1
|
Heindryckx F, Sjöblom M. Endoplasmic reticulum stress in the pathogenesis of chemotherapy-induced mucositis: Physiological mechanisms and therapeutic implications. Acta Physiol (Oxf) 2024; 240:e14188. [PMID: 38874396 DOI: 10.1111/apha.14188] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2024] [Revised: 05/24/2024] [Accepted: 05/29/2024] [Indexed: 06/15/2024]
Abstract
Chemotherapy is a common and effective treatment for cancer, but these drugs are also associated with significant side effects affecting patients' well-being. One such debilitating side effect is mucositis, characterized by inflammation, ulcerations, and altered physiological functions of the gastrointestinal (GI) tract's mucosal lining. Understanding the mechanisms of chemotherapy-induced intestinal mucositis (CIM) is crucial for developing effective preventive measures and supportive care. Chemotherapeutics not only target cancer cells but also rapidly dividing cells in the GI tract. These drugs disrupt endoplasmic reticulum (ER) homeostasis, leading to ER-stress and activation of the unfolded protein response (UPR) in various intestinal epithelial cell types. The UPR triggers signaling pathways that exacerbate tissue inflammation and damage, influence the differentiation and fate of intestinal epithelial cells, and compromise the integrity of the intestinal mucosal barrier. These factors contribute significantly to mucositis development and progression. In this review, we aim to give an in-depth overview of the role of ER-stress in mucositis and its impact on GI function. This will provide valuable insights into the underlying mechanisms and highlighting potential therapeutic interventions that could improve treatment-outcomes and the quality of life of cancer patients.
Collapse
Affiliation(s)
- Femke Heindryckx
- Department of Medical Cell Biology, Uppsala University, Uppsala, Sweden
| | - Markus Sjöblom
- Department of Medical Cell Biology, Uppsala University, Uppsala, Sweden
| |
Collapse
|
2
|
Ly KL, Rajtboriraks M, Elgerbi A, Luo X, Raub CB. Recombinant Human Keratinocyte Growth Factor Ameliorates Cancer Treatment-Induced Oral Mucositis on a Chip. Adv Healthc Mater 2024; 13:e2302970. [PMID: 38351394 PMCID: PMC11144107 DOI: 10.1002/adhm.202302970] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2023] [Revised: 02/06/2024] [Indexed: 02/23/2024]
Abstract
Oral mucositis (OM) is a severe complication of cancer therapies caused by off-target cytotoxicity. Palifermin, which is recombinant human keratinocyte growth factor (KGF), is currently the only mitigating treatment available to a subset of OM patients. This study used a previously established model of oral mucositis on a chip (OM-OC) comprised of a confluent human gingival keratinocytes (GIE) layer attached to a basement membrane-lined subepithelial layer consisting of human gingival fibroblasts (HGF) and human dermal microvascular endothelial cells (HMEC) on a stable collagen I gel. Cisplatin, radiation, and combined treatments are followed by a recovery period in the OM-OC to determine possible cellular and molecular mechanisms of OM under effects of KGF. Cancer treatments affected the keratinocyte layer, causing death and epithelial barrier loss. Both keratinocytes and subepithelial cells died rapidly, as evidenced by propidium iodide staining. In response to radiation exposure, cell death occurred in the apical epithelial layer, predominantly, within 24h. Cisplatin exposure predominantly promoted death of basal epithelial cells within 32-36h. Presence of KGF in OM-OC protected tissues from damage caused by cancer treatments in a dose-dependent manner, being more effective at 10 ng/mL. As verified by F-actin staining and the Alamar Blue assay, KGF contributed to epithelial survival and induced proliferation of GIE and HGF as well as HMEC within 120h. When the expression of eighty inflammatory cytokines is evaluated at OM induction (Day 12) and resolution (Day 18) stages in OM-OC, some cytokines are identified as potential novel therapeutic targets. In comparison with chemoradiation exposure, KGF treatment showed a trend to decrease IL-8 and TNF-a expression at Day 12 and 18, and TGF-β1 at Day 18 in OM-OC. Taken together, these findings support the utility of OM-OC as a platform to model epithelial damage and evaluate molecular mechanisms following OM treatment.
Collapse
Affiliation(s)
- Khanh L Ly
- Department of Biomedical Engineering, School of Engineering, The Catholic University of America, Washington, DC, 20064, USA
| | - May Rajtboriraks
- Department of Biomedical Engineering, School of Engineering, The Catholic University of America, Washington, DC, 20064, USA
| | - Ahmed Elgerbi
- Department of Biology, School of Arts and Sciences, The Catholic University of America, Washington, DC, 20064, USA
| | - Xiaolong Luo
- Department of Mechanical Engineering, School of Engineering, The Catholic University of America, Washington, DC, 20064, USA
| | - Christopher B Raub
- Department of Biomedical Engineering, School of Engineering, The Catholic University of America, Washington, DC, 20064, USA
| |
Collapse
|
3
|
Stringer A. The systemic outcomes of gastrointestinal mucositis: host-microbe interaction leading to systemic inflammatory responses. Curr Opin Support Palliat Care 2024; 18:71-72. [PMID: 38757684 DOI: 10.1097/spc.0000000000000704] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/18/2024]
Affiliation(s)
- Andrea Stringer
- Clinical and Health Sciences, University of South Australia, Adelaide, Australia
| |
Collapse
|
4
|
Bai X, Deng J, Duan Z, Fu R, Zhu C, Fan D. Ginsenoside Rh4 alleviates gastrointestinal mucositis and enhances chemotherapy efficacy through modulating gut microbiota. PHYTOMEDICINE : INTERNATIONAL JOURNAL OF PHYTOTHERAPY AND PHYTOPHARMACOLOGY 2024; 128:155577. [PMID: 38608488 DOI: 10.1016/j.phymed.2024.155577] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/03/2023] [Revised: 03/07/2024] [Accepted: 03/28/2024] [Indexed: 04/14/2024]
Abstract
BACKGROUND Gastrointestinal mucositis stands as one of the most severe side effects of irinotecan (CPT-11). however, only palliative treatment is available at present. Therefore, there is an urgent need for adjunctive medications to alleviate the side effects of CPT-11. PURPOSE In this study, our objective was to explore whether ginsenoside Rh4 could serve as a modulator of the gut microbiota and an adjunctive agent for chemotherapy, thereby alleviating the side effects of CPT-11 and augmenting its anti-tumor efficacy. STUDY DESIGN A CPT-11-induced gastrointestinal mucositis model was used to investigate whether ginsenoside Rh4 alleviated CPT-11-induced gastrointestinal mucositis and enhanced the anti-tumor activity of CPT-11. METHODS In this study, we utilized CT26 cells to establish a xenograft tumor model, employing transcriptomics, genomics, and metabolomics techniques to investigate the impact of ginsenoside Rh4 on CPT-11-induced gastrointestinal mucositis and the effect on the anti-tumor activity of CPT-11. Furthermore, we explored the pivotal role of gut microbiota and their metabolites through fecal microbiota transplantation (FMT) experiments and supplementation of the key differential metabolite, hyodeoxycholic acid (HDCA). RESULTS The results showed that ginsenoside Rh4 repaired the impairment of intestinal barrier function and restored intestinal mucosal homeostasis in a gut microbiota-dependent manner. Ginsenoside Rh4 treatment modulated gut microbiota diversity and upregulated the abundance of beneficial bacteria, especially Lactobacillus_reuteri and Akkermansia_muciniphila, which further regulated bile acid biosynthesis, significantly promoted the production of the beneficial secondary bile acid hyodeoxycholic acid (HDCA), thereby alleviating CPT-11-induced gut microbiota dysbiosis. Subsequently, ginsenoside Rh4 further alleviated gastrointestinal mucositis through the TGR5-TLR4-NF-κB signaling pathway. On the other hand, ginsenoside Rh4 combination therapy could further reduce the weight and volume of colon tumors, promote tumor cell apoptosis, and enhance the anti-tumor activity of CPT-11 by inhibiting the PI3K-Akt signaling pathway, thus exerting a synergistic anti-tumor effect. CONCLUSION In summary, our findings confirm that ginsenoside Rh4 can alleviate CPT-11-induced gastrointestinal mucositis and enhance the anti-tumor activity of CPT-11 by modulating gut microbiota and its related metabolites. Our study validates the potential of ginsenoside Rh4 as a modulator of the gut microbiota and an adjunctive agent for chemotherapy, offering new therapeutic strategies for addressing chemotherapy side effects and improving chemotherapy efficacy.
Collapse
Affiliation(s)
- Xue Bai
- Engineering Research Center of Western Resource Innovation Medicine Green Manufacturing, Ministry of Education, School of Chemical Engineering, Northwest University, Xi'an, 710069, China; Biotech. & Biomed. Research Institute, Northwest University, Xi'an, 710069, China
| | - Jianjun Deng
- Engineering Research Center of Western Resource Innovation Medicine Green Manufacturing, Ministry of Education, School of Chemical Engineering, Northwest University, Xi'an, 710069, China; Biotech. & Biomed. Research Institute, Northwest University, Xi'an, 710069, China
| | - Zhiguang Duan
- Engineering Research Center of Western Resource Innovation Medicine Green Manufacturing, Ministry of Education, School of Chemical Engineering, Northwest University, Xi'an, 710069, China; Biotech. & Biomed. Research Institute, Northwest University, Xi'an, 710069, China
| | - Rongzhan Fu
- Engineering Research Center of Western Resource Innovation Medicine Green Manufacturing, Ministry of Education, School of Chemical Engineering, Northwest University, Xi'an, 710069, China; Biotech. & Biomed. Research Institute, Northwest University, Xi'an, 710069, China.
| | - Chenhui Zhu
- Engineering Research Center of Western Resource Innovation Medicine Green Manufacturing, Ministry of Education, School of Chemical Engineering, Northwest University, Xi'an, 710069, China; Biotech. & Biomed. Research Institute, Northwest University, Xi'an, 710069, China.
| | - Daidi Fan
- Engineering Research Center of Western Resource Innovation Medicine Green Manufacturing, Ministry of Education, School of Chemical Engineering, Northwest University, Xi'an, 710069, China; Biotech. & Biomed. Research Institute, Northwest University, Xi'an, 710069, China.
| |
Collapse
|
5
|
Khalil M, Hamadah O, Saifo M, Khalil H, Adi M, Alabeedi F, Kujan O. Effect of Photobiomodulation on Salivary Cytokines in Head and Neck Cancer Patients with Oral Mucositis: A Systematic Review. J Clin Med 2024; 13:2822. [PMID: 38792366 PMCID: PMC11122140 DOI: 10.3390/jcm13102822] [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: 03/16/2024] [Revised: 04/11/2024] [Accepted: 05/08/2024] [Indexed: 05/26/2024] Open
Abstract
Background: Oral mucositis is a common and distressing side effect of head and neck oncology treatment. Photobiomodulation therapy can be utilized to prevent and treat oral mucositis. Its impact on salivary cytokines has yet to be thoroughly investigated. This is the first systematic review aiming to evaluate the effect of photobiomodulation on salivary cytokines in patients undergoing anticancer treatment. Methods: Numerous data resources, from the Web of Science, Embase, ScienceDirect, PubMed, Cochrane Library, and Scopus were sought. Articles published up until February 2024 were included if they met the following inclusion criteria: clinical trials reporting the effect on salivary cytokines in patients undergoing anticancer therapy. The methodological quality was assessed using several appraisal tools. Results: Four studies were deemed eligible for inclusion. All the studies were conducted in Brazil and used an InGaAlP diode laser with a wavelength of 660 nm. The included studies had a relatively low risk of bias. The head and neck cancer patients' salivary cytokines that were assessed by the studies, along with photobiomodulation therapy, included IL-12p70, TNF-α, IL-6, IL-8, IL-10, CXCL8, and IL-1β. The results varied among the studies. Conclusions: Our results show that photobiomodulation demonstrated positive results for reducing the severity of OM in all the included studies. Among the examined salivary cytokines, IL-6 is the most relevant cytokine for oral mucositis development and severity. A variation in the cytokine levels between the studies was noted due to differences in the type of anticancer treatment and saliva sampling.
Collapse
Affiliation(s)
- Marwa Khalil
- Department of Oral Medicine, Faculty of Dental Medicine, Damascus University, Damascus P.O. Box 30621, Syria; (M.K.); (O.H.)
| | - Omar Hamadah
- Department of Oral Medicine, Faculty of Dental Medicine, Damascus University, Damascus P.O. Box 30621, Syria; (M.K.); (O.H.)
- The Higher Institute for Laser Research and Applications, Damascus University, Damascus P.O. Box 30621, Syria
| | - Maher Saifo
- Faculty of Medicine, Medical Oncology, Damascus University, Damascus P.O. Box 30621, Syria;
- Albairouni University Hospital, Damascus University, Damascus P.O. Box 30621, Syria
| | - Hasan Khalil
- Department of Microbiology and Biochemistry, Tishreen University, Lattakia P.O. Box 2230, Syria;
| | - Mowaffak Adi
- Shining Horizons Dental Center, Inaya Medical Colleges, Riyadh 13541, Saudi Arabia;
| | - Faris Alabeedi
- UWA Dental School, The University of Western Australia, Nedlands, WA 6009, Australia;
| | - Omar Kujan
- UWA Dental School, The University of Western Australia, Nedlands, WA 6009, Australia;
| |
Collapse
|
6
|
Gobbo M, Joy J, Guedes H, Shazib MA, Anderson C, Abdalla-Aslan R, Peechatanan K, Lajolo C, Nasir KS, Gueiros LA, Nagarajan N, Hafezi Motlagh K, Kandwal A, Rupe C, Xu Y, Ehrenpreis ED, Tonkaboni A, Epstein JB, Bossi P, Wardill HR, Graff SL. Emerging pharmacotherapy trends in preventing and managing oral mucositis induced by chemoradiotherapy and targeted agents. Expert Opin Pharmacother 2024; 25:727-742. [PMID: 38808634 DOI: 10.1080/14656566.2024.2354451] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2024] [Accepted: 05/08/2024] [Indexed: 05/30/2024]
Abstract
INTRODUCTION The introduction of targeted therapy and immunotherapy has tremendously changed the clinical outcomes and prognosis of cancer patients. Despite innovative pharmacological therapies and improved radiotherapy (RT) techniques, patients continue to suffer from side effects, of which oral mucositis (OM) is still the most impactful, especially for quality of life. AREAS COVERED We provide an overview of current advances in cancer pharmacotherapy and RT, in relation to their potential to cause OM, and of the less explored and more recent literature reports related to the best management of OM. We have analyzed natural/antioxidant agents, probiotics, mucosal protectants and healing coadjuvants, pharmacotherapies, immunomodulatory and anticancer agents, photobiomodulation and the impact of technology. EXPERT OPINION The discovery of more precise pathophysiologic mechanisms of CT and RT-induced OM has outlined that OM has a multifactorial origin, including direct effects, oxidative damage, upregulation of immunologic factors, and effects on oral flora. A persistent upregulated immune response, associated with factors related to patients' characteristics, may contribute to more severe and long-lasting OM. The goal is strategies to conjugate individual patient, disease, and therapy-related factors to guide OM prevention or treatment. Despite further high-quality research is warranted, the issue of prevention is paramount in future strategies.
Collapse
Affiliation(s)
- Margherita Gobbo
- Unit of Oral and Maxillofacial Surgery, Ca' Foncello Hospital, Piazzale Ospedale, Treviso, Italy
| | - Jamie Joy
- Department of Pharmacy, Fred Hutchinson Cancer Center, Seattle, WA, USA
| | - Helena Guedes
- Medical Oncology Department, Centro Hospitalar Vila Nova de Gaia/Espinho, Porto, Portugal
| | - Muhammad Ali Shazib
- Workman School of Dental Medicine, High Point University, High Point, NC, USA
| | - Carryn Anderson
- Department of Radiation Oncology, University of Iowa Hospitals & Clinics, Iowa City, USA
| | - Ragda Abdalla-Aslan
- Department of Oral and Maxillofacial Surgery, Rambam Health Care Campus, Haifa, Israel
- Ruth and Bruce Rappaport Faculty of Medicine, Technion Israel Institute of Technology, Haifa, Israel
| | - Khunthong Peechatanan
- Supportive and Palliative Care Unit, Monash Health, Clayton, VIC, Australia
- Department of Medicine, Division of Medical Oncology, Phramongkutklao Hospital and College of Medicine, Bangkok, Thailand
| | - Carlo Lajolo
- Head and Neck Department, Fondazione Policlinico Universitario A. Gemelli-IRCCS, School of Dentistry, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Khawaja Shehryar Nasir
- Department of Internal Medicine, Shaukat Khanum Memorial Cancer Hospital and Research Centre, Lahore, Pakistan
| | - Luiz Alcino Gueiros
- Department of Clinic and Preventive Dentistry & Oral Medicine Unit, Health Sciences Center, Hospital das Clínicas, Federal University of Pernambuco, Recife, Brazil
| | - Nivethitha Nagarajan
- Department of Orofacial Sciences, School of Dentistry, University of California San Francisco, California, USA
| | - Kimia Hafezi Motlagh
- Department of Oral Medicine, School of Dentistry, Tehran University of Medical Sciences, Tehran, Iran
| | - Abhishek Kandwal
- Himalayan Institute of Medical Sciences Cancer Research Institute Swami Rama Himalayan University, Uttarakhand, India
| | - Cosimo Rupe
- Head and Neck Department, Fondazione Policlinico Universitario A. Gemelli-IRCCS, School of Dentistry, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Yuanming Xu
- Department of Diagnostic Sciences, Tufts University School of Dental Medicine, Boston, MA, USA
| | - Eli D Ehrenpreis
- Department of Medicine, Advocate Lutheran General Hospital, Park Ridge, IL, USA
- E2Bio Life Sciences, Skokie, IL, USA
| | - Arghavan Tonkaboni
- Oral Medicine Department, School of Dentistry, Tehran University of Medical Science, Tehran, Iran
| | - Joel B Epstein
- Department of Surgery, City of Hope National Cancer Center, Duarte, CA, USA
| | - Paolo Bossi
- Medical Oncology and Hematology Unit, IRCCS Humanitas Research Hospital, Rozzano (Milan), Italy
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, Milan, Italy
| | - Hannah R Wardill
- School of Biomedicine, The University of Adelaide, Adelaide, Australia
- Supportive Oncology Research Group, Precision Cancer Medicine Theme, South Australian Health and Medical Research Institute, Adelaide, Australia
| | - Stephanie L Graff
- Lifespan Cancer Institute, Providence, RI, USA
- Legorreta Cancer Center, Brown University, Providence, RI, USA
| |
Collapse
|
7
|
de Arruda JAA, Heimlich FV, Oliveira SR, Drumond VZ, Travassos DV, Abreu LG, Teixeira AL, Mesquita RA, Silva TA. Influence of anxiety/depression on chemotherapy-induced oral mucositis and related quality of life: A prospective cohort study. J Psychosom Res 2024; 177:111577. [PMID: 38154442 DOI: 10.1016/j.jpsychores.2023.111577] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/23/2023] [Revised: 11/15/2023] [Accepted: 12/19/2023] [Indexed: 12/30/2023]
Abstract
OBJECTIVE The impact of anxiety and depression on chemotherapy-induced oral mucositis has not been extensively explored in the literature. The aim of the present study was to evaluate anxiety/depressive symptoms, health-related quality of life, and oral health-related quality of life and their association with oral mucositis among individuals receiving chemotherapy. METHODS This is a prospective longitudinal study carried out at a Brazilian referral service. The Hospital Anxiety and Depression Scale (HADS), World Health Organization Quality of Life-BREF (WHOQOL-BREF), and Oral Health Impact Profile questionnaire (OHIP-14) were applied at D0 (before chemotherapy) and D15 of chemotherapy. Clinicodemographic data and oral mucositis severity scores were evaluated. RESULTS A total of 37 individuals (median age: 49 years) were included in the study. Nearly 38% of patients developed chemotherapy-induced oral mucositis and had higher anxiety/depression scores at baseline. Oral mucositis had a negative impact on oral health-related quality of life regarding functional limitation, physical pain, physical disability, and handicap. CONCLUSION Anxiety/depressive symptoms are associated with oral mucositis that affects overall health and oral health-related quality of life.
Collapse
Affiliation(s)
- José Alcides Almeida de Arruda
- Department of Oral Surgery, Pathology and Clinical Dentistry, School of Dentistry, Universidade Federal de Minas Gerais, Belo Horizonte, Minas Gerais, Brazil
| | - Fernanda Vieira Heimlich
- Department of Oral Surgery, Pathology and Clinical Dentistry, School of Dentistry, Universidade Federal de Minas Gerais, Belo Horizonte, Minas Gerais, Brazil
| | - Sicília Rezende Oliveira
- Department of Oral Surgery, Pathology and Clinical Dentistry, School of Dentistry, Universidade Federal de Minas Gerais, Belo Horizonte, Minas Gerais, Brazil
| | | | - Denise Vieira Travassos
- Multiprofessional Integrated Residency in Health, Hospital das Clínicas, Department of Social and Preventive Dentistry, School of Dentistry, Universidade Federal de Minas Gerais, Belo Horizonte, Minas Gerais, Brazil
| | - Lucas Guimarães Abreu
- Department of Child and Adolescent Oral Health, School of Dentistry, Universidade Federal de Minas Gerais, Belo Horizonte, Minas Gerais, Brazil
| | - Antonio Lucio Teixeira
- Faculdade Santa Casa BH, Belo Horizonte, Minas Gerais, Brazil; Neuropsychiatry Program, Department of Psychiatry and Behavioral Sciences, The University of Texas Health Science Center at Houston, Houston, TX, USA
| | - Ricardo Alves Mesquita
- Department of Oral Surgery, Pathology and Clinical Dentistry, School of Dentistry, Universidade Federal de Minas Gerais, Belo Horizonte, Minas Gerais, Brazil.
| | - Tarcília Aparecida Silva
- Multiprofessional Integrated Residency in Health, Hospital das Clínicas, Department of Oral Surgery, Pathology and Clinical Dentistry, School of Dentistry, Universidade Federal de Minas Gerais, Belo Horizonte, Minas Gerais, Brazil.
| |
Collapse
|
8
|
Choudhury M, Brunton P, Schwass D, Pletzer D, Ratnayake J, Dias G, Tompkins G. Effectiveness of gold nanoparticles in prevention and treatment of oral mucositis in animal models: a systematic review. Syst Rev 2024; 13:39. [PMID: 38273391 PMCID: PMC10809540 DOI: 10.1186/s13643-023-02425-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/29/2023] [Accepted: 12/08/2023] [Indexed: 01/27/2024] Open
Abstract
BACKGROUND Oral mucositis remains a significant complication during cancer therapy with no effective treatment. Gold nanoparticles offer anti-inflammatory, antioxidant properties with low toxicity. This study systematically reviews the literature assessing gold nanoparticles in the management of oral mucositis in animal models. METHODS A literature search was undertaken using MEDLINE, Embase, PubMed, and Web of Science databases, using the format for Systematic Review Centre for Laboratory Animal Experimentation. Prior to the review, the protocol was registered in the systematic review register, PROSPERO (registration no. CRD42021272169). Outcome measures included ulceration, histopathological scores, inflammatory mediators, microbial growth, and pain. Study quality was analysed by SYRCLE risk-of-bias tool. RESULTS Only one study met the inclusion criteria, documenting reduction in ulceration, inflammatory, and oxidative biomarkers. Exposure to AuNPs prevented inflammatory response induced by 5-fluorouracil in oral mucosa of hamsters. However, a high risk of bias necessitates further research. CONCLUSION This review identifies a potential therapeutic strategy for prevention and management of oral mucositis. It also provides future direction for gold nanoparticle research in oral mucositis; however, there is lack of sufficient evidence to derive any conclusion. Research with standardized parameters including nanoparticle size, capping agent, surface charge, and appropriate oral mucositis animal models will establish risk-benefit balance and margin of safety for therapeutic use of gold nanoparticles for oral mucositis.
Collapse
Affiliation(s)
- Minati Choudhury
- Sir John Walsh Research Institute, Faculty of Dentistry, University of Otago, Dunedin, New Zealand.
- Restorative Dentistry, School of Dentistry, International Medical University, Kuala Lumpur, Malaysia.
| | - Paul Brunton
- Sir John Walsh Research Institute, Faculty of Dentistry, University of Otago, Dunedin, New Zealand
- DVCA, Curtin University, Perth, Australia
| | - Donald Schwass
- Department of Oral Rehabilitation, Faculty of Dentistry, University of Otago, Dunedin, New Zealand
| | - Daniel Pletzer
- Department of Microbiology and Immunology, University of Otago, Dunedin, New Zealand.
| | - Jithendra Ratnayake
- Department of Oral Sciences, Faculty of Dentistry, University of Otago, Dunedin, New Zealand
| | - George Dias
- Department of Anatomy, University of Otago, Dunedin, New Zealand
| | - Geoffrey Tompkins
- Sir John Walsh Research Institute, Faculty of Dentistry, University of Otago, Dunedin, New Zealand
| |
Collapse
|
9
|
Belfiore E, Di Prima G, Angellotti G, Panzarella V, De Caro V. Plant-Derived Polyphenols to Prevent and Treat Oral Mucositis Induced by Chemo- and Radiotherapy in Head and Neck Cancers Management. Cancers (Basel) 2024; 16:260. [PMID: 38254751 PMCID: PMC10813700 DOI: 10.3390/cancers16020260] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2023] [Revised: 12/30/2023] [Accepted: 01/03/2024] [Indexed: 01/24/2024] Open
Abstract
Oral Mucositis (OM) is the most common side effect due to chemotherapy and radiotherapy, which are the conventional treatment options for head and neck cancers. OM is a severe inflammatory condition characterized by multifactorial etiopathogenesis. It further negatively affects patients' quality of life by severe impairment of normal oral functions. Consequently, it is mandatory to identify new effective therapeutic approaches to both prevent and treat OM while also avoiding any recurrence. Polyphenols recently attracted the interest of the scientific community due to their low toxicity and wide range of biological activities making them ideal candidates for several applications in the odontostomatological field, particularly against OM. This review collects the in vivo studies and the clinical trials conducted over the past 13 years evaluating the preventive and curative effects of several polyphenolic compounds towards chemo- and radiotherapy-induced OM, both when administered alone or as a plant-extracted phytocomplex. The literature fully confirms the usefulness of these molecules, thus opening the possibility of their clinical application. However, polyphenol limitations (e.g., unfavourable physicochemical properties and susceptibility to degradation) have emerged. Consequently, the interest of the scientific community should be focused on developing innovative delivery systems able to stabilize polyphenols, thus facilitating topical administration and maximizing their efficacy.
Collapse
Affiliation(s)
- Elena Belfiore
- Department of Surgical, Oncological and Oral Sciences, University of Palermo, Via L. Giuffrè 5, 90127 Palermo, Italy; (E.B.); (V.P.)
| | - Giulia Di Prima
- Department of Biological, Chemical and Pharmaceutical Sciences and Technologies, University of Palermo, Via Archirafi 32, 90123 Palermo, Italy;
| | - Giuseppe Angellotti
- Institute of Nanostructured Materials, National Research Council, Via U. La Malfa 153, 90146 Palermo, Italy;
| | - Vera Panzarella
- Department of Surgical, Oncological and Oral Sciences, University of Palermo, Via L. Giuffrè 5, 90127 Palermo, Italy; (E.B.); (V.P.)
| | - Viviana De Caro
- Department of Biological, Chemical and Pharmaceutical Sciences and Technologies, University of Palermo, Via Archirafi 32, 90123 Palermo, Italy;
| |
Collapse
|
10
|
Wardill HR, Wooley LT, Bellas OM, Cao K, Cross CB, van Dyk M, Kichenadasse G, Bowen JM, Zannettino ACW, Shakib S, Crawford GB, Boublik J, Davis MM, Smid SD, Price TJ. Supporting gut health with medicinal cannabis in people with advanced cancer: potential benefits and challenges. Br J Cancer 2024; 130:19-30. [PMID: 37884682 PMCID: PMC10781684 DOI: 10.1038/s41416-023-02466-w] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2023] [Revised: 10/08/2023] [Accepted: 10/12/2023] [Indexed: 10/28/2023] Open
Abstract
The side effects of cancer therapy continue to cause significant health and cost burden to the patient, their friends and family, and governments. A major barrier in the way in which these side effects are managed is the highly siloed mentality that results in a fragmented approach to symptom control. Increasingly, it is appreciated that many symptoms are manifestations of common underlying pathobiology, with changes in the gastrointestinal environment a key driver for many symptom sequelae. Breakdown of the mucosal barrier (mucositis) is a common and early side effect of many anti-cancer agents, known to contribute (in part) to a range of highly burdensome symptoms such as diarrhoea, nausea, vomiting, infection, malnutrition, fatigue, depression, and insomnia. Here, we outline a rationale for how, based on its already documented effects on the gastrointestinal microenvironment, medicinal cannabis could be used to control mucositis and prevent the constellation of symptoms with which it is associated. We will provide a brief update on the current state of evidence on medicinal cannabis in cancer care and outline the potential benefits (and challenges) of using medicinal cannabis during active cancer therapy.
Collapse
Affiliation(s)
- Hannah R Wardill
- The School of Biomedicine, Faculty of Health and Medical Sciences, The University of Adelaide, Adelaide, SA, Australia.
- Supportive Oncology Research Group, Precision Cancer Medicine Theme, South Australian Health and Medical Research Institute (SAHMRI), Adelaide, SA, Australia.
| | - Luke T Wooley
- The School of Biomedicine, Faculty of Health and Medical Sciences, The University of Adelaide, Adelaide, SA, Australia
| | - Olivia M Bellas
- The School of Biomedicine, Faculty of Health and Medical Sciences, The University of Adelaide, Adelaide, SA, Australia
- Supportive Oncology Research Group, Precision Cancer Medicine Theme, South Australian Health and Medical Research Institute (SAHMRI), Adelaide, SA, Australia
| | - Katrina Cao
- Supportive Oncology Research Group, Precision Cancer Medicine Theme, South Australian Health and Medical Research Institute (SAHMRI), Adelaide, SA, Australia
- School of Public Health, Faculty of Health and Medical Sciences, The University of Adelaide, Adelaide, SA, Australia
| | - Courtney B Cross
- The School of Biomedicine, Faculty of Health and Medical Sciences, The University of Adelaide, Adelaide, SA, Australia
- Supportive Oncology Research Group, Precision Cancer Medicine Theme, South Australian Health and Medical Research Institute (SAHMRI), Adelaide, SA, Australia
| | - Madele van Dyk
- Flinders Centre for Innovation in Cancer, Flinders Medical Centre/Flinders University, SA Health, Adelaide, SA, Australia
| | - Ganessan Kichenadasse
- Flinders Centre for Innovation in Cancer, Flinders Medical Centre/Flinders University, SA Health, Adelaide, SA, Australia
- Northern Adelaide Local Health Network South Australia, SA Health, Adelaide, SA, Australia
| | - Joanne M Bowen
- The School of Biomedicine, Faculty of Health and Medical Sciences, The University of Adelaide, Adelaide, SA, Australia
| | - Andrew C W Zannettino
- The School of Biomedicine, Faculty of Health and Medical Sciences, The University of Adelaide, Adelaide, SA, Australia
| | - Sepehr Shakib
- The School of Biomedicine, Faculty of Health and Medical Sciences, The University of Adelaide, Adelaide, SA, Australia
| | - Gregory B Crawford
- Northern Adelaide Local Health Network South Australia, SA Health, Adelaide, SA, Australia
- Adelaide Medical School, Faculty of Health and Medical Sciences, The University of Adelaide, Adelaide, SA, Australia
| | | | - Mellar M Davis
- The Geisinger Commonwealth School of Medicine, Scranton, PA, USA
| | - Scott D Smid
- The School of Biomedicine, Faculty of Health and Medical Sciences, The University of Adelaide, Adelaide, SA, Australia
| | - Timothy J Price
- Adelaide Medical School, Faculty of Health and Medical Sciences, The University of Adelaide, Adelaide, SA, Australia
- Queen Elizabeth Hospital, Adelaide, SA, Australia
| |
Collapse
|
11
|
Sampaio MEA, Bezerra PMM, Santos FGD, Ribeiro ILA, Sousa SAD, Santiago BM, Valença AMG. A hospital-based oral health education program impacts in pediatric cancer patients-A pilot study. SPECIAL CARE IN DENTISTRY 2024; 44:196-205. [PMID: 36895126 DOI: 10.1111/scd.12847] [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: 07/21/2022] [Revised: 02/14/2023] [Accepted: 02/24/2023] [Indexed: 03/11/2023]
Abstract
OBJECTIVES To assess the impact of an oral health education and preventive program (OHEPP) for pediatric cancer patients. METHODS This was a single-arm study with 27 children and adolescents undergoing antineoplastic treatments. Patients were followed up for 10 weeks, and their oral health conditions were evaluated using the Modified Gingival Index (MGI), Visible Plaque Index (VPI), and the modified Oral Assessment Guide (OAG). Audiovisual resources, storytelling, and ludic instruments were used to provide oral health education to patients and parents/caregivers. RESULTS The patients' mean age was 9.41 (±4.49) years, and acute lymphoblastic leukemia was the most prevalent diagnosis (22.2%). Mean MGI and VPI values were 0.82 (±0.59) and 54.11% (±19.92%) at baseline and 0.33 (±0.29) and 19.83% (± 11.47%) after 10 weeks, respectively (p < .05). The mean OAG score was 9.51 (±2.54) and 36 cases (19.8%) of severe oral mucositis (SOM) were documented. Patients with higher MGI were more likely to develop SOM. CONCLUSION The OHEPP had a positive impact on pediatric patients undergoing cancer therapy by improving their periodontal health, reducing biofilm accumulation, and preventing the development of OM lesions.
Collapse
Affiliation(s)
| | | | - Fabio Gomes Dos Santos
- Postgraduate Program in Dentistry, Federal University of Paraíba, João Pessoa, Paraíba, Brazil
| | | | - Simone Alves de Sousa
- Postgraduate Program in Dentistry, Federal University of Paraíba, João Pessoa, Paraíba, Brazil
| | - Bianca Marques Santiago
- Postgraduate Program in Dentistry, Federal University of Paraíba, João Pessoa, Paraíba, Brazil
| | | |
Collapse
|
12
|
Garutti M, Noto C, Pastò B, Cucciniello L, Alajmo M, Casirati A, Pedrazzoli P, Caccialanza R, Puglisi F. Nutritional Management of Oncological Symptoms: A Comprehensive Review. Nutrients 2023; 15:5068. [PMID: 38140327 PMCID: PMC10745914 DOI: 10.3390/nu15245068] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2023] [Revised: 12/06/2023] [Accepted: 12/07/2023] [Indexed: 12/24/2023] Open
Abstract
Throughout their experience of illness and during the course of treatment, a substantial proportion of cancer patients are prone to develop nutritional and/or metabolic disturbances. Additionally, cancer patients often encounter long-term side effects from therapies, which may lead to impaired digestion, nutrient absorption or bowel motility. Therefore, the preservation and maintenance of an optimal and balanced nutritional status are pivotal to achieving a better prognosis, increasing the tolerance and adherence to cancer therapies and improving the overall quality of life. In this context, personalized nutritional programs are essential for addressing conditions predisposing to weight loss, feeding difficulties, digestion problems and intestinal irregularity, with the goal of promoting adequate nutrient absorption and minimizing the detrimental effects of treatment regimens. The focus of this research is to examine the most common clinical conditions and metabolic changes that cancer patients may experience, including stomatitis, xerostomia, diarrhea, nausea, vomiting, dysphagia, sub-occlusion, dysgeusia, dysosmia, anorexia, and cachexia. Furthermore, we present a pragmatic example of a multidisciplinary workflow that incorporates customized recipes tailored to individual clinical scenarios, all while maintaining the hedonic value of the meals.
Collapse
Affiliation(s)
- Mattia Garutti
- CRO Aviano, National Cancer Institute, IRCCS, 33081 Aviano, Italy
| | - Claudia Noto
- CRO Aviano, National Cancer Institute, IRCCS, 33081 Aviano, Italy
- Department of Medicine, University of Udine, 33100 Udine, Italy
| | - Brenno Pastò
- CRO Aviano, National Cancer Institute, IRCCS, 33081 Aviano, Italy
- Department of Medicine, University of Udine, 33100 Udine, Italy
| | - Linda Cucciniello
- CRO Aviano, National Cancer Institute, IRCCS, 33081 Aviano, Italy
- Department of Medicine, University of Udine, 33100 Udine, Italy
| | | | - Amanda Casirati
- Clinical Nutrition and Dietetics Unit, Fondazione IRCCS Policlinico San Matteo, 27100 Pavia, Italy
| | - Paolo Pedrazzoli
- Department of Internal Medicine and Medical Therapy, University of Pavia, 27100 Pavia, Italy
- Medical Oncology Unit, Fondazione IRCCS Policlinico San Matteo, 27100 Pavia, Italy
| | - Riccardo Caccialanza
- Clinical Nutrition and Dietetics Unit, Fondazione IRCCS Policlinico San Matteo, 27100 Pavia, Italy
- Department of Internal Medicine and Medical Therapy, University of Pavia, 27100 Pavia, Italy
| | - Fabio Puglisi
- CRO Aviano, National Cancer Institute, IRCCS, 33081 Aviano, Italy
- Department of Medicine, University of Udine, 33100 Udine, Italy
| |
Collapse
|
13
|
Yoshimatsu M, Kawashita Y, Soutome S, Murata M, Sawayama Y, Kurogi T, Nakao N, Miyazaki Y, Umeda M, Ukai T. Hangeshashinto for prevention of oral mucositis in patients undergoing hematopoietic stem cell transplantation: a randomized phase II study. Support Care Cancer 2023; 31:707. [PMID: 37979045 PMCID: PMC10657322 DOI: 10.1007/s00520-023-08175-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2023] [Accepted: 11/08/2023] [Indexed: 11/19/2023]
Abstract
PURPOSE Oral mucositis (OM) is a side effect associated with cancer treatment. Hangeshashinto (HST), a Kampo medicine, was originally prescribed to treat diarrhea, gastritis, and stomatitis. Several reports have described the effects of HST for OM induced by chemotherapy in patients with gastric or colorectal cancer. In this study, the effects of HST for prevention of OM were investigated in patients undergoing hematopoietic stem cell transplantation (HSCT). METHODS Thirty patients scheduled to receive allogeneic grafts were enrolled from July 2020 to December 2021. They were randomly assigned to two groups and instructed to wash their mouth using HST dissolved in saline solution or using only saline solution three times a day. The observation period was from the initiation date of the conditioning regimen to the date of engraftment, and the end point was the incidence of OM. RESULTS Eighteen patients developed OM, the most severe of which was Grade (G)3. There was no significant difference in the incidence of OM between the HST group and the control group. However, a negative correlation tended to be observed between the duration using HST use and the duration of OM (G2-3: P = 0.027, G3: P = 0.047). CONCLUSIONS The present study demonstrated that HST use did not clearly inhibit onset of OM but showed a tendency to inhibit OM exacerbation. However, further studies are necessary to fully understand the effects of HST on OM in patients undergoing HSCT. TRIAL REGISTRATION This study was registered in the Japan Registry of Clinical Trials on 7 May 2020 (jRCTs071200012).
Collapse
Affiliation(s)
- Masako Yoshimatsu
- Oral Management Center, Nagasaki University Hospital, 1-7-1 Sakamoto, Nagasaki, 852-8501, Japan.
| | - Yumiko Kawashita
- Department of Oral Health, Nagasaki University Graduate School of Biomedical Sciences, Nagasaki, Japan
| | - Sakiko Soutome
- Department of Oral Health, Nagasaki University Graduate School of Biomedical Sciences, Nagasaki, Japan
| | - Maho Murata
- Department of Clinical Oral Oncology, Nagasaki University Graduate School of Biomedical Sciences, Nagasaki, Japan
| | - Yasushi Sawayama
- Department of Hematology, Japanese Red Cross Nagasaki Genbaku Hospital, Nagasaki, Japan
| | - Tadafumi Kurogi
- Oral Management Center, Nagasaki University Hospital, 1-7-1 Sakamoto, Nagasaki, 852-8501, Japan
| | - Noriko Nakao
- Oral Management Center, Nagasaki University Hospital, 1-7-1 Sakamoto, Nagasaki, 852-8501, Japan
| | - Yasushi Miyazaki
- Department of Hematology, Atomic Bomb Disease and Hibakusha Medicine Unit, Nagasaki University Graduate School of Biomedical Sciences, Nagasaki, Japan
| | - Masahiro Umeda
- Department of Clinical Oral Oncology, Nagasaki University Graduate School of Biomedical Sciences, Nagasaki, Japan
| | - Takashi Ukai
- Oral Management Center, Nagasaki University Hospital, 1-7-1 Sakamoto, Nagasaki, 852-8501, Japan
| |
Collapse
|
14
|
Agholme MB, Dahllöf G, Törlén JK, Majorana A, Brennan MT, von Bültzingslöwen I, Tan PL, Hu S, Sim YF, Hong C. Incidence, severity, and temporal development of oral complications in pediatric allogeneic hematopoietic stem cell transplant patients - a multicenter study. Support Care Cancer 2023; 31:702. [PMID: 37971651 PMCID: PMC10654176 DOI: 10.1007/s00520-023-08151-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2023] [Accepted: 10/29/2023] [Indexed: 11/19/2023]
Abstract
PURPOSE Oral mucositis is a common complication for patients undergoing allogeneic hematopoietic stem cell transplantation (HSCT) and causes pain and difficulties in functions like eating and swallowing, resulting in lower quality of life and greater need of treatment with opioids and parenteral nutrition. This prospective multicenter study focused on pediatric recipients of HSCT in the neutropenic phase concerning oral complications, timing, severity, and patient experience. METHODS The cohort comprised 68 patients, median age 11.1 years (IQR 6.3) receiving allogeneic HSCT at three clinical sites. Medical records were retrieved for therapy regimens, concomitant medications, oral and dental history, and subjective oral complaints. Calibrated dentists conducted an oral and dental investigation before HSCT. After HSCT graft infusion, study personnel made bedside assessments and patients filled out a questionnaire once or twice a week until neutrophil engraftment. RESULTS We followed 63 patients through the neutropenic phase until engraftment. 50% developed oral mucositis of grades 2-4. Peak severity occurred at 8-11 days after stem cell infusion. Altogether, 87% had subjective oral complaints. The temporal distribution of adverse events is similar to the development of oral mucositis. The most bothersome symptoms were blisters and oral ulcerations, including mucositis; 40% reported severe pain and major impact on activities of daily living despite continuous use of opioids. CONCLUSION This study highlights the burden of oral complications and their negative effect on the health and quality of life of HSCT recipients.
Collapse
Affiliation(s)
- Monica Barr Agholme
- Division of Orthodontics and Pediatric Dentistry, Department of Dental Medicine, Karolinska Institutet, Huddinge, Sweden
| | - Göran Dahllöf
- Division of Orthodontics and Pediatric Dentistry, Department of Dental Medicine, Karolinska Institutet, Huddinge, Sweden.
- Center for Oral Health Services and Research, Mid-Norway (TkMidt), Trondheim, Norway.
| | - Johan Karlsson Törlén
- Cellular Therapy and Allogeneic Stem Cell Transplantation (CAST), Karolinska Comprehensive Cancer Center, Karolinska University Hospital, Huddinge, Sweden
- Department of Clinical Science, Intervention and Technology (CLINTEC), Karolinska Institute, Stockholm, Sweden
| | - Alessandra Majorana
- Department of Pediatric Dentistry, School of Dentistry, University of Brescia, Brescia, Italy
| | - Michael T Brennan
- Department of Oral Medicine/Oral & Maxillofacial Surgery, Atrium Health Carolinas Medical Center, Charlotte, NC, USA
- Department of Otolaryngology/Head and Neck Surgery, Wake Forest University School of Medicine, Winston Salem, NC, USA
| | - Inger von Bültzingslöwen
- Department of Oral Microbiology and Immunology, Institute of Odontology, The Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Poh Lin Tan
- Department of Paediatrics, Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
- Khoo Teck Puat-National University Children's Medical Institute, National University Hospital, National University Health System, Singapore, Singapore
| | - Shijia Hu
- Discipline of Orthodontics and Paediatric Dentistry, Faculty of Dentistry, National University of Singapore, Singapore, Singapore
| | - Yu Fan Sim
- Discipline of Orthodontics and Paediatric Dentistry, Faculty of Dentistry, National University of Singapore, Singapore, Singapore
| | - Catherine Hong
- Discipline of Orthodontics and Paediatric Dentistry, Faculty of Dentistry, National University of Singapore, Singapore, Singapore
| |
Collapse
|
15
|
Sankar V, Xu Y. Oral Complications from Oropharyngeal Cancer Therapy. Cancers (Basel) 2023; 15:4548. [PMID: 37760517 PMCID: PMC10526346 DOI: 10.3390/cancers15184548] [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: 08/15/2023] [Revised: 09/07/2023] [Accepted: 09/11/2023] [Indexed: 09/29/2023] Open
Abstract
Post-oropharyngeal cancer treatment complications include a multitude of oral side effects that impact overall survival and quality of life. These include acute and chronic conditions affecting the oral cavity and head and neck, such as mucositis, infection, xerostomia, dysgeusia, radiation caries, osteonecrosis, and trismus. This review will summarize the most common oral complications from oropharyngeal cancer therapy. The authors would like to point out that the literature cited frequently combines oropharyngeal and head and neck cancer results. If recommendations are made strictly related to oropharyngeal cancers, this will be highlighted.
Collapse
Affiliation(s)
- Vidya Sankar
- Department of Diagnostic Sciences, Tufts University School of Dental Medicine, Boston, MA 02111, USA;
| | | |
Collapse
|
16
|
Maddern AS, Coller JK, Bowen JM, Gibson RJ. The Association between the Gut Microbiome and Development and Progression of Cancer Treatment Adverse Effects. Cancers (Basel) 2023; 15:4301. [PMID: 37686576 PMCID: PMC10487104 DOI: 10.3390/cancers15174301] [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: 06/27/2023] [Revised: 08/18/2023] [Accepted: 08/23/2023] [Indexed: 09/10/2023] Open
Abstract
Adverse effects are a common consequence of cytotoxic cancer treatments. Over the last two decades there have been significant advances in exploring the relationship between the gut microbiome and these adverse effects. Changes in the gut microbiome were shown in multiple clinical studies to be associated with the development of acute gastrointestinal adverse effects, including diarrhoea and mucositis. However, more recent studies showed that changes in the gut microbiome may also be associated with the long-term development of psychoneurological changes, cancer cachexia, and fatigue. Therefore, the aim of this review was to examine the literature to identify potential contributions and associations of the gut microbiome with the wide range of adverse effects from cytotoxic cancer treatments.
Collapse
Affiliation(s)
- Amanda S. Maddern
- School of Allied Health Science and Practice, The University of Adelaide, Adelaide, SA 5005, Australia;
| | - Janet K. Coller
- School of Biomedicine, The University of Adelaide, Adelaide, SA 5005, Australia; (J.K.C.); (J.M.B.)
| | - Joanne M. Bowen
- School of Biomedicine, The University of Adelaide, Adelaide, SA 5005, Australia; (J.K.C.); (J.M.B.)
| | - Rachel J. Gibson
- School of Allied Health Science and Practice, The University of Adelaide, Adelaide, SA 5005, Australia;
| |
Collapse
|
17
|
Nangia S, Gaikwad U, Noufal MP, Sawant M, Wakde M, Mathew A, Chilukuri S, Sharma D, Jalali R. Proton therapy and oral mucositis in oral & oropharyngeal cancers: outcomes, dosimetric and NTCP benefit. Radiat Oncol 2023; 18:121. [PMID: 37468950 DOI: 10.1186/s13014-023-02317-1] [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: 09/01/2022] [Accepted: 07/06/2023] [Indexed: 07/21/2023] Open
Abstract
INTRODUCTION Radiation-induced oral mucositis (RIOM), is a common, debilitating, acute side effect of radiotherapy for oral cavity (OC) and oropharyngeal (OPx) cancers; technical innovations for reducing it are seldom discussed. Intensity-modulated-proton-therapy (IMPT) has been reported extensively for treating OPx cancers, and less frequently for OC cancers. We aim to quantify the reduction in the likelihood of RIOM in treating these 2 subsites with IMPT compared to Helical Tomotherapy. MATERIAL AND METHODS We report acute toxicities and early outcomes of 22 consecutive patients with OC and OPx cancers treated with IMPT, and compare the dosimetry and normal tissue complication probability (NTCP) of ≥ grade 3 mucositis for IMPT and HT. RESULTS Twenty two patients, 77% males, 41% elderly and 73% OC subsite, were reviewed. With comparable target coverage, IMPT significantly reduced the mean dose and D32, D39, D45, and D50, for both the oral mucosa (OM) and spared oral mucosa (sOM). With IMPT, there was a 7% absolute and 16.5% relative reduction in NTCP for grade 3 mucositis for OM, compared to HT. IMPT further reduced NTCP for sOM, and the benefit was maintained in OC, OPx subsites and elderly subgroup. Acute toxicities, grade III dermatitis and mucositis, were noted in 50% and 45.5% patients, respectively, while 22.7% patients had grade 3 dysphagia. Compared with published data, the hospital admission rate, median weight loss, feeding tube insertion, unplanned treatment gaps were lower with IMPT. At a median follow-up of 15 months, 81.8% were alive; 72.7%, alive without disease and 9%, alive with disease. CONCLUSION The dosimetric benefit of IMPT translates into NTCP reduction for grade 3 mucositis compared to Helical Tomotherapy for OPx and OC cancers and encourages the use of IMPT in their management.
Collapse
Affiliation(s)
- Sapna Nangia
- Department of Radiation Oncology, Apollo Proton Cancer Centre, Dr. Vikram Sarabhai Instronic Estate, Taramani, Chennai, Tamil Nadu, India.
| | - Utpal Gaikwad
- Department of Radiation Oncology, Apollo Proton Cancer Centre, Dr. Vikram Sarabhai Instronic Estate, Taramani, Chennai, Tamil Nadu, India
| | - M P Noufal
- Department of Medical Physics, Apollo Proton Cancer Centre, Chennai, Tamil Nadu, India
| | - Mayur Sawant
- Department of Radiation Oncology, Tata Memorial Centre, Mumbai, India
| | - Manoj Wakde
- Department of Radiation Oncology, Apollo Proton Cancer Centre, Dr. Vikram Sarabhai Instronic Estate, Taramani, Chennai, Tamil Nadu, India
| | - Ashwathy Mathew
- Department of Radiation Oncology, Apollo Proton Cancer Centre, Dr. Vikram Sarabhai Instronic Estate, Taramani, Chennai, Tamil Nadu, India
| | - Srinivas Chilukuri
- Department of Radiation Oncology, Apollo Proton Cancer Centre, Dr. Vikram Sarabhai Instronic Estate, Taramani, Chennai, Tamil Nadu, India
| | - Dayananda Sharma
- Department of Medical Physics, Apollo Proton Cancer Centre, Chennai, Tamil Nadu, India
| | - Rakesh Jalali
- Department of Radiation Oncology, Apollo Proton Cancer Centre, Dr. Vikram Sarabhai Instronic Estate, Taramani, Chennai, Tamil Nadu, India
| |
Collapse
|
18
|
Gobbi MF, Ferreira MH, de Carvalho DLC, Silva GBL, Macari KSM, Neves LDJ, Santos PSDS, Junior LAVS, Melo WR, Antunes HS, De Macedo LD, Eduardo FDP, Bezinelli LM. Dental consensus on HSCT - Part II: dental Care during HSCT. Hematol Transfus Cell Ther 2023; 45:368-378. [PMID: 37321878 PMCID: PMC10499574 DOI: 10.1016/j.htct.2023.04.003] [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: 03/24/2023] [Accepted: 04/17/2023] [Indexed: 06/17/2023] Open
Abstract
During the state of immune vulnerability in hematopoietic stem cell transplantation (HSCT), the patient has an increased risk of developing a vast number of complications, including severe problems in the oral cavity. These situations require professional oral care to act in the diagnosis and treatment of these conditions, as well as to develop prevention protocols to minimize patient's complications. Oral mucositis, opportunistic infections, bleeding, specific microbiota, taste, and salivary alterations are complications that can occur during HSCT and interfere with various aspects, such as pain control, oral intake, nutrition, bacteremia and sepsis, days of hospitalization and morbidity. Several guidelines have been published to address the role of professional oral care during the HSCT, we describe a consensus regarding these recommendations.
Collapse
Affiliation(s)
| | | | | | - Geisa Badauy Lauria Silva
- Serviço de Odontologia do Hospital Aráujo Jorge/Associação de Combate ao Câncer em Goiás, Goiânia, Goiás, Brazil
| | - Karina Silva Moreira Macari
- Departamento de Odontologia, Hospital de Câncer Infantojuvenil de Barretos do Hospital de Amor, Barretos, SP, Brazil
| | - Lilian de Jesus Neves
- Departamento de Odontologia, Hospital de Câncer Infantojuvenil de Barretos do Hospital de Amor, Barretos, SP, Brazil
| | - Paulo Sérgio da Silva Santos
- Departamento de Cirurgia, Estomatologia, Patologia e Radiologia da Faculdade de Odontologia de Bauru, Universidade de São Paulo, Bauru, Brazil
| | | | | | | | - Leandro Dorigan De Macedo
- Serviço de Odontologia e Estomatologia do Hospital das Clínicas da Faculdade de Medicina de Ribeirão Preto, Brazil; Faculdade de Medicina de Ribeirão Preto da Universidade de São Paulo, Brazil
| | | | | |
Collapse
|
19
|
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.
Collapse
|
20
|
Wardill HR, Da Silva Ferreira AR, Kumar H, Bateman EH, Cross CB, Bowen JM, Havinga R, Harmsen HJM, Knol J, Dorresteijn B, van Dijk M, van Bergenhenegouwen J, Tissing WJE. Whey-based diet containing medium chain triglycerides modulates the gut microbiota and protects the intestinal mucosa from chemotherapy while maintaining therapy efficacy. Cell Death Dis 2023; 14:338. [PMID: 37221162 DOI: 10.1038/s41419-023-05850-9] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2022] [Revised: 04/24/2023] [Accepted: 05/02/2023] [Indexed: 05/25/2023]
Abstract
Cytotoxicity (i.e. cell death) is the core mechanism by which chemotherapy induces its anti-cancer effects. Unfortunately, this same mechanism underpins the collateral damage it causes to healthy tissues. The gastrointestinal tract is highly susceptible to chemotherapy's cytotoxicity, resulting in ulcerative lesions (termed gastrointestinal mucositis, GI-M) that impair the functional capacity of the gut leading to diarrhea, anorexia, malnutrition and weight loss, which negatively impact physical/psychological wellbeing and treatment adherence. Preventing these side effects has proven challenging given the overlapping mechanisms that dictate chemotherapy efficacy and toxicity. Here, we report on a novel dietary intervention that, due to its localized gastrointestinal effects, is able to protect the intestinal mucosal from unwanted toxicity without impairing the anti-tumor effects of chemotherapy. The test diet (containing extensively hydrolyzed whey protein and medium chain triglycerides (MCTs)), was investigated in both tumor-naïve and tumor-bearing models to evaluate its effect on GI-M and chemo-efficacy, respectively. In both models, methotrexate was used as the representative chemotherapeutic agent and the diet was provided ad libitum for 14 days prior to treatment. GI-M was measured using the validated biomarker plasma citrulline, and chemo-efficacy defined by tumor burden (cm3/g body weight). The test diet significantly attenuated GI-M (P = 0.03), with associated reductions in diarrhea (P < 0.0001), weight loss (P < 0.05), daily activity (P < 0.02) and maintenance of body composition (P < 0.02). Moreover, the test diet showed significant impact on gut microbiota by increasing diversity and resilience, whilst also altering microbial composition and function (indicated by cecal short and brained chain fatty acids). The test diet did not impair the efficacy of methotrexate against mammary adenocarcinoma (tumor) cells. In line with the first model, the test diet minimized intestinal injury (P = 0.001) and diarrhea (P < 0.0001). These data support translational initiatives to determine the clinical feasibility, utility and efficacy of this diet to improve chemotherapy treatment outcomes.
Collapse
Affiliation(s)
- Hannah R Wardill
- Department of Pediatrics, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands.
- School of Biomedicine, Faculty of Health and Medical Sciences, The University of Adelaide, Adelaide, SA, Australia.
- Supportive Oncology Research Group, Precision Cancer Medicine, The South Australian Health and Medical Research Institute, Adelaide, Australia.
| | - Ana Rita Da Silva Ferreira
- Department of Medical Microbiology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | | | - Emma H Bateman
- School of Biomedicine, Faculty of Health and Medical Sciences, The University of Adelaide, Adelaide, SA, Australia
| | - Courtney B Cross
- Supportive Oncology Research Group, Precision Cancer Medicine, The South Australian Health and Medical Research Institute, Adelaide, Australia
| | - Joanne M Bowen
- School of Biomedicine, Faculty of Health and Medical Sciences, The University of Adelaide, Adelaide, SA, Australia
| | - Rick Havinga
- Department of Pediatrics, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Hermie J M Harmsen
- Department of Medical Microbiology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Jan Knol
- Danone Nutricia Research, Utrecht, the Netherlands
- Laboratory of Microbiology, Wageningen University, Wageningen, The Netherlands
| | | | | | | | - Wim J E Tissing
- Department of Pediatrics, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
- Princess Máxima Center for Pediatric Oncology, Utrecht, The Netherlands
| |
Collapse
|
21
|
Luisa Valerio de Mello Braga L, Simão G, Silva Schiebel C, Caroline Dos Santos Maia A, Mulinari Turin de Oliveira N, Barbosa da Luz B, Rita Corso C, Soares Fernandes E, Maria Ferreira D. Rodent models for anticancer toxicity studies: contributions to drug development and future perspectives. Drug Discov Today 2023:103626. [PMID: 37224998 DOI: 10.1016/j.drudis.2023.103626] [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: 08/12/2022] [Revised: 05/08/2023] [Accepted: 05/17/2023] [Indexed: 05/26/2023]
Abstract
Antineoplastic treatment induces a type of gastrointestinal toxicity known as mucositis. Findings in animal models are usually easily reproducible, and standardized treatment regimens are often used, thus supporting translational science. Essential characteristics of mucositis, including intestinal permeability, inflammation, immune and oxidative responses, and tissue repair mechanisms, can be easily investigated in these models. Given the effects of mucositis on the quality of life of patients with cancer, and the importance of experimental models in the development of more effective new therapeutic alternatives, this review discusses progress and current challenges in using experimental models of mucositis in translational pharmacology research. Teaser Experimental models for studying gastrointestinal mucositis have provided a wealth of information improving the understanding of antineoplastic toxicity.
Collapse
Affiliation(s)
- Lara Luisa Valerio de Mello Braga
- Instituto de Pesquisa Pelé Pequeno Príncipe, Faculdades Pequeno Príncipe, Curitiba, PR, Brazil; Programa de Pós-graduação em Biotecnologia Aplicada à Saúde da Criança e do Adolescente, Faculdades Pequeno Príncipe, Curitiba, PR, Brazil
| | - Gisele Simão
- Instituto de Pesquisa Pelé Pequeno Príncipe, Faculdades Pequeno Príncipe, Curitiba, PR, Brazil; Programa de Pós-graduação em Biotecnologia Aplicada à Saúde da Criança e do Adolescente, Faculdades Pequeno Príncipe, Curitiba, PR, Brazil
| | - Carolina Silva Schiebel
- Instituto de Pesquisa Pelé Pequeno Príncipe, Faculdades Pequeno Príncipe, Curitiba, PR, Brazil; Programa de Pós-graduação em Biotecnologia Aplicada à Saúde da Criança e do Adolescente, Faculdades Pequeno Príncipe, Curitiba, PR, Brazil
| | - Andressa Caroline Dos Santos Maia
- Instituto de Pesquisa Pelé Pequeno Príncipe, Faculdades Pequeno Príncipe, Curitiba, PR, Brazil; Programa de Pós-graduação em Biotecnologia Aplicada à Saúde da Criança e do Adolescente, Faculdades Pequeno Príncipe, Curitiba, PR, Brazil
| | - Natalia Mulinari Turin de Oliveira
- Instituto de Pesquisa Pelé Pequeno Príncipe, Faculdades Pequeno Príncipe, Curitiba, PR, Brazil; Programa de Pós-graduação em Biotecnologia Aplicada à Saúde da Criança e do Adolescente, Faculdades Pequeno Príncipe, Curitiba, PR, Brazil
| | - Bruna Barbosa da Luz
- Departamento de Farmacologia, Universidade Federal do Paraná, Curitiba, PR, Brazil
| | - Claudia Rita Corso
- Instituto de Pesquisa Pelé Pequeno Príncipe, Faculdades Pequeno Príncipe, Curitiba, PR, Brazil; Programa de Pós-graduação em Biotecnologia Aplicada à Saúde da Criança e do Adolescente, Faculdades Pequeno Príncipe, Curitiba, PR, Brazil
| | - Elizabeth Soares Fernandes
- Instituto de Pesquisa Pelé Pequeno Príncipe, Faculdades Pequeno Príncipe, Curitiba, PR, Brazil; Programa de Pós-graduação em Biotecnologia Aplicada à Saúde da Criança e do Adolescente, Faculdades Pequeno Príncipe, Curitiba, PR, Brazil
| | - Daniele Maria Ferreira
- Instituto de Pesquisa Pelé Pequeno Príncipe, Faculdades Pequeno Príncipe, Curitiba, PR, Brazil; Programa de Pós-graduação em Biotecnologia Aplicada à Saúde da Criança e do Adolescente, Faculdades Pequeno Príncipe, Curitiba, PR, Brazil.
| |
Collapse
|
22
|
Śledzińska A, Śledzińska P, Bebyn M, Komisarek O. Title: Chemotherapy-Induced Oral Complications and Prophylaxis Strategies. Cancer Invest 2023:1-24. [PMID: 36892292 DOI: 10.1080/07357907.2023.2188558] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/10/2023]
Abstract
Cancer is currently a significant therapeutic challenge and is frequently connected with numerous adverse effects. Despite many improvements in chemotherapy, oral complications are common, leading to poor quality of life and chemotherapeutic dose reduction, which impair survival. This review summarizes the most common dental complications in patients receiving chemotherapy. We mainly focus on oral mucositis as it is a major cause of dose-limiting toxicity. Furthermore, oral candidiasis, viral infections, and xerostomia will be discussed. Conclusions: preventing complications is significantly more important than treating them. All patients beginning systemic anticancer treatment should undergo a thorough oral examination and get appropriate prophylaxis.
Collapse
Affiliation(s)
- Aleksandra Śledzińska
- Faculty of Medicine, Poznan University of Medical Sciences, Fredry 10, 61-701 Poznań, Poland
| | - Paulina Śledzińska
- Molecular Oncology and Genetics Department, Innovative Medical Forum, The F. Lukaszczyk Oncology Center, 85-796 Bydgoszcz, Poland
| | - Marek Bebyn
- Molecular Oncology and Genetics Department, Innovative Medical Forum, The F. Lukaszczyk Oncology Center, 85-796 Bydgoszcz, Poland
| | - Oskar Komisarek
- Department of Maxillofacial Orthopedics and Orthodontics, Fredry 10, 61-701 Poznań University of Medical Sciences, Poznan, Poland
| |
Collapse
|
23
|
Singh K, Pituch K, Zhu Q, Gu H, Ernst B, Tofthagen C, Brewer M, Kober KM, Cooper BA, Paul SM, Conley YP, Hammer M, Levine JD, Miaskowski C. Distinct Nausea Profiles Are Associated With Gastrointestinal Symptoms in Oncology Patients Receiving Chemotherapy. Cancer Nurs 2023; 46:92-102. [PMID: 35671438 PMCID: PMC9437145 DOI: 10.1097/ncc.0000000000001076] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Unrelieved chemotherapy-induced nausea (CIN) occurs 48% of patients undergoing chemotherapy and is one of the most debilitating symptoms that patients report. OBJECTIVE The aims of this study were to identify subgroups of patients with distinct CIN profiles and determine how these subgroups differed on demographic and clinical characteristics; severity, frequency, and distress of CIN; and the co-occurrence of common gastrointestinal symptoms. METHODS Patients (n = 1343) completed demographic questionnaire and Memorial Symptom Assessment Scale 6 times over 2 cycles of chemotherapy. Latent class analysis was used to identify subgroups of patients with distinct CIN profiles. Differences among these subgroups were evaluated using parametric and nonparametric statistics. RESULTS Four distinct CIN profiles were identified: none (40.8%), increasing-decreasing (21.5%), decreasing (8.9%), and high (28.8%). Compared with the none class, patients in the high class were younger, had a lower annual household income, had child care responsibilities, had a lower Karnofsky Performance Status score and a higher Self-administered Comorbidity Questionnaire score, and were more likely to have received chemotherapy on a 14-day cycle and a highly emetogenic chemotherapy regimen. In addition, patients in the high class reported high occurrence rates for dry mouth, feeling bloated, diarrhea, lack of appetite, abdominal cramps, difficulty swallowing, mouth sores, weight loss, and change in the way food tastes. CONCLUSIONS That 60% of the patients reported moderate to high CIN occurrence rates confirms that this unrelieved symptom is a significant clinical problem. IMPLICATIONS FOR PRACTICE Nurses need to evaluate patients' level of adherence to their antiemetic regimen and make appropriate referrals for physical therapy, psychological services, and dietary counseling.
Collapse
Affiliation(s)
- Komal Singh
- Author Affiliations: Edson College of Nursing and Health Innovation, Arizona State University, Phoenix (Drs Singh, Pituch, and Brewer); Biodesign Center for Fundamental and Applied Microbiomics, Arizona State University, Tempe (Dr Zhu); Department of Environmental Health Sciences, Florida International University, Port Saint Lucie (Dr Gu); Cancer Center, Mayo Clinic, Phoenix, Arizona (Drs Singh and Ernst); Department of Nursing, Mayo Clinic, Jacksonville, Florida (Dr Tofthagen), HonorHealth Research Institute, Scottsdale, Arizona (Dr Brewer); School of Nursing, University of California, San Francisco (Drs Kober, Cooper, Paul, and Miaskowski); School of Nursing, University of Pittsburgh, Pennsylvania (Dr Conley); The Phyllis F. Cantor Center for Research in Nursing and Patient Care Services, Dana Farber Cancer Institute, Boston, Massachusetts (Dr Hammer); School of Medicine, University of California, San Francisco (Drs Levine and Miaskowski)
| | | | | | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
24
|
Subramaniam CB, Wardill HR, Davies MR, Heng V, Gladman MA, Bowen JM. 5-Fluorouracil Induces an Acute Reduction in Neurogenesis and Persistent Neuroinflammation in a Mouse Model of the Neuropsychological Complications of Chemotherapy. Mol Neurobiol 2023; 60:1408-1424. [PMID: 36449255 DOI: 10.1007/s12035-022-03136-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2022] [Accepted: 11/12/2022] [Indexed: 12/05/2022]
Abstract
The neuropsychological symptoms associated with chemotherapy treatment remain a major challenge with their prevention hampered by insufficient understanding of pathophysiology. While long-term neuroimmune changes have been identified as a hallmark feature shared by neurological symptoms, the exact timeline of mechanistic events preceding neuroinflammation, and the relationship between the glial cells driving this neuroinflammatory response, remain unclear. We therefore aimed to longitudinally characterize the neuroimmunological changes following systemic 5-fluorouracil (5-FU) treatment to gain insight into the timeline of events preceding the well-documented chronic neuroinflammation seen following chemotherapy. Eighteen female C57Bl/6 mice received a single intraperitoneal dose of 5-FU and groups were killed at days 1 and 2 (acute timepoint), days 4 and 8 (subacute timepoint), and days 16 and 32 (chronic timepoint). A further six mice were administered with vehicle control with tissues collected from three mice on day 1 and day 32 of the study. The expression of key genes of interest, BCL2, BDNF, TIMP1, MMP-9, MMP-2, TNFα, IL-1β, and IL-6R were assessed using real time polymerase chain reaction. Levels of neurogenesis were determined through immunofluorescent staining of doublecortin (DCX). The density of microglia and astrocytes were assessed using immunofluorescence staining of Iba1 and GFAP respectively. 5-FU treatment caused significant decreases to DCX staining at acute timepoints (p = 0.0030) which was positively correlated with BCL2 expression levels. An increase to microglial density was observed in the prefrontal cortex (p = 0.0256), CA3 region (p = 0.0283), and dentate gyrus (p = 0.0052) of the hippocampus at acute timepoints. 5-FU caused increases to astrocyte density, across multiple brains regions, at subacute and chronic timepoints which were positively correlated with TNFα, TIMP-1, MMP-2, and IL-6R expression. This study has identified acute objective neuroinflammatory changes suggesting that the role of early intervention should be explored to prevent the development of neuropsychological deficits in the longer-term following chemotherapy.
Collapse
Affiliation(s)
- Courtney B Subramaniam
- School of Biomedicine, Adelaide Medical School, University of Adelaide, Adelaide, South Australia, Australia.
- Supportive Oncology Research Group, Precision Medicine (Cancer), South Australian Health and Medical Research Institute (SAHMRI), University of Adelaide, Adelaide, South Australia, Australia.
| | - Hannah R Wardill
- Supportive Oncology Research Group, Precision Medicine (Cancer), South Australian Health and Medical Research Institute (SAHMRI), University of Adelaide, Adelaide, South Australia, Australia
| | - Maya R Davies
- Supportive Oncology Research Group, Precision Medicine (Cancer), South Australian Health and Medical Research Institute (SAHMRI), University of Adelaide, Adelaide, South Australia, Australia
| | - Vivien Heng
- School of Biomedicine, Adelaide Medical School, University of Adelaide, Adelaide, South Australia, Australia
| | - Marc A Gladman
- School of Biomedicine, Adelaide Medical School, University of Adelaide, Adelaide, South Australia, Australia
| | - Joanne M Bowen
- School of Biomedicine, Adelaide Medical School, University of Adelaide, Adelaide, South Australia, Australia
| |
Collapse
|
25
|
Jakubauskas M, Jakubauskiene L, Leber B, Horvath A, Strupas K, Stiegler P, Schemmer P. Probiotic Supplementation Attenuates Chemotherapy-Induced Intestinal Mucositis in an Experimental Colorectal Cancer Liver Metastasis Rat Model. Nutrients 2023; 15:nu15051117. [PMID: 36904117 PMCID: PMC10005486 DOI: 10.3390/nu15051117] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2023] [Revised: 02/14/2023] [Accepted: 02/20/2023] [Indexed: 02/25/2023] Open
Abstract
The use of chemotherapeutic agents is of paramount importance when treating colorectal cancer (CRC). Unfortunately, one of the most frequent chemotherapy (CTx) side effects is intestinal mucositis (IM), which may present with several clinical symptoms such as nausea, bloating, vomiting, pain, and diarrhea and even can result in life-threatening complications. There is a focused scientific effort towards developing new therapies to prevent and treat IM. The aim of this study was to assess the outcomes of probiotic supplementation on CTx-induced IM in a CRC liver metastasis rat model. Six-week-old male Wistar rats received either a multispecies probiotic or placebo mixture. On the 28th experiment day, rats received FOLFOX CTx, and afterwards, the severity of diarrhea was evaluated twice daily. Stool samples were collected for further microbiome analysis. Additionally, immunohistochemical stainings of ileum and colon samples with were performed with MPO, Ki67, and Caspase-3 antibodies. Probiotic supplementation alleviates the severity and length of CTx-induced diarrhea. Additionally, probiotics significantly reduced FOLFOX-induced weight and blood albumin loss. Furthermore, probiotic supplementation mitigated CTx-induced histological changes in the gut and promoted intestinal cell regeneration. This study shows that multispecies probiotic supplementation attenuates FOLFOX-induced IM symptoms by inhibiting apoptosis and promoting intestinal cell proliferation.
Collapse
Affiliation(s)
- Matas Jakubauskas
- General, Visceral and Transplant Surgery, Department of Surgery, Medical University of Graz, Auenbruggerplatz 2, 8036 Graz, Austria
- Faculty of Medicine, Vilnius University, M. K. Ciurlionio str. 21, 03101 Vilnius, Lithuania
| | - Lina Jakubauskiene
- General, Visceral and Transplant Surgery, Department of Surgery, Medical University of Graz, Auenbruggerplatz 2, 8036 Graz, Austria
- Faculty of Medicine, Vilnius University, M. K. Ciurlionio str. 21, 03101 Vilnius, Lithuania
| | - Bettina Leber
- General, Visceral and Transplant Surgery, Department of Surgery, Medical University of Graz, Auenbruggerplatz 2, 8036 Graz, Austria
| | - Angela Horvath
- Division of Gastroenterology and Hepatology, Medical University of Graz, Auenbruggerplatz 2, 8036 Graz, Austria
| | - Kestutis Strupas
- Faculty of Medicine, Vilnius University, M. K. Ciurlionio str. 21, 03101 Vilnius, Lithuania
| | - Philipp Stiegler
- General, Visceral and Transplant Surgery, Department of Surgery, Medical University of Graz, Auenbruggerplatz 2, 8036 Graz, Austria
- Correspondence: ; Tel.: +43-316-385-84094
| | - Peter Schemmer
- General, Visceral and Transplant Surgery, Department of Surgery, Medical University of Graz, Auenbruggerplatz 2, 8036 Graz, Austria
| |
Collapse
|
26
|
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.
Collapse
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.
| |
Collapse
|
27
|
Muscaritoli M, Bar-Sela G, Battisti NML, Belev B, Contreras-Martínez J, Cortesi E, de Brito-Ashurst I, Prado CM, Ravasco P, Yalcin S. Oncology-Led Early Identification of Nutritional Risk: A Pragmatic, Evidence-Based Protocol (PRONTO). Cancers (Basel) 2023; 15:cancers15020380. [PMID: 36672329 PMCID: PMC9856655 DOI: 10.3390/cancers15020380] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2022] [Revised: 12/22/2022] [Accepted: 12/30/2022] [Indexed: 01/11/2023] Open
Abstract
Nutritional issues, including malnutrition, low muscle mass, sarcopenia (i.e., low muscle mass and strength), and cachexia (i.e., weight loss characterized by a continuous decline in skeletal muscle mass, with or without fat loss), are commonly experienced by patients with cancer at all stages of disease. Cancer cachexia may be associated with poor nutritional status and can compromise a patient's ability to tolerate antineoplastic therapy, increase the likelihood of post-surgical complications, and impact long-term outcomes including survival, quality of life, and function. One of the primary nutritional problems these patients experience is malnutrition, of which muscle depletion represents a clinically relevant feature. There have been recent calls for nutritional screening, assessment, treatment, and monitoring as a consistent component of care for all patients diagnosed with cancer. To achieve this, there is a need for a standardized approach to enable oncologists to identify patients commencing and undergoing antineoplastic therapy who are or who may be at risk of malnutrition and/or muscle depletion. This approach should not replace existing tools used in the dietitian's role, but rather give the oncologist a simple nutritional protocol for optimization of the patient care pathway where this is needed. Given the considerable time constraints in day-to-day oncology practice, any such approach must be simple and quick to implement so that oncologists can flag individual patients for further evaluation and follow-up with appropriate members of the multidisciplinary care team. To enable the rapid and routine identification of patients with or at risk of malnutrition and/or muscle depletion, an expert panel of nutrition specialists and practicing oncologists developed the PROtocol for NuTritional risk in Oncology (PRONTO). The protocol enables the rapid identification of patients with or at risk of malnutrition and/or muscle depletion and provides guidance on next steps. The protocol is adaptable to multiple settings and countries, which makes implementation feasible by oncologists and may optimize patient outcomes. We advise the use of this protocol in countries/clinical scenarios where a specialized approach to nutrition assessment and care is not available.
Collapse
Affiliation(s)
- Maurizio Muscaritoli
- Department of Translational and Precision Medicine, Sapienza University of Rome, 00185 Rome, Italy
- Correspondence:
| | - Gil Bar-Sela
- Oncology Department, Emek Medical Center, Afula 1834111, Israel
| | - Nicolo Matteo Luca Battisti
- The Royal Marsden NHS Foundation Trust, London SW3 6JJ, UK
- Breast Cancer Research Division, The Institute of Cancer Research, London SW3 6JJ, UK
| | - Borislav Belev
- Clinical Hospital Center Zagreb, School of Medicine, University of Zagreb, 10000 Zagreb, Croatia
| | | | - Enrico Cortesi
- Department of Radiological, Oncological and Pathological Sciences, Sapienza University of Rome, 00185 Rome, Italy
| | | | - Carla M. Prado
- Department of Agricultural, Food and Nutritional Science, University of Alberta, Edmonton, AB T6G 2R3, Canada
| | - Paula Ravasco
- Faculty of Medicine and Centre for Interdisciplinary Research in Health (CIIS-UCP), Universidade Católica Portuguesa, 1649-023 Lisbon, Portugal
- Centre for Interdisciplinary Research Egas Moniz (CiiEM), Instituto Universitário Egas Moniz, 2829-511 Almada, Portugal
| | - Suayib Yalcin
- Department of Medical Oncology, Institute of Cancer, Hacettepe University, Ankara 06800, Turkey
| |
Collapse
|
28
|
Märtson AG, da Silva Ferreira AR, Veringa A, Liu L, Wardill HR, Junier LAT, van der Werf TS, Harmsen HJM, Sturkenboom MGG, Span LF, Tissing WJE, Alffenaar JWC. Exposure of anti-infective drugs and the dynamic changes of the gut microbiota during gastrointestinal mucositis in autologous stem cell transplant patients: a pilot study. Ann Hematol 2023; 102:421-427. [PMID: 36648505 PMCID: PMC9844184 DOI: 10.1007/s00277-023-05091-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2022] [Accepted: 01/01/2023] [Indexed: 01/18/2023]
Abstract
Gastrointestinal mucositis could potentially compromise drug absorption due to functional loss of mucosa and other pathophysiological changes in the gastrointestinal microenvironment. Little is known about this effect on commonly used anti-infectives. This study aimed to explore the association between different stages of gastrointestinal mucositis, drug exposure, and gut microbiota. A prospective, observational pilot study was performed in HSCT patients aged ≥ 18 years receiving anti-infectives orally. Left-over blood samples and fecal swabs were collected from routine clinical care until 14 days after HSCT to analyze drug and citrulline concentrations and to determine the composition of the gut microbiota. 21 patients with a median age of 58 (interquartile range 54-64) years were included with 252 citrulline, 155 ciprofloxacin, 139 fluconazole, and 76 acyclovir concentrations and 48 fecal swabs obtained. Severe gastrointestinal mucositis was observed in all patients. Due to limited data correlation analysis was not done for valacyclovir and fluconazole, however we did observe a weak correlation between ciprofloxacin and citrulline concentrations. This could suggest that underexposure of ciprofloxacin can occur during severe mucositis. A follow-up study using frequent sampling rather than the use of left-over would be required to investigate the relationship between gastrointestinal mucositis, drug exposure, and gut microbiome.
Collapse
Affiliation(s)
- Anne-Grete Märtson
- Department of Clinical Pharmacy and Pharmacology, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Ana Rita da Silva Ferreira
- Department of Medical Microbiology and Infection Prevention, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Anette Veringa
- Department of Clinical Pharmacy and Pharmacology, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Lei Liu
- Department of Medical Microbiology and Infection Prevention, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Hannah R. Wardill
- Adelaide Medical School, The University of Adelaide, Adelaide, Australia ,Precision Medicine (Cancer), South Australian Health and Medical Research Institute, Adelaide, Australia
| | - Lenneke A. T. Junier
- Department of Clinical Pharmacy and Pharmacology, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Tjip S. van der Werf
- Department of Pulmonary Diseases and Tuberculosis, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands ,Department of Internal Medicine, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Hermie J. M. Harmsen
- Department of Medical Microbiology and Infection Prevention, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Marieke G. G. Sturkenboom
- Department of Clinical Pharmacy and Pharmacology, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Lambert F. Span
- Department of Hematology, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Wim J. E. Tissing
- Department of Pediatrics (Oncology and Hematology), University of Groningen, University Medical Center Groningen, Groningen, The Netherlands ,Princess Maxima Centre for Pediatric Oncology, Utrecht, The Netherlands
| | - Jan-Willem C. Alffenaar
- Department of Clinical Pharmacy and Pharmacology, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands ,School of Pharmacy, Faculty of Medicine and Health, University of Sydney, Sydney, NSW Australia ,Westmead Hospital, Sydney, NSW Australia ,Marie Bashir Institute of Infectious Diseases and Biosecurity, University of Sydney, Sydney, NSW Australia
| |
Collapse
|
29
|
Dalby S, Skallerup S, Baun C, Christensen LG, Rathe M, Palner M, Husby S, Moeller JB. PET/CT imaging detects intestinal inflammation in a mouse model of doxorubicin-induced mucositis. Front Oncol 2022; 12:1061804. [PMID: 36591502 PMCID: PMC9798215 DOI: 10.3389/fonc.2022.1061804] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2022] [Accepted: 12/01/2022] [Indexed: 12/23/2022] Open
Abstract
Introduction A severe side effect of cancer chemotherapy is the development of gastrointestinal mucositis, characterised by mucosal inflammation. We investigated if 2-deoxy-2-[18F] fluoro-D-glucose positron emission tomography combined with computed tomography (2-[18F]FDG-PET/CT) could visualise gastrointestinal mucositis in mice treated with the chemotherapeutic agent doxorubicin. Methods In this study, gastrointestinal inflammation was longitudinally evaluated by 2-[18F]FDG-PET/CT scans before and 1, 3, 6, and 10 days after treatment with doxorubicin. Doxorubicin-treated mice were compared to saline-treated littermates using the abdominal standard uptake value of 2-[18F]FDG corrected for body weight (SUVBW). Results Abdominal SUVBW was significantly increased on day 1 (p < 0.0001), day 3 (p < 0.0001), and day 6 (p < 0.05) in the doxorubicin-treated group compared to controls. Abdominal SUVBW returned to baseline levels on day 10. In the doxorubicin group, the largest weight loss was observed on day 3 (control vs doxorubicin, mean percent of baseline weight: (98.5 ± 3.2% vs 87.9 ± 4.6%, p < 0.0001). Moreover, in the doxorubicin-treated group, villus lengths were decreased by 23-28% on days 1 and 3 in the small intestine (p < 0.05), and jejunal levels of tumour necrosis factor and interleukin-1β were significantly increased on day 3 (p < 0.05). Discussion Together, these findings indicate that sequential 2-[18F]FDG-PET/CT scans can objectively quantify and evaluate the development and resolution of intestinal inflammation over time in a mouse model of doxorubicin-induced mucositis.
Collapse
Affiliation(s)
- Sina Dalby
- Hans Christian Andersen Children’s Hospital, Odense University Hospital, Odense, Denmark
- Department of Clinical Research, University of Southern Denmark, Odense, Denmark
| | - Sofie Skallerup
- Department of Cancer and Inflammation Research, Department of Molecular Medicine, University of Southern Denmark, Odense, Denmark
| | - Christina Baun
- Department of Nuclear Medicine, Odense University Hospital, Odense, Denmark
| | | | - Mathias Rathe
- Hans Christian Andersen Children’s Hospital, Odense University Hospital, Odense, Denmark
- Department of Clinical Research, University of Southern Denmark, Odense, Denmark
| | - Mikael Palner
- Department of Clinical Research, University of Southern Denmark, Odense, Denmark
- Department of Nuclear Medicine, Odense University Hospital, Odense, Denmark
| | - Steffen Husby
- Hans Christian Andersen Children’s Hospital, Odense University Hospital, Odense, Denmark
- Department of Clinical Research, University of Southern Denmark, Odense, Denmark
| | - Jesper Bonnet Moeller
- Department of Cancer and Inflammation Research, Department of Molecular Medicine, University of Southern Denmark, Odense, Denmark
- Danish Institute for Advanced Study, University of Southern Denmark, Odense, Denmark
| |
Collapse
|
30
|
Linder LA, Gerdy C, Jo Y, Stark C, Wilson A. Changes in Central Line–Associated Bloodstream Infection (CLABSI) Rates Following Implementation of Levofloxacin Prophylaxis for Children and Adolescents With High-Risk Leukemia. JOURNAL OF PEDIATRIC HEMATOLOGY/ONCOLOGY NURSING 2022; 40:69-81. [PMID: 36358024 DOI: 10.1177/27527530221122683] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
Background: Despite initiatives to reduce central line–associated bloodstream infection (CLABSI), children and adolescents with hematologic malignancies, as well as those with relapsed disease, remain at the greatest risk for infection. This single-institution project evaluated changes in CLABSI rates following implementation of antibacterial prophylaxis with levofloxacin for patients with high-risk hematologic malignancies. Methods: Positive blood culture events meeting National Health Safety Network surveillance criteria to be classified as CLABSIs from January 1, 2006, to December 31, 2019, were included. Data were organized into four time periods for comparison based on implementation of CLABSI-reduction interventions. Conditional Poisson regression models were used to evaluate the effect of time (intervention period) on CLABSI rates with post hoc Tukey pairwise comparisons between each of the four time periods. Results: From 2006 and 2019, 227 patients experienced 310 CLABSIs. Clinically important decreases in CLABSI rates from baseline (4.84 per 1,000 line days) occurred with implementation of Children's Hospital Association (CHA) bundles (3.29 per 1,000 line days); however, this difference was not significant ( p = .16). CLABSI rates decreased from baseline with the addition of formalized supportive cares (2.66 per 1,000 line days; incidence rate ratio [IRR] = 0.60; p < .01), and with the use of antibacterial prophylaxis (1.66 per 1,000 line days; IRR = 0.35; p < .01). Post hoc comparisons indicated decreased CLABSI rates with the use of antibacterial prophylaxis compared with CHA bundles alone (IRR = 0.49; p = .011) and CHA bundles plus formalized supportive cares (IRR = 0.58; p = .046). Discussion: Results demonstrate sustained success using a practice-based evidence approach to guide CLABSI-reduction interventions. Follow-up research, applying machine learning algorithms, may identify additional risk factors and inform future interventions.
Collapse
Affiliation(s)
- Lauri A. Linder
- University of Utah College of Nursing, Salt Lake City, UT, USA
- Primary Children’s Hospital, Center for Cancer and Blood Disorders, Salt Lake City, UT, USA
| | - Cheryl Gerdy
- Primary Children’s Hospital, Center for Cancer and Blood Disorders, Salt Lake City, UT, USA
| | - Yeonjung Jo
- Huntsman Cancer Institute, Salt Lake City, UT, USA
- University of Utah School of Medicine, Population Health Sciences, Salt Lake City, UT, USA
| | - Crystal Stark
- Primary Children’s Hospital, Center for Cancer and Blood Disorders, Salt Lake City, UT, USA
| | - Andrew Wilson
- Parexel, Durham, NC, USA
- University of Utah Department of Family and Preventive Medicine, Salt Lake City, UT, USA
| |
Collapse
|
31
|
Semerci R, Kocaaslan EN. Effect of chewing gum on the management of chemotherapy-induced oral mucositis in children: Systematic review of experimental studies. Eur J Cancer Care (Engl) 2022; 31:e13727. [PMID: 36239087 DOI: 10.1111/ecc.13727] [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: 06/11/2022] [Revised: 09/15/2022] [Accepted: 09/27/2022] [Indexed: 11/27/2022]
Abstract
OBJECTIVE It was aimed to systematically synthesise the available literature on examining the effect of chewing gum in the management/reduction of chemotherapy-induced oral mucositis in children. METHODS The PRISMA was followed for the systematic review. All published studies obtained from the relevant databases were examined while the research question and inclusion and exclusion criteria were considered. The Joanna Briggs Institute (JBI) critical appraisal tools were used to evaluate the quality of the studies. RESULTS A total of five studies met the inclusion criteria: three randomised controlled trials (RCT) and two quasi-experimental studies with a total of 461 paediatric oncology patients were included. Heterogeneity was found across all studies regarding the application of gum chewing and regarding the effectiveness of gum chewing. Two RTCs and one quasi-experimental study reported that gum chewing is not effective to reduce severe oral mucositis, but effective to reduce moderate and mild oral mucositis, and one RTC reported that gum chewing is not effective to reduce oral mucositis. CONCLUSION Experimental studies particularly randomised controlled trials using rigorous designs, consistent outcome measures, and larger sample sizes are required to determine the efficacy of chewing gum in reducing chemotherapy-induced oral mucositis in paediatric oncology patients. Study was registered in PROSPERO and number was CRD42022328916.
Collapse
Affiliation(s)
- Remziye Semerci
- Department of Pediatric Nursing, School of Nursing, Koç University, İstanbul, Turkey
| | - Esra Nur Kocaaslan
- Department of Pediatric Nursing, Trakya University Faculty of Health Sciences, Edirne, Turkey
| |
Collapse
|
32
|
Mitigating acute chemotherapy-associated adverse events in patients with cancer. Nat Rev Clin Oncol 2022; 19:681-697. [PMID: 36221000 DOI: 10.1038/s41571-022-00685-3] [Citation(s) in RCA: 24] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/07/2022] [Indexed: 11/08/2022]
Abstract
Despite the enthusiasm surrounding novel targeted agents and immunotherapies, chemotherapy remains the mainstay treatment for most human malignancies, either alone or in combination. Yet, the burden of chemotherapy-associated adverse events (CAAEs) remains high and, importantly, is associated with considerable morbidity, mortality and costs that affect patients across multiple dimensions, including physical, emotional and social functioning. CAAEs can directly affect patient outcomes and indirectly increase the risk of cancer recurrence by compromising treatment intensity and continuity. Systematic efforts to identify and critically summarize the evidence on management approaches for CAAEs remain limited. Herein, we review the most common acute CAAEs having a major effect on survival, quality of life, function and/or continuation of optimal therapy. We focus on selected acute toxicities that occur during treatment, summarizing their underlying pathophysiology, multifactorial aetiologies, evidenced-based treatments, prevention strategies and management recommendations. We also summarize the available evidence on risk factors, validated risk assessment tools and other efforts to optimize symptom control in patients most likely to benefit in order to personalize the prevention and treatment of acute CAAEs. Finally, we discuss innovative symptom monitoring and supportive care interventions that are under development to further improve the outcomes of patients with cancer.
Collapse
|
33
|
Wardill HR, Sonis ST, Blijlevens NMA. Using real world data to advance the provision of supportive cancer care: mucositis as a case study. Curr Opin Support Palliat Care 2022; 16:161-167. [PMID: 35929562 DOI: 10.1097/spc.0000000000000600] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
PURPOSE OF REVIEW For decades, clinical decision making and practice has been largely informed by data generated through randomized clinical trials (RCTs). By design, RCTs are highly restricted in both scope and scale, resulting in narrow indications and iterative advances in clinical practice. With the transition to electronic health records, there are now endless opportunities to utilize these 'real world' data (RWD) to make more substantive advances in our understanding that are, by nature, more applicable to reality. This review discusses the current paradigm of using big data to advance and inform the provision of supportive cancer care, using mucositis as a case study. RECENT FINDINGS Global efforts to synthesize RWD in cancer have almost exclusively focused on tumor classification and treatment efficacy, leveraging on routine tumor pathology and binary response outcomes. In contrast, clinical notes and billing codes are not as applicable to treatment side effects which require integration of both clinical and biological data, as well as patient-reported outcomes. SUMMARY Cancer treatment-induced toxicities are heterogeneous and complex, and as such, the use of RWD to better understand their etiology and interaction is challenging. Multidisciplinary cooperation and leadership are needed to improve data collection and governance to ensure the right data is accessible and reliable.
Collapse
Affiliation(s)
- Hannah R Wardill
- School of Biomedicine, The Faculty of health and Medical Sciences, The University of Adelaide
- Supportive Oncology Research Group, Precision Medicine (Cancer), The South Australian Health and Medical Research Institute, Adelaide, Australia
| | - Steve T Sonis
- Division of Oral Medicine, Brigham and Women's Hospital and the Dana-Farber Cancer Institute; Department of Oral Medicine, Infection and Immunity, Harvard School of Dental Medicine, Boston
- Primary Endpoint Solutions, Waltham, Massachusetts, USA
| | - Nicole M A Blijlevens
- Department of Hematology
- Radboud Institute for Health Sciences, Radboud University Medical Center, Nijmegen, The Netherlands
| |
Collapse
|
34
|
Robijns J, Nair RG, Lodewijckx J, Arany P, Barasch A, Bjordal JM, Bossi P, Chilles A, Corby PM, Epstein JB, Elad S, Fekrazad R, Fregnani ER, Genot MT, Ibarra AMC, Hamblin MR, Heiskanen V, Hu K, Klastersky J, Lalla R, Latifian S, Maiya A, Mebis J, Migliorati CA, Milstein DMJ, Murphy B, Raber-Durlacher JE, Roseboom HJ, Sonis S, Treister N, Zadik Y, Bensadoun RJ. Photobiomodulation therapy in management of cancer therapy-induced side effects: WALT position paper 2022. Front Oncol 2022; 12:927685. [PMID: 36110957 PMCID: PMC9468822 DOI: 10.3389/fonc.2022.927685] [Citation(s) in RCA: 31] [Impact Index Per Article: 15.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2022] [Accepted: 07/28/2022] [Indexed: 11/13/2022] Open
Abstract
DisclaimerThis article is based on recommendations from the 12th WALT Congress, Nice, October 3-6, 2018, and a follow-up review of the existing data and the clinical observations of an international multidisciplinary panel of clinicians and researchers with expertise in the area of supportive care in cancer and/or PBM clinical application and dosimetry. This article is informational in nature. As with all clinical materials, this paper should be used with a clear understanding that continued research and practice could result in new insights and recommendations. The review reflects the collective opinion and, as such, does not necessarily represent the opinion of any individual author. In no event shall the authors be liable for any decision made or action taken in reliance on the proposed protocols.ObjectiveThis position paper reviews the potential prophylactic and therapeutic effects of photobiomodulation (PBM) on side effects of cancer therapy, including chemotherapy (CT), radiation therapy (RT), and hematopoietic stem cell transplantation (HSCT).BackgroundThere is a considerable body of evidence supporting the efficacy of PBM for preventing oral mucositis (OM) in patients undergoing RT for head and neck cancer (HNC), CT, or HSCT. This could enhance patients’ quality of life, adherence to the prescribed cancer therapy, and treatment outcomes while reducing the cost of cancer care.MethodsA literature review on PBM effectiveness and dosimetry considerations for managing certain complications of cancer therapy were conducted. A systematic review was conducted when numerous randomized controlled trials were available. Results were presented and discussed at an international consensus meeting at the World Association of photobiomoduLation Therapy (WALT) meeting in 2018 that included world expert oncologists, radiation oncologists, oral oncologists, and oral medicine professionals, physicists, engineers, and oncology researchers. The potential mechanism of action of PBM and evidence of PBM efficacy through reported outcomes for individual indications were assessed.ResultsThere is a large body of evidence demonstrating the efficacy of PBM for preventing OM in certain cancer patient populations, as recently outlined by the Multinational Association for Supportive Care in Cancer/International Society of Oral Oncology (MASCC/ISOO). Building on these, the WALT group outlines evidence and prescribed PBM treatment parameters for prophylactic and therapeutic use in supportive care for radiodermatitis, dysphagia, xerostomia, dysgeusia, trismus, mucosal and bone necrosis, lymphedema, hand-foot syndrome, alopecia, oral and dermatologic chronic graft-versus-host disease, voice/speech alterations, peripheral neuropathy, and late fibrosis amongst cancer survivors.ConclusionsThere is robust evidence for using PBM to prevent and treat a broad range of complications in cancer care. Specific clinical practice guidelines or evidence-based expert consensus recommendations are provided. These recommendations are aimed at improving the clinical utilization of PBM therapy in supportive cancer care and promoting research in this field. It is anticipated these guidelines will be revised periodically.
Collapse
Affiliation(s)
- Jolien Robijns
- UHasselt, Faculty of Medicine and Life Sciences, Diepenbeek, Belgium
| | - Raj G. Nair
- Oral Medicine, Oral Pathology and Oral Oncology, Griffith University, Department of Haematology and Oncology, Gold Coast University Hospital, Gold Coast, QL, Australia
| | - Joy Lodewijckx
- UHasselt, Faculty of Medicine and Life Sciences, Diepenbeek, Belgium
| | - Praveen Arany
- School of Dental Medicine, Oral Biology and Biomedical Engineering, University at Buffalo, Buffalo, NY, United States
| | - Andrei Barasch
- Harvard School of Dental Medicine, Division of Oral Medicine and Dentistry, Boston, MA, United States
| | - Jan M. Bjordal
- Physiotherapy Research Group, IGS, University of Bergen, Bergen, Norway
| | - Paolo Bossi
- Department of Medical and Surgical Specialties, Radiological Sciences and Public Health, University of Brescia, Brescia, Italy
| | - Anne Chilles
- Radiotherapy Department, Institut Curie, Paris, France
| | - Patricia M. Corby
- New York University College of Dentistry, Bluestone Center for Clinical Research, New York, NY, United States
| | - Joel B. Epstein
- City of Hope Duarte, CA and Cedars-Sinai Health System, Los Angeles, CA, United States
| | - Sharon Elad
- Eastman Institute for Oral Health, University of Rochester Medical Center, Rochester, NY, United States
| | - Reza Fekrazad
- Department of Periodontology, Dental Faculty – Radiation Sciences Research Center, Laser Research Center in Medical Sciences, AJA University of Medical Sciences, Tehran, Iran
| | | | - Marie-Thérèse Genot
- Laser Therapy Unit, Institut Jules Bordet, Centre des Tumeurs de l’Université Libre de Bruxelles, Brussels, Belgium
| | - Ana M. C. Ibarra
- Postgraduate Program on Biophotonics Applied to Health Sciences, Nove de Julho University, São Paulo, Brazil
| | - Michael R. Hamblin
- Wellman Center for Photomedicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA, United States
| | - Vladimir Heiskanen
- Oral and Maxillofacial Diseases, University of Helsinki, Helsinki, Finland
| | - Ken Hu
- Department of Radiation Oncology, NYU Langone Health, New York, NY, United States
| | | | - Rajesh Lalla
- Section of Oral Medicine, University of Connecticut School of Dental Medicine, Farmington, CT, United States
| | - Sofia Latifian
- Department of Medicine, Institut Jules Bordet, Universiteí Libre de Bruxelles, Brussels, Belgium
| | - Arun Maiya
- Manipal College of Health Professions, MAHE, Manipal, India
| | - Jeroen Mebis
- UHasselt, Faculty of Medicine and Life Sciences, Diepenbeek, Belgium
| | - Cesar A. Migliorati
- Department of Oral and Maxillofacial Diagnostic Sciences, University of Florida College of Dentistry, Gainesville, Florida, United States
| | - Dan M. J. Milstein
- Oral and Maxillofacial Surgery, Academic Medical Center, University of Amsterdam, Amsterdam, Netherlands
| | - Barbara Murphy
- Department of Oncology, Vanderbilt University Medical Center, Nashville, TN, United States
| | - Judith E. Raber-Durlacher
- Department of Oral and Maxillofacial Surgery, Amsterdam UMC, University of Amsterdam, Department of Oral Medicine, Academic Centre for Dentistry Amsterdam, University of Amsterdam and VU University, Amsterdam, Netherlands
| | - Hendrik J. Roseboom
- Department of Oral and Maxillofacial Surgery, Amsterdam UMC, University of Amsterdam, Department of Oral Medicine, Academic Centre for Dentistry Amsterdam, University of Amsterdam and VU University, Amsterdam, Netherlands
| | - Stephen Sonis
- Division of Oral Medicine and Dentistry, Brigham and Women’s Hospital; Department of Oral Medicine, Infection and Immunity, Harvard School of Dental Medicine; Division of Oral Medicine and Dentistry, Brigham and Women’s Hospital, Dana-Farber Cancer Institute, Boston, MA, United States
| | - Nathaniel Treister
- Division of Oral Medicine and Dentistry, Brigham and Women’s Hospital; Department of Oral Medicine, Infection and Immunity, Harvard School of Dental Medicine; Division of Oral Medicine and Dentistry, Brigham and Women’s Hospital, Dana-Farber Cancer Institute, Boston, MA, United States
| | - Yehuda Zadik
- Department of Military Medicine, Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel, and Department of Oral Medicine, Sedation and Maxillofacial Imaging, Hebrew University-Hadassah School of Dental Medicine, Jerusalem, Israel
| | - René-Jean Bensadoun
- Department of Radiation Oncology, Centre de Haute Energie, Nice, France
- *Correspondence: René-Jean Bensadoun,
| |
Collapse
|
35
|
Paraprobiotics and Postbiotics of Lactobacillus delbrueckii CIDCA 133 Mitigate 5-FU-Induced Intestinal Inflammation. Microorganisms 2022; 10:microorganisms10071418. [PMID: 35889136 PMCID: PMC9324481 DOI: 10.3390/microorganisms10071418] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2022] [Revised: 06/22/2022] [Accepted: 07/01/2022] [Indexed: 12/02/2022] Open
Abstract
Intestinal mucositis is a commonly reported side effect in oncology practice. Probiotics are considered an excellent alternative therapeutic approach to this debilitating condition; however, there are safety questions regarding the viable consumption of probiotics in clinical practice due to the risks of systemic infections, especially in immune-compromised patients. The use of heat-killed or cell-free supernatants derived from probiotic strains has been evaluated to minimize these adverse effects. Thus, this work evaluated the anti-inflammatory properties of paraprobiotics (heat-killed) and postbiotics (cell-free supernatant) of the probiotic Lactobacillus delbrueckii CIDCA 133 strain in a mouse model of 5-Fluorouracil drug-induced mucositis. Administration of paraprobiotics and postbiotics reduced the neutrophil cells infiltrating into the small intestinal mucosa and ameliorated the intestinal epithelium architecture damaged by 5-FU. These ameliorative effects were associated with a downregulation of inflammatory markers (Tlr2, Nfkb1, Il12, Il17a, Il1b, Tnf), and upregulation of immunoregulatory Il10 cytokine and the epithelial barrier markers Ocln, Cldn1, 2, 5, Hp and Muc2. Thus, heat-killed L. delbrueckii CIDCA 133 and supernatants derived from this strain were shown to be effective in reducing 5-FU-induced inflammatory damage, demonstrating them to be an alternative approach to the problems arising from the use of live beneficial microorganisms in clinical practice.
Collapse
|
36
|
Wardill HR, de Mooij CEM, Da Silva Ferreira AR, Havinga H, Harmsen HJM, van der Velden WJFM, van Groningen LFJ, Tissing WJE, Blijlevens NMA. Supporting the gastrointestinal microenvironment during high-dose chemotherapy and stem cell transplantation by inhibiting IL-1 signaling with anakinra. Sci Rep 2022; 12:6803. [PMID: 35546555 PMCID: PMC9095632 DOI: 10.1038/s41598-022-10700-3] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2021] [Accepted: 04/07/2022] [Indexed: 11/20/2022] Open
Abstract
High-dose chemotherapy causes intestinal inflammation and subsequent breakdown of the mucosal barrier, permitting translocation of enteric pathogens, clinically manifesting as fever. Antibiotics are mainstay for controlling these complications, however, they are increasingly recognized for their detrimental effects, including antimicrobial resistance and dysbiosis. Here, we show that mucosal barrier injury induced by the mucotoxic chemotherapeutic agent, high-dose melphalan (HDM), is characterized by hyper-active IL-1b/CXCL1/neutrophil signaling. Inhibition of this pathway with IL-1RA, anakinra, minimized the duration and intensity of mucosal barrier injury and accompanying clinical symptoms, including diarrhea, weight loss and fever in rats. 16S analysis of fecal microbiome demonstrated a more stable composition in rats receiving anakinra, with reduced pathogen expansion. In parallel, we report through Phase IIA investigation that anakinra is safe in stem cell transplant patients with multiple myeloma after HDM. Ramping-up anakinra (100–300 mg administered intravenously for 15 days) did not cause any adverse events or dose limiting toxicities, nor did it change time to neutrophil recovery. Our results reinforce that strengthening the mucosal barrier may be an effective supportive care strategy to mitigate local and systemic clinical consequences of HDM. We are now conducting a Phase IIB multicenter, placebo-controlled, double-blinded trial to assess clinical efficacy of anakinra (AFFECT-2). Trial registration: ClinicalTrials.gov identifier: NCT03233776.
Collapse
Affiliation(s)
- H R Wardill
- School of Biomedicine, The University of Adelaide, Adelaide, SA, Australia. .,The Supportive Oncology Research Group, Precision Medicine Theme (Cancer), The South Australian Health and Medical Research Institute, Adelaide, SA, Australia. .,Department of Pediatrics, The University of Groningen, University Medical Center Groningen, Groningen, The Netherlands.
| | - C E M de Mooij
- Department of Hematology, Radboud University Medical Center, Nijmegen, The Netherlands
| | - A R Da Silva Ferreira
- Department of Medical Microbiology, The University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - H Havinga
- Department of Pediatrics, The University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - H J M Harmsen
- Department of Medical Microbiology, The University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | | | - L F J van Groningen
- Department of Hematology, Radboud University Medical Center, Nijmegen, The Netherlands
| | - W J E Tissing
- Department of Pediatrics, The University of Groningen, University Medical Center Groningen, Groningen, The Netherlands.,Princes Maxima Center for Pediatric Oncology, Utrecht, The Netherlands
| | - N M A Blijlevens
- Department of Hematology, Radboud University Medical Center, Nijmegen, The Netherlands
| |
Collapse
|
37
|
Al-Qadami G, Van Sebille Y, Bowen J, Wardill H. Oral-Gut Microbiome Axis in the Pathogenesis of Cancer Treatment-Induced Oral Mucositis. FRONTIERS IN ORAL HEALTH 2022; 3:881949. [PMID: 35419563 PMCID: PMC8996059 DOI: 10.3389/froh.2022.881949] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2022] [Accepted: 03/07/2022] [Indexed: 11/13/2022] Open
Abstract
Oral mucositis (OM) is one of the most common and debilitating oral complications of cancer treatments including chemotherapy, radiotherapy, and hematopoietic stem cell transplantation. It is associated with severe pain and difficulties in chewing, swallowing, and speech. This leads to impairment of basic oral functions and could result in unplanned treatment interruption or modification. As such, OM negatively impacts both patients' quality of life as well as tumor prognostic outcomes. Understanding pathways underlying OM pathogenesis help identify new targets for intervention or prevention. The pathophysiology of OM has been widely studied over past decades with several pathways related to oxidative stress, inflammation, and molecular and cellular signaling being implicated. In this mini-review, we will discuss the emerging role of the oral-gut microbiome axis in the development of OM. Particularly, we will elaborate on how the alterations in the oral and gut microbiota as well as intestinal dysfunction caused by cancer treatments could contribute to the pathogenesis of OM. Further, we will briefly discuss the potential methods for targeting the oral-gut microbiome axis to improve OM outcomes.
Collapse
Affiliation(s)
- Ghanyah Al-Qadami
- School of Biomedicine, University of Adelaide, Adelaide, SA, Australia
| | | | - Joanne Bowen
- School of Biomedicine, University of Adelaide, Adelaide, SA, Australia
| | - Hannah Wardill
- School of Biomedicine, University of Adelaide, Adelaide, SA, Australia
- Precision Medicine Theme (Cancer), South Australian Health and Medical Research Institute, Adelaide, SA, Australia
| |
Collapse
|
38
|
Wardill HR, Chan RJ, Chan A, Keefe D, Costello SP, Hart NH. Dual contribution of the gut microbiome to immunotherapy efficacy and toxicity: supportive care implications and recommendations. Support Care Cancer 2022; 30:6369-6373. [PMID: 35266052 PMCID: PMC9213341 DOI: 10.1007/s00520-022-06948-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2021] [Accepted: 02/27/2022] [Indexed: 12/19/2022]
Abstract
The efficacy of immune checkpoint inhibitors (immunotherapy) is increasingly recognized to be linked to the composition the gut microbiome. Given the high rates of resistance, interventions targeting the gut microbiome are now being investigated for its ability to improve the efficacy of immunotherapy. In light of recently published data demonstrating a strong correlation between the efficacy and toxicity of immunotherapy, there is a risk that efforts to enhance immunotherapy efficacy may be undermined by increases in immune-related adverse events (IrAEs) This is particularly important for microbial interventions aimed at increasing immunotherapy efficacy, with many microbes implicated in tumour response also linked to IrAEs, especially colitis. IrAEs have a profound impact on patient quality of life, causing physical, psychosocial, and financial distress. Here, we outline strategies at the discovery, translational, and clinical research phases to ensure the impact of augmenting immunotherapy efficacy is approached in a manner that considers adverse implications. Adopting these strategies will ensure that our ongoing efforts to overcome immunotherapy resistance are not impacted by unacceptable toxicity.
Collapse
Affiliation(s)
- Hannah R Wardill
- School of Biomedicine, The University of Adelaide, Adelaide, South Australia, Australia. .,Precision Medicine Theme, South Australian Health and Medical Research Institute, Adelaide, South Australia, Australia.
| | - Raymond J Chan
- Caring Futures Institute, College of Nursing and Health Sciences, Flinders University, Adelaide, South Australia, Australia.,Division of Cancer Services, Princess Alexandra Hospital, Woolloongabba, Queensland, Australia
| | - Alexandre Chan
- School of Pharmacy & Pharmaceutical Sciences, University of California Irvine, Irvine, CA, USA
| | - Dorothy Keefe
- School of Biomedicine, The University of Adelaide, Adelaide, South Australia, Australia.,Cancer Australia, Surry Hills, New South Wales, Australia.,Adelaide Medical School, the University of Adelaide, Adelaide, South Australia, Australia
| | - Samuel P Costello
- School of Biomedicine, The University of Adelaide, Adelaide, South Australia, Australia.,Department of Gastroenterology, Queen Elizabeth Hospital, Woodville South, South Australia, Australia
| | - Nicolas H Hart
- Caring Futures Institute, College of Nursing and Health Sciences, Flinders University, Adelaide, South Australia, Australia.,School of Medical and Health Sciences, Edith Cowan University, Joondalup, Western Australia, Australia.,Institute for Health Research, University of Notre Dame Australia, Fremantle, Western Australia, Australia
| |
Collapse
|
39
|
Ávila TV, Menezes-Garcia Z, do Nascimento Arifa RD, Soriani FM, Machado ADMV, Teixeira MM, Fagundes CT, Souza DG. Mitochondrial DNA as a Possible Ligand for TLR9 in Irinotecan-induced Small Intestinal Mucositis. Immunol Invest 2022; 51:1756-1771. [PMID: 35152824 DOI: 10.1080/08820139.2022.2026379] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
Abstract
Cancer chemotherapy and radiotherapy may result in mucositis characterized by stem cell damage and inflammation in the gastrointestinal tract. The molecular mechanisms underlying this pathology remain unknown. Based on the assumption that mitochondrial CPG-DNA (mtDNA) released and sensed by TLR9 could underlie mucositis pathology, we analyzed the mtDNA levels in sera as well as inflammatory and disease parameters in the small intestine from wild-type (WT) and TLR9-deficient mice (TLR9-/-) in an experimental model of intestinal mucositis induced by irinotecan. Additionally, we verified the ability of WT and TLR9-/- macrophages to respond to CpG-DNA in vitro. WT mice injected with irinotecan presented a progressive increase in mtDNA in the serum along with increased hematocrit, shortening of small intestine length, reduction of intestinal villus:crypt ratio and increased influx of neutrophils, which were followed by higher expression of Nlrp3 and Casp1 mRNA and increased IL-1β levels in the ileum when compared to vehicle-injected mice. TLR9-deficient mice were protected in all these parameters when compared to WT mice. Furthermore, TLR9 was required for the production of IL-1β and NO after macrophage stimulation with CpG-DNA. Overall, our findings show that the amount of circulating free CpG-DNA is increased upon chemotherapy and that TLR9 activation is important for NLRP3 inflammasome transcription and further IL-1β release, playing a central role in the development of irinotecan-induced intestinal mucositis. We suggest that TLR9 antagonism may be a new therapeutic strategy for limiting irinotecan-induced intestinal inflammation.
Collapse
Affiliation(s)
- Thiago Vinicius Ávila
- Department of Pharmacology, Universidade Federal de Juiz de Fora, Juiz de Fora, Brazil
| | - Zélia Menezes-Garcia
- Department of Microbiology and Biochemistry, The University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Raquel Duque do Nascimento Arifa
- Laboratório de Interação Microorganismo-Hospedeiro, Department de Microbiology, Universidade Federal de Minas Gerais, Belo Horizonte, Brazil
| | | | | | - Mauro Martins Teixeira
- Department of Biochemistry and Immunology, Universidade Federal de Minas Gerais, Belo Horizonte, Brazil
| | - Caio Tavares Fagundes
- Laboratório de Interação Microorganismo-Hospedeiro, Department de Microbiology, Universidade Federal de Minas Gerais, Belo Horizonte, Brazil
| | - Daniele G Souza
- Laboratório de Interação Microorganismo-Hospedeiro, Department de Microbiology, Universidade Federal de Minas Gerais, Belo Horizonte, Brazil
| |
Collapse
|
40
|
Isozaki AB, Brant JM. Clinical Updates in Mucositis-Related Symptom Management. Semin Oncol Nurs 2022; 38:151252. [DOI: 10.1016/j.soncn.2022.151252] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
|
41
|
The science of mucositis. Support Care Cancer 2022; 30:2915-2917. [PMID: 35067733 DOI: 10.1007/s00520-022-06840-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2021] [Accepted: 01/15/2022] [Indexed: 10/19/2022]
|
42
|
Evaluation of the antiapoptotic and anti-inflammatory properties of chitosan in methotrexate-induced oral mucositis in rats. Mol Biol Rep 2022; 49:3237-3245. [PMID: 35064410 DOI: 10.1007/s11033-022-07158-x] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2021] [Accepted: 01/17/2022] [Indexed: 10/19/2022]
Abstract
BACKGROUND Methotrexate (MTX), a chemotherapeutic agent, is known to cause oral mucositis. Chitosan has been shown to have a protective effect in inflammatory animal models. This research aimed to examine the protective effect of chitosan against oral mucositis caused by MTX. METHODS AND RESULTS Wistar albino rats were randomly divided into three groups. Control (n = 8), (saline via oral gavage for 5 days), MTX (n = 8), (60 mg/kg single dose MTX intraperitoneally on the 1st day and for the following 4 days saline via oral gavage), and MTX + chitosan (n = 8), (1st day single dose 60 mg/kg MTX intraperitoneally and followed with 200 mg/kg chitosan via oral gavage for 4 days). After 24 h of the last dose, the animals were euthanised. Blood, tongue, buccal and palatal mucosa tissues were collected. Serum interleukin 1-beta (IL1-β), tumour necrosis factor-alpha (TNF-α), matrix metalloproteinase (MMP-1, and MMP-2) activities, tissue bcl-2/bax ratio and the expression of caspase-3 (casp-3), and casp-9 were detected. The tissues were also examined histologically. Serum TNF-α, IL1-β, MMP-1 and MMP-2 activities and tissue casp-3 and casp-9 activities significantly increased but the bcl-2/bax ratio significantly decreased in the MTX group compared those of the control group. Histologically, diffuse inflammatory cells were observed in MTX group. However, In the MTX + chitosan group, all the values were close to those of the control group. CONCLUSION It was demonstrated that chitosan has a protective effect against oral mucosal damage caused by MTX. Thus, it may be a candidate agent against MTX induced oral mucositis.
Collapse
|
43
|
Quintanilha MF, Miranda VC, Souza RO, Gallotti B, Cruz C, Santos EA, Alvarez-Leite JI, Jesus LC, Azevedo V, Trindade LM, Cardoso VN, Ferreira E, Carvalho BA, Soares PM, Vieira AT, Nicoli JR, Martins FS. Bifidobacterium longum subsp. longum 51A attenuates intestinal injury against irinotecan-induced mucositis in mice. Life Sci 2022; 289:120243. [DOI: 10.1016/j.lfs.2021.120243] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2021] [Revised: 12/07/2021] [Accepted: 12/13/2021] [Indexed: 02/07/2023]
|
44
|
Kahn AM, Blenman KR, Sonis ST, Lustberg MB. Strategies to mitigate the toxicity of cancer therapeutics. Adv Cancer Res 2022; 155:215-244. [DOI: 10.1016/bs.acr.2022.02.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
|
45
|
Baliga M, Rao S, Kalekhan F, Hegde S, Rao P, Suresh S. Serum zinc status and the development of mucositis and dermatitis in head-and-neck cancer patients undergoing curative radiotherapy: A pilot study. J Cancer Res Ther 2022; 18:42-48. [DOI: 10.4103/jcrt.jcrt_344_20] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
|
46
|
Abstract
Chemotherapy-induced gastrointestinal dysfunction is a common occurrence associated with many different classes of chemotherapeutic agents. Gastrointestinal toxicity includes mucositis, diarrhea, and constipation, and can often be a dose-limiting complication, induce cessation of treatment and could be life threatening. The gastrointestinal epithelium is rich in rapidly dividing cells and hence is a prime target for chemotherapeutic drugs. The incidence of gastrointestinal toxicity, including diarrhea and mucositis, is extremely high for a wide array of chemotherapeutic and radiation regimens. In fact, 60%-100% of patients on high-dose chemotherapy suffer from gastrointestinal side effects. Unfortunately, treatment options are limited, and therapy is often restricted to palliative care. Therefore, there is a great unmet therapeutic need for preventing and treating chemotherapy-induced gastrointestinal toxicities in the clinic. In this review, we discuss our current understanding of the mechanisms underlying chemotherapy-induced diarrhea and mucositis, and emerging mechanisms involving the enteric nervous system, smooth muscle cells and enteric immune cells. Recent evidence has also implicated gut dysbiosis in the pathogenesis of not only chemotherapy-induced mucositis and diarrhea, but also chemotherapy-induced peripheral neuropathy. Oxidative stress induced by chemotherapeutic agents results in post-translational modification of ion channels altering neuronal excitability. Thus, investigating how chemotherapy-induced changes in the gut- microbiome axis may lead to gut-related toxicities will be critical in the discovery of new drug targets for mitigating adverse gastrointestinal effects associated with chemotherapy treatment.
Collapse
Affiliation(s)
- Hamid I Akbarali
- Department of Pharmacology and Toxicology, School of Medicine, Virginia Commonwealth University, Richmond, VA, United States.
| | - Karan H Muchhala
- Department of Pharmacology and Toxicology, School of Medicine, Virginia Commonwealth University, Richmond, VA, United States
| | - Donald K Jessup
- Department of Pharmacology and Toxicology, School of Medicine, Virginia Commonwealth University, Richmond, VA, United States
| | - Stanley Cheatham
- Department of Pharmacology and Toxicology, School of Medicine, Virginia Commonwealth University, Richmond, VA, United States
| |
Collapse
|
47
|
Liang L, Liu Z, Zhu H, Wang H, Wei Y, Ning X, Shi Z, Jiang L, Lin Z, Yan H, Wang R, Hu K. Efficacy and safety of thalidomide in preventing oral mucositis in patients with nasopharyngeal carcinoma undergoing concurrent chemoradiotherapy: A multicenter, open-label, randomized controlled trial. Cancer 2021; 128:1467-1474. [PMID: 34910297 DOI: 10.1002/cncr.34074] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2021] [Revised: 11/19/2021] [Accepted: 12/01/2021] [Indexed: 12/28/2022]
Abstract
BACKGROUND This multicenter clinical trial was designed to evaluate the efficacy and safety of thalidomide (THD) in preventing oral mucositis (OM) in patients with nasopharyngeal carcinoma (NPC) undergoing concurrent chemoradiotherapy (CCRT). METHODS Patients with locally advanced NPC were randomly assigned to either a THD group or a control group. All 160 patients received radical intensity-modulated radiotherapy plus cisplatin-based concurrent chemotherapy and basic oral hygiene guidance. Patients in the THD group received additional THD at the beginning of CCRT. The primary end points were the latency period and the incidence of OM. The secondary end points were mouth and throat soreness (MTS), weight loss, short-term efficacy, and adverse events. RESULTS The median latency period of OM was 30 and 14 days in the THD and control groups, respectively (hazard ratio, 0.32; 95% confidence interval, 0.23-0.35; P < .0001). The incidence of OM and severe OM (World Health Organization grade 3 or higher) was significantly lower in the THD group than the control group (87.5% vs 97.5% [P = .016] and 27.5% vs 46.3% [P = .014], respectively). THD treatment also remarkably reduced the intensity of MTS and the degree of weight loss. In comparison with the control group, the incidence of nausea, vomiting, and insomnia was significantly decreased, whereas the incidence of dizziness and constipation was obviously increased in the THD group. The objective response rates 3 months after CCRT were similar between the groups. CONCLUSIONS THD prolonged the latency period, reduced the incidence of OM, and did not affect the short-term efficacy of CCRT in patients with NPC. LAY SUMMARY Oral mucositis is the most common complication of nasopharyngeal carcinoma during chemoradiotherapy; it decreases the patient's quality of life, and ideal mucosal protective agents are lacking. A few basic research and preclinical studies have shown that thalidomide may be an approach to ameliorating oral mucositis. The results of the current study confirm that thalidomide has a protective effect against oral mucositis in patients who have received chemoradiotherapy for nasopharyngeal carcinoma.
Collapse
Affiliation(s)
- Leifeng Liang
- Department of Oncology, Sixth Affiliated Hospital of Guangxi Medical University, First People's Hospital of Yulin, Yulin, China
| | - Zhibing Liu
- Department of Radiation Oncology, First Affiliated Hospital of Guangxi Medical University, Nanning, China
| | - Haisheng Zhu
- Department of Oncology, Sixth Affiliated Hospital of Guangxi Medical University, First People's Hospital of Yulin, Yulin, China
| | - Hongqian Wang
- Department of Radiation Oncology, Red Cross Hospital of Yulin, Yulin, China
| | - Yan Wei
- Department of Oncology, Guigang People's Hospital, Guigang, China
| | - Xuejian Ning
- Department of Oncology, Liuzhou Hospital of Chinese Medicine, Liuzhou, China
| | - Zhiling Shi
- Department of Radiation Oncology, First Affiliated Hospital of Guangxi Medical University, Nanning, China
| | - Liujun Jiang
- Department of Oncology, Sixth Affiliated Hospital of Guangxi Medical University, First People's Hospital of Yulin, Yulin, China
| | - Zhan Lin
- Department of Oncology, Sixth Affiliated Hospital of Guangxi Medical University, First People's Hospital of Yulin, Yulin, China
| | - Haolin Yan
- Department of Oncology, Sixth Affiliated Hospital of Guangxi Medical University, First People's Hospital of Yulin, Yulin, China
| | - Rensheng Wang
- Department of Radiation Oncology, First Affiliated Hospital of Guangxi Medical University, Nanning, China
| | - Kai Hu
- Department of Radiation Oncology, First Affiliated Hospital of Guangxi Medical University, Nanning, China
| |
Collapse
|
48
|
Oliveira MMB, de Araújo AA, Ribeiro SB, de Sales Mota PCM, Marques VB, da Silva Martins Rebouças C, Figueiredo JG, Barra PB, de Castro Brito GA, de Carvalho Leitão RF, Guerra GCB, de Medeiros CACX. Losartan improves intestinal mucositis induced by 5-fluorouracil in mice. Sci Rep 2021; 11:23241. [PMID: 34853351 PMCID: PMC8636633 DOI: 10.1038/s41598-021-01969-x] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2021] [Accepted: 11/01/2021] [Indexed: 02/07/2023] Open
Abstract
Intestinal mucositis (IM) is a common side effect of 5-fluorouracil (5-FU)-based chemotherapy, which negatively impacts therapeutic outcomes and delays subsequent cycles of chemotherapy resulting in dose reductions and treatment discontinuation. In search of new pharmacological alternatives that minimize your symptoms, this work set out to study the effect of losartan (LOS), a receptor type I (AT1) angiotensin II antagonist, on intestinal mucositis induced by 5-FU. Intestinal mucositis was induced by a single intraperitoneal administration of 5-FU (450 mg/kg) in Swiss mice. Losartan (5, 25 or 50 mg/kg) or saline was orally administered 30 min before 5-FU and daily for 4 days. On 4th day, the animals were euthanized and segments of small intestine were collected to evaluate histopathological alterations (morphometric analysis), concentration of inflammatory cytokines, oxidative stress markers and genic expression of NF-κB p65, Fn-14 and TWEAK. Weight evaluation and changes in leukogram were also analyzed. 5-FU induced intense weight loss, leukopenia and reduction in villus height compared to saline group. Losartan (50 mg/kg) prevented 5-FU-induced inflammation by decreasing in the analyzed parameters compared to the 5-FU group. Our findings suggest that 50 mg/kg of losartan prevents the effects of 5-FU on intestinal mucosa in mice.
Collapse
Affiliation(s)
| | - Aurigena Antunes de Araújo
- Post Graduate Program in Pharmaceutical Science, Post Graduate Program Dental Sciences, Department of Biophysics and Pharmacology, Federal University of Rio Grande do Norte (UFRN), Natal, RN, Brazil
| | - Susana Barbosa Ribeiro
- Junior Postdoctoral Student CNPq-Federal University of Rio Grande do Norte (UFRN), Natal, RN, Brazil
| | | | | | | | - Jozi Godoy Figueiredo
- Department of Biochemistry, Faculty of Vale do São Lourenço (EDUVALE), Jaciara, MT, Brazil
| | - Patrícia Batista Barra
- Post Graduate Program in Biology Teaching in National Network-PROFBIO, Department of Biomedical Sciences, State University of Rio Grande do Norte (UERN), Mossoró, RN, Brazil
| | - Gerly Anne de Castro Brito
- Post Graduate Program Morphofunctional Sciences, Post Graduate Program Medical Sciences, Department of Morphology, Faculty of Medicine, Federal University of Ceará (UFC), Fortaleza, CE, Brazil
| | - Renata Ferreira de Carvalho Leitão
- Post Graduate Program Morphofunctional Sciences, Department of Morphology, Faculty of Medicine, Federal University of Ceará (UFC), Fortaleza, CE, Brazil
| | - Gerlane Coelho Bernardo Guerra
- Post Graduate Program Biochemistry and Molecular Biology, Post Graduate Program Pharmaceutical Science, Department of Biophysics and Pharmacology, Federal University of Rio Grande do Norte (UFRN), Natal, RN, Brazil
| | - Caroline Addison Carvalho Xavier de Medeiros
- Post Graduate Program Biotechnology-RENORBIO, Post Graduate Program Biochemistry and Molecular Biology, Department of Biophysics and Pharmacology, Federal University of Rio Grande do Norte (UFRN), Natal, RN, Brazil.
| |
Collapse
|
49
|
Maracajá Bezerra PM, De Lima Santana YN, Batista de Medeiros Serpa E, Alves de Sousa S, Gondim Valença AM, Ferreti Bonan PR. Geographic tongue induced by cytarabine in a pediatric patient. PEDIATRIC HEMATOLOGY ONCOLOGY JOURNAL 2021. [DOI: 10.1016/j.phoj.2021.12.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022] Open
|
50
|
da Silva Ferreira AR, van der Aa SAJ, Wehkamp T, Wardill HR, Ten Klooster JP, Garssen J, Harthoorn LF, Hartog A, Harmsen HJM, Tissing WJE, van Bergenhenegouwen J. Development of a self-limiting model of methotrexate-induced mucositis reinforces butyrate as a potential therapy. Sci Rep 2021; 11:22911. [PMID: 34824316 PMCID: PMC8617074 DOI: 10.1038/s41598-021-02308-w] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2021] [Accepted: 10/13/2021] [Indexed: 12/19/2022] Open
Abstract
Gastrointestinal mucositis is a complication of anticancer treatment, with few validated in vitro systems suitable to study the complex mechanisms of mucosal injury. Therefore, we aimed to develop and characterize a chemotherapeutic-induced model of mucositis using 3D intestinal organoids. Organoids derived from mouse ileum were grown for 7 days and incubated with different concentrations of the chemotherapeutic agent methotrexate (MTX). Metabolic activity, citrulline levels and cytokine/chemokine production were measured to determine the optimal dosage and incubation time. The protective effects of folinic acid on the toxicity of MTX were investigated by pre-treating organoids with (0.0005-50 µg/mL) folinic acid. The impact of microbial-derived short-chain fatty acids was evaluated by supplementation with butyrate in the organoid model. MTX caused a dose-dependent reduction in cell metabolic activity and citrulline production that was salvaged by folinic acid treatment. Overall, MTX causes significant organoid damage, which can be reversed upon removal of MTX. The protective effect of folinic acid suggest that the organoids respond in a clinical relevant manner. By using the model for intervention, it was found that prophylactic treatment with butyrate might be a valuable strategy for prophylactic mucositis prevention.
Collapse
Affiliation(s)
- A R da Silva Ferreira
- Department of Medical Microbiology and Infection prevention, University of Groningen, University Medical Center Groningen, Hanzeplein 1 EB80, 9713 GZ, Groningen, The Netherlands
- Research Centre for Healthy and Sustainable Living, Innovative Testing in Life Sciences and Chemistry, University of Applied Sciences, Utrecht, The Netherlands
| | - S A J van der Aa
- Department of Pediatric Oncology, University of Groningen, Beatrix Children's Hospital, University Medical Center Groningen, Groningen, The Netherlands
- Danone Nutricia Research, Utrecht, The Netherlands
- Research Centre for Healthy and Sustainable Living, Innovative Testing in Life Sciences and Chemistry, University of Applied Sciences, Utrecht, The Netherlands
| | - T Wehkamp
- Danone Nutricia Research, Utrecht, The Netherlands
- Research Centre for Healthy and Sustainable Living, Innovative Testing in Life Sciences and Chemistry, University of Applied Sciences, Utrecht, The Netherlands
| | - H R Wardill
- Department of Pediatric Oncology, University of Groningen, Beatrix Children's Hospital, University Medical Center Groningen, Groningen, The Netherlands
- Adelaide Medical School, The University of Adelaide, Adelaide, Australia
- Precision Medicine Theme, South Australian Health and Medical Research Institute, Adelaide, Australia
- Research Centre for Healthy and Sustainable Living, Innovative Testing in Life Sciences and Chemistry, University of Applied Sciences, Utrecht, The Netherlands
| | - J P Ten Klooster
- Division of Pharmacology, Faculty of Science, Utrecht Institute for Pharmaceutical Sciences, Utrecht University, Utrecht, The Netherlands
- Research Centre for Healthy and Sustainable Living, Innovative Testing in Life Sciences and Chemistry, University of Applied Sciences, Utrecht, The Netherlands
| | - J Garssen
- Danone Nutricia Research, Utrecht, The Netherlands
- Division of Pharmacology, Faculty of Science, Utrecht Institute for Pharmaceutical Sciences, Utrecht University, Utrecht, The Netherlands
- Research Centre for Healthy and Sustainable Living, Innovative Testing in Life Sciences and Chemistry, University of Applied Sciences, Utrecht, The Netherlands
| | - L F Harthoorn
- Danone Nutricia Research, Utrecht, The Netherlands
- Research Centre for Healthy and Sustainable Living, Innovative Testing in Life Sciences and Chemistry, University of Applied Sciences, Utrecht, The Netherlands
| | - A Hartog
- Danone Nutricia Research, Utrecht, The Netherlands
- Research Centre for Healthy and Sustainable Living, Innovative Testing in Life Sciences and Chemistry, University of Applied Sciences, Utrecht, The Netherlands
| | - H J M Harmsen
- Department of Medical Microbiology and Infection prevention, University of Groningen, University Medical Center Groningen, Hanzeplein 1 EB80, 9713 GZ, Groningen, The Netherlands.
- Research Centre for Healthy and Sustainable Living, Innovative Testing in Life Sciences and Chemistry, University of Applied Sciences, Utrecht, The Netherlands.
| | - W J E Tissing
- Department of Pediatric Oncology, University of Groningen, Beatrix Children's Hospital, University Medical Center Groningen, Groningen, The Netherlands
- Research Centre for Healthy and Sustainable Living, Innovative Testing in Life Sciences and Chemistry, University of Applied Sciences, Utrecht, The Netherlands
- Princess Maxima Center for Pediatric Oncology, Utrecht, The Netherlands
| | - J van Bergenhenegouwen
- Danone Nutricia Research, Utrecht, The Netherlands
- Division of Pharmacology, Faculty of Science, Utrecht Institute for Pharmaceutical Sciences, Utrecht University, Utrecht, The Netherlands
- Research Centre for Healthy and Sustainable Living, Innovative Testing in Life Sciences and Chemistry, University of Applied Sciences, Utrecht, The Netherlands
| |
Collapse
|