Bojungikki-Tang Improves Response to PD-L1 Immunotherapy by Regulating the Tumor Microenvironment in MC38 Tumor-Bearing Mice

Evaluation of efficacy, safety and underlying mechanism on Traditional Chinese medicine as synergistic agents for cancer immunotherapy: A preclinical systematic review and meta-analysis

ETHNOPHARMACOLOGICAL RELEVANCE

Based on the documentation in Shennong's Herbal Classics, numerous Traditional Chinese medicine (TCM) are noted to possess anti-tumor properties, and TCM has been used in China for thousands of years. Particularly, current research have demonstrated that TCM combined with immunotherapy exhibited enhanced anti-tumor effects.

AIM OF THE STUDY

This meta-analysis aimed to evaluate the effectiveness, security, and potential mechanisms of TCM coupled with programmed cell death protein-1/programmed death ligand-1 (PD-1/PD-L1) inhibitors in cancer animal models.

MATERIALS AND METHODS

The pertinent research was performed in English database including PubMed, Web of Science, Embase, and Cochrane Library, as well as Chinese database including China National Knowledge Infrastructure (CNKI) and Wanfang Data Database published until January 2024. The quality of the included studies was evaluated with Systematic Review Center for Laboratory animal Experimentation (SYRCLE) risk assessment tool, and statistical analysis was conducted with Revman 5.4 software. Egger's test and funnel plots were used to assess potential publication bias.

RESULTS

An aggregate of 30 articles comprising 39 studies fulfilled the conditions for examination. The meta-analysis revealed that TCM + PD-1/PD-L1 inhibitors exhibited significant effects in inhibiting tumor growth (standard mean difference (SMD) = -2.61, 95% confidence interval (CI) = [-3.15, -2.07]), reducing tumor weight [SMD = -2.79 (-3.75, -1.83)], prolonging the survival time, and enhancing immune function in both cellular (CD4+ T cell percentage: 3.00 [1.45, 4.55]; CD8+ T cell percentage: 3.06 [2.16, 3.95]) and humoral immunity (interferon-γ (IFN-γ): 3.43, [2.54, 4.32]; tumor necrosis factor-α (TNF-α): 2.78 [1.46, 4.09]; interleukin (IL)-2: 1.79, [0.62, 2.95]; IL-6: 2.34, [0.07, 4.60]), and the differences between the two groups of the above indicators were statistically significant. No significant difference was found for aspartate aminotransferase (AST) and alanine aminotransferase (ALT) levels. The mechanisms of TCM impacting PD-1/PD-L1 inhibitors therapy were closely associated with regulating tumor microenvironment, modulating gut microbiota, suppressing expression of PD-1 or PD-L1, and regulating cytokine signaling.

CONCLUSION

TCM displayed a potential enhanced anti-tumor efficacy of PD-1/PD-L1 inhibitors on six types of tumor including colon, breast, colorectal, melanoma, and bladder cancer in animals. However, due to significant heterogeneity in the included studies, caution should be exercised regarding the results. More high-quality randomized controlled animal experiments are need.

Peripheral blood CD8 + CD28+ T cells as predictive biomarkers for treatment response in metastatic colorectal cancer

BACKGROUND

Colorectal cancer (CRC) is a substantial global health burden, with treatment outcomes significantly influenced by the interaction between the immune system and the tumor microenvironment.

OBJECTIVE

This study aims to investigate the role of peripheral blood immune cell subpopulations, particularly CD8+ CD28+ T cells, in predicting treatment response in metastatic CRC patients receiving bevacizumab combined with chemotherapy.

METHODS

A cohort of 45 CRC patients was analyzed. Flow cytometry was utilized to assess immune cell subpopulations.

RESULTS

Higher CD8+ CD28+ T cell counts were associated with better treatment responses, including improved objective response rates. In a murine CRC model, the combination therapy significantly inhibited tumor growth and enhanced immune cell function.

CONCLUSION

These findings highlight the importance of CD8+ CD28+ T cells as potential biomarkers for predicting treatment outcomes in CRC. They also suggest that bevacizumab, when combined with chemotherapy, can modulate immune function and improve clinical efficacy.

Efficacy and Safety of Herbal Medicine Bojungikki-Tang in Combination with Pembrolizumab versus Pembrolizumab Monotherapy for Stage IV Non-Small Cell Lung Cancer: Study Protocol for a Randomized, Open-Label, Double-Arm, Multicenter Trial

BACKGROUND

Non-small cell lung cancer (NSCLC) exhibits low survival rates. Although immune checkpoint inhibitors (ICIs) have become first-line treatment for NSCLC, their limited response to ICI monotherapy has led to exploration of combination treatments. However, the high incidence of treatment-related adverse events associated with conventional drug combinations has highlighted the need for alternative herbal therapy. Bojungikki-tang (BJIKT), a traditional herbal medicine, has been used to treat gastrointestinal disorders and enhance immune function. Our preclinical studies have demonstrated that BJIKT combined with anti-PD-1 or anti-PD-L1 antibodies exhibits significant efficacy in suppressing tumor growth by modulating the immunosuppressive tumor microenvironment. Building on these preclinical findings, this study aims to evaluate the efficacy and safety of BJIKT with pembrolizumab combination therapy compared to pembrolizumab monotherapy in advanced NSCLC patients.

METHODS

70 individuals with stage IV NSCLC scheduled for first-line pembrolizumab monotherapy will be randomly assigned to intervention or control groups. The primary outcome will be progression-free survival, with secondary outcomes including disease control rate, overall survival, and quality of life assessment. Adverse events will be monitored for safety. This study will explore the synergistic mechanism of combinatorial therapy using immune profiling and multi-omics analysis, and the possibility for personalized integrative therapy based on cold-heat syndrome differentiation (SD) types in East Asian medicine.

DISCUSSION

This study will provide novel evidence regarding survival outcomes, quality of life, and safety profiles of combined ICI and BJIKT therapy for advanced NSCLC. The exploratory data will contribute to tailoring treatments to immune-based SD types in NSCLC patients.

Targeted modulation of myeloid-derived suppressor cells in the tumor microenvironment: Implications for cancer therapy

Myeloid-derived suppressor cells (MDSCs) represent a heterogeneous population of immature myeloid cells originating from the bone marrow, known for their potent immunosuppressive functions that contribute to tumor immune evasion and progression. This paper provides a comprehensive analysis of the multifaceted interactions between MDSCs and tumors, exploring their distinct phenotypes and immunosuppressive mechanisms. Key roles of MDSCs in tumor biology are discussed, including their involvement in the formation of the pre-metastatic niche, facilitation of angiogenesis, enhancement of vascular permeability, suppression of tumor cell apoptosis, and promotion of resistance to cancer therapies. Additionally, the review highlights recent advances in the development of MDSC-targeting therapies, with a focus on their potential to enhance anti-tumor immunity. The therapeutic potential of Traditional Chinese Medicine (TCM) in modulating MDSC quantity and function is also explored, suggesting a novel approach to cancer treatment by integrating traditional and modern therapeutic strategies.

Bojungikki-Tang Augments Pembrolizumab Efficacy in Human PBMC-Injected H460 Tumor-Bearing Mice

Bojungikki-Tang (BJIKT) is traditionally used to enhance digestive function and immunity. It has gained attention as a supplement to chemotherapy or targeted therapy owing to its immune-boosting properties. This study aimed to evaluate the synergistic anti-tumor effects of BJIKT in combination with pembrolizumab in a preclinical model. MHC I/II double knockout NSG mice were humanized with peripheral blood mononuclear cells (PBMCs) and injected subcutaneously with H460 lung tumor cells to establish a humanized tumor model. Both agents were administered to evaluate their impact on tumor growth and immune cell behavior. Immunohistochemistry showed decreased exhaustion markers in CD8(+) and CD4(+) T cells within the tumor, indicating enhanced T cell activity. Additionally, RNA sequencing, transcriptome analysis, and quantitative PCR analysis were performed on tumor tissues to investigate the molecular mechanisms underlying the observed effects. The results confirmed that BJIKT improved T cell function and tumor necrosis factor signaling while suppressing transforming growth factor-β signaling. This modulation led to cell cycle arrest and apoptosis. These findings demonstrate that BJIKT, when combined with pembrolizumab, produces significant anti-tumor effects by altering immune pathways and enhancing the anti-tumor immune response. This study provides valuable insights into the role of BJIKT in the tumor microenvironment and its potential to improve therapeutic outcomes.

Therapeutic and immunomodulatory effects of Bojungikki-tang on cancer: a scoping review

BACKGROUND

Cancer remains a major global health concern, with conventional treatments often limited by side effects and resistance. Bojungikki-tang (BJIKT), a traditional herbal formula, has shown promise in alleviating cancer-related symptoms and enhancing anti-cancer effects when combined with conventional treatments. As immune checkpoint inhibitors (ICIs) have become the standard for cancer treatment, a combination of BJIKT and ICIs may exhibit immune-mediated anti-cancer effects. This review aims to summarize the recent evidence on BJIKT use in cancer treatment, investigate its immunomodulatory effects, and identify research gaps.

METHODS

This review was conducted and reported following the Arksey and O'Malley framework and the Preferred Reporting Items for Systematic Reviews and Meta-Analysis Scoping Review. A comprehensive search of six electronic databases was conducted, and studies published between 2013 and 2022 were identified. Reports on oral administration of BJIKT to patients with cancer were included and analyzed by two reviewers. The extracted data were synthesized using descriptive reporting and meta-analysis.

RESULTS

Overall, 56 studies met the inclusion criteria: 36 human studies, 14 experimental studies, and 6 reviews on clinical and preclinical investigations. The use of BJIKT in restoring immune function and improving fatigue, cancer-related fever, and quality of life after chemotherapy has been reported in clinical studies. The different medication forms of BJIKT included decoction, extract granules, pills, and water extract. The meta-analysis revealed a significantly higher Karnofsky Performance Scale score in the BJIKT plus chemotherapy group than in the chemotherapy alone group. Preclinical studies have demonstrated that BJIKT has anti-cancer effects, enhances gastrointestinal function and immunomodulatory effects, and supports favorable chemotherapy outcomes.

CONCLUSION

In recent clinical research on BJIKT, its impact on fatigue, quality of life, and alleviating cancer-related fever has mostly been examined. The direct anti-cancer activities and immunomodulatory mechanisms of BJIKT have been reported in preclinical studies; however, clinical research on BJIKT-induced enhancement of immune function is lacking. Further research on the efficacy and safety of ICI combined with BJIKT and the association of immunomarker changes with clinical outcomes is required to precisely identify the effect of BJIKT on immune system modulation.

Influence of extraction solvents on the chemical constituents and biological activities of Astragalus aduncus from Turkey flora: In vitro and in silico insights

The n-hexane, ethyl acetate, ethanol, ethanol/water (70% ethanol), and water extracts of Astragalus aduncus aerial parts were investigated for their antioxidant potential, enzyme inhibition activity (anti-acetylcholinesterase [AChE], anti-butyrylcholinesterase [BChE], antityrosinase, antiamylase, and antiglucosidase) and antiproliferative effect (against colon adenocarcinoma cell line [HT-29], gastric cancer cell line [HGC-27], prostate carcinoma cell line [DU-145], breast adenocarcinoma cell line [MDA-MB-231], and cervix adenocarcinoma cell line [HeLa]). In addition, the phytochemical profile of the extracts was evaluated using validated spectrophotometric and high-pressure liquid chromatography-electrospray ionization/tandem mass spectroscopy methods. Generally, the 70% ethanol extract demonstrated the strongest antioxidant properties, and it was the richest source of total phenolic constituents. Our findings indicated that the ethyl acetate extract was the most potent BChE inhibitor (11.44 mg galantamine equivalents [GALAE]/g) followed by the ethanol extract (8.51 mg GALAE/g), while the ethanol extract was the most promising AChE inhibitor (3.42 mg GALAE/g) followed by the ethanol/water extract (3.17 mg GALAE/g). Excellent tyrosinase inhibitory activity (66.25 mg kojic acid equivalent/g) was observed in ethanol/water extracts of the aerial part of A. aduncus. Тhese results showed that the most cytotoxic effects were exhibited by the ethyl acetate extract against HGC-27 cells (IC50: 36.76 µg/mL), the ethanol extract against HT-29 cells (IC50: 30.79 µg/mL), and the water extract against DU-145 cells (IC50: 37.01 µg/mL). A strong correlation was observed between the highest total flavonoid content and the highest content of individual compounds in the ethanol extract, including rutin, hyperoside, isoquercitrin, delphinidin-3,5-diglucoside (delphinidin-3,5-O-diglucoside), and kaempferol-3-glucoside (kaempferol-3-O-glucoside). In the present study, the A. aduncus plant was considered a new source of antioxidants, enzyme inhibitors, and anticancer agents and could be used as a future health-benefit natural product.

The role of innate immune cells in the colorectal cancer tumor microenvironment and advances in anti-tumor therapy research

Innate immune cells in the colorectal cancer microenvironment mainly include macrophages, neutrophils, natural killer cells, dendritic cells and bone marrow-derived suppressor cells. They play a pivotal role in tumor initiation and progression through the secretion of diverse cytokines, chemokines, and other factors that govern these processes. Colorectal cancer is a common malignancy of the gastrointestinal tract, and understanding the role of innate immune cells in the microenvironment of CRC may help to improve therapeutic approaches to CRC and increase the good prognosis. In this review, we comprehensively explore the pivotal role of innate immune cells in the initiation and progression of colorectal cancer (CRC), alongside an extensive evaluation of the current landscape of innate immune cell-based immunotherapies, thereby offering valuable insights for future research strategies and clinical trials.

Immune-Related Adverse Events due to Concomitant Use of Immune Checkpoint Inhibitors and Chinese Herbal Medicines: A Study Based on a Japanese Adverse Event Database

BACKGROUND

Fatigue is an immune-related adverse event (irAE) associated with immune checkpoint inhibitors (ICIs) used for cancer treatment. Chinese herbal medicines (Ho-zai) are used to treat cancer-related fatigue. However, no interactions between ICIs and Ho-zai have been reported. Herein, we investigated the risk of irAEs associated with the concomitant use of ICIs and Ho-zai.

METHODS

We extracted data of patients who used ICI and Ho-zai from the Japanese Adverse Event Reporting Database. The proportional reporting ratio (PRR) was calculated for patients using ICI, Ho-zai, or both. We focused on cases of interstitial lung disease (ILD) and colitis, which were among the most severe cases of irAEs among these patients. The shrinkage method used by the World Health Organization-Uppsala Monitoring Center was used to detect the interactions.

RESULTS

Of the 799,670 patients in the database, 77,219, 2060, and 92 were using ICIs, Ho-zai, and combination treatment, respectively. The ILD and colitis groups included 39,388 and 17,522 patients, respectively. ILD signals were detected for both ICIs and Ho-zai. There were 24 cases of patients treated with concomitant ICIs and Ho-zai who developed ILD. For all combinations of all ICIs and all Ho-zai, Ω025 was negative, which suggested no ILD-related interactions. Colitis signals were detected for ICIs except for atezolizumab, avelumab, and durvalumab. There were eight patients treated with concomitant ICI and Ho-zai who developed colitis. For all combinations of all ICIs and all Ho-zai, Ω025 was negative, which suggested no colitis-related interactions.

CONCLUSION

To our knowledge, this is the first study to investigate interactions between ICIs and Ho-zai. Signals were detected for ILD in both ICI and Ho-zai groups, and colitis in the ICI group. However, the combined use of these treatments did not increase the risk of irAEs.

Antitumor activity of alkylphospholipid edelfosine in prostate cancer models and endoplasmic reticulum targeting

Prostate cancer is the second most frequent cancer and the fifth leading cause of cancer death among men worldwide. While the five-year survival in local and regional prostate cancer is higher than 99%, it falls to about 28% in advanced metastatic prostate cancer. The ether lipid edelfosine is considered the prototype of a family of promising antitumor drugs collectively named as alkylphospholipid analogs. Here, we found that edelfosine was the most potent alkylphospholipid analog in inducing apoptosis in three different human prostate cancer cell lines (LNCaP, PC3, and DU145) with distinct androgen dependency, and differing in tumor suppressor phosphatase and tensin homolog (PTEN) and p53 status. Edelfosine accumulated in the endoplasmic reticulum of prostate cancer cells, leading to endoplasmic reticulum stress and cell death in the three prostate cancer cells. Inhibition of autophagy potentiated the pro-apoptotic activity of edelfosine in LNCaP and PC3 cells, where autophagy was induced as a survival response. Edelfosine induced a slight and transient inhibition of AKT in PTEN-negative LNCaP and PC3 cells, but not in PTEN-positive DU145 cells. Daily oral administration of edelfosine in murine prostate restricted AKT kinase transgenic mice, expressing active AKT in a prostate-specific manner, and in a DU145 xenograft mouse model resulted in significant tumor regression and apoptosis in tumor cells. Taken together, these results show a significant in vitro and in vivo antitumor activity of edelfosine against prostate cancer, and highlight the endoplasmic reticulum as a novel and promising therapeutic target in prostate cancer.

Bojungikgi-tang improves skin barrier function and immune response in atopic dermatitis mice fed a low aryl hydrocarbon receptor ligand diet

BACKGROUND

The aryl hydrocarbon receptor (AhR) is a transcription factor that plays a crucial role in regulating the immune system and maintaining skin barrier function. AhR signaling is pivotal in the pathogenesis of inflammatory diseases such as atopic dermatitis (AD), and the absence of AhR ligands further contributes to the progression or worsening of AD symptoms.

METHODS

AD was induced with 2,4-dinitrochlorobenzene (DNCB), and Bojungikgi-tang (BJIKT) was administered orally daily for 10 weeks. Serum IgE, splenocyte IL-4, and IFN-γ levels, skin barrier genes, and AhR target gene expressions were analyzed using RNA-sequencing analysis. Spleen tissues were extracted for fluorescence-activated cell sorting (FACS) analysis to analyze the effect of BJIKT on immune responses. A correlation analysis was conducted to analyze the correlation between immune markers and skin barrier genes and AhR target genes.

RESULTS

BJIKT effectively improved AD symptoms in AD mice fed a low AhR ligand diet by reducing neutrophil and eosinophil counts, lowering IgE levels in the blood, and decreasing IL-4 and IFN-γ levels in the splenocytes. Additionally, BJIKT significantly reduced epithelial skin thickness and transepidermal water loss (TEWL) values and reversed the decreased expression of skin barrier genes. BJIKT also considerably altered the expression of AhR target genes, including Ahr, Ahrr, cytochrome P450 1A1 (CYP1A1), and CYP1B1. Furthermore, AhR target pathway genes were negatively correlated with immune cell subtypes, including CD4 + and CD8 + T cells and macrophages (CD11b + F4/80 +) at the systemic level.

CONCLUSIONS

BJIKT can regulate AhR activation and may help reduce inflammation in AD by regulating the expression of skin barrier genes and immune responses.

Evaluation of the potential herb-drug interaction between Bojungikki-tang and PD-L1 immunotherapy in a syngeneic mouse model

Atezolizumab (a PD-L1 inhibitor) has shown remarkable efficacy and tolerability in various cancer types. Despite its efficacy and safety, atezolizumab monotherapy has limitations, such as acquired resistance and adverse events. Bojungikki-tang (BJIKT) is an herbal decoction widely prescribed in Asian countries and used to treat cancer-related symptoms including fatigue, appetite loss, gastrointestinal disorders, and other side effects from cancer therapy. Due to its immunomodulatory effects, Bojungikki-tang has been investigated as a combined treatment with anticancer agents. We evaluated the potential drug-drug interaction (DDI) between Bojungikki-tang and the anti-PD-L1 antibody based on the Food and Drug Administration (FDA) guidelines. In the study, we conducted an in vivo drug-drug interaction study using a syngeneic mouse model of CMT-167 in C57BL/6. We then determined the antibody concentrations to evaluate the pharmacokinetic (PK) drug-drug interaction and measured variable biomarkers related to therapeutic efficacy and immune response. The pharmacodynamic (PD) drug-drug interaction study investigated changes in response between anti-PD-L1 antibody monotherapy and combination therapy. Using the pharmacokinetic and pharmacodynamic data, we conducted a statistical analysis to assess drug-drug interaction potential. In the presence of Bojungikki-tang, the pharmacokinetic characteristics of the anti-PD-L1 antibody were not changed. This study suggested that combination treatment with Bojungikki-tang and atezolizumab is a safe treatment option for non-small cell lung cancer. Clinical studies are warranted to confirm this finding.

Bojungikki-Tang Enhances the Effect of PD-1 Blockade in a Syngeneic Murine Model of Lung Carcinoma

Although immunotherapy has become the standard of treatment for non-small cell lung cancer (NSCLC), only a limited number of patients benefit from it clinically because of the resistance to immunotherapeutic agents. Of late, the usefulness of herbal medicines in combination with immunotherapy has been investigated. Bojungikki-Tang (BJIKT) is a widely used traditional herbal medicine. It synergistically enhances the antitumor effects of chemotherapy and regulates the immune responses in cancer, but its antitumor effect with immunotherapy in NSCLC is unclear. In this study, we investigated the combined effects of BJIKT and an anti-PD-1 antibody in a KLN205-DBA/2 syngeneic lung cancer model. Immunohistochemistry and flow cytometry analyses were performed to analyze the changes in immune cells in the tumor microenvironment. BJIKT plus an anti-PD-1 antibody treatment significantly inhibited tumor growth, unlike the respective monotherapies. Compared to monotherapy, the combination treatment resulted in a higher population of CD8+ cytotoxic T cells and a lower number of Ki67+ cells in the tumor tissues. Furthermore, the combination treatment decreased the proportion of myeloid-derived suppressor cells but increased the proportion of M1-like macrophages compared to that observed with monotherapy. Cytokine analysis showed that the combination treatment increased the levels of T helper type 1-related cytokines. Network pharmacology analysis revealed that BJIKT might regulate multiple signaling pathways related to immune function and tumor progression in NSCLC. These findings indicate that the combination treatment with BJIKT and an anti-PD-1 antibody effectively suppresses tumor growth by regulating immune function and may be an alternative therapeutic option for the treatment of NSCLC.