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Methods Mol Biol. Author manuscript; available in PMC 2013 April 12.
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Methods Mol Biol. 2012 ; 863: 411–435. doi:10.1007/978-1-61779-612-8_26.
Multifactorial Etiology of Gastric Cancer

Jovanny Zabaleta
Abstract
The prevalence of gastric cancer is associated with several factors including geographical location,
diet, and genetic background of the host. However, it is evident that infection with Helicobacter
pylori (H. pylori) is crucial for the development of the disease. Virulence of the bacteria is also
important in modulating the risk of the disease. After infection, H. pylori gains access to the
gastric mucosa and triggers the production of cytokines that promote recruitment of inflammatory
cells, probably involved in tissue damage. Once the infection is established, a cascade of
inflammatory steps associated with changes in the gastric epithelia that may lead to cancer is
triggered. H. pylori-induced gastritis and H. pylori-associated gastric cancer have been the focus
of extensive research aiming to discover the underlying mechanisms of gastric tissue damage. This
research has led to the association of host genetic components with the risk of the disease. Among
these is the presence of single nucleotide polymorphisms (SNPs) in several genes, including
cytokine genes, which are able to differentially modulate the production of inflammatory
cytokines and then modulate the risk of gastric cancer. Interestingly, the frequency of some of
these SNPs is different among populations and may serve as a predictive factor for gastric cancer
risk within that specific population. However, the role played by other genetic modifications
should not be minimized. Methylation of gene promoters has been recognized as a major
mechanism of gene expression regulation without changing the primary structure of the DNA.
Most DNA methylation occurs in cytosine residues in CpG dinucleotide, but it can also be found
in other DNA bases. DNA methyltransferases add methyl groups to the CpG dinucleotide, and
when this methylation level is too high, the gene expression is turned off. In H. pylori infection as
well as in gastric cancer, hypermethylation of promoters of genes involved in cell cycle control,
metabolism of essential nutrients, and production of inflammatory mediators, among others, has
been described. Interestingly, DNA changes like SNPs or mutations can create CpG sites in
sequences where transcription factors normally sit, affecting transcription.
In this chapter, we review the literature about the role of SNPs and methylation on H. pylori
infection and gastric cancer, with big emphasis to the H. pylori role in the development of the
disease due to the strong association between both.
Keywords
Helicobacter pylori; Gastric cancer; Single nucleotide polymorphisms; Methylation
1. Introduction
In 2008, close to one million new cases of gastric cancer (7.8% of the total cases) were
estimated, with 736,000 deaths (9.7% of the total) due to the disease in the same period,
making gastric cancer the second leading cause of cancer-related deaths worldwide (1).
However, the incidence and mortality of gastric cancer around the world varies significantly
according to the geographical location. The incidence in Asia and Eastern Europe is more
than 20 cases per 100,000 individuals, contrasting with incidence rates lower than 10 cases
per 100,000 individuals in North America, New Zealand, and Oceania (2, 3). The contrast in
the survival rate of stomach cancer is significant as well. Japan, North America, and
Western Europe have the highest survival rates (52, 21, and 27%, respectively) compared
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with only 6% survival in the sub-Saharan regions (2). Parkin et al. suggested that the
incidence of stomach cancer is higher in men than in women in most of these regions (2). In
the United States, it is estimated that approximately 13,000 men and 8,000 women were
diagnosed with gastric cancer in 2010 (4); more than 10,000 of them are expected to have
died as a direct result of the neoplasia.
Several classifications of gastric cancer have been proposed over the years, based on
different aspects including histopathology, clinical aspects, and endoscopic characteristics
(5–9). However, the most widely followed classification is the one by Laurén (8), which,
after few later updates, classifies cancer into intestinal and diffuse types, according to
structural characteristics of the tumors. In general, the diffuse type seems to be diagnosed at
earlier stages, more frequent in women than in men, and to be associated with specific blood
types and associated to pangastritis without atrophy (10, 11). In contrast, the intestinal type
of gastric cancer is more associated with gastritis in the corpus that leads to atrophy and
intestinal metaplasia, dysplasia, and finally cancer (see below) (10). In addition, the
intestinal type seems to be more common in men and diagnosed at later ages (11, 12). The
observed decline in gastric cancer globally seems to be associated to a reduction in the
incidence of the intestinal type, while there is an increase of the diffuse-type gastric cancer
(13, 14).
2. Risk Factors: Helicobacter pylori Is Fundamental for Gastric Cancer

Development
Infection with Helicobacter pylori (H. pylori) is considered essential for the development of
gastric cancer, such that H. pylori has been classified as a type I carcinogen by the
International Agency for Research in Cancer (IARC) (15). It is estimated that nearly half of
the world’s population is infected with this bacterium; however, most people are
asymptomatic, and approximately 1–3% develop cancer (16–18). This infection induces an
inflammatory response that increases the infiltration of lymphocytes, macrophages, and
plasma cells into the gastric mucosa. Neutrophils can also be found when acute
inflammation is present. When the inflammatory response is not accompanied by loss of
gastric glands (atrophy), it is referred to as non-atrophic gastritis (NAG), according to the
updated Sydney classification (19). NAG lesions are associated with the development of
duodenal ulcer, especially if it is localized to the gastric antrum (20). A small percentage of
patients with NAG progress to multifocal atrophic gastritis (MAG). MAG is characterized
by the loss of gastric glands and the appearance of fibrotic tissue (21). This disease can later
progress to MAG with intestinal metaplasia (MAG-IM), in which cells of the gastric
epithelium are replaced by intestinal absorptive and goblet cells (for a graphical view of the
lesions, please see refs. (21, 22)). MAG-IM is considered to be a true preneoplastic lesion
leading to the development of dysplasia, with abnormal nuclear morphology and abnormal
tissue architecture. It is estimated that up to 85% of patients with dysplasia and a high
degree of atypical features progress to invasive carcinomas (23). Even though some of these
lesions may regress to the previous, less malignant states, the rate of progression is higher
than the rate of regression (24).
It is widely accepted that gastric cancer is the result of the above-described cascade of
histological events leading from normal epithelia to cancer. However, the molecular and
cellular events controlling the transition from one step to the next are not yet fully
understood. Inflammation is a common finding in cancer (25). The inflammatory process is
mediated by pro- and anti-inflammatory cytokines, the levels of which are controlled,
among other things, by changes in the primary sequence of the DNA sequence. Several
single nucleotide polymorphisms (SNPs) in genes encoding cytokines involved in the
inflammatory process have been associated with risk of gastric cancer among several
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populations (26–29). Our work with premalignant inflammatory stages in African-American

and Caucasian individuals from the southern region of the United States has suggested that
many of these SNPs associations observed in gastric cancer are also present in the
premalignant stages and that there is a significant difference in the frequency of these SNPs
between the two ethnic groups (22, 30). These findings are important because it would help
to identify people at increased risk of developing cancer at an earlier stage, allowing for
better intervention strategies and remediation of the possible mucosal damage already
inflicted by the inflammatory reaction.
3. Biology of H. pylori Infection

H. pylori is a gram-negative bacterium that infects humans early in life (31). Infection
occurs at earlier ages in developing countries than in more advanced areas (31, 32) and is
related to socioeconomic status (33, 34). Upon infection, H. pylori gains access to the
mucosa overlying the gastric epithelia, delivering several pathogenic factors. Vacuolating
cytotoxin (VacA) can be secreted as a soluble protein (35) but can also be found attached to
the membrane of the bacteria (36). VacA is responsible for the formation of large
intracellular vacuoles in mammalian cells (37) and for opening channels on the membrane of
the gastric epithelial cells (38), allowing molecules like urea to enter the gastric lumen (39).
Once in the gastric lumen, the urea is broken down into ammonia and carbon dioxide by the
H. pylori urease, a metalloenzyme that uses nickel as a cofactor (40). The importance of H.
pylori urease is evidenced by the fact that urease (−) H. pylori strains are unable to colonize
the stomachs of several animal models (41, 42). In addition, H. pylori urease accounts for up
to 10% of the total protein produced by the bacteria (43). The ammonia generated by the
breakdown of urea can, by itself, neutralize the gastric acid (44), thus helping the bacteria
survive and causing damage to the gastric epithelia (45).
The cytotoxin-associated antigen (CagA) is injected into the membranes of the gastric cells
by a type IV secretion system (46, 47). Once inserted into the host’s cell membrane, CagA is
activated by phosphorylation at the carboxy-terminal end of the protein by c-Src/Lyn
kinases (48). This phosphorylation occurs at the tyrosine residues of the EPIYA motifs
(protein domains formed by glutamic acid, proline, isoleucine, tyrosine, and alanine
residues) (48, 49). Phosphorylation-activated CagA recruits the cytoplasmic SRC homology
2 domain-containing tyrosine phosphatase (SHP-2 tyrosine phosphatase) to the membrane
and deregulates the phosphatase domain (49). Tyrosine phosphorylation of the CagA protein
and its subsequent binding to the SHP-2 phosphatase are essential for the induction of the
cellular changes associated with CagA since H. pylori harboring cagA genes without the
EPIYA motifs are able to translocate the protein into the cell membranes, but once there, it
is not phosphorylated nor able to induce any cellular changes (48, 49). Activated and SHP-2
associated CagA triggers a cascade of phosphorylation events (50) that lead to changes in
the cell shape (46, 48). Interestingly, the promoter activity of the H. pylori cagA gene was
found to be increased in the presence of NaCl in a dose-dependent manner (48, 51).
Furthermore, the levels of the CagA protein were higher in H. pylori grown in higher salt
concentrations and resulted in increased interaction with gastric epithelial cells and
increased phenotypic changes associated with CagA (51, 52). CagA is also responsible for
the induction of inflammatory responses, including interleukin (IL) 8 released by gastric
epithelia, which serves as a chemotactic factor for inflammatory cells (53–56). Once
recruited to the gastric mucosa, the inflammatory cells mount a response essentially
mediated by lymphocyte-derived cytokines which, if not controlled, can promote tissue
damage.
Another important factor produced by H. pylori is the arginase enzyme which is encoded by
the rocF gene (57–59). This enzyme is found in many other organisms (60) and is involved
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in the generation of urea and ornithine, the latter being the primary source for the production
of polyamines (61). In Leishmania, the generation of polyamines is essential for the survival
of the parasite, such that arginase gene knockout parasites are unable to survive in culture
media unless supplemented with polyamines (62). In H. pylori, the enzyme seems to be
critical for survival of the H. pylori in acidic environments, but the lack of the gene does not
affect colonization of mouse stomach (57). Mendz and Hazell (63) have shown that H.
pylori lacks some of the enzymes required for the synthesis of L-arginine (L-Arg) and
depends on L-Arg generated by the host. We and others have shown that H. pylori arginase
can inhibit functions of both macrophages and T cells, making the bacterium able to control
both acquired and innate immune responses to the infection (64, 65).
4. Immune Dysfunction Caused by H. pylori Products in T Cells

H. pylori antigens, including urease and H. pylori DNA, can impair T-cell function (66, 67).
It has been shown that lysates of H. pylori reduce the proliferation of both peripheral blood
lymphocytes (PBL) and Jurkat cells (68). This effect is not limited to T cells but also
includes human monocytic cell lines and even human gastric cell lines (67, 69). Several
studies have been designed to identify the factors involved in the modulation of the immune
response to H. pylori. VacA and CagA antigens have been associated with virulence in H.
pylori and are believed to be the mediators of T-cell dysfunction. Paziak-Domanska et al.
(70) have shown that crude extracts of CagA+VacA− H. pylori G27 leads to downregulation
of PHA-induced proliferation of T cells. This effect was not observed when crude extracts of
the isogenic CagA−VacA+ was used. On the other hand, H. pylori CagA and VacA are
responsible for the downregulation of the proliferation of gastric cell lines (71, 72), an effect
not mediated by apoptosis (73). Interestingly, the dysfunction of T cells observed in H.
pylori infection is also seen in gastric cancer (74, 75).
We have shown that H. pylori arginase contributes to the depletion of L-Arg in culture
media, leading to the downregulation of the CD3ξ molecule, essential for activation of T
cells (64). Some studies have shown that in gastric cancer there is a reduced expression of
CD3ξ in T cells in local lymph nodes (76). Whether this happens in response to the infection
with H. pylori, or if the virulence of the bacteria is differentially associated with this event,
is still to be determined.
5. Cytokine Production in Response to H. pylori Infection

It has been shown that mice deficient in B and T cells (RAG-1−/−), or mice deficient in T
cells alone (TCRβδ−/−), do not develop gastritis when infected with Helicobacter felis (77).
This supports the idea that the immune response is essential for the development of gastritis
after infection with Helicobacter. In addition, interferon response factor element 1-deficient
mice (IRF-1−/−), which do not produce IFNγ, also fail to develop gastritis after infection
with H. pylori. Mohammadi et al. (78) and Nedrud et al. (79) clearly demonstrated that
C57Bl/6 mice infected with H. felis develop aggressive gastritis due to a strong Th1
response. In contrast, Balb/c mice that have a preferential Th2 response developed a
protective immune response. Therefore, the type of cytokine response is closely associated
with the pathological outcome of the infection.
In humans, most reports agree that a Th1 response is elicited both in vitro and in vivo after
H. pylori exposure, while a Th2 response is absent or negligible. Increased levels of IFNγ in
the mucosa of patients infected with H. pylori were observed both in situ and after purifying
the epithelia-infiltrating lymphocytes. No production of IL4 or IL5 could be detected (80,
81). Cytokines like IL8 and IL6 have also been reported to be increased; however, the
increase of IL8 appears to be independent of the presence of H. pylori and may be more of a
response to the inflammatory process initiated by the infection (82). In contrast, increased
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expression of IL6 within the gastric mucosa is largely associated with the presence of the
bacteria, such that its levels significantly decrease after clearance of the infection (82).
6. H. pylori Infection, Arginine, Arginase, and Immunity

In humans, the metabolism of the amino acid L-Arg has been associated with regulation of
the immune responses (83). In patients with trauma, liver transplantation, and some tumors,
an increase production of arginase I has been linked to significantly decreased responses of
T cells (84, 85). The lack of L-Arg induces a low expression of CD3ζ, which has been
associated with reduction in T-cell proliferation and decreased production of cytokines (85–
87). However, it is possible to suggest that in addition to the CD3ζ molecule, other
mechanisms might be important in the induction of this altered state of the T lymphocytes.
Recent data has shown that one of the mechanisms associated with L-Arg reduction includes
an increased expression of the cationic amino acid transporter (CAT-2B) in murine myeloid-
derived suppressor cells (MDSC, characterized as macrophages in mice), which increase the
uptaking of L-Arg by CAT-2B (86). This mechanism is not present in human MDSC, which
are characterized as polymorphonuclear neutrophils (PMN). In contrast, human MDSC
release arginase I into the microenvironment, where it depletes L-Arg and induces T-cell
dysfunction by impairing all the described functions of T cells (88, 89). Interestingly, the
same phenomenon has been described in the placenta of pregnant women, suggesting some
role of L-Arg metabolism in the tolerance of the fetus (90).
The enzyme arginase (EC 3.5.3.1) is one of the enzymes involved in the metabolism of L-
Arg, producing L-ornithine and urea, the first needed for the synthesis of polyamines
required for cell proliferation (91, 92). Additionally, nitric oxide synthase (EC 1.14.13.39)
metabolizes L-Arg into citrulline and nitric oxide, an innate mechanism involved in
cytotoxic cellular responses mediated by macrophages (93, 94).
L-Arg metabolism by arginase is emerging as an important regulator of T-cell responses in

human diseases, including infectious diseases and cancer (95–101). Our work with H. pylori
has shown that the presence of an arginase enzyme, previously characterized in the bacteria
(102), is responsible for reducing the expression of the CD3ξ molecule in Jurkat T cells and
primary T lymphocytes cultured in the presence of H. pylori (64). In addition, H. pylori
arginase plays an important role in reducing the levels of nitric oxide production by
macrophages, an event that may be associated to increased survival of the bacteria (65). On
the other hand, H. pylori infection also induces the expression of macrophage arginase II,
which reduces intracellular availability of arginine with subsequent reduction of nitric oxide
responses (103, 104). In fact, the critical role of arginase II in H. pylori infection has been
shown in arginase knockout mice (arg2−/−) (105). This study suggested that arginase II
affects the degree of cellular immunity against H. pylori, by reducing the levels of Th1/Th17
cytokines, including IFNγ, IL17a, and IL12p40 (105). The latter has been shown also in
macrophages in the intestinal muscularis (jejunum and ileum) of mice infected with
Helicobacter hepaticus (106). Even though these macrophages did not show any signs of
infection by the Helicobacter, those obtained from infected mice had significantly reduced
induction of inflammatory cytokines than those obtained from uninfected, after being
stimulated in vitro with LPS and IFNγ (106). These results indicate that even if the
Helicobacter never encounters cells of the immune system, soluble factors released by the
bacteria, or by the inflamed gastric epithelia, may influence the immune response associated
with gastric damage. The possibility about H. pylori being able to invade the gastric mucosa
and interact directly with cells of the immune system is still controversial, but there are
some research showing actual in vivo phagocytosis of H. pylori at the gastric level (107–
109). This controversy is far from being solved, but some in vitro assays suggest that, even
if ingested, H. pylori is able to delay the intracellular killing, at least by macrophages (110–
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113). If this is a phenomenon that actually happens in vivo, it may lead to intracellular H.
pylori replication, as shown in vitro (114), and explain the persistence of the infection,
which in turns may lead to antibiotic resistance, selecting more aggressive strains able to
induce stronger inflammatory responses associated to mucosal damage.
7. Single Nucleotide Polymorphisms and the Regulation of Cytokine Genes

Under normal circumstances, modulation of the immune response is achieved at several
levels, including gene expression. SNPs are, in general, biallelic variations of one nucleotide
occurring throughout the genome. SNPs can cause alteration of the primary structure of a
protein. If, on the other hand, the allelic variation does not involve changes in the amino acid
sequence, it is referred to as synonymous or conservative. SNPs in noncoding regions may
be involved in splicing or in the formation of transcription factor-binding regions. Several
SNPs in cytokine genes have been associated with the regulation of cytokine levels. For
example, one haplotype on the IL10 gene (IL10-1082A/IL10-819T/IL10-592A) has been
associated with reduced levels of IL10 production (115). On the other hand, IL1B-511T/T
and the presence of allele 2 of the IL1 receptor antagonist gene (IL1RN*2) is associated
with increased levels of IL1β production in the mucosa (116). This has been associated with
gastric inflammation and intestinal metaplasia (116, 117). Pociot et al. (118) have also
shown that a C to T change at IL1B+3954 position is associated with increased secretion of
IL1β from monocytes after stimulation with LPS. Other studies (119, 120) using transiently
transfected cells have shown that allele A at position -308 of the TNFA gene (TNF*2) is
associated with increased levels of TNF-α, suggesting a role for this SNP in inflammatory
and infectious processes. The proinflammatory IL6 is responsible for inducing fever after
injection of IL1 in animals (121). The levels of IL6 are also controlled by genetic
mechanisms. An SNP at position -174 (G > C change) has been associated with differential
production of IL6 with increased activity of promoters containing G (121). After stimulation
with LPS, PBMCs obtained from healthy individuals with IL6-174GG or IL1-174GC
genotypes produced significantly higher amounts of IL6 in response to LPS than individuals
with the IL6-174CC (121). Furthermore, haplotype analysis of the IL6 promoter has
suggested that the IL6 expression is controlled by the interaction of at least four
polymorphisms in the IL6 promoter (122). The clinical importance of genetically controlled
levels of cytokines has been demonstrated in transplantation (123, 124), autoimmune
diseases (125), and infectious diseases (126, 127).
8. Cancer Health Disparities, Ethnicity, and SNPs

The incidence of most cancers is higher in African-Americans than in Caucasians (128).
Many factors may be playing a significant role in these disparities. According to the
National Institutes of Health, cancer health disparities are defined as “all adverse differences
in cancer incidence, cancer prevalence, cancer death, cancer survivor-ship, and burden of
cancer or related health conditions that exist among specific population groups in the United
States” (129). Even though the socioeconomic status is highlighted as one of the major
factors leading to lack of appropriate health care, it is possible to suggest that ethnic
differences are also playing some role in defining such disparities. Recent reports have
shown that the composition of genetic blocks between African-Americans and Caucasians is
different, with more heterogeneity observed in the African-American group (130, 131). This
could be associated to a differential genetic background that makes one individual more
susceptible to suffer specific diseases, including cancer (132). These differences may
include differential transcription of regulatory genes, increased transcription of genes that
promote inflammation and reduced transcription of those that are anti-inflamatory. Because
gene transcription may be affected by the presence of SNPs at the promoter level, these may
potentially be used as determinants of risk of disease in specific ethnic groups. An example
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of differential SNPs distribution between ethnic groups and its possible association with
disease is given by the gene of the multidrug transporter (MDR1), which mediates the
transport of many types of drugs including anticancer drugs (133, 134). The frequency of
one SNP in exon 26 of the MDR1 gene (a C > T change at position 3435) has been found to
be differentially associated with African-Americans, Caucasians, and Asian populations
(135), as well as with differential expression of the MDR1 protein and with plasma levels of
several drugs (136–142). Additional work has shown that such SNP is in linkage
disequilibrium with two other nearby SNPs forming haplotype blocks differentially
associated with three ethnic groups in Asia (143). Regarding to inflammatory mediators,
several cytokine SNPs have been associated with the development of gastric cancer. A
seminal work by El-Omar et al. (26) associated a transition from C to T at position −511 of
the IL1B gene (ILB-511C>T) with gastric cancer in European populations. This finding has
been later confirmed by other groups (28, 29, 144, 145), even though racial and ethnicity
factors have been associated with differential gastric cancer risk in various populations
worldwide. However, most studies agree that the presence of allele IL1B-511T increases the
risk of intestinal-type and noncardia gastric cancer in Caucasian but not in Asian
populations, a fact that has been validated by several meta-analyses (146–149).
Interestingly, this SNP has also been linked to increased secretion of IL1β (116, 117); this,
in turn, is associated with reduction of gastric acid secretion (150), promoting the
colonization by H. pylori. IL1B-511 is in near complete linkage disequilibrium with another
SNP at position −31 (IL1B-31) (26), and its capacity to modulate IL1B gene transcription is
modified depending on the presence of other nearby SNPs (151). This strongly suggests that
SNP’s association with disease needs to be studied not only individually but also as
haplotypes.
The biological activity of the IL1β is regulated by the presence of a natural antagonist, the
interleukin 1 receptor antagonist (IL1ra), which is encoded by the IL1RN gene (152). Allele
2 of a variable number of tandem repeats (VNTR) on intron 2 of the IL1RN gene
(IL2RN*2) has been associated with reduced levels of IL1ra (153, 154) and with the
increased risk of several types of cancer, including gastric cancer (26–28).
Another cytokine important in the initiation and maintenance of immune responses is tumor
necrosis factor alpha (TNF-α), in which SNPs have been associated with gastric cancer as
well as other types of cancer. The presence of allele A at position −308 of the TNFA gene
(TNF-308A) has been associated with an increased risk of gastric cancer and non-small cell
lung carcinoma (28, 29, 155). In addition to the effect of the TNF-308 SNP, TNF-857T has
been linked to the development of gastric intestinal metaplasia (156) and gastric B-cell
lymphoma (157).
Interleukin 8 (IL8) is a member of the CXC chemokine family and functions as a

chemoattractant for neutrophils (53–56). Its role in gastric cancer is suggested by the high
levels of mRNA and IL8 protein in gastric cancer cell lines (82, 158, 159). Gastric cancer
patients carrying the IL8-251A allele or the haplotype of IL8 AGT/AGC (−251/+396/+781)
had a two- and fourfold increased risk of developing adenocarcinoma of gastric cardia,
respectively (160). Interestingly, the IL8-251AA genotype increases the risk of gastric
cancer only in individuals infected with H. pylori CagA+ strains (161).
IL10 is an anti-inflammatory cytokine (162). The level of IL10, as mentioned before, is

associated with the presence of specific SNPs and haplotypes in its promoter region, and
these, in turn, have been associated with differential risk of gastric cancer and other
malignancies (29, 115, 163–165).
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Recent genome-wide association studies (GWAS) using Japanese and Korean populations
found that two SNPs in the prostate stem cell antigen gene (PSCA) were significantly
associated with diffuse-type gastric cancer (166). A later study showed that one of those
SNPs, rs2976392, is associated with a significant increase risk of both gastric cancer types,
intestinal and diffuse, in a Chinese population (167). These results were further confirmed
by a more recent GWAS in a Chinese population, which, in addition to finding that the same
two SNPs in the PSCA gene were associated with noncardia gastric cancer, also found that
risk of gastric cardia cancer was associated with two SNPs, rs22742223 and rs3765524, that
create missense mutations in the region 10q23 encoding the phospholipase Cε1 (PLCE1)
(168).
Our work with African-American and Caucasian individuals from Louisiana has identified
SNPs, alone or arranged in haplotypes, in several cytokine genes differentially associated
with more severe forms of gastritis (22, 30). Interestingly, African-Americans have higher
frequency of proinflammatory SNPs and haplotypes in both IL1B and IL10 genes (22, 30),
present higher incidence of more aggressive forms of the disease (22, 30), and are infected
more frequently with aggressive H. pylori strains (30). Taken together, and considering that
these inflammatory stages may lead to gastric malignancy, our results may help explain in
part why African-Americans have increased risk of developing gastric cancer than
Caucasian individuals.
In summary, the balance of the pro- and anti-inflammatory responses to an offending agent
(H. pylori) appears to play a central role in gastric mucosal damage and repair. Defects on
the type of the response elicited, or in their balance, result in an abnormal environment that
can be detrimental for the host and favor the development of malignancy. However, the
interplay between the virulence of the bacteria and the genetic background of the host is
crucial in determining the fate of the inflammation initiated by the H. pylori infection.
9. DNA Methylation, H. pylori Infection, and Gastric Cancer

DNA methylation has been described as one important way of gene regulation that occurs
normally in imprinted genes, X-chromosome inactivation, and silencing of tumor suppressor
genes, among other situations (169). Most DNA methylation events occur in CpG
dinucleotides and very especially in those located in gene promoters (170). Even though the
mechanisms of this regulation are no totally understood, many clues point to either a direct
interference (by the methyl groups) of the binding of transcription factors or by the
formation of protein complexes by the recruitment of methyl-binding proteins, which
ultimately inhibit transcription (171–176).
DNA methylation is carried out by several DNA methyltransferase (DNMT) enzymes,

DNMT1, DNMT22, and DNMT3 (comprising 3A, 3B and 3L) involved in de novo and
maintenance methylation of hemi- and unmethylated DNA sequences (177, 178).
Interestingly, there is an increased expression of DNMT proteins in gastric cancer tissues, as
compared to tissues with normal histology. A recent study has found an SNP at position
−448 of the DNMT3A gene (DNMT3A-448A) highly associated with risk of gastric cancer
in a Chinese population (179). The presence of DNMT3A-448A increases more than
twofold the activity of the promoter, and homozygous carriers of this SNP
(DNMT3A-448AA) have more than sixfold increased risk of gastric cancer when compared
with GG carriers (179).
Hypermethylation of gene promoters has been described in gastric tissues, and this process
seems to be directly associated with the inactivation of specific genes in gastric cancer
samples (180, 181). However, as different population may have differences in their genetic
contents, differences in the methylation patterns may also vary. In a sample from Colombia,
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South America, when comparing two populations with different risks of gastric cancer,
hypermethylation of the RPRM gene was associated with the disease and with infection with
virulent H. pylori strains (cagA+/vacA s1m1+) in the high-risk population (182), as
compared with an area of low risk for gastric cancer. H. pylori virulence seem to be also
associated with differential methylation on enzymes involved in the pathway that generates
S-adenosylmethionine, the universal donor of methyl groups in humans (183). In a study
from Brazil, it was found that infection with virulent strains of H. pylori is associated with a
polymorphism in the methylenetetrahydrofolate reductase gene (MTHFR) enzyme (MTHFR
C677T) in patients 60 years old or older (184). In addition, hypermethylation of cell cycle
controlling genes (E-cadherin and CDKN2A) have been reported in patients infected with H.
pylori (184–188). Regarding to E-cadherin (encoded by the gene CDH1), the
hypermethylation of this gene seems to be directly related to the infection with H. pylori
since its eradication by antibiotic treatment lead to a significant reduction of the methylation
level (188). This type of inactivation of this gene adds to the importance of CDH1 in the
process of the progression of malignancy associated with gastric cancer. One study using
New Zealand families have found that a G to T mutation in the sequence of exon 7 leads to
an aberrant product and is associated with familial gastric cancer (189).
Many factors may influence the degree of methylation on one specific genomic region. One
of those factors is the presence of SNPs that either create CpG sites at the promoter levels,
maybe modifying the binding of proteins involved in the transcription machinery, or
increase the binding of transcription factor that promotes the increased transcription of the
gene. One example of the latter is the effect that C to T change at position −511 in the IL1B
gene (IL1B-511T) has on the methylation of CpG islands of several genes, including
TWIST1 and CYPB1 (190). It was noted that gastric cancer patients with the allele
IL1B-511T had significantly increased methylation on genes like TWIST1, CAGNA1G,
GRIN2B, CYPB1, and CRABP1, when compared to individuals with the allele IL1B-511C
(190). One possible explanation of these results may be the association between the levels of
IL1β at the gastric mucosa and the IL1B gene polymorphisms. It has been shown that
individuals with the IL1BTT genotype have significantly higher IL1β at the gastric level
than those with the genotype IL1BCC genotype (117). This cytokine has a plethora of
effects, and among them are both the increased expression of DNMT1 and the increased
activity of the enzyme, which, as discussed before, is involved in the transfer of S-
adenosylmethionine to cytosine residues in CpG sites (183).
10. Other Risk Factors Associated with Gastric Cancer

It is very clear that environmental factors are involved in the development of gastric cancer.
Studies have shown that the risk of gastric cancer changes if people move to geographical
areas with different gastric cancer risk, either increasing or decreasing, according to the risk
of the new area of settlement (191, 192). Several factors have been associated with the
development of gastric cancer, including environmental, microbial, and genetic factors (33,
193). It has been shown that fruits and vegetables reduce the risk of gastric cancer, without
regard to the anatomical position or histological type of cancer (194). A large study
involving more than 10,000 individuals reported that those with the very low to none intake
of fruits and vegetables had a relative risk (RR) of developing gastric cancer of 5.5 (95% CI
1.7–18.3), compared to those with a high intake of these foods (195). In addition, a study
with more than 12,000 individuals from seven countries reported a reduced risk for gastric
cancer in individuals with high consumption of fruits, even though no effect was associated
with vegetable consumption (196). Such studies have helped identify the specific
micronutrients that are involved in preventing this malignancy. Despite conflicting results
(197–199), it is commonly found that beta-carotene intake is inversely associated with the
Zabaleta Page 10
risk of gastric cancer (200–203), while the consumption of salted meats seem to increase the
risk of the disease (204, 205).
11. Models of H. pylori-Induced Gastric Inflammation

The role of the immune system in response to infection with Helicobacter strains has been
extensively studied using animal models. These models have helped to clarify the process of
the infection, the preneoplastic steps, and the severity and different outcomes of the
neoplasia. Mongolian gerbils have been used as H. pylori infection models because they
develop a disease very similar to human gastritis (206). However, phenotypic studies in
gerbils are limited because of the lack of many gerbil cell-specific reagents. Mice infected
with H. felis have also been used to study the human gastritis. Furthermore, H. pylori strains
have been adapted to infect mice and are preferred because the Helicobacter infection seems
to be highly host specific (77, 207, 208).
In humans, it has been shown that T cells isolated from the antral mucosa of patients with
active gastritis or duodenal ulcer disease, associated with H. pylori infection, are
preferentially producing Th1 cytokine (77, 80, 209–211). Other studies have shown that
CD4+ T-cell clones isolated from the gastric mucosa of these patients proliferate in response
to specific H. pylori antigens, including CagA, VacA, and urease, thus showing antigen
specificity (209, 210). This enhanced proliferation is related to the cytokine response which
appears to be associated with the presence of CagA and VacA (73). Patients infected with H.
pylori strains expressing these two proteins show an activation of nuclear transcription
factors AP-1 and NFkB and several tyrosine kinases including MAP kinases. All of these
factors participate in the transactivation of proinflammatory cytokine genes (212–214).
Even though most of the research on H. pylori-induced gastritis has focused on T cells, other
cells involved in the inflammatory reaction including the gastric epithelium,
polymorphonuclear cells, and macrophage/dendritic cells play an important role in the
response to H. pylori infection. Gastric epithelial cells can produce IL6 and IL10 upon
contact with H. pylori (215). Furthermore, they express B7.1 and B7.2 costimulatory
molecules, suggesting they could play an important role as antigen-presenting cells (216).
Initial reports about the role of macrophage/dendritic cells suggested that H. pylori severely
impairs phagocytosis and antigen processing in these cells, a mechanism that may be
dependent on the presence of the CagA protein (217). Furthermore, urease from H. pylori
can degrade urea which is needed to produce CO2 and NH3, effectively blocking the
bactericidal function of peroxynitrite, a metabolite derived from nitric oxide (218). Thus, it
is possible that the detrimental effects of H. pylori on macrophages could lead to the T-cell
dysfunction observed in chronic infections.
12. Concluding Remarks

Even though many advances in the understanding of gastric cancer have been made, the
disease is still one of the malignancies with the highest incidence and mortality rates
worldwide. The identification of H. pylori as a crucial player in the pathology of gastric
cancer was a pivotal step in the understanding and control of the disease. However, it is
important to fully understand the inflammatory response initiated by the infection in order to
fully block the cascade of events that lead to gastric cancer. This pathogen–host interaction
is one of the highest hierarchies since H. pylori has evolved mechanisms to hijack the
immune responses of the host and make its survival easier. Even though the environment,
the host’s genetic background, diet, and gender, among other factors, add to the H. pylori-
associated risk of gastric cancer, making the disease very complex and difficult to
understand and devise strategies to prevent, cure, and/or better treat patients diagnose with
the disease, our efforts should converge in finding the commonalities of the disease: what is
Zabaleta Page 11
common among individuals who become infected with H. pylori and also among the
different strains of the bacteria able to colonize and induce inflammation in humans. Genetic
and epigenetic markers of the infection and of the damage induced by it are necessary tools
to devise strategies aiming at limiting the degree of inflammation and to restore the
homeostasis of the gastric environment. These markers will probably show differences
among populations and related to H. pylori virulence, but our actual capacity to fully
sequence the human genome will, for sure, identify those common DNA sequences and
transcripts able to modify the risk not only of being infected with the bacteria but also of
developing gastric cancer.
Acknowledgments
This work was supported by a NCRR-NIH grant number 149740220B to J. Zabaleta
References
1. GLOBOCAN. Stomach Cancer Incidence and Mortality Worldwide in 2008. 2008. http://
globocan.iarc.fr/
2. Parkin DM, Bray F, Ferlay J, Pisani P. Global cancer statistics, 2002. CA Cancer J Clin. 2005;
55:74–108. [PubMed: 15761078]
3. Parkin DM. International variation. Oncogene. 2004; 23:6329–6340. [PubMed: 15322508]
4. Jemal A, Siegel R, Xu J, Ward E. Cancer statistics, 2010. CA Cancer J Clin. 2010; 60:277–300.
[PubMed: 20610543]
5. Jass JR, Sobin LH, Watanabe H. The World Health Organization’s histologic classification of
gastrointestinal tumors. A commentary on the second edition. Cancer. 1990; 66:2162–2167.
[PubMed: 2171747]
6. Mulligan RM. Histogenesis and biologic behavior of gastric carcinoma. Pathol Annu. 1972; 7:349–
415. [PubMed: 4557936]
7. Ming SC. Gastric carcinoma. A pathobiological classification. Cancer. 1977; 39:2475–2485.
[PubMed: 872047]
8. LAURÉN P. The two histological main types of gastric carcinoma: diffuse and so-called intestinal-
type carcinoma. An attempt at histo-clinical classification. Acta Pathol Microbiol Scand. 1965;
64:31–49. [PubMed: 14320675]
9. Goseki N, Takizawa T, Koike M. Differences in the mode of the extension of gastric cancer
classified by histological type: new histological classification of gastric carcinoma. Gut. 1992;
33:606–612. [PubMed: 1377153]
10. Crew KD, Neugut AI. Epidemiology of gastric cancer. World J Gastroenterol. 2006; 12:354–362.
[PubMed: 16489633]
11. Correa P, Sasano N, Stemmermann GN, Haenszel W. Pathology of gastric carcinoma in Japanese
populations: comparisons between Miyagi prefecture, Japan, and Hawaii. J Natl Cancer Inst. 1973;
51:1449–1459. [PubMed: 4762929]
12. Mohar A, Suchil-Bernal L, Hernandez-Guerrero A, Podolsky-Rapoport I, Herrera-Goepfert R,
Mora-Tiscareno A, et al. Intestinal type: diffuse type ratio of gastric carcinoma in a Mexican
population. J Exp Clin Cancer Res. 1997; 16:189–194. [PubMed: 9261746]
13. Kaneko S, Yoshimura T. Time trend analysis of gastric cancer incidence in Japan by histological
types, 1975–1989. Br J Cancer. 2001; 84:400–405. [PubMed: 11161407]
14. Henson DE, Dittus C, Younes M, Nguyen H, Bores-Saavedra J. Differential trends in the intestinal
and diffuse types of gastric carcinoma in the United States, 1973–2000: increase in the signet ring
cell type. Arch Pathol Lab Med. 2004; 128:765–770. [PubMed: 15214826]
15. IARC. IARC monograph on the evaluation of carcinogenic risks to humans:Schistosomes, liver
flukes and Helicobacter pylori. IARC. 1994; 61:177–240.
16. Suerbaum S, Michetti P. Helicobacter pylori infection. N Engl J Med. 2002; 347:1175–1186.
[PubMed: 12374879]
Zabaleta Page 12
17. Uemura N, Okamoto S, Yamamoto S, Matsumura N, Yamaguchi S, Yamakido M, et al.

Helicobacter pylori infection and the development of gastric cancer. N Engl J Med. 2001;
345:784–789. [PubMed: 11556297]
18. Wroblewski LE, Peek RM Jr, Wilson KT. Helicobacter pylori and gastric cancer: factors that
modulate disease risk. Clin Microbiol Rev. 2010; 23:713–739. [PubMed: 20930071]
19. Dixon MF, Genta RM, Yardley JH, Correa P. Classification and grading of gastritis. The updated
Sydney System. International Workshop on the Histopathology of Gastritis, Houston 1994. Am J
Surg Pathol. 1996; 20:1161–1181. [PubMed: 8827022]
20. Hansson LE, Nyren O, Hsing AW, Bergstrom R, Josefsson S, Chow WH, et al. The risk of
stomach cancer in patients with gastric or duodenal ulcer disease. N Engl J Med. 1996; 335:242–
249. [PubMed: 8657240]
21. Correa P, Houghton J. Carcinogenesis of Helicobacter pylori. Gastroenterology. 2007; 133:659–
672. [PubMed: 17681184]
22. Zabaleta J, Camargo MC, Piazuelo MB, Fontham E, Schneider BG, Sicinschi LA, et al.
Association of interleukin-1beta gene polymorphisms with precancerous gastric lesions in African
Americans and Caucasians. Am J Gastroenterol. 2006; 101:163–171. [PubMed: 16405550]
23. Rugge M, Correa P, Dixon MF, Hattori T, Leandro G, Lewin K, et al. Gastric dysplasia: the
Padova international classification. Am J Surg Pathol. 2000; 24:167–176. [PubMed: 10680883]
24. Correa P, Haenszel W, Cuello C, Zavala D, Fontham E, Zarama G, et al. Gastric precancerous
process in a high risk population: cohort follow-up. Cancer Res. 1990; 50:4737–4740. [PubMed:
2369748]
25. Coussens LM, Werb Z. Inflammation and cancer. Nature. 2002; 420:860–867. [PubMed:
12490959]
26. El-Omar EM, Carrington M, Chow WH, McColl KE, Bream JH, Young HA, et al. Interleukin-1
polymorphisms associated with increased risk of gastric cancer. Nature. 2000; 404:398–402.
[PubMed: 10746728]
27. Alpizar-Alpizar W, Perez-Perez GI, Une C, Cuenca P, Sierra R. Association of interleukin-1B and
interleukin-1RN polymorphisms with gastric cancer in a high-risk population of Costa Rica. Clin
Exp Med. 2005; 5:169–176. [PubMed: 16362796]
28. Machado JC, Figueiredo C, Canedo P, Pharoah P, Carvalho R, Nabais S, et al. A proinflammatory
genetic profile increases the risk for chronic atrophic gastritis and gastric carcinoma.
Gastroenterology. 2003; 125:364–371. [PubMed: 12891537]
29. El-Omar EM, Rabkin CS, Gammon MD, Vaughan TL, Risch HA, Schoenberg JB, et al. Increased
risk of noncardia gastric cancer associated with proinflammatory cytokine gene polymorphisms.
30. Zabaleta J, Camargo MC, Ritchie MD, Piazuelo MB, Sierra RA, Turner SD, et al. Association of
haplotypes of inflammation-related genes with gastric preneoplastic lesions in African Americans
and Caucasians. Int J Cancer. 2011; 128:668–675. [PubMed: 20473875]
31. Banatvala N, Mayo K, Megraud F, Jennings R, Deeks JJ, Feldman RA. The cohort effect and
Helicobacter pylori. J Infect Dis. 1993; 168:219–221. [PubMed: 8515114]
32. Lindkvist P, Asrat D, Nilsson I, Tsega E, Olsson GL, Wretlind B, et al. Age at acquisition of
Helicobacter pylori infection: comparison of a high and a low prevalence country. Scand J Infect
Dis. 1996; 28:181–184. [PubMed: 8792487]
33. Fiedorek SC, Malaty HM, Evans DL, Pumphrey CL, Casteel HB, Evans DJ Jr, et al. Factors
influencing the epidemiology of Helicobacter pylori infection in children. Pediatrics. 1991;
88:578–582. [PubMed: 1881740]
34. Sitas F, Yarnell J, Forman D. Helicobacter pylori infection rates in relation to age and social class
in a population of Welsh men. Gut. 1992; 33:1582. [PubMed: 1452089]
35. Cover TL, Blaser MJ. Purification and characterization of the vacuolating toxin from Helicobacter
pylori. J Biol Chem. 1992; 267:10570–10575. [PubMed: 1587837]
36. Ilver D, Barone S, Mercati D, Lupetti P, Telford JL. Helicobacter pylori toxin VacA is transferred
to host cells via a novel contact-dependent mechanism. Cell Microbiol. 2004; 6:167–174.
[PubMed: 14706102]
Zabaleta Page 13
37. Leunk RD, Johnson PT, David BC, Kraft WG, Morgan DR. Cytotoxic activity in broth-culture
filtrates of Campylobacter pylori. J Med Microbiol. 1988; 26:93–99. [PubMed: 3385767]
38. Szabo I, Brutsche S, Tombola F, Moschioni M, Satin B, Telford JL, et al. Formation of anion-
selective channels in the cell plasma membrane by the toxin VacA of Helicobacter pylori is
required for its biological activity. EMBO J. 1999; 18:5517–5527. [PubMed: 10523296]
39. Tombola F, Morbiato L, Del GG, Rappuoli R, Zoratti M, Papini E. The Helicobacter pylori VacA
toxin is a urea permease that promotes urea diffusion across epithelia. J Clin Invest. 2001;
108:929–937. [PubMed: 11560962]
40. Mobley HL, Island MD, Hausinger RP. Molecular biology of microbial ureases. Microbiol Rev.
1995; 59:451–480. [PubMed: 7565414]
41. Eaton KA, Brooks CL, Morgan DR, Krakowka S. Essential role of urease in pathogenesis of
gastritis induced by Helicobacter pylori in gnotobiotic piglets. Infect Immun. 1991; 59:2470–2475.
[PubMed: 2050411]
42. Eaton KA, Krakowka S. Effect of gastric pH on urease-dependent colonization of gnotobiotic
piglets by Helicobacter pylori. Infect Immun. 1994; 62:3604–3607. [PubMed: 8063376]
43. Bauerfeind P, Garner R, Dunn BE, Mobley HL. Synthesis and activity of Helicobacter pylori
urease and catalase at low pH. Gut. 1997; 40:25–30. [PubMed: 9155571]
44. Goodwin CS, Armstrong JA, Marshall BJ. Campylobacter pyloridis, gastritis, and peptic
ulceration. J Clin Pathol. 1986; 39:353–365. [PubMed: 3517070]
45. Smoot DT, Mobley HL, Chippendale GR, Lewison JF, Resau JH. Helicobacter pylori urease
activity is toxic to human gastric epithelial cells. Infect Immun. 1990; 58:1992–1994. [PubMed:
2341188]
46. Odenbreit S, Puls J, Sedlmaier B, Gerland E, Fischer W, Haas R. Translocation of Helicobacter
pylori CagA into gastric epithelial cells by type IV secretion. Science. 2000; 287:1497–1500.
[PubMed: 10688800]
47. Backert S, Ziska E, Brinkmann V, Zimny-Arndt U, Fauconnier A, Jungblut PR, et al.
Translocation of the Helicobacter pylori CagA protein in gastric epithelial cells by a type IV
secretion apparatus. Cell Microbiol. 2000; 2:155–164. [PubMed: 11207572]
48. Stein M, Bagnoli F, Halenbeck R, Rappuoli R, Fantl WJ, Covacci A. c-Src/Lyn kinases activate
Helicobacter pylori CagA through tyrosine phosphorylation of the EPIYA motifs. Mol Microbiol.
2002; 43:971–980. [PubMed: 11929545]
49. Higashi H, Tsutsumi R, Muto S, Sugiyama T, Azuma T, Asaka M, et al. SHP-2 tyrosine
phosphatase as an intracellular target of Helicobacter pylori CagA protein. Science. 2002;
295:683–686. [PubMed: 11743164]
50. Puls J, Fischer W, Haas R. Activation of Helicobacter pylori CagA by tyrosine phosphorylation is
essential for dephosphorylation of host cell proteins in gastric epithelial cells. Mol Microbiol.
2002; 43:961–969. [PubMed: 11936078]
51. Loh JT, Torres VJ, Cover TL. Regulation of Helicobacter pylori cagA expression in response to
salt. Cancer Res. 2007; 67:4709–4715. [PubMed: 17510398]
52. Segal ED, Cha J, Lo J, Falkow S, Tompkins LS. Altered states: involvement of phosphorylated
CagA in the induction of host cellular growth changes by Helicobacter pylori. Proc Natl Acad Sci
U S A. 1999; 96:14559–14564. [PubMed: 10588744]
53. Kunkel SL, Standiford T, Kasahara K, Strieter RM. Interleukin-8 (IL-8): the major neutrophil
chemotactic factor in the lung. Exp Lung Res. 1991; 17:17–23. [PubMed: 2013270]
54. Papoff P, Fiorucci P, Ottaviano C, Bucci G. Interleukin-8: a potent neutrophil chemotactic factor.
Arch Dis Child Fetal Neonatal Ed. 1995; 73:F54. [PubMed: 7552603]
55. Matsushima K, Baldwin ET, Mukaida N. Interleukin-8 and MCAF: novel leukocyte recruitment
and activating cytokines. Chem Immunol. 1992; 51:236–265. [PubMed: 1567543]
56. Roebuck KA. Regulation of interleukin-8 gene expression. J Interferon Cytokine Res. 1999;
19:429–438. [PubMed: 10386854]
57. McGee DJ, Radcliff FJ, Mendz GL, Ferrero RL, Mobley HL. Helicobacter pylori rocF is required
for arginase activity and acid protection in vitro but is not essential for colonization of mice or for
urease activity. J Bacteriol. 1999; 181:7314–7322. [PubMed: 10572136]
Zabaleta Page 14
58. Tomb JF, White O, Kerlavage AR, Clayton RA, Sutton GG, Fleischmann RD, et al. The complete
genome sequence of the gastric pathogen Helicobacter pylori. Nature. 1997; 388:539–547.
[PubMed: 9252185]
59. Alm RA, Ling LS, Moir DT, King BL, Brown ED, Doig PC, et al. Genomic-sequence comparison
of two unrelated isolates of the human gastric pathogen Helicobacter pylori. Nature. 1999;
397:176–180. [PubMed: 9923682]
60. Sekowska A, Danchin A, Risler JL. Phylogeny of related functions: the case of polyamine
biosynthetic enzymes. Microbiology. 2000; 146 (Pt 8):1815–1828. [PubMed: 10931887]
61. Tabor CW, Tabor H. Polyamines. Annu Rev Biochem. 1984; 53:749–790. [PubMed: 6206782]
62. Roberts SC, Tancer MJ, Polinsky MR, Gibson KM, Heby O, Ullman B. Arginase plays a pivotal
role in polyamine precursor metabolism in Leishmania. Characterization of gene deletion mutants.
J Biol Chem. 2004; 279:23668–23678. [PubMed: 15023992]
63. Mendz GL, Hazell SL. Aminoacid utilization by Helicobacter pylori. Int J Biochem Cell Biol.
1995; 27:1085–1093. [PubMed: 7496998]
64. Zabaleta J, McGee DJ, Zea AH, Hernandez CP, Rodriguez PC, Sierra RA, et al. Helicobacter
pylori arginase inhibits T cell proliferation and reduces the expression of the TCR zeta-chain
(CD3zeta). J Immunol. 2004; 173:586–593. [PubMed: 15210820]
65. Gobert AP, McGee DJ, Akhtar M, Mendz GL, Newton JC, Cheng Y, et al. Helicobacter pylori
arginase inhibits nitric oxide production by eukaryotic cells: a strategy for bacterial survival. Proc
Natl Acad Sci U S A. 2001; 98:13844–13849. [PubMed: 11717441]
66. Chmiela M, Lelwala-Guruge JA, Wadstrom T, Rudnicka W. The stimulation and inhibition of T
cell proliferation by Helicobacter pylori components. J Physiol Pharmacol. 1996; 47:195–202.

[PubMed: 8777299]
67. Rudnicka W, Covacci A, Wadstrom T, Chmiela M. A recombinant fragment of Helicobacter pylori
CagA affects proliferation of human cells. J Physiol Pharmacol. 1998; 49:111–119. [PubMed:
9594415]
68. Meyer F, Wilson KT, James SP. Modulation of innate cytokine responses by products of
Helicobacter pylori. Infect Immun. 2000; 68:6265–6272. [PubMed: 11035734]
69. Knipp U, Birkholz S, Kaup W, Opferkuch W. Partial characterization of a cell proliferation-
inhibiting protein produced by Helicobacter pylori. Infect Immun. 1996; 64:3491–3496. [PubMed:
8751889]
70. Paziak-Domanska B, Chmiela M, Jarosinska A, Rudnicka W. Potential role of CagA in the
inhibition of T cell reactivity in Helicobacter pylori infections. Cell Immunol. 2000; 202:136–139.
[PubMed: 10896773]
71. Ricci V, Ciacci C, Zarrilli R, Sommi P, Tummuru MK, Del Vecchio BC, et al. Effect of
Helicobacter pylori on gastric epithelial cell migration and proliferation in vitro: role of VacA and
CagA. Infect Immun. 1996; 64:2829–2833. [PubMed: 8698518]
72. Smoot DT, Wynn Z, Elliott TB, Allen CR, Mekasha G, Naab T, et al. Effects of Helicobacter
pylori on proliferation of gastric epithelial cells in vitro. Am J Gastroenterol. 1999; 94:1508–1511.
[PubMed: 10364015]
73. Rokkas T, Ladas S, Liatsos C, Petridou E, Papatheodorou G, Theocharis S, et al. Relationship of

Helicobacter pylori CagA status to gastric cell proliferation and apoptosis. Dig Dis Sci. 1999;
44:487–493. [PubMed: 10080139]
74. Kim CW, Choi SH, Chung EJ, Lee MJ, Byun EK, Ryu MH, et al. Alteration of signal-transducing
molecules and phenotypical characteristics in peripheral blood lymphocytes from gastric
carcinoma patients. Pathobiology. 1999; 67:123–128. [PubMed: 10394132]
75. Takahashi A, Kono K, Amemiya H, Iizuka H, Fujii H, Matsumoto Y. Elevated caspase-3 activity
in peripheral blood T cells coexists with increased degree of T-cell apoptosis and down-regulation
of TCR zeta molecules in patients with gastric cancer. Clin Cancer Res. 2001; 7:74–80. [PubMed:
11205921]
76. Ishigami S, Natsugoe S, Miyazono F, Tokuda K, Nakajo A, Matsumoto M, et al. CD3 zeta
expression of regional lymph node and peripheral blood lymphocytes in gastric cancer. Anticancer
Res. 2004; 24:2123–2126. [PubMed: 15274412]
Zabaleta Page 15
77. Roth KA, Kapadia SB, Martin SM, Lorenz RG. Cellular immune responses are essential for the
development of Helicobacter felis-associated gastric pathology. J Immunol. 1999; 163:1490–1497.
[PubMed: 10415051]
78. Mohammadi M, Nedrud J, Redline R, Lycke N, Czinn SJ. Murine CD4 T-cell response to
Helicobacter infection: TH1 cells enhance gastritis and TH2 cells reduce bacterial load.
79. Nedrud, JG.; Mohammadi, M.; Blanchard, T.; Redline, R.; Czinn, SJ. TH1/TH2 lymphocyte
responses in Helicobacter infections. In: Hunt, R.; Tycgat, S., editors. Helicobacter pylori
Mechanisms to clinical cure. Kluwer Academics Publishers; Boston: 1998. p. 101-9.
80. Bamford KB, Fan X, Crowe SE, Leary JF, Gourley WK, Luthra GK, et al. Lymphocytes in the
human gastric mucosa during Helicobacter pylori have a T helper cell 1 phenotype.
81. Lindholm C, Quiding-Jarbrink M, Lonroth H, Hamlet A, Svennerholm AM. Local cytokine
response in Helicobacter pylori-infected subjects. Infect Immun. 1998; 66:5964–5971. [PubMed:
9826379]
82. Yamaoka Y, Kodama T, Kita M, Imanishi J, Kashima K, Graham DY. Relation between cytokines
and Helicobacter pylori in gastric cancer. Helicobacter. 2001; 6:116–124. [PubMed: 11422466]
83. Morris SM Jr. Recent advances in arginine metabolism. Curr Opin Clin Nutr Metab Care. 2004;
7:45–51. [PubMed: 15090903]
84. Roth E, Steininger R, Winkler S, Langle F, Grunberger T, Fugger R, et al. L-Arginine deficiency
after liver transplantation as an effect of arginase efflux from the graft. Influence on nitric oxide
metabolism. Transplantation. 1994; 57:665–669. [PubMed: 8140629]

85. Zea AH, Rodriguez PC, Atkins MB, Hernandez C, Signoretti S, Zabaleta J, et al. Arginase-
producing myeloid suppressor cells in renal cell carcinoma patients: a mechanism of tumor
evasion. Cancer Res. 2005; 65:3044–3048. [PubMed: 15833831]
86. Rodriguez PC, Quiceno DG, Zabaleta J, Ortiz B, Zea AH, Piazuelo MB, et al. Arginase I
production in the tumor microenvironment by mature myeloid cells inhibits T-cell receptor
expression and antigen-specific T-cell responses. Cancer Res. 2004; 64:5839–5849. [PubMed:
15313928]
87. Rodriguez PC, Zea AH, Culotta KS, Zabaleta J, Ochoa JB, Ochoa AC. Regulation of T cell
receptor CD3zeta chain expression by L-arginine. J Biol Chem. 2002; 277:21123–21129.
[PubMed: 11950832]
88. Munder M, Mollinedo F, Calafat J, Canchado J, Gil-Lamaignere C, Fuentes JM, et al. Arginase I is
constitutively expressed in human granulocytes and participates in fungicidal activity. Blood.
2005; 105:2549–2556. [PubMed: 15546957]
89. Munder M, Schneider H, Luckner C, Giese T, Langhans CD, Fuentes JM, et al. Suppression of T-
cell functions by human granulocyte arginase. Blood. 2006; 108:1627–1634. [PubMed: 16709924]
90. Kropf P, Baud D, Marshall SE, Munder M, Mosley A, Fuentes JM, et al. Arginase activity
mediates reversible T cell hyporesponsiveness in human pregnancy. Eur J Immunol. 2007;
37:935–945. [PubMed: 17330821]
91. Chang CI, Liao JC, Kuo L. Macrophage arginase promotes tumor cell growth and suppresses nitric
oxide-mediated tumor cytotoxicity. Cancer Res. 2001; 61:1100–1106. [PubMed: 11221839]
92. Mendez JD, Arreola MA. Effect of L-arginine on pancreatic arginase activity and polyamines in
alloxan treated rats. Biochem Int. 1992; 28:569–575. [PubMed: 1482395]
93. Mori M, Gotoh T. Regulation of nitric oxide production by arginine metabolic enzymes. Biochem
Biophys Res Commun. 2000; 275:715–719. [PubMed: 10973788]
94. Murray HW, Teitelbaum RF. L-arginine-dependent reactive nitrogen intermediates and the
antimicrobial effect of activated human mononuclear phagocytes. J Infect Dis. 1992; 165:513–517.
[PubMed: 1538156]
95. Das P, Lahiri A, Lahiri A, Chakravortty D. Modulation of the arginase pathway in the context of
microbial pathogenesis: a metabolic enzyme moonlighting as an immune modulator. PLoS Pathog.
2010; 6:e1000899. [PubMed: 20585552]
96. Hung CY, Xue J, Cole GT. Virulence mechanisms of coccidioides. Ann N Y Acad Sci. 2007;
1111:225–235. [PubMed: 17513466]
Zabaleta Page 16
97. Luiking YC, Poeze M, Dejong CH, Ramsay G, Deutz NE. Sepsis: an arginine deficiency state?
Crit Care Med. 2004; 32:2135–2145. [PubMed: 15483426]
98. Luiking YC, Poeze M, Ramsay G, Deutz NE. The role of arginine in infection and sepsis. JPEN J
Parenter Enteral Nutr. 2005; 29:S70–S74. [PubMed: 15709548]

99. Molnar B, Galamb O, Sipos F, Leiszter K, Tulassay Z. Molecular pathogenesis of Helicobacter
pylori infection: the role of bacterial virulence factors. Dig Dis. 2010; 28:604–608. [PubMed:
21088410]
100. Mori M, Gotoh T. Arginine metabolic enzymes, nitric oxide and infection. J Nutr. 2004;
134:2820S–2825S. [PubMed: 15465793]
101. Wanasen N, Soong L. L-arginine metabolism and its impact on host immunity against
Leishmania infection. Immunol Res. 2008; 41:15–25. [PubMed: 18040886]
102. Mendz GL, Holmes EM, Ferrero RL. In situ characterization of Helicobacter pylori arginase.
Biochim Biophys Acta. 1998; 1388:465–477. [PubMed: 9858781]
103. Lewis ND, Asim M, Barry DP, Singh K, de ST, Boucher JL, et al. Arginase II restricts host
defense to Helicobacter pylori by attenuating inducible nitric oxide synthase translation in
macrophages. J Immunol. 2010; 184:2572–2582. [PubMed: 20097867]
104. Gobert AP, Cheng Y, Wang JY, Boucher JL, Iyer RK, Cederbaum SD, et al. Helicobacter pylori
induces macrophage apoptosis by activation of arginase II. J Immunol. 2002; 168:4692–4700.
[PubMed: 11971019]
105. Lewis ND, Asim M, Barry DP, de ST, Singh K, Piazuelo MB, et al. Immune Evasion by
Helicobacter pylori Is Mediated by Induction of Macrophage Arginase II. J Immunol. 2011;
186:3632–3641. [PubMed: 21296975]

106. Hoffman SM, Fleming SD. Natural Helicobacter infection modulates mouse intestinal muscularis
macrophage responses. Cell Biochem Funct. 2010; 28:686–694. [PubMed: 21104937]
107. el-Zimaity HM, Graham DY. Ultrastructural evidence of in vivo phagocytosis of Helicobacter
pylori. Ultrastruct Pathol. 2001; 25:159. [PubMed: 11407530]
108. Zu Y, Cassai ND, Sidhu GS. Light microscopic and ultrastructural evidence of in vivo
phagocytosis of Helicobacter pylori by neutrophils. Ultrastruct Pathol. 2000; 24:319–323.
[PubMed: 11071570]
109. Ozbek A, Ozbek E, Dursun H, Kalkan Y, Demirci T. Can Helicobacter pylori invade human
gastric mucosa?: an in vivo study using electron microscopy, immunohistochemical methods,
and real-time polymerase chain reaction. J Clin Gastroenterol. 2010; 44:416–422. [PubMed:
19904218]
110. Ramarao N, Gray-Owen SD, Backert S, Meyer TF. Helicobacter pylori inhibits phagocytosis by
professional phagocytes involving type IV secretion components. Mol Microbiol. 2000;
37:1389–1404. [PubMed: 10998171]
111. Allen LA, Schlesinger LS, Kang B. Virulent strains of Helicobacter pylori demonstrate delayed
phagocytosis and stimulate homotypic phagosome fusion in macrophages. J Exp Med. 2000;
191:115–128. [PubMed: 10620610]
112. Zheng PY, Jones NL. Helicobacter pylori strains expressing the vacuolating cytotoxin interrupt
phagosome maturation in macrophages by recruiting and retaining TACO (coronin 1) protein.
Cell Microbiol. 2003; 5:25–40. [PubMed: 12542468]
113. Ramarao N, Meyer TF. Helicobacter pylori resists phagocytosis by macrophages: quantitative
assessment by confocal microscopy and fluorescence-activated cell sorting. Infect Immun. 2001;
69:2604–2611. [PubMed: 11254625]
114. Wang YH, Wu JJ, Lei HY. When Helicobacter pylori invades and replicates in the cells.
Autophagy. 2009; 5:540–542. [PubMed: 19270492]
115. Turner DM, Williams DM, Sankaran D, Lazarus M, Sinnott PJ, Hutchinson IV. An investigation
of polymorphism in the interleukin-10 gene promoter. Eur J Immunogenet. 1997; 24:1–8.
[PubMed: 9043871]
116. Rad R, Dossumbekova A, Neu B, Lang R, Bauer S, Saur D, et al. Cytokine gene polymorphisms
influence mucosal cytokine expression, gastric inflammation, and host specific colonisation
during Helicobacter pylori infection. Gut. 2004; 53:1082–1089. [PubMed: 15247172]
Zabaleta Page 17
117. Hwang IR, Kodama T, Kikuchi S, Sakai K, Peterson LE, Graham DY, et al. Effect of interleukin
1 polymorphisms on gastric mucosal interleukin 1beta production in Helicobacterpyloriinfection.
118. Pociot F, Molvig J, Wogensen L, Worsaae H, Nerup J. A TaqI polymorphism in the human
interleukin-1 beta (IL-1 beta) gene correlates with IL-1 beta secretion in vitro. Eur J Clin Invest.
1992; 22:396–402. [PubMed: 1353022]
119. Kroeger KM, Carville KS, Abraham LJ. The -308 tumor necrosis factor-alpha promoter
polymorphism effects transcription. Mol Immunol. 1997; 34:391–399. [PubMed: 9293772]
120. Wilson AG, Symons JA, McDowell TL, McDevitt HO, Duff GW. Effects of a polymorphism in
the human tumor necrosis factor alpha promoter on transcriptional activation. Proc Natl Acad Sci
U S A. 1997; 94:3195–3199. [PubMed: 9096369]
121. Fishman D, Faulds G, Jeffery R, Mohamed-Ali V, Yudkin JS, Humphries S, et al. The effect of
novel polymorphisms in the interleukin-6 (IL-6) gene on IL-6 transcription and plasma IL-6
levels, and an association with systemic-onset juvenile chronic arthritis. J Clin Invest. 1998;
102:1369–1376. [PubMed: 9769329]
122. Terry CF, Loukaci V, Green FR. Cooperative influence of genetic polymorphisms on interleukin
6 transcriptional regulation. J Biol Chem. 2000; 275:18138–18144. [PubMed: 10747905]
123. Abdallah AN, Cucchi-Mouillot P, Biteau N, Cassaigne A, Haras D, Iron A. Analysis of the
polymorphism of the tumour necrosis factor (TNF) gene and promoter and of circulating TNF-
alpha levels in heart-transplant patients suffering or not suffering from severe rejection. Eur J
Immunogenet. 1999; 26:249–255. [PubMed: 10457886]
124. Bunnapradist S, Jordan SC. The role of cytokines and cytokine gene polymorphism in T-cell
activation and allograft rejection. Ann Acad Med Singapore. 2000; 29:412–416. [PubMed:
10976399]
125. Hajeer AH, Lazarus M, Turner D, Mageed RA, Vencovsky J, Sinnott P, et al. IL-10 gene
promoter polymorphisms in rheumatoid arthritis. Scand J Rheumatol. 1998; 27:142–145.
[PubMed: 9572641]
126. Cabrera M, Shaw MA, Sharples C, Williams H, Castes M, Convit J, et al. Polymorphism in tumor
necrosis factor genes associated with mucocutaneous leishmaniasis. J Exp Med. 1995; 182:1259–
1264. [PubMed: 7595196]
127. Wilkinson RJ, Patel P, Llewelyn M, Hirsch CS, Pasvol G, Snounou G, et al. Influence of
polymorphism in the genes for the interleukin (IL)-1 receptor antagonist and IL-1beta on
tuberculosis. J Exp Med. 1999; 189:1863–1874. [PubMed: 10377182]
128. SEER. SEER Cancer Statistics Review 1975–2004. 2004. http://seer.cancer.gov/csr/1975_2004/
results_merged/topic_inc_trends.pdf
129. Cancer Health Disparities. 2008. http://www.cancer.gov/cancertopics/types/disparities
130. Gabriel SB, Schaffner SF, Nguyen H, Moore JM, Roy J, Blumenstiel B, et al. The structure of
haplotype blocks in the human genome. Science. 2002; 296:2225–2229. [PubMed: 12029063]
131. Huang W, He Y, Wang H, Wang Y, Liu Y, Wang Y, et al. Linkage disequilibrium sharing and
haplotype-tagged SNP portability between populations. Proc Natl Acad Sci U S A. 2006;
103:1418–1421. [PubMed: 16432195]

132. Epplein M, Signorello LB, Zheng W, Peek RM Jr, Michel A, Williams SM, et al. Race, African
ancestry, and Helicobacter pylori infection in a low-income United States population. Cancer
Epidemiol Biomarkers Prev. 2011
133. Lee CG, Gottesman MM, Cardarelli CO, Ramachandra M, Jeang KT, Ambudkar SV, et al. HIV-1
protease inhibitors are substrates for the MDR1 multi-drug transporter. Biochemistry. 1998;
37:3594–3601. [PubMed: 9530286]
134. Lee CG, Gottesman MM. HIV-1 protease inhibitors and the MDR1 multidrug transporter. J Clin
Invest. 1998; 101:287–288. [PubMed: 9435298]
135. Balram C, Sharma A, Sivathasan C, Lee EJ. Frequency of C3435T single nucleotide MDR1
genetic polymorphism in an Asian population: phenotypic-genotypic correlates. Br J Clin
Pharmacol. 2003; 56:78–83. [PubMed: 12848778]
136. Hitzl M, Drescher S, van der KH, Schaffeler E, Fischer J, Schwab M, et al. The C3435T mutation
in the human MDR1 gene is associated with altered efflux of the P-glycoprotein substrate
Zabaleta Page 18
rhodamine 123 from CD56+ natural killer cells. Pharmacogenetics. 2001; 11:293–298. [PubMed:
11434506]
137. Hoffmeyer S, Burk O, von RO, Arnold HP, Brockmoller J, Johne A, et al. Functional
polymorphisms of the human multidrug-resistance gene: multiple sequence variations and

correlation of one allele with P-glycoprotein expression and activity in vivo. Proc Natl Acad Sci
U S A. 2000; 97:3473–3478. [PubMed: 10716719]
138. Tanabe M, Ieiri I, Nagata N, Inoue K, Ito S, Kanamori Y, et al. Expression of P-glycoprotein in
human placenta: relation to genetic polymorphism of the multidrug resistance (MDR)-1 gene. J
Pharmacol Exp Ther. 2001; 297:1137–1143. [PubMed: 11356939]
139. Kim RB, Leake BF, Choo EF, Dresser GK, Kubba SV, Schwarz UI, et al. Identification of
functionally variant MDR1 alleles among European Americans and African Americans. Clin
Pharmacol Ther. 2001; 70:189–199. [PubMed: 11503014]
140. Sakaeda T, Nakamura T, Horinouchi M, Kakumoto M, Ohmoto N, Sakai T, et al. MDR1
genotype-related pharmacokinetics of digoxin after single oral administration in healthy Japanese
subjects. Pharm Res. 2001; 18:1400–1404. [PubMed: 11697464]
141. Fellay J, Marzolini C, Meaden ER, Back DJ, Buclin T, Chave JP, et al. Response to antiretroviral
treatment in HIV-1-infected individuals with allelic variants of the multidrug resistance
transporter 1: a pharmacogenetics study. Lancet. 2002; 359:30–36. [PubMed: 11809184]
142. von AN, Richter M, Grupp C, Ringe B, Oellerich M, Armstrong VW. No influence of the MDR-1
C3435T polymorphism or a CYP3A4 promoter polymorphism (CYP3A4-V allele) on dose-
adjusted cyclosporin A trough concentrations or rejection incidence in stable renal transplant
recipients. Clin Chem. 2001; 47:1048–1052. [PubMed: 11375290]
143. Tang K, Ngoi SM, Gwee PC, Chua JM, Lee EJ, Chong SS, et al. Distinct haplotype profiles and
strong linkage disequilibrium at the MDR1 multidrug transporter gene locus in three ethnic Asian
populations. Pharmacogenetics. 2002; 12:437–450. [PubMed: 12172212]
144. Machado JC, Pharoah P, Sousa S, Carvalho R, Oliveira C, Figueiredo C, et al. Interleukin 1B and
interleukin 1RN polymorphisms are associated with increased risk of gastric carcinoma.
145. Sicinschi LA, Lopez-Carrillo L, Camargo MC, Correa P, Sierra RA, Henry RR, et al. Gastric
cancer risk in a Mexican population: role of Helicobacter pylori CagA positive infection and
polymorphisms in interleukin-1 and -10 genes. Int J Cancer. 2006; 118:649–657. [PubMed:
16114018]
146. Xue H, Lin B, Ni P, Xu H, Huang G. Interleukin-1B and interleukin-1 RN polymorphisms and
gastric carcinoma risk: a meta-analysis. J Gastroenterol Hepatol. 2010; 25:1604–1617. [PubMed:
20880168]
147. Wang P, Xia HH, Zhang JY, Dai LP, Xu XQ, Wang KJ. Association of interleukin-1 gene
polymorphisms with gastric cancer: a meta-analysis. Int J Cancer. 2007; 120:552–562. [PubMed:
17096351]
148. Camargo MC, Mera R, Correa P, Peek RM Jr, Fontham ET, Goodman KJ, et al. Interleukin-1beta
and interleukin-1 receptor antagonist gene polymorphisms and gastric cancer: a meta-analysis.
Cancer Epidemiol Biomarkers Prev. 2006; 15:1674–1687. [PubMed: 16985030]

149. Persson C, Canedo P, Machado JC, El-Omar EM, Forman D. Polymorphisms in inflammatory
response genes and their association with gastric cancer: A HuGE systematic review and meta-
analyses. Am J Epidemiol. 2011; 173:259–270. [PubMed: 21178102]
150. Beales IL, Calam J. Interleukin 1 beta and tumour necrosis factor alpha inhibit acid secretion in
cultured rabbit parietal cells by multiple pathways. Gut. 1998; 42:227–234. [PubMed: 9536948]
151. Chen H, Wilkins LM, Aziz N, Cannings C, Wyllie DH, Bingle C, et al. Single nucleotide
polymorphisms in the human interleukin-1B gene affect transcription according to haplotype
context. Hum Mol Genet. 2006; 15:519–529. [PubMed: 16399797]
152. Arend WP, Malyak M, Guthridge CJ, Gabay C. Interleukin-1 receptor antagonist: role in biology.
Annu Rev Immunol. 1998; 16:27–55. [PubMed: 9597123]
153. Andus T, Daig R, Vogl D, Aschenbrenner E, Lock G, Hollerbach S, et al. Imbalance of the
interleukin 1 system in colonic mucosa--association with intestinal inflammation and interleukin
1 receptor antagonist (corrected) genotype 2. Gut. 1997; 41:651–657. [PubMed: 9414973]
Zabaleta Page 19
154. Tountas NA, Casini-Raggi V, Yang H, Di Giovine FS, Vecchi M, Kam L, et al. Functional and
ethnic association of allele 2 of the interleukin-1 receptor antagonist gene in ulcerative colitis.
155. Shih CM, Lee YL, Chiou HL, Chen W, Chang GC, Chou MC, et al. Association of TNF-alpha
polymorphism with susceptibility to and severity of non-small cell lung cancer. Lung Cancer.
2006; 52:15–20. [PubMed: 16476505]
156. Zambon CF, Basso D, Navaglia F, Belluco C, Falda A, Fogar P, et al. Pro- and anti-inflammatory
cytokines gene polymorphisms and Helicobacter pylori infection: interactions influence outcome.
Cytokine. 2005; 29:141–152. [PubMed: 15652446]
157. Hellmig S, Fischbach W, Goebeler-Kolve ME, Folsch UR, Hampe J, Schreiber S. A functional
promotor polymorphism of TNF-alpha is associated with primary gastric B-Cell lymphoma. Am
J Gastroenterol. 2005; 100:2644–2649. [PubMed: 16393214]
158. Kido S, Kitadai Y, Hattori N, Haruma K, Kido T, Ohta M, et al. Interleukin 8 and vascular
endothelial growth factor—prognostic factors in human gastric carcinomas? Eur J Cancer. 2001;
37:1482–1487. [PubMed: 11506954]
159. Kitadai Y, Haruma K, Mukaida N, Ohmoto Y, Matsutani N, Yasui W, et al. Regulation of
disease-progression genes in human gastric carcinoma cells by interleukin 8. Clin Cancer Res.
2000; 6:2735–2740. [PubMed: 10914718]
160. Savage SA, Abnet CC, Mark SD, Qiao YL, Dong ZW, Dawsey SM, et al. Variants of the IL8 and
IL8RB genes and risk for gastric cardia adenocarcinoma and esophageal squamous cell
carcinoma. Cancer Epidemiol Biomarkers Prev. 2004; 13:2251–2257. [PubMed: 15598788]
161. Kato I, Van Doorn LJ, Canzian F, Plummer M, Franceschi S, Vivas J, et al. Host-bacterial
interaction in the development of gastric precancerous lesions in a high risk population for gastric
cancer in Venezuela. Int J Cancer. 2006; 119:1666–1671. [PubMed: 16671087]
162. Mege JL, Meghari S, Honstettre A, Capo C, Raoult D. The two faces of interleukin 10 in human
infectious diseases. Lancet Infect Dis. 2006; 6:557–569. [PubMed: 16931407]
163. Havranek E, Howell WM, Fussell HM, Whelan JA, Whelan MA, Pandha HS. An interleukin-10
promoter polymorphism may influence tumor development in renal cell carcinoma. J Urol. 2005;
173:709–712. [PubMed: 15711248]
164. Nikolova PN, Pawelec GP, Mihailova SM, Ivanova MI, Myhailova AP, Baltadjieva DN, et al.
Association of cytokine gene polymorphisms with malignant melanoma in Caucasian population.
Cancer Immunol Immunother. 2007; 56:371–379. [PubMed: 16835788]
165. Seifart C, Plagens A, Dempfle A, Clostermann U, Vogelmeier C, von WP, et al. TNF-alpha,
TNF-beta, IL-6, and IL-10 polymorphisms in patients with lung cancer. Dis Markers. 2005;
21:157–165. [PubMed: 16276011]
166. Sakamoto H, Yoshimura K, Saeki N, Katai H, Shimoda T, Matsuno Y, et al. Genetic variation in
PSCA is associated with susceptibility to diffuse-type gastric cancer. Nat Genet. 2008; 40:730–
740. [PubMed: 18488030]
167. Lu Y, Chen J, Ding Y, Jin G, Wu J, Huang H, et al. Genetic variation of PSCA gene is associated
with the risk of both diffuse- and intestinal-type gastric cancer in a Chinese population. Int J
Cancer. 2010; 127:2183–2189. [PubMed: 20131315]

168. Abnet CC, Freedman ND, Hu N, Wang Z, Yu K, Shu XO, et al. A shared susceptibility locus in
PLCE1 at 10q23 for gastric adenocarcinoma and esophageal squamous cell carcinoma. Nat
Genet. 2010; 42:764–767. [PubMed: 20729852]
169. Bird A. DNA methylation patterns and epigenetic memory. Genes Dev. 2002; 16:6–21. [PubMed:
11782440]
170. Wang Y, Leung FC. An evaluation of new criteria for CpG islands in the human genome as gene
markers. Bioinformatics. 2004; 20:1170–1177. [PubMed: 14764558]
171. Tate PH, Bird AP. Effects of DNA methylation on DNA-binding proteins and gene expression.
Curr Opin Genet Dev. 1993; 3:226–231. [PubMed: 8504247]
172. Nan X, Meehan RR, Bird A. Dissection of the methyl-CpG binding domain from the
chromosomal protein MeCP2. Nucleic Acids Res. 1993; 21:4886–4892. [PubMed: 8177735]
173. Prendergast GC, Ziff EB. Methylation-sensitive sequence-specific DNA binding by the c-Myc
basic region. Science. 1991; 251:186–189. [PubMed: 1987636]
Zabaleta Page 20
174. Watt F, Molloy PL. Cytosine methylation prevents binding to DNA of a HeLa cell transcription
factor required for optimal expression of the adenovirus major late promoter. Genes Dev. 1988;
2:1136–1143. [PubMed: 3192075]
175. Jones PL, Veenstra GJ, Wade PA, Vermaak D, Kass SU, Landsberger N, et al. Methylated DNA
and MeCP2 recruit histone deacetylase to repress transcription. Nat Genet. 1998; 19:187–191.
[PubMed: 9620779]
176. Nan X, Ng HH, Johnson CA, Laherty CD, Turner BM, Eisenman RN, et al. Transcriptional
repression by the methyl-CpG-binding protein MeCP2 involves a histone deacetylase complex.
Nature. 1998; 393:386–389. [PubMed: 9620804]
177. Kim GD, Ni J, Kelesoglu N, Roberts RJ, Pradhan S. Co-operation and communication between
the human maintenance and de novo DNA (cytosine-5) methyltransferases. EMBO J. 2002;
21:4183–4195. [PubMed: 12145218]
178. Okano M, Bell DW, Haber DA, Li E. DNA methyltransferases Dnmt3a and Dnmt3b are essential
for de novo methylation and mammalian development. Cell. 1999; 99:247–257. [PubMed:
10555141]
179. Fan H, Liu D, Qiu X, Qiao F, Wu Q, Su X, et al. A functional polymorphism in the DNA
methyltransferase-3A promoter modifies the susceptibility in gastric cancer but not in esophageal
carcinoma. BMC Med. 2010; 8:12. [PubMed: 20128888]
180. Esteller M. CpG island hypermethylation and tumor suppressor genes: a booming present, a
brighter future. Oncogene. 2002; 21:5427–5440. [PubMed: 12154405]
181. Yamashita S, Tsujino Y, Moriguchi K, Tatematsu M, Ushijima T. Chemical genomic screening
for methylation-silenced genes in gastric cancer cell lines using 5-aza-2′-deoxycytidine treatment
and oligo-nucleotide microarray. Cancer Sci. 2006; 97:64–71. [PubMed: 16367923]
182. Schneider BG, Peng DF, Camargo MC, Piazuelo MB, Sicinschi LA, Mera R, et al. Promoter
DNA hypermethylation in gastric biopsies from subjects at high and low risk for gastric cancer.
Int J Cancer. 2010; 127:2588–2597. [PubMed: 20178103]
183. Shen H, Xu Y, Zheng Y, Qian Y, Yu R, Qin Y, et al. Polymorphisms of 5,10-
methylenetetrahydrofolate reductase and risk of gastric cancer in a Chinese population: a case-
control study. Int J Cancer. 2001; 95:332–336. [PubMed: 11494235]
184. Neves Filho EH, Alves MK, Lima VP, Rabenhorst SH. MTHFR C677T polymorphism and
differential methylation status in gastric cancer: an association with Helicobacter pylori infection.
Virchows Arch. 2010; 457:627–633. [PubMed: 20957490]
185. Dong CX, Deng DJ, Pan KF, Zhang L, Zhang Y, Zhou J, et al. Promoter methylation of p16
associated with Helicobacter pylori infection in precancerous gastric lesions: a population-based
study. Int J Cancer. 2009; 124:434–439. [PubMed: 18821580]
186. Kague E, Thomazini CM, Pardini MI, de CF, Leite CV, Pinheiro NA. Methylation status of
CDH1 gene in samples of gastric mucous from Brazilian patients with chronic gastritis infected
by Helicobacter pylori. Arq Gastroenterol. 2010; 47:7–12. [PubMed: 20520968]
187. Alves MK, Lima VP, Ferrasi AC, Rodrigues MA, De Moura Campos Pardini MI, Rabenhorst SH.
CDKN2A promoter methylation is related to the tumor location and histological subtype and
associated with Helicobacter pylori flaA(+) strains in gastric adenocarcinomas. APMIS. 2010;
118:297–307. [PubMed: 20402675]
188. Chan AO, Peng JZ, Lam SK, Lai KC, Yuen MF, Cheung HK, et al. Eradication of Helicobacter
pylori infection reverses E-cadherin promoter hypermethylation. Gut. 2006; 55:463–468.
[PubMed: 16428266]
189. Guilford P, Hopkins J, Harraway J, McLeod M, McLeod N, Harawira P, et al. E-cadherin
germline mutations in familial gastric cancer. Nature. 1998; 392:402–405. [PubMed: 9537325]
190. Yoo EJ, Park SY, Cho NY, Kim N, Lee HS, Kim D, et al. Influence of IL1B polymorphism on
CpG island hypermethylation in Helicobacter pylori-infected gastric cancer. Virchows Arch.
2010; 456:647–652. [PubMed: 20405297]
191. McMichael AJ, McCall MG, Hartshorne JM, Woodings TL. Patterns of gastro-intestinal cancer in
European migrants to Australia: the role of dietary change. Int J Cancer. 1980; 25:431–437.
[PubMed: 7372370]
Zabaleta Page 21
192. Haenszel W, Kurihara M. Studies of Japanese migrants. I. Mortality from cancer and other
diseases among Japanese in the United States. J Natl Cancer Inst. 1968; 40:43–68. [PubMed:
5635018]
193. Plummer M, Franceschi S, Munoz N. Epidemiology of gastric cancer. IARC Sci Publ. 2004:311–
326. [PubMed: 15055304]
194. Lunet N, Valbuena C, Vieira AL, Lopes C, Lopes C, David L, et al. Fruit and vegetable
consumption and gastric cancer by location and histological type: case-control and meta-analysis.
Eur J Cancer Prev. 2007; 16:312–327. [PubMed: 17554204]
195. Terry P, Nyren O, Yuen J. Protective effect of fruits and vegetables on stomach cancer in a cohort
of Swedish twins. Int J Cancer. 1998; 76:35–37. [PubMed: 9533759]
196. Jansen MC, Bueno-de-Mesquita HB, Rasanen L, Fidanza F, Menotti A, Nissinen A, et al.
Consumption of plant foods and stomach cancer mortality in the seven countries study. Is grain
consumption a risk factor? Seven Countries Study Research Group. Nutr Cancer. 1999; 34:49–
55. [PubMed: 10453441]
197. Risch HA, Jain M, Choi NW, Fodor JG, Pfeiffer CJ, Howe GR, et al. Dietary factors and the
incidence of cancer of the stomach. Am J Epidemiol. 1985; 122:947–959. [PubMed: 2998182]
198. Nomura AM, Hankin JH, Kolonel LN, Wilkens LR, Goodman MT, Stemmermann GN. Case-
control study of diet and other risk factors for gastric cancer in Hawaii (United States). Cancer
Causes Control. 2003; 14:547–558. [PubMed: 12948286]
199. Lagiou P, Samoli E, Lagiou A, Peterson J, Tzonou A, Dwyer J, et al. Flavonoids, vitamin C and
adenocarcinoma of the stomach. Cancer Causes Control. 2004; 15:67–72. [PubMed: 14970736]
200. Ramon JM, Serra-Majem L, Cerdo C, Oromi J. Nutrient intake and gastric cancer risk: a case-
control study in Spain. Int J Epidemiol. 1993; 22:983–988. [PubMed: 8144311]
201. Kaaks R, Tuyns AJ, Haelterman M, Riboli E. Nutrient intake patterns and gastric cancer risk: a
case-control study in Belgium. Int J Cancer. 1998; 78:415–420. [PubMed: 9797127]
202. Palli D, Russo A, Decarli A. Dietary patterns, nutrient intake and gastric cancer in a high-risk area
of Italy. Cancer Causes Control. 2001; 12:163–172. [PubMed: 11246845]
203. Mayne ST, Risch HA, Dubrow R, Chow WH, Gammon MD, Vaughan TL, et al. Nutrient intake
and risk of subtypes of esophageal and gastric cancer. Cancer Epidemiol Biomarkers Prev. 2001;
10:1055–1062. [PubMed: 11588131]
204. De SE, Correa P, Boffetta P, eo-Pellegrini H, Ronco AL, Mendilaharsu M. Dietary patterns and
risk of gastric cancer: a case-control study in Uruguay. Gastric Cancer. 2004; 7:211–220.
[PubMed: 15616769]
205. Campos F, Carrasquilla G, Koriyama C, Serra M, Carrascal E, Itoh T, et al. Risk factors of gastric
cancer specific for tumor location and histology in Cali, Colombia. World J Gastroenterol. 2006;
12:5772–5779. [PubMed: 17007041]
206. Wirth HP, Beins MH, Yang M, Tham KT, Blaser MJ. Experimental infection of Mongolian
gerbils with wild-type and mutant Helicobacter pylori strains. Infect Immun. 1998; 66:4856–
4866. [PubMed: 9746590]
207. Dey A, Yokota K, Kobayashi K, Oguma K, Hirai Y, Akagi T. Antibody and cytokine responses
in Helicobacter pylori-infected various mouse strains. Acta Med Okayama. 1998; 52:41–48.
[PubMed: 9548993]
208. Marchetti M, Arico B, Burroni D, Figura N, Rappuoli R, Ghiara P. Development of a mouse
model of Helicobacter pylori infection that mimics human disease. Science. 1995; 267:1655–
1658. [PubMed: 7886456]
209. D’Elios MM, Manghetti M, Almerigogna F, Amedei A, Costa F, Burroni D, et al. Different
cytokine profile and antigen-specificity repertoire in Helicobacter pylori-specific T cell clones
from the antrum of chronic gastritis patients with or without peptic ulcer. Eur J Immunol. 1997;
27:1751–1755. [PubMed: 9247587]
210. D’Elios MM, Manghetti M, De CM, Costa F, Baldari CT, Burroni D, et al. T helper 1 effector
cells specific for Helicobacter pylori in the gastric antrum of patients with peptic ulcer disease. J
Immunol. 1997; 158:962–967. [PubMed: 8993017]
Zabaleta Page 22
211. Sommer F, Faller G, Konturek P, Kirchner T, Hahn EG, Zeus J, et al. Antrum-and corpus
mucosa-infiltrating CD4(+) lymphocytes in Helicobacter pylori gastritis display a Th1
phenotype. Infect Immun. 1998; 66:5543–5546. [PubMed: 9784570]
212. Maeda S, Yoshida H, Ogura K, Mitsuno Y, Hirata Y, Yamaji Y, et al. H. pylori activates NF-
kappaB through a signaling pathway involving IkappaB kinases, NF-kappaB-inducing kinase,
TRAF2, and TRAF6 in gastric cancer cells. Gastroenterology. 2000; 119:97–108. [PubMed:
10889159]
213. Yasumoto K, Okamoto S, Mukaida N, Murakami S, Mai M, Matsushima K. Tumor necrosis
factor alpha and interferon gamma synergistically induce interleukin 8 production in a human
gastric cancer cell line through acting concurrently on AP-1 and NF-kB-like binding sites of the
interleukin 8 gene. J Biol Chem. 1992; 267:22506–22511. [PubMed: 1331059]
214. Mitsuno Y, Yoshida H, Maeda S, Ogura K, Hirata Y, Kawabe T, et al. Helicobacter pylori
induced transactivation of SRE and AP-1 through the ERK signalling pathway in gastric cancer
cells. Gut. 2001; 49:18–22. [PubMed: 11413105]
215. Karttunen RA, Karttunen TJ, Yousfi MM, el-Zimaity HM, Graham DY, el-Zaatari FA.
Expression of mRNA for interferon-gamma, interleukin-10, and interleukin-12 (p40) in normal
gastric mucosa and in mucosa infected with Helicobacter pylori. Scand J Gastroenterol. 1997;
32:22–27. [PubMed: 9018762]
216. Ye G, Barrera C, Fan X, Gourley WK, Crowe SE, Ernst PB, et al. Expression of B7-1 and B7-2
costimulatory molecules by human gastric epithelial cells: potential role in CD4+ T cell
activation during Helicobacter pylori infection. J Clin Invest. 1997; 99:1628–1636. [PubMed:
9120006]
217. Allen LA, Schlesinger LS, Kang B. Virulent strains of Helicobacter pylori demonstrate delayed
phagocytosis and stimulate homotypic phagosome fusion in macrophages. J Exp Med. 2000;
191:115–128. [PubMed: 10620610]
218. Kuwahara H, Miyamoto Y, Akaike T, Kubota T, Sawa T, Okamoto S, et al. Helicobacter pylori
urease suppresses bactericidal activity of peroxynitrite via carbon dioxide production. Infect
Immun. 2000; 68:4378–4383. [PubMed: 10899833]

Jurnal Manggis

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Methods Mol Biol. 2012 ; 863: 411–435. doi:10.1007/978-1-61779-612-8_26.

Multifactorial Etiology of Gastric Cancer

2. Risk Factors: Helicobacter pylori Is Fundamental for Gastric Cancer

populations (26–29). Our work with premalignant inflammatory stages in African-American

3. Biology of H. pylori Infection

4. Immune Dysfunction Caused by H. pylori Products in T Cells

5. Cytokine Production in Response to H. pylori Infection

6. H. pylori Infection, Arginine, Arginase, and Immunity

L-Arg metabolism by arginase is emerging as an important regulator of T-cell responses in

induce stronger inflammatory responses associated to mucosal damage.

7. Single Nucleotide Polymorphisms and the Regulation of Cytokine Genes

8. Cancer Health Disparities, Ethnicity, and SNPs

Interleukin 8 (IL8) is a member of the CXC chemokine family and functions as a

IL10 is an anti-inflammatory cytokine (162). The level of IL10, as mentioned before, is

9. DNA Methylation, H. pylori Infection, and Gastric Cancer

DNA methylation is carried out by several DNA methyltransferase (DNMT) enzymes,

10. Other Risk Factors Associated with Gastric Cancer

11. Models of H. pylori-Induced Gastric Inflammation

12. Concluding Remarks

17. Uemura N, Okamoto S, Yamamoto S, Matsumura N, Yamaguchi S, Yamakido M, et al.

cell proliferation by Helicobacter pylori components. J Physiol Pharmacol. 1996; 47:195–202.

73. Rokkas T, Ladas S, Liatsos C, Petridou E, Papatheodorou G, Theocharis S, et al. Relationship of

metabolism. Transplantation. 1994; 57:665–669. [PubMed: 8140629]

Parenter Enteral Nutr. 2005; 29:S70–S74. [PubMed: 15709548]

186:3632–3641. [PubMed: 21296975]

103:1418–1421. [PubMed: 16432195]

polymorphisms of the human multidrug-resistance gene: multiple sequence variations and

Cancer Epidemiol Biomarkers Prev. 2006; 15:1674–1687. [PubMed: 16985030]

Cancer. 2010; 127:2183–2189. [PubMed: 20131315]

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