Chemotherapy-associated hepatotoxicity: how concerned should we be?

Increasing the Accumulation of Modular Nanotransporters in Mouse Tumors by Attaching Polyethylene Glycol to These Nanotransporters with the Possibility of Its Release into the Tumors

Previously, polypeptide constructs-modular nanotransporters (MNTs)-were created to deliver biologically active molecules into the nuclei of melanoma cells. In the present work, polyethylene glycol (PEG) molecules were attached to them at the N-terminal cysteine, both with the possibility of their subsequent cleavage at the hydrolysis site of tumor-specific proteases, and without this site (non-detachable PEG). All MNT variants labeled with the radioisotope 111In were administered to mice with inoculated Cloudman S91 melanoma. The kinetics of radioactivity distribution in the mouse body was studied using single-photon emission computed tomography. Analysis of the obtained data using a compartmental mathematical model allowed us to establish that the attachment of PEG to MNT increased its lifetime in the blood and significantly increased its accumulation in the tumor. Addition of a PEG detachment site by tumor-specific protease led to a strong retention of this MNT in the tumor. The data obtained can serve as a basis for the creation of new effective antitumor drugs.

GALA3-Containing Modular Nanotransporters Are Capable of Delivering Keap1 Monobody to Target Cells and Inhibiting the Formation of Reactive Oxygen Species in the Cells

In the previously created modular nanotransporter (MNT) capable of delivering a monobody to Keap1 into the cytosol, the endosomolytic module, translocation domain of diphtheria toxin (DTox), was replaced by the endosomolytic peptide GALA3. It was found that this substitution more than doubles the lifetime of MNT in the blood. Using confocal microscopy, it was shown that MNT with GALA3 was internalized into AML12 cells mainly due to binding to the epidermal growth factor receptor, and is also able to exit from endosomes into the cytosol. Using cellular thermal shift assay, it was shown that MNT with GALA3 and MNT with DTox are equally effective in disrupting the formation of the Nrf2 complex with Keap1, which led to similar protection of AML12 cells from the action of hydrogen peroxide. The obtained results allow not only optimizing the systemic use of MNT, but can also serve as a basis for creating agents aimed at treating diseases associated with oxidative stress.

The validation of a newly developed Arabic scale to assess patient-reported side-effects of antineoplastic agents

Background

Multiple scales in different languages were developed to measure patient-reported side effects of antineoplastics. However, these scales vary in their coverage of antineoplastics’ side effects, and none of them address both the severity and impact of antineoplastics’ side effects on patient quality of life. Hence, there is a need to develop a comprehensive, concise, and general scale to assess patients’ perceptions of both severity and impact of the commonly reported side effects of antineoplastics on patients’ activities of daily living and make it available in Arabic.

Objectives

To develop and validate a new scale in Arabic to assess patient-reported antineoplastics’ side-effects among Arabic-speaking patients undergoing chemotherapy.

Methods

A new scale was developed in Arabic that addresses 40 different emotional, cognitive, and physical side-effects of antineoplastics. The Antineoplastic Side effects Scale (ASES) contained three subscales focused on the side effects frequency, severity, and interference with patients’ activities of daily living. Seventy-eight patients with different cancer types were recruited from the oncology clinics of a university-affiliated tertiary care hospital in Riyadh, Saudi Arabia. The reliability of the questionnaire was examined using Cronbach’s alpha method. The construct validity was examined using principal component analysis with varimax rotation. The association between the scores of ASES subscales and various patient medical and sociodemographic characteristics were also examined.

Results

The mean age of participants was 53.8 (12.5) years and most of them were female (65.3%) and married (84.6%). The ASES demonstrated good internal consistency (Cronbach’s alpha = 0.91). The severity of the perceived side effects and their impact on activities of daily living were positively associated with female gender.

Conclusion

The newly developed ASES demonstrated good validity and reliability. This tool will hopefully help healthcare providers and patients to identify commonly reported antineoplastic side effects.

Short-term intravenous fish-oil emulsions in pediatric oncologic patients--effect on liver parameters

Pediatric oncologic patients often need parenteral nutrition (PN) during chemotherapy. Long-term use of soybean-based lipid emulsions is associated with progressive liver disease and cholestasis, whereas fish-oil based emulsions have anticholestatic effects. We studied the potentially hepato-protective effects of short-term use of SMOF lipids in children undergoing chemotherapy. Fifteen pediatric oncologic patients treated with SMOF lipids were retrospectively analyzed in respect to bilirubin and liver parameters and compared to matched-controls who had received soybean-based fat emulsions. For statistics the time-points baseline, Day 14 of PN (PN14), and post (Day+7) were chosen. None of the study patients developed cholestasis. Within the SMOF-lipid group there were no differences in the laboratory parameters between baseline, PN14, and post. In the control group, gamma glutamyltransferase (γGT) levels increased during PN (baseline vs. PN14, 26.43 vs. 63.00 U/l, P < 0.05). Lactate dehydrogenase (LDH) levels showed a significantly different behavior in the 2 groups: In the SMOF lipids group, LDH decreased whereas it increased in the controls (-32.75 U/l vs. + 29.57 U/l, P < 0.05). An advantage of fish oil-based fat emulsions can be shown even after short-term PN. In children undergoing chemotherapy the use of soybean-based fat emulsions but not SMOF lipids led to increased γGT levels.

Biomarkers of small intestinal mucosal damage induced by chemotherapy: an emerging role for the 13C sucrose breath test

Gastrointestinal mucosal toxicity is extremely common following cytotoxic therapies. The alimentary mucosa is particularly susceptible to injury and dysfunction, leading to many debilitating complications. Despite much research, there is currently no single noninvasive biomarker to detect gut injury. Several biomarkers have been investigated in the context of gastrointestinal diseases, which may prove useful in the oncology arena. Identification of a biomarker that is easy to obtain and measure and that accurately identifies mucosal damage would allow for improved patient diagnosis of toxicities and for personalized treatment regimens. In this review, we highlight the effectiveness of urine and breath tests as potential clinically effective biomarkers, with significant focus placed on the emerging role of the carbon-13 sucrose breath test (13C SBT). The 13C SBT provides a simple, noninvasive, and integrated measure of gut function. The 13C SBT also has the potential to monitor gut function in the setting of cytotoxic therapy-induced mucositis, or in the assessment of the efficacy of antimucositis agents.

Extended preoperative chemotherapy, extent of liver resection and blood transfusion are predictive factors of liver failure following resection of colorectal liver metastasis

AIM

The aim of this study was to determine the incidence and prognostic factors of postoperative liver failure in patients submitted to liver resection for colorectal metastases.

METHOD

Patients with CLM who underwent hepatectomy from 1998 to 2009 were included in retrospective analysis. Postoperative liver failure was defined using either the 50-50 criteria or the peak of serum bilirubin level above 7 mg/dL independently.

RESULTS

Two hundred and nine (209) procedures were performed in 170 patients. 120 surgeries were preceded by chemotherapy within six months. The overall morbidity rate was 53.1% and 90-day mortality was 2.3%. Postoperative liver failure occurred in 10% of all procedures, accounting for a mortality rate of 9.5% among this group of patients. In multivariate analysis, extent of liver resection, need of blood transfusion and more than eight preoperative chemotherapy cycles were independent prognostic factors of postoperative liver insufficiency. This complication was not related with the chemotherapy regimen used.

CONCLUSION

We conclude that postoperative liver failure has a relatively low incidence (10%) after CLM resection, but a remarkable impact on postoperative mortality rate. The amount of liver resected, the need of blood transfusion and extended preoperative chemotherapy are independent predictors of its occurrence and this knowledge can be used to prevent postoperative liver failure in a multidisciplinary approach.

Colorectal liver metastases

BACKGROUND

With modern multimodality therapy, patients with resected colorectal cancer (CRC) liver metastases (CLM) can experience up to 50-60 % 5-year survival. These improved outcomes have become more commonplace via achievements in multidisciplinary care, improved definition of resectability, and advances in technical skill.

DISCUSSION

Even patients with synchronous and/or extensive bilateral disease have benefited from novel surgical strategies. Treatment sequencing of synchronous CRC with CLM can be simplified into the following three paradigms: (classic colorectal-first), simultaneous (combined), or reverse approach (liver-first). The decision of whether to treat the CLM or CRC first depends on which site dominates oncologically and symptomatically. Oxaliplatin with 5-fluorouracil/leucovorin (FOLFOX) and irinotecan with 5-fluorouracil/leucovorin (FOLFIRI) are the foundations of modern chemotherapy. Although each regimen has positively impacted survivals, both have the potential for negative effects on the non-tumor liver. Oxaliplatin is associated with vascular injury (sinusoidal ballooning, microvascular injury, nodular regenerative hyperplasia, and long-term fibrosis) but not steatosis. Irinotecan has been associated with steatohepatitis, especially in patients with obesity and diabetes. Steatohepatitis from irinotecan is the only chemotherapy-associated liver injury (CALI) associated with increased mortality from postoperative hepatic insufficiency. Extended duration of preoperative chemotherapy is also associated with CALI.

CONCLUSIONS

To determine resectability and to prevent overtreatment with systemic therapy, all patients should receive high-quality cross-sectional imaging and be evaluated by a hepatobiliary surgeon before starting chemotherapy. Even as chemotherapy improves, liver surgeons will continue to play a central role in treatment planning by offering the best chance for prolonged survival-safe R0 resection with curative intent.

Colorectal liver metastases

BACKGROUND

With modern multimodality therapy, patients with resected colorectal cancer (CRC) liver metastases (CLM) can experience up to 50-60 % 5-year survival. These improved outcomes have become more commonplace via achievements in multidisciplinary care, improved definition of resectability, and advances in technical skill.

DISCUSSION

Even patients with synchronous and/or extensive bilateral disease have benefited from novel surgical strategies. Treatment sequencing of synchronous CRC with CLM can be simplified into the following three paradigms: (classic colorectal-first), simultaneous (combined), or reverse approach (liver-first). The decision of whether to treat the CLM or CRC first depends on which site dominates oncologically and symptomatically. Oxaliplatin with 5-fluorouracil/leucovorin (FOLFOX) and irinotecan with 5-fluorouracil/leucovorin (FOLFIRI) are the foundations of modern chemotherapy. Although each regimen has positively impacted survivals, both have the potential for negative effects on the non-tumor liver. Oxaliplatin is associated with vascular injury (sinusoidal ballooning, microvascular injury, nodular regenerative hyperplasia, and long-term fibrosis) but not steatosis. Irinotecan has been associated with steatohepatitis, especially in patients with obesity and diabetes. Steatohepatitis from irinotecan is the only chemotherapy-associated liver injury (CALI) associated with increased mortality from postoperative hepatic insufficiency. Extended duration of preoperative chemotherapy is also associated with CALI.

CONCLUSIONS

To determine resectability and to prevent overtreatment with systemic therapy, all patients should receive high-quality cross-sectional imaging and be evaluated by a hepatobiliary surgeon before starting chemotherapy. Even as chemotherapy improves, liver surgeons will continue to play a central role in treatment planning by offering the best chance for prolonged survival-safe R0 resection with curative intent.

Obesity and colorectal cancer

Obesity is a risk factor for colorectal cancer based on its molecular and metabolic effects on insulin and IGF-1, leptin, adipocytokines, and sex hormones. Obese men have a higher risk of colorectal cancer compared with normal weight men, but the association between obesity and rectal cancer is weaker than with colon cancer. There is a weaker association between obesity and colon cancer in women than in men, and no appreciable association between obesity and rectal cancer in women. Although obesity does not seem to have an effect on the number of lymph nodes harvested with resection, obesity does seem to be associated with more-aggressive colorectal cancers in a handful of studies. Survival and local recurrence studies are contradictory with no conclusive evidence that obesity predisposes to worse overall survival or increased recurrence in colon and rectal cancers. The literature is not definitive as far as overall morbidity and mortality rates in the obese are concerned, though obese rectal cancer patients seem to incur proportionally more morbidity and mortality. Preexisting steatosis or steatohepatitis in obese colorectal cancer patients or chemotherapy-induced liver dysfunction may lead to an increased mortality in obese patients with colorectal liver metastases. Diabetes may cause poorer response to neoadjuvant therapy in rectal cancer and contribute to higher mortality and recurrence in colon cancer.