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Dahlgren D, Lennernäs H. Review on the effect of chemotherapy on the intestinal barrier: Epithelial permeability, mucus and bacterial translocation. Biomed Pharmacother 2023; 162:114644. [PMID: 37018992 DOI: 10.1016/j.biopha.2023.114644] [Citation(s) in RCA: 15] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2023] [Revised: 03/30/2023] [Accepted: 03/30/2023] [Indexed: 04/05/2023] Open
Abstract
Chemotherapy kills fast-growing cells including gut stem cells. This affects all components of the physical and functional intestinal barrier, i.e., the mucus layer, epithelium, and immune system. This results in an altered intestinal permeability of toxic compounds (e.g., endotoxins) as well as luminal bacterial translocation into the mucosa and central circulation. However, there is uncertainty regarding the relative contributions of the different barrier components for the development of chemotherapy-induced gut toxicity. This review present an overview of the intestinal mucosal barrier determined with various types of molecular probes and methods, and how they are affected by chemotherapy based on reported rodent and human data. We conclude that there is overwhelming evidence that chemotherapy increases bacterial translocation, and that it affects the mucosal barrier by rendering the mucosa more permeable to large permeability probes. Chemotherapy also seems to impede the intestinal mucus barrier, even though this has been less clearly evaluated from a functional standpoint but certainly plays a role in bacteria translocation. Combined, it is however difficult to outline a clear temporal or succession between the different gastrointestinal events and barrier functions, especially as chemotherapy-induced neutropenia is also involved in intestinal immunological homeostasis and bacterial translocation. A thorough characterization of this would need to include a time dependent development of neutropenia, intestinal permeability, and bacterial translocation, ideally after a range of chemotherapeutics and dosing regimens.
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2
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Kullenberg F, Peters K, Luna-Marco C, Salomonsson A, Kopsida M, Degerstedt O, Sjöblom M, Hellström PM, Heindryckx F, Dahlgren D, Lennernäs H. The progression of doxorubicin-induced intestinal mucositis in rats. NAUNYN-SCHMIEDEBERG'S ARCHIVES OF PHARMACOLOGY 2023; 396:247-260. [PMID: 36271936 PMCID: PMC9832110 DOI: 10.1007/s00210-022-02311-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 07/15/2022] [Accepted: 10/14/2022] [Indexed: 01/29/2023]
Abstract
Chemotherapy-induced intestinal mucositis is a severe side effect contributing to reduced quality of life and premature death in cancer patients. Despite a high incidence, a thorough mechanistic understanding of its pathophysiology and effective supportive therapies are lacking. The main objective of this rat study was to determine how 10 mg/kg doxorubicin, a common chemotherapeutic, affected jejunal function and morphology over time (6, 24, 72, or 168 h). The secondary objective was to determine if the type of dosing administration (intraperitoneal or intravenous) affected the severity of mucositis or plasma exposure of the doxorubicin. Morphology, proliferation and apoptosis, and jejunal permeability of mannitol were examined using histology, immunohistochemistry, and single-pass intestinal perfusion, respectively. Villus height was reduced by 40% after 72 h, preceded at 24 h by a 75% decrease in proliferation and a sixfold increase in apoptosis. Villus height recovered completely after 168 h. Mucosal permeability of mannitol decreased after 6, 24, and 168 h. There were no differences in intestinal injury or plasma exposure after intraperitoneal or intravenous doxorubicin dosing. This study provides an insight into the progression of chemotherapy-induced intestinal mucositis and associated cellular mucosal processes. Knowledge from this in vivo rat model can facilitate development of preventive and supportive therapies for cancer patients.
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Affiliation(s)
- F Kullenberg
- Department of Pharmaceutical Biosciences, Uppsala University, 752 37, Uppsala, Sweden
| | - K Peters
- Department of Pharmaceutical Biosciences, Uppsala University, 752 37, Uppsala, Sweden
- Department of Medical Cell Biology, Uppsala University, 751 23, Uppsala, Sweden
| | - C Luna-Marco
- Department of Pharmaceutical Biosciences, Uppsala University, 752 37, Uppsala, Sweden
- Department of Medical Cell Biology, Uppsala University, 751 23, Uppsala, Sweden
| | - A Salomonsson
- Department of Pharmaceutical Biosciences, Uppsala University, 752 37, Uppsala, Sweden
| | - M Kopsida
- Department of Medical Cell Biology, Uppsala University, 751 23, Uppsala, Sweden
| | - O Degerstedt
- Department of Pharmaceutical Biosciences, Uppsala University, 752 37, Uppsala, Sweden
| | - M Sjöblom
- Department of Medical Cell Biology, Uppsala University, 751 23, Uppsala, Sweden
| | - P M Hellström
- Department of Medical Sciences, Uppsala University, 751 85, Uppsala, Sweden
| | - F Heindryckx
- Department of Medical Cell Biology, Uppsala University, 751 23, Uppsala, Sweden
| | - D Dahlgren
- Department of Pharmaceutical Biosciences, Uppsala University, 752 37, Uppsala, Sweden
| | - H Lennernäs
- Department of Pharmaceutical Biosciences, Uppsala University, 752 37, Uppsala, Sweden.
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3
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Cheng H, Chen L, Huang M, Hou J, Chen Z, Yang X. Hunting down NLRP3 inflammasome: An executioner of radiation-induced injury. Front Immunol 2022; 13:967989. [PMID: 36353625 PMCID: PMC9637992 DOI: 10.3389/fimmu.2022.967989] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2022] [Accepted: 10/05/2022] [Indexed: 11/13/2022] Open
Abstract
Radiotherapy is one of the mainstream treatment modalities for several malignancies. However, radiation-induced injury to surrounding normal tissues limits its efficacy. The NLRP3 inflammasome is an essential mechanism of innate immunity that reacts to challenges from endogenous danger signals and pathological microbes. A growing body of evidence has demonstrated a key role of NLRP3 inflammasome in the pathogenesis of radiation-induced tissue injury. Despite accumulating evidence, the potential value of the NLRP3 inflammasome in the management of radiation-induced tissue injury is not adequately recognized. We conducted a literature review to characterize the relationship between NLRP3 inflammasome and radiation injury. By analyzing recent evidence, we identify NLRP3 inflammasome as one of the executioners of radiation-induced injury, since it responds to the challenges of radiation, induces cell pyroptosis and tissue dysfunction, and initiates non-resolving inflammation and fibrosis. Based on these concepts, we propose early intervention/prevention strategies targeting NLRP3 inflammasome in a radiation context, which may help resolve imperative clinical problems.
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Affiliation(s)
- Han Cheng
- First School of Clinical Medicine, Southern Medical University, Guangzhou, China,Department of Stomatology, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Lingling Chen
- First School of Clinical Medicine, Southern Medical University, Guangzhou, China,Department of Stomatology, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Minchun Huang
- Department of Stomatology, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Jin Hou
- Department of Stomatology, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Zhifeng Chen
- Department of Stomatology, Nanfang Hospital, Southern Medical University, Guangzhou, China,*Correspondence: Xiaojun Yang, ; Zhifeng Chen,
| | - Xiaojun Yang
- Department of Stomatology, Nanfang Hospital, Southern Medical University, Guangzhou, China,*Correspondence: Xiaojun Yang, ; Zhifeng Chen,
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4
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Medical Resource Use and Medical Costs for Radiotherapy-Related Adverse Effects: A Systematic Review. Cancers (Basel) 2022; 14:cancers14102444. [PMID: 35626049 PMCID: PMC9139402 DOI: 10.3390/cancers14102444] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2022] [Revised: 05/09/2022] [Accepted: 05/11/2022] [Indexed: 12/03/2022] Open
Abstract
Simple Summary Cancer patients who receive radiotherapy often suffer from adverse effects that require healthcare resources to manage. This study summarized evidence of healthcare resource use and costs related to radiotherapy-induced adverse effects and provided recommendations for including this evidence in economic evaluations. Our findings revealed unignorable differences for the same adverse effects, which implied that the potential for the economic burden of adverse effects was overestimated or underestimated. Abstract Background: Despite the need for a proper economic evaluation of new radiotherapies, the economic burden of radiotherapy-induced adverse effects remains unclear. A systematic review has been conducted to identify the existing evidence of healthcare resource use and costs related to radiotherapy-induced adverse effects and also to provide recommendations for including this evidence in economic evaluations. Methods: This systematic review of healthcare resource use and/or medical costs related to radiotherapy-induced adverse effects was performed up until 2020, focusing on patients with head and neck cancer, brain cancer, prostate cancer, eye cancer and breast cancer. Results: Resource use for treating the same adverse effects varied considerably across studies; for instance, the cost for mucositis ranged from USD 2949 to USD 17,244. This broad range could be related to differences in (1) severity of adverse effects in the study population, (2) study design, (3) cost estimation approach and (4) country and clinical practice. Conclusions: Our findings revealed unignorable differences for the same adverse effects, which implied that the potential for the economic burden of adverse effects was being overestimated or underestimated in economic evaluation for radiotherapy.
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Sauruk da Silva K, Carla da Silveira B, Bueno LR, Malaquias da Silva LC, da Silva Fonseca L, Fernandes ES, Maria-Ferreira D. Beneficial Effects of Polysaccharides on the Epithelial Barrier Function in Intestinal Mucositis. Front Physiol 2021; 12:714846. [PMID: 34366901 PMCID: PMC8339576 DOI: 10.3389/fphys.2021.714846] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2021] [Accepted: 06/30/2021] [Indexed: 12/11/2022] Open
Abstract
Intestinal mucositis is a clinically relevant side effect of anticancer therapies. It is experienced by 60–100% of patients undergoing treatment with high doses of chemotherapy, radiation therapy, and bone marrow transplantation. Intestinal mucositis can manifest as pain, weight loss, inflammation, diarrhea, rectal bleeding, and infection; affecting normal nutritional intake and intestinal function. It often impacts adherence to anticancer therapy as it frequently limits patient’s ability to tolerate treatment, causing schedule delays, interruptions, or premature discontinuation. In some cases, local and systemic secondary infections are observed, increasing the costs toward medical care and hospitalization. Several strategies for managing mucositis are available which do not always halt this condition. In this context, new therapeutic strategies are under investigation to prevent or treat intestinal mucositis. Polysaccharides from natural resources have recently become promising molecules against intestinal damage due to their ability to promote mucosal healing and their anti-inflammatory actions. These effects are associated with the protection of intestinal mucosa and regulation of microbiota and immune system. This review aims to discuss the recent advances of polysaccharides from natural resources as potential therapies for intestinal mucositis. The source, species, doses, treatment schedules, and mechanisms of action of polysaccharides will be discussed in detail.
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Affiliation(s)
- Karien Sauruk da Silva
- Instituto de Pesquisa Pelé Pequeno Príncipe, Faculdades Pequeno Príncipe, Curitiba, Brazil.,Programa de Pós-graduação em Biotecnologia Aplicada à Saúde da Criança e do Adolescente, Faculdades Pequeno Príncipe, Curitiba, Brazil
| | - Bruna Carla da Silveira
- Instituto de Pesquisa Pelé Pequeno Príncipe, Faculdades Pequeno Príncipe, Curitiba, Brazil.,Programa de Pós-graduação em Biotecnologia Aplicada à Saúde da Criança e do Adolescente, Faculdades Pequeno Príncipe, Curitiba, Brazil
| | - Laryssa Regis Bueno
- Instituto de Pesquisa Pelé Pequeno Príncipe, Faculdades Pequeno Príncipe, Curitiba, Brazil.,Programa de Pós-graduação em Biotecnologia Aplicada à Saúde da Criança e do Adolescente, Faculdades Pequeno Príncipe, Curitiba, Brazil
| | - Liziane Cristine Malaquias da Silva
- Instituto de Pesquisa Pelé Pequeno Príncipe, Faculdades Pequeno Príncipe, Curitiba, Brazil.,Programa de Pós-graduação em Biotecnologia Aplicada à Saúde da Criança e do Adolescente, Faculdades Pequeno Príncipe, Curitiba, Brazil
| | - Lauany da Silva Fonseca
- Instituto de Pesquisa Pelé Pequeno Príncipe, Faculdades Pequeno Príncipe, Curitiba, Brazil.,Programa de Pós-graduação em Biotecnologia Aplicada à Saúde da Criança e do Adolescente, Faculdades Pequeno Príncipe, Curitiba, Brazil
| | - Elizabeth Soares Fernandes
- Instituto de Pesquisa Pelé Pequeno Príncipe, Faculdades Pequeno Príncipe, Curitiba, Brazil.,Programa de Pós-graduação em Biotecnologia Aplicada à Saúde da Criança e do Adolescente, Faculdades Pequeno Príncipe, Curitiba, Brazil
| | - Daniele Maria-Ferreira
- Instituto de Pesquisa Pelé Pequeno Príncipe, Faculdades Pequeno Príncipe, Curitiba, Brazil.,Programa de Pós-graduação em Biotecnologia Aplicada à Saúde da Criança e do Adolescente, Faculdades Pequeno Príncipe, Curitiba, Brazil
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Dahlgren D, Sjöblom M, Hellström PM, Lennernäs H. Chemotherapeutics-Induced Intestinal Mucositis: Pathophysiology and Potential Treatment Strategies. Front Pharmacol 2021; 12:681417. [PMID: 34017262 PMCID: PMC8129190 DOI: 10.3389/fphar.2021.681417] [Citation(s) in RCA: 40] [Impact Index Per Article: 13.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2021] [Accepted: 04/19/2021] [Indexed: 12/11/2022] Open
Abstract
The gastrointestinal tract is particularly vulnerable to off-target effects of antineoplastic drugs because intestinal epithelial cells proliferate rapidly and have a complex immunological interaction with gut microbiota. As a result, up to 40-100% of all cancer patients dosed with chemotherapeutics experience gut toxicity, called chemotherapeutics-induced intestinal mucositis (CIM). The condition is associated with histological changes and inflammation in the mucosa arising from stem-cell apoptosis and disturbed cellular renewal and maturation processes. In turn, this results in various pathologies, including ulceration, pain, nausea, diarrhea, and bacterial translocation sepsis. In addition to reducing patient quality-of-life, CIM often leads to dose-reduction and subsequent decrease of anticancer effect. Despite decades of experimental and clinical investigations CIM remains an unsolved clinical issue, and there is a strong consensus that effective strategies are needed for preventing and treating CIM. Recent progress in the understanding of the molecular and functional pathology of CIM had provided many new potential targets and opportunities for treatment. This review presents an overview of the functions and physiology of the healthy intestinal barrier followed by a summary of the pathophysiological mechanisms involved in the development of CIM. Finally, we highlight some pharmacological and microbial interventions that have shown potential. Conclusively, one must accept that to date no single treatment has substantially transformed the clinical management of CIM. We therefore believe that the best chance for success is to use combination treatments. An optimal combination treatment will likely include prophylactics (e.g., antibiotics/probiotics) and drugs that impact the acute phase (e.g., anti-oxidants, apoptosis inhibitors, and anti-inflammatory agents) as well as the recovery phase (e.g., stimulation of proliferation and adaptation).
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Affiliation(s)
- David Dahlgren
- Department of Pharmaceutical Biosciences, Uppsala University, Uppsala, Sweden
| | - Markus Sjöblom
- Department of Neuroscience, Division of Physiology, Uppsala University, Uppsala, Sweden
| | - Per M Hellström
- Department of Medical Sciences, Gastroenterology/Hepatology, Uppsala University, Uppsala, Sweden
| | - Hans Lennernäs
- Department of Pharmaceutical Biosciences, Uppsala University, Uppsala, Sweden
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Keefe DMK, Bateman EH. Potential Successes and Challenges of Targeted Cancer Therapies. J Natl Cancer Inst Monogr 2020; 2019:5551349. [PMID: 31425592 DOI: 10.1093/jncimonographs/lgz008] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2018] [Revised: 01/29/2019] [Accepted: 04/19/2019] [Indexed: 01/15/2023] Open
Abstract
The concept and realization of targeted anticancer therapy (TAT) have existed for at least two decades and continue to expand rapidly. It has become clear that there is no "magic bullet" to cure cancer and that even TATs are unlikely to be successful as single agents, necessitating combination with chemotherapy, radiotherapy, or even other targeting agents. The other promise that has not been fulfilled by TAT is that of reduced toxicity. It was thought that by targeting receptors on or within cells, rather than particular phases of the cell cycle, TATs would not be toxic. However, it turns out that the targets also exist on or within normal cells and that there is even cross-reactivity between receptors on nontarget tissues. All of this results in toxicity, the mechanism of which are the same as the mechanism of action of the drugs, making toxicity reduction or prevention very difficult. This leads to new toxicities with new targeted treatments. Nevertheless, all of the above should not detract from the obvious successes of targeted agents, which have turned several acutely fatal cancers into chronic diseases and rendered some hitherto untreatable cancers into treatable diseases.
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Affiliation(s)
- Dorothy M K Keefe
- Mucositis Research Group, Discipline of Medicine, Faculty of Health Sciences, University of Adelaide, Adelaide, Australia
| | - Emma H Bateman
- Mucositis Research Group, Discipline of Medicine, Faculty of Health Sciences, University of Adelaide, Adelaide, Australia
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8
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Cinausero M, Aprile G, Ermacora P, Basile D, Vitale MG, Fanotto V, Parisi G, Calvetti L, Sonis ST. New Frontiers in the Pathobiology and Treatment of Cancer Regimen-Related Mucosal Injury. Front Pharmacol 2017. [PMID: 28642709 PMCID: PMC5462992 DOI: 10.3389/fphar.2017.00354] [Citation(s) in RCA: 133] [Impact Index Per Article: 19.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
Mucositis is a common complication of chemotherapy, radiotherapy and targeted agents. It often affects compliance to anticancer therapies as it frequently causes schedule delays, interruptions or discontinuations of treatment. Moreover, the economic impact related to the management of mucositis is topical and several estimations of additional hospital costs due to this clinical condition have been recently reported. The ability to determine risk factors for mucositis, to early detect its onset, to assess correctly the degree of this toxicity and to plan its multidisciplinary management are all key elements to guarantee the quality of life of patients and to avoid useless dose reduction or interruption of treatment. The pathogenesis of mucositis is multifactorial and it is classily subdivided into oral and gastrointestinal mucositis according to its anatomic presentation. Treatment and patients’ related factors might help in predicting the frequency and the potential degree of symptoms onset. Here we discuss about clinical presentation and pathogenesis of mucositis in relation to different kinds of treatments. Moreover, we focus on therapeutic and prevention strategies, describing past and present management according to international guidelines and the most promising new data about agents potentially able to further improve the treatment of mucositis in the next future.
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Affiliation(s)
- Marika Cinausero
- Department of Oncology, University and General HospitalUdine, Italy
| | - Giuseppe Aprile
- Department of Oncology, University and General HospitalUdine, Italy.,Department of Oncology, San Bortolo General HospitalVicenza, Italy
| | - Paola Ermacora
- Department of Oncology, University and General HospitalUdine, Italy
| | - Debora Basile
- Department of Oncology, University and General HospitalUdine, Italy
| | - Maria G Vitale
- Department of Oncology, University and General HospitalUdine, Italy
| | | | - Giuseppe Parisi
- Department of Oncology, University and General HospitalUdine, Italy
| | - Lorenzo Calvetti
- Department of Oncology, San Bortolo General HospitalVicenza, Italy
| | - Stephen T Sonis
- Divisions of Oral Medicine, Brigham and Women's Hospital, BostonMA, United States.,Dana-Farber Cancer InstituteBoston, MA, United States.,Biomodels LLC, WatertownMA, United States
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9
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Villa A, Sonis S. Toxicities associated with head and neck cancer treatment and oncology-related clinical trials. Curr Probl Cancer 2016; 40:244-257. [DOI: 10.1016/j.currproblcancer.2016.06.001] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2016] [Accepted: 06/09/2016] [Indexed: 12/21/2022]
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10
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Van Sebille YZA, Stansborough R, Wardill HR, Bateman E, Gibson RJ, Keefe DM. Management of Mucositis During Chemotherapy: From Pathophysiology to Pragmatic Therapeutics. Curr Oncol Rep 2015; 17:50. [DOI: 10.1007/s11912-015-0474-9] [Citation(s) in RCA: 36] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
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