Sentinel lymph node biopsy using dye alone method is reliable and accurate even after neo-adjuvant chemotherapy in locally advanced breast cancer--a prospective study

Evaluation of Axilla With Sentinel Lymph Node Biopsy (Using Methylene-Blue) and Reverse Axillary Mapping (Using Fluorescein) to Validate Optimum and Safe Axillary Dissection in Breast Cancer

Introduction Sentinel lymph node biopsy (SLNB) has replaced routine axillary lymph node dissection (ALND) in node-negative axillae. In cases where the axilla needs to be dissected, one must dissect below the uppermost intercostobrachial nerve (ICBN) to avoid damaging arm lymphatics. Methods One milliliter of methylene blue dye was injected around the areola. Fluorescein dye (1 ml) was injected into the upper arm. After SLNB and ALND, the axilla was visualized under blue light. The location of fluorescent lymphatics was mapped with respect to the uppermost ICBN. Results The identification rate of sentinel lymph nodes and arm lymphatics was 100%. Arm lymphatics were above ICBN in 86.7%. The false negative rate of SLNB was 13%, with sensitivity and specificity of 87% and 100%, respectively. Conclusions SLNB using the single-dye technique has results comparable to dual agent studies that utilize blue dye and radioactive colloid. The uppermost ICBN could define the superior limit of axillary dissection.

The value of sentinel lymph-node biopsy in women with node-positive breast cancer at diagnosis and node-negative tumour after neoadjuvant therapy: a systematic review

PURPOSE

To conduct a systematic review to analyse the performance of the sentinel lymph-node biopsy (SLNB) in women with node-positive breast cancer at diagnosis and node-negative tumour after neoadjuvant therapy, compared to axillary lymph-node dissection.

METHODS

The more relevant databases were searched. Main outcomes were false-negative rate (FNR), sentinel lymph-node identification rate (SLNIR), negative predictive value (NPV), and accuracy. We conducted meta-analyses when appropriate.

RESULTS

Twenty studies were included. The pooled FNR was 0.14 (95% CI 0.11-0.17), the pooled SLNIR was 0.89 (95% CI 0.86-0.92), NPV was 0.83 (95% CI 0.79-0.87), and summary accuracy was 0.92 (95% CI 0.90-0.94). SLNB performed better when more than one node was removed and double mapping was used.

CONCLUSIONS

SLNB can be performed in women with a node-negative tumour after neoadjuvant therapy. It has a better performance when used with previous marking of the affected node and with double tracer.

Outcomes of Sentinel Node Biopsy for Women with Breast Cancer After Neoadjuvant Therapy: Systematic Review and Meta-Analysis of Real-World Data

BACKGROUND

Evidence on the accuracy of sentinel lymph node biopsy (SLNB) after neoadjuvant therapy (NAT) for patients with breast cancer is inconclusive. This study reviewed the real-world data to determine the acceptability of SLNB after NAT.

METHODS

The study searched for articles in the PubMed, EMBASE, and Cochrane Library databases. The primary outcomes were the identification rate for sentinel lymph nodes (SLNs) and the false-negative rate (FNR) for SLNB. The study also evaluated the FNR in subgroups defined by tumor stage, nodal stage, hormone receptor status, human epidermal growth factor receptor-2 status, tumor response, mapping technique, and number of SLNs removed.

RESULTS

The study retrieved 61 prospective and 18 retrospective studies with 10,680 initially cN± patients. The pooled estimate of the identification rate was 0.906 (95 % confidence interval [CI], 0.891-0.922), and the pooled FNR was 0.118 (95 % CI, 0.103-0.133). In subgroup analysis, the FNR was significantly higher for the patients with estrogen receptor (ER)-negative status and fewer than three SLNs removed. The FNR did not differ significantly between the patients with and those without complete tumor response. Among the patients with initial clinical negative axillary lymph nodes, the incidence of node metastasis was 26.8 % (275/1041) after NAT.

CONCLUSION

Real-world evidence indicates that the FNR of SLNB after NAT in breast cancer is 11.8 %, exceeding only slightly the commonly adopted threshold of 10 %. The FNR is significantly higher for patients with ER-negative status and removal of fewer than three SLNs. Using a dual tracer and removing at least three SLNs may increase the accuracy of SLNB after NAT.

Feasibility and reliability of sentinel lymph node biopsy after neoadjuvant chemotherapy in breast cancer patients with positive axillary nodes at initial diagnosis: An up-to date meta-analysis of 3,578 patients

Purpose

Neoadjuvant chemotherapy (NACT) is increasingly adopted in the therapy of breast cancer (BC) patients with positive axillary nodes (cN+), but the reliability and feasibility of sentinel lymph node biopsy (SLNB) following NACT are still controversial. The objective of the present study is to conduct an updated meta-analysis on this issue.

Methods

A literature search was performed using PubMed, Cochrane, Embase, and Web of Science to identify papers published from January 1, 2000 to October 22, 2020 to research SLNB after NACT in BC patients. Studies that met the quality standard were enrolled for this meta-analysis.

Results

A total of 3578 participants from 27 trials were included in this meta-analysis. The pooled estimate of the identification rate (IR) for SLNB was 91 %, and the false negative rate (FNR) was 15 %. The pooled negative prediction value (NPV), accuracy, specificity, and sensitivity were 82 %, 89 %, 97 %, and 85 %, respectively. In subgroup analysis, the application of dual mapping could clearly decrease the FNR. The FNR was significantly high in the luminal types, and it declined as more sentinel lymph nodes (SLNs) were removed.

Conclusion

SLNB following NACT is now technically feasible for BC with cN+. However, it must be emphasized that the FNR is unacceptable high.

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We performed a meta-analysis to provide a consensus regarding the application of SLNB post-NACT in cN + patients.

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One comprehensive database search yielded 27 studies (3578 patients).

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The pooled estimate of IR for SLNB was 91 %, and FNR was 15 %.

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The application of dual mapping could clearly decrease the FNR.

Quercetin Loaded Nanoparticles in Targeting Cancer: Recent Development

The spread of metastatic cancer cell is the main cause of death worldwide. Cellular and molecular basis of the action of phytochemicals in the modulation of metastatic cancer highlights the importance of fruits and vegetables. Quercetin is a natural bioflavonoid present in fruits, vegetables, seeds, berries, and tea. The cancer-preventive activity of quercetin is well documented due to its anti-inflammatory, anti-proliferative and anti-angiogenic activities. However, poor water solubility and delivery, chemical instability, short half-life, and low-bioavailability of quercetin limit its clinical application in cancer chemoprevention. A better understanding of the molecular mechanism of controlled and regulated drug delivery is essential for the development of novel and effective therapies. To overcome the limitations of accessibility by quercetin, it can be delivered as nanoconjugated quercetin. Nanoconjugated quercetin has attracted much attention due to its controlled drug release, long retention in tumor, enhanced anticancer potential, and promising clinical application. The pharmacological effect of quercetin conjugated nanoparticles typically depends on drug carriers used such as liposomes, silver nanoparticles, silica nanoparticles, PLGA (Poly lactic-co-glycolic acid), PLA (poly(D,L-lactic acid)) nanoparticles, polymeric micelles, chitosan nanoparticles, etc. In this review, we described various delivery systems of nanoconjugated quercetin like liposomes, silver nanoparticles, PLGA (Poly lactic-co-glycolic acid), and polymeric micelles including DOX conjugated micelles, metal conjugated micelles, nucleic acid conjugated micelles, and antibody-conjugated micelles on in vitro and in vivo tumor models; as well as validated their potential as promising onco-therapeutic agents in light of recent updates.

Sentinel Lymph Node Biopsy in Locally Advanced Breast Cancer After Neoadjuvant Chemotherapy-an Indian Perspective

Sentinel lymph node biopsy (SLNB) alone in early breast cancer is an established standard of care. However, the same results have not been replicated in locally advanced breast cancer (LABC) after neoadjuvant chemotherapy (NACT). We aim to examine the feasibility of SLNB in LABC patients post NACT to determine identification rates (IR) and false negative rates (FNR). This was a single tertiary cancer center-based prospective study from February 2017 to November 2018. Forty-four patients with LABC (T3, T4 with N0 or N1) were studied and response after NACT was assessed. Only those patients who were N0 or who converted from N1 to N0 after NACT were included. Those patients who remained node positive after NACT directly proceeded with axillary dissection without SLNB and were excluded from the study. Demographic and clinical data is expressed in ratios and percentage and presented in table format. The median age at the time of study was 45.18 years. Most of the patients had T3 and above (97.7%) and N1 (86.3%) disease at the start of neoadjuvant therapy. The mean number of axillary lymph nodes dissected was 13.97. Dual method of sentinel lymph node mapping (methylene blue dye and radiolabeled colloid) was used in 26 (59.1%) patients. At least 1 SLN was identified in 86.4% patients with 100% identification in those patients in whom the dual method of SLN mapping was used. Median of 2 SLN was removed. Overall, false negative rate was 21.4%. FNR was high with the single method of SLN mapping (50% and 33.3% with methylene blue and radioactive colloid respectively) while it was considerably low when both were used simultaneously (11%). An average of 2 (range 0-4) SLN were identified and FNR were zero when 2 or more SLN were identified. Our study shows that SLNB in patients with LABC post NACT though viable cannot be recommended at present due to unacceptable high FNR. However, this should not dissuade us from exploring recurrence-free survival and overall survival associated with such IR and FNR albeit strictly under a clinical trial setting.

Optimization of sentinel lymph node identification techniques in the Indian setting: A randomized clinical trial

INTRODUCTION

The recommended technique of sentinel lymph node biopsy (SLNB) in breast cancer is a combination of blue dye and radiotracer. In the Indian scenario, SLNB is still not routinely practiced due to lack of nuclear medicine facilities and unavailability of isosulfan blue or patent blue violet (PBV). This study was conducted for optimizing SLN identification techniques by comparing the identification rate using PBV and methylene blue (MB) in combination with radiotracer.

MATERIALS AND METHODS

Single-blinded two-arm parallel design randomized control trial was conducted at an apex teaching and research medical institute in India. Patients with axillary LN-negative breast cancer were included. Blue dye and radio tracer were injected preoperatively, and SLNB was performed using a combination technique. Frozen section was performed. Demographic, clinical, radiological, operative, and histopathological data were recorded. Descriptive statistics were used to represent patient characteristics. Baseline characteristics for entire cohort and between groups were compared using Student's t-test for quantitative variables and Chi-square test for qualitative variables.

RESULTS

A total of 119 patients were randomized for mapping with MB and 118 patients with PBV between 2011 and 2015. SLN was identified in 116 patients with MB and 115 with PBV. SLN identification proportions were 97.4% (MB) and 96.6% (PBV). In patients undergoing axillary lymph node dissection, concordance with SLNB was 98.5% and 96.61% in MB and PBV, respectively. False-negative proportion for MB was 2.56% and 7.69% for PBV, respectively. The cost of MB is about INR 15 per ~10-mL vial. The cost of PBV is approximately ~$91 per ampoule (equivalent to approximately INR 8190).

CONCLUSION

SLNB using MB can be recommended as the technique of choice in low-resource settings.

Neoadjuvant chemotherapy in combination with surgery in the treatment of local advanced breast cancer

Objective:

To investigate the effect of neoadjuvant chemotherapy combined with surgery on locally advanced breast cancer and its prognosis.

Methods:

One hundred and fifty-four patients with locally advanced breast cancer who were admitted to our hospital from February 2014 to April 2015 were selected as the study subjects. They were divided into an observation group and a control group according to the principle of random equalization, 77 each group. The observation group was treated with TAC scheme, neoadjuvant chemotherapy combined with modified radical resection, and continuously treated with the same scheme after operation until the end of the course of treatment. The control group was treated with modified radical resection and TAC scheme. The clinical efficacy of the two groups was observed, and the perioperative indications, prognosis and occurrence of adverse reactions were compared between the two groups.

Results:

The total effective rate of the observation group was 76.62%, significantly higher than that of the control group (55.84%, P<0.05). The observation group had shorter operation time and hospitalization time and less bleeding amount compared to the control group (P<0.05). The metastasis rate and recurrence rate of the observation group were significantly lower than those of the control group (P<0.05); there was a significant difference between the two groups (P<0.05). The one-year and three-year survival rates of the observation group were significantly higher than those of the control group (P<0.05). There was no significant difference in the incidence of adverse reactions between the two groups after operation (P>0.05).

Conclusion:

Preoperative neoadjuvant chemotherapy in combination with TAC scheme can reduce the difficulty of operation, improve the curative effect of patients, significantly improve the prognosis of patients and prolong the survival time, which is worth clinical application.

Assessment of sentinel lymph node biopsy after neoadjuvant chemotherapy for breast cancer in two subgroups: Initially node negative and node positive converted to node negative - A systemic review and meta-analysis

BACKGROUND

Neoadjuvant chemotherapy (NAC) is increasingly used to treat patients with breast cancer, but the reliability of sentinel lymph node biopsy (SLNB) following chemotherapy is in doubt. In this meta-analysis, we aimed to evaluate studies that examine the results of SLNB after NAC to assess identification rate (IR) and false-negative rate (FNR).

MATERIALS AND METHODS

Systemic searches were performed in the PubMed, ISI Web of Sciences, Scopus, and Cochrane databases from January 1, 2000, to November 30, 2016, for studies of SLNB after NAC for breast cancer and followed by axillary lymph node (LN) dissection in two subgroups: initially node negative and node positive converted to node negative. Two reviewers independently review quality of included studies. A random-effects model was used to pool IR and FNR with 95% confidence intervals (CI), and heterogeneity among studies was assessed by I 2 and Q-test.

RESULTS

A total of 23 studies with 1521 patients in the initially node-negative subgroup and 13 studies with 1088 patients in the node-positive converted to node-negative subgroup, were included in this meta-analysis with IR and FNR of 94% (95% CI: 92-96) and 7% (95% CI: 5-9) in the initially node-negative subgroup and 89% (95% CI: 85-94) and 13% (95% CI: 7-18) in the node-positive converted to node-negative subgroup, respectively.

CONCLUSION

Our meta-analysis showed acceptable IR and FNR in initially node-negative group and it seems feasible in these patients, but these parameters did not reach to predefined value in node-positive converted to node-negative group, and thus, it is not recommended in these patients.

A survey of current surgical treatment of early stage breast cancer in China

The purpose of this national survey is to explore the patterns of surgical management for early stage breast cancer patients in China. A paper questionnaire survey was sent to the representatives from 520 hospitals who attended an international symposium in Guangzhou, China, 2014. The questionnaire included demographic information, initials and most preferred approaches for breast cancer surgery. The results were presented descriptively. The response rate was 42.5%. Only 7% of hospitals with >50% rate of breast conserving surgery (BCS). Intraoperative frozen sections and additional cavity margins assessment were used at 88% and 30.9% of hospitals, respectively. For invasive carcinoma, 15% of participants defined an adequate margin as no tumor cells on the ink. Sentinel lymph node biopsy (SLNB) was routinely performed in 93.2% of hospitals. Only 16.6% of hospitals would embrace the conclusions of the American College of Surgeons Oncology Group (ACOSOG) Z0011 study and omit axillary lymph node dissection (ALND) for patients who fit the Z0011 criteria. The current patterns for the management of breast cancer patients are still lagging behind. Chinese doctors need to catch up with the updated results of the cutting-edge clinical studies and multiple measures are in need to improve this situation.

Breast cancer: An overview of published Indian data

The Incidence of breast cancer has been steadily increasing in the last two decades, more so in urban areas of the sub-continent. Cancer ceters across the country have large numbers of patients being treated with multiple publications in this field. Inspite of paucity of prospective data and randomised clinical trials from India, there are large number of retrospective publications on various aspects of the disease including pathology, radiology, surgery, chemotherapy, radiation, palliative care and alternatitive treatment modalities. These published data provide an insight into the trends of breast cancer in the country and this comprehensive data review of Indian data will provide a basis for designing trials relevant to our population and planning health care.

Blue dye is sufficient for sentinel lymph node biopsy in breast cancer

BACKGROUND

Most previous studies have reported superior results when blue dye and radiocolloids were used together for sentinel lymph node (SLN) biopsy in early breast cancer. Blue dye was reported to perform poorly when used alone, although more recent studies have found otherwise. This study reviewed the authors' practice of performing SLN biopsy with blue dye alone.

METHODS

This was a retrospective review of patients who underwent SLN biopsy using blue dye alone from 2001 to 2005, when SLN biopsy was performed selectively and always followed by axillary lymph node dissection (ALND), and from 2006 to 2010, when SLN biopsy was offered to all suitable patients and ALND done only when the SLN was not identified or positive for metastasis.

RESULTS

Between 2001 and 2005, 170 patients underwent SLN biopsy with blue dye alone. The overall SLN non-identification rate was 8·4 per cent. The overall false-negative rate was 34 per cent, but decreased with each subsequent year to 13 per cent in 2005. From 2006 to 2010, 610 patients underwent SLN biopsy with blue dye alone. The SLN was not identified in 12 patients (2·0 per cent) and no significant contributing factor was identified. A median of 2 (range 1-11) SLNs were identified. A non-SLN was found to be positive for metastasis in two patients with negative SLNs. Axillary nodal recurrence developed in one patient; none developed internal mammary nodal recurrence. Anaphylaxis occurred in one patient.

CONCLUSION

Blue dye performed well as a single modality for SLN biopsy. Non-identification, axillary nodal recurrence and serious allergic reactions were uncommon.

The Ever-Changing Role of Sentinel Lymph Node Biopsy in the Management of Breast Cancer

Context.—Axillary nodal status remains one of the most important prognostic indicators in the management of breast cancer. Axillary node metastases are seen in fewer than half of breast cancer cases, and axillary lymph node dissection is associated with significant morbidity. Sentinel lymph node biopsy (SLNB) has become the gold standard for axillary staging of breast cancer.

Objective.—To present a detailed review of the existing studies on SLNB in relation to the various techniques, the pathologic evaluation of the sentinel node, and special situations that can involve SLNB. We discuss recent trials that have already had an influence on surgical and pathologic management of breast cancer. In this article, we also discuss our practice and experience at UMass Memorial Medical Center, Worcester, Massachusetts, from a pathologic and surgical perspective.

Data Sources.—Published articles from peer-reviewed journals in PubMed (US National Library of Medicine).

Conclusions.—Sentinel node biopsy has become standard of care in the surgical management of breast cancer, and emerging data show that the survival benefits of axillary lymph node dissection may not be greater than sentinel node biopsy alone in patients with up to 2 positive sentinel nodes. Therefore, there have been recent changes to the role of intraoperative sentinel node evaluation, and an impact on overall breast cancer management.

Sentinel lymph node biopsy after neoadjuvant chemotherapy in patients with operable breast cancer and positive axillary nodes at initial diagnosis

AIM

To evaluate the utility of the sentinel lymph node biopsy (SLNB) in patients with operable breast cancer and positive axillary nodes at initial diagnosis treated with neoadjuvant chemotherapy (NAC).

MATERIAL AND METHODS

A prospective study was performed from January 2008 to December 2012 in 52 women, mean age 50.7 years, with infiltrating breast carcinoma T1-3, N1, M0 (1 bilateral, 7 multifocal) treated with epirubicin/cyclophosphamide, docetaxel and trastuzumab in Her2/neu-positive patients. Axillary evaluation included physical examination, axillary ultrasound, and ultrasound-guided core needle biopsy of any suspicious lymph node. The day before surgery, 74-111 MBq of (99m)Tc-albumin nanocolloid was injected periareolarly. All patients underwent breast surgery, with SLNB and complete axillary lymph node dissection (ALND). The SLNs were examined by frozen sections, hematoxylin-eosin staining, immunohistochemical analysis or one-step nucleic acid amplification assay (OSNA).

RESULTS

Mean tumor size: 3.5 cm. Histologic type: 81.1% invasive ductal carcinoma. Complete response of primary tumor was clinical 43.4%, pathological 41.5%. All patients were clinically node-negative after NAC. Pathological complete response of axillary node was 42.2%. SLN identification rate was 84.9%. Axilla was positive in the pathology study in 6 of 8 patients without nanocolloid migration. SLN accurately represented the axillary status in 95.5%. False negative rate was 8.3%. SLN was the only positive node in 68.2% of patients. Mean number of SLN removed was 1.9 and of nodes resected from the ALND 13.2.

CONCLUSION

SLN biopsy after NAC is a feasible and accurate tool in patients with operable breast cancer T1-3, N1 and clinically node-negative after therapy.

The false-negative rate of sentinel node biopsy in patients with breast cancer: a meta-analysis

BACKGROUND

In sentinel node surgery for breast cancer, procedural accuracy is assessed by calculating the false-negative rate. It is important to measure this since there are potential adverse outcomes from missing node metastases. We performed a meta-analysis of published data to assess which method has achieved the lowest false-negative rate.

METHODS

We found 3,588 articles concerning sentinel nodes and breast cancer published from 1993 through mid-2011; 183 articles met our inclusion criteria. The studies described in these 183 articles included a total of 9,306 patients. We grouped the studies by injection material and injection location. The false-negative rates were analyzed according to these groupings and also by the year in which the articles were published.

RESULTS

There was significant variation related to injection material. The use of blue dye alone was associated with the highest false-negative rate. Inclusion of a radioactive tracer along with blue dye resulted in a significantly lower false-negative rate. Although there were variations in the false-negative rate according to injection location, none were significant.

CONCLUSIONS

The use of blue dye should be accompanied by a radioactive tracer to achieve a significantly lower false-negative rate. Location of injection did not have a significant impact on the false-negative rate. Given the limitations of acquiring appropriate data, the false-negative rate should not be used as a metric for training or quality control.

Indocyanine green injection for detecting sentinel nodes using color fluorescence camera in the laparoscopy-assisted gastrectomy

BACKGROUND AND AIM

We seek for the accurate and simple method for detecting sentinel nodes of gastric cancer which can be popularized in community hospitals. The indocyanine green (ICG) fluorescence-guided method is reported to be sensitive. However, the ordinal fluorescence cameras have gray scale imaging and require a dark room. We have developed a new device, Hyper Eye Medical System (HEMS) which can simultaneously detect color and near-infrared rays and can be used under room light. This study was planned to examine whether submucosal injection of 0.5 mL × 4 of 50 µg/mL ICG on the day before operation is the adequate administration for detecting sentinel nodes using HEMS in the gastric cancer surgery.

METHODS

The patients underwent gastrectomy for clinical T1a (mucosa)-T2 (muscularis propria) and clinical N0 were enrolled in the present study. As a preliminary trial, one case each of the ICG 25 and 100 µg/mL, injected on the day before operation and intraoperative injection, was examined. Then, 10 cases injected 50 µg/mL ICG on the day before operation were examined.

RESULTS

The ICG fluorescence of the patient injected 100 µg/mL was too intense and that of the patient injected 25 µg/mL was too faint. Sentinel lymph nodes were detected in all of 10 cases injected 50 µg/mL, the day before operation and number of sentinel lymph nodes per patient was 3.6 ± 2.1. Metastasis was observed in one case. All of ICG fluorescence-positive sentinel nodes were positive for the metastasis. In the patient who underwent intraoperative injection, sentinel lymphatic basins could be identified.

CONCLUSION

The present study shows that HEMS-guided abdominal surgery is feasible under room light. Submucosal injection of 0.5 mL × 4 of 50 µg/mL ICG on the day before operation is the adequate administration for detecting sentinel nodes using HEMS in the gastric cancer surgery.

Curcumin enhances the efficacy of chemotherapy by tailoring p65NFκB-p300 cross-talk in favor of p53-p300 in breast cancer

Breast cancer cells often develop multiple mechanisms of drug resistance during tumor progression, which is the major reason for the failure of breast cancer therapy. High constitutive activation of NFκB has been found in different cancers, creating an environment conducive for chemotherapeutic resistance. Here we report that doxorubicin-induced SMAR1-dependent transcriptional repression and SMAR1-independent degradation of IkBα resulted in nuclear translocation of p65NFκB and its association with p300 histone acetylase and subsequent transcription of Bcl-2 to impart protective response in drug-resistant cells. Consistently SMAR1-silenced drug-resistant cells exhibited IkBα-mediated inhibition of p65NFκB and induction of p53-dependent apoptosis. Interestingly, curcumin pretreatment of drug-resistant cells alleviated SMAR1-mediated p65NFκB activation and hence restored doxorubicin sensitivity. Under such anti-survival condition, induction of p53-p300 cross-talk enhanced the transcriptional activity of p53 and intrinsic death cascade. Importantly, promyelocyte leukemia-mediated SMAR1 sequestration that relieved the repression of apoptosis-inducing genes was indispensable for such chemo-sensitizing ability of curcumin. A simultaneous decrease in drug-induced systemic toxicity by curcumin might also have enhanced the efficacy of doxorubicin by improving the intrinsic defense machineries of the tumor-bearer. Overall, the findings of this preclinical study clearly demonstrate the effectiveness of curcumin to combat doxorubicin-resistance. We, therefore, suggest curcumin as a potent chemo-sensitizer to improve the therapeutic index of this widely used anti-cancer drug. Taken together, these results suggest that curcumin can be developed into an adjuvant chemotherapeutic drug.