Transplant oncology and anti-cancer immunosuppressants

Abstract

Organ transplantation is a life-saving intervention that enhances the quality of life for patients with end-stage organ failure. However, long-term immunosuppressive therapy is required to prevent allogeneic graft rejection, which inadvertently elevates the risk of post-transplant malignancies, especially for liver transplant recipients with a prior history of liver cancer. In response, the emerging field of transplant oncology integrates principles from oncology and immunology to improve outcomes for patients at high risk of tumor occurrence or recurrence following transplantation. Therefore, it is of substantial clinical significance to develop immunosuppressants that possess both immunosuppressive and anti-tumor properties. For instance, mTOR inhibitors demonstrate anti-tumor effects among antimetabolite immunosuppressive drugs, and recent studies indicate that capecitabine, an antimetabolite chemotherapeutic, may also exhibit immunosuppressive activity in the clinic for liver transplants suffering from hepatocellular carcinoma. This review systematically explores potential immunosuppressants with dual anti-tumor and immunosuppressive effects to support the management of transplant patients at elevated risk of tumor occurrence or recurrence.

1 Introduction

Organ transplantation is the only way to extend the lives of many patients with end-stage organ failure. In 1963, Starzl et al. performed the first orthotopic liver transplantation, introducing the concept that primary liver malignancies unresponsive to conventional techniques, such as subtotal liver resection, should be considered for total hepatectomy and liver transplantation (1). Although transplant oncology is not a new concept, it has recently regained attention with advancements in transplant immunology and oncology, leading to the formal introduction of the term Transplant Oncology in 2015 (2). Transplant oncology involves replacing a cancerous organ with a healthy one and integrates multiple specialties from transplantation and oncology. It encompasses not only the surgical procedure but also the comprehensive management before and after organ transplantation. This multidisciplinary field relies on four pillars: the evolution of cancer care, the exploration of disease mechanisms, the elucidation of tumor and transplant immunology, and the extension of the limits of hepatobiliary cancer surgery. To date, liver transplantation remains the only solid organ transplantation that provides curative treatment for malignancies in selected patients (3).

However, after organ transplantation, cancer risk is one of the three major causes of death for the patients (4). Understanding of post-transplant malignancy is inadequate regarding early detection and lack of established guidelines. The risk factor is most elusive because of altered dynamics of immunity, host response, and different clinical presentation. Studies have shown an overall two to four-fold elevated risk of cancer after the organ transplant. The mechanisms involved in the oncogenesis are long-term immunosuppression leading to reduced immune surveillance of neoplastic cells, and the opportunistic post-transplant infections especially viral infections because of Epstein-Barr virus, Varicella, Cytomegalovirus and Human herpesvirus-8, etc. Physicians and patients face a challenging problem that cancer after an organ transplant is more biologically aggressive and patients may receive less aggressive cancer treatment because of comorbidities and the fear of transplant rejection.

Recurrence of hepatocellular carcinoma (HCC) following liver transplantation occurs in 6%–18% of patients transplanted for HCC (5). Recurrence is partially predictable and thus represents not only the loss of a potential donor resource, but also the added, and problematic challenge, of managing a presumably accelerated tumor progression in an immunocompromised host (6, 7). The Israel Penn International Transplant Tumor Registry, the largest and most comprehensive registry in the world records non-melanoma skin cancers as the most prevalent cancer in post organ transplant state. Following is the list of various cancers associated with the organ transplant: Kaposi sarcoma, skin (non-melanoma, non-epithelial), non-Hodgkin lymphoma, liver, anus, vulva, and lip tumors (8).

After organ transplantation, a triple therapy regimen, typically comprising calcineurin inhibitors (CNIs, such as tacrolimus or cyclosporine), mycophenolate mofetil (MMF), and glucocorticoids, is routinely administered for immunosuppression in the clinic (9, 10). However, experimental and early observational clinical studies have highlighted the interaction between immunosuppressive therapy and HCC recurrence (11). Several retrospective studies have demonstrated an association between CNIs levels and HCC recurrence. For example, one study found that recurrence was highest (46%) when high CNIs levels were present alongside other clinical or histological risk factors (Alpha-fetoprotein > 50ng/mL, macrovascular invasion, and G3–G4 grading). In patients with the same non-immunosuppressive risk factors but under low CNI levels, the recurrence rate was only 15%. These results link intensive immunosuppression with a high risk of tumor recurrence after liver transplantation (12). Therefore, for liver transplant patients with liver cancer or those at high risk of postoperative tumor development, it is necessary to introduce novel clinical strategies to prevent tumor recurrence after transplantation. Additionally, replacing CNIs with rapamycin drugs in the early postoperative period to mitigate the risk of tumor recurrence is also being adopted in clinical practice, this strategy decreases the rate of tumorigenesis after organ transplantation.

In 2004, Guba et al. proposed the notion that certain reagents with both anti-tumor and immunosuppressive effects could be used for liver transplantation in patients at high risk of tumor recurrence, we defined these agents referred to as anti-cancer immunosuppressants (ACIS) (13, 14). Additionally, they confirmed rapamycin as an effective ACIS in clinical settings. In recent years, some novel drugs have emerged as potential ACIS which may promote the development of transplant oncology, as shown in Table 1. In this review, we will summarize the current ACIS identified from experimental and clinical studies and mechanisms.

2 Mammalian target of rapamycin inhibitors and derivates

Interestingly, immunosuppression is correlated with tumor occurrence risk (15), some HCC pathways are also the target of some immunosuppression agents, such as the mammalian target of rapamycin (mTOR) inhibitors (mTORi) (16, 17) (Figure 1). Indeed, activation of the PI3K/AKT/mTOR pathway is common (50%–60%) in HCC, and is correlated with poor HCC prognosis. Retrospective studies have documented lower HCC recurrence and higher posttransplant survival in patients under mTORi immunosuppression compared to CNIs. In the largest study (n = 2491 HCC patients and 12167 non-HCC patients), sirolimus (SRL)-based immunosuppression was associated with improved 5-year survival in those with an HCC indication (18, 19).

Figure 1

In HCC, mTOR promotes protein synthesis by activating S6K1 and inhibiting 4E-BP1, both of which enhance protein translation. This supports the uncontrolled growth and proliferation of HCC cells. mTOR controls glucose metabolism, lipid synthesis, and mitochondrial function (20). In HCC, hyperactivation of mTOR drives anabolic processes, providing the energy and biomass needed for rapid tumor growth. mTOR also regulates angiogenesis through vascular endothelial growth factor (VEGF) production, ensuring an adequate blood supply for the expanding tumor mass in HCC. Under normal conditions, mTOR inhibits autophagy, a cellular degradation process. In HCC, sustained mTOR activation suppresses autophagy, which may contribute to tumor survival by preventing the clearance of damaged organelles and proteins (17, 21, 22).

2.1 Sirolimus and Everolimus

While in transplantation, rapamycin binds to FKBP12 and inhibits mTOR, which blocks T-cell and B-cell activation and proliferation by preventing the response to IL-2 (23). SRL and Everolimus are both mTOR inhibitors that share a similar mechanism of action but differ in their chemical properties, pharmacokinetics, and clinical applications (24, 25). Both SRL and Everolimus are used as immunosuppressants to prevent organ rejection after transplantation, but they have different pharmacokinetic profiles and clinical applications.

3 Antimetabolites

3.1 5-Fluorouracil and Capecitabine

5-Fluorouracil (5-FU) is a uracil analogue wherein the hydrogen at the 5-position of uracil is substituted with fluorine. As a quintessential antimetabolic agent, it has been extensively utilized in clinical oncology for the treatment of various malignancies. 5-FU itself lacks inherent biological activity and must be metabolized in vivo to its active forms: fluorouracil deoxynucleotide (F-dUMP) and fluorouracil triphosphate nucleoside (FUTP). F-dUMP, structurally analogous to dUMP, inhibits deoxythymidine synthase, while FUTP is integrated into RNA as FUMP. In addition to its antitumor properties, 5-FU exhibits significant immunosuppressive effects, which may facilitate its use in preventing organ rejection post-transplantation. Prior research has demonstrated that 5-FU can extend the survival of rat heart allografts (26). Nonetheless, the potential for serious side effects, such as bone marrow suppression, constrains the feasibility of its prolonged use in transplant background.

Capecitabine (CAP), a prodrug of 5-FU, has emerged as a first-line chemotherapeutic agent for the treatment of malignancies such as colorectal cancer. Following oral administration, CAP is absorbed in the gastrointestinal tract and subsequently metabolized into its intermediary forms: 5’-deoxy-5-fluorocytidine and 5’-deoxy-5-fluorouridine, through the action of carboxylesterase and cytidine deaminase, respectively. Ultimately, these intermediates are converted to 5-FU by thymidylate phosphorylase (TP). The expression of TP is markedly elevated in cancerous tissues compared to adjacent normal tissues, leading to a higher accumulation of 5-FU in tumor cells and enhanced anticancer efficacy (27). Consequently, the therapeutic effectiveness of CAP is closely associated with the distribution and expression of TP.

Early research has established that CAP is effective in preventing acute rejection of canine renal allografts. Although neurotoxicity has been observed, it can be attenuated by dose reduction (28, 29). Subsequent studies have demonstrated that, in addition to its presence in tumor cells, TP is highly expressed in T cells, whereas its expression in bone marrow tissue remains minimal. This differential tissue distribution of TP not only mitigates the myelosuppressive side effects of CAP but also promotes selective enrichment of 5-FU in T cells, thereby minimizing its cytotoxic effects. Research has demonstrated that CAP reduces the proportion of T cells in mice and lowers the levels of associated proinflammatory factors, including IL-2, TNF-α, and IL-6, suggesting that CAP primarily exerts its immunosuppressive effects on compromised T cells (30). Further investigations revealed that CAP can T cell apoptosis by inhibiting the AKT/SMARCC1/AP-1 axis through HSP90AB1 (31). Metronomic chemotherapy is characterized by the frequent administration of conventional chemotherapy drugs at low doses with no prolonged drug-free breaks. Compared to traditional chemotherapy, it not only exerts direct effects on tumor cells, but also inhibits angiogenesis by inhibiting the synthesis and release of anti-angiogenic factors inducing thrombospondin-1, endostatin, angiostatin and pigment epithelium-derived factor (32). In addition, it minimizes the cytotoxicity of conventional chemotherapy drugs (33). In a clinical study examining liver cancer recurrence following liver transplantation, metronomic CAP achieved comparable efficacy to sorafenib without causing acute rejection, indicating its potential as an anti-rejection therapy post-transplantation (34). Zheng et al. has shown that metronomic CAP administered to recipient rats can induce T cell ferroptosis by inhibiting the Nrf2/HO-1/GPX4 antioxidant system, thereby mitigating liver allograft rejection (35). Additionally, they demonstrated that CAP targets thymidylate synthase (TYMS) inhibition, an enzyme essential for DNA synthesis and pyrimidine metabolism, thereby suppressing CD4+ T cell activation and Th1 cell differentiation, effects that contribute to CAP-mediated inhibition of cardiac allograft rejection (36). Further studies have confirmed that rapamycin enhances the protective effects of metronomic CAP, prolonging survival in rat liver transplantation and murine cardiac allograft models (37). At present, the immunosuppressive effects of metronomic CAP on organ transplantation have only been demonstrated in experimental animal models, highlighting the need for further basic and clinical research to validate these findings.

3.2 Mycophenolic acid and its derivatives

Mycophenolic acid (MPA), an antibiotic derived from Penicillium stoloniferum and similar fungal strains, inhibits the proliferation and function of T and B lymphocytes by targeting inosine monophosphate dehydrogenase, the rate-limiting enzyme in the de novo synthesis of guanine nucleotides. Currently, MPA and its derivatives, including MMF and mycophenolate sodium, are predominantly employed clinically as immunosuppressants in organ transplantation and for the treatment of autoimmune diseases such as systemic lupus erythematosus and rheumatoid arthritis.

Studies have substantiated the anti-tumor effects of MPA and its derivatives both in vivo and in vitro. Previous research indicates that MPA effectively inhibits the proliferation of various human and mouse tumor cell lines in a dose-dependent manner, ranging from low doses (0.01 μM) to high doses (100 μM) in vitro. Tumor cell lines exhibit varying degrees of sensitivity to MPA, with human lymphocytic leukemia cells (Molt-4) demonstrating the highest susceptibility (IC50 < 0.1 μM). Conversely, not all tumor cell lines are responsive to MPA; for instance, gastric adenocarcinoma cells (Hs746T), pancreatic ductal carcinoma cells (PANC-1), and human HCC cells (HepG2) show resistance to MPA’s antiproliferative effects, even after 72 hours of treatment with concentrations up to 20 μg/mL (38). In alignment with these in vitro findings, numerous studies have reported that MMF, when administered either by gavage or intraperitoneal injection, can inhibit the growth and metastasis of several tumors in tumor-bearing mice or rats. However, certain tumors, such as mouse colon adenocarcinoma cells (CT26), liver endothelioma cells (SK-Hep-1), and liver adenocarcinoma cells (Hep-3B), exhibit resistance to MMF when implanted in animal models (39, 40).

Clinical studies have demonstrated that the inclusion of MMF in standard immunosuppressive regimens is associated with a significantly reduced risk of developing malignancies (41–43). Two notable clinical trials have investigated the anti-cancer effects of MMF. In 2004, Takebe et al. conducted a Phase I clinical trial to evaluate MMF for the treatment of advanced multiple myeloma. The study revealed that patients with relapsed and refractory multiple myeloma tolerated MMF well at doses ranging from 1 to 5 grams per day, and the clinical response correlated positively with a decrease in intracellular deoxyguanosine triphosphate levels (44). In another trial, 12 patients with resectable pancreatic ductal adenocarcinoma were treated with MMF or a placebo for 5 to 15 days prior to surgery. Unfortunately, the MMF-treated group (n = 6) did not exhibit significant anti-tumor effects compared to the untreated group (n = 6) (45). Consequently, further investigation is required to fully understand the therapeutic potential of MPA-based drugs across various malignancies.

3.3 Cyclophosphamide

Cyclophosphamide (CP) is a nitrogen mustard derivative that, upon hydrolysis by phosphoramidase or phosphatase in the liver or tumor tissue, is converted into its active form, phosphoramide mustard. This active metabolite induces cross-linking of DNA by alkylating guanine bases, leading to the formation of cross-links between DNA strands or within the same strand, thereby disrupting the DNA structure. As a cytotoxic chemotherapeutic agent, CP is utilized clinically for the treatment of various malignancies, including malignant lymphoma, multiple myeloma, breast cancer, small cell lung cancer, and ovarian cancer. Additionally, CP serves as an immunosuppressant in the management of autoimmune diseases and in preventing organ rejection during transplantation.

In 1963, Berenbaum first demonstrated that a single dose of CP could extend the survival of skin allografts in mice (46). In 1971, Starzl et al. reported the application of CP in human organ transplantation (47). Following this, CP was employed clinically to prevent rejection in kidney, heart, liver, and other organ transplants (48–50). However, as an early immunosuppressive agent, due to its significant toxicities, including bladder toxicity and gonadotoxicity, CP has been increasingly supplanted by safer alternatives, such as cyclosporine A (51).

3.4 6-mercaptopurine and its derivatives

6-mercaptopurine (6-MP) is a purine analog that impedes cell proliferation and induces cell death by interfering with DNA and RNA synthesis. It is primarily utilized in the clinical management of leukemia. Given that activated and proliferating lymphocytes involved in rejection are heavily reliant on purine metabolism, 6-MP can function as an immunosuppressive agent in organ transplantation. In 1960, Zukoski demonstrated that 6-MP could extend the functional survival of renal homografts in canines (52).

Azathioprine (AZA) is a sustained-release prodrug of 6-MP. Although AZA and 6-MP exhibit comparable immunosuppressive activities in vivo, AZA is associated with reduced toxicity at equivalent immunosuppressive concentrations. Consequently, AZA is extensively utilized in the treatment of autoimmune diseases and in the immunosuppressive management of organ transplantation (53). The first application of AZA for immunosuppression in human kidney transplantation occurred in 1961 (54). Subsequently, AZA, in combination with corticosteroids and CNIs, became the standard regimen for immunosuppressive drug therapy in organ transplantation (55). However, in recent years, AZA has been progressively supplanted by MMF, another purine nucleotide inhibitor, owing to MMF’s superior immunosuppressive efficacy compared to AZA (55).

3.5 Methotrexate

Methotrexate (MTX) is a folate analog that inhibits dihydrofolate reductase, thereby preventing the reduction of dihydrofolate to the physiologically active tetrahydrofolate. This inhibition disrupts the transfer of one carbon units during the biosynthesis of purine and pyrimidine nucleotides, ultimately leading to the inhibition of DNA synthesis. Additionally, MTX exerts an inhibitory effect on TYMS; however, its effects on RNA and protein synthesis are relatively weak. Initially developed over 70 years ago as an anti-folate chemotherapy agent, MTX is now widely utilized as a first-line treatment for autoimmune and inflammatory diseases such as rheumatoid arthritis, psoriasis, and Crohn’s disease, etc. (56).

Alexandra et al. demonstrated that the combination of ATG and MTX can achieve long-term survival of mouse heart allografts through the induction of immune tolerance (57). In a clinical study, MTX was utilized as a rescue or adjuvant therapy in both adult and infant heart transplant recipients. The results indicated that while one case of grade 3b rejection was not reversed by MTX, the rejections in all other cases were swiftly reversed following MTX treatment (58). Subsequently, another study investigating the use of MTX in conjunction with conventional triple immunosuppressive therapy for recurrent mild to moderate acute rejection in pediatric heart transplantation found that the frequency of rejection at two months post-MTX treatment was significantly reduced compared to pre-treatment levels (59). However, an additional clinical study on heart transplantation revealed that patients treated with MTX experienced a higher rejection rate after MTX reversal than those who did not receive MTX (60). Therefore, the potential long-term benefits of MTX for organ transplant recipients warrant further investigation.

3.6 L-asparaginase

L-asparaginase, an amidohydrolase, is the first enzyme used in cancer treatment and is widely found in various animals, plants, and microorganisms, including bacteria, fungi, algae, yeast, and actinomycetes, but not in humans (61). Clinically, L-asparaginase is primarily extracted and isolated from Escherichia coli bacteria for the treatment of acute lymphoblastic leukemia. This anti-tumor drug exerts cytotoxic effects by inhibiting intracellular protein synthesis. Specifically, L-asparaginase catalyzes the hydrolysis of L-asparagine into L-aspartate and ammonia in the bloodstream. Normal cells, equipped with asparagine synthetase, can synthesize L-asparagine, whereas leukemia cells, deficient in asparagine synthetase, are unable to synthesize sufficient L-asparagine, leading to impaired protein synthesis and subsequent anti-tumor effects (62).

Early studies have established the immunosuppressive effects of L-asparaginase. Following treatment with L-asparaginase, mice exhibited reduced lymphocyte counts, atrophy of the lymph nodes, thymus, and spleen, and impaired migration of lymph node cells to the lymph nodes when injected into recipients of the same genotype. In vivo experiments have further demonstrated that L-asparaginase can mitigate skin graft rejection and inhibit the production of antibodies against sheep red blood cells (63). Additionally, Rapaport et al. confirmed that L-asparaginase can prolong the survival of canine renal allografts (64), and Levin et al. verified its immunosuppressive effects in an inbred rat renal transplant model (65). However, there are few reports on the immunosuppressive effects of L-asparaginase and its application in clinical solid organ transplantation.

4 Traditional Chinese herb-derived drugs

Traditional Chinese herbs or plant extracts have demonstrated promising antitumor effects in preclinical studies, while also showing immunosuppressive properties in organ transplantation models, suggesting their potential as novel immunosuppressants with antitumor effects.

4.1 Icaritin

Icaritin (ICT) is an active monomer extracted and isolated from the epimedium plant. Due to its potent therapeutic effects against human malignancies, ICT has entered clinical trials for the treatment of PD-L1-positive advanced HCC (Phase III, ClinicalTrials, NCT03236649), HCC (Phase III, ClinicalTrials, NCT03236636), advanced solid tumors (Phase Ib, completed, ClinicalTrials, NCT02496949), and advanced breast cancer (Phase I, ClinicalTrials, NCT01278810). The antitumor mechanisms of ICT include the downregulation of cyclin-dependent kinase 2 (CDK2) (66–68), inducing cell cycle arrest in HCC, colon cancer, and prostate cancer. ICT activates NF-related apoptosis-inducing ligand, Fas-caspase-3/8 (69, 70), inhibits the phosphorylation of Akt and mTOR (71, 72), activates PTEN/Parkin-dependent mitochondrial autophagy (73), downregulates Jak-2, p-Stat3, and p-Akt expression (74), and upregulates p-JNK and p-C-Jun expression (75, 76), thereby inducing apoptosis in human glioblastoma, liver cancer, ovarian cancer, and chronic myeloid leukemia cells. Additionally, ICT suppresses tumor cell glycolysis by upregulating p53, thereby inhibiting energy metabolism and hindering liver cancer growth (77). ICT also modulates the tumor immune microenvironment by directly binding to MyD88 or IKKα to inhibit the TLR-MyD88-IKK-NF-κB inflammatory pathway, reducing the production of inflammatory cytokines such as TNF-α and IL-6 (78). In organ transplantation, ICT has been reported to extend the survival time of allogeneic skin grafts by inhibiting T cell activation (79), indicating its immunosuppressive effects. While ICT is already in clinical use as an antitumor drug, its immunosuppressive effects in organ transplantation warrant further investigation.

4.2 Artemisinin and its derivatives

Artemisinin (ART) and its derivatives are natural compounds extracted from the artemisia annua plant, a member of the Asteraceae family, which has been traditionally used in Chinese medicine. They are renowned for their potent antimalarial properties. In addition to their antimalarial effects, ART and its derivatives have also demonstrated significant antitumor activity. Furthermore, in allogeneic transplant animal models, ART and its derivatives have notably extended graft survival, suggesting potential immunosuppressive effects.

4.2.1 Artemisinin

The antitumor effects of ART began to receive attention in the early 1990s (80). ART induces cell cycle arrest in human prostate cancer, human gallbladder cancer, and human breast cancer cells by downregulating the expression of cyclin-dependent kinases CDK2 and CDK4 (81–83). ART reduces the expression of p-ERK1/2 and inhibits the proliferation of human gallbladder cancer cells (82). Besides its antimalarial and antitumor properties, ART has also been reported to possess immunosuppressive effects. In rat models of allogeneic cardiac transplantation, oral administration of ART reduced the infiltration of effector T cells and the secretion of inflammatory cytokines, increased the infiltration of regulatory T cells, and decreased macrophage infiltration in the graft, thereby significantly extending graft survival (84). Additionally, ART significantly prolonged the survival time of mouse allogeneic skin grafts, which is associated with the blockade of the OX40-OX40L co-stimulatory signaling pathway and reduced IL-6 secretion (85).

4.2.2 Artesunate

Artesunate (ARS) is derived from the esterification of dihydroartemisinin and succinic anhydride, and it exhibits better aqueous solubility compared to ART. Multiple clinical studies have shown that ARS treatment results in a significant inhibition of tumor growth (86–90). ARS affects signaling pathways and transcription factors associated with tumor growth, including the inhibition of the IL-6-JAK-STAT pathway (91), reduction of NF-κB p65 transcriptional activity (92), activation of p38 MAPK (93), and suppression of the Wnt/β-catenin pathway (94). ARS inhibits the proliferation of rat HCC, mouse multiple myeloma, human acute myeloid leukemia, and rhabdomyosarcoma cells. ARS also suppresses the secretion of VEGF and its receptor KDR/flk-1, and inhibits microvascular formation in human ovarian cancer (95). By upregulating intracellular free iron levels, ARS promotes the accumulation of intracellular lipid peroxides and induces ferroptosis in human rhabdomyosarcoma, Burkitt’s lymphoma, human pancreatic cancer, human cervical cancer, and human fibrosarcoma cells (93, 96–99). ARS induces oxidative DNA damage leading to DNA double-strand breaks in human glioblastoma cells (100). ARS has also been reported to have immunosuppressive effects. In mouse allogeneic cardiac transplantation models, ARS significantly reduced the infiltration of inflammatory cells in cardiac tissue and the proportion of CD4+ CD8+ T cells in the spleen and lymph nodes, decreased cardiomyocyte apoptosis, and extended graft survival by reducing the expression of PERK, ATF4, and CHOP to mitigate ROS production and endoplasmic reticulum stress, and by inhibiting dendritic cell maturation (101).

4.3 Berberine

Berberine (BBR) is an isoquinoline alkaloid extracted from Coptis chinensis and Phellodendron amurense, commonly used in the treatment of bacterial diarrhea (102). Several preclinical studies have demonstrated BBR’s antitumor properties. BBR induces cell cycle arrest in human thyroid cancer and glioblastoma cells by upregulating the expression of CIP1/p21 and Kip1/p27 proteins and downregulating cyclin-dependent kinases (CDK2, CDK4, CDK6) (103, 104). It inhibits the activation of transcription factor AP-1 (105), blocks the nuclear translocation of p50/p65 NF-κB proteins and their binding to the COX-2 promoter (106), thereby suppressing the proliferation of human cervical cancer and non-small cell lung cancer cells. BBR induces apoptosis in human liver cancer cells by upregulating P53 (107), downregulating CD147 (108), increasing Bax expression, activating caspases 3 and 9 (109), promoting AMPK phosphorylation, and inhibiting Akt phosphorylation (110). Additionally, BBR inhibits the expression of MMP-2 (111), suppresses the expression of Hypoxia-inducible factor-1α, Vascular endothelial growth factor, and Pigment epithelium-derived factor (106), and interacts with vasodilator-stimulated phosphoprotein (112), thereby reducing microvascular proliferation and migration in human non-small cell lung cancer and breast cancer cells. In animal models of solid organ transplantation, BBR has shown immunosuppressive effects. In a murine cardiac allograft model, BBR treatment via intraperitoneal injection significantly extended graft survival through inhibiting the activation and proliferation of CD4+ and CD8+ T cells and inducing T cell apoptosis through activation of the mitochondrial apoptosis pathway (e.g., inducing expression of PCNA, Bcl-2, Bax, cytochrome c, cleaved-caspase-3, and cleaved-PARP), thus prolonging the survival of cardiac allografts in mice (113). Due to its low water solubility and poor oral absorption, BBR has not yet been applied clinically.

4.4 Paclitaxel

Paclitaxel (PTX) is a diterpenoid alkaloid extracted from the Pacific yew tree, known for its anti-cancer properties (114). It has been approved by the U.S. Food and Drug Administration for the treatment of various cancers, including breast cancer, non-small cell lung cancer, and ovarian cancer. PTX exerts its effects by binding to the β-tubulin subunit of microtubules, preventing their depolymerization, thereby stabilizing the microtubule structure. This stabilization inhibits tumor cell proliferation, migration, and neovascularization, while promoting apoptosis in tumor cells (115, 116). The microtubule stabilization induced by PTX is associated with the phosphorylation of Bcl-2, which prevents its interaction with calcineurin and subsequent chelation, thereby allowing the activation of T-cell nuclear factor and subsequent transcription of CD95L (117). This is related to alloantigen-induced lymphocyte activation, suggesting a potential immunosuppressive role for PTX. Studies have shown that intraperitoneal administration of PTX significantly prolongs the survival of allografts in rat heart transplantation models. PTX induces lymphocyte apoptosis, reducing the activity of cytotoxic T cells and the production of IL-2, as well as the levels of cytotoxic antibodies after alloantigen re-exposure (118, 119).

4.5 Oxymatrine

Oxymatrine (OMT) is an alkaloid compound extracted from the traditional Chinese medicine sophora flavescens. OMT is utilized for the treatment of chronic hepatitis, chronic bronchitis, and other conditions. Preclinical studies have demonstrated its anti-tumor effects. OMT reduces the expression of Cyclin D1, CDK4, and CDK6 while enhancing P21 expression (120, 121), leading to cell cycle arrest in human esophageal and gastric cancer cells. It upregulates p53 and Bax proteins (122), increases caspase-3/caspase-9 activity (123), and inhibits the expression of PI3K, p-Akt, p-mTOR, p-p70S6K, and NF-κB (124), inducing apoptosis in human gallbladder, prostate cancer, and acute leukemia cells. In addition, OMT decreases the expression levels of VEGF (125), TGF-β1, and PAI-1 proteins (126), and inhibits tumor micro-vessel formation, invasion, and metastatic potential in human pancreatic and colorectal cancers. In a murine cardiac allograft model, intraperitoneal administration of OMT significantly prolonged graft survival reduced CD3+ T cell infiltration, increased Treg cell infiltration, and suppressed the capacity of splenic dendritic cells to stimulate T cell proliferation, alleviating acute graft rejection (127). The combination of OMT with rapamycin was more effective than either treatment alone in inhibiting mTOR and HIF-1α expression in CD4+ or CD11c+ cells within the graft (128).

4.6 Fingolimod hydrochloride

FTY720, a sphingosine-1-phosphate (S1P) analog derived from the ascomycete Cordyceps sinensis is a potent immunosuppressant widely used in clinical settings for the treatment of multiple sclerosis (129). After phosphorylation, FTY720 binds to S1P receptors to exert its immunosuppressive effects. The non-phosphorylated form of FTY720 induces apoptosis, enhances chemotherapy sensitivity, and inhibits tumor metastasis by suppressing sphingosine kinase 1 and activating protein phosphatase 2A along with various cell death pathways (130). In the field of organ transplantation, Chiba first demonstrated in 1996 that FTY720 could extend the survival of skin, heart, and kidney allografts in rats and dogs (131). Subsequent studies have validated FTY720’s anti-rejection effects in other organ transplantation models, including liver transplants in dogs, and explored its combination with other immunosuppressive agents (132). Additionally, other herbal extracts such as Luteolin (133, 134), Shikonin (135, 136) and Emodin (137, 138) have been reported to exhibit both anti-tumor and immunosuppressive effects.

Although these herbal extracts have demonstrated promising effects in preclinical studies, the absence of relevant Phase III clinical trials highlights the challenges in clinical translation. Key issues requiring further investigation include the standardization and quality control of the extracts, the analysis of their absorption, metabolism, and excretion in the human body, and the monitoring of potential adverse drug reactions.

5 Conclusion and perspectives

In this review, we comprehensively address CAP, an antimetabolic drug, as a promising candidate for ACIS. Evidence suggests that metronomic CAP treatment, an emerging anti-tumor strategy for liver transplant patients with recurrent tumors, can effectively prevent allograft rejection while simultaneously delaying tumor progression (34). Metronomic chemotherapy is clinically advantageous due to its low side effects and suitability for long-term oral administration, offering substantial benefits to patients (139–142). Given that drug monotherapy alone is often insufficient to halt tumor progression or prevent graft rejection in clinical practice, combination therapies are frequently employed. Therefore, we propose criteria for identifying potential ACIS agents for clinical use: agents should effectively inhibit both tumor progression and allograft rejection, be suitable for oral and long-term administration, and demonstrate compatibility with other immunosuppressants to enhance therapeutic efficacy.

In addition, it is worth noting that the use of immune checkpoint inhibitors (ICIs) in solid organ transplant recipients as an adjuvant therapy for recurrent HCC may cause a severe alloimmune injury, even when the drug was introduced years after transplantation (143). In addition, recipients who discontinue ICIs days before transplantation also face a high risk of rejection (144, 145). A safe period between pretransplant ICI administration and transplant remains to be determined. Therefore, ICIs should be used with extreme caution in the peri-transplant or post-transplant.

Allograft rejection and tumor occurrence are two main factors that hinder the long-term survival of transplants, proposing a novel strategy to prevent both rejection and tumor will benefit the patients. Overall, a comprehensive exploration of ACIS warrants further investigations, and we hope that our review and perspectives will contribute to advancements in the field of transplant oncology.

References

• 1

  IwatsukiSKlintmalmGBStarzlTE. Total hepatectomy and liver replacement (orthotopic liver transplantation) for primary hepatic Malignancy. World J Surg. (1982) 6:81–5. doi: 10.1007/BF01656377

  • CrossRef
  • Google Scholar
  • View reference in article

• 2

  KrendlFJBellottiRSapisochinGSchaeferBTilgHScheidlSet al. Transplant oncology - Current indications and strategies to advance the field. Jhep Rep. (2024) 6:100965. doi: 10.1016/j.jhepr.2023.100965

  • CrossRef
  • Google Scholar
  • View reference in article

• 3

  AbdelrahimMEsmailAAbudayyehAMurakamiNSahariaAMcMillanRet al. Transplant oncology: an evolving field in cancer care. Cancers (Basel). (2021) 13(19):4911. doi: 10.3390/cancers13194911

  • CrossRef
  • Google Scholar
  • View reference in article

• 4

  PilmoreHDentHChangSMcDonaldSPChadbanSJ. Reduction in cardiovascular death after kidney transplantation. Transplantation. (2010) 89:851–57. doi: 10.1097/TP.0b013e3181caeead

  • CrossRef
  • Google Scholar
  • View reference in article

• 5

  ChagasALFelgaGDinizMASilvaRFMattosAASilvaRet al. Hepatocellular carcinoma recurrence after liver transplantation in a Brazilian multicenter study: clinical profile and prognostic factors of survival. Eur J Gastroenterol Hepatol. (2019) 31:1148–56. doi: 10.1097/MEG.0000000000001448

  • CrossRef
  • Google Scholar
  • View reference in article

• 6

  GorjiLBrownZJLimkemannASchenkADPawlikTM. Liver transplant as a treatment of primary and secondary liver neoplasms. JAMA Surg. (2024) 159:211–18. doi: 10.1001/jamasurg.2023.6083

  • CrossRef
  • Google Scholar
  • View reference in article

• 7

  JinFVajdicCMPoyntenIMMcGee-AvilaJKCastlePEGrulichAE. Cancer risk in people living with HIV and solid organ transplant recipients: a systematic review and meta-analysis. Lancet Oncol. (2024) 25:933–44. doi: 10.1016/S1470-2045(24)00189-X

  • CrossRef
  • Google Scholar
  • View reference in article

• 8

  EngelsEAPfeifferRMFraumeniJJKasiskeBLIsraniAKSnyderJJet al. Spectrum of cancer risk among US solid organ transplant recipients. Jama. (2011) 306:1891–901. doi: 10.1001/jama.2011.1592

  • CrossRef
  • Google Scholar
  • View reference in article

• 9

  PilchNABowmanLJTaberDJ. Immunosuppression trends in solid organ transplantation: The future of individualization, monitoring, and management. Pharmacotherapy. (2021) 41:119–31. doi: 10.1002/phar.2481

  • CrossRef
  • Google Scholar
  • View reference in article

• 10

  GeisslerEKSchlittHJ. Immunosuppression for liver transplantation. Gut. (2009) 58:452–63. doi: 10.1136/gut.2008.163527

  • CrossRef
  • Google Scholar
  • View reference in article

• 11

  ShalabySBurraP. De novo and recurrent Malignancy. Best Pract Res Clin Gastroenterol. (2020) 46-47:101680. doi: 10.1016/j.bpg.2020.101680

  • CrossRef
  • Google Scholar
  • View reference in article

• 12

  VivarelliMCucchettiALa BarbaGRavaioliMDelGMLauroAet al. Liver transplantation for hepatocellular carcinoma under calcineurin inhibitors: reassessment of risk factors for tumor recurrence. Ann Surg. (2008) 248:857–62. doi: 10.1097/SLA.0b013e3181896278

  • CrossRef
  • Google Scholar

• 13

  GubaMGraebCJauchKWGeisslerEK. Pro- and anti-cancer effects of immunosuppressive agents used in organ transplantation. Transplantation. (2004) 77:1777–82. doi: 10.1097/01.tp.0000120181.89206.54

  • CrossRef
  • Google Scholar

• 14

  KoehlGEAndrassyJGubaMRichterSKroemerASchererMNet al. Rapamycin protects allografts from rejection while simultaneously attacking tumors in immunosuppressed mice. Transplantation. (2004) 77:1319–26. doi: 10.1097/00007890-200405150-00002

  • CrossRef
  • Google Scholar

• 15

  EngelsEA. Epidemiologic perspectives on immunosuppressed populations and the immunosurveillance and immunocontainment of cancer. Am J Transplant. (2019) 19:3223–32. doi: 10.1111/ajt.15495

  • CrossRef
  • Google Scholar

• 16

  AshworthREWuJ. Mammalian target of rapamycin inhibition in hepatocellular carcinoma. World J Hepatol. (2014) 6:776–82. doi: 10.4254/wjh.v6.i11.776

  • CrossRef
  • Google Scholar

• 17

  ZouZTaoTLiHZhuX. mTOR signaling pathway and mTOR inhibitors in cancer: progress and challenges. Cell Biosci. (2020) 10:31. doi: 10.1186/s13578-020-00396-1

  • CrossRef
  • Google Scholar

• 18

  TosoCMeraniSBigamDLShapiroAMKnetemanNM. Sirolimus-based immunosuppression is associated with increased survival after liver transplantation for hepatocellular carcinoma. Hepatology. (2010) 51:1237–43. doi: 10.1002/hep.23437

  • CrossRef
  • Google Scholar

• 19

  VivarelliMDazziAZanelloMCucchettiACesconMRavaioliMet al. Effect of different immunosuppressive schedules on recurrence-free survival after liver transplantation for hepatocellular carcinoma. Transplantation. (2010) 89:227–31. doi: 10.1097/TP.0b013e3181c3c540

  • CrossRef
  • Google Scholar

• 20

  BhatMSonenbergNGoresGJ. The mTOR pathway in hepatic Malignancies. Hepatology. (2013) 58:810–18. doi: 10.1002/hep.26323

  • CrossRef
  • Google Scholar

• 21

  CharetteNDe SaegerCLannoyVHorsmansYLeclercqIStarkelP. Salirasib inhibits the growth of hepatocarcinoma cell lines in vitro and tumor growth in vivo through ras and mTOR inhibition. Mol Cancer. (2010) 9:256. doi: 10.1186/1476-4598-9-256

  • CrossRef
  • Google Scholar

• 22

  KudoM. mTOR inhibitor for the treatment of hepatocellular carcinoma. Dig Dis. (2011) 29:310–15. doi: 10.1159/000327565

  • CrossRef
  • Google Scholar

• 23

  ThomsonAWTurnquistHRRaimondiG. Immunoregulatory functions of mTOR inhibition. Nat Rev Immunol. (2009) 9:324–37. doi: 10.1038/nri2546

  • CrossRef
  • Google Scholar

• 24

  De SimonePPrecisiALaiQDucciJCampaniDMarchettiPet al. Everolimus mitigates the risk of hepatocellular carcinoma recurrence after liver transplantation. Cancers (Basel). (2024) 16(7):1243. doi: 10.3390/cancers16071243

  • CrossRef
  • Google Scholar

• 25

  LiangWWangDLingXKaoAAKongYShangYet al. Sirolimus-based immunosuppression in liver transplantation for hepatocellular carcinoma: a meta-analysis. Liver Transpl. (2012) 18:62–9. doi: 10.1002/lt.22441

  • CrossRef
  • Google Scholar

• 26

  ZimmermannTSchemmerPBerghauserKHMyloMBuhrJPadbergWM. Interactions between Malignant tumor growth and allogeneic graft rejection in an experimental rat model. Transpl Int. (1994) 7 Suppl 1:S618–20. doi: 10.1111/j.1432-2277.1994.tb01457.x

  • CrossRef
  • Google Scholar

• 27

  SchullerJCassidyJDumontERoosBDurstonSBankenLet al. Preferential activation of capecitabine in tumor following oral administration to colorectal cancer patients. Cancer Chemother Pharmacol. (2000) 45:291–97. doi: 10.1007/s002800050043

  • CrossRef
  • Google Scholar

• 28

  MilovancevMSchmiedtCWBentleyESchwabMDubielzigRRGendron-FitzpatrickAPet al. Use of capecitabine to prevent acute renal allograft rejection in dog erythrocyte antigen-mismatched mongrel dogs. Vet Surg. (2007) 36:10–20. doi: 10.1111/j.1532-950X.2007.00230.x

  • CrossRef
  • Google Scholar

• 29

  SchmiedtCPenzoCSchwabMDubielzigRMcAnultyJ. Use of capecitabine after renal allograft transplantation in dog erythrocyte antigen-matched dogs. Vet Surg. (2006) 35:113–24. doi: 10.1111/j.1532-950X.2006.00122.x

  • CrossRef
  • Google Scholar

• 30

  ZhangSWangZFanSLiuTYoshidaSYangSet al. Capecitabine can induce T cell apoptosis: A potential immunosuppressive agent with anti-cancer effect. Front Immunol. (2021) 12:737849. doi: 10.3389/fimmu.2021.737849

  • CrossRef
  • Google Scholar

• 31

  ZhangSFanSWangZHouWLiuTYoshidaSet al. Capecitabine regulates HSP90AB1 expression and induces apoptosis via akt/SMARCC1/AP-1/ROS axis in T cells. Oxid Med Cell Longev. (2022) 2022:1012509. doi: 10.1155/2022/1012509

  • CrossRef
  • Google Scholar

• 32

  NataleGBocciG. Does metronomic chemotherapy induce tumor angiogenic dormancy? A review of available preclinical and clinical data. Cancer Lett. (2018) 432:28–37. doi: 10.1016/j.canlet.2018.06.002

  • CrossRef
  • Google Scholar

• 33

  CazzanigaMECordaniNCapiciSCogliatiVRivaFCerritoMG. Metronomic chemotherapy. Cancers (Basel). (2021) 13(9):2236. doi: 10.3390/cancers13092236

  • CrossRef
  • Google Scholar

• 34

  RavaioliMCucchettiAPinnaADDe PaceVNeriFBarberaMAet al. The role of metronomic capecitabine for treatment of recurrent hepatocellular carcinoma after liver transplantation. Sci Rep. (2017) 7:11305. doi: 10.1038/s41598-017-11810-z

  • CrossRef
  • Google Scholar

• 35

  WangHWangZLZhangSKongDJYangRNCaoLet al. Metronomic capecitabine inhibits liver transplant rejection in rats by triggering recipients' T cell ferroptosis. World J Gastroenterol. (2023) 29:3084–102. doi: 10.3748/wjg.v29.i20.3084

  • CrossRef
  • Google Scholar

• 36

  KongDWangZWangHYangRZhangWCaoLet al. Capecitabine mitigates cardiac allograft rejection via inhibition of TYMS-Mediated Th1 differentiation in mice. Int Immunopharmacol. (2024) 141:112955. doi: 10.1016/j.intimp.2024.112955

  • CrossRef
  • Google Scholar

• 37

  WangHYangRWangZCaoLKongDSunQet al. Metronomic capecitabine with rapamycin exerts an immunosuppressive effect by inducing ferroptosis of CD4(+) T cells after liver transplantation in rat. Int Immunopharmacol. (2023) 124:110810. doi: 10.1016/j.intimp.2023.110810

  • CrossRef
  • Google Scholar

• 38

  BenjanuwattraJChaiyawatPPruksakornDKoonrungsesomboonN. Therapeutic potential and molecular mechanisms of mycophenolic acid as an anticancer agent. Eur J Pharmacol. (2020) 887:173580. doi: 10.1016/j.ejphar.2020.173580

  • CrossRef
  • Google Scholar

• 39

  KoehlGEWagnerFStoeltzingOLangSASteinbauerMSchlittHJet al. Mycophenolate mofetil inhibits tumor growth and angiogenesis in vitro but has variable antitumor effects in vivo, possibly related to bioavailability. Transplantation. (2007) 83:607–14. doi: 10.1097/01.tp.0000253756.69243.65

  • CrossRef
  • Google Scholar

• 40

  TresslerRJGarvinLJSlateDL. Anti-tumor activity of mycophenolate mofetil against human and mouse tumors. vivo. Int J Cancer. (1994) 57:568–73. doi: 10.1002/ijc.2910570421

  • CrossRef
  • Google Scholar

• 41

  O'NeillJOEdwardsLBTaylorDO. Mycophenolate mofetil and risk of developing Malignancy after orthotopic heart transplantation: analysis of the transplant registry of the International Society for Heart and Lung Transplantation. J Heart Lung Transplant. (2006) 25:1186–91. doi: 10.1016/j.healun.2006.06.010

  • CrossRef
  • Google Scholar

• 42

  RiviniusRHelmschrottMRuhparwarASchmackBKleinBErbelCet al. Analysis of Malignancies in patients after heart transplantation with subsequent immunosuppressive therapy. Drug Des Devel Ther. (2015) 9:93–102. doi: 10.2147/DDDT.S75464

  • CrossRef
  • Google Scholar

• 43

  RobsonRCeckaJMOpelzGBuddeMSacksS. Prospective registry-based observational cohort study of the long-term risk of Malignancies in renal transplant patients treated with mycophenolate mofetil. Am J Transplant. (2005) 5:2954–60. doi: 10.1111/j.1600-6143.2005.01125.x

  • CrossRef
  • Google Scholar

• 44

  TakebeNChengXWuSBauerKGoloubevaOGFentonRGet al. Phase I clinical trial of the inosine monophosphate dehydrogenase inhibitor mycophenolate mofetil (cellcept) in advanced multiple myeloma patients. Clin Cancer Res. (2004) 10:8301–08. doi: 10.1158/1078-0432.CCR-04-0747

  • CrossRef
  • Google Scholar

• 45

  Rodriguez-PascualJShaPGarcia-GarciaERajeshkumarNVDe VicenteEQuijanoYet al. A preclinical and clinical study of mycophenolate mofetil in pancreatic cancer. Invest New Drugs. (2013) 31:14–9. doi: 10.1007/s10637-012-9822-x

  • CrossRef
  • Google Scholar

• 46

  BerenbaumMcBrownIn. Prolongation of homograft survival in mice with single doses of cyclophosphamide. Nature. (1963) 200:84. doi: 10.1038/200084a0

  • CrossRef
  • Google Scholar

• 47

  StarzlTEHalgrimsonCGPennIMartineauGSchroterGAmemiyaHet al. Cyclophosphamide and human organ transplantation. Lancet. (1971) 2:70–4. doi: 10.1016/s0140-6736(71)92046-0

  • CrossRef
  • Google Scholar

• 48

  EvrardHMMillerCSchwartzMThungSNMayerL. Resistant hepatic allograft rejection successfully treated with cyclophosphamide and plasmapheresis. Transplantation. (1990) 50:702–04. doi: 10.1097/00007890-199010000-00033

  • CrossRef
  • Google Scholar

• 49

  WaiserJDuerrMBuddeKRudolphBWuKBachmannFet al. Treatment of acute antibody-mediated renal allograft rejection with cyclophosphamide. Transplantation. (2017) 101:2545–52. doi: 10.1097/TP.0000000000001617

  • CrossRef
  • Google Scholar

• 50

  GrauhanOKnosallaCEwertRHummelMLoebeMWengYGet al. Plasmapheresis and cyclophosphamide in the treatment of humoral rejection after heart transplantation. J Heart Lung Transplant. (2001) 20:316–21. doi: 10.1016/s1053-2498(00)00211-4

  • CrossRef
  • Google Scholar

• 51

  WisemanAC. Immunosuppressive medications. Clin J Am Soc Nephrol. (2016) 11:332–43. doi: 10.2215/CJN.08570814

  • CrossRef
  • Google Scholar

• 52

  CFZUKOSKIHMLEEHUMEDM. The prolongation of functional survival of canine renal homografts by 6-mercaptopurine. Surg Forum. (1960) 11:470–72.

  • Google Scholar

• 53

  ChanGLCanafaxDMJohnsonCA. The therapeutic use of azathioprine in renal transplantation. Pharmacotherapy. (1987) 7:165–77. doi: 10.1002/j.1875-9114.1987.tb04046.x

  • CrossRef
  • Google Scholar

• 54

  MurrayJeMerrillJpHarrisonJhWilsonReDamminGj. Prolonged survival of human-kidney homografts by immunosuppressive drug therapy. N Engl J Med. (1963) 268:1315–23. doi: 10.1056/NEJM196306132682401

  • CrossRef
  • Google Scholar

• 55

  GermaniGPleguezueloMVillamilFVaghjianiSTsochatzisEAndreanaLet al. Azathioprine in liver transplantation: a reevaluation of its use and a comparison with mycophenolate mofetil. Am J Transplant. (2009) 9:1725–31. doi: 10.1111/j.1600-6143.2009.02705.x

  • CrossRef
  • Google Scholar

• 56

  AlqarniAMZeidlerMP. How does methotrexate work? Biochem Soc Trans. (2020) 48:559–67. doi: 10.1042/BST20190803

  • CrossRef
  • Google Scholar

• 57

  JosephANeffKRichardJGaoLBangariDJolyMet al. Transient low-dose methotrexate induces tolerance to murine anti-thymocyte globulin and together they promote long-term allograft survival. J Immunol. (2012) 189:732–43. doi: 10.4049/jimmunol.1103601

  • CrossRef
  • Google Scholar

• 58

  BouchartFGundrySRVan Schaack-GonzalesJRazzoukAJMarsaRJKawauchiMet al. Methotrexate as rescue/adjunctive immunotherapy in infant and adult heart transplantation. J Heart Lung Transplant. (1993) 12:427–33.

  • Google Scholar

• 59

  ShaddyREBullockEATaniLYOrsmondGSOlsenSLTaylorDOet al. Methotrexate therapy in pediatric heart transplantation as treatment of recurrent mild to moderate acute cellular rejection. J Heart Lung Transplant. (1994) 13:1009–13.

  • Google Scholar

• 60

  CostanzoMRKochDMFisherSGHerouxALKaoWGJohnsonMR. Effects of methotrexate on acute rejection and cardiac allograft vasculopathy in heart transplant recipients. J Heart Lung Transplant. (1997) 16:169–78.

  • Google Scholar

• 61

  BatoolTMakkyEAJalalMYusoffMM. A comprehensive review on L-asparaginase and its applications. Appl Biochem Biotechnol. (2016) 178:900–23. doi: 10.1007/s12010-015-1917-3

  • CrossRef
  • Google Scholar

• 62

  FonsecaMFiuzaTMoraisSBSouzaTTrevizaniR. Circumventing the side effects of L-asparaginase. BioMed Pharmacother. (2021) 139:111616. doi: 10.1016/j.biopha.2021.111616

  • CrossRef
  • Google Scholar

• 63

  WekslerMEWekslerBB. Studies on the immunosuppressive properties of asparaginase. Immunology. (1971) 21:137–50.

  • Google Scholar

• 64

  RapaportFTShimadaTWatanabeK. Prolongation of canine renal allograft survival by L asparaginase. Transplantation. (1971) 12:217–22. doi: 10.1097/00007890-197109000-00011

  • CrossRef
  • Google Scholar

• 65

  LevinBMerrillJP. Immunosuppressive effects of cyclophosphamide and L-asparaginase in the inbred rat renal transplant model. Transplantation. (1972) 13:160–63. doi: 10.1097/00007890-197202000-00017

  • CrossRef
  • Google Scholar

• 66

  ZhangCWangXZhangC. Icaritin inhibits CDK2 expression and activity to interfere with tumor progression. Iscience. (2022) 25:104991. doi: 10.1016/j.isci.2022.104991

  • CrossRef
  • Google Scholar

• 67

  HuangXZhuDLouY. A novel anticancer agent, icaritin, induced cell growth inhibition, G1 arrest and mitochondrial transmembrane potential drop in human prostate carcinoma PC-3 cells. Eur J Pharmacol. (2007) 564:26–36. doi: 10.1016/j.ejphar.2007.02.039

  • CrossRef
  • Google Scholar

• 68

  LiCPengWSongXWangQWangW. Anticancer effect of icaritin inhibits cell growth of colon cancer through reactive oxygen species, Bcl-2 and cyclin D1/E signaling. Oncol Lett. (2016) 12:3537–42. doi: 10.3892/ol.2016.5089

  • CrossRef
  • Google Scholar

• 69

  HanHXuBHouPJiangCLiuLTangMet al. Icaritin sensitizes human glioblastoma cells to TRAIL-induced apoptosis. Cell Biochem Biophys. (2015) 72:533–42. doi: 10.1007/s12013-014-0499-y

  • CrossRef
  • Google Scholar

• 70

  SunLPengQQuLGongLSiJ. Anticancer agent icaritin induces apoptosis through caspase-dependent pathways in human hepatocellular carcinoma cells. Mol Med Rep. (2015) 11:3094–100. doi: 10.3892/mmr.2014.3007

  • CrossRef
  • Google Scholar

• 71

  GaoLChenMOuyangYLiRZhangXGaoXet al. Icaritin induces ovarian cancer cell apoptosis through activation of p53 and inhibition of Akt/mTOR pathway. Life Sci. (2018) 202:188–94. doi: 10.1016/j.lfs.2018.03.059

  • CrossRef
  • Google Scholar

• 72

  GaoLOuyangYLiRZhangXGaoXLinSet al. Icaritin inhibits migration and invasion of human ovarian cancer cells via the akt/mTOR signaling pathway. Front Oncol. (2022) 12:843489. doi: 10.3389/fonc.2022.843489

  • CrossRef
  • Google Scholar

• 73

  LuoPAnYHeJXingXZhangQLiuXet al. Icaritin with autophagy/mitophagy inhibitors synergistically enhances anticancer efficacy and apoptotic effects through PINK1/Parkin-mediated mitophagy in hepatocellular carcinoma. Cancer Lett. (2024) 587:216621. doi: 10.1016/j.canlet.2024.216621

  • CrossRef
  • Google Scholar

• 74

  ZhaoHGuoYLiSHanRYingJZhuHet al. A novel anti-cancer agent Icaritin suppresses hepatocellular carcinoma initiation and Malignant growth through the IL-6/Jak2/Stat3 pathway. Oncotarget. (2015) 6:31927–43. doi: 10.18632/oncotarget.5578

  • CrossRef
  • Google Scholar

• 75

  ZhuJLiZZhangGMengKKuangWLiJet al. Icaritin shows potent anti-leukemia activity on chronic myeloid leukemia in vitro and in vivo by regulating MAPK/ERK/JNK and JAK2/STAT3 /AKT signalings. PloS One. (2011) 6:e23720. doi: 10.1371/journal.pone.0023720

  • CrossRef
  • Google Scholar

• 76

  HeJWangYDuanFJiangHChenMFTangSY. Icaritin induces apoptosis of HepG2 cells via the JNK1 signaling pathway independent of the estrogen receptor. Planta Med. (2010) 76:1834–39. doi: 10.1055/s-0030-1250042

  • CrossRef
  • Google Scholar

• 77

  ZhouXWuDMiTLiRGuoTLiW. Icaritin activates p53 and inhibits aerobic glycolysis in liver cancer cells. Chem Biol Interact. (2024) 392:110926. doi: 10.1016/j.cbi.2024.110926

  • CrossRef
  • Google Scholar

• 78

  MoDZhuHWangJHaoHGuoYWangJet al. Icaritin inhibits PD-L1 expression by Targeting Protein IkappaB Kinase alpha. Eur J Immunol. (2021) 51:978–88. doi: 10.1002/eji.202048905

  • CrossRef
  • Google Scholar

• 79

  LiXHuYHeLWangSZhouHLiuS. Icaritin inhibits T cell activation and prolongs skin allograft survival in mice. Int Immunopharmacol. (2012) 13:1–07. doi: 10.1016/j.intimp.2012.02.011

  • CrossRef
  • Google Scholar

• 80

  SunWCHanJXYangWYDengDAYueXF. Antitumor activities of 4 derivatives of artemisic acid and artemisinin B in vitro. Zhongguo Yao Li Xue Bao. (1992) 13:541–43.

  • Google Scholar

• 81

  WilloughbyJSSundarSNCheungMTinASModianoJFirestoneGL. Artemisinin blocks prostate cancer growth and cell cycle progression by disrupting Sp1 interactions with the cyclin-dependent kinase-4 (CDK4) promoter and inhibiting CDK4 gene expression. J Biol Chem. (2009) 284:2203–13. doi: 10.1074/jbc.M804491200

  • CrossRef
  • Google Scholar

• 82

  JiaJQinYZhangLGuoCWangYYueXet al. Artemisinin inhibits gallbladder cancer cell lines through triggering cell cycle arrest and apoptosis. Mol Med Rep. (2016) 13:4461–68. doi: 10.3892/mmr.2016.5073

  • CrossRef
  • Google Scholar

• 83

  TinASSundarSNTranKQParkAHPoindexterKMFirestoneGL. Antiproliferative effects of artemisinin on human breast cancer cells requires the downregulated expression of the E2F1 transcription factor and loss of E2F1-target cell cycle genes. Anticancer Drugs. (2012) 23:370–79. doi: 10.1097/CAD.0b013e32834f6ea8

  • CrossRef
  • Google Scholar

• 84

  YangZHanFLiaoTZhengHLuoZMaMet al. Artemisinin attenuates transplant rejection by inhibiting multiple lymphocytes and prolongs cardiac allograft survival. Front Immunol. (2021) 12:634368. doi: 10.3389/fimmu.2021.634368

  • CrossRef
  • Google Scholar

• 85

  LiuLZhaoJLiAYangXSprangersBLiS. Prolongation of allograft survival by artemisinin treatment is associated with blockade of OX40-OX40L. Immunopharmacol Immunotoxicol. (2021) 43:291–98. doi: 10.1080/08923973.2021.1902347

  • CrossRef
  • Google Scholar

• 86

  BergerTGDieckmannDEfferthTSchultzESFunkJOBaurAet al. Artesunate in the treatment of metastatic uveal melanoma–first experiences. Oncol Rep. (2005) 14:1599–603. doi: 10.3892/or.14.6.1599

  • CrossRef
  • Google Scholar

• 87

  MichaelsenFWSaeedMESchwarzkopfJEfferthT. Activity of Artemisia annua and artemisinin derivatives, in prostate carcinoma. Phytomedicine. (2015) 22:1223–31. doi: 10.1016/j.phymed.2015.11.001

  • CrossRef
  • Google Scholar

• 88

  ZhangZYYuSQMiaoLYHuangXYZhangXPZhuYPet al. Artesunate combined with vinorelbine plus cisplatin in treatment of advanced non-small cell lung cancer: a randomized controlled trial. Zhong XI Yi Jie He Xue Bao. (2008) 6:134–38. doi: 10.3736/jcim20080206

  • CrossRef
  • Google Scholar

• 89

  JansenFHAdoubi IJCnodder TDEJansenNTschulakowAEfferthTet al. First study of oral Artenimol-R in advanced cervical cancer: clinical benefit, tolerability and tumor markers. Anticancer Res. (2011) 31:4417–22.

  • Google Scholar

• 90

  KrishnaSGanapathiSSterICSaeedMECowanMFinlaysonCet al. A randomised, double blind, placebo-controlled pilot study of oral artesunate therapy for colorectal cancer. Ebiomedicine. (2015) 2:82–90. doi: 10.1016/j.ebiom.2014.11.010

  • CrossRef
  • Google Scholar

• 91

  IlamathiMPrabuPCAyyappaKASivaramakrishnanV. Artesunate obliterates experimental hepatocellular carcinoma in rats through suppression of IL-6-JAK-STAT signalling. BioMed Pharmacother. (2016) 82:72–9. doi: 10.1016/j.biopha.2016.04.061

  • CrossRef
  • Google Scholar

• 92

  LiSXueFChengZYangXWangSGengFet al. Effect of artesunate on inhibiting proliferation and inducing apoptosis of SP2/0 myeloma cells through affecting NFkappaB p65. Int J Hematol. (2009) 90:513–21. doi: 10.1007/s12185-009-0409-z

  • CrossRef
  • Google Scholar

• 93

  BeccaficoSMorozziGMarchettiMCRiccardiCSidoniADonatoRet al. Artesunate induces ROS- and p38 MAPK-mediated apoptosis and counteracts tumor growth in vivo in embryonal rhabdomyosarcoma cells. Carcinogenesis. (2015) 36:1071–83. doi: 10.1093/carcin/bgv098

  • CrossRef
  • Google Scholar

• 94

  XuNZhouXWangSXuLLZhouHSLiuXL. Artesunate induces SKM-1 cells apoptosis by inhibiting hyperactive beta-catenin signaling pathway. Int J Med Sci. (2015) 12:524–29. doi: 10.7150/ijms.11352

  • CrossRef
  • Google Scholar

• 95

  ChenHHZhouHJWuGDLouXE. Inhibitory effects of artesunate on angiogenesis and on expressions of vascular endothelial growth factor and VEGF receptor KDR/flk-1. Pharmacology. (2004) 71:1–09. doi: 10.1159/000076256

  • CrossRef
  • Google Scholar

• 96

  WangNZengGZYinJLBianZX. Artesunate activates the ATF4-CHOP-CHAC1 pathway and affects ferroptosis in Burkitt's Lymphoma. Biochem Biophys Res Commun. (2019) 519:533–39. doi: 10.1016/j.bbrc.2019.09.023

  • CrossRef
  • Google Scholar

• 97

  ElingNReuterLHazinJHamacher-BradyABradyNR. Identification of artesunate as a specific activator of ferroptosis in pancreatic cancer cells. Oncoscience. (2015) 2:517–32. doi: 10.18632/oncoscience.160

  • CrossRef
  • Google Scholar

• 98

  YangNDTanSHNgSShiYZhouJTanKSet al. Artesunate induces cell death in human cancer cells via enhancing lysosomal function and lysosomal degradation of ferritin. J Biol Chem. (2014) 289:33425–41. doi: 10.1074/jbc.M114.564567

  • CrossRef
  • Google Scholar

• 99

  ChenGQBenthaniFAWuJLiangDBianZXJiangX. Artemisinin compounds sensitize cancer cells to ferroptosis by regulating iron homeostasis. Cell Death Differ. (2020) 27:242–54. doi: 10.1038/s41418-019-0352-3

  • CrossRef
  • Google Scholar

• 100

  BerdelleNNikolovaTQuirosSEfferthTKainaB. Artesunate induces oxidative DNA damage, sustained DNA double-strand breaks, and the ATM/ATR damage response in cancer cells. Mol Cancer Ther. (2011) 10:2224–33. doi: 10.1158/1535-7163.MCT-11-0534

  • CrossRef
  • Google Scholar

• 101

  ChenYZhengSWangZCaiXCheYWuQet al. Artesunate restrains maturation of dendritic cells and ameliorates heart transplantation-induced acute rejection in mice through the PERK/ATF4/CHOP signaling pathway. Mediators Inflammation. (2021) 2021:2481907. doi: 10.1155/2021/2481907

  • CrossRef
  • Google Scholar

• 102

  HabtemariamS. Berberine and inflammatory bowel disease: A concise review. Pharmacol Res. (2016) 113:592–99. doi: 10.1016/j.phrs.2016.09.041

  • CrossRef
  • Google Scholar

• 103

  LiLWangXSharvanRGaoJQuS. Berberine could inhibit thyroid carcinoma cells by inducing mitochondrial apoptosis, G0/G1 cell cycle arrest and suppressing migration via PI3K-AKT and MAPK signaling pathways. BioMed Pharmacother. (2017) 95:1225–31. doi: 10.1016/j.biopha.2017.09.010

  • CrossRef
  • Google Scholar

• 104

  EomKSHongJMYounMJSoHSParkRKimJMet al. Berberine induces G1 arrest and apoptosis in human glioblastoma T98G cells through mitochondrial/caspases pathway. Biol Pharm Bull. (2008) 31:558–62. doi: 10.1248/bpb.31.558

  • CrossRef
  • Google Scholar

• 105

  MahataSBhartiACShuklaSTyagiAHusainSADasBC. Berberine modulates AP-1 activity to suppress HPV transcription and downstream signaling to induce growth arrest and apoptosis in cervical cancer cells. Mol Cancer. (2011) 10:39. doi: 10.1186/1476-4598-10-39

  • CrossRef
  • Google Scholar

• 106

  FuLChenWGuoWWangJTianYShiDet al. Berberine targets AP-2/hTERT, NF-kappaB/COX-2, HIF-1alpha/VEGF and cytochrome-c/caspase signaling to suppress human cancer cell growth. PloS One. (2013) 8:e69240. doi: 10.1371/journal.pone.0069240

  • CrossRef
  • Google Scholar

• 107

  ShuklaSSharmaAPandeyVKRaisuddinSKakkarP. Concurrent acetylation of FoxO1/3a and p53 due to sirtuins inhibition elicit Bim/PUMA mediated mitochondrial dysfunction and apoptosis in berberine-treated HepG2 cells. Toxicol Appl Pharmacol. (2016) 291:70–83. doi: 10.1016/j.taap.2015.12.006

  • CrossRef
  • Google Scholar

• 108

  HouQTangXLiuHTangJYangYJingXet al. Berberine induces cell death in human hepatoma cells in vitro by downregulating CD147. Cancer Sci. (2011) 102:1287–92. doi: 10.1111/j.1349-7006.2011.01933.x

  • CrossRef
  • Google Scholar

• 109

  WangNFengYZhuMTsangCMManKTongYet al. Berberine induces autophagic cell death and mitochondrial apoptosis in liver cancer cells: the cellular mechanism. J Cell Biochem. (2010) 111:1426–36. doi: 10.1002/jcb.22869

  • CrossRef
  • Google Scholar

• 110

  YangXHuangN. Berberine induces selective apoptosis through the AMPK−mediated mitochondrial/caspase pathway in hepatocellular carcinoma. Mol Med Rep. (2013) 8:505–10. doi: 10.3892/mmr.2013.1506

  • CrossRef
  • Google Scholar

• 111

  LiJLiuFJiangSLiuJChenXZhangSet al. Berberine hydrochloride inhibits cell proliferation and promotes apoptosis of non-small cell lung cancer via the suppression of the MMP2 and Bcl-2/Bax signaling pathways. Oncol Lett. (2018) 15:7409–14. doi: 10.3892/ol.2018.8249

  • CrossRef
  • Google Scholar

• 112

  SuKHuPWangXKuangCXiangQYangFet al. Tumor suppressor berberine binds VASP to inhibit cell migration in basal-like breast cancer. Oncotarget. (2016) 7:45849–62. doi: 10.18632/oncotarget.9968

  • CrossRef
  • Google Scholar

• 113

  MaYYanGGuoJLiFZhengHWangCet al. Berberine prolongs mouse heart allograft survival by activating T cell apoptosis via the mitochondrial pathway. Front Immunol. (2021) 12:616074. doi: 10.3389/fimmu.2021.616074

  • CrossRef
  • Google Scholar

• 114

  RowinskyEKCazenaveLADonehowerRC. Taxol: a novel investigational antimicrotubule agent. J Natl Cancer Inst. (1990) 82:1247–59. doi: 10.1093/jnci/82.15.1247

  • CrossRef
  • Google Scholar

• 115

  SwantonCMaraniMPardoOWarnePHKellyGSahaiEet al. Regulators of mitotic arrest and ceramide metabolism are determinants of sensitivity to paclitaxel and other chemotherapeutic drugs. Cancer Cell. (2007) 11:498–512. doi: 10.1016/j.ccr.2007.04.011

  • CrossRef
  • Google Scholar

• 116

  SpencerCMFauldsD. Paclitaxel. A review of its pharmacodynamic and pharmacokinetic properties and therapeutic potential in the treatment of cancer. Drugs. (1994) 48:794–847. doi: 10.2165/00003495-199448050-00009

  • CrossRef
  • Google Scholar

• 117

  SrivastavaRKSasakiCYHardwickJMLongoDL. Bcl-2-mediated drug resistance: inhibition of apoptosis by blocking nuclear factor of activated T lymphocytes (NFAT)-induced Fas ligand transcription. J Exp Med. (1999) 190:253–65. doi: 10.1084/jem.190.2.253

  • CrossRef
  • Google Scholar

• 118

  TangeSSchererMNGraebCWeissTJustlMFrankEet al. The antineoplastic drug Paclitaxel has immunosuppressive properties that can effectively promote allograft survival in a rat heart transplant model. Transplantation. (2002) 73:216–23. doi: 10.1097/00007890-200201270-00011

  • CrossRef
  • Google Scholar

• 119

  TangeSSchererMNGraebCAndrassyJJustlMFrankEet al. Paclitaxel saves rat heart allografts from rejection by inhibition of the primed anti-donor humoral and cellular immune response: implications for transplant patients with cancer. Transpl Int. (2003) 16:471–75. doi: 10.1007/s00147-003-0558-6

  • CrossRef
  • Google Scholar

• 120

  JinYHuJWangQLiZChenY. Effects of Oxymatrine on the apoptosis of human esophageal carcinoma Eca109 cell line and its mechanism. J Huazhong Univ Sci Technolog Med Sci. (2008) 28:314–16. doi: 10.1007/s11596-008-0319-y

  • CrossRef
  • Google Scholar

• 121

  GuoBZhangTSuJWangKLiX. Oxymatrine targets EGFR(p-Tyr845) and inhibits EGFR-related signaling pathways to suppress the proliferation and invasion of gastric cancer cells. Cancer Chemother Pharmacol. (2015) 75:353–63. doi: 10.1007/s00280-014-2651-1

  • CrossRef
  • Google Scholar

• 122

  WuCHuangWGuoYXiaPSunXPanXet al. Oxymatrine inhibits the proliferation of prostate cancer cells. Vitro vivo. Mol Med Rep. (2015) 11:4129–34. doi: 10.3892/mmr.2015.3338

  • CrossRef
  • Google Scholar

• 123

  LiuJYaoYDingHChenR. Oxymatrine triggers apoptosis by regulating Bcl-2 family proteins and activating caspase-3/caspase-9 pathway in human leukemia HL-60 cells. Tumour Biol. (2014) 35:5409–15. doi: 10.1007/s13277-014-1705-7

  • CrossRef
  • Google Scholar

• 124

  WuXSYangTGuJLiMLWuWGWengHet al. Effects of oxymatrine on the apoptosis and proliferation of gallbladder cancer cells. Anticancer Drugs. (2014) 25:1007–15. doi: 10.1097/CAD.0000000000000124

  • CrossRef
  • Google Scholar

• 125

  ChenHZhangJLuoJLaiFWangZTongHet al. Antiangiogenic effects of oxymatrine on pancreatic cancer by inhibition of the NF-kappaB-mediated VEGF signaling pathway. Oncol Rep. (2013) 30:589–95. doi: 10.3892/or.2013.2529

  • CrossRef
  • Google Scholar

• 126

  WangXLiuCWangJFanYWangZWangY. Oxymatrine inhibits the migration of human colorectal carcinoma RKO cells via inhibition of PAI-1 and the TGF-beta1/Smad signaling pathway. Oncol Rep. (2017) 37:747–53. doi: 10.3892/or.2016.5292

  • CrossRef
  • Google Scholar

• 127

  QinZDenHZhuangH. Effect of oxymatrine on prolonging the survival time of cardiac tissue allograft in mice and its immunologic mechanisms. Zhong XI Yi Jie He Za Zhi. (1990) 10:99–100.

  • Google Scholar

• 128

  LanXZhangJRenSWangHShaoBQinYet al. Oxymatrine combined with rapamycin to attenuate acute cardiac allograft rejection. Heliyon. (2024) 10:e29448. doi: 10.1016/j.heliyon.2024.e29448

  • CrossRef
  • Google Scholar

• 129

  StraderCRPearceCJOberliesNH. Fingolimod (FTY720): a recently approved multiple sclerosis drug based on a fungal secondary metabolite. J Nat Prod. (2011) 74:900–07. doi: 10.1021/np2000528

  • CrossRef
  • Google Scholar

• 130

  HanMLiuXHailatiSMaihemutiNNurahmatNDilimulatiDet al. Pharmacological effects of FTY720 and its derivatives. Curr Top Med Chem. (2024) 24:192–200. doi: 10.2174/0115680266273421231222061620

  • CrossRef
  • Google Scholar

• 131

  ChibaKHoshinoYSuzukiCMasubuchiYYanagawaYOhtsukiMet al. FTY720, a novel immunosuppressant possessing unique mechanisms. I. Prolongation of skin allograft survival and synergistic effect in combination with cyclosporine in rats. Transplant Proc. (1996) 28:1056–59.

  • Google Scholar

• 132

  FurukawaHSuzukiTJinMBYamashitaKTaniguchiMMagataSet al. Prolongation of canine liver allograft survival by a novel immunosuppressant, FTY720: effect of monotherapy and combined treatment with conventional drugs. Transplantation. (2000) 69:235–41. doi: 10.1097/00007890-200001270-00008

  • CrossRef
  • Google Scholar

• 133

  ImranMRaufAAbu-IzneidTNadeemMShariatiMAKhanIAet al. Luteolin, a flavonoid, as an anticancer agent: A review. BioMed Pharmacother. (2019) 112:108612. doi: 10.1016/j.biopha.2019.108612

  • CrossRef
  • Google Scholar

• 134

  WangHLiCXiongZLiT. Luteolin attenuates acute liver allograft rejection in rats by inhibiting T cell proliferation and regulating T cell subsets. Int Immunopharmacol. (2023) 121:110407. doi: 10.1016/j.intimp.2023.110407

  • CrossRef
  • Google Scholar

• 135

  ZengQQiuFChenYLiuCLiuHLiangCLet al. Shikonin prolongs allograft survival via induction of CD4(+)FoxP3(+) regulatory T cells. Front Immunol. (2019) 10:652. doi: 10.3389/fimmu.2019.00652

  • CrossRef
  • Google Scholar

• 136

  QianXZhuLXuMLiuHYuXShaoQet al. Shikonin suppresses small cell lung cancer growth via inducing ATF3-mediated ferroptosis to promote ROS accumulation. Chem Biol Interact. (2023) 382:110588. doi: 10.1016/j.cbi.2023.110588

  • CrossRef
  • Google Scholar

• 137

  SrinivasGBabykuttySSathiadevanPPSrinivasP. Molecular mechanism of emodin action: transition from laxative ingredient to an antitumor agent. Med Res Rev. (2007) 27:591–608. doi: 10.1002/med.20095

  • CrossRef
  • Google Scholar

• 138

  QiuFLiuHLiangCLNieGDDaiZ. A new immunosuppressive molecule emodin induces both CD4(+)FoxP3(+) and CD8(+)CD122(+) regulatory T cells and suppresses murine allograft rejection. Front Immunol. (2017) 8:1519. doi: 10.3389/fimmu.2017.01519

  • CrossRef
  • Google Scholar

• 139

  PeinemannFHoembergM. Metronomic chemotherapy for paediatric extracranial solid tumours: a systematic review and meta-analysis of randomised clinical trials. BMJ Open. (2024) 14:e84477. doi: 10.1136/bmjopen-2024-084477

  • CrossRef
  • Google Scholar

• 140

  AbdelradyYAThabetHSSayedAM. The future of metronomic chemotherapy: experimental and computational approaches of drug repurposing. Pharmacol Rep. (2024). doi: 10.1007/s43440-024-00662-w

  • CrossRef
  • Google Scholar

• 141

  MunzoneEColleoniM. Clinical overview of metronomic chemotherapy in breast cancer. Nat Rev Clin Oncol. (2015) 12:631–44. doi: 10.1038/nrclinonc.2015.131

  • CrossRef
  • Google Scholar

• 142

  WuHLZhouHXChenLMWangSS. Metronomic chemotherapy in cancer treatment: new wine in an old bottle. Theranostics. (2024) 14:3548–64. doi: 10.7150/thno.95619

  • CrossRef
  • Google Scholar

• 143

  GassmannDWeilerSMertensJCReinerCSVrugtBNageliMet al. Liver allograft failure after nivolumab treatment-A case report with systematic literature research. Transplant Direct. (2018) 4:e376. doi: 10.1097/TXD.0000000000000814

  • CrossRef
  • Google Scholar

• 144

  NordnessMFHamelSGodfreyCMShiCJohnsonDBGoffLWet al. Fatal hepatic necrosis after nivolumab as a bridge to liver transplant for HCC: Are checkpoint inhibitors safe for the pretransplant patient? Am J Transplant. (2020) 20:879–83. doi: 10.1111/ajt.15617

  • CrossRef
  • Google Scholar

• 145

  MurakamiNMulvaneyPDaneshMAbudayyehADiabAAbdel-WahabNet al. A multi-center study on safety and efficacy of immune checkpoint inhibitors in cancer patients with kidney transplant. Kidney Int. (2021) 100:196–205. doi: 10.1016/j.kint.2020.12.015

  • CrossRef
  • Google Scholar