, we employed a transgenic mouse model for heart hypertrophy and examined the crosstalk between the hypertrophied heart and cancer progression. Heart hypertrophy was induced by adult ATF3 expression in cardiomyocytes followed by either PyMT, breast cancer cells or Lewis lung carcinoma (LLC) cells implantation. PyMT and LLC tumors grow larger in size and display increased cell proliferation in ATF3-transgenic mice as compared with control mice. In addition, pulmonary experimental metastasis assay revealed augmented number and size of metastasis lesions in the lungs. Subsequently, we identified five putative cardiac secreted factors that are highly expressed in the hearts derived from ATF3-transgenic that may be involved in tumor progression. These include Fibronectin, CP, serpin3, CTgF and PSTN. Next, we addressed whether the cause or the effect are necessary to promote tumor growth. Towards this end, ATF3 expression was turned-off after cardiac hypertrophy development followed by cancer cell implantation. The tumor promotion phenotype as well as enhancement of metastatic seeding in these mice was fully preserved, suggesting the generation of an irreversible viscous cycle that lead to cancer progression. Significantly, the expression of Fibronectin and CTgF was dampened in the presence of doxycycline, thus exclude their putative role in mediating the tumor promotion and metastatic seeding phenotypes. Collectively, heart hypertrophy and cancer diseases communicate via secreted factors that result in cancer promotion and disease deterioration. Funding Acknowledgement Type of funding sources: Public grant(s) – National budget only. Main funding source(s): Israel Science Foundation

Activity of heparanase, endoglycosidase that cleaves heparan sulfate side chains in heparan sulfate proteoglycans, is highly implicated in tumor progression and metastasis. Heparanase inhibitors are therefore being evaluated clinically as anti-cancer therapeutics. Heparanase 2 (Hpa2) is a close homolog of heparanase that lacks HS-degrading activity and functions as an endogenous inhibitor of heparanase. As a result, Hpa2 appears to attenuate tumor growth but mechanisms that regulate Hpa2 expression and determine the ratio between heparanase and Hpa2 are largely unknown. We have recently reported that the expression of Hpa2 is induced by endoplasmic reticulum (ER) and proteotoxic stresses, but the mechanism(s) underlying Hpa2 gene regulation was obscure. Here we expand the notion that Hpa2 is regulated by conditions of stress. We report that while ER and hypoxia, each alone, resulted in a 3-7 fold increase in Hpa2 expression, combining ER stress and hypoxia resulted in a noticeable, over 40-fold increase in Hpa2 expression. A prominent induction of Hpa2 expression was also quantified in cells exposed to heat shock, proteotoxic stress, lysosomal stress, and chemotherapy (cisplatin), strongly implying that Hpa2 is regulated by conditions of stress. Furthermore, analyses of the Hpa2 gene promoter led to the identification of activating-transcription-factor 3 (ATF3) as a transcription factor that mediates Hpa2 induction by stress, thus revealing, for the first time, a molecular mechanism that underlies Hpa2 gene regulation. Induction of Hpa2 and ATF3 by conditions of stress that often accompany the rapid expansion of tumors is likely translated to improved survival of cancer patients.

Abstract Background We have previously reported an increased risk for non-hematological malignancies in young patients with moderate or severe aortic stenosis (AS). These findings were the result of a post-hoc analysis from a large echocardiography database and needed verification. Our aim was to determine, using a different study population, whether young patients with AS are at increased risk for cancer. Methods A large echocardiographic database was used to identify patients (age ≥ 20 years) with moderate or severe AS (study group) and patients without aortic stenosis (comparative group). The new occurrence of non-hematological malignancies was determined after the index date (first echo with moderate or severe AS or first recorded echo in the control group). Results The final study group included 7013 patients with AS and 98,884 without AS. During a median follow-up of 6.9 years (3.0–11.1) there were 10,705 new cases of non-hematological cancer. The crude incidence rate of cancer was higher in AS compared to non-AS patients (22.3 vs. 13.7 per 1000 patient-year, crude HR 1.58 (95%CI 1.46–1.71). After adjustment for relevant covariates, there was no difference between groups (HR 0.93, 95% CI 0.86–1.01). Only patients in the lowest age quartile (20–49.7 years), had an increased adjusted risk of cancer (HR 1.91, 95%CI 1.08–3.39). The HR for the risk of cancer associated with AS was inversely proportional to age (P < 0.001 for the interaction between AS and age). Conclusions Young patients with moderate or severe AS may have an increased risk for cancer. Cancer surveillance should be considered for young patients with AS.