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Cancer Therapies
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Effect of Conjugated Linoleic Acid Supplementation on Inflammatory Factors and Matrix

Metalloproteinase Enzymes in Rectal Cancer Patients Undergoing Chemoradiotherapy
Mohammad Mohammadzadeh, Elnaz Faramarzi, Reza Mahdavi, Behnam Nasirimotlagh and Mohammad Asghari
Jafarabadi
Integr Cancer Ther 2013 12: 496 originally published online 30 April 2013
DOI: 10.1177/1534735413485417
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research-article2013

ICTXXX10.1177/1534735413485417Integrative Cancer TherapiesMohammad-zadeh et al

Article

Effect of Conjugated Linoleic Acid

Supplementation on Inflammatory
Factors and Matrix Metalloproteinase
Enzymes in Rectal Cancer Patients
Undergoing Chemoradiotherapy

Integrative Cancer Therapies

12(6) 496502
The Author(s) 2013
Reprints and permissions:
sagepub.com/journalsPermissions.nav
DOI: 10.1177/1534735413485417
ict.sagepub.com

Mohammad Mohammadzadeh, MD1, Elnaz Faramarzi, PhD candidate of

Nutrition1, Reza Mahdavi, PhD1, Behnam Nasirimotlagh, MD1 and
Mohammad Asghari Jafarabadi, PhD1

Abstract
Objectives. The aims of this study were to determine the effect of conjugated linoleic acid (CLA) supplementation on
inflammatory factors and matrix metalloproteinase (MMP) enzymes in rectal cancer patients undergoing chemoradiothetrapy.
Method and Material. In this randomized, double-blind, placebo-controlled pilot study, 34 volunteer patients with rectal
cancer undergoing chemoradiotherapy assigned into the CLA group (n = 16), receiving 3 g CLA/d, and placebo group (n =
18) receiving placebo capsules (sunflower oil) for 6 weeks. The supplementation began 1 week before starting RT (loading
period) and continued every day during treatment. Before and after intervention, serum tumor necrosis factor (TNF-),
interleukin 1 (IL-1), IL-6, MMP-2, MMP-9, and high-sensitivity C-reactive protein (hsCRP) were measured by enzymelinked immunosorbent assay (ELISA) kits and immunoturbidimetric method, respectively. Independent t tests and paired
t tests were used to compare parameters between and within groups, respectively. Results. In the CLA group, the mean
serum TNF-, IL-1, hsCRP, MMP-9, and MMP-2 levels reduced insignificantly. However, significant changes in TNF-
(P = 0.04), hsCRP (P = 0.03), and MMP-9 (P = 0.04) concentrations were observed in the CLA group when compared with
the placebo group. The mean serum IL-6 level remained unchanged in the CLA group but increased remarkably in the
placebo group. Conclusion. According to our results, CLA supplementation improved inflammatory factors, MMP-2, and
MMP-9 as biomarkers of angiogenesis and tumor invasion. It seems that CLA may provide new complementary treatment
by reducing tumor invasion and resistance to cancer treatment in patients with rectal cancer.
Keywords
rectal cancer, chemoradiotherapy, conjugated linoleic acid supplementation, inflammatory factors, matrix metalloproteinase
enzymes1

Introduction
Colorectal cancer is one of the most prevalent cancers in the
world, and it is the third most common cancer in both men
and women.1 Surgery and preoperative chemoradiotherapy
(CRT) or postoperative CRT are the main treatments for
rectal cancer.1 In most oncology departments, preoperative
chemoradiation is now the current standard of care for
locally advanced operable rectal cancer.2
It is now known that exposure to clinically relevant
doses of ionizing radiation stimulates various biological
responses at the cell and tissue levels through the early
activation of cytokine cascades.3 Increases in proinflammatory cytokines such as tumor necrosis factor (TNF),interleukin 1 (IL-1), IL-6, and IL-8 as a result of cancer

or cancer treatments may be responsible for the incidence

of symptoms such as pain, fatigue, distress, and so on.3
Moreover, many of these inflammatory downstream
responses to radiation are harmful to normal tissue, and
they gave a survival advantage to tumor cells.3 Therefore,
new adjuvant anti-inflammatory therapeutic approaches
may be a useful tool to downregulate inflammatory signaling pathways that include TNF-, IL-1, and Cox-2
1

Tabriz University of Medical Sciences, Tabriz, Iran

Corresponding Author:
Elnaz Faramarzi, Nutrition Research Center, Tabriz University of
Medical Sciences, Tabrzi 51677, Iran.
Email: elnazfaramarzi849@gmail.com

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497

Mohammad-zadeh et al
activities for the prevention of radiotherapy (RT) failure
and tumor recurrence and the enhancement of tumor radiosensitivity while reducing tumor vascularization and cell
invasion.4-6
Conjugated linoleic acids (CLAs), which represent a
heterogeneous group of positional and geometric isomers
of linoleic acid are found mainly in foods derived from
ruminant animals (such as dairy products and meats).7
CLA consists of a mixture of geometric and positional isomers (cis or trans double-bond positioning at ([7,9],
[8,10], [9,11], [10,12], or [11,13]). The most abundant isomer in dietary sources is cis-9,trans-11-CLA (more than
75%-90% of total CLA).7 The trans-10,cis-12 is the other
main isomer, which represents 1% to 10% of total CLA
from food sources.8 According to findings from animal
and human studies, CLA has beneficial effects on cancer,
inflammation, body composition, diabetes and cardiovascular disease.9 Nowadays, most research is focused on
CLA because of its anti-inflammatory and anticancer
properties. The findings of in vitro and in vivo studies
indicate that CLA has anti-inflammatory effects, for
example, reducing colonic inflammation10 and modulating
the production of cytokines and prostaglandins.11,12 In
humans, CLA has modest anti-inflammatory effects and
improves immune function.13 The results of another clinical trial showed that 6 g of CLA mixture per day in patients
with Crohns disease suppressed the production of proinflammatory cytokines.14 Furthermore, results from animal
studies showed that CLA supplementation inhibited colon
cancer incidence, progression, and metastasis.15-17 Also,
several in vitro studies have demonstrated that CLA supplementation inhibited metastasis and immigration of
human colon cancer cell line Colo32018 and SW480 cells17
by different mechanisms. Recently, Grdzka et al19
reported that C9,t11-CLA increased sensitivity of HT-29
cells to X radiation. Also, Cho et al20 found that t10,c12CLA isomer inhibited HT-29 cells growth via the induction of G1 cell cycle arrest. The results of another
study indicated that the t10,c12 isomer has more inhibitory effects than the c9,t11 isomer on colorectal cancer
proliferation.21
Anti-inflammatory properties of CLA have been investigated less in human studies, and to the best of our knowledge, there is no published article about the effect of mixed
CLA supplementation in cancer patients. Therefore, we
evaluated the effect of CLA supplementation on serum
inflammatory factors and matrix metalloproteinase (MMP)
enzymes as biomarkers of angiogenesis and tumor invasion,
and serum liver enzyme levels in rectal cancer patients
undergoing CRT.

Methods and Materials

This randomized, double-blind, placebo-controlled pilot
study was approved by the Ethics Committee of Tabriz

University of Medical Sciences and registered as an RCT

study (IRCT:201012041197N9). In all, 34 volunteer
patients with rectal cancer who were referred to the RT center of Imama Hospital in Tabriz were recruited. Written
informed consent was obtained from all patients.
Those included were ambulatory rectal cancer patients
in stage II or III (based on TNM [tumor-nodemetastasis]
staging), who were slated to receive standard preoperative
CRT treatment. RT treatment was administered in 25 fractions of 1.8-Gy (total dose, 45 Gy) concomitant chemotherapy with 5-fluorouracil and leucovorin (intravenous bolus
infusion for 5 consecutive days in weeks 1 and 5). Exclusion
criteria were history of any other cancer, RT and chemotherapy treatments, underweight (BMI < 18.5 kg/m2), vitamin and mineral supplementation within the past month,
diabetes, and liver, renal, or endocrine dysfunction.
Patients and those involved in doing the assessment and
chemical analyses were blinded to group assignments.
Patients were assigned to the CLA group (n = 16), receiving
four 1000-mg capsules (providing 3 g CLA) 3 times/d (1
capsule at breakfast and dinner and 2 capsules at lunch) or
the placebo group (n = 18) receiving 4 placebo capsules for
6 weeks. Placebo capsules were made up with sunflower oil
and were carefully matched in appearance with that of the
CLA capsules. The CLA capsules (Tonalin, Natural factor,
Canada) contained 2 active isomers 18:2 c9, t11 and 18:2
t10,c12 in a 50/50 ratio. The dose of 3 g/d of CLA was chosen on the basis of previous studies carried out in healthy
individuals or in those with other diseases.13,22 The supplementation began 1 week before starting RT (loading period)
and continued every day during RT.
Patients were monitored weekly for any side effects of
supplementation. Compliance was assessed by a capsule
count every 2 weeks. Patients who consumed less than 90%
of the planned number of capsules were excluded from the
study. At the onset of the study, height was measured using
a mounted tape, with the participants arms hanging freely
by their sides, and recorded to the nearest 0.5 cm. After
ensuring that they were barefoot and wore light clothing,
their weight was recorded to the nearest 0.1 kg with a Seca
scale. BMI was calculated by dividing weight (in kilograms) by the square of height (in meters).
Before and after intervention, blood samples were collected after an overnight fast of 12 hours. The serums of
patients were kept at 80C until biochemical analyses.
Serum TNF-, IL-1, IL-6, and high-sensitivity C-reactive
protein (hsCRP) were measured by platinum enzyme-linked
immunosorbent assay (ELISA) kits (Bender MedSystem
eBioscience, Vienna, Austria) and immunoturbidimetric
method. Serum MMP-2 and MMP-9 were assessed by
ELISA kits (Boster, China, and Bender MedSystem eBioscience, Vienna, Austria). Serum liver enzyme levels (alkaline phosphatase [ALP], alanine transaminase [ALT], and
aspartate transaminase [AST]) were determined by the photometric method.

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Integrative Cancer Therapies 12(6)

Table 1. Baseline Characteristics of Study Groups.

Supplemented Group (n = 15)
Age (year)
Gender, n (%)
Male
Female
Stage rectal cancer, n (%)b
II
III
Height (cm)
Weight (kg)
BMI (kg/m2)

Placebo Group (n = 17)

62.4 15.6

58.05 16.4

8 (53.38%)
7 (46.7%)

10 (58.8%)
7 (41.2%)

6 (40%)
9 (60%)
161.7 8.7
66.1 11.2
25.3 4.2

6 (35.3%)
11 (64.7%)
156.5 22.9
64.8 10.1
24.6 3.7

P
0.44a
0.75c

0.78c

0.42a
0.73a
0.61a

Independent t test.
Based on TNM staging.
c 2
test.
b

Statistical Analysis
The data were analyzed using Statistical Package for the
Social Sciences (SPSS, version 11.5, Chicago, IL).We used
the independent t test on quantitative parameters and the 2
test on qualitative variables (gender and stage of disease) to
determine whether baseline characteristics differed between
the CLA and placebo groups. Because all quantitative parameters had normal distributions according to the KolmogorovSmirnov test, data were presented as mean standard
deviation. The paired t test was used to compare serum biochemical factors at the end of the study with baseline values.
An independent t test was performed to compare changes
(from preintervention to the end of study) of biochemical factors between the 2 groups. An analysis of covariance test was
used to adjust the effect of confounding factors (baseline values of biochemical parameters). A P value of less than 0.05
was considered statistically significant.

Results
In this study, 34 patients were recruited. In the CLA group,
1 patient consumed less than 90% of the planned number of
capsules because of forgetting to take CLA capsules regularly and was excluded from the study. In the placebo group,
one patient was hospitalized and excluded from the study.
Finally, statistical analysis was performed on 32 patients
(CLA group, n = 15; placebo group, n = 17). There were no
significant differences in baseline characteristics between
the 2 groups, as presented in Table 1. The mean biochemical
factors and comparison of changes between the study
groups before and after intervention are indicated in Tables
2 and 3, respectively. Only the baseline values of MMP-9
were significantly (P = 0.01) different from those of the
control group (Table 2).
After intervention, the mean serum TNF- and IL-1
levels did not change significantly within each group (Table

2). However, significant changes (P = 0.04) of TNF- levels

(1.07 pg/mL) were observed in the CLA group when compared with the placebo group (1.8 pg/mL; Table 3).
The mean serum IL-6 levels remained unchanged in the
supplemented group but increased in the placebo group. At
the end of study, the mean serum hsCRP levels reduced in
the CLA group and increased in the placebo group when
compared with baseline (Table 2). The reduction of hsCRP
levels in the supplemented group was significant (P = 0.03)
in comparison with that in the placebo group (Table 3).
After intervention, the mean serum MMP-9 reduced
insignificantly in both groups. However, changes in MMP-9
levels were 78.1 ng/mL for the CLA group and 23.4 ng/
mL for the placebo group, which indicated a significant difference from the placebo group (P = 0.04; Table3). This finding was also significant after adjusting for baseline values of
MMP-9.
CLA supplementation reduced serum MMP-2 levels
(0.093 ng/mL) insignificantly, whereas they increased in the
placebo group (2.85 ng/mL; Table 3) but not significantly.
No significant alterations were observed in ALT and
AST levels within each group during the intervention (Table
2). The mean serum ALP concentration decreased significantly (P = 0.02) in the supplemented group, whereas it did
not change in the placebo group (Table 2).

Discussion
A variety of cytokines (TNF-, Il-6, Il-1) and other factors
such as NF-B and COX2 are involved in the incidence of
inflammation resulting from cancer and cancer treatments.3,17 It has been reported that inflammation plays an
important role in progression, invasion, metastasis, chemoresistance, and radioresistance of colorectal cancer.23,24
Therefore, today, many studies are focused on the development of new anti-inflammatory therapeutic approaches
for blocking their synthesis or action,25 especially by

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Mohammad-zadeh et al
Table 2. The Mean Serum Biochemical Factors Before and After Intervention in Both Supplemented and Placebo Groups.a.
CLA Group (n = 15)

TNF- (pg/mL)
IL-1 (pg/mL)
IL-6 (pg/mL)
hsCRP (mg/L)
MMP-9 (ng/mL)
MMP-2 (ng/mL)
ALT (U/L)
AST (U/L)
ALP (U/L)

Placebo Group (n = 17)

Before

After

Pb

Before

After

55.6 8.67
45.4 5.18
6.1 3.9
2.5 2.1
578.01 237.14c
21.28 16.17
15.1 11.4
15.6 3.2
218.7 55.16

54.5 3.06
45.1 4.84
6.5 4.5
1.7 1.5
499.8 297.3
21.19 4.69
15.3 6.0
15.1 5.34
190.4 36.95

0.68
0.81
0.89
0.45
0.31
0.98
0.90
0.31
0.02

55.8 7.2
44.7 5.3
8.03 5.4
2.4 2.26
839.1 302.43
22.26 18.58
14.8 9.04
17.93 4.25
221.2 53.60

57.7 4.39
45.7 10.84
12.3 11.8
3.8 3.2
815.7 291.72
25.11 20.74
13.6 9.7
16.2 6.01
220.3 56.29

Pb
0.30
0.35
0.19
0.06
0.80
0.64
0.57
0.28
0.94

Abbreviations: CLA, conjugated linoleic acid; TNF-, tumor necrosis factor ; IL, interleukin 1; hsCRP, high-sensitivity C-reactive protein; MMP,
matrix metalloproteinase; ALT, alanine transaminase; AST, aspartate transaminase; ALP, alkaline phosphatase.
a
Mean value standard deviation.
b
P, comparison within group by paired t test.
c
Baseline values were significantly different from that in the placebo group.

Table 3. Comparison of Changes in Biochemical Factors Between the Study Groups.a.

CLA Group (n = 15)
TNF- (pg/mL)
IL-1 (pg/mL)
IL-6 (pg/mL)
hsCRP (mg/L)
MMP-9 (ng/mL)
MMP-2 (ng/mL)
ALT (IU/L)
AST (U/L)
ALP (U/L)

1.07 (6.64, 4.48)

0.32 (3.26, 2.60)
0.38 (3.06, 3.83)
0.84 (2.95, 1.26)
78.1 (235.2, 78.88)
0.093 (9.29, 9.10)
0.21 (4.3, 4.8)
0.46 (3.71, 2.78)
28.3 (52.31, 4.2)

Placebo Group (n = 17)

Pb

1.88 (2.66, 6.42)

1.00 (3.6, 5.69)
4.3 (2.57, 11.20)
1.41 (0.069, 2.89)
23.4 (224.3, 177.5)
2.85 (10.07, 15.78)
1.13 (5.3, 3.12)
1.73 (5.09, 1.63)
0.85 (27.7, 26.05)

0.04
0.60
0.26
0.03
0.04
0.69
0.60
0.56
0.05

Abbreviations: CLA, conjugated linoleic acid; TNF-, tumor necrosis factor ; IL, interleukin 1; hsCRP, high-sensitivity C-reactive protein; MMP,
matrix metalloproteinase; ALT, alanine transaminase; AST, aspartate transaminase; ALP, alkaline phosphatase.
a
ANCOVA was used to adjust baseline values of biochemical parameters; mean value (95% confidence interval).
b
P, comparison between groups by independent t test.

dietary supplementation26 such as CLA. The findings from

several animal studies have documented anti-inflammatory
properties of CLA in gut inflammation27,28 and suppressing
colon carcinogenesis and progression.15,29 In pigs with bacterial-induced colitis, CLA supplementation decreased
inflammatory colonic lesion developments and upregulated
colonic peroxisome proliferatoractivated receptor (PPAR)
expression.27 Also, Evans and colleagues29 reported that
CLA supplementation not only attenuated inflammation
induced colorectal cancer in mice but also decreased disease
activity and suppressed colitis-related adenoma and tumor
formation via activation of PPAR. Furthermore, findings of
other researchers showed that a diet containing 1% t10,c12
or 9t,t11 in rats reduced the incidence and growth of colon
cancer by inducing apoptosis in colonic mucosa of rats
treated with 1,2-dimethylhydrazine.30,31 In a clinical trial,
Bassaganya-Riera et al14 found that CLA supplementation (6

g/d for 12 weeks) in patients with Crohns disease suppressed the ability of peripheral blood T cells to produce
proinflammatory cytokines and decreased disease activity.
They concluded that CLA supplementation represents a new
complementary treatment for gut inflammation. Taking into
account the important role of inflammation in tumor formation and progression of colorectal cancer and the antiinflammatory and anti-carcinogenic properties of CLA, we
assumed that dietary CLA ameliorates inflammatory conditions and, therefore, it can prevent disease progression. In
support of this hypothesis, the result of our study showed
that 3 g/d CLA supplementation for 6 weeks in rectal cancer
patients undergoing CRT reduced TNF- levels significantly
as compared with the placebo group. To the best of our
knowledge, there is no published article about the effect of
CLA supplementation on inflammatory factors and MMP
enzymes in rectal cancer patients undergoing CRT.

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Integrative Cancer Therapies 12(6)

Therefore, we compared our results with in vitro and animal

studies or human studies, which were conducted in healthy
individuals or patients with other diseases.
The results of the study by Yang and Cook indicated that
the plasma TNF- level after lipopolysaccharide injection
was suppressed in CLA-fed mice.32 Also, Rahman et al33
demonstrated that CLA mixture supplementation for 10
weeks reduced TNF- levels in mice. In healthy individuals, 3 CLA mixtures per day (50:50 c9,t11 CLA and t10,c12
CLA for 12 weeks) decreased TNF- concentration.13 In
another clinical trial, CLA (cis-9,trans-11 isomer) supplementation in those with birch pollen allergy decreased the
in vitro production of TNF-.34 The finding of the present
study is in agreement with results of the above-mentioned
studies.13,32-34
Another result of this study was that IL-1 decreased
slightly in the CLA group while increasing in the placebo
group. The findings of other studies showed that CLA supplementation had no effect on serum IL-1 concentration in
healthy individuals.35,36 Previously, Song et al13 reported
that CLA mixture supplementation (3 g/d for 12 weeks) in
healthy young individuals reduced serum IL-1 levels
significantly.
In this study, CLA supplementation did not change IL-6
levels in cancer patients. Similarly, the findings of previous
studies showed that CLA mixture supplementation had no
effect on serum IL-6 concentration in healthy individuals36,37 and patients with diabetes.22
In contrast to the supplemented group, IL-6 levels
increased remarkably in the placebo group, which is compatible with the study by Wang et al, who noted that serum
IL-6 concentration increased in non-small-cell lung cancer
during CRT.38 According to our results, CLA supplementation may prevent the enhancement of IL-1 and IL-6 concentrations in patients with cancer during CRT.
At the end of the study, hsCRP levels were elevated in the
placebo group. In line with the present result, Cengiz et al39
observed significant elevation of CRP levels in cancer
patients undergoing pelvic RT. As compared with the placebo group, CLA supplementation resulted in significant
reduction of hsCRP concentration in the supplemented
group. In contrast to our result, Smedman et al40 observed
significant increases in hsCRP levels in healthy individuals
supplemented with 4.2 g of CLA mixture per day. On the
other hand, the findings of other studies showed that CLA
mixture supplementation (3 g/d and 3.2 g/d) had no effect on
CRP levels among overweight37 and obese individuals.41
It can be assumed that the observed difference between
our results and those of previous studies regarding the effect
of CLA on CRP may be a result of different doses of CLA
supplementation used or the health condition of the individuals. It has been suggested that the anti-inflammatory
properties of CLA are more profound in inflammatory
conditions.34

In this study, the observed modulatory effects of CLA

supplementation on proinflammatory cytokines and
hsCRP in rectal cancer patients can be ascribed to differences in the mechanisms which that are proposed by in
vitro and in vivo studies. CLA isomers are reported to be a
ligand for PPAR,42,43 which has a crucial role in the regulation of inflammation, especially inflammatory bowel
disease and the incidence and metastasis of colorectal cancer.44,45 The results of several animal studies have shown
that CLA attenuated gut inflammation via activation of
PPAR.10,27,29 Also, various CLA isomers activate PPAR
in RAW 264.7 cells and reduce the production of proinflammatory cytokines such as TNF-, IL-1, and IL-6.45
Therefore, CLA can improve different inflammatory conditions through activation of PPAR. In addition, CLA
reduces proinflammatory eicosanoid (PGE2, LTB4)
production46,47and attenuates the NF-B pathway,48 which
is involved in cytokine gene expression, cell cycle activation, apoptosis, and carcinogenesis.26 It seems that CLA
may have a beneficial effect on inflammation, which influences initiation, progression, and metastasis of colorectal
tumors49and also tumor resistance to cancer treatments
and side effects of these treatments.
In comparison with the placebo group, noticeable
changes in MMP-9 and MMP-2 levels were observed in the
CLA group. As far as we know, this is the first study evaluating the effect of CLA supplementation on MMP-2 and
MMP-9 levels in rectal cancer patients. The present findings in rectal cancer patients are compatible with those of
previous studies.17,50 Soel et al17 noted that MMP-9 activity
in SW480 human colon cancer cells was significantly suppressed by c9,t11 CLA. The results of another study showed
that MMP-2 and MMP-9 synthesis and activity were inhibited by CLA in rats.50 MMP-2 and MMP-9 are 2 important
members of the MMP family that play vital roles in tumor
invasion and angiogenesis; therefore, inhibition of MMP
synthesis or activity in different ways can suppress tumor
invasion and metastasis.51 However, more studies are
needed to clarify the inhibitory mechanism of CLA on the
synthesis and activity of MMP enzymes.
Taking into account that this is the first study to examine
the effect of CLA supplementation in cancer patients, we
determined serum liver enzymes to assess the safety of
CLA in cancer patients. No significant alterations were
observed in ALT and AST levels in the CLA group during
the intervention. Moreover, the mean serum ALP concentrations decreased significantly in the CLA group. The
mean serum liver enzyme levels were in the normal range
in both the groups.
In conclusion, the results of the present study indicate
that CLA supplementation (50:50 cis-9,trans-11 and trans10,cis-12 CLA) improved TNF- and hsCRP levels as indicators of inflammation and MMP-2 and MMP-9 enzymes
as biomarkers of angiogenesis and tumor invasion.

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Mohammad-zadeh et al
Moreover, CLA supplementation prevented the elevation of
IL-1 and IL-6 concentrations as biomarkers of inflammation when compared with the placebo group in rectal cancer
patients undergoing CRT.
Based on the results of previous animal studies and
the present study, it seems that CLA may provide a
new complementary treatment by reducing tumor invasion
and resistance to cancer treatment in patients with rectal
cancer. However, further studies with larger sample sizes
are needed to achieve more precise results. Moreover,
it would be worthwhile to study the effect of different
doses of oral CLA supplementation on the production of
inflammatory factors and the immune function in cancer
patients.
Acknowledgment
The authors are grateful for the financial support of the Nutrition
Research Center, Tabriz University of Medical Sciences. The
authors also are deeply indebted to all patients who participated in
this study.

Authors Note
This article was written based on a data set for the PhD thesis
(Elnaz Faramarzi) registered in Tabriz University of Medical
Sciences.

Declaration of Conflicting Interests

The authors declared no potential conflicts of interest with respect
to the research, authorship, and/or publication of this article.

Funding
The authors disclosed receipt of the following financial support for
the research, authorship, and/or publication of this article: The
authors are grateful for the financial support of the Nutrition
Research Center, Tabriz University of Medical Sciences.

References
1. American Cancer Society. Cancer Facts and Figures 2012.
Atlanta, GA: American Cancer Society; 2012.
2. Kachnic LA. Adjuvant chemoradiation for localized rectal cancer: current trends and future directions. Gastrointest
Cancer Res. 2007;1S:S64-S72.
3. Deorukhkar A, Krishnan S. Targeting inflammatory pathways for tumor radiosensitization. Biochem Pharmacol.
2010;80:1904-1914.
4. Dinarello CA. Anti-inflammatory agents: present and future.
Cell. 2010;140:935-950.
5. Balkwill F, Mantovani A. Cancer and inflammation: implications for pharmacology and therapeutics. Clin Pharmacol
Ther. 2010;87:401-406.
6. Grivennikov SI, Greten FR, Karin M. Immunity, inflammation, and cancer. Cell. 2010;140:883-899.
7. Chin SF, Storkson JM, Ha YL, et al. Dietary sources of conjugated dienoic isomers of linoleic acid. J Food Compos Anal.
1992;5:185-197.

8. Choi JS, Jung MH, Park HS, et al. Effect of conjugated linoleic acid isomers on insulin resistance and mRNA levels
of genes regulating energy metabolism in high fat-fed rats.
Nutrition. 2004;20:1008-1017.
9. Park Y. Conjugated linoleic acid (CLA): good or bad trans fat.
J Food Compos Anal. 2009;225:S4-S12.
10. Bassaganya-Riera J, Hontecillas R. Dietary conjugated

linoleic acid and n-3 polyunsaturated fatty acids in inflammatory bowel disease. Curr Opin Clin Nutr Metab Care.
2010;13:569-573.
11. Changhua L, Jindong Y, Defa L, et al. Conjugated linoleic
acid attenuates the production and gene expression of proinflammatory cytokines in weaned pigs challenged with lipopolysaccharide. J Nutr. 2005;135:239-244.
12. Stachowska E, Dolegowska B, Dziedziejko V, et al.

Prostaglandin E2 (PGE2) and thromboxane A2 (TXA2)
synthesis is regulated by conjugated linoleic acids (CLA) in
human macrophages. J Physiol Pharmacol. 2009;60:77-85.
13. Song HJ, Grant I, Rotondo D, et al. Effect of CLA supplementation on immune function in young healthy volunteers. Eur J
Clin Nutr. 2005;59:508-517.
14. Bassaganya-Riera J, Hontecillas R, Horne WT, et al.

Conjugated linoleic acid modulates immune responses in
patients with mild to moderately active Crohns disease. Clin
Nutr. 2012;31:721-727.
15. Shiraishi R, Iwakiri R, Fujise T, et al. Conjugated linoleic acid
suppresses colon carcinogenesis in azoxymethane-pretreated
rats with long-term feeding of diet containing beef tallow. J
Gastroenterology. 2010;45:625-635.
16. Kim KH, Park HS. Dietary supplementation of conjugated
linoleic acid reduces colon tumor incidence in DMH-treated
rats by increasing apoptosis with modulation of biomarkers.
Nutrition. 2003;19:772-777.
17. Soel SM, Choi OS, Bang MH. Influence of conjugated linoleic acid isomers on the metastasis of colon cancer cells in
vitro and in vivo. J Nutr Biochem. 2007;18:650-657.
18. Kuniyasu H, Yoshida K, Sasaki T, et al. Conjugated linoleic
acid inhibits peritoneal metastasis in human gastrointestinal
cancer cells. Int J Cancer. 2006;118:571-576.
19. Grdzka I, Sochanowicz B, Brzska K, et al. Cis-9,trans-11conjugated linoleic acid affects lipid raft composition and
sensitizes human colorectal adenocarcinoma HT-29 cells to
X-radiation. Biochim Biophys Acta. 2013;1830:2223-2242.
20. Cho HJ, Kim EJ, Lim SS, et al. Trans-10,cis-12, not cis9,trans-11, conjugated linoleic acid inhibits G1-S progression
in HT-29 human colon cancer cells. J Nutr. 2006;136:893-898.
21. Palombo JD, Ganguly A, Bristrain BR, et al. The antiproliferative effects of biological active isomers of conjugated
linoleic acid on human colorectal and prostatic cancer cells.
Cancer Lett. 2002;177:163-172.
22. Moloney F, Yeow TP, Mullen A, et al. Conjugated linoleic
acid supplementation, insulin sensitivity, and lipoprotein
metabolism in patients with type 2 diabetes mellitus. Am J
Clin Nutr. 2004;80:887-895.
23. Aggarwal BB, Gehlot P. Inflammation and cancer: how

friendly is the relationship for cancer patients? Curr Opin
Pharmacol. 2009;9:351-369.
24. Terzic J, Grivennikov S, Karin E, Karin M. Inflammation and
colon cancer. Gastroenterology. 2010;138:2101-2114.

Downloaded from ict.sagepub.com by Gheorghies Alina on October 30, 2014

502

Integrative Cancer Therapies 12(6)

25. Germano G, Allavena P, Mantovani A. Cytokines as a

key component of cancer-related inflammation. Cytokine.
2008;43:374-379.
26. Aggarwal BB, Vijayalekshimi RV, Sung B. Targeting inflammatory pathways for prevention and therapy of cancer: shortterm friend, long-term foe. Clin Cancer Res. 2009;15:425-430.
27. Hontecillas R, Wannemeulher MJ, Zimmerman DR, et al.
Nutritional regulation of porcine bacterial-induced colitis by
conjugated linoleic acid. J Nutr. 2002;132:2019-2027.
28. Hontecillas R, Bassaganya-Riera J, Wilson J, et al. CD4+
T-cell responses and distribution at the colonic mucosa during Brachyspira hyodysenteriaeinduced colitis in pigs.
Immunology. 2005;115:127-135.
29. Evans NP, Misyak SA, Schmelz EM, et al. Conjugated linoleic
acid ameliorates inflammation-induced colorectal cancer in
mice through activation of PPAR. J Nutr. 2010;140:515-521.

30. Park HS, Ryu JH, Ha YL, et al. Dietary conjugated linoleic acid (CLA) induces apoptosis of colonic mucosa in 1,
2-dimethylhydrazine-treated rats: a possible mechanism of the
anticarcinogenic effect by CLA. Br J Nutr. 2001;86:549-555.
31. Park HS, Chun CS, Kim S, Ha YL, Park JH. Dietary trans10, cis-12 and cis-9, trans-11 conjugated linoleic acids
induce apoptosis in the colonic mucosa of rats treated with
1,2-dimethylhydrazine. J Med Food. 2006;9:22-27.
32. Yang M, Cook ME. Dietary conjugated linoleic acid decreased
cachexia, macrophage tumor necrosis factor- production,
and modifies splenocyte cytokines production. Exp Biol Med.
2003;228:51-58.
33. Rahman MM, Bhattacharya A, Banu J, et al. Conjugated
linoleic acid protects against age-associated bone loss in
C57BL/6 female mice. J Nutr Biochem. 2007;18:467-474.
34. Turpeinen AM, Ylnen N, von Willebrand E, Basu S, Aro A.
Immunological and metabolic effects of cis-9, trans-11-conjugated linoleic acid in subjects with birch pollen allergy. Br
J Nutr. 2008;100:112-119.
35. Kelley DS, Taylor PC, Rudolph IL, et al. Dietary conjugated
linoleic acid did not alter immune status in young healthy
women. Lipids. 2000;35:1065-1071.
36. Albers R, Van Der Wielen RP, Brink EJ, et al. Effects of
cis-9, trans-11 and trans-10, cis-12 conjugated linoleic acid
(CLA) isomers on immune function in healthy men. Eur J
Clin Nutr. 2003;57:595-603.
37. Ramakers JD, Plat J, Sebedio JL, et al. Effects of the individual isomers cis-9,trans-11 vs. trans-10,cis-12 of conjugated
linoleic acid (CLA) on inflammation parameters in moderately overweight subjects with LDL-phenotype B. Lipids.
2005;40:909-918.

38. Wang XS, Shi Q, Williams LA, et al. Inflammatory cytokines

are associated with the development of symptom burden in
patients with NSCLC undergoing concurrent chemoradiation
therapy. Brain Behav Immun. 2010;24:968-974.
39. Cengiz M, Akbulut S, Atahan IL, et al. Acute phase

response during radiotherapy. Int J Radiat Oncol Biol Phys.
2001;49:1093-1096.
40. Smedman A, Basu S, Jovinge S, et al. Conjugated linoleic
acid increased C-reactive protein in human subjects. Br J
Nutr. 2005;94:791-795.
41. Steck SE, Chaleci AM, Miller P, et al. Conjugated linoleic
acid supplementation for twelve weeks increases lean body
mass in obese humans. J Nutr. 2007;137:1188-1193.
42. Mc Carty MF. Activation of PPAR gamma may mediate a
portion of the anti cancer activity of conjugated linoleic acid.
Med Hypotheses. 2000;55:187-188.
43. Martin H. Role of PPAR-gamma in inflammation: prospects
for therapeutic intervention by food components. Mutat Res.
2009;669:1-7.
44. Kuniyasu H. The role of dietary PPAR ligands for metastasis
in colorectal cancer. PPAR Res. 2008;2008:529720.
45. Yu Y, Correl PH, Vanden Heuvel JP. Conjugated linoleic acid
decreases production of proinflammatory products in macrophages evidence for a PPAR gamma-dependent mechanism.
Biochem Biophys Acta. 2002;1581:89-99.
46. Li Y, Watkins BA. Conjugated linoleic acids alter bone

fatty acid composition and reduce ex vivo prostaglandin
E2 biosynthesis in rats fed n-6 or n-3 fatty acids. Lipids.
1998;33:417-425.
47. Sugano M, Tsujita A, Yamasaki M, et al. Conjugated linoleic
acid modulates tissue levels of chemical mediators and immunoglobulins in rats. Lipids. 1998;33:521-527.
48. Zulet MA, Marti A, Parra MD, et al. Inflammation and conjugated linoleic acid: mechanisms of action and implications for
human health. J Physiol Biochem. 2005;61:483-494.
49. Kelley NS, Hubbard NE, Erickson KL. Conjugated linoleic
acid isomers and cancer. J Nutr. 2007;137:2599-2607.
50. Harris MA, Hansen RA, Vidsudhiphan P, et al. Effects of conjugated linoleic acids and docosahexaenoic acid on rat liver
and reproductive tissue fatty acids, prostaglandins and matrix
metalloproteinase production. Prostaglandins Leukot Essent
Fatty Acids. 2001;65:23-29.
51. Sbardella D, Fasciglione GF, Gioia M, et al. Human matrix
metalloproteinases: an ubiquitarian class of enzymes
involved in several pathological processes. Mol Aspects Med.
2012;33:119-208.

Downloaded from ict.sagepub.com by Gheorghies Alina on October 30, 2014