The efficacy and safety of standardized allergen-removed Rhus verniciflua extract as maintenance therapy after first-line chemotherapy in patients with advanced non-small cell lung cancer

Rhus verniciflua stokes extract, a traditional herbal medicine, combined with first-line chemotherapy for unresectable locally advanced and metastatic pancreatic cancer: a prospective observational pilot study

Pancreatic cancer is among the most lethal cancers with limited treatment options. Traditional herbal medicines have been explored as potential adjunct therapies for enhancing the effectiveness of standard chemotherapies. In this study, we investigated the safety and efficacy of Rhus verniciflua Stokes (RVS) in combination with first-line chemotherapy for unresectable locally advanced and metastatic pancreatic cancer in a prospective setting. This prospective observational pilot study enrolled patients with confirmed inoperable stage III or IV pancreatic cancer undergoing or scheduled to receive 5-fluorouracil-based or gemcitabine-based first-line chemotherapy with RVS treatment and were followed up for up to 20 months. The primary endpoint was the safety profile of RVS, which was assessed through adverse events. The secondary endpoints included overall response rate (ORR), disease control rate (DCR), progression-free survival (PFS), and overall survival (OS). Cox regression analysis identified possible prognostic factors for PFS and OS. Of the enrolled 25 patients, 18 completed the follow-up. The median RVS treatment duration was 6.14 months (range 2.23-8.01 months) and the median RVS daily dose was 3.8 capsules/day (range 2.1-5.7 capsules/day). RVS showed a favorable safety profile, with only one case of non-severe pruritus possibly related to RVS treatment. No hepatotoxicity and nephrotoxicity related to RVS was reported. The ORR and DCR were 5.6% and 72.2%, respectively. The median PFS and OS were 7.24 months (95% CI: 3.15-12.9) and 13.9 months (95% CI: 1.14-27.72), respectively. Cox regression analysis showed that baseline CA19-9 level was an independent prognostic factor for OS, and the daily dose of RVS was an independent prognostic factor for PFS and OS. In conclusion, RVS can be administered safely to patients with unresectable locally advanced metastatic pancreatic cancer who are undergoing first-line chemotherapy, and the daily dose was an independent prognostic factor for cancer survival. Further randomized controlled studies are warranted to confirm the exact benefits of RVS treatment.

Clinical trial registration

https://cris.nih.go.kr, identifier KCT0007496.

Prolonged Progression-Free Survival in a Patient With Malignant Pleural Mesothelioma Following Korean Herbal Medicine Treatment Alone: A Case Report

Korean herbal medicine treatment (KHMT) involves treating with a combination of natural products, which have been used for thousands of years. Recently, it has been reported to be effective and safe in cancer patients. This case report demonstrates the efficacy of KHMT in a 49-year-old man with malignant pleural mesothelioma (MPM), a rare and highly aggressive cancer. The patient showed recurrent pleural effusion and was diagnosed with epithelioid MPM at cT3NxM0 stage III in December 2017. The multidisciplinary care team recommended multimodal treatment based on an extrapleural pneumonectomy, but he refused this because the treatment was aggressive and the effectiveness was unclear. He decided to undergo pemetrexed plus cisplatin chemotherapy if his condition worsened. He visited the Korean Medicine Cancer Center for alternative treatment options. A KHMT regimen, consisting of twice-daily Gunchil-dan and thrice-daily Bangam-tang, was initiated in December 2017. Since commencement of KHMT, computed tomography and X-ray imaging scans have shown no significant interval changes and progression. At 21 months into treatment (September 2019), no significant adverse events have occurred. Given that the median overall survival of patients with MPM is approximately 1 year, the ongoing progression-free survival of this patient for 21 months is relatively long. This case, therefore, suggests that KHMT is a potential treatment option for MPM patients.

Traditional uses, phytochemistry, and pharmacology of Toxicodendron vernicifluum (Stokes) F.A. Barkley - A review

ETHNOPHARMACOLOGICAL RELEVANCE

Toxicodendron vernicifluum (Stokes) F.A. Barkley (syn. Rhus verniciflua or vernicifera Stokes, Anacardiaceae) (RVS), the lacquer tree, also known as sumac, has been used in China, Japan and South Korea for thousands of years as a highly durable coating material and a traditional herbal medicine, which contains medicinal ingredients with anti-tumor, anti-inflammatory, antiviral, and anti-rheumatic activities.

AIM OF THIS REVIEW

This review intends to provide a comprehensive and critical appraisal of RVS, including its phytochemical data, botanical and pharmacological literature that support its therapeutic potential in treatment on human diseases, with emphasis on the isolation of natural occurring compounds and detailed pharmacological investigations.

MATERIALS AND METHODS

Specific information of RVS was collected by using the key words "Toxicodendron vernicifluum", "Rhus verniciflua Stokes", "Rhus vernicifera Stokes" and "Lacquer tree" through published scientific materials (including PubMed, ScienceDirect, Wiley, ACS, CNKI, Scifinder, Springer, Web of Science, Google Scholar, and Baidu Scholar) and other literature sources.

RESULTS

The major phytoconstituents, 175 of which are presented in this review, including flavonoids, urushiols, terpenes, phenolic acids and other types of compounds, of which flavonoids and urushiols are main components. The extracts and isolates purified from RVS showed a wide range of in vitro and in vivo pharmacological effects, such as anti-cancer, anti-oxidation, anti-inflammatory, antimicrobial, tyrosinase inhibition and so on.

CONCLUSION

The modern pharmacological research of RVS mainly focus on the pharmacological effects of crude extract or active constituents, of which the flavonoids are widely studied. However, there are few reports on the relationship between pharmacological effects and their structures. And at present, there is still a lack of researches that are of both effective and in-depth. Meanwhile, there is little research on quality control. Apart from the wood and lacquer, other botanical parts also need to be explored further. In addition to phenolic compounds, the study on other types of components in T. vernicifluum would start more sparks for the discovery of new bioactive principles.

Prognostic Value of Ferritin-to-Hemoglobin Ratio in Patients with Advanced Non-Small-Cell Lung Cancer

Background: Among commonly used biomarkers that reflect overall health in patients with cancer, hemoglobin is an iron-containing, oxygen-carrying protein in red blood cells, and serum ferritin is an iron-storage protein. This study investigated the ability of the ferritin-to-hemoglobin ratio to predict survival in patients with advanced non-small-cell lung cancer (NSCLC).

Methods: The medical records of patients with pathologically confirmed advanced NSCLC were retrospectively reviewed. The ferritin level, hemoglobin level, and ferritin-to-hemoglobin ratio at the initiation of treatment were investigated. After descriptive analysis of the ferritin-to-hemoglobin ratio, the optimal diagnostic cutoff value for survival was determined using receiver operating characteristic analysis. After dichotomizing patients according to the optimal cutoff value, the prognostic effect of the ferritin-to-hemoglobin ratio was assessed. Overall survival (OS) was calculated using Kaplan-Meier analysis and compared using log-rank tests. Cox proportional hazards regression was used to evaluate the prognostic effect with respect to survival.

Results: Of the enrolled patients, 91.3% had stage IV NSCLC, 42.0% had an Eastern Cooperative Oncology Group-performance status (ECOG-PS) score of 2, and 56.5% previously underwent systemic chemotherapy. The median OS of enrolled patients was 11.5 months. The range of the ferritin-to-hemoglobin ratio was 0.6-294.2, and the optimal cutoff value of the ferritin-to-hemoglobin ratio for survival was 13.0 (sensitivity, 58.5%; specificity, 80.0%; area under the curve = 0.68; P = 0.004). The median OS of patients with a low ferritin-to-hemoglobin ratio (<13.0) was 19.7 months, whereas that of patients with a high ferritin-to-hemoglobin ratio (≥13.0) was 8.5 months (P < 0.001). After eliminating confounding factors such as age, sex, ECOG-PS, histologic type, and C-reactive protein level, a high ferritin-to-hemoglobin ratio was significantly associated with poor survival. The multivariate proportional hazards model revealed that the ferritin-to-hemoglobin ratio was an independent prognostic marker for survival (hazard ratio, 1.91; 95% confidence interval, 1.27-2.88; P = 0.002).

Conclusion: The ferritin-to-hemoglobin ratio, a potential parameter of tumor progression, was a significant prognostic factor for OS, with a direct correlation to survival time in patients with advanced NSCLC.

Efficacy of Huaier granule in patients with breast cancer

BACKGROUND

Huaier extract has been demonstrated to exhibit potent anti-tumor effects in various types of cancer cells. However, the clinical benefit of Huaier granule in breast cancer has not been reported. In this study, we aimed to evaluate the efficacy of Huaier granule in breast cancer patients.

METHODS

Our study included 284 breast cancer patients treated with or without Huaier granule between January 2005 and October 2016 at Qilu Hospital, Shandong University, Jinan, China. Retrospective data obtained included demographics, clinicopathological characteristics, disease-free survival (DFS), serum concentrations of tumor markers, the Karnofsky performance scale (KPS), and incidences of emotional symptoms. DFS was the main outcome measure.

RESULTS

Of the patients included, 144 were classified into the control group and 140 into the Huaier group. Baseline characteristics were well balanced between the study arms. Median DFS was 91.43 months for control group and 112.61 months for Huaier group (hazard ratio (HR) = 2.97, 95% confidence interval (CI) = 1.57-5.61, p < 0.01). After Huaier granule treatment, the serum levels of tumor markers could be reduced to the normal range. In addition, breast cancer patients with Huaier granule treatment had higher KPS scores and less emotional symptoms.

CONCLUSIONS

Our data demonstrated that patients orally administrated Huaier granule got longer DFS. Furthermore, Huaier granule could reduce serum tumor markers, improve the functional status, and decrease the incidences of emotional symptoms in breast cancer patients. Therefore, Huaier granule was an effective therapy for women with breast cancer.

Significance of serum ferritin as a prognostic factor in advanced hepatobiliary cancer patients treated with Korean medicine: a retrospective cohort study

Background

Advanced hepatobiliary cancers are highly lethal cancers that require precise prediction in clinical practice. Serum ferritin level increases in malignancy and high serum ferritin level is associated with poor survival in various cancers. This study aimed to identify whether serum ferritin could independently predict the overall survival (OS) of patients with advanced hepatobiliary cancers.

Methods

The retrospective cohort study was performed by reviewing medical records of patients with advanced hepatobiliary cancers from June 2006 to September 2016. The demographic and clinicopathological characteristics as well as the biochemical markers were evaluated at the initiation of Korean medicine (KM) treatment. The OS was calculated using Kaplan-Meier estimates. The Cox proportional hazard model was used to identify the independent prognostic significance of serum ferritin for survival.

Results

The median OS of all subjects was 5.1 months (range, 0.5–114.9 months). The median OS of group with low ferritin levels and that with high ferritin levels was 7.5 months (range, 0.7–114.9 months) and 2.8 months (range, 0.5–22.8 months), respectively (P < 0.001). The results of the univariate analysis showed that the Eastern Cooperative Oncology Group Performance Status (ECOG-PS) (P = 0.002), tumor type (P = 0.001), prior treatment (P = 0.023), serum ferritin (P < 0.001), hemoglobin (P = 0.002), total bilirubin (P = 0.002), gamma-glutamyl transpeptidase (P = 0.007), albumin (P = 0.013), white blood cell (P = 0.002), and C-reactive protein (CRP) (P < 0.001) were significant factors for the patients’ survival outcome. On multivariate analysis controlling confounding factors, ferritin (P = 0.041), CRP (P = 0.010), ECOG-PS (P = 0.010), and tumor type (P = 0.018) were identified as independent prognostic factors for survival.

Conclusions

These results indicate that serum ferritin is a valid clinical biochemical marker to predict survival of patients with advanced hepatobiliary cancers.

Potential Efficacy of Allergen Removed Rhus Verniciflua Stokes Extract to Maintain Progression-Free Survival of Patients With Advanced Hepatobiliary Cancer

Hepatobiliary cancers are among the leading causes of cancer-related deaths worldwide. Most of the early-stage, surgically resectable cases show recurrence, and when they do, the prognosis is dismal with limited available treatment options. Here, we report three patients with relapsed hepatobiliary cancers who presented relatively long progression-free survival with the administration of a natural product, allergen removed Rhus verniciflua Stokes (RVS) extract. After commencement of RVS extract, they were progression-free for over 56 months in one case of recurred cholangiocarcinoma, and for over 16 and 114 months respectively, in two cases of advanced hepatocellular carcinoma. These cases suggest that the RVS extract could be a potential alternative for advanced hepatobiliary cancer that has no other available treatment.

Prognostic Significance of Host-related Biomarkers for Survival in Patients with Advanced Non-Small Cell Lung Cancer

OBJECTIVE

This study identified host-related prognostic biomarkers for survival in patients with advanced non-small cell lung cancer (NSCLC).

METHODS

This study was based on the retrospective review of the medical records of 135 patients with pathologically confirmed advanced NSCLC. The host-related biomarkers assessed in this study that reflected patient condition included hemoglobin (Hb) levels; platelet (PLT), neutrophil, lymphocyte, and monocyte counts; and ferritin concentrations. The overall survival (OS) was calculated by Kaplan-Meier analysis and compared using log-rank tests. Univariate and multivariate analyses of Cox proportional hazards regression were used to evaluate the prognostic impact for survival.

RESULTS

Of the enrolled patients, 91.1% had stage IV NSCLC, 42.2% had ECOG-PS scores of 2, and 57% had undergone multiple rounds of prior systemic therapy. The prognostic factors included low Hb concentration (men: Hb < 13 g/dL, women: Hb < 12 g/dL; p = 0.046), increased neutrophil count (> 7,700 cells/μL; p < 0.001), decreased lymphocyte count (≤ 1500 cells/μL; p = 0.011), increased monocyte count (> 800 cells/μL; p < 0.001), and high ferritin level (men: > 200 ng/mL, women: > 150 ng/mL; p < 0.001), which were associated with poor OS and increased hazard of mortality. The multivariate proportional hazards model revealed that lymphocyte count, monocyte count, and ferritin level were independent host-related prognostic biomarkers for survival. Increased monocyte count (HR, 3.15; 95% CI, 1.64-6.04; p < 0.001) and high ferritin level (HR, 1.81; 95% CI, 1.24-2.64; p = 0.002) were significantly associated with poor survival, whereas increased lymphocyte count (HR, 0.57; 95% CI, 0.40-0.83; p = 0.004) showed prolonged survival.

CONCLUSION

Immune factors, such as lymphocyte and monocyte counts, as well as serum ferritin levels, are significant host-related prognostic biomarkers for survival with direct relevance to survival time in patients with advanced NSCLC.

The Effect of Rhus verniciflua Stokes Extracts on Photo-Aged Mouse Skin

Background

Rhus verniciflua Stokes (RV) has traditionally been used in Korea as an indigenous food (Rhus chicken soup) and as an herbal medicinal plant. While the anticancer, antimicrobial, and anti-inflammatory properties of RV have been actively studied in the medical field, its antioxidant effects in the skin that resist the reactive oxygen species in keratinocytes and fibroblasts is less understood.

Objective

We designed to evaluate the effects of R. verniciflua Stokes extract (RVE) on the photo-aged skin by an in vitro experiment using human fibroblasts and an in vivo experiment using a photo-aged murine model.

Methods

For the in vitro experiments, human fibroblasts irradiated with ultraviolet (UV) B were treated with RVE or vehicle, and the growth levels and the expression level of type 1 procollagen were compared. For the in vivo experiment, photo-aged mice irradiated with UVB and UVA were administered drinking water with or without RVE, and histological changes and the expression level of type 1 procollagen and matrix metalloprotease (MMP)-13 were compared.

Results

In vitro experiments using fibroblasts irradiated with UVB showed that RVE promoted growth and significantly increased the expression of type 1 procollagen as compared to the control group. In the photo-aged mice, RVE increased collagen content in the dermis and promoted the synthesis of type 1 procollagen without any visible decrease in MMP-13 as compared to control group.

Conclusion

In addition to the previously reported antioxidant effects of RVE, oral intake of RVE effectively inhibited photo-aging in hairless mice by enhancing collagen synthesis.

Phytochemistry and Anticancer Potential of Notoginseng

Asian ginseng, American ginseng, and notoginseng are three major species in the ginseng family. Notoginseng is a Chinese herbal medicine with a long history of use in many Oriental countries. This botanical has a distinct ginsenoside profile compared to other ginseng herbs. As a saponin-rich plant, notoginseng could be a good candidate for cancer chemoprevention. However, to date, only relatively limited anticancer studies have been conducted on notoginseng. In this paper, after reviewing its anticancer data, phytochemical isolation and analysis of notoginseng is presented in comparison with Asian ginseng and American ginseng. Over 80 dammarane saponins have been isolated and elucidated from different plant parts of notoginseng, most of them belonging to protopanaxadiol or protopanaxatriol groups. The role of the enteric microbiome in mediating notoginseng metabolism, bioavailability, and pharmacological actions are discussed. Emphasis has been placed on the identification and isolation of enteric microbiome-generated notoginseng metabolites. Future investigations should provide key insights into notoginseng's bioactive metabolites as clinically valuable anticancer compounds.

Optimization of the extraction process for fermented Rhus verniciflua stokes using response surface methodology

Extraction conditions for extraction yield (Y 1 ), total phenolic content (TPC, Y 2 ), and inhibition rate in human gastric carcinoma cells (Y 3 ) were optimized using response surface methodology for fermented Rhus verniciflua stokes (FRV). Optimal extraction conditions for effective use of FRV as a biofunctional material in food and pharmaceutical industries were investigated. Independent variables were extraction temperature (X 1 =25-105°C), extraction time (X 2 =4-20 h), and the solvent to solid ratio (X 3 =10-30 mL/g). A second order polynomial model satisfactorily fitted experimental data with coefficient of determination (R 2 ) values of 0.9613, 0.9851, and 0.8038, respectively, for Y 1 , Y 2 , and Y 3 . Optimal conditions for the highest extraction yield of 2.37%, a total phenol content (TPC) value of 113.75 mg of tannic acid equivalents (TAE)/g, and an inhibition rate of 72.61% were derived at X 1 =89.95°C, X 2 =9.25 h, and X 3 =25 mL/g.

Cancer Chemoprevention Effects of Ginger and its Active Constituents: Potential for New Drug Discovery

Ginger is a commonly used spice and herbal medicine worldwide. Besides its extensive use as a condiment, ginger has been used in traditional Chinese medicine for the management of various medical conditions. In recent years, ginger has received wide attention due to its observed antiemetic and anticancer activities. This paper reviews the potential role of ginger and its active constituents in cancer chemoprevention. The phytochemistry, bioactivity, and molecular targets of ginger constituents, especially 6-shogaol, are discussed. The content of 6-shogaol is very low in fresh ginger, but significantly higher after steaming. With reported anti-cancer activities, 6-shogaol can be served as a lead compound for new drug discovery. The lead compound derivative synthesis, bioactivity evaluation, and computational docking provide a promising opportunity to identify novel anticancer compounds originating from ginger.

Ginseng Metabolites on Cancer Chemoprevention: An Angiogenesis Link?

Cancer is a leading cause of death in the United States. Angiogenesis inhibitors have been introduced for the treatment of cancer. Based on the fact that many anticancer agents have been developed from botanical sources, there is a significant untapped resource to be found in natural products. American ginseng is a commonly used herbal medicine in the U.S., which possesses antioxidant properties. After oral ingestion, natural ginseng saponins are biotransformed to their metabolites by the enteric microbiome before being absorbed. The major metabolites, ginsenoside Rg3 and compound K, showed significant potent anticancer activity compared to that of their parent ginsenosides Rb1, Rc, and Rd. In this review, the molecular mechanisms of ginseng metabolites on cancer chemoprevention, especially apoptosis and angiogenic inhibition, are discussed. Ginseng gut microbiome metabolites showed significant anti-angiogenic effects on pulmonary, gastric and ovarian cancers. This review suggests that in addition to the chemopreventive effects of ginseng compounds, as angiogenic inhibitors, ginsenoside metabolites could be used in combination with other cancer chemotherapeutic agents in cancer management.

Chemical Constituents, Quality Control, and Bioactivity of Epimedii Folium (Yinyanghuo)

Epimedii Folium (Yinyanghuo in Chinese) is one of the most commonly used traditional Chinese medicines. Its main active components are flavonoids, which exhibit multiple biological activities, such as promotion of bone formation and sexual function, protection of the nervous system, and prevention of cardiovascular diseases. Flavonoids also show anti-inflammatory and anticancer effects. Various effective methods, including genetic and chemical approaches, have been developed for the quality control of Yinyanghuo. In this review, the studies conducted in the last decade about the chemical constituents, quality control, and bioactivity of Yinyanghuo are summarized and discussed.

Trichosanthes kirilowii fruits inhibit non-small cell lung cancer cell growth through mitotic cell-cycle arrest

Lung cancer is the leading cause of cancer-related death worldwide. Non-small cell lung cancer (NSCLC) accounts for 80% of lung cancer cases and the reported overall 5-year survival rate is less than 5%. Natural medicines have attracted much attention due to their lower toxicity and fewer side effects. Trichosanthes kirilowii Maxim (TKM) fruits are commonly used in cancer treatment in combination with other Chinese medicinal herbs. However, little is known about their biological functions and mechanisms in NSCLC cells. In this study, we investigated the efficacy of TKM fruits in NSCLC cells using cell proliferation, invasion, migration, and anchorage independent assays and a Xenograft NSCLC tumor model, and explored the possible biological mechanism by flow cytometric analysis, cDNA microarray and real-time PCR. Results showed that TKM fruits significantly suppressed NSCLC cell proliferation, migration, invasion, tumorigenicity and tumor growth, and significantly extended the survival time of NSCLC-bearing mice. Flow cytometric analysis showed that TKM fruits significantly induced G2-M arrest, necrosis and apoptosis in NSCLC cells. cDNA microarray analysis revealed that TKM fruits regulated the differential expression of 544 genes, and the differential expression of selected genes was also confirmed. Gene ontology (GO) analysis showed that 18 of first 20 biological processes were involved in cell cycle and mitosis. These results indicate that TKM fruits have certain inhibitory effect on NSCLC cells through cell-cycle and mitosis arrest, and suggest that TKM fruits may be an important resource for developing new antitumor drugs, and a potent natural product for treating patients with NSCLC.

Integrating traditional medicine into modern inflammatory diseases care: multitargeting by Rhus verniciflua Stokes

Despite the fact that numerous researches were performed on prevention and treatment of inflammation related diseases, the overall incidence has not changed remarkably. This requires new approaches to overcome inflammation mediated diseases, and thus traditional medicine could be an efficacious source for prevention and treatment of these diseases. In this review, we discuss the contribution of traditional medicine, especially Rhus verniciflua Stokes, to modern medicine against diverse inflammation mediated diseases. Traditionally, this remedy has been used in Eastern Asia for the treatment of gastric problems, hepatic disorders, infectious diseases, and blood disorders. Modern science has provided the scientific basis for the use of Rhus verniciflua Stokes against such disorders and diseases. Various chemical constituents have been identified from this plant, including phenolic acid, and flavonoids. Cell-based studies have exhibited the potential of this as antibacterial, antioxidant, neuroprotective, anti-inflammatory, growth inhibitory, and anticancer activities. Enormous animal studies have shown the potential of this against proinflammatory diseases, neurodegenerative diseases, diabetes, liver diseases, and chemical insults. At the molecular level, this medicinal plant has been shown to modulate diverse cell-signaling pathways. In clinical studies, Rhus verniciflua Stokes has shown efficacy against various cancer patients such as colorectal, gastric, hepatic, renal, pancreatic, and pulmonary cancers. Thus, this remedy is now exhibiting activities in the clinic.