Topical silymarin administration for prevention of acute radiodermatitis in breast cancer patients: A randomized, double-blind, placebo-controlled clinical trial

Multifaceted role of phytoconstituents based nano drug delivery systems in combating TNBC: A paradigm shift from chemical to natural

Triple negative breast cancer is considered to be a malignancy of grave concern with limited routes of treatment due to the absence of specific breast cancer markers and ambiguity of other potential drug targets. Poor prognosis and inadequate survival rates have prompted further research into the understanding of the molecular pathophysiology and targeting of the disease. To overcome the recurrence and resistance mechanisms of the TNBC cells, various approaches have been devised, and are being continuously evaluated to enhance their efficacy and safety. Chemo-Adjuvant therapy is one such treatment modality being employed to improve the efficiency of standard chemotherapy. Combining chemo-adjuvant therapy with other upcoming approaches of cancer therapeutics such as phytoconstituents and nanotechnology has yielded promising results in the direction of improving the prognosis of TNBC. Numerous nanoformulations have been proven to substantially enhance the specificity and cellular uptake of drugs by cancer cells, thus reducing the possibility of unintended systemic side effects within cancer patients. While phytoconstituents offer a wide variety of beneficial active constituents useful in cancer therapeutics, most favorable outcomes have been observed within the scope of polyphenols, isoquinoline alkaloids and isothiocyanates. With an enhanced understanding of the molecular mechanisms of TNBC and the advent of newer targeting technologies and novel phytochemicals of medicinal importance, a new era of cancer theranostic treatments can be explored. This review hopes to instantiate the current body of research regarding the role of certain phytoconstituents and their potential nanoformulations in targeting specific TNBC pathways for treatment and diagnostic purposes.

Natural Health Products for Anti-Cancer Treatment: Evidence and Controversy

Natural Health Products (NHPs) have long been considered a valuable therapeutic approach for the prevention and treatment of various diseases, including cancer. However, research on this topic has led to inconclusive and often controversial results. This review aims to provide a comprehensive update of the effects and mechanisms related to the use of NHPs, to describe the results of randomized clinical trials (RCTs) on their effects in cancer patients, and to critically discuss factors influencing clinical outcomes. RCTs available in the literature, even those studying the same NHP, are very heterogeneous in terms of indications, doses, route and timing of administration, and outcomes evaluated. Silymarin, ginsenoside, and vitamin E appear to be useful in attenuating adverse events related to radiotherapy or chemotherapy, and curcumin and lycopene might provide some benefit in patients with prostate cancer. Most RCTs have not clarified whether NHP supplementation provides any real benefit, while harmful effects have been shown in some cases. Overall, the available data suggest that although there is some evidence to support the benefits of NHPs in the management of cancer patients, further clinical trials with the same design are needed before their introduction into clinical practice can be considered.

Evolution of radiation-induced dermatitis treatment

Radiation-induced skin damage (RID) is the most prevalent, significant side effect of radiotherapy (RT). Nearly 95% of patients experience moderate to severe skin reactions after receiving radiation therapy. However, criteria for acute radiation dermatitis (ARD) treatment remain unavailable. Topical agents with anti-inflammatory properties may protect the skin and facilitate tissue regeneration in patients with RID. Many of these topical agents function through nuclear factor kappa B pathway regulation. They either reduce the levels of inflammatory factors or elicit anti-inflammatory properties of their own, thus preventing oxidative stress and inflammatory responses and thus enabling RID prevention and management. Herein, we explore the 25 topical agents investigated for RID prevention and management thus far and evaluate their mechanisms of action. These agents include 11 natural agents, 3 miscellaneous agents, 9 topical nonsteroidal agents, and 2 topical corticosteroids.

Evaluation of the effect of herbal agents as management of radiodermatitis in breast cancer patients: A systematic review and meta-analysis

OBJECTIVE

To evaluate the effectiveness of herbal agents in the prevention and therapy of radiodermatitis in breast cancer patients.

METHODS

Randomized controlled trials were searched from databases such as PubMed, Web of Science, Embase, Cochrane Library, and Chinese National Knowledge Infrastructure (CNKI) to assess the effectiveness of herbal agents compared to a standard medication or placebo in prevention or treatment of radiodermatitis in breast cancer.

RESULTS

Data from 16 studies involving 1994 patients were included. This meta-analysis included 10 clinical trials of 562 breast cancer patients treated with calendula, silymarin, or aloe vera for the prevention of radiodermatitis. Silymarin showed positive effects in ameliorating the damage of radiodermatitis, whereas the efficacy of calendula and aloe vera in the treatment of radiodermatitis lacks sufficient evidence.

CONCLUSIONS

Herbal medicine may show therapeutic effects on radiodermatitis in breast cancer, but more comprehensive investigations and clinical trials are required in the future.

The efficacy of medicinal plant preparations in the alleviation of radiodermatitis in patients with breast cancer: A systematic review of clinical trials

Radiodermatitis in breast cancer patients varies from mild irritation to life-threatening lesions. Several studies suggest a role for topical corticosteroid ointments in the treatment of radiodermatitis. Yet, to avoid the adverse effects of corticosteroids, many authors recommend the use of topical herbal products instead. The therapeutic role of herbal treatments has yet to be fully understood. This systematic review evaluates the role of topical or oral herbal medicines in radiodermatitis prevention and treatment. A systematic search of four databases (Embase, PubMed, Web of Science, and Scopus) was performed without language and time restrictions from their inception until April 2023. The bibliographies of potential articles were also searched manually. Studies evaluated and compared the effects of herbal preparations with the control group, on dermatitis induced by radiotherapy for breast cancer. The Cochrane risk of bias tool was used to assess the included studies. Thirty-five studies were included in the systematic review. Studies which used herbal drugs including topical and oral formulations were evaluated. Herbal monotherapy and combination therapy were reported, and their effects on radiodermatitis were explained in the systematic review. In conclusion, henna ointments, silymarin gel, and Juango cream were reported to reduce the severity of radiodermatitis. These agents should be considered for radiodermatitis prophylaxis and treatment. The data on aloe gel and calendula ointment were conflicting. Further randomized controlled trials of herbal medications and new herbal formulations are required to determine their effects on breast cancer radiodermatitis.

Prophylactic Use of Mepitel® Film to Prevent Radiation-Induced Moist Desquamation in Cancer Patients

Cancer patients had limited treatment options for decades, such as surgery, chemotherapy, and radiation therapy, alone or combined. However, there have been substantial improvements in recent years with the introduction of stem cell therapy, hormone therapy, anti-angiogenic treatments, immunotherapy, dendritic cell-based targeted therapy, ablation therapy, nanoparticles, natural antioxidants, radionics, chemodynamic therapy, sonodynamic therapy, and ferroptosis-based therapy. Radiation therapy, or radiotherapy, is a cancer treatment that employs high doses of radiation to eliminate cancer cells and shrink tumors. This treatment is effective as a primary, adjuvant, or palliative therapy. It is an essential, efficient, cost-effective intervention crucial for providing proper palliative oncology care. Although cancer treatment modalities such as intensity-modulated radiotherapy have advanced, they still risk harming the skin and surrounding healthy tissue. Radiotherapy may induce clinical toxicity leading to chronic or acute radiation dermatitis, depending on the toxicity caused by the therapy. Radiation dermatitis, whether in its chronic or acute form, can cause skin shedding that may result in the formation of wounds. Such shedding can also lead to non-healing ulcers and radionecrosis. Mepitel® film helps control radiation-induced moist desquamation in cancer patients. Clinical trials on the prophylactic use of Mepitel film on radiation-induced moist desquamation did not show similarities among patients from various countries; however, the film-based method is more beneficial than other methods. This review examines the various types of dressings utilized in managing radiation-induced dermatitis to enhance wound healing effectiveness while avoiding harm to newly developing tissues. Additionally, this review compares the effectiveness of using Mepitel film for treating radiation-induced moist desquamation to other methods.

Polyphenols as Potential Protectors against Radiation-Induced Adverse Effects in Patients with Thoracic Cancer

Radiotherapy is one of the standard treatment approaches used against thoracic cancers, occasionally combined with chemotherapy, immunotherapy and molecular targeted therapy. However, these cancers are often not highly sensitive to standard of care treatments, making the use of high dose radiotherapy necessary, which is linked with high rates of radiation-induced adverse effects in healthy tissues of the thorax. These tissues remain therefore dose-limiting factors in radiation oncology despite recent technological advances in treatment planning and delivery of irradiation. Polyphenols are metabolites found in plants that have been suggested to improve the therapeutic window by sensitizing the tumor to radiotherapy, while simultaneously protecting normal cells from therapy-induced damage by preventing DNA damage, as well as having anti-oxidant, anti-inflammatory or immunomodulatory properties. This review focuses on the radioprotective effect of polyphenols and the molecular mechanisms underlying these effects in the normal tissue, especially in the lung, heart and esophagus.

Therapy-resistant breast cancer in focus: Clinically relevant mitigation by flavonoids targeting cancer stem cells

Significant limitations of the reactive medical approach in breast cancer management are clearly reflected by alarming statistics recorded worldwide. According to the WHO updates, breast malignancies become the leading cancer type. Further, the portion of premenopausal breast cancer cases is permanently increasing and demonstrates particularly aggressive patterns and poor outcomes exemplified by young patients with triple-negative breast cancer that lacks targeted therapy. Accumulating studies suggest the crucial role of stem cells in tumour biology, high metastatic activity, and therapy resistance of aggressive breast cancer. Therefore, targeting breast cancer stem cells is a promising treatment approach in secondary and tertiary breast cancer care. To this end, naturally occurring substances demonstrate high potential to target cancer stem cells which, however, require in-depth analysis to identify effective anti-cancer agents for cost-effective breast cancer management. The current article highlights the properties of flavonoids particularly relevant for targeting breast cancer stem cells to mitigate therapy resistance. The proposed approach is conformed with the principles of 3P medicine by applying predictive diagnostics, patient stratification and treatments tailored to the individualised patient profile. Expected impacts are very high, namely, to overcome limitations of reactive medical services improving individual outcomes and the healthcare economy in breast cancer management. Relevant clinical applications are exemplified in the paper.

Preparation and Characterization of Silymarin Gel: A Novel Topical Mucoadhesive Formulation for Potential Applicability in Oral Pathologies

Silybum marianum has been used for centuries by herbalists and physicians to treat different forms of liver diseases. It contains flavonoid, which has antioxidant, anti-inflammatory, antifibrotic and anticancer properties. The objective of this research was to develop a silymarin-based mucoadhesive gel for prolonged release in oral mucosa and to evaluate the same by using in vitro drug release kinetic models and ex vivo methods for drug permeation using chicken buccal mucosa. The mucoadhesive gel was formulated in different trials by varying the concentration of silymarin and polymer. Out of 10 formulation trials, the F10 optimized trial was characterized for in vitro physicochemical parameters such as pH, homogeneity, viscosity, stability, drug content, in vitro drug release, in vitro antioxidant assay and ex vivo permeation study. Trial 10 was chosen as the best trial formulation among the other trials and was marked as an optimal trial. The physicochemical properties observed were pH to be 6.4 ± 0.01, the gel free of lumps, spreadability of 23.75 ± 0.03 and drug content of 32.77 ± 0.20 mg/g. It had no physiological changes such as color shift or fluid exudate segregation after 6 months of storage at room temperature. In vitro drug release established the presence of a non-fickian mechanism and demonstrated dose-dependent antioxidant activity. Ex vivo findings indicated 21.97 ± 0.18% release, proving that the gel can permeate through the oral mucosal membrane. Our future research will concentrate on expanding the therapeutic scope by developing the formulation trial F10 to a nanoformulation and conducting clinical trials for its potential use in various oral diseases.

Silymarin as a preventive or therapeutic measure for chemotherapy and radiotherapy-induced adverse reactions: a comprehensive review of preclinical and clinical data

PURPOSE

Thus far, silymarin has been examined in several studies for prevention or treatment of various chemotherapy or radiotherapy-induced adverse reactions. In this review, we try to collect all available human, animal, and pre-clinical data in this field.

METHODS

The search was done in Scopus, PubMed, Medline, and systematic reviews in the Cochrane database, using the following keywords: "Cancer," "Chemotherapy," "Radiotherapy," "Mucositis," "Nephrotoxicity," "Dermatitis," "Ototoxicity," "Cardiotoxicity," "Nephrotoxicity," "Hepatotoxicity," "Reproductive system," "Silybum marianum," "Milk thistle," and "Silymarin" and "Silybin." We included all relevant in vitro, in vivo, and human studies up to the date of publication.

RESULTS

Based on 64 included studies in this review, silymarin is considered a safe and well-tolerated compound, with no known clinical drug interaction. Notably, multiple adverse reactions of chemotherapeutic agents are effectively managed by its antioxidant, anti-apoptotic, anti-inflammatory, and anti-immunomodulatory properties. Clinical trials suggest that oral silymarin may be a promising adjuvant with cancer treatments, particularly against hepatotoxicity (n = 10), nephrotoxicity (n = 3), diarrhea (n = 1), and mucositis (n = 3), whereas its topical formulation can be particularly effective against radiodermatitis (n = 2) and hand-foot syndrome (HFS) (n = 1).

CONCLUSION

Further studies are required to determine the optimal dose, duration, and the best formulation of silymarin to prevent and/or manage chemotherapy and radiotherapy-induced complications.

Effects of topical timolol for the prevention of radiation-induced dermatitis in breast cancer: a pilot triple-blind, placebo-controlled trial

Introduction

Radiation therapy is one of the standard methods in the treatment of breast cancer. Radiotherapy-induced dermatitis (RID) is a common complication of radiotherapy (RT) resulting in less tolerance in RT and even discontinuation of treatment. Timolol is a β-adrenergic receptor antagonist that presents the best wound healing effects on both chronic and incurable wound healing. Topical forms of timolol could be effective in the prevention of RID due to the role of β-adrenergic receptors in skin cells and keratinocyte migration, as well as the anti-inflammatory effect of timolol. However, no placebo-controlled randomized trial is available to confirm its role. The current trial aimed to evaluate the efficacy of topical timolol 0.5% (w/w) on the RID severity and patients' quality of life (QOL).

Method

Patients aged older than 18 years with positive histology confirmed the diagnosis of invasive and localized breast cancer were included. Patients were randomized based on the random number table to receive each of the interventions of timolol 0.5% (w/w) or placebo topical gels from the first day of initiation of RT and for 6 weeks, a thin layer of gel twice daily. Patients were asked to use a thin layer of gel for at least two hours before and after radiation therapy. Primary outcomes were acute radiation dermatitis (ARD) grade using Radiation Therapy Oncology Group and the European Organization for Research and Treatment of Cancer (RTOG/EORTC) scale and severity of desquamation based on Common Terminology Criteria for Adverse Events (CTCAE), version 5.0. Secondary outcomes were QOL based on Skindex16 (SD-16), maximum grade of ARD, and time of initial RD occurrence.

Results

A total of 64 female patients with an age range of 33 to 79 years were included. The means (SD) of age were 53.88 (11.02) and 54.88 (12.48) in the control and timolol groups, respectively. Considering the RTOG/EORTC and CTCAE scores the difference between groups was insignificant (P-Value = 0.182 and P-Value = 0.182, respectively). In addition, the mean (SD) of time of initial RID occurrence in placebo and timolol groups were 4.09 (0.588) and 4.53 (0.983) weeks, respectively (P-Value = 0.035). The maximum grade of RID over time was significantly lower in the timolol group. During the study period, 75.0% of patients in placebo groups had grade 2 of ARD while in the timolol group it was 31.3% (P-Value = 0.002). QoL was not significantly different between groups (P-Value = 0.148).

Conclusion

Although the topical formulation of timolol, 0.5% (w/w), was found to reduce the average maximum grade of ARD and increase the mean (SD) time of initial RID occurrence, it showed no effect on ARD, severity, and QOL. However, future clinical trials should be performed to assess timolol gel formulation in larger study populations.

Trial registration

https://irct.ir/ IRCT20190810044500N11 (17/03/2021).

Mechanistic Insights into the Pharmacological Significance of Silymarin

Medicinal plants are considered the reservoir of diverse therapeutic agents and have been traditionally employed worldwide to heal various ailments for several decades. Silymarin is a plant-derived mixture of polyphenolic flavonoids originating from the fruits and akenes of Silybum marianum and contains three flavonolignans, silibinins (silybins), silychristin and silydianin, along with taxifolin. Silybins are the major constituents in silymarin with almost 70–80% abundance and are accountable for most of the observed therapeutic activity. Silymarin has also been acknowledged from the ancient period and is utilized in European and Asian systems of traditional medicine for treating various liver disorders. The contemporary literature reveals that silymarin is employed significantly as a neuroprotective, hepatoprotective, cardioprotective, antioxidant, anti-cancer, anti-diabetic, anti-viral, anti-hypertensive, immunomodulator, anti-inflammatory, photoprotective and detoxification agent by targeting various cellular and molecular pathways, including MAPK, mTOR, β-catenin and Akt, different receptors and growth factors, as well as inhibiting numerous enzymes and the gene expression of several apoptotic proteins and inflammatory cytokines. Therefore, the current review aims to recapitulate and update the existing knowledge regarding the pharmacological potential of silymarin as evidenced by vast cellular, animal, and clinical studies, with a particular emphasis on its mechanisms of action.

Promoting Comfort: A Clinician Guide and Evidence-Based Skin Care Plan in the Prevention and Management of Radiation Dermatitis for Patients with Breast Cancer

Patients with breast cancer may be offered adjuvant radiation therapy (RT) after surgery. Up to 95% of these patients develop radiation dermatitis (RD) during or following RT. Randomized clinical trials and other literature provide evidence that RD can be prevented or reduced. The aim of this article is to propose a Clinician Guide and Evidence-based Skin Care Plan to prevent and/or reduce radiation dermatitis and promote the comfort of breast cancer patients receiving RT. As an integrative review, the databases searched were CINAHL and Medline, using the key terms: breast cancer, skin care, radiation, radiation therapy, radiotherapy, radiation dermatitis, and radiation skin reaction, prevention, and management. Search criteria included English language, full text, published between 2012 through 2020, and peer-reviewed. The search yielded 320 articles. Relevant articles were evaluated using the Quality Assessment Tool (QAT), and highly rated articles were selected to be included in the review of literature. The outcomes were the development of a Clinician Guide to offer holistic, patient-centered care and an Evidence-based Skin Care Plan. The research literature supports a standard skin care regimen, along with use of an emollient cream to the treatment area, use of deodorants depending on patient preferences, and application of a topical steroid cream daily throughout treatment and two weeks post RT. Clinician’s weekly assessments of patients offers therapeutic support and ensures optimal skin care during and post-RT. The comfort of breast cancer patients receiving RT requires the best level of evidence regarding the efficacy of interventions, coupled with clinician’s judgement, and patient’s preferences and wishes. The clinician-patient relationship is essential in addressing the physical, emotional, social, spiritual, and functional challenges associated with a cancer diagnosis and adjunctive radiation therapy to improve long-term survival.

Silybin and its congeners: from traditional medicine to molecular effects

Covering: 2015 up to 2022 (Feb)Silymarin, an extract of milk thistle (Silybum marianum) fruits, has been used in various medicinal applications since ancient times. A major component of silymarin is the flavonolignan silybin and its relatives isosilybin, silychristin, silydianin, 2,3-dehydrosilybin, and some others. Except for silydianin, they occur in nature as two stereomers. This review focuses on recent developments in chemistry, biosynthesis, modern advanced analytical methods, and transformations of flavonolignans specifically reflecting their chirality. Recently described chemotypes of S. marianum, but also the newest findings regarding the pharmacokinetics, hepatoprotective, antiviral, neuroprotective, and cardioprotective activity, modulation of endocrine functions, modulation of multidrug resistance, and safety of flavonolignans are discussed. A growing number of studies show that the respective diastereomers of flavonolignans have significantly different activities in anisotropic biological systems. Moreover, it is now clear that flavonolignans do not act as antioxidants in vivo, but as specific ligands of biological targets and therefore their chirality is crucial. Many controversies often arise, mainly due to the non-standard composition of this phytopreparation, the use of various undefined mixtures, the misattribution of silymarin vs. silybin, and also the failure to consider the chemistry of the respective components of silymarin.

Plant and Herbal Extracts as Ingredients of Topical Agents in the Prevention and Treatment Radiodermatitis: A Systematic Literature Review

Background: The use of herbal extracts as the source of antioxidant substances capable of neutralizing free radicals and providing protection from ionizing radiation appears to be an alternative therapy for radiodermatitis. As concerns the prevention and treatment of side effects, a lot of recommendations are based on proper experience of radiotherapy centers. We summarize recent research aiming at reducing radiation-induced skin injuries by use of proper skin care, using topical preparations with herbal extracts including onco-cosmetics. Methods: This article is limited to a critical analysis of scientific and professional literature. It concerns preparations in different physicochemical forms, e.g., gels, emulsions, ointments. We stress the connection between the type of applied skin care (type of preparation, its composition, the dose), the properties of the herbal extract and the evaluation of its efficiency in preventing and treating radiation reaction on skin. Conclusions: Herbal extracts can be added to recipes because they are part of a category of cosmeceutical supplements and can be introduced into preparations without prescription. The effectiveness evaluation for herbal extracts in radiotherapy is not an easy task since there are no strict guidelines. Studies should be preceded by the analysis of herbal extracts and recipe in terms of physicochemical, dermatological and performance characteristics.

Topical henna and curcumin (Alpha®) ointment efficacy for prevention of capecitabine induced hand-foot syndrome: A randomized, triple-blinded, placebo-controlled clinical

PURPOSE

In this clinical trial, we evaluated Alpha® ointment efficacy in prevention of capecitabine induced hand-foot syndrome (HFS) in patients with gastrointestinal or breast cancers, for the first time.

METHODS

During this pilot, randomized, triple-blinded, placebo-controlled clinical trial, the effect of Alpha® ointment (Lawsonia inermis 3 g and Curcuma longa 0.15 g/ 30 g) was assessed. It was applied on the palms and the soles, two times daily starting at the first day of chemotherapy for 4 consecutive courses. The severity of HFS was assessed at the end of the chemotherapy courses based on World Health Organization (WHO) scale and scored between 0-4.

RESULTS

Ninety eligible patients were included randomly in the treatment or placebo group. Median WHO HFS grade was not significantly different between the two groups, during the follow-up period (P > 0.05). In the weekly assessment, the scores increased meaningfully in both the placebo and treatment groups, but there was a delay in HFS occurrence and deterioration in Alpha ointment group based on post hoc analysis.

CONCLUSION

Administration of Alpha® ointment containing henna and curcumin could not significantly prevent capecitabine induced HFS during 4 courses of treatment, but can somewhat delay its occurrence in patients with gastrointestinal or breast cancer.

Anti-breast cancer effects of phytochemicals: primary, secondary, and tertiary care

Breast cancer incidence is actually the highest one among all cancers. Overall breast cancer management is associated with challenges considering risk assessment and predictive diagnostics, targeted prevention of metastatic disease, appropriate treatment options, and cost-effectiveness of approaches applied. Accumulated research evidence indicates promising anti-cancer effects of phytochemicals protecting cells against malignant transformation, inhibiting carcinogenesis and metastatic spread, supporting immune system and increasing effectiveness of conventional anti-cancer therapies, among others. Molecular and sub-/cellular mechanisms are highly complex affecting several pathways considered potent targets for advanced diagnostics and cost-effective treatments. Demonstrated anti-cancer affects, therefore, are clinically relevant for improving individual outcomes and might be applicable to the primary (protection against initial cancer development), secondary (protection against potential metastatic disease development), and tertiary (towards cascading complications) care. However, a detailed data analysis is essential to adapt treatment algorithms to individuals’ and patients’ needs. Consequently, advanced concepts of patient stratification, predictive diagnostics, targeted prevention, and treatments tailored to the individualized patient profile are instrumental for the cost-effective application of natural anti-cancer substances to improve overall breast cancer management benefiting affected individuals and the society at large.

Radiation induced skin reactions during and following radiotherapy: A systematic review of interventions

INTRODUCTION

Radiation induced skin reactions (RISR) are a common adverse effect of radiotherapy that can impact on patient quality of life. The aim of this systematic review was to identify new research evidence on interventions for RISR to guide health practitioners on best practice skin care for people receiving radiotherapy.

METHODS

A narrative systematic review was adopted including published research since 2014. The MESH search terms used in the 2014 College of Radiographers skin care systematic review were supplemented with terms identified through a pearl growing search technique.

RESULTS

Thirty-three studies were identified and reviewed, 13(39.4%) were assessed as having a high risk of bias 6(18.2%) moderate risk of bias, and 13(39.4%) low risk of bias; one pilot study was not assessed. Twenty-one of the studies were randomised controlled trials, 2 feasibility studies, 9 non-randomised trials, and 1 a pilot study.

CONCLUSION

Evidence from well conducted studies identified prophylactic use of steroid cream for patients, at high risk of RISR, as being the most efficacious in reducing acute skin reactions. Further research is needed on photo biomodulation therapy, studied within standard dose fractionation schedules, before it is recommended for use in practice. There is insufficient evidence to support the use of barrier films or any topical emollients currently in practice to reduce RISRs. Despite the number of new studies in this area there is limited good comparative research of RISR that accounts for predictive risk and new radiotherapy techniques.

IMPLICATIONS FOR PRACTICE

Practitioners are encouraged to risk assess patients prior to radiotherapy to guide interventions and record and monitor patient skin toxicity regularly during treatment, comparing toxicity changes with scores recorded at baseline and support patient self-monitoring of skin reactions.

Recapitulation of Evidence of Phytochemical, Pharmacokinetic and Biomedical Application of Silybin

Silymarin is a standardized extract obtained from seeds of Silybum marianum (SM) belonging to the family Asteraceae. It is a flavonolignan complex and consists of various compounds like silybin A silybin B, isosilybin A, isosilybin B, silydianin, silychristin and isosilychristin. Silybin is the major active component present in 60-70% of the silymarin extract. It has been used traditionally for the treatment of various liver disorders like cirrhosis, jaundice, and hepatitis. Silymarin possesses antioxidant and anti-inflammatory properties and is responsible for its antitumor activity. Other than hepatoprotective effect SM also possesses renoprotective, anti-diabetic, neuroprotective, hypolipidemic, anti-atherosclerosis and cardioprotective effects. Rather antimicrobial property of silymarin was observed against specific microbes, fungi, and viruses. This manuscript covered recent preclinical and clinical evidence of specific components silybin, responsible for its efficacy and about clinical studies has been conducted so far, which proven it's safety and offers mild effect like nausea, diarrhea and bloating. This review specifically focused on recent updates on its active components therapeutic applications against complicated ailments not covered in earlier reports.

Herbal Medicines for Treatment of Radiodermatitis: A Systematic Review and Meta-Analysis

Background: There is some evidence in favor of the efficacy of herbal medicine in the treatment of radiodermatitis as a frequent complication among cancer patients. Purpose: The present study aimed to evaluate the effect of herbal medicines on the treatment of radiodermatitis in cancer patients. Study design: Systematic review performed in accordance with the PRISMA guideline. Methods: We searched the electronic databases, Scopus, PubMed, Cochrane Library, Embase, Google Scholar, and ISI Web of Science, through July 2020 for randomized controlled trials (RCTs) that compared herbal compounds against a standard medication or placebo for treatment or prevention of radiodermatitis. Results: A total of 16 RCTs involving 1886 patients with breast, head and neck, or unspecified cancer were included. Risk of bias generally was high. Of those, three RCTs with 562 cancer patients (mainly breast cancer) who used Aloe vera to treat radiodermatitis were included in the meta-analysis. There was a significant level of heterogeneity between the studies (I² = 95.8). One RCT found positive effects of Aloe vera in reducing the severity of radiodermatitis (standardized mean difference [SMD] = 3.37), whereas another revealed an inverse effect (SMD = -4). Conclusion: At present, there are no herbal compositions that are effective in treating radiodermatitis, with Aloe vera failing to show sufficient efficacy in the meta-analysis.

Overview of the Active Ingredients in Cosmetic Products for the Care of Skin That Has Been Exposed to Ionizing Radiation - Analysis of Their Effectiveness in Breast Cancer Radiotherapy

Treatment that uses ionizing radiation is one of the most common therapeutic methods in case of breast cancer. However, it often results in radiation dermatitis, which manifests itself, among others, as erythema, burning, itching and pain as well as dry or moist desquamation of the epidermis in the irradiated areas. The intensity of these symptoms significantly reduces the patient's quality of life, which could affect the effectiveness of the entire therapy. There are more and more cosmetic preparations on the market for daily care of skin that has been exposed to radiation. The composition of the active ingredients in these preparations is designed to support the protective functions of the skin, delay the occurrence of the side effects of ionizing radiation, reduce their intensity, and accelerate the regeneration of the irradiated areas. Unfortunately, there is little scientific evidence of the effectiveness of the active ingredients that are contained in these preparations. This paper presents a narrative review of the most commonly used ingredients and compares them with the current state of knowledge on their effectiveness in preventing radiodermatitis.

Pharmacological Properties of Polyphenols: Bioavailability, Mechanisms of Action, and Biological Effects in In Vitro Studies, Animal Models, and Humans

Drugs are bioactive compounds originally discovered from chemical structures present in both the plant and animal kingdoms. These have the ability to interact with molecules found in our body, blocking them, activating them, or increasing or decreasing their levels. Their actions have allowed us to cure diseases and improve our state of health, which has led us to increase the longevity of our species. Among the molecules with pharmacological activity produced by plants are the polyphenols. These, due to their molecular structure, as drugs, also have the ability to interact with molecules in our body, presenting various pharmacological properties. In addition, these compounds are found in multiple foods in our diet. In this review, we focused on discussing the bioavailability of these compounds when we ingested them through diet and the specific mechanisms of action of polyphenols, focusing on studies carried out in vitro, in animals and in humans over the last five years. Knowing which foods have these pharmacological activities could allow us to prevent and aid as concomitant treatment against various pathologies.

Prevention of colistin induced nephrotoxicity: a review of preclinical and clinical data

Introduction: The emergence of antimicrobial resistance in Gram-negative bacteria is a concerning challenge for health systems. The polymyxins, including colistin, are one of the limited available options these pathogens management. Nephrotoxicity, beside neurotoxicity is the major dose-limiting adverse reaction of polymyxins, with an up to 60% prevalence. As oxidative stress, inflammatory pathways and apoptosis are considered as the main mechanisms of colistin-induced kidney damage, various studies have evaluated antioxidant and/or antiapoptotic compounds for its prevention. In this article, we reviewed animal and human studies on these probable preventive measures.Area covered: PubMed, Scopus, and google scholar databases were searched using several combination of 'colistin', 'polymyxin E', 'CMS', 'Colistimethate sodium', 'nephrotoxicity', 'kidney injury', 'kidney damage', 'renal injury', 'renal damage', 'nephroprotectants', 'renoprotective', 'nephroprotective', and 'prevention'. All eligible articles including animal and human studies up to the end of 2020 were included.Expert opinion: Most of available studies are in vivo researches on anti-oxidant and anti-apoptotic agents like NAC, vitamin C and E, silymarin, and curcumin which mostly showed promising findings. However, limited human studies on NAC and vitamin C did not demonstrate considerable efficacy. So, before proposing these compounds, further well-designed randomized clinical trials are necessary.

Path of Silibinin from diet to medicine: A dietary polyphenolic flavonoid having potential anti-cancer therapeutic significance

In the last few decades, targeting cancer by the use of dietary phytochemicals has gained enormous attention. The plausible reason and believe or mind set behind this fact is attributed to either lesser or no side effects of natural compounds as compared to the modern chemotherapeutics, or due to their conventional use as dietary components by mankind for thousands of years. Silibinin is a naturally derived polyphenol (a flavonolignans), possess following biochemical features; molecular formula C₂₅H₂₂O₁₀, Molar mass: 482.44 g/mol, Boiling point 793 °C, with strikingly high antioxidant and anti-tumorigenic properties. The anti-cancer properties of Silibinin are determined by a variety of cellular pathways which include induction of apoptosis, cell cycle arrest, inhibition of angiogenesis and metastasis. In addition, Silibinin controls modulation of the expression of aberrant miRNAs, inflammatory response, and synergism with existing anti-cancer drugs. Therefore, modulation of a vast array of cellular responses and homeostatic aspects makes Silibinin an attractive chemotherapeutic agent. However, like other polyphenols, the major hurdle to declare Silibinin a translational chemotherapeutic agent, is its lesser bioavailability. After summarizing the chemistry and metabolic aspects of Silibinin, this extensive review focuses on functional aspects governed by Silibinin in chemoprevention with an ultimate goal of summarizing the evidence supporting the chemopreventive potential of Silibinin and clinical trials that are currently ongoing, at a single platform.

Health Benefits of Silybum marianum: Phytochemistry, Pharmacology, and Applications

Silybum marianum (SM), a well-known plant used as both a medicine and a food, has been widely used to treat various diseases, especially hepatic diseases. The seeds and fruits of SM contain a flavonolignan complex called silymarin, the active compounds of which include silybin, isosilybin, silychristin, dihydrosilybin, silydianin, and so on. In this review, we thoroughly summarize high-quality publications related to the pharmacological effects and underlying mechanisms of SM. SM has antimicrobial, anticancer, hepatoprotective, cardiovascular-protective, neuroprotective, skin-protective, antidiabetic, and other effects. Importantly, SM also counteracts the toxicities of antibiotics, metals, and pesticides. The diverse pharmacological activities of SM provide scientific evidence supporting its use in both humans and animals. Multiple signaling pathways associated with oxidative stress and inflammation are the common molecular targets of SM. Moreover, the flavonolignans of SM are potential agonists of PPARγ and ABCA1, PTP1B inhibitors, and metal chelators. At the end of the review, the potential and perspectives of SM are discussed, and these insights are expected to facilitate the application of SM and the discovery and development of new drugs. We conclude that SM is an interesting dietary medicine for health enhancement and drug discovery and warrants further investigation.

A monocentric, open-label randomized standard-of-care controlled study of XONRID®, a medical device for the prevention and treatment of radiation-induced dermatitis in breast and head and neck cancer patients

Background

This study was an open-label, 2-arms, monocentric, randomized clinical trial comparing Xonrid®, a topical medical device, versus standard of care (SOC) in preventing and treating acute radiation dermatitis (ARD) in Head and Neck Cancer (HNC) and Breast Cancer (BC) patients undergoing radiotherapy (RT).

Methods

Eligible HNC and BC patients were randomized 1:1 to receive Xonrid® + SOC or SOC during RT. Patients were instructed to apply Xonrid® on the irradiated area three times daily, starting on the first day of RT and until 2 weeks after RT completion or until the development of grade ≥ 3 skin toxicity. The primary endpoint was to evaluate the proportion of patients who developed an ARD grade < 2 at the 5th week in both groups. Secondary endpoints were median time to grade 2 (G2) skin toxicity onset; changes in skin erythema and pigmentation and trans-epidermal water loss (TEWL); patient-reported skin symptoms. All patients were evaluated at baseline, weekly during RT and 2 weeks after treatment completion. The evaluation included: clinical toxicity assessment; reflectance spectrometry (RS) and TEWL examination; measurement of patients’ quality of life (QoL) through Skindex-16 questionnaire.

Results

Eighty patients (40 for each cancer site) were enrolled between June 2017 and July 2018. Groups were well balanced for population characteristics. All BC patients underwent 3-Dimensional Conformal RT (3D-CRT) whereas HNC patients underwent Volumetric-Modulated Arc Therapy (VMAT). At week 5 the proportion of BC patients who did not exhibit G2 ARD was higher in Xonrid® + SOC group (p = 0.091). In the same group the onset time of G2 ARD was significantly longer than in SOC-alone group (p < 0.0491). For HNC groups there was a similar trend, but it did not reach statistical significance. For both cancer sites, patients’ QoL, measured by the Skindex-16 score, was always lower in the Xonrid® + SOC group.

Conclusion

Despite the failure to achieve the primary endpoint, this study suggests that Xonrid® may represent a valid medical device in the prevention and treatment of ARD at least in BC patients, delaying time to develop skin toxicity and reducing the proportion of patients who experienced G2 ARD during RT treatment and 2 weeks later.

Trial registration

The study was approved by the Ethical Committee of Fondazione IRCCS Istituto Nazionale dei Tumori di Milano (INT 52/14 - NCT02261181). Registered on ClinicalTrial.gov on 21st August 2017.

Dietary Flavonoids in p53-Mediated Immune Dysfunctions Linking to Cancer Prevention

The p53 protein plays a central role in mediating immune functioning and determines the fate of the cells. Its role as a tumor suppressor, and in transcriptional regulation and cytokine activity under stress conditions, is well defined. The wild type (WT) p53 functions as a guardian for the genome, while the mutant p53 has oncogenic roles. One of the ways that p53 combats carcinogenesis is by reducing inflammation. WT p53 functions as an anti-inflammatory molecule via cross-talk activity with multiple immunological pathways, such as the major histocompatibility complex I (MHCI) associated pathway, toll-like receptors (TLRs), and immune checkpoints. Due to the multifarious roles of p53 in cancer, it is a potent target for cancer immunotherapy. Plant flavonoids have been gaining recognition over the last two decades to use as a potential therapeutic regimen in ameliorating diseases. Recent studies have shown the ability of flavonoids to suppress chronic inflammation, specifically by modulating p53 responses. Further, the anti-oxidant Keap1/Nrf2/ARE pathway could play a crucial role in mitigating oxidative stress, leading to a reduction of chronic inflammation linked to the prevention of cancer. This review aims to discuss the pharmacological properties of plant flavonoids in response to various oxidative stresses and immune dysfunctions and analyzes the cross-talk between flavonoid-rich dietary intake for potential disease prevention.

Flavonolignans: One Step Further in the Broad-Spectrum Approach of Cancer

BACKGROUND

The small chemical class of flavonolignans encompasses unique hybrid molecules with versatile biological activities. Their anticancer effects have received considerable attention, and a large body of supporting evidence has accumulated. Moreover, their ability to interact with proteins involved in drug resistance, and to enhance the effects of conventional chemotherapeutics in decreasing cell viability make them influential partners in addressing cancer.

OBJECTIVE

The review provides an outline of the various ways in which flavonolignans advance the combat against cancer. While the main focus falls on flavonolignans from milk thistle, attention is drawn to the yet, underexplored potential of less known flavonolignan subgroups derived from isoflavonoids and aurones.

METHODS

Proceeding from the presentation of natural flavonolignan subtypes and their occurrence, the present work reviews these compounds with regard to their molecular targets in cancer, anti-angiogenetic effects, synergistic efficacy in conjunction with anticancer agents, reversal of drug resistance, and importance in overcoming the side effects of anticancer therapy. Recent advances in the endeavor to improve flavonolignan bioavailability in cancer are also presented.

CONCLUSIONS

Significant progress has been achieved in detailing the molecular mechanisms of silybin and its congeners in experimental models of cancer. The availability of novel formulations with improved bioavailability, and data from phase I clinical trials in cancer patients provide an encouraging basis for more extensive trials aimed at evaluating the benefits of Silybum flavonolignans in cancer management. On the other hand, further research on the antitumor efficacy of iso-flavonolignans and other subtypes of flavonolignans should be pursued.

Radiation-Induced Skin Fibrosis: Pathogenesis, Current Treatment Options, and Emerging Therapeutics

Radiotherapy (RT) has become an indispensable part of oncologic treatment protocols for a range of malignancies. However, a serious adverse effect of RT is radiodermatitis; almost 95% of patients develop moderate to severe skin reactions following radiation treatment. In the acute setting, these can be erythema, desquamation, ulceration, and pain. Chronically, soft tissue atrophy, alopecia, and stiffness can be noted. Radiodermatitis can delay oncologic treatment protocols and significantly impair quality of life. There is currently a paucity of effective treatment options and prevention strategies for radiodermatitis. Importantly, recent preclinical and clinical studies have suggested that fat grafting may be of therapeutic benefit, reversing detrimental changes to soft tissue following RT. This review outlines the damaging effects of RT on the skin and soft tissue as well as discusses available treatment options for radiodermatitis. Emerging strategies to mitigate detrimental, chronic radiation-induced changes are also presented.

Safety and toxicity of silymarin, the major constituent of milk thistle extract: An updated review

Milk thistle (Silybum marianum) is a medicinal plant from the Asteraceae family. Silymarin is the major constituent of milk thistle extract and is a mixture of some flavonolignans such as silybin, which is the most active component of silymarin. It is most commonly known for its hepatoprotective effect. Also, studies have shown other therapeutic effects such as anticancer, anti-Alzheimer, anti-Parkinson, and anti-diabetic, so its safety is very important. It has no major toxicity in animals. Silymarin was mutagen in Salmonella typhimurium strains in the presence of metabolic enzymes. Silybin, silydianin, and silychristin were not cytotoxic and genotoxic at concentration of 100 μM. Silymarin is safe in humans at therapeutic doses and is well tolerated even at a high dose of 700 mg three times a day for 24 weeks. Some gastrointestinal discomforts occurred like nausea and diarrhea. One clinical trial showed silymarin is safe in pregnancy, and there were no anomalies. Consequently, caution should be exercised during pregnancy, and more studies are needed especially in humans. Silymarin has low-drug interactions, and it does not have major effects on cytochromes P-450. Some studies demonstrated that the use of silymarin must be with caution when co-administered with narrow therapeutic window drugs.