Clinical efficacy and safety of NSCLC ancillary treatment with compound Kushen injection through immunocompetence regulation: A systematic review and meta-analysis

Clinical efficacy and safety of Chinese herbal injections in combination with platinum-based chemotherapy for advanced non-small cell lung cancer: a systematic review and meta-analysis of 140 randomized controlled trials

Background and aim

Chinese herbal injection (CHI) is a widely used preparation for advanced non-small cell lung cancer (NSCLC) treatment to alleviate the adverse drug reactions and enhance the clinical efficacy of chemotherapy. However, its efficacy and safety in combination with platinum-based chemotherapy (PBC) remain poorly understood owing to the lack of high-level evidence in the face of a wide variety of CHIs. Therefore, in this study, we aimed to explore the efficacy and safety of CHIs in combination with PBC regimens in the treatment of mid- and advanced NSCLC.

Methods

Systematic evaluation and meta-analysis were conducted as per the Preferred Reporting Project for Systematic Evaluation and Meta-Analysis Protocols (PRISMA-P). Seven databases were comprehensively searched for relevant randomized controlled trials (RCTs) through August 1, 2022. The quality of each study was evaluated based on the Cochrane Handbook for Systematic Reviews of Interventions. Statistical analysis was performed using Revman 5.3, with dichotomies expressed as risk ratio (RR) and 95% confidence interval (CI). Objective response rate (ORR) and disease control rate (DCR) were selected as the primary outcomes, with quality of life (QoL) and toxic side effects as secondary outcomes.

Results

A total of 140 RCTs were included in this study. The results of the meta-analysis suggested that, compared with PBC alone, PBC combined with CHIs significantly improved the ORR (RR=1.35, 95% CI: 1.30-1.41, P<0.001), DCR (RR=1.15, 95% CI: 1.13-1.18, P<0.001) and QoL (RR=1.29, 95% CI: 1.24-1.33, P<0.001). Moreover, the combination treatment reduced chemotherapy-induced leukopenia (RR=0.69, 95% CI: 0.64-0.75, P<0.001), anemia (RR=0.70, 95% CI: 0.62-0.79, P<0.001), thrombocytopenia (RR=0.68, 95% CI: 0.62-0.75, P<0.001), nausea and vomiting (RR=0.69, 95% CI: 0.63-0.76, P<0.001), diarrhea (RR=0.59, 95% CI: 0.48-0.73, P<0.001), and constipation (RR=0.68, 95% CI: 0.54-0.86, P=0.001).

Conclusion

According to the available evidence, CHIs in combination with PBC can improve clinical efficacy and reduce the toxic side effects in the treatment of advanced NSCLC. However, considering the study's limitations, more rigorous and high-quality studies are needed to further confirm the results.

Systematic review registration

https://inplasy.com/inplasy-2022-1-0104/, identifier INPLASY202210104.

Adjunctive effect of compound Kushen injection for cancer: An overview of systematic reviews

ETHNOPHARMACOLOGICAL RELEVANCE

Compound Kushen (Sophora flavescens Aiton) Injection (CKI) is a Chinese herbal injection made from extracts of Kushen and Baituling (Heterosmilax japonica Kunth), containing matrine (MAT), oxymatrine (OMT) and other alkaloids with significant anti-tumor activity, and is widely used as an adjuvant treatment for cancer in China.

AIM OF THE STUDY

The existing systematic reviews/meta-analyses (SRs/MAs) were re-evaluated to provide a reference for the clinical application of CKI.

MATERIALS AND METHODS

SRs/MAs of CKI adjuvant therapy for cancer-related diseases were searched in four English language databases: PubMed, Embase, Web of Science, and Cochrane Library, all from the time of database construction to October 2022. 5 researchers independently conducted literature search and identification according to the inclusion criteria, and the data of the final literature were independently extracted, and finally the AMSTAR 2 tool, PRISMA statement and GRADE classification were used to evaluate the methodological quality of the included SRs/MAs, the degree of completeness of reporting and the quality of evidence for outcome indicators. Database registration: PROSPERO ID：CRD42022361349.

RESULTS

Eighteen SRs/MAs were finally included, with studies covering non-small cell lung cancer, primary liver cancer, gastric cancer, colorectal cancer, breast cancer, head and neck tumors, and cancer-related bone pain. The evaluation showed that the methodological quality of the included literature was extremely low, but most of the literature reported relatively complete entries; nine clinical effectiveness indicators for non-small cell lung cancer and digestive system tumors were rated as moderate in the GRADE quality of evidence, and the quality of other outcomes was low to very low.

CONCLUSION

CKI is a potentially effective drug for the adjuvant treatment of neoplastic diseases and may be more convincing for the adjuvant treatment of non-small cell lung cancer and digestive system tumors; however, due to the low methodological and evidentiary quality of the current SRs, their effectiveness needs to be confirmed by more high-quality evidence-based medical evidence.

A real-world study and network pharmacology analysis of EGFR-TKIs combined with ZLJT to delay drug resistance in advanced lung adenocarcinoma

OBJECTIVE

This study aimed to explore the efficacy and safety of combining epidermal growth factor receptor tyrosine kinase inhibitors (EGFR-TKIs) with ZiLongJin Tablet (ZLJT) in delaying acquired resistance in advanced EGFR-mutant lung adenocarcinoma (LUAD) patients. Furthermore, we employed network pharmacology and molecular docking techniques to investigate the underlying mechanisms.

METHODS

A retrospective comparative study was conducted on stage IIIc/IV LUAD patients treated with EGFR-TKIs alone or in combination with ZLJT at the Second Affiliated Hospital of the Air Force Medical University between January 1, 2017, and May 1, 2023. The study evaluated the onset of TKI resistance, adverse reaction rates, safety indicators (such as aspartate aminotransferase, alanine aminotransferase, and creatinine), and inflammatory markers (neutrophil-to-lymphocyte ratio and platelet-to-lymphocyte ratio) to investigate the impact of EGFR-TKI combined with ZLJT on acquired resistance and prognostic indicators. Additionally, we utilized the Traditional Chinese Medicine Systems Pharmacology Database and Analysis Platform, the Bioinformatics Analysis Tool for Molecular Mechanism of Traditional Chinese Medicine, PubChem, UniProt, and Swiss Target Prediction databases to identify the active ingredients and targets of ZLJT. We obtained differentially expressed genes related to EGFR-TKI sensitivity and resistance from the Gene Expression Omnibus database using the GSE34228 dataset, which included sensitive (n = 26) and resistant (n = 26) PC9 cell lines. The "limma" package in R software was employed to detect DEGs. Based on this, we constructed a protein‒protein interaction network, performed gene ontology and KEGG enrichment analyses, and conducted pathway network analysis to elucidate the correlation between the active ingredients in ZLJT and signaling pathways. Finally, molecular docking was performed using AutoDockVina, PYMOL 2.2.0, and Discovery Studio Client v19.1.0 software to simulate spatial and energy matching during the recognition process between predicted targets and their corresponding compounds.

RESULTS

(1) A total of 89 patients were included, with 40 patients in the EGFR-TKI combined with ZLJT group (combination group) and 49 patients in the EGFR-TKI alone group (monotherapy group). The baseline characteristics of the two groups were comparable. There was a significant difference in the onset of resistance between the combination group and the monotherapy group (P < 0.01). Compared to the monotherapy group, the combination group showed a prolongation of 3.27 months in delayed acquired resistance. There was also a statistically significant difference in the onset of resistance to first-generation TKIs between the two groups (P < 0.05). (2) In terms of safety analysis, the incidence of adverse reactions related to EGFR-TKIs was 12.5% in the combination group and 14.3% in the monotherapy group, but this difference was not statistically significant (P > 0.05). There were no statistically significant differences in serum AST, ALT, CREA, TBIL, ALB and BUN levels between the two groups after medication (P > 0.05). (3) Regarding inflammatory markers, there were no statistically significant differences in the changes in neutrophil-to-lymphocyte Ratio(NLR) and Platelet-to-lymphocyte Ratio(PLR) values before and after treatment between the two groups (P > 0.05). (4) Network pharmacology analysis identified 112 active ingredients and 290 target genes for ZLJT. From the GEO database, 2035 differentially expressed genes related to resistant LUAD were selected, and 39 target genes were obtained by taking the intersection. A "ZLJT-compound-target-disease" network was successfully constructed using Cytoscape 3.7.0. GO enrichment analysis revealed that ZLJT mainly affected biological processes such as adenylate cyclase-modulating G protein-coupled receptor. In terms of cellular components, ZLJT was associated with the cell projection membrane. The molecular function primarily focused on protein heterodimerization activity. KEGG enrichment analysis indicated that ZLJT exerted its antitumor and anti-drug resistance effects through pathways such as the PI3K-Akt pathway. Molecular docking showed that luteolin had good binding activity with FOS (-9.8 kJ/mol), as did tanshinone IIA with FOS (-9.8 kJ/mol) and quercetin with FOS (-8.7 kJ/mol).

CONCLUSION

ZLJT has potential antitumor progression effects. For patients with EGFR gene-mutated non-small cell LUAD, combining ZLJT with EGFR-TKI treatment can delay the occurrence of acquired resistance. The underlying mechanisms may involve altering signal transduction pathways, blocking the tumor cell cycle, inhibiting tumor activity, enhancing cellular vitality, and improving the bioavailability of combination therapy. The combination of EGFR-TKI and ZLJT represents an effective approach for the treatment of tumors using both Chinese and Western medicine.

A new strategy to identify ADAM12 and PDGFRB as a novel prognostic biomarker for matrine regulates gastric cancer via high throughput chip mining and computational verification

BACKGROUND

Gastric cancer is a life-threatening disease that poses a serious risk to human health. Although there are numerous molecular targets for gastric cancer in clinical practice, they often exhibit low specificity and sensitivity. Consequently, this can result in a low early diagnosis rate, delayed treatment, and poor prognosis for patients with gastric cancer. Hence, it remains crucial to identify more precise diagnostic markers for this disease.

METHODS

This study utilized ceRNA chips and bioinformatics methods to investigate the key genes and mechanisms involved in matrine intervention in gastric cancer cells.

RESULTS

ADAM12 and PDGFRB are the key genes that are down-regulated after matrine intervention in gastric cancer cells. By conducting bioinformatics analysis, two ceRNA regulatory axes were identified, which are associated with the prognosis of gastric cancer. These axes are lncRNA DGCR5/hsa-miR-206/ADAM12 and circRNA ITGA3/hsa-miR-24-3p/PDGFRB.

CONCLUSION

The low expression of ADAM12 may weaken the digestion of extracellular matrix (ECM) molecules, which can result in the invasion and metastasis of tumor cells. This occurs without the catalysis of ECM proteases, thereby impacting the invasion and metastasis of gastric cancer cells. Additionally, the analysis of immune infiltration suggests that ADAM12 and PDGFRB may influence changes in the tumor immune microenvironment, thereby affecting the occurrence and development of gastric cancer. This study contributes to a deeper understanding of the role of the matrine-related ceRNA network in gastric cancer, providing a reference for clinical diagnosis and treatment. It holds significant importance in discovering new drug treatment targets.

Sophflarine A, a novel matrine-derived alkaloid from Sophora flavescens with therapeutic potential for non-small cell lung cancer through ROS-mediated pyroptosis and autophagy

BACKGROUND

Novel compounds and more efficient treatment options are urgently needed for the treatment of non-small cell lung cancer (NSCLC). The decoction of Sophora flavescens has been used to treat NSCLC in the clinic, and matrine-type alkaloids are generally considered to be the key pharmacodynamic material basis. But the previous study showed that common matrine-type alkaloids exhibit significant cytotoxicity only when at concentrations close to the millimolar (mM) level. The key antitumor alkaloids in S. flavescens seem to have not yet been revealed.

PURPOSE

The aim of this study was to screen water-soluble matrine alkaloid with novel skeleton and enhanced activity from S. flavescens, and to reveal the pharmacological mechanism of its therapeutic effect on NSCLC.

METHODS

Alkaloid was obtained from S. flavescens by chromatographic separation methods. The structure of alkaloid was determined by spectroscopic methods, and single-crystal X-ray diffraction. The mechanism of anti-NSCLC in vitro with cellular models was evaluated by MTT assay, western blotting, cell migration and invasion assay, plate colony-formation assay, tube formation assay, immunohistochemistry assay, hematoxylin and eosin staining. The antitumor efficacy in vivo was test in NSCLC xenograft models.

RESULTS

A novel water-soluble matrine-derived alkaloid incorporating 6/8/6/6 tetracyclic ring system, named sophflarine A (SFA), was isolated from the roots of S. flavescens. SFA had significantly enhanced cytotoxicity compared with the common matrine-type alkaloids, having an IC₅₀ value of 11.3 μM in A549 and 11.5 μM in H820 cells at 48 h. Mechanistically, SFA promoted NSCLC cell death by inducing pyroptosis via activating the NLRP3/caspase-1/GSDMD signaling pathway, and inhibited cancer cell proliferation by increasing the ROS production to activate autophagy via blocking the PI3K/AKT/mTOR signaling pathway. Additionally, SFA also inhibited NSCLC cell migration and invasion by suppressing EMT pathway, and inhibited cancer cell colony formation and human umbilical vein endothelial cell angiogenesis. In concordance with the above results, SFA treatment blocked tumor growth in an A549 cell-bearing orthotopic mouse model.

CONCLUSION

This study revealed a potential therapeutic mechanism of a novel matrine-derived alkaloid, which not only described a rational explanation for the clinical utilization of S. flavescens, but also provided a potential candidate compound for NSCLC treatment.