The role of bacteria and its derived biomaterials in cancer radiotherapy

Modeling cancer-microbiome interactions in vitro: A guide to co-culture platforms

The biology of cancer is characterized by an intricate interplay of cells originating not only from the tumor mass, but also its surrounding environment. Different microbial species have been suggested to be enriched in tumors and the impacts of these on tumor phenotypes is subject to intensive investigation. For these efforts, model systems that accurately reflect human-microbe interactions are rapidly gaining importance. Here we present a guide for selecting a suitable in vitro co-culture platform used to model different cancer-microbiome interactions. Our discussion spans a variety of in vitro models, including 2D cultures, tumor spheroids, organoids, and organ-on-a-chip platforms, where we delineate their respective advantages, limitations, and applicability in cancer microbiome research. Particular focus is placed on methodologies that facilitate the exposure of cancer cells to microbes, such as organoid microinjections and co-culture on microfluidic devices. We highlight studies offering critical insights into possible cancer-microbe interactions and underscore the importance of in vitro models in those discoveries. We anticipate the integration of more complex microbial communities and the inclusion of immune cells into co-culture systems to more accurately simulate the tumor microenvironment. The advent of ever more sophisticated co-culture models will aid in unraveling the mechanisms of cancer-microbiome interplay and contribute to exploiting their potential in novel diagnostic and therapeutic strategies.

Engineered Mycobacterium smegmatis expressing anti-PD-L1/IL-15 immunocytokine induces and activates specific antitumor immunity

BACKGROUND

Immune checkpoint inhibitors and cytokines have revolutionized tumor treatment but are still limited by dose-dependent toxicity and efficacy. In situ vaccine platforms based on intelligent microbes are promising therapeutic strategies that sustainably deliver drugs locally without causing severe systemic risks.

METHODS

In this study, we have innovatively engineered a non-pathogenic, adjuvant-acting Mycobacterium smegmatis (M. smegmatis) that co-expresses a programmed cell death-ligand 1 (PD-L1) inhibitor and an interleukin-15 (IL-15) cytokine complex containing the interleukin-15 receptor alpha (IL-15Rα) sushi domain (Ms-PDL1scfv-IL15).

RESULTS

We demonstrate that the fusion protein of PD-L1 inhibitor and IL-15 cytokine systemically binds mouse or human PD-L1 and maintains IL-15 stimulatory activity. The bifunctional Ms-PDL1scfv-IL15 overcomes resistance to PD-L1 blockade, recruits numerous immune cells in situ, induces dendritic cells (DCs) maturation, initiates the M1 antitumor polarization of macrophages, increases the proliferation and activation of natural killer cells and tumor-infiltrating CD8+ T cells, inhibits regulatory T cells, elicits abscopal effects, stimulates rapid tumor regression, prevents metastasis, and leads to long-term survival in several syngeneic tumor mouse models. We also found that the combination of Ms-PDL1scfv-IL15 with granulocyte-macrophage colony-stimulating factor (GM-CSF) synergistically stunted the tumor progress and stasis. Moreover, intratumoral administration of Ms-PDL1scfv-IL15 can capture tumor antigen fragments, and boost DCs presentation of antigens, which remarkably initiates tumor antigen-specific immune response, leading to durable tumor regression and specific antitumor immunity.

CONCLUSION

In summary, the engineered M. smegmatis can recruit and activate innate and adaptive antitumor immune responses, offering a potent cancer immunotherapy strategy to treat patients with cold tumors or resistance to checkpoint blockade.

TREM2 scFv-Engineering Escherichia coli Displaying Modulation of Macrophages to Boost Cancer Radio-Immunotherapy

Preoperative neoadjuvant radio-chemotherapy is a cornerstone in the treatment of low rectal cancer, yet its effectiveness can be limited by the insensitivity of some patients, profoundly impacting their quality of life. Through preliminary research, it is found that TREM2+ macrophages play a pivotal role in the non-responsiveness to immunotherapy. To address this challenge, a novel ionizing radiation-responsive delivery system is developed for the precise expression of anti-TREM2 single-chain antibody fragments (scFv) using an engineered probiotic, Escherichia coli Nissle 1917 (EcN), to modulate immunotherapy. The released anti-TREM2 scFv can be precisely targeted and delivered to the tumor site via the engineered EcN outer membrane vesicles (OMVs), thereby reversing the immunosuppressive tumor microenvironment and enhancing tumor therapeutic efficiency when used in combination with the αPD-L1 immune checkpoint inhibitor. Additionally, these engineered bacteria can be further modified to enhance the intestinal colonization capabilities through oral administration, thereby regulating the gut microbiota and its metabolic byproducts. Consequently, the ionizing radiation-responsive drug delivery system based on the engineered bacteria not only introduces a promising new therapeutic option for low rectal cancer but also showcases the potential to finely tune immune responses within the intricate tumor microenvironment, paving the way for innovative strategies in tumor radio-immunotherapy.

Bacterial oncolytic therapy as a novel approach for cancer treatment in humans

Cancer is the leading cause of death worldwide. Conventional cancer therapies, such as chemotherapy, radiation therapy, and immunotherapy often face certain limitations in treating cancer, such as toxicity, resistance, and ineffectiveness against different cancer types. Therefore, there is an urgent need for alternative treatment strategies. One emerging area of interest is the use of bacterial oncolytic therapy. It employs the natural properties of bacteria to target and destroy cancer cells. Both natural and genetically modified bacterial strains have shown potential to target the hypoxic regions of tumors, which are often resistant to conventional treatments. These bacteria also produce therapeutic molecules that induce cancer cell death. Furthermore, they can stimulate immune responses against tumors, making them helpful in developing cancer vaccines and exploiting antitumor bacterial metabolites. The versatility of bacterial oncolytic therapy extends beyond direct tumor targeting. It can be combined with conventional methods to enhance overall treatment efficacy. Moreover, bacteria can also serve as delivery vehicles for anticancer drugs, ensuring more precise targeting and reduced side effects. Different bacterial genera, such as Salmonella, Clostridium, Bifidobacterium, and Listeria, have demonstrated significant anticancer potential. This review aims to provide a comprehensive overview of bacterial oncolytic therapy, exploring its various applications and potential in conjunction with traditional cancer treatments.

Orthogonally Engineered Bacteria Capture Metabolically Labeled Tumor Antigens to Improve the Systemic Immune Response in Irradiated Tumors

In situ vaccination is considered a promising cancer immunotherapy strategy to elicit a tumor-specific T cell response. Live bacteria effectively enhanced the immune response in irradiated tumors as it can activate multiple immune cells. However, the adaptive immune response remains low since bacteria lack the efficient delivery of antigen to dendritic cells (DCs). Here, we show that tumor antigens can be metabolically labeled with azido groups in situ, allowing for their specific capture by orthogonally engineered Salmonella via bioorthogonal chemistry. Subsequently, these antigens are efficiently delivered to DCs through the active movement of the bacteria. Intratumorally injected engineered bacteria captured the labeled antigens and improved their presentation by DCs. This increased the proportion of antigen-specific CD8+ T cells in tumors, further resulting in systemic antitumor effects in the bilateral melanoma mouse model. The antitumor effects were abrogated in Batf3-/- mice or after CD8+ T cell depletion, indicating that systemic antitumor effects were dependent on adaptive immune responses. Overall, our work presents a strategy combining bacterial engineering and antigen labeling, which may guide the development of in situ vaccines in the future.

Bacterial and bacterial derivatives-based drug delivery systems: a novel approach for treating central nervous system disorders

INTRODUCTION

Bacteria and their derivatives show great potential as drug delivery systems due to their unique chemotaxis, biocompatibility, and targeting abilities. In CNS disease treatment, bacterial carriers can cross the blood-brain barrier (BBB) and deliver drugs precisely, overcoming limitations of traditional methods. Advances in genetic engineering, synthetic biology, and nanotechnology have transformed these systems into multifunctional platforms for personalized CNS treatment.

AREAS COVERED

This review examines the latest research on bacterial carriers for treating ischemic brain injury, neurodegenerative diseases, and gliomas. Bacteria efficiently cross the blood-brain barrier via active targeting, endocytosis, paracellular transport, and the nose-to-brain route for precise drug delivery. Various bacterial drug delivery systems, such as OMVs and bacterial ghosts, are explored for their design and application. Databases were searched in Google Scholar for the period up to December 2024.

EXPERT OPINION

Future developments in bacterial drug delivery will rely on AI-driven design and high-throughput engineering, enhancing treatment precision. Personalized medicine will further optimize bacterial carriers for individual patients, but challenges such as biosafety, immune rejection, and scalability must be addressed. As multimodal diagnostic and therapeutic strategies advance, bacterial carriers are expected to play a central role in CNS disease treatment, offering novel precision medicine solutions.

Engineered Bacteria for Disease Diagnosis and Treatment Using Synthetic Biology

Using synthetic biology techniques, bacteria have been engineered to serve as microrobots for diagnosing diseases and delivering treatments. These engineered bacteria can be used individually or in combination as microbial consortia. The components within these consortia complement each other, enhancing diagnostic accuracy and providing synergistic effects that improve treatment efficacy. The application of microbial therapies in cancer, intestinal diseases, and metabolic disorders underscores their significant potential. The impact of these therapies on the host's native microbiota is crucial, as engineered microbes can modulate and interact with the host's microbial environment, influencing treatment outcomes and overall health. Despite numerous advancements, challenges remain. These include ensuring the long-term survival and safety of bacteria, developing new chassis microbes and gene editing techniques for non-model strains, minimising potential toxicity, and understanding bacterial interactions with the host microbiota. This mini-review examines the current state of engineered bacteria and microbial consortia in disease diagnosis and treatment, highlighting advancements, challenges, and future directions in this promising field.

Microbiota-Induced Radioprotection: A Novel Approach to Enhance Human Radioresistance with In-Situ Genetically Engineered Gut Bacteria

The high sensitivity of living organic forms to space radiation remains the critical issue during spaceflight, to which they will be chronically exposed during months of interplanetary or even decades of interstellar spaceflight. In the human body, all actively dividing and poorly differentiated cells are always close to being damaged by radiological or chemical agents. The chronic exposure to ionizing radiation primarily causes changes in blood counts and intestinal damage such as fibrosis, obliterative vasculitis, changes in the gut microbiota, and atrophy or degeneration of muscle fibers. The project “MISS: Microbiome Induced Space Suit” was presented at the Giant Jamboree of the International Genetically Engineered Machine Competition 2021, with the aim to investigate the ability of the novel microbiota-mediated approach to enhance human resistance to ionizing radiation. The key innovative part of the project was the idea to create a novel radioprotector delivery mechanism based on human gut microbiota with the function of outer membrane vesicles (OMVs) secretion. The project concept proposed the feasibility of genetically modifying the human microbiota in situ through the delivery of genetic constructs to the host’s crypts using silicon nanoparticles with chemically modified surfaces. In this perspective, we discuss the advances in modifying microbiota-mediated secretory activity as a promising approach for radioprotection and as an alternative to hormone therapy and other health conditions that currently require continuous drug administration. Future clinical trials of in situ methods to genetic engineering the crypt microbiota may pave the way for indirect regulation of human cells.

Biomaterials to regulate tumor extracellular matrix in immunotherapy

The tumor extracellular matrix (ECM) provides physical support and influences tumor development, metastasis, and the tumor microenvironment, creating barriers to immune drug delivery and cell infiltration. Therefore, modulating or degrading the ECM is of significant importance to enhance the efficacy of tumor immunotherapy. This manuscript initially summarizes the main strategies and mechanisms of biomaterials in modulating various components of the ECM, including collagen, fibronectin, hyaluronic acid, and in remodeling the ECM. Subsequently, it discusses the benefits of biomaterials for immunotherapy following ECM modulation, such as promoting the infiltration of drugs and immune cells, regulating immune cell function, and alleviating the immunosuppressive microenvironment. The manuscript also briefly introduces the application of biomaterials that utilize and mimic the ECM for tumor immunotherapy. Finally, it addresses the current challenges and future directions in this field, providing a comprehensive overview of the potential and innovation in leveraging biomaterials to enhance cancer treatment outcomes. Our work will offer a comprehensive overview of ECM modulation strategies and their application in biomaterials to enhance tumor immunotherapy.

Microbial Therapeutics in Oncology: A Comprehensive Review of Bacterial Role in Cancer Treatment

Conventional cancer therapies, including chemotherapy, radiotherapy, and immunotherapy, have significantly advanced cancer treatment. However, these modalities often face limitations such as systemic toxicity, lack of specificity, and the emergence of resistance. Recent advancements in genetic engineering and synthetic biology have rekindled interest in using bacteria as a novel therapeutic approach in oncology. This comprehensive review explores the potential of microbial therapeutics, particularly bacterial therapies, in the treatment of cancer. Bacterial therapies offer several unique advantages, such as the ability to selectively target and colonize hypoxic and necrotic regions of tumors, areas typically resistant to conventional treatments. The review delves into the mechanisms through which bacteria exert antitumor effects, including direct tumor cell lysis, modulation of the immune response, and delivery of therapeutic agents like cytotoxins and enzymes. Various bacterial species, such as Salmonella, Clostridium, Lactobacillus, and Listeria, have shown promise in preclinical and clinical studies, demonstrating diverse mechanisms of action and therapeutic potential. Moreover, the review discusses the challenges associated with bacterial therapies, such as safety concerns, immune evasion, and the need for precise targeting, and how recent advances in genetic engineering are being used to overcome these hurdles. Current clinical trials and combination strategies with conventional therapies are also highlighted to provide a comprehensive overview of the ongoing developments in this field. In conclusion, while bacterial therapeutics present a novel and promising avenue in cancer treatment, further research and clinical validation is required to fully realize their potential. This review aims to inspire further exploration into microbial oncology, paving the way for innovative and more effective cancer therapies.

Harnessing Bacterial Membrane Components for Tumor Vaccines: Strategies and Perspectives

Tumor vaccines stand at the vanguard of tumor immunotherapy, demonstrating significant potential and promise in recent years. While tumor vaccines have achieved breakthroughs in the treatment of cancer, they still encounter numerous challenges, including improving the immunogenicity of vaccines and expanding the scope of vaccine application. As natural immune activators, bacterial components offer inherent advantages in tumor vaccines. Bacterial membrane components, with their safer profile, easy extraction, purification, and engineering, along with their diverse array of immune components, activate the immune system and improve tumor vaccine efficacy. This review systematically summarizes the mechanism of action and therapeutic effects of bacterial membranes and its derivatives (including bacterial membrane vesicles and hybrid membrane biomaterials) in tumor vaccines. Subsequently, the authors delve into the preparation and advantages of tumor vaccines based on bacterial membranes and hybrid membrane biomaterials. Following this, the immune effects of tumor vaccines based on bacterial outer membrane vesicles are elucidated, and their mechanisms are explained. Moreover, their advantages in tumor combination therapy are analyzed. Last, the challenges and trends in this field are discussed. This comprehensive analysis aims to offer a more informed reference and scientific foundation for the design and implementation of bacterial membrane-based tumor vaccines.

Engineered bacteria breach tumor physical barriers to enhance radio-immunotherapy

Radiotherapy widely applied for local tumor therapy in clinic has been recently reinvigorated by the discovery that radiotherapy could activate systematic antitumor immune response. Nonetheless, the endogenous radio-immune effect is still incapable of radical tumor elimination due to the prevention of immune cell infiltration by the physical barrier in tumor microenvironment (TME). Herein, an engineered Salmonella secreting nattokinase (VNPNKase) is developed to synergistically modulate the physical and immune characteristics of TME to enhance radio-immunotherapy of colon tumors. The facultative anaerobic VNPNKase enriches at the tumor site after systemic administration, continuously secreting abundant NKase to degrade fibronectin, dredge the extracellular matrix (ECM), and inactivate cancer-associated fibroblasts (CAFs). The VNPNKase- dredged TME facilitates the infiltration of CD103+ dendritic cells (DCs) and thus the presentation of tumor-associated antigens (TAAs) after radiotherapy, recruiting sufficient CD8+ T lymphocytes to specifically eradicate localized tumors. Moreover, the pre-treatment of VNPNKase before radiotherapy amplifies the abscopal effect and achieves a long-term immune memory effect, preventing the metastasis and recurrence of tumors. Our research suggests that this strategy using engineered bacteria to breach tumor physical barrier for promoting immune cell infiltration possesses great promise as a translational strategy to enhance the effectiveness of radio-immunotherapy in treating solid tumors.

Harnessing and Mimicking Bacterial Features to Combat Cancer: From Living Entities to Artificial Mimicking Systems

Bacterial-derived micro-/nanomedicine has garnered considerable attention in anticancer therapy, owing to the unique natural features of bacteria, including specific targeting ability, immunogenic benefits, physicochemical modifiability, and biotechnological editability. Besides, bacterial components have also been explored as promising drug delivery vehicles. Harnessing these bacterial features, cutting-edge physicochemical and biotechnologies have been applied to attenuated tumor-targeting bacteria with unique properties or functions for potent and effective cancer treatment, including strategies of gene-editing and genetic circuits. Further, the advent of bacteria-inspired micro-/nanorobots and mimicking artificial systems has furnished fresh perspectives for formulating strategies for developing highly efficient drug delivery systems. Focusing on the unique natural features and advantages of bacteria, this review delves into advances in bacteria-derived drug delivery systems for anticancer treatment in recent years, which has experienced a process from living entities to artificial mimicking systems. Meanwhile, a summary of relative clinical trials is provided and primary challenges impeding their clinical application are discussed. Furthermore, future directions are suggested for bacteria-derived systems to combat cancer.

Biomaterials-mediated radiation-induced diseases treatment and radiation protection

In recent years, the intersection of the academic and medical domains has increasingly spotlighted the utilization of biomaterials in radioactive disease treatment and radiation protection. Biomaterials, distinguished from conventional molecular pharmaceuticals, offer a suite of advantages in addressing radiological conditions. These include their superior biological activity, chemical stability, exceptional histocompatibility, and targeted delivery capabilities. This review comprehensively delineates the therapeutic mechanisms employed by various biomaterials in treating radiological afflictions impacting the skin, lungs, gastrointestinal tract, and hematopoietic systems. Significantly, these nanomaterials function not only as efficient drug delivery vehicles but also as protective agents against radiation, mitigating its detrimental effects on the human body. Notably, the strategic amalgamation of specific biomaterials with particular pharmacological agents can lead to a synergistic therapeutic outcome, opening new avenues in the treatment of radiation- induced diseases. However, despite their broad potential applications, the biosafety and clinical efficacy of these biomaterials still require in-depth research and investigation. Ultimately, this review aims to not only bridge the current knowledge gaps in the application of biomaterials for radiation-induced diseases but also to inspire future innovations and research directions in this rapidly evolving field.

Nanozyme-Coated Bacteria Hitchhike on CD11b+ Immune Cells to Boost Tumor Radioimmunotherapy

Bacterial-based delivery strategies have recently emerged as a unique research direction in the field of drug delivery. However, bacterial vectors are quickly phagocytosed by immune cells after entering the bloodstream. Taking advantage of this phenomenon, herein, this work seeks to harness the potential of immune cells to delivery micron-sized bacterial vectors, and find that inactivated bacterial can accumulate at tumor-site after intravenous injection through CD11b+ cells hitchhiking. To this end, this work then designs a gold-platinum bimetallic nanozyme coated bacterial vector (Au-Pt@VNP20009, APV). Utilizing strong tumor inflammatory response induced by low dose X-rays, this work further heightens the ability of CD11b+ immune cells to assist APV hitchhiking for tumor-targeted delivery, which can significantly relieve tumor hypoxia and immunosuppression, and inhibit tumor growth and metastasis. This work elucidates the potential mechanisms of bacterial vector targeted delivery, opening up new horizons for bacterial vector delivery strategies and clinical tumor radioimmunotherapy.

Bacterial therapies at the interface of synthetic biology and nanomedicine

Bacteria are emerging as living drugs to treat a broad range of disease indications. However, the inherent advantages of these replicating and immunostimulatory therapies also carry the potential for toxicity. Advances in synthetic biology and the integration of nanomedicine can address this challenge through the engineering of controllable systems that regulate spatial and temporal activation for improved safety and efficacy. Here, we review recent progress in nanobiotechnology-driven engineering of bacteria-based therapies, highlighting limitations and opportunities that will facilitate clinical translation.

Anti-tumor Effects of Cisplatin Synergist in Combined Treatment with Clostridium novyi-NT Spores Against Hypoxic Microenvironments in a Mouse Model of Cervical Cancer Caused by TC-1 Cell Line

Purpose

Despite the development of anti-human papillomavirus (HPV) vaccines, cervical cancer is still a common disease in women, especially in developing countries. The presence of a hypoxic microenvironment causes traditional treatments to fail. In this study, we presented a combined treatment method based on the chemotherapeutic agent cisplatin and Clostridium novyi-NT spores to treat normoxic and hypoxic areas of the tumor.

Methods

TC-1 Cell line capable of expressing HPV-16 E6/7 oncoproteins was subcutaneously transplanted into female 6-8 week old C57/BL6 mice. The tumor-bearing mice were randomly divided into four groups and treated with different methods after selecting a control group. Group 1: Control without treatment (0.1 mL sterile PBS intratumorally), Group: C. novyi-NT (107 C. novyi-NT). Group 3: Receives cisplatin intraperitoneally (10 mg/kg). Fourth group: Intratumoral administration of C. novyi-NT spores + intraperitoneal cisplatin. Western blot analysis was used to examine the effects of anti-hypoxia treatment and expression of hypoxia-inducible factor 1 (HIF-1) and vascular endothelial growth factor (VEGF) proteins.

Results

The results clearly showed that combined treatment based on C. novyi-NT and cisplatin significantly reduced the expression of HIF-1 alpha and VEGF proteins compared to cisplatin alone. At the same time, the amount of necrosis of tumor cells in the combined treatment increased significantly compared to the single treatment and the control. At the same time, the mitotic count decreased significantly.

Conclusion

Our research showed that developing a combined treatment method based on C. novyi-NT and cisplatin against HPV-positive cervical cancer could overcome the treatment limitations caused by the existence of hypoxic areas of the tumor.

Bacteria and Bacterial Components as Natural Bio-Nanocarriers for Drug and Gene Delivery Systems in Cancer Therapy

Bacteria and bacterial components possess multifunctional properties, making them attractive natural bio-nanocarriers for cancer diagnosis and targeted treatment. The inherent tropic and motile nature of bacteria allows them to grow and colonize in hypoxic tumor microenvironments more readily than conventional therapeutic agents and other nanomedicines. However, concerns over biosafety, limited antitumor efficiency, and unclear tumor-targeting mechanisms have restricted the clinical translation and application of natural bio-nanocarriers based on bacteria and bacterial components. Fortunately, bacterial therapies combined with engineering strategies and nanotechnology may be able to reverse a number of challenges for bacterial/bacterial component-based cancer biotherapies. Meanwhile, the combined strategies tend to enhance the versatility of bionanoplasmic nanoplatforms to improve biosafety and inhibit tumorigenesis and metastasis. This review summarizes the advantages and challenges of bacteria and bacterial components in cancer therapy, outlines combinatorial strategies for nanocarriers and bacterial/bacterial components, and discusses their clinical applications.

N-acetyl-L-tryptophan (NAT) provides protection to intestinal epithelial cells (IEC-6) against radiation-induced apoptosis via modulation of oxidative stress and mitochondrial membrane integrity

BACKGROUND

Ionizing radiation generates oxidative stress in biological systems via inducing free radicals. Gastro-intestinal system has been known for its high radiosensitivity. Therefore, to develop an effective radiation countermeasure for gastrointestinal system, N-acetyl L-tryptophan was evaluated for its radioprotective efficacy using intestinal epithelial cells-6 (IEC-6) cells as the experimental model.

METHODS AND RESULTS

Cellular metabolic and lysosomal activity of L-NAT and L-NAT treated irradiated IEC-6 cells were assessed by MTT and NRU staining, respectively. ROS and mitochondrial superoxide levels along with mitochondrial disruption were detected using specific fluorescent probes.  Endogenous antioxidants (CAT, SOD, GST, GPx) activities were determined using calorimetric assay.  Apoptosis and DNA damage were assessed using flow cytometery and Comet assay, respectively. Results of the study were demonstrated that L-NAT pre-treatment (- 1 h) to irradiated IEC-6 cells significantly contribute to ensuring 84.36% to 87.68% (p < 0.0001) survival at 0.1 μg/mL concentration against LD50 radiation dose (LD50; 20 Gy). Similar level of radioprotection was observed with a clonogenic assay against γ radiation (LD50; 5 Gy). L-NAT was found to provide radioprotection by neutralizing radiation-induced oxidative stress, enhancing antioxidant enzymes (CAT, SOD, GST, and GPx), and protecting DNA from radiation-induced damage. Further, significant restoration of mitochondrial membrane integrity along with apoptosis inhibition was observed with irradiated IEC-6 cells upon L-NAT pretreatment.