Vol.3, No.4, 238-244 (2011) Health
Copyright © 2011 SciRes. Openly accessible at http://www.scirp.org/journal/HEALTH/
Internal environment for growth of cancer cells in mice:
hypothermia, anemia and lymphocytopenia
Mayumi Watanabe1, Hiroaki Matsumoto1, Chikako Tomiyama2, Kohei Akazawa3, Toru Abo 1*
1Department of Immunology, Niigata University School of Medicine, Niigata, Japan;
*Corresponding author: immunol2@med.niigata-u.ac.jp
2School of Health Sciences, Faculty of Medicine, Niigata University, Niigata, Japan;
3Department of Medical Informatics, Niigata University Medical & Dental Hospital, Niigata, Japan
Received 14 February 2011; revised 15 March 2011; accepted 5 April 2011.
The internal environment in tumor-bearing mice
was investigated in det ail. When EL-4 ly mphoma
cells (5 × 106 cells/mouse) were intraperitoneally
inoculated into C57BL/6 mice, approximately
70% of the mice died by day 24. In this regard,
the internal environment w as compared between
control mice, surviving mice and tumor-bearing
mice which died. The most prominent sign was
hypothermia (<34˚C from day 16) seen in tu-
mor-bearing mice which died. Control mice and
surviving mice did not show such hypothermia
(around 38˚C). Other changes, including anemia
and lymphocytopenia, were also seen in tu-
mor-bearing mice w hich died, but not in control
mice and surviving mice. Immunological study
revealed that NKT cells, which have been pre-
viously identified to be the major effector lym-
phocytes against EL-4 cells, almost disappeared,
especially in the liver of tumor-bearing mice
which died. These results suggest that a spe-
cific internal environment might be required for
continuous tumor growth in vivo. Such internal
environmental factors include hypothermia, ane-
mia and severe immunosuppression.
Keywords: Cancer; Hypothermia; Anemia;
Immunosuppression; Glycolysis; Mitochondria
Many clinicians have noticed that cancer patients have
anemia and immunosuppression, especially those in their
advanced stage [1-7]. One hypothesis is that such condi-
tions are the results from cachexia in cancer patients
[8-12]. Cachexia is known to be mediated by TNFα,
TGFβ, etc., and these responses are common phenomena
seen in patients with advanced cancer.
In a recent study, it was demonstrated that cancer pa-
tients even in their early stage suffered from hypother-
mia, anemia and immunosuppression [13]. This raised
the possibility that these internal conditions might be
essential for the onset of cancer and the maintenance of
cancer cell growth. Cancer cells carry few mitochondria
in the cytoplasm and their major energy production is
supported by glycolysis [14-16]. To maintain the glyco-
lysis pathway, hypothermia and anemia (hypoxia) are
In light of these findings, the object of this research is
to investigate whether a similar internal environment is
seen in tumor-bearing mice. Under the present applied
protocol using EL-4 lymphoma cells [17,18], approxi-
mately 70% of the mice inoculated with EL-4 cells died
of cancer while the remaining 30% of the mice survived
irrespective of the inoculation. Therefore, the data were
analyzed between three groups, i.e., control mice, sur-
viving mice and tumor-bearing mice which died. As a
result, only tumor-bearing mice which died consistently
showed hypothermia, anemia and immunosuppression.
2.1. Mice
C57BL/6 (B6) mice [19] were purchased from Clea
Japan (Tokyo, Japan). All mice were used at 6–8 weeks
of age in these experiments. These mice were fed under
specific pathogen-free conditions in the animal facility
of Niigata University (Niigata, Japan).
2.2. Tumor Inoculation
EL-4 lymphoma cells (5 × 106 cells/mouse) were in-
jected into mice intraperitoneally (i.p.) [17,18]. This cell
line is of B6 background. At day 16 after tumor inocula-
tion, their liver, spleen, thymus and bone marrow (BM)
were harvested.
M. Watanabe et al. / Health 3 (2011) 238-244
Copyright © 2011 SciRes. Openly accessible at http://www.scirp.org/journal/HEALTH/
2.3. Cell Preparation
Mice anaesthetized with ether were sacrificed by ex-
sanguination from the subclavian artery and vein, and
various organs were removed. Hepatic lymphocytes
were prepared as previously described [20]. Briefly, the
liver was pressed through 200-gauge stainless steel mesh
and suspended in Eagle’s MEM medium supplemented
with 5 mM Hepes (Nissui Pharmaceutical, Tokyo, Japan)
and 2% FCS. After one washing, the pellet was resus-
pended in 35% Percoll solution containing 100 U/ml
heparin and centrifuged at 2000 rpm for 15 min. The
pellet was resuspended in red blood cell (RBC) lysis
solution (155 mM NH4Cl, 10 mM KHCO3, 1 mM EDTA,
170 mM Tris, pH 7.3) and then washed twice with the
medium. Splenocytes and thymocytes were obtained by
forcing the spleen and thymus, respectively, through
stainless steel mesh. BM cells were obtained by flushing
femurs with medium. Splenocytes and BM cells were
treated with 0.2% NaCl solution to remove RBC.
2.4. Measurement of Body Temperature
(Rectal Temperature), Glucose, Lactate
and β-ketone
Body temperature (rectal temperature) was deter-
mined by using THERMAC SENSOR (Shibaura Denki
Co., Tokyo). Blood glucose and β-ketone were measured
by Precision Xtra (TM) (Abbott Japan Co., Ltd., Chiba,
Japan). Urine glucose level was checked by Bayer Keto-
Diastix urine checker (Siemens Healthcare Diagnostics,
UK). To analyze the hematological parameters, the
numbers of leukocytes and erythrocytes (RBC) in the
blood were determined by hemocytemeter. Granulocytes,
lymphocytes and monocytes were determined by Giemsa
2.5. Flow Cytometric Analysis
The phenotype of cells was identified by two-color
immunofluorescence tests [20]. The reagents used here
included anti-CD3ε (145-2C11), anti-IL-2Rβ (TMβ-1),
and anti-NK1.1 (PK136) mAbs (PharMingen, San Diego,
CA). All mAbs were used in fluorescein isothiocyanate
(FITC)-, phycocerythrin (PE)-forms. To prevent nonspe-
cific binding of mAb, anti-CD16/CD32 (2.4 G2) mAb
was added before staining with labeled mAbs. The sus-
pended cells (5 × 105 – 2 × 106/tube) were stained with
mAbs and stained cells were analyzed with a FACScan
(Becton-Dickinson). Dead cells were excluded by for-
ward scatter, side scatter, and propidium iodide gating.
2.6. StatisticalAnalysis
The difference between the values was determined by
ANOVA and a post-hoc test.
3.1. Cancer Death and Hypothermia
Tumor-bearing mice began to die around day 20 after
the inoculation of cancer cells (Figure 1(a)). Up to day
24, approximately 70% of the mice died. Since these
results (i.e., 70% died and 30% survived) were consis-
tently repeated, we separated the mice into two groups,
i.e., those which died and those which survived. In
comparison with control mice, the body weight of two
tumor-bearing mice was almost comparable up to day 20
(Figure 1(b)). However, body temperatures of two
groups were found to be different. From day 16, the
group of mice which eventually died showed a decrease
of body temperature. All mice which died suffered from
3.2. Glucose in the Blood and Urine of
Tumor-Bearing Mice
In our previous human study [13], some cancer pa-
tients had hyperglycemia as well as hypothermia. We
therefore examined whether a variation of blood glucose
was also shown in tumor-bearing mice (Figure 2(a)).
Control mice and mice which survived did not show any
variation of blood glucose. In contrast, tumor-bearing
mice which died finally showed a decreased level of
blood glucose. This was due to the leakage of glucose
into the urine (Figure 2(a), bottom). The levels of lactate
and β-ketone were comparable between all tested groups
(Figure 2(b)). There was a tendency that these levels
were slightly high in tumor-bearing mice, especially in
mice which died.
3.3. Anemia and Lymphocytopenia in
Tumor-Bearing Mice
The number of RBC was enumerated in the blood of
control and tumor-bearing mice (Figure 3(a)) From day
16 after tumor inoculation, anemia was seen in tu-
mor-bearing mice. This was true in both tumor-bearing
mice which died and those which survived. The number
of WBC was also enumerated. However, there was not
big difference among all tested mice. We then examined
the ratios of leukocyte subsets, including granulocytes,
lymphocytes and monocytes (Figure 3(b)). The most
prominent change was seen in tumor-bearing mice which
died. Namely, the ratios of granulocytes and monocytes
increased and that of lymphocytes decreased from day
16. This pattern showed severe immunosuppression at
the late stage in tumor-bearing mice which died.
M. Watanabe et al. / Health 3 (2011) 238-244
Copyright © 2011 SciRes. Openly accessible at http://www.scirp.org/journal/HEALTH/
Figure 1. Time-kinetic study after tumor inoculation. (a).
Survival ratio, (b). Body weight and body temperature
(rectal temperature). Ten mice were used to determine
survival ratio. The mean and one SD of body weight and
body temperature were produced from 4 mice at each
point of time. † death ** P < 0.01.
Figure 2 Parameters in the blood and urine. (a). Glu-
cose in the blood and urine, (b). Lactate and β-ketone
in the blood. The mean and one SD of parameters in
the blood were produced from 4 mice at each point of
time. † death ** P < 0.01.
M. Watanabe et al. / Health 3 (2011) 238-244
Copyright © 2011 SciRes. Openly accessible at http://www.scirp.org/journal/HEALTH/
Figure 3. Number and proportion of cells in the blood.
(a). The number of RBC, (b). The proportion of granu-
locytes, lymphocytes and monocytes. The mean and one
SD of parameters in the blood were produced from 4
mice at each point of time. † death ** P < 0.01.
3.4. Decrease in the Proportion of NKT Cells
Which subsets of lymphocytes decreased in tumor-
bearing mice were examined (Figure 4). Two-color im-
munofluorescence tests were conducted to identify lym-
phocytes subsets. Lymphocytes were isolated from the
liver, spleen and thymus on day 16. Two-color staining
for CD3 and IL-2Rβ identified IL-2Rβ+CD3int cells,
whereas that for CD3 and NK1.1 identified NKT cells
(NK1.1+CD3int). The proportions of both IL-2Rβ+CD3int
cells and NKT cells were found to decrease in the liver
of tumor-bearing mice which died. Surviving tumor-
bearing mice did not show such a decrease.
Figure 4. Immunofluorescence tests to identify lymphocyte
subsets. Lymphocytes were isolated from the liver, spleen
and thymus at day 16 after tumor inoculation. Two-color
staining for CD3 and IL-2Rβ (or NK1.1) was conducted to
identify NK cells (CD3IL-2Rβ+ or CD3NK1.1+), NKT cells
(CD3intNK1.1+) and T cells (CD3+IL-2Rβ or CD3+NK1.1).
Two-color staining for CD4 and CD8 was conducted to iden-
tify double-positive cells (CD4+CD8+) in the thymus. Num-
bers in the figure represent the percentages of fluores-
cence-positive cells. The difference is indicated by arrow-
M. Watanabe et al. / Health 3 (2011) 238-244
Copyright © 2011 SciRes. Openly accessible at http://www.scirp.org/journal/HEALTH/
Two-color staining of thymocytes for CD4 and CD8
was also conducted (Figure 4, bottom). The proportion
of double-positive CD4+CD8+ cells prominently de-
creased in tumor-bearing mice which died. In other
words, this pattern showed immunosuppressive states as
reported previously. Thymic atrophy (50%) was also
observed in these mice.
Two-color staining for CD3 and B220 to identify
CD3B220+ B cells and such staining for Mac-1 and
Gr-1 to identify Mac-1+Gr-1 macrophages and Mac-
1+Gr-1+ granulocytes were then conducted (Figure 5).
Lymphocytes were isolated from the liver, spleen and
Figure 5. Identification of B cells and macrophages.
Mononuclear cells were isolated from the liver, spleen and
bone marrow (BM). Two-color staining for CD3 and B220
and that for Mac-1 and Gr-1 was conducted to identify B
cells (B220+CD3) and macrophages (Mac-1+Gr-1). Num-
bers in the figure represent the percentages of fluorescence-
positive cells. The difference is indicated by arrowheads.
BM on day 16. The proportion of CD3B220 + B cells
increased in the liver and spleen of tumor-bearing mice
which died. Surviving tumor-bearing mice did not show
such change.
The proportion of Mac-1+Gr-1 macrophages tended
to increase in the liver of tumor-bearing mice. The pro-
portion of Mac-1+Gr-1+ granulocytes tended to slightly
increase in the BM of tumor-bearing mice. These changes
were seen in both tumor-bearing mice which died and
those which survived.
In the present study, we demonstrated that hypother-
mia appeared consistently in tumor-bearing mice and
that these mice finally died of cancer. Such hypothermia
was observed around day 16 after EL-4 cell inoculation
and at this stage cancer cells grew well. In addition to
hypothermia, anemia and immunosuppression were pre-
sent in tumor-bearing mice. In our recent study in hu-
mans [13], cancer patients always suffered from hypo-
thermia, anemia (hypoxia) and immunosuppression. In
this regard, it is speculated that a specific internal envi-
ronment such as hypothermia, anemia and immunosup-
pression might be required for the maintenance of cancer
cell growth.
Several investigators have noticed that cancer cells
have few mitochondria in the cytoplasm and produce
energy by the glycolysis pathway [14-16]. Recent cu-
mulative evidence also supports this earlier observation
[21-25]. On the other hand, normal cells, which divide
less (i.e., cardiac cells and red muscle fiber cells), carry
many mitochondria and produce energy mainly by the
oxidative phosphorylation [13,26]. Concerning this, the
specific internal environment of hypothermia, anemia
and immunosuppression is essential to grow cancer cells
in vivo in both animals and humans. Indeed, at the pre-
sent experimental protocol, 30% of mice with EL-4 in-
oculation survived and the inoculated EL-4 cells did not
grow well in the peritoneal cavity. None of these mice
showed hypothermia, anemia and immunosuppression.
In addition to anemia (hypoxia), hypothermia is im-
portant to maintain the glycolysis pathway which sup-
ports cell division [13]. Even normal dividing cells such
as sperms and skin cells have few mitochondria in the
cytoplasm and the optimal temperature is around 32 to
33˚C (Ta b l e 1). For example, the testicles of males de-
scend in the fetal stage. This is to obtain an internal en-
vironment of hypothermia for sperm cell division
[27,28]. It is speculated that tumor cell division may
similarly or more strictly require hypothermia.
In our earlier study, we reported that the major effec-
tor lymphocyte subsets were invariant NKT cells in mice
which were injected with EL-4 lymphoma cells [17,18].
M. Watanabe et al. / Health 3 (2011) 238-244
Copyright © 2011 SciRes. Openly accessible at http://www.scirp.org/journal/HEALTH/
Table 1. Energy production in body.
Glycolysis Mitochondria
Site cytoplasm mitochondria
Oxygen – +
Source glucose glucose and lipid
Temperature 32˚C > 37˚C
Usage prompt force
cell division
continuous force
suppression of cell
ATP production quick (×100) slow (×1)
Efficiency low (2 ATP/glucose) high (36 ATP/glucose)
The actual cytotoxicity against EL-4 cells was mediated
by such NKT cells. Mice inoculated with EL-4 cells in
the present protocol also showed both lymphocytopenia
in the blood and a decreased proportion of NKT cells in
the liver. These immunosuppression conditions are also
speculated to support the growth of EL-4 cells. A similar
pattern of lymphocytopenia in the blood has also been
seen in almost all cancer patients [13].
There is a question as to why hypothermia and anemia
are related to the onset of cancer in humans. We previ-
ously proposed the possibility that severe and continuous
stress is associated of this phenomenon, namely, severe
stress induces hypothermia, hypoxia and hyperglycemia
[29,30]. Both sympathetic nerve activation and gluco-
corticoid secretion induce such internal environment.
For a short span of life, these internal conditions are
beneficial for the stimulation of the glycolysis pathway
of energy production [13,26]. As a result, prompt force
of white muscle fiber increases and person is able to
escape from emergency. If stress continues for a long
time, however, such condition suppresses oxidative
phosphorylation in the mitochondria and results in cer-
tain diseased conditions and the onset of cancer. In the
present murine model, hyperglycemia was not seen in
tumor-bearing mice. However, this result might be an
outcome from the leakage of glucose from the urine.
This animal model did not contain the onset stage of
cancer but only the maintenance of cancer growth. This
notion is alternatively possible.
At the last stage of cancer, hypothermia might also be
induced by the conditions of cachexia. It was reported
that TNFα production is related to the formation of this
internal conditions [31,32]. In other words, the cause of
hypothermia is different between the onset stage and the
late stage.
Other changes in the tested parameters include a slight
increase in the level of lactate and β-ketone. Another
speculation is that there is an increase of the glycolysis
pathway and/or a decrease of the oxidative phosphoryla-
tion pathway. In humans, it is known that many cancer
patients show acidosis due to the increase of glycolysis
[33,34] and some cancer patients show increased levels
of ketone bodies [35,36].
It is concluded that hypothermia, anemia (hypoxia)
and lymphocytopenia (immunosuppression) are essential
for growth of cancer in animals and that they are com-
mon signs seen in cancer patients and tumor-bearing
mice. These adverse conditions seem to be important for
the maintenance of cancer cell growth in vivo. However,
a further research including a cancer cell culture experi-
ment under conditions of hypothermia, hypoxia and hy-
perglycemia is required to support our proposal defi-
The authors wish to thank Yuko Kaneko for preparation of
the manuscript.
[1] Henke M. (2001) Correction of cancer anemia-impact on
disease course, prognosis and treatment efficacy, par-
ticularly for patients undergoing radiotherapy. Onkologie,
24, 450-454. doi:10.1159/000055125
[2] Rubin H. (2003) Cancer cachexia: its correlations and
causes. Proceedings of the National Academy of Sciences
of the United States of America, 100, 5384-5389.
[3] Tanvetyanon T. and Stiff P.J. (2005) Recurrent steroid-re-
sponsive pancreatitis associated with myelodysplastic
syndrome and transformations. Leukemia and lymphoma,
46, 151-154. doi:10.1080/10428190400011617
[4] Birgegård G., Aapro M.S., Bokemeyer C., Dicato M.,
Drings P., Hornedo J., Krzakowski M., Ludwig H., Pe-
corelli S., Schmoll H., Schneider M., Schrijvers D., Sha-
sha D. and Vab Belle S. (2005) Cancer-rela- ted anemia:
pathogenesis, prevalence and treatment. Oncology, 68,
3-11. doi:10.1159/000083128
[5] Varlotto J. and Stevenson M.A. (2005) Anemia, tumor
hypoxemia, and the cancer patient. International Journal
of Radiation Oncology, Biology, Physics, 63, 25-36.
[6] Al-Waili N.S. (2007) A potential concept in the manage-
ment of tumors with modulation of prosta- glandin, nitric
oxide and antioxidants. Scientific World Journal, 7,
[7] Grotto H.Z. (2008) Anemia of cancer: an overview of
mechanisms involved in its pathogenesis. Medical On-
cology, 25, 12-21. doi:10.1007/s12032-007-9000-8
[8] Lagman R.L., Davis M.P.,. LeGrand S.B and Walsh D.
(2005) Common symptoms in advanced cancer. Surgical
Clinics of North America, 85, 237-255.
M. Watanabe et al. / Health 3 (2011) 238-244
Copyright © 2011 SciRes. Openly accessible at http://www.scirp.org/journal/HEALTH/
[9] Delano M.J. and Moldawer L.L. (2006) The origins of
cachexia in acute and chronic inflammatory diseases.
Nutrition in Clinical Practice, 21, 68-81.
[10] Argilés J.M., Busquets S. and López-Soriano F.J. (2006)
Cytokines as mediators and targets for cancer cachexia.
Cancer Treatment and Research, 130, 199-217.
[11] Argilés J.M., Busquets S., Moore-Carrasco R., Figueras
M., Almendro V. and López-Soriano F.J. (2007) Targets
in clinical oncology: the metabolic environment of the
patients. Frontiers in Bioscience, 12, 3024-3051.
[12] Lelbach A., Muzes G. and Feher J. (2007) Current per-
spectives of catabolic mediators of cancer cachexia.
Medical Science Monitor, 13, 168-173.
[13] Watanabe M., Miyajima K., Matsui I., Tomiyama-Miyaji
C., Kainuma E., Inoue M., Matsumoto H., Kuwano Y.
and Abo T. (2010) Internal environment in cancer pa-
tients and proposal that carcinogenesis is adaptive re-
sponse of glycolysis to overcome adverse internal condi-
tions. Health, 2, 781-788. doi:10.4236/health.2010.27118
[14] Dang C.V. and Semenza G.L. (1999) Oncogenic altera-
tion of metabolism. Trends in Biochemical Sciences, 24,
68-72. doi:10.1016/S0968-0004(98)01344-9
[15] Shaw R.J. (2006) Glucose metabolism and cancer. Cur-
rent Opinion in Cell Biology, 18, 598-608.
[16] Warburg O. (1956) On the origin of cancer cells. Science,
123, 309-314. doi:10.1126/science.123.3191.309
[17] Halder R.C., Seki S., Weerasinghe A., Kawamura T.,
Watanabe H. and Abo T. (1998) Characterization of NK
cells and extrathymic T cells generated in the liver of ir-
radiated mice with a liver shield. Clinical and Experi-
mental Immunology, 144, 434-447.
[18] Li C., Bai X., Wang S., Tomiyama-Miyaji C., Nagura T.,
Kawamura T. and Abo T. (2004) Immunopotentiation of
NKT cells by low-protein diet and the suppressive effect
on tumor metastasis. Cellular Immunology, 231, 96-102.
[19] Ren H.-W., Shen J.-W., Tomiyama-Miyaji C., Watanabe
M., Kainuma E., Inoue M., Kuwano Y. and Abo T. (2006)
Augmentation of innate immunity by low- dose irradia-
tion. Cellular Immunology, 244, 50-56.
[20] Watanabe H., Miyaji C., Seki S. and Abo T. (1996) C-kit+
stem cells and thymocyte precursors in the livers of adult
mice. Journal of Experimental medicine, 184, 687-693.
[21] Kondoh H. (2008) Cellular life span and the Warburg
effect. Experimental Cell Research, 314, 1923-1928.
[22] Nijsten M.W.N. and van Dam G.M. (2009) Hypothesis:
using the Warburg effect against cancer by reducing glu-
cose and providing lactate. Medical Hypotheses, 73,
48-51. doi:10.1016/j.mehy.2009.01.041
[23] Heiden M.G.V., Cantley L.C. and Thompson C.B. (2009)
Understanding the Warburg effect: the metabolic re-
quirements of cell proliferation. Science, 324, 1029-1033.
[24] Máximo V., Lima J., Soares P., Sobrinho- Simões M.
(2009) Mitochondria and cancer. Virchows Archiv, 454,
[25] Lee H.-C. and Wei Y.-H. (2009) Mitochondria DNA in-
stability and metabolic shift in human cancers. Interna-
tional Journal of Molecular Sciences. 10, 674–701.
[26] Kainuma E., Watanabe M., Tomiyama-Miyaji C., Inoue
M., Kuwano Y., Ren H.-W. and Abo T. (2009) Proposal
of alternative mechanism responsible for the function of
high-speed swimsuits. Biomedical Research, 30, 69-70.
[27] Zorgniotti A.W. and Sealfon A.I. (1984) Scrotal hypo-
thermia: new therapy for poor semen. Urology, 23,
439-441. doi:10.1016/S0090-4295(84)80006-0
[28] Davis J.R. and Horowitz A.M. (1979) Response of the
rabbit isolated testicular capsule at hypothermic and hy-
perthermic temperatures to norepinephrine, acetylcholine
and prostaglandin F2 alpha. Andrologia, 11, 453-460.
[29] Watanabe M., Tomiyama-Miyaji C., Kainuma E., Inoue
M., Kuwano Y., Ren H.-W., Shen J.-W. and Abo T. (2008)
Role of α-adrenergic stimulus in stress-induced modula-
tion of body temperature, blood glucose and innate im-
munity. Immunology Letters, 115, 43-49.
[30] Kainuma E., Watanabe M., Tomiyama-Miyaji C., Inoue
M., Kuwano Y., Ren H.-W. and Abo T. (2009) Associa-
tion of glucocorticoid with stress-induced modulation of
body temperature, blood glucose and innate immunity.
Psychoneuroendocrinology, 34, 1459-1468.
[31] Smith B.K., Conn C.A. and Kluger M.J. (1993) Experi-
mental cachexia: effects of MCA sarcoma in the Fischer
rat. American Journal of Physiology, 265, R376-384.
[32] Smith B.K. and Kluger M.J. (1993) Anti-TNF-alpha
antibodies normalized body temperature and enhanced
food intake in tumor-bearing rats. American Journal of
Physiology, 265, R615-619.
[33] DeClerck K. and Elble R.C. (2010) The role of hypoxia
and acidosis in promoting metastasis and resistance to
chemotherapy. Frontiers in Bioscience, 15, 213-225.
[34] Chiche J., Brahimi-Horn M.C. and Pouysségur J. (2010)
Tumour hypoxia induces a metabolic shift causing acido-
sis: a common feature in cancer. Journal of Cellular and
Molecular Medicine, 14, 771-794.
[35] Lin M.V., Bishop G. and Benito-Herrero M. (2010) Dia-
betic ketoacidosis in type 2 diabetics: a novel presenta-
tion of pancreatic adenocarcinoma. Journal of General
Internal Medicine, 25, 369-373.
[36] Jobe B.A., Bierman M.H. and Mezzacappa F.J (1993)
Hyperglycemia as a paraneoplastic endocrinopathy in
renal cell carcinoma: a case report and review of the lit-
erature. Nebraska Medical Journal, 78, 349-351.