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Abdelfattah-Hassan A, Ibrahim D, Saleh AA, Kishawy AT, Mohamed RH, Khater SI. Effects of 5-fluorouracil, thymoquinone, and mammary stem cells' exosomes on in vitro cultured breast cancer cells. Open Vet J 2024; 14:525-533. [PMID: 38633189 PMCID: PMC11018403 DOI: 10.5455/ovj.2024.v14.i1.47] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2023] [Accepted: 12/15/2023] [Indexed: 04/19/2024] Open
Abstract
Background 5-fluorouracil (5-FU) is an antimetabolic agent used for treating slowly growing solid tumors like breast and ovarian carcinoma. Thymoquinone (TQ) is the main biologically active constituent of Nigella sativa, it has been found to demonstrate anticancerous effects in several preclinical studies, and this is because TQ possesses multitarget nature. Stem cells-derived exosomes are in the spotlight of research and are promising tissue regenerative and anticancer cell-derived nanovesicles. Aim Herein, we studied the antineoplastic effects of Exosomes derived from mammary stem cells (MaSCs-Exo) on breast cancer cells, alone or combined with TQ when compared to a breast cancer chemotherapeutic agent; 5-FU. Methods Our approach included performing viability test and measuring the expression of pro-apoptotic gene (Bax), anti-apoptotic gene (BCL-2) and angiogenic gene (VEGF) on Human MCF-7 cells (breast adenocarcinoma cells), the MCF-7 cells were cultured and incubated with medium containing 5-FU (25 μg/ml), TQ (200 μg/ml), MaSCs-Exo (100 μg protein equivalent), a combination of TQ (200 μg/ml) and MaSCs-Exo (100 μg). Results Our obtained results show that TQ and MaSCs-Exo each can effectively inhibit breast cancer cell line (MCF-7) proliferation and growth. Also, the results show that the combination of TQ and MaSCs-Exo had higher cytotoxic effects on MCF-7 breast cancer cells than TQ or 5-FU, alone. Conclusion The present study shows a promising anticancer potential of exosomes isolated from mammary stem cells; this effect was potentiated by adding TQ with MaSCs-derived exosomes.
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Affiliation(s)
- Ahmed Abdelfattah-Hassan
- Department of Anatomy and Embryology, Faculty of Veterinary Medicine, Zagazig University, Zagazig, Egypt
- Biomedical Sciences Program, University of Science and Technology, Zewail City of Science and Technology, Giza, Egypt
| | - Doaa Ibrahim
- Department of Nutrition and Clinical Nutrition, Faculty of Veterinary Medicine, Zagazig University, Zagazig, Egypt
| | - Ayman A. Saleh
- Department of Animal Wealth Development, Genetics and Genetic Engineering, Faculty of Veterinary Medicine, Zagazig University, Zagazig, Egypt
| | - Asmaa T.Y. Kishawy
- Department of Nutrition and Clinical Nutrition, Faculty of Veterinary Medicine, Zagazig University, Zagazig, Egypt
| | - Reham H.A. Mohamed
- Department of Biochemistry, Faculty of Veterinary Medicine, Zagazig University, Zagazig, Egypt
| | - Safaa I. Khater
- Department of Biochemistry, Faculty of Veterinary Medicine, Zagazig University, Zagazig, Egypt
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Bahman A, Abaza MS, Khoushaish S, Al-Attiyah RJ. Therapeutic efficacy of sorafenib and plant-derived phytochemicals in human colorectal cancer cells. BMC Complement Med Ther 2023; 23:210. [PMID: 37365571 DOI: 10.1186/s12906-023-04032-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2022] [Accepted: 06/09/2023] [Indexed: 06/28/2023] Open
Abstract
BACKGROUND The present study aimed to investigate the sequence-dependent anticancer effects of combined treatment with sorafenib (Sora), a Food and Drug Administration-approved multikinase inhibitor drug, and plant-derived phytochemicals (PPCs) on human colorectal cancer (CRC) cell growth, and proteins associated with the control of cell cycle and apoptosis. METHODS The cytotoxic effects of 14 PPCs on CRL1554 fibroblast cells were determined using an MTT assay. Moreover, the cytotoxicity of Sora, PPCs, and a combination of both on CRC cells were also investigated. Cell cycle analysis was performed using flow cytometry, and cell apoptosis was investigated using DNA fragmentation, Annexin V/propidium iodide double staining, and mitochondrial membrane potential analyses. The cell cycle- and apoptosis-associated protein expression levels were analysed using western blotting. RESULTS Based on their low levels of cytotoxicity in CRL1554 cells at ≤ 20%, curcumin, quercetin, kaempferol, and resveratrol were selected for use in subsequent experiments. The combined treatment of sora and PPCs caused levels of CRC cytotoxicity in a dose-, cell type-, and schedule-dependent manner. Moreover, the combined treatment of CRC cells arrested cell growth at the S and G2/M phases, induced apoptotic cell death, caused extensive mitochondrial membrane damage, and altered the expression of the cell cycle and apoptotic proteins. CONCLUSIONS Results of the present study highlighted a difference in the level of sora efficacy in CRC cells when combined with PPCs. Further in vivo and clinical studies using the combined treatment of sora and PPCs are required to determine their potential as a novel therapeutic strategy for CRCs.
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Affiliation(s)
- Abdulmajeed Bahman
- Department of Biological Sciences, Molecular Biology Program, Faculty of Science, Kuwait University, P.O. Box 5969, 13060, Safat, Kuwait
| | - Mohamed-Salah Abaza
- Department of Biological Sciences, Molecular Biology Program, Faculty of Science, Kuwait University, P.O. Box 5969, 13060, Safat, Kuwait.
| | - Sarah Khoushaish
- Department of Biological Sciences, Molecular Biology Program, Faculty of Science, Kuwait University, P.O. Box 5969, 13060, Safat, Kuwait
| | - Rajaa J Al-Attiyah
- Department of Microbiology and Immunology, Faculty of Medicine, Kuwait University, P.O. Box 24923, 13110, Safat, Kuwait
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Zhang X, Cao L, Xu G, He H, Zhao H, Liu T. Co-delivery of sorafenib and metformin from amphiphilic polypeptide-based micelles for colon cancer treatment. Front Med (Lausanne) 2022; 9:1009496. [PMID: 36304185 PMCID: PMC9592705 DOI: 10.3389/fmed.2022.1009496] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2022] [Accepted: 08/12/2022] [Indexed: 11/13/2022] Open
Abstract
Colorectal cancer (CRC) is a common clinical disease with a poor prognosis and a high recurrence rate. Chemotherapy is important to inhibit the post-surgical recurrence of CRC patients. But many limitations restrict the further application of chemotherapy. In this study, sorafenib (Sor) and metformin (Met) co-loaded poly(ethylene glycol)-block-poly(L-glutamic acid-co-L-phenylalanine) [mPEG-b-P(Glu-co-Phe)] micelles were developed. The characterizations, drug release, in vivo biodistribution, and pharmacokinetics of the micelles were analyzed. The treatment efficacy of the dual-drug loaded micelles was evaluated in a subcutaneous colon cancer mice model. Sor is a common molecular target agent that can inhibit the mitogen-activated protein kinase (MAPK) pathway to treat solid tumors. Met can also regulate the MAPK pathway and inhibit the expression of the phosphorylated extracellular signal-regulated kinase (p-ERK). Moreover, both Sor and Met play important roles in cell cycle arrest. The integration of these two drugs aims to achieve synergistic effects against colon cancer. The micelles can be targeted to cancer cells and possess longer blood circulation time. The two agents can be released rapidly in the tumor sites. The in vivo study showed that the micelles can prevent tumor progression by inhibiting the expressions of p-ERK and cyclin D1. This study indicated that the Sor/Met-loaded micelles are suitable for CRC treatment.
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Affiliation(s)
- Xiaohui Zhang
- Department of General Surgery, The Second Hospital of Jilin University, Changchun, China,Department of Thyroid, Breast and Hernia Surgery, Affiliated Hospital of Inner Mongolia University for the Nationalities, Tongliao, China
| | - Lanqing Cao
- Department of Pathology, The Second Hospital of Jilin University, Changchun, China
| | - Guangmeng Xu
- Department of General Surgery, The Second Hospital of Jilin University, Changchun, China
| | - Hongyu He
- Operating Theater and Department of Anesthesiology, The Second Hospital of Jilin University, Changchun, China
| | - Hongyu Zhao
- Gastroenterology and Center of Digestive Endoscopy, The Second Hospital of Jilin University, Changchun, China,*Correspondence: Hongyu Zhao
| | - Tongjun Liu
- Department of General Surgery, The Second Hospital of Jilin University, Changchun, China,Tongjun Liu
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Khiewkamrop P, Surangkul D, Srikummool M, Richert L, Pekthong D, Parhira S, Somran J, Srisawang P. Epigallocatechin gallate triggers apoptosis by suppressing de novo lipogenesis in colorectal carcinoma cells. FEBS Open Bio 2022; 12:937-958. [PMID: 35243817 PMCID: PMC9063442 DOI: 10.1002/2211-5463.13391] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2021] [Revised: 12/18/2021] [Accepted: 03/02/2022] [Indexed: 11/11/2022] Open
Abstract
The de novo lipogenesis (DNL) pathway has been identified as a regulator of cancer progression and aggressiveness. Downregulation of key lipogenesis enzymes has been shown to activate apoptosis in cancerous cells. Epigallocatechin gallate (EGCG) inhibits cancer cell proliferation without causing cytotoxicity in healthy cells. The aim of the present study is to investigate the effects of EGCG on the promotion of apoptosis associated with the DNL pathway inhibition in cancer cells, both in vitro and in vivo. We observed that two colorectal cancer (CRC) cell lines (HCT116 and HT-29) had a higher cytotoxic response to EGCG treatment than hepatocellular carcinoma cells, including HepG2 and HuH-7. EGCG treatment decreased cell viability and increased mitochondrial damage-triggered apoptosis in both HCT116 and HT-29 cancer cells. Additionally, we treated mice transplanted with HCT116 cells with 30 or 50 mg/kg EGCG for 7 days to evaluate the apoptotic effects of EGCN treatment in a xenograft mouse model of cancer. We observed a decrease in intracellular fatty acid levels, which suggested that EGCG-induced apoptosis was associated with a decrease in fatty acid levels in cancer. Suppression of adenosine triphosphate synthesis by EGCG indicated that cell death induction in cancer cells could be mediated by shared components of the DNL and energy metabolism pathways. In addition, EGCG-induced apoptosis suppressed the expression of the phosphorylation protein kinase B and extracellular signal-regulated kinase 1/2 signaling proteins in tumors from xenografted mice. Cytotoxic effects in unaffected organs and tissues of the mouse xenograft model were absent upon EGCG treatment.
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Affiliation(s)
- Phuriwat Khiewkamrop
- Department of Physiology, Faculty of Medical Science, Naresuan University, Phitsanulok, Thailand, 65000
| | - Damratsamon Surangkul
- Department of Biochemistry, Faculty of Medical Science, Naresuan University, Phitsanulok, Thailand, 65000
| | - Metawee Srikummool
- Department of Biochemistry, Faculty of Medical Science, Naresuan University, Phitsanulok, Thailand, 65000
| | - Lysiane Richert
- KaLy-Cell, 20A rue du Général Leclerc, 67115, Plobsheim, France.,Université de Bourgogne Franche-Comté, EA 4267 PEPITE, France
| | - Dumrongsak Pekthong
- Department of Pharmacy Practice, Faculty of Pharmaceutical Sciences, Naresuan University, Phitsanulok, Thailand, 65000
| | - Supawadee Parhira
- Department of Pharmaceutical Technology, Faculty of Pharmaceutical Sciences, Naresuan University, Phitsanulok, Thailand, 65000
| | - Julintorn Somran
- Department of Pathology, Faculty of Medicine, Naresuan University, Phitsanulok, Thailand, 65000
| | - Piyarat Srisawang
- Department of Physiology, Faculty of Medical Science, Naresuan University, Phitsanulok, Thailand, 65000
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Sanaei MJ, Baghery Saghchy Khorasani A, Pourbagheri-Sigaroodi A, Shahrokh S, Zali MR, Bashash D. The PI3K/Akt/mTOR axis in colorectal cancer: Oncogenic alterations, non-coding RNAs, therapeutic opportunities, and the emerging role of nanoparticles. J Cell Physiol 2021; 237:1720-1752. [PMID: 34897682 DOI: 10.1002/jcp.30655] [Citation(s) in RCA: 25] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2021] [Revised: 11/02/2021] [Accepted: 11/24/2021] [Indexed: 02/06/2023]
Abstract
Colorectal cancer (CRC) is one of the deadliest human malignancies worldwide. Several molecular pathways have been demonstrated to be involved in the initiation and development of CRC which among them, the overactivation of the phosphatidyl-inositol 3-kinase (PI3K)/Akt/mTOR axis is of importance. The current review aims to unravel the mechanisms by which the PI3K/Akt/mTOR pathway affects CRC progression; and also, to summarize the original data obtained from international research laboratories on the oncogenic alterations and polymorphisms affecting this pathway in CRC. Besides, we provide a special focus on the regulatory role of noncoding RNAs targeting the PI3K/Akt/mTOR pathway in this malignancy. Questions on how this axis is involved in the inhibition of apoptosis, in the induction of drug resistance, and the angiogenesis, epithelial to mesenchymal transition, and metastasis are also responded. We also discussed the PI3K/Akt pathway-associated prognostic and predictive biomarkers in CRC. In addition, we provide a general overview of PI3K/Akt/mTOR pathway inhibition whether by chemical-based drugs or by natural-based medications in the context of CRC, either as monotherapy or in combination with other therapeutic agents; however, those treatments might have life-threatening side effects and toxicities. To the best of our knowledge, the current review is one of the first ones highlighting the emerging roles of nanotechnology to overcome challenges related to CRC therapy in the hope that providing a promising platform for the treatment of CRC.
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Affiliation(s)
- Mohammad-Javad Sanaei
- Department of Hematology and Blood Banking, School of Allied Medical Sciences, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | | | - Atieh Pourbagheri-Sigaroodi
- Department of Hematology and Blood Banking, School of Allied Medical Sciences, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Shabnam Shahrokh
- Gastroenterology and Liver Diseases Research Center, Research Institute for Gastroenterology and Liver Diseases, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Mohammad Reza Zali
- Gastroenterology and Liver Diseases Research Center, Research Institute for Gastroenterology and Liver Diseases, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Davood Bashash
- Department of Hematology and Blood Banking, School of Allied Medical Sciences, Shahid Beheshti University of Medical Sciences, Tehran, Iran
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Xie H, Lafky JM, Morlan BW, Stella PJ, Dakhil SR, Gross GG, Loui WS, Hubbard JM, Alberts SR, Grothey A. Dual VEGF inhibition with sorafenib and bevacizumab as salvage therapy in metastatic colorectal cancer: results of the phase II North Central Cancer Treatment Group study N054C (Alliance). Ther Adv Med Oncol 2020; 12:1758835920910913. [PMID: 32201506 PMCID: PMC7066587 DOI: 10.1177/1758835920910913] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2019] [Accepted: 01/20/2020] [Indexed: 01/26/2023] Open
Abstract
Background Bevacizumab (BEV), a monoclonal antibody against vascular endothelial growth factor-A (VEGF-A), is a standard component of medical therapy of metastatic colorectal cancer (mCRC). Activation of alternative angiogenesis pathways has been implicated in resistance to BEV. This phase II study examines the activity of combined vertical blockade of VEGF signaling with sorafenib and BEV as salvage therapy in patients with progressive disease (PD) on all standard therapy in mCRC. Methods mCRC patients with documented PD on standard therapy, received sorafenib (200 mg orally twice daily, days 1-5 and 8-12) and BEV (5 mg/kg intravenously, day 1) every 2 weeks. Primary endpoint was 3-month progression-free survival (PFS) rate and secondary endpoints were overall survival (OS), response rate (RR), safety, and feasibility. Results Of the 83 patients enrolled, 79 were evaluable. Of these, 42 (53%) were progression-free at 3 months. Median PFS was 3.5 months and median OS was 8.3 months. One patient had a partial response and 50 patients (63.3%) had at least one stable tumor assessment. Of 79 evaluable patients, 54 (68%) experienced grade 3/4 adverse events (AEs) at least possibly related to treatment. Most frequent grade 3/4 AEs were: fatigue (24.1%), hypertension (16.5%), elevated lipase (8.9%), hand-foot skin reaction (8.9%), diarrhea (7.6%), and proteinuria (7.6%). Reasons for treatment discontinuation were PD (72%), AEs (18%), patient refusal (8%), physician decision (1%), and death (1%). Conclusions The combination of BEV and sorafenib as salvage therapy in heavily pretreated mCRC patients is tolerable and manageable, with evidence of promising activity. ClinicalTrialsgov identifier NCT00826540, URL:http://clinicaltrials.gov/ct2/show/NCT00826540.
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Affiliation(s)
- Hao Xie
- Division of Medical Oncology, Mayo Clinic, Rochester, MN, USA
| | - Jacqueline M Lafky
- Alliance Statistics and Data Center, Mayo Clinic, Rochester, MN, USA Department of Biostatistics, Mayo Clinic, Rochester, MN, USA
| | - Bruce W Morlan
- Department of Biostatistics, Mayo Clinic, Rochester, MN, USA
| | | | - Shaker R Dakhil
- Wichita Community Clinical Oncology Program, Wichita, KS, USA
| | | | | | | | | | - Axel Grothey
- Medical Oncology, West Cancer Center, 9745 Wolf River Blvd, Germantown, TN 38138-1762, USA
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7
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Abeni E, Salvi A, Marchina E, Traversa M, Arici B, De Petro G. Sorafenib induces variations of the DNA methylome in HA22T/VGH human hepatocellular carcinoma-derived cells. Int J Oncol 2017; 51:128-144. [PMID: 28560380 PMCID: PMC5467784 DOI: 10.3892/ijo.2017.4019] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2017] [Accepted: 04/18/2017] [Indexed: 12/21/2022] Open
Abstract
Sorafenib is currently used to treat advanced and/or unresectable hepatocellular carcinoma (HCC), but the increase of the median survival was only 3 months. Moreover, sorafenib has severe side effects and patients develop resistance quickly. Epigenetic alterations such as DNA methylation play a decisive role in the development and progression of HCC. To our knowledge, there are no studies that analysed the global DNA methylation changes in HCC cells treated with sorafenib. Using MeDip-chip technologies, we found 1230 differentially methylated genes in HA22T/VGH cells treated with sorafenib compared to untreated cells. Gene ontology and pathway analysis allowed identifying several enriched signaling pathways involved in tumorigenesis and cancer progression. Among the genes differentially methylated we found genes related to apoptosis, angiogenesis and invasion, and genes belonging to pathways known to be deregulated in HCC such as RAF/MEK/ERK, JAK-STAT, PI3K/AKT/mTOR and NF-κB. Generally, we found that oncogenes tended to be hypermethylated and the tumor suppressor genes tended to be hypomethylated after sorafenib treatment. Finally, we validated MeDip-chip results for several genes found differentially methylated such as BIRC3, FOXO3, MAPK3, SMAD2 and TSC2, using both COBRA assay and direct bisulfite sequencing and we evaluated their mRNA expression. Our findings suggest that sorafenib could affect the methylation level of genes associated to cancer-related processes and pathways in HCC cells, some of which have been previously described to be directly targeted by sorafenib.
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Affiliation(s)
- Edoardo Abeni
- Department of Molecular and Translational Medicine, Division of Biology and Genetics, University of Brescia, Brescia, Italy
| | - Alessandro Salvi
- Department of Molecular and Translational Medicine, Division of Biology and Genetics, University of Brescia, Brescia, Italy
| | - Eleonora Marchina
- Department of Molecular and Translational Medicine, Division of Biology and Genetics, University of Brescia, Brescia, Italy
| | - Michele Traversa
- Department of Molecular and Translational Medicine, Division of Biology and Genetics, University of Brescia, Brescia, Italy
| | - Bruna Arici
- Department of Molecular and Translational Medicine, Division of Biology and Genetics, University of Brescia, Brescia, Italy
| | - Giuseppina De Petro
- Department of Molecular and Translational Medicine, Division of Biology and Genetics, University of Brescia, Brescia, Italy
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West MA, Roman A, Sayan E, Primrose JN, Wedge SR, Underwood TJ, Mirnezami AH. A minimum core outcome dataset for the reporting of preclinical chemotherapeutic drug studies: Lessons learned from multiple discordant methodologies in the setting of colorectal cancer. Crit Rev Oncol Hematol 2017; 112:80-102. [PMID: 28325268 DOI: 10.1016/j.critrevonc.2017.02.008] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2016] [Revised: 01/11/2017] [Accepted: 02/13/2017] [Indexed: 12/27/2022] Open
Abstract
In vivo studies in animal models are critical tools necessary to study the fundamental complexity of carcinogenesis. A constant strive to improve animal models in cancer exists, especially those investigating the use of chemotherapeutic effectiveness. In the present systematic review, colorectal cancer (CRC) is used as an example to highlight and critically evaluate the range of reporting strategies used when investigating chemotherapeutic agents in the preclinical setting. A systematic review examining the methodology and reporting of preclinical chemotherapeutic drug studies using CRC murine models was conducted. A total of 45 studies were included in this systematic review. The literature was found to be highly heterogeneous with various cell lines, animal strains, animal ages and chemotherapeutic compounds/regimens tested, proving difficult to compare outcomes between similar studies or indeed gain any significant insight into which chemotherapeutic regimen caused adverse events. From this analysis we propose a minimum core outcome dataset that could be regarded as a standardised way of reporting results from in vivo experimentation.
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Affiliation(s)
- M A West
- University Surgery, University of Southampton, Southampton General Hospital, Southampton SO16 6YD, UK; Academic Unit of Cancer Sciences, Somers Cancer Research Building, University of Southampton, UK.
| | - A Roman
- University Surgery, University of Southampton, Southampton General Hospital, Southampton SO16 6YD, UK; Academic Unit of Cancer Sciences, Somers Cancer Research Building, University of Southampton, UK
| | - E Sayan
- Academic Unit of Cancer Sciences, Somers Cancer Research Building, University of Southampton, UK
| | - J N Primrose
- University Surgery, University of Southampton, Southampton General Hospital, Southampton SO16 6YD, UK; Academic Unit of Cancer Sciences, Somers Cancer Research Building, University of Southampton, UK
| | - S R Wedge
- Northern Institute for Cancer Research, Newcastle University, Newcastle upon Tyne, UK
| | - T J Underwood
- University Surgery, University of Southampton, Southampton General Hospital, Southampton SO16 6YD, UK; Academic Unit of Cancer Sciences, Somers Cancer Research Building, University of Southampton, UK
| | - A H Mirnezami
- University Surgery, University of Southampton, Southampton General Hospital, Southampton SO16 6YD, UK; Academic Unit of Cancer Sciences, Somers Cancer Research Building, University of Southampton, UK
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Chen L, Chen C, Yen Y, Tam KW. Chemotherapy for advanced biliary tract carcinoma: A meta-analysis of randomized controlled trials. Medicine (Baltimore) 2016; 95:e4584. [PMID: 27537589 PMCID: PMC5370815 DOI: 10.1097/md.0000000000004584] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
BACKGROUND Although gemcitabine and platinum-based agents (GP) are currently regarded as the standard chemotherapy for advanced biliary tract cancer (BTC), the prognosis remains poor. Combinations with fluoropyrimidines and targeted therapy have demonstrated modest benefits. Therefore, we conducted a meta-analysis of randomized controlled trials to evaluate the efficacy of different chemotherapy regimens. METHODS The PubMed, EMBASE, Cochrane Library, Scopus, and ClinicalTrials.gov registries were searched for studies published until April 2016. A meta-analysis was conducted to calculate the pooled effect size by using random effects models. Treatment efficacies were measured using progression-free survival (PFS) and overall survival. The secondary outcomes included the objective response rate (ORR), 1-year survival rate, quality of life, disease control rate, and adverse events. RESULTS Fifteen trials that involved examining 1775 patients were reviewed. Patients who received epidermal growth factor receptor (EGFR)-targeted therapy in addition to standard GP chemotherapy exhibited a significantly higher median PFS (weighted mean difference = -1.49; 95% confidence interval -2.56 to -0.43), PFS (hazard ratio = 0.79; 95% confidence interval 0.63-0.99), and ORR (odd ratio = 0.56; 95% confidence interval 0.38-0.82). Combining GP with fluoropyrimidines or vascular EGFR inhibitors (VEGFR) did not improve patient outcomes. CONCLUSION Combining EGFR-targeted therapy with the current standard GP chemotherapy is a safe and viable option that may improve the median PFS, PFS, and ORR in patients with advanced BTC. Further research investigating the optimal dosage and drug type of EGFR inhibitors for specific BTC patient groups is warranted.
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Affiliation(s)
- Lawrence Chen
- Center for Evidence-based Health Care, Shuang Ho Hospital, Taipei Medical University, New Taipei City
| | - Chiehfeng Chen
- Cochrane Taiwan
- Department of Public Health, School of Medicine, College of Medicine
- Division of Plastic Surgery, Department of Surgery, Wan Fang Hospital
| | - Yun Yen
- Graduate Institute of Cancer Biology and Drug Discovery, College of Medical Science and Technology, Taipei Medical University, Taipei
| | - Ka-Wai Tam
- Center for Evidence-based Health Care, Shuang Ho Hospital, Taipei Medical University, New Taipei City
- Cochrane Taiwan
- Division of General Surgery, Department of Surgery, Shuang Ho Hospital, Taipei Medical University, New Taipei City
- Department of Surgery, School of Medicine, College of Medicine, Taipei Medical, University, Taipei, Taiwan
- Correspondence to Ka-Wai Tam, Center for Evidence-based Health Care, Shuang Ho Hospital, Taipei Medical University 291, Zhongzheng Road, Zhonghe District, New Taipei City 23561, Taiwan (e-mail: )
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10
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Martchenko K, Schmidtmann I, Thomaidis T, Thole V, Galle PR, Becker M, Möhler M, Wehler TC, Schimanski CC. Last line therapy with sorafenib in colorectal cancer: A retrospective analysis. World J Gastroenterol 2016; 22:5400-5405. [PMID: 27340356 PMCID: PMC4911348 DOI: 10.3748/wjg.v22.i23.5400] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/18/2015] [Accepted: 01/30/2016] [Indexed: 02/06/2023] Open
Abstract
AIM: To analyze the efficacy of last line sorafenib treatment in colorectal cancer patients.
METHODS: All patients receiving chemotherapy for colorectal cancer in the outpatient clinic of the University of Mainz since 2006 were retrospectively analyzed for last line sorafenib exposure. Charts of identified patients were analyzed for clinic-pathological parameters, like data on gender, age, date of initial diagnosis, UICC stage, number and kind of the pre-therapies, therapy start and end of sorafenib, sorafenib mediated treatment cessation, side effects, response rates, time to progression and overall survival.
RESULTS: Ten patients with a median of 3.0 prior chemotherapy lines had received a last line sorafenib therapy either alone (10%) or in combination with 5-fluorouracil derivates (90%). All patients suffered from colorectal cancer stage UICC 4 and were routinely seen in 2-wk intervals in the oncology outpatient clinic. Median duration of treatment was 142.0 d. At 8 wk 80% of patients showed stable disease but we did not observe any remissions. Median time to progression was 140.5 d (4.7 mo), while median overall survival reached 176.5 d. One patient ceased treatment due to side effects. Reason for treatment stop was bleeding complication in one case and non-specified sorafenib intolerance in another case. Due to the retrospective approach we did not further quantify side effects.
CONCLUSION: This retrospective analysis encourages further investigation of sorafenib in colorectal cancer last line therapy.
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Krishnamoorthy SK, Relias V, Sebastian S, Jayaraman V, Saif MW. Management of regorafenib-related toxicities: a review. Therap Adv Gastroenterol 2015; 8:285-97. [PMID: 26327919 PMCID: PMC4530428 DOI: 10.1177/1756283x15580743] [Citation(s) in RCA: 58] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023] Open
Abstract
Regorafenib (Stivarga, BAY 73-4506; Bayer Pharma AG, Berlin, Germany) is an oral multikinase inhibitor that targets the angiogenic tumor microenvironment and oncogenic kinases including vascular endothelial growth factor receptor 2 (VEGFR2), VEGFR1, VEGFR3, fibroblast growth factor receptor 1 (FGFR1), RAF, KIT, RET and BRAF. Its antiangiogenic effect is greater than that of its related drug, sorafenib. Regorafenib has been approved by the US Food and Drug Administration (FDA) for the treatment of metastatic colorectal cancer (mCRC) in patients who have failed treatment with fluoropyrimidine, oxaliplatin and irinotecan based chemotherapy, an anti-VEGF therapy and, if KRAS wild type, an anti-EGFR therapy. The FDA based this approval on data from the CORRECT trial, which showed the efficacy of regorafenib compared with placebo. The most common grade 3-4 adverse reactions with the drug are hand foot skin reactions (HFSR), diarrhea, hypertension and fatigue. This review discusses the efficacy data, and the incidence and management of regorafenib's toxicities.
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Affiliation(s)
| | - Valerie Relias
- Division of Hematology/Oncology and Experimental Therapeutics, Tufts Medical Center, Boston, MA, USA
| | | | | | - Muhammad Wasif Saif
- Department of Medicine and Cancer Center, Tufts Medical Center, 800 Washington Street Box 245, Boston, MA 02111, USA
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Anitha A, Maya S, Sivaram AJ, Mony U, Jayakumar R. Combinatorial nanomedicines for colon cancer therapy. WILEY INTERDISCIPLINARY REVIEWS-NANOMEDICINE AND NANOBIOTECHNOLOGY 2015; 8:151-9. [PMID: 26061225 DOI: 10.1002/wnan.1353] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/16/2015] [Revised: 03/29/2015] [Accepted: 04/19/2015] [Indexed: 12/11/2022]
Abstract
Colon cancer is one of the major causes of cancer deaths worldwide. Even after surgical resection and aggressive chemotherapy, 50% of colorectal carcinoma patients develop recurrent disease. Thus, the rationale of developing new therapeutic approaches to improve the current chemotherapeutic regimen would be highly recommended. There are reports on the effectiveness of combination chemotherapy in colon cancer and it has been practiced in clinics for long time. These approaches are associated with toxic side effects. Later, the drug delivery research had shown the potential of nanoencapsulation techniques and active targeting as an effective method to improve the effectiveness of chemotherapy with less toxicity. This current focus article provides a brief analysis of the ongoing research in the colon cancer area using the combinatorial nanomedicines and its outcome.
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Affiliation(s)
- A Anitha
- Amrita Centre for Nanosciences and Molecular Medicine, Amrita Institute of Medical Sciences and Research Centre, Amrita Vishwa Vidyapeetham University, Kochi-682041, India
| | - S Maya
- Amrita Centre for Nanosciences and Molecular Medicine, Amrita Institute of Medical Sciences and Research Centre, Amrita Vishwa Vidyapeetham University, Kochi-682041, India
| | - Amal J Sivaram
- Amrita Centre for Nanosciences and Molecular Medicine, Amrita Institute of Medical Sciences and Research Centre, Amrita Vishwa Vidyapeetham University, Kochi-682041, India
| | - U Mony
- Amrita Centre for Nanosciences and Molecular Medicine, Amrita Institute of Medical Sciences and Research Centre, Amrita Vishwa Vidyapeetham University, Kochi-682041, India
| | - R Jayakumar
- Amrita Centre for Nanosciences and Molecular Medicine, Amrita Institute of Medical Sciences and Research Centre, Amrita Vishwa Vidyapeetham University, Kochi-682041, India
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13
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Moehler M, Maderer A, Schimanski C, Kanzler S, Denzer U, Kolligs FT, Ebert MP, Distelrath A, Geissler M, Trojan J, Schütz M, Berie L, Sauvigny C, Lammert F, Lohse A, Dollinger MM, Lindig U, Duerr EM, Lubomierski N, Zimmermann S, Wachtlin D, Kaiser AK, Schadmand-Fischer S, Galle PR, Woerns M. Gemcitabine plus sorafenib versus gemcitabine alone in advanced biliary tract cancer: a double-blind placebo-controlled multicentre phase II AIO study with biomarker and serum programme. Eur J Cancer 2014; 50:3125-35. [PMID: 25446376 DOI: 10.1016/j.ejca.2014.09.013] [Citation(s) in RCA: 97] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2014] [Revised: 09/13/2014] [Accepted: 09/22/2014] [Indexed: 02/08/2023]
Abstract
BACKGROUND Since sorafenib has shown activity in different tumour types and gemcitabine regimens improved the outcome for biliary tract cancer (BTC) patients, we evaluated first-line gemcitabine plus sorafenib in a double-blind phase II study. PATIENTS AND METHODS 102 unresectable or metastatic BTC patients with histologically proven adenocarcinoma of gallbladder or intrahepatic bile ducts, Eastern Cooperative Oncology Group (ECOG) 0-2 were randomised to gemcitabine (1000 mg/m2 once weekly, first 7-weeks+1-week rest followed by once 3-weeks+1-week rest) plus sorafenib (400 mg twice daily) or placebo. Treatment continued until progression or unacceptable toxicity. Tumour samples were prospectively stained for sorafenib targets and potential biomarkers. Serum samples (first two cycles) were measured for vascular endothelial growth factors (VEGFs), vascular endothelial growth factor receptor 2 (VEGFR-2) and stromal cell-derived factor 1 (SDF1)α by enzyme-linked immunosorbent assay (ELISA). RESULTS Gemcitabine plus sorafenib was generally well tolerated. Four and three patients achieved partial responses in the sorafenib and placebo groups, respectively. There was no difference in the primary end-point, median progression-free survival (PFS) for gemcitabine plus sorafenib versus gemcitabine plus placebo (3.0 versus 4.9 months, P=0.859), and no difference for median overall survival (OS) (8.4 versus 11.2 months, P=0.775). Patients with liver metastasis after resection of primary BTC survived longer with sorafenib (P=0.019) compared to placebo. Patients who developed hand-foot syndrome (HFS) showed longer PFS and OS than patients without HFS. Two sorafenib targets, VEGFR-2 and c-kit, were not expressed in BTC samples. VEGFR-3 and Hif1α were associated with lymph node metastases and T stage. Absence of PDGFRβ expression correlated with longer PFS. CONCLUSION The addition of sorafenib to gemcitabine did not demonstrate improved efficacy in advanced BTC patients. Biomarker subgroup analysis suggested that some patients might benefit from combined treatment.
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Affiliation(s)
- M Moehler
- Department of Internal Medicine, Johannes Gutenberg-University of Mainz, Mainz, Germany.
| | - A Maderer
- Department of Internal Medicine, Johannes Gutenberg-University of Mainz, Mainz, Germany
| | - C Schimanski
- Department of Internal Medicine, Marienhospital Darmstadt, Darmstadt, Germany
| | - S Kanzler
- 2nd Department of Medicine, Leopoldina Hospital, Schweinfurt, Germany
| | - U Denzer
- 1st Department of Medicine, University Hospital Hamburg, Hamburg, Germany
| | - F T Kolligs
- Department of Medicine II, University Hospital Munich, Munich, Germany
| | - M P Ebert
- 2nd Department of Medicine, University Hospital Mannheim, Mannheim, Germany
| | - A Distelrath
- Tumor Department, Hospital Fulda, Fulda, Germany
| | - M Geissler
- Department of Internal Medicine, Hospital Esslingen, Esslingen, Germany
| | - J Trojan
- Department of Internal Medicine I, University Hospital Frankfurt, Frankfurt, Germany
| | - M Schütz
- Department of Internal Medicine, Johannes Gutenberg-University of Mainz, Mainz, Germany
| | - L Berie
- Department of Internal Medicine, Johannes Gutenberg-University of Mainz, Mainz, Germany
| | - C Sauvigny
- Department of Internal Medicine, Johannes Gutenberg-University of Mainz, Mainz, Germany
| | - F Lammert
- Department of Internal Medicine II, University Hospital Homburg, Homburg, Germany
| | - A Lohse
- 1st Department of Medicine, University Hospital Hamburg, Hamburg, Germany
| | - M M Dollinger
- Department of Internal Medicine I, University Hospital Ulm, Ulm, Germany
| | - U Lindig
- Department of Internal Medicine II, University Hospital Jena, Jena, Germany
| | - E M Duerr
- Department of Medicine II, University Hospital Munich, Munich, Germany
| | - N Lubomierski
- Department of Internal Medicine I, University Hospital Frankfurt, Frankfurt, Germany
| | - S Zimmermann
- Department of Internal Medicine II, University Hospital Homburg, Homburg, Germany
| | - D Wachtlin
- Interdisciplinary Center for Clinical Trials of the University Medical Center Mainz, Germany
| | - A-K Kaiser
- Interdisciplinary Center for Clinical Trials of the University Medical Center Mainz, Germany
| | - S Schadmand-Fischer
- Department of Radiology, Johannes Gutenberg-University of Mainz, Mainz, Germany
| | - P R Galle
- Department of Internal Medicine, Johannes Gutenberg-University of Mainz, Mainz, Germany
| | - M Woerns
- Department of Internal Medicine, Johannes Gutenberg-University of Mainz, Mainz, Germany
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Cheng XS, Li YF, Tan J, Sun B, Xiao YC, Fang XB, Zhang XF, Li Q, Dong JH, Li M, Qian HH, Yin ZF, Yang ZB. CCL20 and CXCL8 synergize to promote progression and poor survival outcome in patients with colorectal cancer by collaborative induction of the epithelial–mesenchymal transition. Cancer Lett 2014; 348:77-87. [DOI: 10.1016/j.canlet.2014.03.008] [Citation(s) in RCA: 85] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2013] [Revised: 03/02/2014] [Accepted: 03/07/2014] [Indexed: 01/13/2023]
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Chang YJ, Hsu WH, Chang CH, Lan KL, Ting G, Lee TW. Combined therapeutic efficacy of 188Re-liposomes and sorafenib in an experimental colorectal cancer liver metastasis model by intrasplenic injection of C26- luc murine colon cancer cells. Mol Clin Oncol 2014; 2:380-384. [PMID: 24772304 DOI: 10.3892/mco.2014.246] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2013] [Accepted: 10/15/2013] [Indexed: 12/19/2022] Open
Abstract
Rhenium-188 (188Re) displays abundant intermediate energy β emission and possesses a physical half-life of 16.9 h. Sorafenib is an orally available multikinase inhibitor that targets Raf kinases and vascular endothelial growth factor receptors (VEGFRs). Sorafenib has demonstrated preclinical and clinical activity against several types of tumors, such as renal cell and colorectal carcinoma. In this study, we investigated the efficacy of radiotherapeutics of 188Re-liposomes combined with sorafenib in a C26-luc metastatic colorectal liver tumour mouse model. Liver metastases were established by intrasplenic injection of C26-luc murine colon cancer cells. Based on the results of the toxicity assessment, an administration dose of 80% the maximum tolerated dose was selected. 188Re-liposomes were administered on day 1, when metastases of several hundred micrometers in diameter were observed. In the combination therapy group, 10 mg/kg sorafenib (co-developed and co-marketed by Bayer and Onyx Pharmaceuticals as Nexavar) was administered every other day for 1 week and the survival of mice was assessed. The tumor growth was more significantly inhibited in the 188Re-liposome plus sorafenib group compared with the 188Re-liposome alone, sorafenib alone and untreated normal saline groups (P=0.0000). Furthermore, 188Re-liposomes combined with sorafenib achieved higher survival rates compared with the 188Re-liposome alone, sorafenib alone and untreated normal saline groups (P=0.0000). These results support the use of combined radio-chemotherapy with 188Re-liposomes plus sorafenib as a viable treatment option in the adjuvant setting for liver metastases of colorectal cancer.
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Affiliation(s)
- Ya-Jen Chang
- Institute of Nuclear Energy Research, Lungtan, Taoyuan
| | - Wei-Hsin Hsu
- Institute of Nuclear Energy Research, Lungtan, Taoyuan
| | | | - Keng-Li Lan
- Cancer Center, Taipei Veterans General Hospital
| | - Gann Ting
- National Health Research Institutes, Taipei, Taiwan, R.O.C
| | - Te-Wei Lee
- Institute of Nuclear Energy Research, Lungtan, Taoyuan
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Kline CLB, El-Deiry WS. Personalizing colon cancer therapeutics: targeting old and new mechanisms of action. Pharmaceuticals (Basel) 2013; 6:988-1038. [PMID: 24276379 PMCID: PMC3817731 DOI: 10.3390/ph6080988] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2013] [Revised: 07/30/2013] [Accepted: 08/16/2013] [Indexed: 12/17/2022] Open
Abstract
The use of pharmaceuticals for colon cancer treatment has been increasingly personalized, in part due to the development of new molecular tools. In this review, we discuss the old and new colon cancer chemotherapeutics, and the parameters that have been shown to be predictive of efficacy and safety of these chemotherapeutics. In addition, we discuss how alternate pharmaceuticals have been developed in light of a potential lack of response or resistance to a particular chemotherapeutic.
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Affiliation(s)
- Christina Leah B Kline
- Hematology/Oncology Division, Penn State Hershey Medical Center, Hershey, PA 17033, USA.
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Deng L, Ren Z, Jia Q, Wu W, Shen H, Wang Y. Schedule-dependent antitumor effects of 5-fluorouracil combined with sorafenib in hepatocellular carcinoma. BMC Cancer 2013; 13:363. [PMID: 23895220 PMCID: PMC3734040 DOI: 10.1186/1471-2407-13-363] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2012] [Accepted: 07/22/2013] [Indexed: 01/05/2023] Open
Abstract
Background Recently, a phase II clinical trial in hepatocellular carcinoma (HCC) has suggested that the combination of sorafenib and 5-fluorouracil (5-FU) is feasible and side effects are manageable. However, preclinical experimental data explaining the interaction mechanism(s) are lacking. Our objective is to investigate the anticancer efficacy and mechanism of combined sorafenib and 5-FU therapy in vitro in HCC cell lines MHCC97H and SMMC-7721. Methods Drug effects on cell proliferation were evaluated by cell viability assays. Combined-effects analyses were conducted according to the median-effect principle. Cell cycle distribution was measured by flow cytometry. Expression levels of proteins related to the RAF/MEK/ERK and STAT3 pathways and to cell cycle progression (cyclin D1) were determined by western blot analysis. Results Sorafenib and 5-FU alone or in combination showed significant efficacy in inhibiting cell proliferation in both cell lines tested. However, a schedule-dependent combined effect, associated with the order of compound treatments, was observed. Efficacy was synergistic with 5-FU pretreatment followed by sorafenib, but it was antagonistic with the reverse treatment order. Sorafenib pretreatment resulted in a significant increase in the half inhibitory concentration (IC50) of 5-FU in both cell lines. Sorafenib induced G1-phase arrest and significantly decreased the proportion of cells in S phase when administrated alone or followed by 5-FU. The RAF/MEK/ERK and STAT3 pathways were blocked and cyclin D1 expression was down regulated significantly in both cell lines by sorafenib; whereas, the kinase pathways were hardly affected by 5-FU, and cyclin D1 expression was up regulated. Conclusions Antitumor activity of sorafenib and 5-FU, alone or in combination, is seen in HCC cell lines. The nature of the combined effects, however, depends on the particular cell line and treatment order of the two compounds. Sorafenib appears to reduce sensitivity to 5-FU through down regulation of cyclin D1 expression by inhibiting RAF/MEK/ERK and STAT3 signaling, resulting in G1-phase arrest and reduction of the S-phase cell subpopulation when 5-FU is administrated after sorafenib, in which situation, combination treatment of the two agents results in antagonism; on the other hand, when sorafenib is administrated afterward, it can continue to work since it is not cell cycle specific, as a result, combination treatment of the two agents shows an additive-to-synergistic effect.
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Affiliation(s)
- Lifen Deng
- Liver Cancer Institute, Zhongshan Hospital, Fudan University, Shanghai, 200032, People's Republic of China
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Jitawatanarat P, Wee W. Update on antiangiogenic therapy in colorectal cancer: aflibercept and regorafenib. J Gastrointest Oncol 2013; 4:231-8. [PMID: 23730520 DOI: 10.3978/j.issn.2078-6891.2013.008] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/28/2012] [Accepted: 02/22/2013] [Indexed: 12/13/2022] Open
Abstract
Angiogenesis plays an important role in colorectal carcinogenesis and approaches targeting the vascular growth factor receptor (VEGF) signaling such as bevacizumab yielded significant survival improvement for metastatic colorectal cancer patients. Recent evidence demonstrated the benefit of continuing angiogenic suppression after first-progression following bevacizumab-containing cytotoxic regimen though no benefit was observed with the use of bevacizumab in adjuvant setting. Aflibercept, a soluble fusion protein with high affinity for VEGF-A, -B and PlGF, administered in combination with irinotecan-containing regimen improved the survival of metastatic colorectal cancer patients in second-line setting (VELOUR trial). Regorafenib, a small molecule multikinase inhibitor against various pro-angiogenic and -proliferation targets, improved the survival of metastatic colorectal cancer patients who had progressed on all standard therapy. These developments had renewed enthusiasm in the field and the role of aflibercept and regorafenib in other treatment settings will continue to be defined by on-going and future clinical trials. As other anti-angiogenic approaches are being tested clinically, other novel non-angiogenic targets deserve to be evaluated in our effort to improve the outcome of colorectal cancer patients.
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