Can Kushen injection combined with TACE improve therapeutic efficacy and safety in patients with advanced HCC? a systematic review and network meta-analysis

Virtual screening and network pharmacology-based synergistic coagulation mechanism identification of multiple components contained in compound Kushen Injection against hepatocellular carcinoma

BACKGROUND

Hepatocellular carcinoma (HCC) is a primary liver malignancy commonly encountered in the setting of chronic liver disease and cirrhosis. Compound Kushen Injection (CKI) has been widely used in HCC, however, the underlying mechanisms are scarce.

OBJECTIVE

To explore the molecular mechanisms of CKI for HCC.

MATERIALS AND METHODS

The chemical ingredients of CKI were reviewed from published articles and the potential targets were got from Herbal Ingredients' Targets Platform. Coagulation-related targets were from Kyoto Encyclopedia of Genes and Genomes and HCC-related targets were from Therapeutic Target Database, Gene Expression Omnibus, and The Cancer Genome Atlas. Then the CKI-Herb-Target and CKI-Herb-Target-HCC networks were built. The shared targets between CKI and HCC were used for functional enrichment through Metascape and the shared coagulation-related target was used for molecular docking and survival analysis.

RESULTS

A total of 23 chemical ingredients and 41 potential targets shared between CKI and HCC were obtained. The results of functional enrichment indicated that several canonical pathways of CKI mostly participated in the treatment of HCC. Furthermore, a chemical ingredient of CKI formed a stable hydrogen bond link with the ASN-189 on PLG, with a best binding energy of -4.7 kcal/mol. Finally, PLG was confirmed as the shared coagulation-related target and interrelated with the prognosis of HCC.

CONCLUSION

CKI probably improves HCC prognosis through PLG. Our research undoubtedly deepened the understanding of the molecular mechanism of CKI anti-HCC.

Compound Kushen injection combined with transarterial chemoembolization for hepatocellular carcinoma: An evidence map and overview of systematic reviews

ETHNOPHARMACOLOGICAL RELEVANCE

For the treatment of hepatocellular carcinoma (HCC), compound Kushen injection (CKi) is commonly used in combination with transarterial chemoembolization (TACE).

AIMS OF THE STUDY

Our objective was to evaluate the reporting quality, methodological quality, risk of bias, and certainty of evidence for CKi combined with TACE for the treatment of patients with HCC by conducting systematic reviews (SRs). The purpose of this study was to improve the clinical application of CKis, strengthen clinical decision-making regarding CKis, and inform future research.

MATERIALS AND METHODS

We used eight databases to systematically search SRs of CKi combined with TACE for HCC through February 21, 2023. The quality of reporting of SRs was evaluated using the 2009 Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines, methodological quality using A MeaSurement Tool to Assess systematic Reviews 2, risk of bias using the Risk of Bias in Systematic Review, and certainty of evidence using the Grading of Recommendations Assessment. Finally, the assessment results were visualized by the evidence mapping method. This overview has been registered on PROSPERO with the registration title "Compound Kushen injection for hepatocellular carcinoma: An overview of systematic reviews" and registration number CRD42022369120.

RESULTS

A total of 12 SRs meeting the inclusion criteria were included. In terms of reporting quality, 42% of SRs reported relatively complete reports and 58% had certain deficiencies. The methodological quality of all SRs was " critically low". The risk of bias was evaluated as low in 33% of SRs and high in 67% of SRs. The results of the evidence synthesis showed that, in the "moderate" level of evidence, CKi combined with TACE resulted in a 12.7%-21.5% benefit for one-year survival rate, 11.7%-17.2% benefit for objective response rate (ORR), 20.5%-27.1% benefit for quality of life, 22.2% benefit for nausea and vomiting, and 24.7%-27.4% benefit for leukopenia in HCC patients.

CONCLUSION

In conclusion, CKi combined with TACE improved survival, ORR and quality of life in patients with HCC, and reduced adverse events. The results should be interpreted with caution due to the low methodological quality of the included SRs. The clinical efficacy of CKis must be confirmed in a large number of randomized controlled trials.

A Single Nucleotide Mixture Enhances the Antitumor Activity of Molecular-Targeted Drugs Against Hepatocellular Carcinoma

New strategies for molecular-targeted drug therapy for advanced hepatocellular carcinoma (HCC) ignore the contribution of the nutritional status of patients and nutritional support to improve physical status and immunity. We aimed to elucidate the role of a single nucleotide mixture (SNM) in the anti-tumor therapy of HCC, and to explore the importance of a SNM as adjuvant therapy for HCC. Compared with a lipid emulsion (commonly used nutritional supplement for HCC patients), the SNM could not induce metabolic abnormalities in HCC cells (Warburg effect), and did not affect expression of metabolic abnormality-related factors in HCC cells. The SNM could also attenuate the lymphocyte injury induced by antitumor drugs in vitro and in vivo, and promote the recruitment and survival of lymphocytes in HCC tissues. Using HCC models in SCID (server combined immune-deficiency) mice or BalB/c mice, the SNM had anti-tumor activity, and could significantly upregulate the antitumor activity of molecular-targeted drugs (tyrosine-kinase inhibitors [TKI] and immune-checkpoint inhibitors [ICI]) against HCC. We employed research models in vivo and in vitro to reveal the anti-tumor activity of the SNM on HCC. Our findings expand understanding of the SNM and contribute to HCC (especially nutritional support) therapy.

An advanced network pharmacology study to explore the novel molecular mechanism of Compound Kushen Injection for treating hepatocellular carcinoma by bioinformatics and experimental verification

Background

Compound Kushen Injection (CKI) is a Chinese patent drug that exerts curative effects in the clinical treatment of hepatocellular carcinoma (HCC). This study aimed to explore the targets and potential pharmacological mechanisms of CKI in the treatment of HCC.

Methods

In this study, network pharmacology was used in combination with molecular biology experiments to predict and verify the molecular mechanism of CKI in the treatment of HCC. The constituents of CKI were identified by UHPLC-MS/MS and literature search. The targets corresponding to these compounds and the targets related to HCC were collected based on public databases. To screen out the potential hub targets of CKI in the treatment of HCC, a compound-HCC target network was constructed. The underlying pharmacological mechanism was explored through the subsequent enrichment analysis. Interactive Gene Expression Profiling Analysis and Kaplan-Meier plotter were used to examine the expression and prognostic value of hub genes. Furthermore, the effects of CKI on HCC were verified through molecular docking simulations and cell experiments in vitro.

Results

Network analysis revealed that BCHE, SRD5A2, EPHX2, ADH1C, ADH1A and CDK1 were the key targets of CKI in the treatment of HCC. Among them, only CDK1 was highly expressed in HCC tissues, while the other 5 targets were lowly expressed. Furthermore, the six hub genes were all closely related to the prognosis of HCC patients in survival analysis. Molecular docking revealed that there was an efficient binding potential between the constituents of CKI and BCHE. Experiments in vitro proved that CKI inhibited the proliferation of HepG2 cells and up-regulated SRD5A2 and ADH1A, while down-regulated CDK1 and EPHX2.

Conclusions

This study revealed and verified the targets of CKI on HCC based on network pharmacology and experiments and provided a scientific reference for further mechanism research.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12906-022-03530-3.

Adjunctive effect of compound Kushen Injection to chemotherapy for non-small cell lung cancer: An evidence map and overview of systematic reviews

ETHNOPHARMACOLOGICAL RELEVANCE

Extract from Kushen (Sophora flavescens Aiton) and Baituling (Heterosmilax japonica Kunth), Compound Kushen Injection has a long history for cancer treatment in China. As a common adjunctive drug in chemotherapy of non-small cell lung cancer (NSCLC), the evidence of effectiveness and safety of Compound Kushen Injection needs to be synthesized.

AIM OF THE STUDY

The objective of this overview is to synthesize recent evidence and assess the methodological quality of systematic reviews (SRs) of Compound Kushen Injection, in treating NSCLC as an adjunctive treatment of chemotherapy.

MATERIALS AND METHODS

We searched PubMed, PubMed Central, China National Knowledge Infrastructure, Wanfang Data Knowledge Service Platform and VIP China Science and Technology Journal Database from inception to April 22, 2020. We included SRs of the efficacy and safety of Compound Kushen Injection combined with chemotherapy in the treatment of NSCLC. Two authors assessed eligibility and extracted data. The quality of SRs was assessed using AMSTAR-2. A meta-analysis was conducted for the original trials where good homogeneity was present. Evidence maps using bubble plots illustrated overall results. The quality of the evidence was graded by the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) approach.

RESULTS

Twelve SRs were included, with 91 randomized controlled trials and 7466 participants. Overall, the quality of the included SRs was low. Only six SRs reported specific chemotherapy regimens, three using vinorelbine combined with cisplatin (NP), one using paclitaxel combined with cisplatin (TP), one using gemcitabine combined with cisplatin (GP), and one discussed the three regimens in subgroups. Meta-analysis showed that CKI used as an adjuvant to chemotherapy was superior to chemotherapy alone in promoting tumor complete response rate, tumor partial response rate, Kamofsky score, and relieving some chemotherapy related side effects. Evidence mapping showed that Kushen Injection combined with NP and GP had better effect. The evidence quality of increasing Kamofsky score and decreasing the incidence of leukopenia were moderate, others were low or very low.

CONCLUSIONS

There are some favorable effects in improving short-term effectiveness, quality of life and alleviating some side effects of chemotherapy in patients with NSCLC. Results are more promising when Compound Kushen injection is used as an adjunctive to NP and GP. Promising results are however, compromised by the poor quality overall of the clinical trials.

Compound kushen injection relieves tumor-associated macrophage-mediated immunosuppression through TNFR1 and sensitizes hepatocellular carcinoma to sorafenib

Background

There is an urgent need for effective treatments for hepatocellular carcinoma (HCC). Immunotherapy is promising especially when combined with traditional therapies. This study aimed to investigate the immunomodulatory function of an approved Chinese medicine formula, compound kushen injection (CKI), and its anti-HCC efficiency in combination with low-dose sorafenib.

Methods

Growth of two murine HCC cells was evaluated in an orthotopic model, a subcutaneous model, two postsurgical recurrence model, and a tumor rechallenge model with CKI and low-dose sorafenib combination treatment. In vivo macrophage or CD8⁺ T cell depletion and in vitro primary cell coculture models were used to determine the regulation of CKI on macrophages and CD8⁺ T cells.

Results

CKI significantly enhanced the anticancer activity of sorafenib at a subclinical dose with no obvious side effects. CKI and sorafenib combination treatment prevented the postsurgical recurrence and rechallenged tumor growth. Further, we showed that CKI activated proinflammatory responses and relieved immunosuppression of tumor-associated macrophages in the HCC microenvironment by triggering tumor necrosis factor receptor superfamily member 1 (TNFR1)-mediated NF-κB and p38 MAPK signaling cascades. CKI-primed macrophages significantly promoted the proliferation and the cytotoxic ability of CD8⁺ T cells and decreased the exhaustion, which subsequently resulted in apoptosis of HCC cells.

Conclusions

CKI acts on macrophages and CD8⁺ T cells to reshape the immune microenvironment of HCC, which improves the therapeutic outcomes of low-dose sorafenib and avoids adverse chemotherapy effects. Our study shows that traditional Chinese medicines with immunomodulatory properties can potentiate chemotherapeutic drugs and provide a promising approach for HCC treatment.

Which probiotic has the best effect on preventing Clostridium difficile-associated diarrhea? A systematic review and network meta-analysis

OBJECTIVE

Clostridium difficile-associated diarrhea (CDAD) accounts for up to 25% of patients with antibiotic-associated diarrhea (AAD). We aimed to determine which probiotic is most effective in preventing CDAD using a network meta-analysis.

METHODS

Studies were identified by searching PubMed, EMBASE and the Cochrane Library databases for randomized controlled trials (RCTs) that evaluated the efficacy of probiotic interventions for CDAD. Primary outcomes were the incidence rates of AAD and CDAD, and secondary outcomes were the duration of diarrhea and the time until onset of diarrhea. The PROSPERO registered number of this study is CRD42018106115.

RESULTS

Ten RCTs including 11 analyses and including 4 692 patients were identified. Compared with the control group, probiotic intervention reduced the incidence rates of CDAD (odds ratio [OR] 0.33, 95% confidence interval [CI] 0.17-0.61) and AAD (OR 0.39, 95% CI 0.23-0.66). Similar results were observed regarding the duration of diarrhea and the time until onset of diarrhea. Meta-regression analysis showed a correlation between the type of probiotic used and the incidence of CDAD and AAD. All nine kinds of probiotic interventions were statistically more effective than the placebo, with Lactobacillus casei ranking as the best intervention (OR 0.19, 95% credible interval [CrI] 0.06-0.63) for decreasing the incidence rate of CDAD. L. casei also ranked the highest in reducing the incidence rate of AAD (OR 0.32, 95% CrI 0.14-0.74).

CONCLUSION

Lactobacilli strains, especially L. casei, have a good effect on the prevention of CDAD and AAD.

The Optimal Chinese Herbal Injections for Use With Radiotherapy to Treat Esophageal Cancer: A Systematic Review and Bayesian Network Meta-Analysis

Ethnopharmacological relevance: Esophageal cancer is one of the most common human cancers, and its incidence is highly endemic in China. The combination of Chinese herbal injections (CHIs) and radiotherapy should be informed by the best available evidence.

Aim of the study: To update and expand on previous work in order to compare and rank the efficacy and safety of CHIs in combination with radiotherapy to treat esophageal cancer.

Materials and Methods: We searched several electronic databases to identify randomized controlled trials (RCTs) regarding CHIs to treat esophageal cancer from their inception to March 15, 2017. In a network meta-analysis (NMA), the bias of the included trials was assessed by two individuals independently in accordance with the Cochrane Handbook for Systematic Reviews of Interventions. Outcomes such as the clinical effectiveness rate, performance status, adverse reactions (ADRs), and survival rate were evaluated. We performed a random-effects NMA to obtain estimates of efficacy and safety outcomes, and we present these estimates as odds ratios (ORs) and corresponding 95% confidence intervals (CIs) calculated via Stata 13.1 and WinBUGS 1.4 software. Furthermore, the surface under cumulative the ranking curve (SUCRA) was used to rank the efficacy and safety of different CHIs in relation to each outcome.

Results: Of 685 identified trials, 55 were eligible for inclusion in the study. These 55 trials included 12 CHIs and 4,114 participants. The cluster analysis results suggested that Compound kushen injection therapy is the optimal CHI treatment for patients with esophageal cancer in terms of improving the clinical effectiveness rate and performance status. Huachansu and Kangai injection are superior in improving 1-year and 2-year survival rates. Lentinan injection may be considered a favorable choice for reliving ADRs, and Compound kushen injection may provide treatment benefits by reducing both gastrointestinal reaction and radiation esophagitis.

Conclusions: The current clinical evidence indicated that Compound kushen injection combined with radiotherapy is the most preferable and beneficial option for patients with esophageal cancer in terms of efficacy and safety. However, the results of our study should be interpreted with caution given the limitations of the sample size and the methodological quality of the included trials.

Transcatheter hepatic arterial chemoembolization plus cinobufotalin injection adjuvant therapy for advanced hepatocellular carcinoma: a meta-analysis of 27 trials involving 2,079 patients

Objective

The aim of this study was to systematically investigate the safety and efficacy of the combination of transcatheter hepatic arterial chemoembolization (TACE) and cinobufotalin injection for advanced hepatocellular carcinoma (HC).

Methods

Clinical trials were searched from Web of Science, Cochrane Library, PubMed, Embase, Chinese Medical Citation Index (CMCI), China National Knowledge Infrastructure (CNKI), Chinese Scientific Journal Database (VIP), and Wanfang database. Outcome measures including therapeutic efficacy, quality of life, liver function, immune function, and adverse events were extracted and evaluated.

Results

After final assessment, 27 studies including 2,079 advanced HC patients were involved in this study. Compared with TACE alone, the combination of TACE with cinobufotalin injection adjuvant therapy significantly prolonged the patients’ 1-, 1.5-, 2-, and 3-year overall survival (OS) rate (1-year OS, OR=2.84, 95% CI=2.20–3.67, P<0.00001; 1.5-year OS, OR=3.57, 95% CI=1.92–6.66, P<0.0001; 2-year OS, OR=3.17, 95% CI=2.36–4.25, P<0.00001; 3-year OS, OR=2.88, 95% CI=1.82–4.57, P<0.00001). The combined therapy also improved patients’ overall response rate (ORR; OR=1.86, 95% CI=1.54–2.24, P<0.00001), disease control rate (DCR; OR=2.05, 95% CI=1.59–2.64, P<0.00001), and quality of life improved rate (QIR; OR=3.45, 95% CI=2.52–4.72, P<0.00001). Moreover, the immune function and liver function of HC patients were all significantly enhanced after the combined therapy of TACE and cinobufotalin injection (CD3⁺, P=0.001; CD4⁺, P=0.0006; CD4⁺/CD8⁺, P=0.03; natural killer [NK] cell, P=0.01; total bilirubin [TBIL], P=0.003; alanine aminotransferase [ALT], P<0.00001; aspartate aminotransferase [AST], P<0.00001). No serious adverse events occurred during cinobufotalin injection-mediated therapy.

Conclusion

The combination of TACE and cinobufotalin injection adjuvant therapy is safe and more effective for end-stage HC treatment than TACE alone.

Which is the best combination of TACE and Sorafenib for advanced hepatocellular carcinoma treatment? A systematic review and network meta-analysis

The aim of this study was to assess the comparative efficacy and safety of combination therapy with transarterial chemoembolization (TACE) and Sorafenib for patients with advanced hepatocellular carcinoma (HCC) through a systematic review and network meta-analysis and identify the best combination of TACE and Sorafenib. We searched databases for publications prior to May 2018. The prespecified efficacy outcomes were the objective response rate, overall survival rate, and time to progression. adverse effects included dermatologic, gastrointestinal, and general disorders. Subgroup analyses, meta-regression, and a network meta-analysis regarding two types of outcomes by different chemotherapy agents in TACE (5-fluorouracil, Adriamycin, Platinum, mitomycin C, hydroxycamptothecin) were included. The study is registered with PROSPERO (CRD42018098541). For efficacy outcomes, subgroups which included 5-fluorouracil and hydroxycamptothecin ranked higher than other chemotherapy agents, while mitomycin C ranked the lowest. For advanced effects, the use of mitomycin C or 5-fluorouracil as the chemotherapy agent ranked higher, while hydroxycamptothecin ranked the lowest. Therefore, we excluded 5-Fu and Mitomycin C in subsequent studies. Additionally, in the evaluation of primary adverse effects by the network meta-analysis, Platinum ranked the highest while hydroxycamptothecin ranked the lowest. Therefore, we excluded Platinum this time. Furthermore, all types of Adriamycin are not same, and some studies included two types of Adriamycin. The network meta-analysis results showed that the TACE (hydroxycamptothecin + pirarubicin) +Sorafenib arm and TACE (hydroxycamptothecin + epirubicin) +Sorafenib arm had significant efficacy differences. In conclusion, for patients with advanced HCC, combination therapy with HCPT plus THP/EPI in TACE and Sorfenib may be used as a first-line treatment.

Do genetic polymorphisms of the vitamin D receptor contribute to breast/ovarian cancer? A systematic review and network meta-analysis

BACKGROUND

To identify the most suitable genetic model for detecting the risk of breast cancer (BC)/ovarian cancer (OC) in specific populations.

METHODS

Databases were searched for related studies published up to October 2017. First, VDR genetic polymorphisms were compared in patients with and without cancer. Second, a network meta-analysis was used to reveal the relation between VDR genetic polymorphisms with disease outcomes. Subgroup analyses and a meta-regression were performed according to cancer types, ethnicity and genotypic method. The study is registered in PROSPERO with an ID: CRD42017075505.

RESULTS

Forty-five studies were eligible, which included 65,754 patients and 55 clinical analyses. Of genetic models, results suggested that the recessive model with the CDX2 polymorphism predicted the risk of BC in all cases. The recessive polymorphism model with the rs2228570 (FokI) polymorphism seemed to the best predictor of BC in Caucasian patients, whereas the homozygote model with the CDX2 polymorphism appeared to best predict BC in African-American patients. The homozygote model with the rs2228570 (FokI) polymorphism model appeared to detect the risk of OC in all cases, whereas the heterozygote model with the rs1544410 (BsmI) polymorphism seemed to detect the risk of OC in Caucasian patients.

CONCLUSIONS

By detecting the risk of BC, the recessive model with the rs2228570 (FokI) polymorphism is likely the best genetic model in Caucasian patients, and the homozygote model with the CDX2 polymorphism appears to be best genetic model in African-American patients. Moreover, for detecting clinical risk of OC, heterozygote models with the rs1544410 (BsmI) polymorphism is likely the best genetic model for detecting the risk of OC in Caucasian patients.

The effects of polysaccharides from Auricularia auricula (Huaier) in adjuvant anti-gastrointestinal cancer therapy: A systematic review and network meta-analysis

The aim of this study was to assess the comparative efficacy and safety of polysaccharides from Auricularia auricula (Huaier) for patients with gastrointestinal cancers (GICs) through a systematic review and network meta-analysis. We performed a network meta-analysis to identify evidence from clinical trials. We searched databases for publications up to February 2018. The prespecified primary efficacy outcomes were clinical therapeutic effects, which included the treatment response rate, 0.5-year overall survival rate, 1-year overall survival rate, 2-year overall survival rate, KPS improved rate and AFP decreased rate. The safety outcomes were the side effects of Huaier. The secondary efficacy outcome was immune function. Subgroup analyses and meta-regression were performed according to the various cancer types in all of the efficacy and safety outcomes. The study is registered with PROSPERO (CRD42018086481). A total of 33 trials, involving 2884 patients and 10 treatment arms, were eligible. Huaier significantly increased the treatment response rate (2.48, 1.83-3.35) and survival rate (0.5-year, 1-year and 2-year) and improved immune function without increasing the incidence of adverse effects. Significant efficacy was observed in most subgroups. Network meta-analysis revealed that Huaier was very suitable for combination therapy with TACE and ¹²⁵I particle implantation. Similarly, Huaier also had a good adjuvant therapeutic effect on enhancing platinum (L-OHP and DDP) and adriamycin (ADM). Huaier offers clear advantages for patients with GICs. Moreover, patients should be encouraged to accept Huaier treatment, especially HCC patients undergoing combination therapy with TACE and ¹²⁵I particle implantation.