Separation, characterization and dose-effect relationship of the PPARgamma-activating bio-active constituents in the Chinese herb formulation 'San-Ao decoction'

Naoxintong capsule accelerates mitophagy in cerebral ischemia-reperfusion injury via TP53/PINK1/PRKN pathway based on network pharmacology analysis and experimental validation

ETHNOPHARMACOLOGICAL RELEVANCE

The incidence and mortality of cerebrovascular diseases are increasing year by year. Cerebral ischemia-reperfusion injury (CIRI) is common in patients with ischemic stroke. Naoxintong (NXT) is composed of a variety of Chinese medicines and has the ability to treat CIRI.

AIM OF THE STUDY

The aim of this study is to investigate whether NXT regulates mitophagy in CIRI based on network pharmacology analysis and experimental validation.

MATERIALS AND METHODS

Oxygen and glucose deprivation/re-oxygenation (OGD/R, 2/22 h) model of PC12 cells and transient middle cerebral artery occlusion (tMCAO, 2/22 h) model of rats were established. Pharmacodynamic indicators include neurological deficit score, 2,3,5-triphenyte-trazoliumchloride (TTC) staining, hematoxylin-eosin (HE) staining and cell viability. Network pharmacology was used to predict pharmacological mechanisms. Pharmacological mechanism indexes include transmission electron microscopy (TEM), drug affinity responsive target stability (DARTS), cellular thermal shift assay (CETSA), immunohistochemistry (IHC), western blot (WB) and immunofluorescence (IF). Kevetrin (an agonists of p53) and pifithrin-α (an inhibitor of p53) used to detect the key role of p53 in mitophagy of NXT.

RESULTS

NXT (1% serum containing NXT and 110 mg/kg) improved the damage of OGD/R PC12 cells and tMCAO rats, and this protective effect was related to the anti-oxidation and ability to promote mitophagy of NXT. NXT and pifithrin-α increased the expression of promoting-mitophagy targets (PINK1, PRKN and LC3B) and inhibited the expression of inhibiting-mitophagy targets (p52) via restraining p53, and finally accelerated mitophagy caused by CIRI.

CONCLUSION

This study demonstrates that NXT promotes mitophagy in CIRI through restraining p53 and promoting PINK1/PRKN in vivo and in vitro.

Insights into the molecular mechanisms of Huangqi decoction on liver fibrosis via computational systems pharmacology approaches

BACKGROUND

The traditional Chinese medicine Huangqi decoction (HQD) consists of Radix Astragali and Radix Glycyrrhizae in a ratio of 6: 1, which has been used for the treatment of liver fibrosis. In this study, we tried to elucidate its action of mechanism (MoA) via a combination of metabolomics data, network pharmacology and molecular docking methods.

METHODS

Firstly, we collected prototype components and metabolic products after administration of HQD from a publication. With known and predicted targets, compound-target interactions were obtained. Then, the global compound-liver fibrosis target bipartite network and the HQD-liver fibrosis protein-protein interaction network were constructed, separately. KEGG pathway analysis was applied to further understand the mechanisms related to the target proteins of HQD. Additionally, molecular docking simulation was performed to determine the binding efficiency of compounds with targets. Finally, considering the concentrations of prototype compounds and metabolites of HQD, the critical compound-liver fibrosis target bipartite network was constructed.

RESULTS

68 compounds including 17 prototype components and 51 metabolic products were collected. 540 compound-target interactions were obtained between the 68 compounds and 95 targets. Combining network analysis, molecular docking and concentration of compounds, our final results demonstrated that eight compounds (three prototype compounds and five metabolites) and eight targets (CDK1, MMP9, PPARD, PPARG, PTGS2, SERPINE1, TP53, and HIF1A) might contribute to the effects of HQD on liver fibrosis. These interactions would maintain the balance of ECM, reduce liver damage, inhibit hepatocyte apoptosis, and alleviate liver inflammation through five signaling pathways including p53, PPAR, HIF-1, IL-17, and TNF signaling pathway.

CONCLUSIONS

This study provides a new way to understand the MoA of HQD on liver fibrosis by considering the concentrations of components and metabolites, which might be a model for investigation of MoA of other Chinese herbs.

Pharmacological Activities of Coumarin Compounds in Licorice: A Review

Licorice is a traditional medicine commonly used in China and many other countries. Over the last 50 years, the structure and pharmacological effects of coumarin compounds in licorice have been investigated. However, a comprehensive review of the literature summarizing current trends is currently lacking. Thus, the aim of the present review is to provide an up-to-date summary of the scientific literature regarding the pharmacological effects of coumarin compounds in licorice, thereby laying the foundation for further research and optimal utilization of licorice. We retrieved 111 articles on the coumarin components of licorice and their potential pharmacological effects, based on titles, keywords, and abstracts from databases (including PubMed and Web of Science). Glycycoumarin, isoglycycoumarin, licoarylcoumarin, licopyranocoumarin, glycyrin, isotrifoliol, glycyrol, and glycyrurol have been investigated for their anticancer, hepatoprotective, antispasmodic, immunosuppressive, anti-inflammatory, and antibacterial properties, and use as therapeutic agents in metabolic syndrome, thereby demonstrating their potential for clinical applications. Future research should further explore the pharmacological mechanisms of action of coumarin compounds, including their antibacterial activities. Investigations into the pharmacological activities of different glycycoumarin isomers might open new research frontiers.

Effect of San'ao decoction on aggravated asthma mice model induced by PM2.5 and TRPA1/TRPV1 expressions

OBJECTIVE

San'ao decoction (SAD), a traditional Chinese prescription, is well-known in asthma treatment. In the current study, the protective role of SAD and its mechanism in aggravated asthma mice model via regulation of TRP channel were evaluated and explored.

METHODS

UPLC-QTOF-MS was used for analyzing the chemicals in SAD. The major chemical components in SAD were separated and detected under an optimized chromatographic and MS condition. 75 BALB/c mice were randomly divided into five groups: normal group, model group, dexamethasone group (0.75 mg kg^-1), SAD-high dose group (1.8 g kg^-1) and SAD-low dose group (0.9 g kg^-1). A 42 days aggravated asthmatic model was established in mice induced by ovalbumin (OVA) plus PM2.5 (1.6 mg kg^-1). After treated with corresponding medicine, peripheral blood and bronchoalveolar lavage fluid (BALF) from each group were assessed, airway responsiveness was determined, histopathological changes in lungs were detected, relevant cytokines and neurokines levels were measured, TRPA1 and TRPV1 mRNA and protein expressions in lung tissues were examined as well.

RESULTS

21 signal peaks of the chemicals in SAD were identified with the method of UPLC-QTOF-MS. SAD, especially SAD-high dose exerted significant effects on OVA plus PM2.5 mice model in relieving lung injury score (P < 0.05), reducing eosinophil (EOS) count in blood (P < 0.05) and inflammatory cells ratio in BALF (P < 0.05, P < 0.01), decreasing RI value (P < 0.05) while increasing Cdyn value (P < 0.05), reducing IL-13, PGD₂ and NGF levels in BALF (P < 0.01), as well as down-regulating TRPA1 and TRPV1 mRNA and protein expressions in lung tissues (P < 0.05, P < 0.01).

CONCLUSION

SAD could improve pulmonary functions, relieve lung injury, as well as reduce IL-13, PGD₂ and NGF levels of OVA plus PM2.5 aggravated asthma model in mice. The effect and mechanism of SAD might be related to the inhibition of TRPA1 and TRPV1 channels.

Network pharmacology-based strategy for predicting active ingredients and potential targets of Yangxinshi tablet for treating heart failure

ETHNOPHARMACOLOGICAL RELEVANCE

Yangxinshi tablet (YXST) is an effective treatment for heart failure and myocardial infarction; it consists of 13 herbal medicines formulated according to traditional Chinese Medicine (TCM) practices. It has been used for the treatment of cardiovascular disease for many years in China.

MATERIALS AND METHODS

In this study, a network pharmacology-based strategy was used to elucidate the mechanism of action of YXST for the treatment of heart failure. Cardiovascular disease-related protein target and compound databases were constructed for YXST. A molecular docking platform was used to predict the protein targets of YXST. The affinity between proteins and ingredients was determined using surface plasmon resonance (SPR) assays. The action modes between targets and representative ingredients were calculated using Glide docking, and the related pathways were predicted using the Kyoto Encyclopedia of Genes and Genomes (KEGG) database.

RESULTS

A protein target database containing 924 proteins was constructed; 179 compounds in YXST were identified, and 48 compounds with high relevance to the proteins were defined as representative ingredients. Thirty-four protein targets of the 48 representative ingredients were analyzed and classified into two categories: immune and cardiovascular systems. The SPR assay and molecular docking partly validated the interplay between protein targets and representative ingredients. Moreover, 28 pathways related to heart failure were identified, which provided directions for further research on YXST.

CONCLUSIONS

This study demonstrated that the cardiovascular protective effect of YXST mainly involved the immune and cardiovascular systems. Through the research strategy based on network pharmacology, we analysis the complex system of YXST and found 48 representative compounds, 34 proteins and 28 related pathways of YXST, which could help us understand the underlying mechanism of YSXT's anti-heart failure effect. The network-based investigation could help researchers simplify the complex system of YXSY. It may also offer a feasible approach to decipher the chemical and pharmacological bases of other TCM formulas.

Synthesis and Characterization of a Phosphate Prodrug of Isoliquiritigenin

Isoliquiritigenin (1) possesses a variety of biological activities in vitro. However, its poor aqueous solubility limits its use for subsequent in vivo experimentation. In order to enable the use of 1 for in vivo studies without the use of toxic carriers or cosolvents, a phosphate prodrug strategy was implemented relying on the availability of phenol groups in the molecule. In this study, a phosphate group was added to position C-4 of 1, leading to the more water-soluble prodrug 2 and its ammonium salt 3, which possesses increased stability compared to 2. Herein are reported the synthesis, characterization, solubility, and stability of phosphate prodrug 3 in biological medium in comparison to 1, as well as new results on its anti-inflammatory properties in vivo. As designed, the solubility of prodrug 3 was superior to that of the parent natural product 1 (9.6 mg/mL as opposed to 3.9 μg/mL). Prodrug 3 as an ammonium salt was also found to possess excellent stability as a solid and in aqueous solution, as opposed to its phosphoric acid precursor 2.

Pharmacological Activities and Phytochemical Constituents

Glycyrrhiza glabra is one of the most popular medicinal plants and it has been used in traditional herbal remedy since ancient times (Blumenthal et al. in Herbal medicine: expanded commission E monographs. Integrative Medicine Communications, Newton, 2000; Parvaiz et al. in Global J Pharmocol 8(1):8–13, 2014; Altay et al. in J Plant Res 129(6):1021–1032, 2016). Many experimental, pharmacological and clinical studies show that liquorice has antimicrobial, antibacterial, antiviral, antifungal, antihepatotoxic, antioxidant, antiulcer, anti-hemorrhoid antihyperglycemic, antidiuretic, antinephritic, anticarcinogenic, antimutagenic, anticytotoxic, anti-inflammatory, and blood stopper activity.

The Flavonoid Isoliquiritigenin Reduces Lung Inflammation and Mouse Morbidity during Influenza Virus Infection

The host response to influenza virus infection is characterized by an acute lung inflammatory response in which intense inflammatory cell recruitment, hypercytokinemia, and a high level of oxidative stress are present. The sum of these events contributes to the virus-induced lung damage that leads to high a level of morbidity and mortality in susceptible infected patients. In this context, we identified compounds that can simultaneously reduce the excessive inflammatory response and the viral replication as a strategy to treat influenza virus infection. We investigated the anti-inflammatory and antiviral potential activities of isoliquiritigenin (ILG). Interestingly, we demonstrated that ILG is a potent inhibitor of influenza virus replication in human bronchial epithelial cells (50% effective concentration [EC50] = 24.7 μM). In addition, our results showed that this molecule inhibits the expression of inflammatory cytokines induced after the infection of cells with influenza virus. We demonstrated that the anti-inflammatory activity of ILG in the context of influenza virus infection is dependent on the activation of the peroxisome proliferator-activated receptor gamma pathway. Interestingly, ILG phosphate (ILG-p)-treated mice displayed decreased lung inflammation as depicted by reduced cytokine gene expression and inflammatory cell recruitment. We also demonstrated that influenza virus-specific CD8(+) effector T cell recruitment was reduced up to 60% in the lungs of mice treated with ILG-p (10 mg/kg) compared to that in saline-treated mice. Finally, we showed that administration of ILG-p reduced lung viral titers and morbidity of mice infected with the PR8/H1N1 virus.

Botanical compounds and their regulation of nuclear receptor action: the case of traditional Chinese medicine

Nuclear receptors (NRs) are major pharmacological targets that allow an access to the mechanisms controlling gene regulation. As such, some NRs were identified as biological targets of active compounds contained in herbal remedies found in traditional medicines. We aim here to review this expanding literature by focusing on the informative articles regarding the mechanisms of action of traditional Chinese medicines (TCMs). We exemplified well-characterized TCM action mediated by NR such as steroid receptors (ER, GR, AR), metabolic receptors (PPAR, LXR, FXR, PXR, CAR) and RXR. We also provided, when possible, examples from other traditional medicines. From these, we draw a parallel between TCMs and phytoestrogens or endocrine disrupting chemicals also acting via NR. We define common principle of action and highlight the potential and limits of those compounds. TCMs, by finely tuning physiological reactions in positive and negative manners, could act, in a subtle but efficient way, on NR sensors and their transcriptional network.

The peroxisome proliferator-activated receptors in cardiovascular diseases: experimental benefits and clinical challenges

The peroxisome proliferator-activated receptors, PPARα, PPARβ/δ and PPARγ, are ligand-activated transcriptional factors belonging to the nuclear receptors superfamily and they are known to play important roles in glucose and lipid metabolism. Experimental studies in animal models of metabolic diseases have also revealed that activation of PPARs protects against the vascular complications of diabetes, hypertension, atherosclerosis, myocardial infarction and stroke, through exerting their anti-inflammatory, anti-atherogenic and antioxidant effects. In clinical trials and post-market surveillance, agonists of PPARs have been shown to effectively prevent cardiovascular events. However, adverse effects, particularly for PPARγ agonists, are also observed with the use of investigational PPAR agonists and even some approved drugs. Further exploration of underlying mechanisms is needed to develop novel ways of PPAR activation without causing serious side effects. This article reviews the cardiovascular effects of PPARs, with emphasis on the therapeutic potential of PPAR agonists in combating metabolic vascular diseases.

Qualitative and quantitative analysis of the major constituents in Chinese medical preparation Lianhua-Qingwen capsule by UPLC-DAD-QTOF-MS

Lianhua-Qingwen capsule (LQC) is a commonly used Chinese medical preparation to treat viral influenza and especially played a very important role in the fight against severe acute respiratory syndrome (SARS) in 2002-2003 in China. In this paper, a rapid ultraperformance liquid chromatography coupled with diode-array detector and quadrupole time-of-flight mass spectrometry (UPLC-DAD-QTOF-MS) method was established for qualitative and quantitative analysis of the major constituents of LQC. A total of 61 compounds including flavonoids, phenylpropanoids, anthraquinones, triterpenoids, iridoids, and other types of compounds were unambiguously or tentatively identified by comparing the retention times and accurate mass measurement with reference compounds or literature data. Among them, twelve representative compounds were further quantified as chemical markers in quantitative analysis, including salidroside, chlorogenic acid, forsythoside E, cryptochlorogenic acid, amygdalin, sweroside, hyperin, rutin, forsythoside A, phillyrin, rhein, and glycyrrhizic acid. The UPLC-DAD method was evaluated with linearity, limit of detection (LOD), limit of quantification (LOQ), precision, stability, repeatability, and recovery tests. The results showed that the developed quantitative method was linear, sensitive, and precise for the quality control of LQC.

2-(2-Bromophenyl)-formononetin and 2-heptyl-formononetin are PPARγ partial agonists and reduce lipid accumulation in 3T3-L1 adipocytes

Isoflavones are bioactive compounds that have been shown to decrease lipid accumulation in vitro. However, the knowledge of the isoflavone formononetin is limited. The aim of the study was to assess the effects of formononetin and its two synthetic analogues, 2-(2-bromophenyl)-formononetin and 2-heptyl-formononetin, on lipid accumulation in 3T3-L1 adipocytes and investigate possible mechanisms. Formononetin and the two analogues were added day 0-8 or day 8-10 of the differentiation period, and lipid accumulation, glycerol release and gene expression were measured. Additionally, competitive peroxisome proliferator-activated receptor (PPAR)-γ binding assay, PPARγ transactivation assay and Western blot for phosphorylated AMP-activated protein kinase (AMPK) were performed. Chronic treatment (day 0-8) with formononetin increased lipid accumulation, whereas the two analogues decreased lipid accumulation partly due to decreased differentiation. The two analogues, but not formononetin, also decreased lipid content in mature adipocytes. 2-Heptyl-formononetin increased glycerol release and lipolytic gene expression and decreased lipogenic gene expression. Formononetin did not bind to or activate PPARγ whereas both analogues bound to the receptor and behaved as PPARγ partial agonists in the transactivation assay. Neither of the compounds affected phosphorylation of AMPK. In conclusion, the analogues of formononetin decreased lipid accumulation possibly in part by acting as PPARγ partial agonists.

Bioactivity and potential health benefits of licorice

Licorice is an herbal plant named for its unique sweet flavor. It is widely used in the food and tobacco industries as a sweetener. Licorice is also used in traditional Chinese medicine (TCM) and complementary medicine. Because the use of licorice has long been a part of TCM, the details of its therapeutic applications have been thoroughly established. In modern science, licorice is of interest because of its broad range of applications. Extracts of and compounds isolated from licorice have been well studied and biologically characterized. In this review, we discuss the nutraceutical and functional activities of licorice as well as those of the extracts of and the isolated compounds from licorice, including agents with anti-inflammatory activity, cell-protective abilities, and chemopreventive effects. The side effects of licorice are also enumerated. A comparison of the activities of licorice described by modern science and TCM is also presented, revealing the correspondence of certain characteristics.

Absorption and interaction of the main constituents from the traditional Chinese drug pair Shaoyao-Gancao via a Caco-2 cell monolayer model

Shaoyao-Gancao (Paeoniae Radix Alba and Glycyrrhizae Radix et Rhizoma) is a traditional Chinese drug pair widely used in decoctions for relieving pains, especially abdominal pain. We aimed to determine the intestinal absorption and interaction of three active compounds (glycyrrhizic acid, liquiritin, and paeoniflorin) in this drug pair. We investigated the transport of these compounds across intestinal epithelial cells by using the Caco-2 cell monolayer in both the apical-to-basolateral (A-B) and B-A directions. All compounds could only travel through the Caco-2 cell monolayer at a low level when the cells were treated with single component solutions. In the presence of verapamil, an inhibitor of P-glycoprotein (P-gp), the absorptive permeability (P_AB) of paeoniflorin and liquiritin increased significantly (p < 0.05) and efflux ratios decreased, while the absorption of glycyrrhizic acid did not change significantly, which indicated that paeoniflorin and liquiritin might be P-gp substrates. In addition, when liquiritin and glycyrrhizic acid in Gancao extract and paeoniflorin in Shaoyao extract were examined, P_AB of paeoniflorin and liquiritin were significantly higher, while glycyrrhizic acid retained the same absorption level compared to the corresponding single component solutions, which suggested that some certain ingredients in the extracts can promote the absorption of paeoniflorin and liquiritin, but not that of glycyrrhizic acid. Furthermore, compared to the results of treatment with individual extracts, treatment of cells with a mixture of the two extracts considerably increased (p < 0.05) the absorption of glycyrrhizic acid and paeoniflorin and showed no change in the absorption of liquiritin, which implied that the transport of glycyrrhizic acid and paeoniflorin is increased by some ingredients from the complementary drug in the drug pair, while that of liquiritin remains unaffected.

Comparative analysis of the main bioactive components of San-ao decoction and its series of formulations

A high performance liquid chromatographic (HPLC) method with diode array detection (DAD) was established for simultaneous determination of seven main bioactive components in San-ao decoction and its series of formulae (San-ao decoction, Wu-ao decoction, Qi-ao decoction and Jia-wei San-ao decoction). Seven compounds were analyzed simultaneously with a XTerra C₁₈ column (4.6 mm × 250 mm, 5 µm) using a linear gradient elution of a mobile phase containing acetonitrile (A) and a buffer solution (0.02 mol/L potassium dihydrogen phosphate and adjusted to pH 3 using phosphoric acid) (B); the flow rate was 1.0 mL/min. The sample was detected with DAD at 210, 254 and 360 nm and the column was maintained at 30 °C. All the compounds showed good linearity (r² > 0.9984) in the tested concentration range. The precisions were evaluated by intra-day and inter-day tests, and relative standard deviation (R.S.D.) values within the range of 0.83%–2.53% and 0.64%–2.77% were reported, respectively. The recoveries of the quantified compounds were observed to cover a range from 95.34% and 104.82% with R.S.D. values less than 2.72%. The validated method was successfully applied for the simultaneous determination of seven main bioactive components including ephedrine (1), amygdalin (2), liquiritin (3), benzoic acid (4), isoliquiritin (5), formononetin (6) and glycyrrhizic acid (7) in San-ao decoction and its series of formulae. The results also showed a wide variation in the content of the identified active compounds in these samples, which could also be helpful to illustrate the drug interactions after some herbs combined in different formulations.

Interaction of the main components from the traditional Chinese drug pair Chaihu-Shaoyao based on rat intestinal absorption

The Chaihu-Shaoyao drug pair (Bupleuri Radix and Paeoniae Radix Alba) which is a traditional Chinese drug pair, has been widely used for anti-inflammatory purposes. Saikosaponin a (SSA), saikosaponin d (SSD) and paeoniflorin are identified as the main components in the pair. The present study focused on the interaction of the main components based on investigating their intestinal absorption using a four-site perfused rat intestinal model in order to clarify the mechanism of the compatibility of Chaihu-Shaoyao. The concentrations of SSA, SSD and paeoniflorin in the intestinal perfusate were determined by LC/MS or UPLC (Ultra Performance Liquid Chromatography) methods, followed by P*(eff) (effective permeability) and 10% ABS (the percent absorption of 10 cm of intestine) calculations. The results showed that all of the three main components displayed very low permeabilities (P*(eff) < 0.4), which implied their poor absorption in the rat intestine. The absorption levels of SSA and SSD were similar in intestine and higher in ileum than those in other intestinal regions in the decreasing order: colon, jejunum and duodenum. However, there is no significant difference in the absorption of paeoniflorin in the four segments (P < 0.05). The P*(eff) values of paeoniflorin exhibited an almost 2.11-fold or 1.90-fold increase in ileum when it was co-administrated with SSA and SSD, as well as 2.42-, 2.18-fold increase in colon, respectively, whereas the absorptions of SSA and SSD were not influenced by paeoniflorin. In conclusion, SSA and SSD could promote the absorption of paeoniflorin. To some extent this might explain the nature of the compatibility mechanisms of composite formulae in TCMs.

Traditional Chinese Medicine Herbal Treatment May Have a Relevant Impact on the Prognosis of Patients With Stage IV Adenocarcinoma of the Lung Treated With Platinum-Based Chemotherapy or Combined Targeted Therapy and Chemotherapy

Background: Targeted therapy (TT), chemotherapy, and traditional Chinese medicine herbal treatment (TCM) can improve the prognosis of advanced pulmonary adenocarcinoma patients. Their independent prognostic value is unknown. Objective: To study whether TCM improves survival in stage IV pulmonary adenocarcinoma patients with platinum-based chemotherapy (PBT), or combined PBT and second-line TT. Methods: Retrospective analysis of 133 fully ambulant clinical outpatients treated with PBT alone or PBT with/without second-line TT, with/without TCM. Univariate (Kaplan—Meier) and multivariable (Cox model) survival analysis were performed, using disease-specific mortality as an endpoint. Results: Gender ( P = .002), TT ( P < .0001), and TCM ( P < .0001) had univariate prognostic value but not age, radiotherapy, or TCM syndrome differentiation ( P > .10). TCM herbal treatment ( P < .0001) and TT ( P = .03) had multivariable independent prognostic value. TCM-treated patients (n = 103, PBT+TT+TCM+ = 62; PBT+TT−TCM+ =41) had 88% 1-year overall survival rate with median survival time (MST) of 27 months, contrasting 27% 1-year overall survival and MST of 5.0 months for non-TCM-treated (n = 30) patients. Patients with chemotherapy/TT/TCM (PBT+TT+TCM+, n = 62), TCM without TT (PBT+TT−TCM+, n = 41), or chemotherapy only (PBT+TT−TCM−, n = 30), had 1-year survival rates of 94%, 78%, and 27% respectively; for these 3 groups, respectively, MST was not reached (MST of 30.9 months), 22.6, and 5.0 months ( P < .0001). Conclusions: TCM herbal treatment may improve survival of stage IV pulmonary adenocarcinoma patients treated with chemotherapy without or with second-line TT. This warrants formal phase 1 and 2 trials and ultimately properly designed prospective clinical validation trials with adequate methodology developed for data collection.