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Hofmann S, Luther J, Plank V, Oswald A, Mai J, Simons I, Miller J, Falcone V, Hansen-Palmus L, Hengel H, Nassal M, Protzer U, Schreiner S. Arsenic trioxide impacts hepatitis B virus core nuclear localization and efficiently interferes with HBV infection. Microbiol Spectr 2024; 12:e0378823. [PMID: 38567974 PMCID: PMC11064512 DOI: 10.1128/spectrum.03788-23] [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: 10/30/2023] [Accepted: 03/14/2024] [Indexed: 05/03/2024] Open
Abstract
The key to a curative treatment of hepatitis B virus (HBV) infection is the eradication of the intranuclear episomal covalently closed circular DNA (cccDNA), the stable persistence reservoir of HBV. Currently, established therapies can only limit HBV replication but fail to tackle the cccDNA. Thus, novel therapeutic approaches toward curative treatment are urgently needed. Recent publications indicated a strong association between the HBV core protein SUMOylation and the association with promyelocytic leukemia nuclear bodies (PML-NBs) on relaxed circular DNA to cccDNA conversion. We propose that interference with the cellular SUMOylation system and PML-NB integrity using arsenic trioxide provides a useful tool in the treatment of HBV infection. Our study showed a significant reduction in HBV-infected cells, core protein levels, HBV mRNA, and total DNA. Additionally, a reduction, albeit to a limited extent, of HBV cccDNA could be observed. Furthermore, this interference was also applied for the treatment of an established HBV infection, characterized by a stably present nuclear pool of cccDNA. Arsenic trioxide (ATO) treatment not only changed the amount of expressed HBV core protein but also induced a distinct relocalization to an extranuclear phenotype during infection. Moreover, ATO treatment resulted in the redistribution of transfected HBV core protein away from PML-NBs, a phenotype similar to that previously observed with SUMOylation-deficient HBV core. Taken together, these findings revealed the inhibition of HBV replication by ATO treatment during several steps of the viral replication cycle, including viral entry into the nucleus as well as cccDNA formation and maintenance. We propose ATO as a novel prospective treatment option for further pre-clinical and clinical studies against HBV infection. IMPORTANCE The main challenge for the achievement of a functional cure for hepatitis B virus (HBV) is the covalently closed circular DNA (cccDNA), the highly stable persistence reservoir of HBV, which is maintained by further rounds of infection with newly generated progeny viruses or by intracellular recycling of mature nucleocapsids. Eradication of the cccDNA is considered to be the holy grail for HBV curative treatment; however, current therapeutic approaches fail to directly tackle this HBV persistence reservoir. The molecular effect of arsenic trioxide (ATO) on HBV infection, protein expression, and cccDNA formation and maintenance, however, has not been characterized and understood until now. In this study, we reveal ATO treatment as a novel and innovative therapeutic approach against HBV infections, repressing viral gene expression and replication as well as the stable cccDNA pool at low micromolar concentrations by affecting the cellular function of promyelocytic leukemia nuclear bodies.
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Affiliation(s)
- Samuel Hofmann
- Institute of Virology, School of Medicine, Technical University of Munich, Munich, Germany
- Institute of Virology, Hannover Medical School, Hannover, Germany
- Cluster of Excellence RESIST (Resolving Infection Susceptibility, EXC 2155), Hannover Medical School, Hannover, Germany
- Division of Pediatric Neurology and Metabolic Medicine, Center for Pediatric and Adolescent Medicine, University Hospital Heidelberg, Heidelberg, Germany
| | - Julius Luther
- Institute of Virology, Hannover Medical School, Hannover, Germany
- Cluster of Excellence RESIST (Resolving Infection Susceptibility, EXC 2155), Hannover Medical School, Hannover, Germany
| | - Verena Plank
- Institute of Virology, School of Medicine, Technical University of Munich, Munich, Germany
| | - Andreas Oswald
- Institute of Virology, School of Medicine, Technical University of Munich, Munich, Germany
| | - Julia Mai
- Institute of Virology, Hannover Medical School, Hannover, Germany
- Cluster of Excellence RESIST (Resolving Infection Susceptibility, EXC 2155), Hannover Medical School, Hannover, Germany
- Department of Internal Medicine II/Molecular Biology, University Hospital Freiburg, Freiburg, Germany
| | - Ilka Simons
- Institute of Virology, Hannover Medical School, Hannover, Germany
- Cluster of Excellence RESIST (Resolving Infection Susceptibility, EXC 2155), Hannover Medical School, Hannover, Germany
| | - Julija Miller
- Department of Internal Medicine II/Molecular Biology, University Hospital Freiburg, Freiburg, Germany
| | - Valeria Falcone
- Institute of Virology, Medical Center – University of Freiburg, Freiburg, Germany
| | - Lea Hansen-Palmus
- Institute of Virology, School of Medicine, Technical University of Munich, Munich, Germany
| | - Hartmut Hengel
- Institute of Virology, Medical Center – University of Freiburg, Freiburg, Germany
| | - Michael Nassal
- Department of Internal Medicine II/Molecular Biology, University Hospital Freiburg, Freiburg, Germany
| | - Ulrike Protzer
- Institute of Virology, School of Medicine, Technical University of Munich, Munich, Germany
- Institute of Virology, Helmholtz Zentrum München, Munich, Germany
- German Center for Infection Research (DZIF), Munich, Germany
| | - Sabrina Schreiner
- Institute of Virology, School of Medicine, Technical University of Munich, Munich, Germany
- Institute of Virology, Hannover Medical School, Hannover, Germany
- Cluster of Excellence RESIST (Resolving Infection Susceptibility, EXC 2155), Hannover Medical School, Hannover, Germany
- Institute of Virology, Medical Center – University of Freiburg, Freiburg, Germany
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Jhuang JR, Lee CH, Chiang CJ, Chen CJ, Lee WC. Reduced burden of Arsenic-Related cancers after water mitigation in Taiwan. ENVIRONMENT INTERNATIONAL 2024; 185:108542. [PMID: 38461779 DOI: 10.1016/j.envint.2024.108542] [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: 10/29/2023] [Revised: 01/31/2024] [Accepted: 02/28/2024] [Indexed: 03/12/2024]
Abstract
BACKGROUND Epidemiological evidence has demonstrated an association between arsenic in drinking water and increased cancer incidence. This population-based study investigates the impact of a tap water supply system installation in Blackfoot disease-endemic regions of Taiwan on cancer incidence. METHODS By using the Taiwan Cancer Registry dataset, we enrolled patients aged 40-84 diagnosed with arsenic-related cancers, including hepatocellular carcinoma, small and squamous cell lung cancer, Bowen's disease, basal and squamous cell skin cancer, urothelial bladder cancer, and upper tract urothelial carcinoma between 1995 and 2019. Random-effects age-period-cohort models were used to estimate the cancer incidence data, and a stabilized kriging method was employed to interpolate incidence rates to more precise spatiotemporal units. RESULTS The results showed that the age-standardized incidence rates of all six types of studied cancers were consistently higher in Blackfoot disease-endemic areas than those in other areas from 1995 to 2019. However, the gap in incidence rates between Blackfoot disease-endemic areas and the remaining regions began to narrow approximately after the 1960 birth cohort when the tap water supply system installation commenced. For small and squamous cell lung cancer, Bowen's disease, and urothelial bladder cancer, the excess incidence rates sharply declined to null for those born after the year of arsenic mitigation. For upper tract urothelial carcinoma, the excess incidence rates decreased more gradually for those born after the year of arsenic mitigation. For hepatocellular carcinoma and basal and squamous cell skin cancer, the excess incidence rates remained constant. Spatiotemporal clusters of high incidence rates were identified in the core townships of Blackfoot disease-endemic areas. These clusters began to dissipate mainly after the 1960 birth cohort. CONCLUSION Arsenic mitigation from drinking water in Taiwan is associated with a reduced burden of small and squamous cell lung cancers, Bowen's disease, urothelial bladder cancer, and upper tract urothelial carcinoma.
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Affiliation(s)
- Jing-Rong Jhuang
- Institute of Epidemiology and Preventive Medicine, College of Public Health, National Taiwan University, Taipei, Taiwan; Taiwan Cancer Registry, Taipei, Taiwan
| | - Chih-Hung Lee
- Department of Dermatology, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung, Taiwan
| | - Chun-Ju Chiang
- Institute of Epidemiology and Preventive Medicine, College of Public Health, National Taiwan University, Taipei, Taiwan; Taiwan Cancer Registry, Taipei, Taiwan
| | - Chien-Jen Chen
- Genomics Research Center, Academia Sinica, Taipei, Taiwan; College of Medicine, Fu-Jen Catholic University, New Taipei, Taiwan
| | - Wen-Chung Lee
- Institute of Epidemiology and Preventive Medicine, College of Public Health, National Taiwan University, Taipei, Taiwan; Taiwan Cancer Registry, Taipei, Taiwan; Institute of Health Data Analytics and Statistics, College of Public Health, National Taiwan University, Taipei, Taiwan.
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Kostoff RN, Briggs MB, Kanduc D, Shores DR, Kovatsi L, Drakoulis N, Porter AL, Tsatsakis A, Spandidos DA. Contributing factors common to COVID‑19 and gastrointestinal cancer. Oncol Rep 2021; 47:16. [PMID: 34779496 PMCID: PMC8611322 DOI: 10.3892/or.2021.8227] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2021] [Accepted: 11/04/2021] [Indexed: 12/11/2022] Open
Abstract
The devastating complications of coronavirus disease 2019 (COVID-19) result from the dysfunctional immune response of an individual following the initial severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection. Multiple toxic stressors and behaviors contribute to underlying immune system dysfunction. SARS-CoV-2 exploits the dysfunctional immune system to trigger a chain of events, ultimately leading to COVID-19. The authors have previously identified a number of contributing factors (CFs) common to myriad chronic diseases. Based on these observations, it was hypothesized that there may be a significant overlap between CFs associated with COVID-19 and gastrointestinal cancer (GIC). Thus, in the present study, a streamlined dot-product approach was used initially to identify potential CFs that affect COVID-19 and GIC directly (i.e., the simultaneous occurrence of CFs and disease in the same article). The nascent character of the COVID-19 core literature (~1-year-old) did not allow sufficient time for the direct effects of numerous CFs on COVID-19 to emerge from laboratory experiments and epidemiological studies. Therefore, a literature-related discovery approach was used to augment the COVID-19 core literature-based ‘direct impact’ CFs with discovery-based ‘indirect impact’ CFs [CFs were identified in the non-COVID-19 biomedical literature that had the same biomarker impact pattern (e.g., hyperinflammation, hypercoagulation, hypoxia, etc.) as was shown in the COVID-19 literature]. Approximately 2,250 candidate direct impact CFs in common between GIC and COVID-19 were identified, albeit some being variants of the same concept. As commonality proof of concept, 75 potential CFs that appeared promising were selected, and 63 overlapping COVID-19/GIC potential/candidate CFs were validated with biological plausibility. In total, 42 of the 63 were overlapping direct impact COVID-19/GIC CFs, and the remaining 21 were candidate GIC CFs that overlapped with indirect impact COVID-19 CFs. On the whole, the present study demonstrates that COVID-19 and GIC share a number of common risk/CFs, including behaviors and toxic exposures, that impair immune function. A key component of immune system health is the removal of those factors that contribute to immune system dysfunction in the first place. This requires a paradigm shift from traditional Western medicine, which often focuses on treatment, rather than prevention.
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Affiliation(s)
- Ronald Neil Kostoff
- School of Public Policy, Georgia Institute of Technology, Gainesville, VA 20155, USA
| | | | - Darja Kanduc
- Department of Biosciences, Biotechnologies and Biopharmaceutics, University of Bari, I‑70125 Bari, Italy
| | - Darla Roye Shores
- Department of Pediatrics, Division of Gastroenterology, Johns Hopkins University School of Medicine, Baltimore, MD 21287, USA
| | - Leda Kovatsi
- Laboratory of Forensic Medicine and Toxicology, School of Medicine, Aristotle University of Thessaloniki, 54124 Thessaloniki, Greece
| | - Nikolaos Drakoulis
- Research Group of Clinical Pharmacology and Pharmacogenomics, Faculty of Pharmacy, School of Health Sciences, National and Kapodistrian University of Athens, 15771 Athens, Greece
| | | | - Aristidis Tsatsakis
- Department of Forensic Sciences and Toxicology, Faculty of Medicine, University of Crete, 71003 Heraklion, Greece
| | - Demetrios A Spandidos
- Laboratory of Clinical Virology, Medical School, University of Crete, 71003 Heraklion, Greece
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Martínez-Castillo M, García-Montalvo EA, Arellano-Mendoza MG, Sánchez-Peña LDC, Soria Jasso LE, Izquierdo-Vega JA, Valenzuela OL, Hernández-Zavala A. Arsenic exposure and non-carcinogenic health effects. Hum Exp Toxicol 2021; 40:S826-S850. [PMID: 34610256 DOI: 10.1177/09603271211045955] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Inorganic arsenic (iAs) exposure is a serious health problem that affects more than 140 million individuals worldwide, mainly, through contaminated drinking water. Acute iAs poisoning produces several symptoms such as nausea, vomiting, abdominal pain, and severe diarrhea, whereas prolonged iAs exposure increased the risk of several malignant disorders such as lung, urinary tract, and skin tumors. Another sensitive endpoint less described of chronic iAs exposure are the non-malignant health effects in hepatic, endocrine, renal, neurological, hematological, immune, and cardiovascular systems. The present review outlines epidemiology evidence and possible molecular mechanisms associated with iAs-toxicity in several non-carcinogenic disorders.
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Affiliation(s)
- Macario Martínez-Castillo
- Sección de Estudios de Posgrado e Investigación, Escuela Superior de Medicina, 27740Instituto Politécnico Nacional, Ciudad de México, México
| | | | - Mónica G Arellano-Mendoza
- Laboratorio de Investigación en Enfermedades Crónico-Degenerativas, Sección de Estudios de Posgrado e Investigación, Escuela Superior de Medicina, 27740Instituto Politécnico Nacional, Ciudad de México, México
| | - Luz Del C Sánchez-Peña
- Departamento de Toxicología, 540716Centro de Investigación y de Estudios Avanzados del Instituto Politécnico Nacional, Ciudad de Mexico, México
| | - Luis E Soria Jasso
- Centro de Investigación en Biología de la Reproducción, Área Académica de Medicina del Instituto de Ciencias de la Salud, 103794Universidad Autónoma del Estado de Hidalgo, Pachuca, México
| | - Jeannett A Izquierdo-Vega
- Área Académica de Medicina, Instituto de Ciencias de la Salud, 103794Universidad Autónoma del Estado de Hidalgo, Pachuca, México
| | - Olga L Valenzuela
- Facultad de Ciencias Químicas, 428055Universidad Veracruzana, Orizaba, México
| | - Araceli Hernández-Zavala
- Sección de Estudios de Posgrado e Investigación, Escuela Superior de Medicina, 27740Instituto Politécnico Nacional, Ciudad de México, México
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Jain RB. Contribution of diet and other factors for urinary concentrations of total arsenic and arsenic species: data for US children, adolescents, and adults. ENVIRONMENTAL SCIENCE AND POLLUTION RESEARCH INTERNATIONAL 2021; 28:50094-50116. [PMID: 33948846 DOI: 10.1007/s11356-021-14230-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/21/2021] [Accepted: 04/28/2021] [Indexed: 06/12/2023]
Abstract
A comprehensive analysis of the associations between the consumptions of 17 food products with urinary concentrations of arsenobetaine, total arsenic, arsenous acid, dimethylarsinic acid (UDMA), monomethylarsonic acid (UMMA), and total inorganic arsenic for US children aged 3-5 years (N = 439), children aged 6-11 years (N = 2139), adolescents aged 12-19 years (N = 2434), and adults aged >= 20 years (N = 10902) was conducted. Data from National Health and Nutrition Examination Survey for 2005-2016 were used for this study. Concentrations of arsenobetaine were as much as > 15 times higher among consumers of fish/shellfish than non-consumers for children aged 6-11 years, > 12 times higher for children aged 3-5 years, > 13 times higher for adolescents, and > 7 times higher for adults. Consumption of rice as opposed to non-consumption of rice was associated with as much as 36.5% higher concentrations of total arsenic, 12.7% higher concentrations of arsenous acid, 43.9% higher concentrations of UDMA, 18.2% higher concentrations of UMMA, and 14.1% higher concentrations of total inorganic arsenic. Thus, consumption of fish/shell fish and rice was associated with higher concentrations of organic/inorganic arsenic. In addition, consumption of alcohol was also found to be associated with higher concentrations of organic/inorganic arsenic. However, consumption of milk and milk products, vegetables, organ and other meats, and nutritional drinks was found to be associated with lower concentrations of organic/inorganic arsenic. Thus, while consumption of several foods is associated with higher concentrations of arsenic, there are also foods whose consumption is associated with decreased concentrations of arsenic. Further studies are needed to identify foods that may lead to decreased concentrations of arsenic and as such arsenic toxicity.
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Skalny AV, Lima TRR, Ke T, Zhou JC, Bornhorst J, Alekseenko SI, Aaseth J, Anesti O, Sarigiannis DA, Tsatsakis A, Aschner M, Tinkov AA. Toxic metal exposure as a possible risk factor for COVID-19 and other respiratory infectious diseases. Food Chem Toxicol 2020; 146:111809. [PMID: 33069759 PMCID: PMC7563920 DOI: 10.1016/j.fct.2020.111809] [Citation(s) in RCA: 46] [Impact Index Per Article: 11.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2020] [Revised: 09/25/2020] [Accepted: 10/01/2020] [Indexed: 01/08/2023]
Abstract
Multiple medical, lifestyle, and environmental conditions, including smoking and particulate pollution, have been considered as risk factors for COronaVIrus Disease 2019 (COVID-19) susceptibility and severity. Taking into account the high level of toxic metals in both particulate matter (PM2.5) and tobacco smoke, the objective of this review is to discuss recent data on the role of heavy metal exposure in development of respiratory dysfunction, immunotoxicity, and severity of viral diseases in epidemiological and experimental studies, as to demonstrate the potential crossroads between heavy metal exposure and COVID-19 severity risk. The existing data demonstrate that As, Cd, Hg, and Pb exposure is associated with respiratory dysfunction and respiratory diseases (COPD, bronchitis). These observations corroborate laboratory findings on the role of heavy metal exposure in impaired mucociliary clearance, reduced barrier function, airway inflammation, oxidative stress, and apoptosis. The association between heavy metal exposure and severity of viral diseases, including influenza and respiratory syncytial virus has been also demonstrated. The latter may be considered a consequence of adverse effects of metal exposure on adaptive immunity. Therefore, reduction of toxic metal exposure may be considered as a potential tool for reducing susceptibility and severity of viral diseases affecting the respiratory system, including COVID-19.
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Affiliation(s)
- Anatoly V Skalny
- IM Sechenov First Moscow State Medical University (Sechenov University), Moscow, Russia; Federal Research Centre of Biological Systems and Agro-technologies of the Russian Academy of Sciences, Orenburg, Russia.
| | - Thania Rios Rossi Lima
- São Paulo State University - UNESP, Center for Evaluation of Environmental Impact on Human Health (TOXICAM), Botucatu, SP, Brazil; Department of Molecular Pharmacology, Albert Einstein College of Medicine, Bronx, NY, USA
| | - Tao Ke
- Department of Molecular Pharmacology, Albert Einstein College of Medicine, Bronx, NY, USA
| | - Ji-Chang Zhou
- School of Public Health (Shenzhen), Sun Yat-sen University, Shenzhen, Guangdong Province, China
| | - Julia Bornhorst
- Food Chemistry, Faculty of Mathematics and Natural Sciences, University of Wuppertal, Wuppertal, Germany
| | - Svetlana I Alekseenko
- I.I. Mechnikov North-Western State Medical University, St. Petersburg, Russia; K.A. Rauhfus Children's City Multidisciplinary Clinical Center for High Medical Technologies, St. Petersburg, Russia
| | - Jan Aaseth
- IM Sechenov First Moscow State Medical University (Sechenov University), Moscow, Russia; Research Department, Innlandet Hospital Trust, Brumunddal, Norway
| | - Ourania Anesti
- Laboratory of Toxicology, Medical School, University of Crete, Voutes, Heraklion, Crete, Greece; HERACLES Research Center on the Exposome and Health, Center for Interdisciplinary Research and Innovation, Aristotle University of Thessaloniki, Thermi, Greece
| | - Dimosthenis A Sarigiannis
- HERACLES Research Center on the Exposome and Health, Center for Interdisciplinary Research and Innovation, Aristotle University of Thessaloniki, Thermi, Greece; University School of Advanced Studies IUSS, Pavia, Italy
| | - Aristides Tsatsakis
- IM Sechenov First Moscow State Medical University (Sechenov University), Moscow, Russia; Laboratory of Toxicology, Medical School, University of Crete, Voutes, Heraklion, Crete, Greece
| | - Michael Aschner
- IM Sechenov First Moscow State Medical University (Sechenov University), Moscow, Russia; Department of Molecular Pharmacology, Albert Einstein College of Medicine, Bronx, NY, USA
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Huang HW, Lee CH, Yu HS. Arsenic-Induced Carcinogenesis and Immune Dysregulation. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2019; 16:ijerph16152746. [PMID: 31374811 PMCID: PMC6696092 DOI: 10.3390/ijerph16152746] [Citation(s) in RCA: 50] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/24/2019] [Revised: 07/28/2019] [Accepted: 07/29/2019] [Indexed: 12/16/2022]
Abstract
Arsenic, a metal ubiquitously distributed in the environment, remains an important global health threat. Drinking arsenic-contaminated water is the major route of human exposure. Exposure to arsenic contributes to several malignancies, in the integumentary, respiratory, hepatobiliary, and urinary systems. Cutaneous lesions are important manifestations after long-term arsenic exposure. Arsenical skin cancers usually herald the development of other internal cancers, making the arsenic-induced skin carcinogenesis a good model to investigate the progression of chemical carcinogenesis. In fact, only a portion of arsenic-exposed humans eventually develop malignancies, likely attributed to the arsenic-impaired immunity in susceptible individuals. Currently, the exact pathophysiology of arsenic-induced carcinogenesis remains elusive, although increased reactive oxidative species, aberrant immune regulations, and chromosome abnormalities with uncontrolled cell growth might be involved. This review discusses how arsenic induces carcinogenesis, and how the dysregulated innate and adaptive immunities in systemic circulation and in the target organs contribute to arsenic carcinogenesis. These findings offer evidence for illustrating the mechanism of arsenic-related immune dysregulation in the progression of carcinogenesis, and this may help explain the nature of multiple and recurrent clinical lesions in arsenic-induced skin cancers.
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Affiliation(s)
- Hsin-Wei Huang
- Department of Dermatology, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung 833, Taiwan
| | - Chih-Hung Lee
- Department of Dermatology, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung 833, Taiwan
| | - Hsin-Su Yu
- Graduate Institute of Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung 807, Taiwan.
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