Time course of exhaled hydrogen peroxide and nitric oxide during chemotherapy

Nitric oxide in occurrence, progress and therapy of lung Cancer: a systemic review and meta-analysis

Background

Nitric oxide (NO) plays an important role in lung cancer. However, the results of previous studies about NO in the occurrence, progress and therapy were not consistent. Therefore, we conducted a meta-analysis to evaluate the relationship between NO and lung cancer.

Method

We carried out comprehensive search in the databases, and collected related studies. The data of fraction of exhaled nitric oxide (FeNO) or blood NO in different populations (lung cancer patients and control subjects) and different time points (before therapy and after therapy) were extracted by two investigators. A random effect model was applied to analyze the differences of FeNO and blood NO in different populations and different time points. To further compare NO level of each subgroup with different pathological types and different stages, a network meta-analysis (NMA) was performed.

Results

Fifty studies including 2551 cases and 1691 controls were adopted in this meta-analysis. The FeNO (SMD 3.01, 95% CI 1.89–4.13, p < 0.00001) and blood NO (SMD 1.34, 95% CI 0.84–1.85, p < 0.00001) level in lung cancer patients was much higher than that in control subjects. NMA model indicated blood NO level in each cancer type except SCLC was higher than that in control patients. There was no significant difference of blood NO level among four kinds of lung cancer patients. Blood NO level in LCC patients (SUCRA = 83.5%) was the highest. Blood NO level in advanced stage but not early stage was higher than that in control subjects. Patients in advanced stage (SUCRA = 95.5%) had the highest blood NO level. No significant difference of FeNO (SMD -0.04, 95% CI -0.46-0.38, p > 0.05) and blood NO level (SMD -0.36, 95% CI -1.08-0.36, p > 0.05) was observed between pretreatment and posttreatment in all patients. However, FeNO level elevated (SMD 0.28, 95% CI 0.04–0.51, p = 0.02) and blood NO level decreased in NSCLC patients (SMD -0.95, 95% CI -1.89-0.00, p = 0.05) after therapy.

Conclusion

FeNO and blood NO level would contribute to diagnosis of lung cancer and evaluation of therapy effect, especially for NSCLC patients.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12885-021-08430-2.

Measurement of exhaled nitric oxide and serum surfactant protein D levels for monitoring radiation pneumonitis following thoracic radiotherapy

The present study aimed to examine the role of exhaled nitric oxide (eNO) and serum surfactant protein D (SP-D) level in the determination of radiation pneumonitis (RP) after thoracic radiotherapy (RT). The study included 34 treatments for 33 patients, including 16 three-dimensional conformal and 18 stereotactic body RT treatments. eNO levels were measured prior to RT, immediately subsequent to RT, every week during the RT course and at 1, 3, 6, 9 and 12 months following the treatment. The therapy reduced the eNO from 24.3±12.8 ppb prior to RT to 19.0±10.4 ppb immediately subsequent to RT (P=0.04). A total of 5 patients (14%) developed symptomatic RP of grade 2 or higher 3–5 months later, and exhibited an eNO elevation of 2.1±0.68-fold the minimum value, whereas the RP- group exhibited 1.4±0.6-fold elevation (P=0.02). The sensitivity of a cut-off of a 1.4-fold increase in the eNO ratio at the onset of RP was 100%; however, the specificity was 52%, and no predictive alterations to eNO levels were observed prior to the onset of RP. RT was associated with an elevated serum SP-D level at 3–6 months after RT. There was a statistically significant difference in the initial serum SP-D level between RP+ and RP- patients. In conclusion, obtaining the eNO ratio was a useful RP monitoring tool but did not predict RP occurrence in the present setting, whereas serum SP-D level may be a potential predictor for the detection of RP risk.

Coexistence of diffuse panbronchiolitis and asthma: reciprocity of neutrophilic and eosinophilic inflammation

Diffuse panbronchiolitis (DPB) and asthma are obstructive airway diseases, the former being characterized by Th1‐type and the latter by Th2‐type airway inflammation. Differential diagnosis is often a problem, but coexistence has rarely been reported. A 76‐year‐old man with asthma was admitted to our hospital because of one‐month history of dyspnoea on exertion with bilateral diffuse granular shadows. He also had a history of chronic sinusitis. Auscultation of the lungs showed coarse crackles and wheezes. Laboratory data revealed an elevated total serum immunoglobulin E and a high titre of cold agglutinin. Bronchoscopic evaluations of the shadows revealed compatible pathological findings in both DPB and asthma. Low‐dose macrolide caused a prompt reduction of symptoms, along with improvements in radiographic findings and pulmonary functions, whereas the eosinophilic airway inflammation transiently worsened. When DPB and asthma coexist, the balance of Th1/Th2 immune response may be reciprocally altered by therapeutic intervention.

Elevated exhalation of hydrogen peroxide in patients with non-small cell lung cancer is not affected by chemotherapy

OBJECTIVES

Reactive oxygen species, which are implicated in the process of carcinogenesis, are also responsible for cell death during chemotherapy (CHT). Therefore, the aim of the study was to evaluate exhaled H₂O₂ levels in non-small cell lung cancer (NSCLC) patients before and after CHT.

METHODS

Thirty patients (age 61.3 ± 9.3 years) with advanced NSCLC (stage IIIB-IV) and 15 age-matched healthy cigarette smokers were enrolled into the study. Patients received four cycles of cisplatin or carboplatin with vinorelbine every three weeks. Before and after the first, second, and fourth cycle, the concentration of H₂O₂ in exhaled breath condensate was measured with respect to treatment response.

RESULTS

At the baseline, NSCLC patients exhaled 3.8 times more H₂O₂ than the control group (0.49 ± 0.14 vs. 0.13 ± 0.03 µmol/L, P < 0.05); this difference persisted throughout the study. CHT had no noticeable effect on exhaled H₂O₂ levels independent of the treatment response (partial remission vs. progressive disease). Pre- and post-CHT cycles of H₂O₂ levels generally correlated positively.

DISCUSSION

The study demonstrated the occurrence of oxidative stress in the airways of advanced NSCLC patients. Exhaled H₂O₂ level was not affected by CHT and independent of treatment results and changes in the number of circulating neutrophils.

Hydrogen peroxide in exhaled air: a source of error, a paradox and its resolution

The concentration of hydrogen peroxide (H₂O₂) in exhaled air has been reported to be elevated in asthma and chronic obstructive pulmonary disease (COPD), but results are inconsistent and difficult to reproduce. As H₂O₂ occurs in ambient air, we examined its association with exhaled H₂O₂ in human subjects. Exhaled breath condensate (EBC) of 12 COPD patients and nine healthy control subjects was collected either with an inhalation filter (efficiency 81%) or without. Ambient air condensate (AAC) was collected in parallel and samples were analysed for H₂O₂. Additionally, ambient H₂O₂ was recorded by an atmospheric measuring device (online fluorometric measurement). H₂O₂ concentration in AAC was significantly higher (p<0.001) than in EBC. AAC variations were concordant with the data from the atmospheric measuring instrument. In both subjects' groups, the inhalation filter reduced H₂O₂ values (p<0.01). Despite generally low levels in exhaled air, analysis by a mathematical model revealed a contribution from endogenous H₂O₂ production. The low H₂O₂ levels in exhaled air are explained by the reconditioning of H₂O₂-containing inhaled air in the airways. Inhaled H₂O₂ may be one factor in the heterogeneity and limited reproducibility of study results. A valid determination of endogenous H₂O₂ production requires inhalation filters.

Evaluation of anti-asthmatic and antioxidant potential of Boerhavia procumbens in toluene diisocyanate (TDI) treated rats

AIM OF THE STUDY

Asthma is an ailment of airways characterized by activation of the T helper (Th) 2 lymphocytes and subsequent movement of inflammatory cells. Boerhavia procumbens of family Nyctaginaceae is locally used for the treatment of asthma, cough, hemorrhoids, dropsy, cardiac, eyes and kidney problems. We have evaluated its methanol extract (BPM) as a therapeutic candidate for asthma against toluene diisocyanate (TDI) allergic model in rat. The BPM extract was obtained from the whole plant of B. procumbens in methanol. Sprague-Dawley male 36 rats (200-250 g) were categorized into 6 groups having six rats in each category. The animals were provoked (10%) and sensitized (5%) by TDI. Animals of groups I-III were vehicle control (ethyl acetate), diseased control (TDI) and reference control (TDI+dexamethasone {2.5mg/kg bw}), respectively. Animals of group IV (TDI+200mg/kg bw) and group V (TDI+400mg/kg bw) were administered with BPM whereas group VI was administered with 400mg/kg bw alone of BPM. Protective effects of BPM were determined by counting the number of leucocytes and estimation of interleukines in blood, bronchoalveolar lavage (BAL) and in in vitro culture of spleen cells. Estimation of antioxidant enzymes, lipid peroxides and H2O2 and histopathology of lungs were carried out for antioxidant potential of plant extract used.

RESULTS

Methanol extract of B. procumbens suppressed the asthmatic symptoms and inhibited the infiltration of eosinophils and lymphocytes in lungs of TDI provoked rats. Administration of BPM to TDI provoked rats, dose dependently, inhibited the release of interleukins (IL)-2 in serum and IL-4, IL-6 interferon gamma (IFN-γ) in bronchoalveolar lavage (BAL) and in in vitro culture of spleen cells, and ameliorated the oxidative stress in lung tissues. Quantitative scoring of the lung histopathology exhibited protective effects of BPM and the inflammation, mucus, thickening of peribronchial smooth muscle layer and subepithelial deposition of collagen induced with TDI were ameliorated. The BPM has the anti-inflammatory properties that may be used to treat the asthma and inflammatory related ailments.

Measurement of exhaled alveolar nitrogen oxide in patients with lung cancer: a friend from the past still precious today

Nitric oxide (NO) is a marker of airway inflammation and indirectly a general indicator of inflammation and oxidative stress. NO is a contributing factor in lung cancer at an early stage and also after chemotherapy treatment of lung cancer. We studied whether exhaled NO levels were altered by three cycles of chemotherapy at diagnosis and after chemotherapy, and whether, directly or indirectly, these changes were related to the course of disease. Also, a correlation of NO levels with other markers of inflammation was performed. We studied 42 patients diagnosed early: 26 men and 16 women with lung cancer. We analyzed blood tests for control of inflammatory markers, functional pulmonary tests, and alveolar exhaled NO. We recorded a decrease in exhaled NO after three cycles of chemotherapy in all patients, regardless of histological type and stage: there were 42 patients with mean 9.8 NO after three cycles (average 7.7). Also, a strong correlation appeared between NO measurements before and after chemotherapy and C-reactive protein (P < 0.05, r = 0.42, before) and (P < 0.045, r = 0.64, after). NO alveolar measurement as an indicator of airway inflammation indicates response to chemotherapy in lung cancer. Also, the inflammatory process in lung cancer was confirmed and indicated response to chemotherapy through an index that is sensitive to inflammatory disease of the airways.

Hydrogen peroxide detection in wet air with a Prussian Blue based solid salt bridged three electrode system

We report on a novel electroanalytical system for hydrogen peroxide (H2O2) detection in humidity or droplets of aerosol, formed by air bubbling through a washing chamber; the resulting flow mimics the exhaled human breath. The system is based on a planar three-electrode structure (with a Prussian Blue based H2O2 transducer modified working electrode) bridged by a solid salt-saturated filament material (filter paper, cotton textile). Respective to the hydrogen peroxide content in the washing valve, the response of the aerosol-sensing system is linear in the concentration range of 0.1-10 μM, which overlaps the generally accepted H2O2 content in exhaled breath condensate (EBC), with the sensitivity of 8 A M(-1) cm(-2). The response to the upper limit of the calibration range is stable for more than 50 injection cycles recorded within 3 days. Both the stability and the suitable calibration range allow one to consider the reported aerosol-sensing system as a prototype for a simple (avoiding intermediate EBC collection) noninvasive diagnostic tool for pulmonary patients.

FENO measurement and sputum analysis for diagnosing asthma in clinical practice

OBJECTIVES

To determine the diagnostic accuracy of fractional exhaled nitric oxide (FENO) measurement in pneumologists routine diagnostic work-up; and to determine the impact of the inflammatory pattern on diagnostic accuracy.

METHODS

Prospective diagnostic study in 393 patients attending a private practice of pneumologists with complaints suspicious of obstructive airway disease (OAD). Index test was FENO measurement. Reference standard was the Tiffeneau ratio (FEV(1)/VC) or airway resistance as assessed by whole body plethysmography, with additional bronchoprovocation or bronchodilator testing. Morning sputum was analysed with smear slides which were prepared and stained by Giemsa.

RESULTS

154 patients were diagnosed as having asthma (145 diagnoses based on bronchial provocation, 9 based on bronchodilator results), 5 had COPD. For the whole group, asthma could be ruled in at FENO > 71 ppb (PPV 80%; 95% CI 63-90%) and ruled out at FENO ≤ 9 ppb (NPV 82%; 95% CI 67-91%) (area under the curve (AUC) = 0.656; 95% CI 0.600-0.712; p < 0.001). 128 patients delivered sputum. FENO was 44.3 ppb (sd 48.9) in patients with predominant eosinophilic inflammation, 18.5 ppb with neutrophilic inflammation, and 23.1 ppb in others (p = 0.003). Diagnostic accuracy of FENO increased when patients with neutrophilic inflammation were omitted from analysis (AUC = 0.745; 95% CI 0.651-0.838; p < 0.001). Then asthma could be ruled in at FENO > 31 ppb (PPV 82%; 95% CI 63-92%) and ruled out at FENO ≤ 12 ppb (NPV 81%; 95% CI 62-91%).

CONCLUSIONS

FENO measurement can be useful as an additional diagnostic tool in pneumologists' practice. The diagnostic value of FENO could be improved when inflammatory patterns are taken into account.

Can exhaled NO fraction predict radiotherapy-induced lung toxicity in lung cancer patients?

Background

A large increase in nitric oxide fraction (FeNO) after radiotherapy (RT) for lung cancer may predict RT-induced lung toxicity.

Methods

In this study, we assessed the relationships between FeNO variations and respiratory symptoms, CT scan changes or dose volume histogram (DVH) parameters after RT. We measured FeNO before RT, 4, 5, 6, 10 weeks, 4 and 7.5 months after RT in 65 lung cancer patients.

Results

Eleven lung cancer patients (17%) complained of significant respiratory symptoms and 21 (31%) had radiation pneumonitis images in >1/3 of the irradiated lung after RT. Thirteen patients (20%) showed increases in FeNO >10 ppb. The sensitivity and specificity of a >10 ppb FeNO increase for the diagnosis of RT-associated respiratory symptoms were 18% and 83%, respectively. There was no correlation between DVH parameters or CT scan changes after RT and FeNO variations. Three patients (5%) showed intriguingly strong (2 or 3-fold, up to 55 ppb) and sustained increases in FeNO at 4 and 5 weeks, followed by significant respiratory symptoms and/or radiation-pneumonitis images.

Conclusion

Serial FeNO measurements during RT had a low ability to identify lung cancer patients who developed symptoms or images of radiation pneumonitis. However, three patients presented with a particular pattern which deserves to be investigated.