1
|
Hua S, Zhao J, Li L, Liu C, Zhou L, Li K, Huang Q, Zhou M, Wang K. Photosynthetic bacteria-based whole-cell inorganic-biohybrid system for multimodal enhanced tumor radiotherapy. J Nanobiotechnology 2024; 22:379. [PMID: 38943158 PMCID: PMC11212166 DOI: 10.1186/s12951-024-02654-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2024] [Accepted: 06/18/2024] [Indexed: 07/01/2024] Open
Abstract
The whole-cell inorganic-biohybrid systems show special functions and wide potential in biomedical application owing to the exceptional interactions between microbes and inorganic materials. However, the hybrid systems are still in stage of proof of concept. Here, we report a whole-cell inorganic-biohybrid system composed of Spirulina platensis and gold nanoclusters (SP-Au), which can enhance the cancer radiotherapy through multiple pathways, including cascade photocatalysis. Such systems can first produce oxygen under light irradiation, then convert some of the oxygen to superoxide anion (•O2-), and further oxidize the glutathione (GSH) in tumor cells. With the combination of hypoxic regulation, •O2- production, GSH oxidation, and the radiotherapy sensitization of gold nanoclusters, the final radiation is effectively enhanced, which show the best antitumor efficacy than other groups in both 4T1 and A549 tumor models. Moreover, in vivo distribution experiments show that the SP-Au can accumulate in the tumor and be rapidly metabolized through biodegradation, further indicating its application potential as a new multiway enhanced radiotherapy sensitizer.
Collapse
Affiliation(s)
- Shiyuan Hua
- Department of Respiratory and Critical Care Medicine, The Fourth Affiliated Hospital, Zhejiang University School of Medicine, Yiwu, 322000, China
- University-University of Edinburgh Institute (ZJU-UoE Institute), Zhejiang University School of Medicine, Zhejiang University, Haining, 314400, China
- Institute of Translational Medicine, Zhejiang University, Hangzhou, 310009, China
| | - Jun Zhao
- School of Basic Medicine, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430030, Hubei, China
| | - Lin Li
- Department of Orthopedic Oncology, Spine Tumor Center, Changzheng Hospital, Naval Medical University, 415 Fengyang Road, Shanghai, 200003, China
| | - Chaoyi Liu
- Institute of Translational Medicine, Zhejiang University, Hangzhou, 310009, China
| | - Lihui Zhou
- Department of Neurosurgey, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, 320000, China
| | - Kun Li
- Health Science Center, Ease China Normal University, Shanghai, 200241, China.
| | - Quan Huang
- Department of Orthopedic Oncology, Spine Tumor Center, Changzheng Hospital, Naval Medical University, 415 Fengyang Road, Shanghai, 200003, China.
| | - Min Zhou
- Department of Respiratory and Critical Care Medicine, The Fourth Affiliated Hospital, Zhejiang University School of Medicine, Yiwu, 322000, China.
- University-University of Edinburgh Institute (ZJU-UoE Institute), Zhejiang University School of Medicine, Zhejiang University, Haining, 314400, China.
- Institute of Translational Medicine, Zhejiang University, Hangzhou, 310009, China.
- Zhejiang University-Ordos City Etuoke Banner Joint Research Center, Zhejiang University, Haining, 314400, China.
- The National Key Laboratory of Biobased Transportation Fuel Technology, Zhejiang University, Hangzhou, 310027, China.
| | - Kai Wang
- Department of Respiratory and Critical Care Medicine, The Fourth Affiliated Hospital, Zhejiang University School of Medicine, Yiwu, 322000, China.
| |
Collapse
|
2
|
Dong J, Wang B, Xiao Y, Liu J, Wang Q, Xiao H, Jin Y, Liu Z, Chen Z, Li Y, Fan S, Li Y, Cui M. Roseburia intestinalis sensitizes colorectal cancer to radiotherapy through the butyrate/OR51E1/RALB axis. Cell Rep 2024; 43:113846. [PMID: 38412097 DOI: 10.1016/j.celrep.2024.113846] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2023] [Revised: 10/30/2023] [Accepted: 02/06/2024] [Indexed: 02/29/2024] Open
Abstract
The radioresistant signature of colorectal cancer (CRC) hampers the clinical utility of radiotherapy. Here, we find that fecal microbiota transplantation (FMT) potentiates the tumoricidal effects of radiation and degrades the intertwined adverse events in azoxymethane (AOM)/dextran sodium sulfate (DSS)-induced CRC mice. FMT cumulates Roseburia intestinalis (R. intestinalis) in the gastrointestinal tract. Oral gavage of R. intestinalis assembles at the CRC site and synthetizes butyrate, sensitizing CRC to radiation and alleviating intestinal toxicity in primary and CRC hepatic metastasis mouse models. R. intestinalis-derived butyrate activates OR51E1, a G-protein-coupled receptor overexpressing in patients with rectal cancer, facilitating radiogenic autophagy in CRC cells. OR51E1 shows a positive correlation with RALB in clinical rectal cancer tissues and CRC mouse model. Blockage of OR51E1/RALB signaling restrains butyrate-elicited autophagy in irradiated CRC cells. Our findings highlight that the gut commensal bacteria R. intestinalis motivates radiation-induced autophagy to accelerate CRC cell death through the butyrate/OR51E1/RALB axis and provide a promising radiosensitizer for CRC in a pre-clinical setting.
Collapse
Affiliation(s)
- Jiali Dong
- Tianjin Key Laboratory of Radiation Medicine and Molecular Nuclear Medicine, Institute of Radiation Medicine, Chinese Academy of Medical Sciences and Peking Union Medical College, Tianjin 300192, China
| | - Bin Wang
- Tianjin Key Laboratory of Radiation Medicine and Molecular Nuclear Medicine, Institute of Radiation Medicine, Chinese Academy of Medical Sciences and Peking Union Medical College, Tianjin 300192, China
| | - Yunong Xiao
- Tianjin Key Laboratory of Radiation Medicine and Molecular Nuclear Medicine, Institute of Radiation Medicine, Chinese Academy of Medical Sciences and Peking Union Medical College, Tianjin 300192, China
| | - Jia Liu
- Department of Microbiology, College of Life Sciences, Nankai University, Tianjin 300071, China
| | - Qi Wang
- Tianjin Key Laboratory of Radiation Medicine and Molecular Nuclear Medicine, Institute of Radiation Medicine, Chinese Academy of Medical Sciences and Peking Union Medical College, Tianjin 300192, China
| | - Huiwen Xiao
- Department of Microbiology, College of Life Sciences, Nankai University, Tianjin 300071, China
| | - Yuxiao Jin
- Department of Anesthesiology, Changshu No. 2 People's Hospital, Changshu, Jiangsu Province 215501, China
| | - Zhihong Liu
- Department of General Surgery, The Second Affiliated Hospital of Soochow University, Suzhou, Jiangsu Province 215004, China
| | - Zhiyuan Chen
- Tianjin Key Laboratory of Radiation Medicine and Molecular Nuclear Medicine, Institute of Radiation Medicine, Chinese Academy of Medical Sciences and Peking Union Medical College, Tianjin 300192, China
| | - Yiliang Li
- Tianjin Key Laboratory of Radiation Medicine and Molecular Nuclear Medicine, Institute of Radiation Medicine, Chinese Academy of Medical Sciences and Peking Union Medical College, Tianjin 300192, China
| | - Saijun Fan
- Tianjin Key Laboratory of Radiation Medicine and Molecular Nuclear Medicine, Institute of Radiation Medicine, Chinese Academy of Medical Sciences and Peking Union Medical College, Tianjin 300192, China
| | - Yuan Li
- Tianjin Key Laboratory of Radiation Medicine and Molecular Nuclear Medicine, Institute of Radiation Medicine, Chinese Academy of Medical Sciences and Peking Union Medical College, Tianjin 300192, China.
| | - Ming Cui
- Tianjin Key Laboratory of Radiation Medicine and Molecular Nuclear Medicine, Institute of Radiation Medicine, Chinese Academy of Medical Sciences and Peking Union Medical College, Tianjin 300192, China.
| |
Collapse
|
3
|
Ruan J, Zhao Z, Qian Y, Xu R, Liao G, Kong FM(S. The predictive role of soluble programmed death ligand 1 in digestive system cancers. Front Oncol 2023; 13:1170220. [PMID: 37519785 PMCID: PMC10374258 DOI: 10.3389/fonc.2023.1170220] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2023] [Accepted: 06/22/2023] [Indexed: 08/01/2023] Open
Abstract
Introduction The prognostic role of soluble programmed death ligand 1 (sPD-L1) in digestive system cancers (DSCs) remains inconclusive. This study aimed to explore the predictive value of sPD-L1 expression in DSCs. Methods Comprehensive searches were run on the electronic databases (PubMed, Web of Science, EMBASE, and the Cochrane Library) to identify studies that assessed the prognostic role of sPD-L1 in DSCs. Review Manager software (version 5.3) was used for all analyses. Pooled data for survival outcomes were measured as hazard ratios (HRs), 95% confidence intervals (CIs), and odds ratios and their 95% CIs. Results The search identified 18 studies involving 2,070 patients with DSCs. The meta-outcome revealed that a high level of sPD-L1 was related to poorer overall survival (HR, 3.06; 95% CI: 2.22-4.22, p<0.001) and disease-free survival (HR, 2.53; 95% CI: 1.67-3.83, p<0.001) in DSCs. Individually, the prognostic significance of high level of sPD-L1 expression was the highest in hepatic cell carcinoma (HR, 4.76; p<0.001) followed by gastric cancer (HR=3.55, p<0.001). Conclusion sPD-L1 may be a prognostic factor in DSCs for overall survival and disease-free survival. Inflammatory cytokines, treatment approaches, and other factors may affect the expression of sPD-L1. Therefore, the prognostic value of sPD-L1 for recurrence and metastasis should be further investigated. sPD-L1 may also predict response to treatment. Well-designed prospective studies with standard assessment methods should be conducted to determine the prognostic value of sPD-L1 in DSCs.
Collapse
Affiliation(s)
- Jian Ruan
- The Second Clinical Medical College, Jinan University, Guangdong, China
| | - Zhihong Zhao
- Department of Nephrology, Shenzhen People’s Hospital, The Second Clinical Medical College, Jinan University, Guangdong, China
| | - Yuting Qian
- The Second Clinical Medical College, Jinan University, Guangdong, China
| | - Ruilian Xu
- The Second Clinical Medical College, Jinan University, Guangdong, China
| | - Guixiang Liao
- The Second Clinical Medical College, Jinan University, Guangdong, China
| | - Feng-Ming (Spring) Kong
- Department of Clinical Oncology, Hong Kong University Shenzhen Hospital and Queen Mary Hospital, Hong Kong University Li Ka Shing Medical School, Hong Kong, Hong Kong SAR, China
- Department of Clinical Oncology, Queen Mary Hospital, Hong Kong University Li Ka Shing Faculty of Medicine, Hong Kong, Hong Kong SR, China
| |
Collapse
|
4
|
Miranda J, Horvat N, Assuncao AN, de M Machado FA, Chakraborty J, Pandini RV, Saraiva S, Nahas CSR, Nahas SC, Nomura CH. MRI-based radiomic score increased mrTRG accuracy in predicting rectal cancer response to neoadjuvant therapy. Abdom Radiol (NY) 2023; 48:1911-1920. [PMID: 37004557 PMCID: PMC10942660 DOI: 10.1007/s00261-023-03898-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2022] [Revised: 03/22/2023] [Accepted: 03/23/2023] [Indexed: 04/04/2023]
Abstract
PURPOSE To develop a magnetic resonance imaging (MRI)-based radiomics score, i.e., "rad-score," and to investigate the performance of rad-score alone and combined with mrTRG in predicting pathologic complete response (pCR) in patients with locally advanced rectal cancer following neoadjuvant chemoradiation therapy. METHODS This retrospective study included consecutive patients with LARC who underwent neoadjuvant chemoradiotherapy followed by surgery from between July 2011 to November 2015. Volumes of interest of the entire tumor on baseline rectal MRI and of the tumor bed on restaging rectal MRI were manually segmented on T2-weighted images. The radiologist also provided the ymrTRG score on the restaging MRI. Radiomic score (rad-score) was calculated and optimal cut-off points for both mrTRG and rad-score to predict pCR were selected using Youden's J statistic. RESULTS Of 180 patients (mean age = 63 years; 60% men), 33/180 (18%) achieved pCR. High rad-score (> - 1.49) yielded an area under the curve (AUC) of 0.758, comparable to ymrTRG 1-2 which yielded an AUC of 0.759. The combination of high rad-score and ymrTRG 1-2 yielded a significantly higher AUC of 0.836 compared with ymrTRG 1-2 and high rad-score alone (p < 0.001). A logistic regression model incorporating both high rad-score and mrTRG 1-2 was built to calculate adjusted odds ratios for pCR, which was 4.85 (p < 0.001). CONCLUSION Our study demonstrates that a rectal restaging MRI-based rad-score had comparable diagnostic performance to ymrTRG. Moreover, the combined rad-score and ymrTRG model yielded a significant better diagnostic performance for predicting pCR.
Collapse
Affiliation(s)
- Joao Miranda
- Department of Radiology, University of Sao Paulo, Sao Paulo, SP, Brazil
| | - Natally Horvat
- Department of Radiology, Memorial Sloan Kettering Cancer Center, 1275 York Ave, Box 29, New York, NY, 10065, USA.
| | - Antonildes N Assuncao
- Department of Radiology, University of Sao Paulo, Sao Paulo, SP, Brazil
- Research and Education Institute, Hospital Sirio-Libanes, Sao Paulo, SP, Brazil
| | | | - Jayasree Chakraborty
- Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | | | - Samya Saraiva
- Department of Radiology, Hospital Sirio-Libanes, Sao Paulo, SP, Brazil
| | | | | | - Cesar Higa Nomura
- Department of Radiology, University of Sao Paulo, Sao Paulo, SP, Brazil
- Department of Radiology, Hospital Sirio-Libanes, Sao Paulo, SP, Brazil
| |
Collapse
|
5
|
Tessmann JW, Rocha MR, Morgado-Díaz JA. Mechanisms of radioresistance and the underlying signaling pathways in colorectal cancer cells. J Cell Biochem 2023; 124:31-45. [PMID: 36565460 DOI: 10.1002/jcb.30361] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2022] [Revised: 11/23/2022] [Accepted: 12/13/2022] [Indexed: 12/25/2022]
Abstract
Radiotherapy is one of the most common modalities for the treatment of a wide range of tumors, including colorectal cancer (CRC); however, radioresistance of cancer cells remains a major limitation for this treatment. Following radiotherapy, the activities of various cellular mechanisms and cell signaling pathways are altered, resulting in the development of radioresistance, which leads to therapeutic failure and poor prognosis in patients with cancer. Furthermore, even though several inhibitors have been developed to target tumor resistance, these molecules can induce side effects in nontumor cells due to low specificity and efficiency. However, the role of these mechanisms in CRC has not been extensively studied. This review discusses recent studies regarding the relationship between radioresistance and the alterations in a series of cellular mechanisms and cell signaling pathways that lead to therapeutic failure and tumor recurrence. Our review also presents recent advances in the in vitro/in vivo study models aimed at investigating the radioresistance mechanism in CRC. Furthermore, it provides a relevant biochemical basis in theory, which can be useful to improve radiotherapy sensitivity and prolong patient survival.
Collapse
Affiliation(s)
- Josiane W Tessmann
- Cellular and Molecular Oncobiology Program, Brazilian National Cancer Institute (INCA), Rio de Janeiro, Brazil
| | - Murilo R Rocha
- Cellular and Molecular Oncobiology Program, Brazilian National Cancer Institute (INCA), Rio de Janeiro, Brazil
| | - Jose A Morgado-Díaz
- Cellular and Molecular Oncobiology Program, Brazilian National Cancer Institute (INCA), Rio de Janeiro, Brazil
| |
Collapse
|
6
|
Sadat SMA, Wuest M, Paiva IM, Munira S, Sarrami N, Sanaee F, Yang X, Paladino M, Binkhathlan Z, Karimi-Busheri F, Martin GR, Jirik FR, Murray D, Gamper AM, Hall DG, Weinfeld M, Lavasanifar A. Nano-Delivery of a Novel Inhibitor of Polynucleotide Kinase/Phosphatase (PNKP) for Targeted Sensitization of Colorectal Cancer to Radiation-Induced DNA Damage. Front Oncol 2022; 11:772920. [PMID: 35004293 PMCID: PMC8733593 DOI: 10.3389/fonc.2021.772920] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2021] [Accepted: 11/24/2021] [Indexed: 12/29/2022] Open
Abstract
Inhibition of the DNA repair enzyme polynucleotide kinase/phosphatase (PNKP) increases the sensitivity of cancer cells to DNA damage by ionizing radiation (IR). We have developed a novel inhibitor of PNKP, i.e., A83B4C63, as a potential radio-sensitizer for the treatment of solid tumors. Systemic delivery of A83B4C63, however, may sensitize both cancer and normal cells to DNA damaging therapeutics. Preferential delivery of A83B4C63 to solid tumors by nanoparticles (NP) was proposed to reduce potential side effects of this PNKP inhibitor to normal tissue, particularly when combined with DNA damaging therapies. Here, we investigated the radio-sensitizing activity of A83B4C63 encapsulated in NPs (NP/A83) based on methoxy poly(ethylene oxide)-b-poly(α-benzyl carboxylate-ε-caprolactone) (mPEO-b-PBCL) or solubilized with the aid of Cremophor EL: Ethanol (CE/A83) in human HCT116 colorectal cancer (CRC) models. Levels of γ-H2AX were measured and the biodistribution of CE/A83 and NP/A83 administered intravenously was determined in subcutaneous HCT116 CRC xenografts. The radio-sensitization effect of A83B4C63 was measured following fractionated tumor irradiation using an image-guided Small Animal Radiation Research Platform (SARRP), with 24 h pre-administration of CE/A83 and NP/A83 to Luc+/HCT116 bearing mice. Therapeutic effects were analyzed by monitoring tumor growth and functional imaging using Positron Emission Tomography (PET) and [18F]-fluoro-3’-deoxy-3’-L:-fluorothymidine ([18F]FLT) as a radiotracer for cell proliferation. The results showed an increased persistence of DNA damage in cells treated with a combination of CE/A83 or NP/A83 and IR compared to those only exposed to IR. Significantly higher tumor growth delay in mice treated with a combination of IR and NP/A83 than those treated with IR plus CE/A83 was observed. [18F]FLT PET displayed significant functional changes for tumor proliferation for the drug-loaded NP. This observation was attributed to the higher A83B4C63 levels in the tumors for NP/A83-treated mice compared to those treated with CE/A83. Overall, the results demonstrated a potential for A83B4C63-loaded NP as a novel radio-sensitizer for the treatment of CRC.
Collapse
Affiliation(s)
- Sams M A Sadat
- Faculty of Pharmacy and Pharmaceutical Sciences, University of Alberta, Edmonton, AB, Canada
| | - Melinda Wuest
- Department of Oncology, Cross Cancer Institute, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, AB, Canada
| | - Igor M Paiva
- Faculty of Pharmacy and Pharmaceutical Sciences, University of Alberta, Edmonton, AB, Canada
| | - Sirazum Munira
- Faculty of Pharmacy and Pharmaceutical Sciences, University of Alberta, Edmonton, AB, Canada
| | - Nasim Sarrami
- Faculty of Pharmacy and Pharmaceutical Sciences, University of Alberta, Edmonton, AB, Canada
| | - Forughalsadat Sanaee
- Faculty of Pharmacy and Pharmaceutical Sciences, University of Alberta, Edmonton, AB, Canada
| | - Xiaoyan Yang
- Department of Oncology, Cross Cancer Institute, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, AB, Canada
| | - Marco Paladino
- Department of Chemistry, Faculty of Science, University of Alberta, Edmonton, AB, Canada
| | - Ziyad Binkhathlan
- Faculty of Pharmacy and Pharmaceutical Sciences, University of Alberta, Edmonton, AB, Canada.,Department of Pharmaceutics, College of Pharmacy, King Saud University, Riyadh, Saudi Arabia
| | - Feridoun Karimi-Busheri
- Department of Oncology, Cross Cancer Institute, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, AB, Canada
| | - Gary R Martin
- Department of Biochemistry and Molecular Biology, University of Calgary, Calgary, AB, Canada
| | - Frank R Jirik
- Department of Biochemistry and Molecular Biology, University of Calgary, Calgary, AB, Canada.,Department of Medicine, University of Calgary, Calgary, AB, Canada
| | - David Murray
- Department of Oncology, Cross Cancer Institute, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, AB, Canada
| | - Armin M Gamper
- Department of Oncology, Cross Cancer Institute, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, AB, Canada
| | - Dennis G Hall
- Department of Chemistry, Faculty of Science, University of Alberta, Edmonton, AB, Canada
| | - Michael Weinfeld
- Department of Oncology, Cross Cancer Institute, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, AB, Canada
| | - Afsaneh Lavasanifar
- Faculty of Pharmacy and Pharmaceutical Sciences, University of Alberta, Edmonton, AB, Canada.,Department of Chemical and Material Engineering, University of Alberta, Edmonton, AB, Canada
| |
Collapse
|
7
|
Xu HG, Reshetnikov V, Wondrak M, Eckhardt L, Kunz-Schughart LA, Janko C, Tietze R, Alexiou C, Borchardt H, Aigner A, Gong W, Schmitt M, Sellner L, Daum S, Özkan HG, Mokhir A. Intracellular Amplifiers of Reactive Oxygen Species Affecting Mitochondria as Radiosensitizers. Cancers (Basel) 2021; 14:208. [PMID: 35008371 PMCID: PMC8750417 DOI: 10.3390/cancers14010208] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2021] [Revised: 12/27/2021] [Accepted: 12/29/2021] [Indexed: 02/07/2023] Open
Abstract
Radiotherapy (RT) efficacy can be improved by using radiosensitizers, i.e., drugs enhancing the effect of ionizing radiation (IR). One of the side effects of RT includes damage of normal tissue in close proximity to the treated tumor. This problem can be solved by applying cancer specific radiosensitizers. N-Alkylaminoferrocene-based (NAAF) prodrugs produce reactive oxygen species (ROS) in cancer cells, but not in normal cells. Therefore, they can potentially act as cancer specific radiosensitizers. However, early NAAF prodrugs did not exhibit this property. Since functional mitochondria are important for RT resistance, we assumed that NAAF prodrugs affecting mitochondria in parallel with increasing intracellular ROS can potentially exhibit synergy with RT. We applied sequential Cu+-catalyzed alkyne-azide cycloadditions (CuAAC) to obtain a series of NAAF derivatives with the goal of improving anticancer efficacies over already existing compounds. One of the obtained prodrugs (2c) exhibited high anticancer activity with IC50 values in the range of 5-7.1 µM in human ovarian carcinoma, Burkitt's lymphoma, pancreatic carcinoma and T-cell leukemia cells retained moderate water solubility and showed cancer specificity. 2c strongly affects mitochondria of cancer cells, leading to the amplification of mitochondrial and total ROS production and thus causing cell death via necrosis and apoptosis. We observed that 2c acts as a radiosensitizer in human head and neck squamous carcinoma cells. This is the first demonstration of a synergy between the radiotherapy and NAAF-based ROS amplifiers.
Collapse
Affiliation(s)
- Hong-Gui Xu
- Organic Chemistry Chair II, Department of Chemistry and Pharmacy, Friedrich-Alexander University Erlangen-Nürnberg (FAU), Nikolaus-Fiebiger-Str. 10, 91058 Erlangen, Germany; (H.-G.X.); (V.R.); (S.D.); (H.G.Ö.)
| | - Viktor Reshetnikov
- Organic Chemistry Chair II, Department of Chemistry and Pharmacy, Friedrich-Alexander University Erlangen-Nürnberg (FAU), Nikolaus-Fiebiger-Str. 10, 91058 Erlangen, Germany; (H.-G.X.); (V.R.); (S.D.); (H.G.Ö.)
| | - Marit Wondrak
- OncoRay—National Center for Radiation Research in Oncology, Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden and Helmholtz-Zentrum Dresden—Rossendorf, 01307 Dresden, Germany; (M.W.); (L.E.); (L.A.K.-S.)
| | - Lisa Eckhardt
- OncoRay—National Center for Radiation Research in Oncology, Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden and Helmholtz-Zentrum Dresden—Rossendorf, 01307 Dresden, Germany; (M.W.); (L.E.); (L.A.K.-S.)
| | - Leoni A. Kunz-Schughart
- OncoRay—National Center for Radiation Research in Oncology, Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden and Helmholtz-Zentrum Dresden—Rossendorf, 01307 Dresden, Germany; (M.W.); (L.E.); (L.A.K.-S.)
- National Center for Tumor Diseases (NCT), Partner Site Dresden, 01307 Dresden, Germany
| | - Christina Janko
- Department of Otorhinolaryngology, Head and Neck Surgery, Section of Experimental Oncology and Nanomedicine (SEON), Universitätsklinikum Erlangen, 91054 Erlangen, Germany; (C.J.); (R.T.); (C.A.)
| | - Rainer Tietze
- Department of Otorhinolaryngology, Head and Neck Surgery, Section of Experimental Oncology and Nanomedicine (SEON), Universitätsklinikum Erlangen, 91054 Erlangen, Germany; (C.J.); (R.T.); (C.A.)
| | - Christoph Alexiou
- Department of Otorhinolaryngology, Head and Neck Surgery, Section of Experimental Oncology and Nanomedicine (SEON), Universitätsklinikum Erlangen, 91054 Erlangen, Germany; (C.J.); (R.T.); (C.A.)
| | - Hannes Borchardt
- Rudolf-Boehm-Institute for Pharmacology and Toxicology, Clinical Pharmacology, Faculty of Medicine, Leipzig University, 04107 Leipzig, Germany; (H.B.); (A.A.)
| | - Achim Aigner
- Rudolf-Boehm-Institute for Pharmacology and Toxicology, Clinical Pharmacology, Faculty of Medicine, Leipzig University, 04107 Leipzig, Germany; (H.B.); (A.A.)
| | - Wenjie Gong
- Department of Medicine V, Heidelberg University Hospital, 69120 Heidelberg, Germany; (W.G.); (M.S.); (L.S.)
- Department of Hematology, First Affiliated Hospital of Soochow University, Suzhou 215006, China
| | - Michael Schmitt
- Department of Medicine V, Heidelberg University Hospital, 69120 Heidelberg, Germany; (W.G.); (M.S.); (L.S.)
| | - Leopold Sellner
- Department of Medicine V, Heidelberg University Hospital, 69120 Heidelberg, Germany; (W.G.); (M.S.); (L.S.)
- Takeda Pharmaceuticals, Cambridge, MA 02139, USA
| | - Steffen Daum
- Organic Chemistry Chair II, Department of Chemistry and Pharmacy, Friedrich-Alexander University Erlangen-Nürnberg (FAU), Nikolaus-Fiebiger-Str. 10, 91058 Erlangen, Germany; (H.-G.X.); (V.R.); (S.D.); (H.G.Ö.)
- Merck, Im Laternenacker 5, 8200 Schaffhausen, Switzerland
| | - Hülya Gizem Özkan
- Organic Chemistry Chair II, Department of Chemistry and Pharmacy, Friedrich-Alexander University Erlangen-Nürnberg (FAU), Nikolaus-Fiebiger-Str. 10, 91058 Erlangen, Germany; (H.-G.X.); (V.R.); (S.D.); (H.G.Ö.)
| | - Andriy Mokhir
- Organic Chemistry Chair II, Department of Chemistry and Pharmacy, Friedrich-Alexander University Erlangen-Nürnberg (FAU), Nikolaus-Fiebiger-Str. 10, 91058 Erlangen, Germany; (H.-G.X.); (V.R.); (S.D.); (H.G.Ö.)
| |
Collapse
|
8
|
Rahma OE, Yothers G, Hong TS, Russell MM, You YN, Parker W, Jacobs SA, Colangelo LH, Lucas PC, Gollub MJ, Hall WA, Kachnic LA, Vijayvergia N, O'Rourke MA, Faller BA, Valicenti RK, Schefter TE, Moxley KM, Kainthla R, Stella PJ, Sigurdson E, Wolmark N, George TJ. Use of Total Neoadjuvant Therapy for Locally Advanced Rectal Cancer: Initial Results From the Pembrolizumab Arm of a Phase 2 Randomized Clinical Trial. JAMA Oncol 2021; 7:1225-1230. [PMID: 34196693 DOI: 10.1001/jamaoncol.2021.1683] [Citation(s) in RCA: 93] [Impact Index Per Article: 31.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
Importance Total neoadjuvant therapy (TNT) is often used to downstage locally advanced rectal cancer (LARC) and decrease locoregional relapse; however, more than one-third of patients develop recurrent metastatic disease. As such, novel combinations are needed. Objective To assess whether the addition of pembrolizumab during and after neoadjuvant chemoradiotherapy can lead to an improvement in the neoadjuvant rectal (NAR) score compared with treatment with FOLFOX (5-fluorouracil, leucovorin, and oxaliplatin) and chemoradiotherapy alone. Design, Setting, and Participants In this open-label, phase 2, randomized clinical trial (NRG-GI002), patients in academic and private practice settings were enrolled. Patients with stage II/III LARC with distal location (cT3-4 ≤ 5 cm from anal verge, any N), with bulky disease (any cT4 or tumor within 3 mm of mesorectal fascia), at high risk for metastatic disease (cN2), and/or who were not candidates for sphincter-sparing surgery (SSS) were stratified based on clinical tumor and nodal stages. Trial accrual opened on August 1, 2018, and ended on May 31, 2019. This intent-to-treat analysis is based on data as of August 2020. Interventions Patients were randomized (1:1) to neoadjuvant FOLFOX for 4 months and then underwent chemoradiotherapy (capecitabine with 50.4 Gy) with or without intravenous pembrolizumab administered at a dosage of 200 mg every 3 weeks for up to 6 doses before surgery. Main Outcomes and Measures The primary end point was the NAR score. Secondary end points included pathologic complete response (pCR) rate, SSS, disease-free survival, and overall survival. This report focuses on end points available after definitive surgery (NAR score, pCR, SSS, clinical complete response rate, margin involvement, and safety). Results A total of 185 patients (126 [68.1%] male; mean [SD] age, 55.7 [11.1] years) were randomized to the control arm (CA) (n = 95) or the pembrolizumab arm (PA) (n = 90). Of these patients, 137 were evaluable for NAR score (68 CA patients and 69 PA patients). The mean (SD) NAR score was 11.53 (12.43) for the PA patients (95% CI, 8.54-14.51) vs 14.08 (13.82) for the CA patients (95% CI, 10.74-17.43) (P = .26). The pCR rate was 31.9% in the PA vs 29.4% in the CA (P = .75). The clinical complete response rate was 13.9% in the PA vs 13.6% in the CA (P = .95). The percentage of patients who underwent SSS was 59.4% in the PA vs 71.0% in the CA (P = .15). Grade 3 to 4 adverse events were slightly increased in the PA (48.2%) vs the CA (37.3%) during chemoradiotherapy. Two deaths occurred during FOLFOX: sepsis (CA) and pneumonia (PA). No differences in radiotherapy fractions, FOLFOX, or capecitabine doses were found. Conclusions and Relevance Pembrolizumab added to chemoradiotherapy as part of total neoadjuvant therapy was suggested to be safe; however, the NAR score difference does not support further study. Trial Registration ClinicalTrials.gov Identifier: NCT02921256.
Collapse
Affiliation(s)
- Osama E Rahma
- NRG Oncology, Philadelphia, Pennsylvania.,Department of Medical Oncology, Dana-Farber Cancer Institute/Alliance, Boston, Massachusetts
| | - Greg Yothers
- NRG Oncology, Philadelphia, Pennsylvania.,Department of Biostatistics, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Theodore S Hong
- NRG Oncology, Philadelphia, Pennsylvania.,Department of Radiation Oncology, Massachusetts General Hospital, Boston
| | - Marcia M Russell
- NRG Oncology, Philadelphia, Pennsylvania.,Veterans Affairs Greater Los Angeles Healthcare System, Los Angeles, California.,David Geffen School of Medicine at UCLA, Los Angeles, California
| | - Y Nancy You
- Department of Surgical Oncology, University of Texas MD Anderson Cancer Center, Houston
| | - William Parker
- NRG Oncology, Philadelphia, Pennsylvania.,Department of Medical Physics, McGill University Health Centre, Montréal, Quebec, Canada
| | | | - Linda H Colangelo
- NRG Oncology, Philadelphia, Pennsylvania.,Department of Biostatistics, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Peter C Lucas
- NRG Oncology, Philadelphia, Pennsylvania.,Department of Pathology, UPMC Hillman Cancer Center, Pittsburgh, Pennsylvania
| | - Marc J Gollub
- Department of Radiology, Memorial Sloan Kettering Cancer Center, New York, New York
| | - William A Hall
- NRG Oncology, Philadelphia, Pennsylvania.,Department of Radiation Oncology, Medical College of Wisconsin, Milwaukee
| | - Lisa A Kachnic
- NRG Oncology, Philadelphia, Pennsylvania.,Department of Radiation Oncology, Columbia University Irving Medical Center, Herbert Irving Comprehensive Cancer Center, New York, New York.,SWOG Cancer Research Network, San Antonio, Texas
| | - Namrata Vijayvergia
- NRG Oncology, Philadelphia, Pennsylvania.,Fox Chase Cancer Center, Philadelphia, Pennsylvania
| | - Mark A O'Rourke
- NRG Oncology, Philadelphia, Pennsylvania.,National Cancer Institute Community Oncology Research Program, Prisma Health Cancer Institute, Greenville, South Carolina
| | - Bryan A Faller
- Missouri Baptist Medical Center, Heartland Cancer Research, National Cancer Institute Community Oncology Research Program, St Louis
| | | | - Tracey E Schefter
- NRG Oncology, Philadelphia, Pennsylvania.,Department of Radiation Oncology, University of Colorado Cancer Center, Aurora
| | - Katherine M Moxley
- NRG Oncology, Philadelphia, Pennsylvania.,Section of Gynecologic Oncology, University of Oklahoma Stephenson Cancer Center, Oklahoma City
| | - Radhika Kainthla
- Department of Internal Medicine, UT Southwestern Medical Center, Dallas, Texas
| | - Philip J Stella
- NRG Oncology, Philadelphia, Pennsylvania.,Department of Medical Oncology, St Joseph Mercy Hospital, Ann Arbor, Michigan
| | - Elin Sigurdson
- Department of Surgical Oncology, Fox Chase Cancer Center, Philadelphia, Pennsylvania
| | - Norman Wolmark
- NRG Oncology, Philadelphia, Pennsylvania.,Department of Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Thomas J George
- NRG Oncology, Philadelphia, Pennsylvania.,Department of Medicine, University of Florida Health Cancer Center, Gainesville
| |
Collapse
|
9
|
Wu C, Williams TM, Robb R, Webb A, Wei L, Chen W, Mikhail S, Ciombor KK, Cardin DB, Timmers C, Krishna SG, Arnold M, Harzman A, Abdel-Misih S, Roychowdhury S, Bekaii-Saab T, Wuthrick E. Phase I Trial of Trametinib with Neoadjuvant Chemoradiation in Patients with Locally Advanced Rectal Cancer. Clin Cancer Res 2020; 26:3117-3125. [PMID: 32253228 DOI: 10.1158/1078-0432.ccr-19-4193] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/26/2019] [Revised: 02/25/2020] [Accepted: 04/01/2020] [Indexed: 12/18/2022]
Abstract
PURPOSE The RAS/RAF/MEK/ERK signaling pathway is critical to the development of colorectal cancers, and KRAS, NRAS, and BRAF mutations foster resistance to radiation. We performed a phase I trial to determine the safety of trametinib, a potent MEK1/2 inhibitor, with 5-fluorouracil (5-FU) chemoradiation therapy (CRT) in patients with locally advanced rectal cancer (LARC). PATIENTS AND METHODS Patients with stage II/III rectal cancer were enrolled on a phase I study with 3+3 study design, with an expansion cohort of 9 patients at the MTD. Following a 5-day trametinib lead-in, with pre- and posttreatment tumor biopsies, patients received trametinib and CRT, surgery, and adjuvant chemotherapy. Trametinib was given orally daily at 3 dose levels: 0.5 mg, 1 mg, and 2 mg. CRT consisted of infusional 5-FU 225 mg/m2/day and radiation dose of 28 daily fractions of 1.8 Gy (total 50.4 Gy). The primary endpoint was to identify the MTD and recommended phase II dose. IHC staining for phosphorylated ERK (pERK) and genomic profiling was performed on the tumor samples. RESULTS Patients were enrolled to all dose levels, and 18 patients were evaluable for toxicities and responses. Treatment was well tolerated, and there was one dose-limiting toxicity of diarrhea, which was attributed to CRT rather than trametinib. At the 2 mg dose level, 25% had pathologic complete response. IHC staining confirmed dose-dependent decrease in pERK with increasing trametinib doses. CONCLUSIONS The combination of trametinib with 5-FU CRT is safe and well tolerated, and may warrant additional study in a phase II trial, perhaps in a RAS/RAF-mutant selected population.
Collapse
Affiliation(s)
- Christina Wu
- Emory University, Winship Cancer Institute, Atlanta, Georgia.
| | | | - Ryan Robb
- The Ohio State University Comprehensive Cancer Center, Columbus, Ohio
| | - Amy Webb
- The Ohio State University Comprehensive Cancer Center, Columbus, Ohio
| | - Lai Wei
- The Ohio State University Comprehensive Cancer Center, Columbus, Ohio
| | - Wei Chen
- The Ohio State University Comprehensive Cancer Center, Columbus, Ohio
| | | | | | - Dana B Cardin
- Vanderbilt-Ingram Cancer Center, Nashville, Tennessee
| | - Cynthia Timmers
- Medical University of South Carolina, Charleston, South Carolina
| | | | - Mark Arnold
- The Ohio State University Comprehensive Cancer Center, Columbus, Ohio
| | - Alan Harzman
- The Ohio State University Comprehensive Cancer Center, Columbus, Ohio
| | | | | | | | | |
Collapse
|
10
|
Wang W, Zhou Z, Xiang L, Lv M, Ni T, Deng J, Wang H, Masatara S, Zhou Y, Liu Y. CHIP-mediated ubiquitination of Galectin-1 predicts colorectal cancer prognosis. Int J Biol Sci 2020; 16:719-729. [PMID: 32025218 PMCID: PMC6990922 DOI: 10.7150/ijbs.41125] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2019] [Accepted: 12/02/2019] [Indexed: 12/11/2022] Open
Abstract
CHIP and Galectin-1 are associated with the development of metastasis in cancer. However, the precise roles of CHIP or Gal1 in colorectal cancer are uncertain. Here, our study explored the relationship and clinical significance of CHIP or Gal1 in CRC. CHIP or Gal1 expression was significantly decreased or up-regulated in CRC compared with adjacent noncancerous tissues by immunohistochemistry on a CRC tissue microarray, respectively. Low CHIP or high Gal1 expression significantly correlated with clinicopathological characteristics in patients, as well as with shorter overall survival. Multivariate Cox regression analysis revealed that CHIP or Gal1 expression was an independent prognostic factor for CRC patients. Moreover, CHIP associated with Gal1 has a synergistic effect on the prediction of CRC prognosis. In vitro and vivo, high CHIP or low Gal1 expression inhibit CRC growth or metastasis. Our results found that CHIP could degradate Gal1 by ubiquitination. In summary, CHIP could inhibit CRC growth or metastasis through promoting Gal1 ubiquitination and degradation by proteasome. CHIP and Gal1 expressions are novel candidate prognostic markers in CRC. A combined effect of CHIP and Gal1 as efficient prognostic indicators was found for the first time.
Collapse
Affiliation(s)
- Weimin Wang
- Institute of Traslational Medicine, Medical College, Yangzhou University, Yangzhou 225001, PR China.,Department of Oncology, Yixing Hospital Affiliated to Medical College of Yangzhou University, Yixing, Jiangsu, 214200, PR China.,The Key Laboratory of Syndrome Differentiation and Treatment of Gastric Cancer of the State Administration of Traditional Chinese Medicine, Yangzhou, 225001, PR China
| | - Zhen Zhou
- Institute of Traslational Medicine, Medical College, Yangzhou University, Yangzhou 225001, PR China.,The Key Laboratory of Syndrome Differentiation and Treatment of Gastric Cancer of the State Administration of Traditional Chinese Medicine, Yangzhou, 225001, PR China
| | - Liangliang Xiang
- Institute of Traslational Medicine, Medical College, Yangzhou University, Yangzhou 225001, PR China.,The Key Laboratory of Syndrome Differentiation and Treatment of Gastric Cancer of the State Administration of Traditional Chinese Medicine, Yangzhou, 225001, PR China
| | - Mengying Lv
- Institute of Traslational Medicine, Medical College, Yangzhou University, Yangzhou 225001, PR China.,The Key Laboratory of Syndrome Differentiation and Treatment of Gastric Cancer of the State Administration of Traditional Chinese Medicine, Yangzhou, 225001, PR China
| | - Tengyang Ni
- Institute of Traslational Medicine, Medical College, Yangzhou University, Yangzhou 225001, PR China.,The Key Laboratory of Syndrome Differentiation and Treatment of Gastric Cancer of the State Administration of Traditional Chinese Medicine, Yangzhou, 225001, PR China
| | - Jianliang Deng
- Department of Oncology, Yixing Hospital Affiliated to Medical College of Yangzhou University, Yixing, Jiangsu, 214200, PR China
| | - Haibo Wang
- Institute of Traslational Medicine, Medical College, Yangzhou University, Yangzhou 225001, PR China.,The Key Laboratory of Syndrome Differentiation and Treatment of Gastric Cancer of the State Administration of Traditional Chinese Medicine, Yangzhou, 225001, PR China
| | - Sunagawa Masatara
- Department of Physiology, School of Medicine, Showa University, Tokyo 142, Japan
| | - Yan Zhou
- Institute of Traslational Medicine, Medical College, Yangzhou University, Yangzhou 225001, PR China.,Department of Oncology, Yixing Hospital Affiliated to Medical College of Yangzhou University, Yixing, Jiangsu, 214200, PR China.,The Key Laboratory of Syndrome Differentiation and Treatment of Gastric Cancer of the State Administration of Traditional Chinese Medicine, Yangzhou, 225001, PR China
| | - Yanqing Liu
- Institute of Traslational Medicine, Medical College, Yangzhou University, Yangzhou 225001, PR China.,Department of Oncology, Yixing Hospital Affiliated to Medical College of Yangzhou University, Yixing, Jiangsu, 214200, PR China.,The Key Laboratory of Syndrome Differentiation and Treatment of Gastric Cancer of the State Administration of Traditional Chinese Medicine, Yangzhou, 225001, PR China
| |
Collapse
|
11
|
Kinsella T, Safran H, Wiersma S, DiPetrillo T, Schumacher A, Rosati K, Vatkevich J, Anderson LW, Hill KD, Kunos C, Collins JM. Phase I and Pharmacology Study of Ropidoxuridine (IPdR) as Prodrug for Iododeoxyuridine-Mediated Tumor Radiosensitization in Advanced GI Cancer Undergoing Radiation. Clin Cancer Res 2019; 25:6035-6043. [PMID: 31337643 PMCID: PMC6801071 DOI: 10.1158/1078-0432.ccr-19-0862] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2019] [Revised: 05/21/2019] [Accepted: 07/17/2019] [Indexed: 12/30/2022]
Abstract
PURPOSE Iododeoxyuridine (IUdR) is a potent radiosensitizer; however, its clinical utility is limited by dose-limiting systemic toxicities and the need for prolonged continuous infusion. 5-Iodo-2-pyrimidinone-2'-deoxyribose (IPdR) is an oral prodrug of IUdR that, compared with IUdR, is easier to administer and less toxic, with a more favorable therapeutic index in preclinical studies. Here, we report the clinical and pharmacologic results of a first-in-human phase I dose escalation study of IPdR + concurrent radiation therapy (RT) in patients with advanced metastatic gastrointestinal (GI) cancers. PATIENTS AND METHODS Adult patients with metastatic GI cancers referred for palliative RT to the chest, abdomen, or pelvis were eligible for study. Patients received IPdR orally once every day × 28 days beginning 7 days before the initiation of RT (37.5 Gy in 2.5 Gy × 15 fractions). A 2-part dose escalation scheme was used, pharmacokinetic studies were performed at multiple time points, and all patients were assessed for toxicity and response to Day 56. RESULTS Nineteen patients were entered on study. Dose-limiting toxicity was encountered at 1,800 mg every day, and the recommended phase II dose is 1,200 mg every day. Pharmacokinetic analyses demonstrated achievable and sustainable levels of plasma IUdR ≥1 μmol/L (levels previously shown to mediate radiosensitization). Two complete, 3 partial, and 9 stable responses were achieved in target lesions. CONCLUSIONS Administration of IPdR orally every day × 28 days with RT is feasible and tolerable at doses that produce plasma IUdR levels ≥1 μmol/L. These results support the investigation of IPdR + RT in phase II studies.
Collapse
Affiliation(s)
- Timothy Kinsella
- Brown University Oncology Group (BrUOG), Providence, Rhode Island.
- EMEK, Inc., Warwick, Rhode Island
| | - Howard Safran
- Brown University Oncology Group (BrUOG), Providence, Rhode Island
| | | | | | | | - Kayla Rosati
- Brown University Oncology Group (BrUOG), Providence, Rhode Island
| | | | | | - Kimberly D Hill
- Leidos Biomedical Research Inc, Frederick National Laboratory for Cancer Research, Frederick, Maryland
| | - Charles Kunos
- Cancer Therapy Evaluation Program (CTEP), NCI, Bethesda, Maryland
| | - Jerry M Collins
- Developmental Therapeutics Program (DTP), NCI, Bethesda, Maryland
| |
Collapse
|