Enhancing the Efficacy of HIPEC Through Bromelain: A Preclinical Investigation in Appendiceal Cancer

Nadeem Wajih; Richard A Erali; Steven D Forsythe; Cecilia R Schaaf; Perry Shen; Edward A Levine; Shay Soker; David L Morris; Konstantinos I Votanopoulos

doi:10.1245/s10434-024-15355-0

Enhancing the Efficacy of HIPEC Through Bromelain: A Preclinical Investigation in Appendiceal Cancer

Ann Surg Oncol. 2024 May 4. doi: 10.1245/s10434-024-15355-0. Online ahead of print.

Authors

Nadeem Wajih^{1

2}, Richard A Erali^{1

2

3}, Steven D Forsythe^{1

2

4

5}, Cecilia R Schaaf^{1

2

6}, Perry Shen³, Edward A Levine³, Shay Soker^{1

2}, David L Morris⁷, Konstantinos I Votanopoulos^{8

9

10

11}

Affiliations

¹ Wake Forest Department of General Surgery, Wake Forest Organoid Research Center (WFORCE), Wake Forest University School of Medicine, Winston-Salem, NC, USA.
² Wake Forest Institute of Regenerative Medicine, Wake Forest University School of Medicine, Winston-Salem, NC, USA.
³ Section of Surgical Oncology, Department of Surgery, Wake Forest University School of Medicine, Winston-Salem, NC, USA.
⁴ Wake Forest Comprehensive Cancer Center, Wake Forest University School of Medicine, Winston-Salem, NC, USA.
⁵ Department of Cancer Biology, Wake Forest University School of Medicine, Winston-Salem, NC, USA.
⁶ Department of Comparative Medicine, Wake Forest University School of Medicine, Winston-Salem, NC, USA.
⁷ Department of Surgery, St. George Hospital, University of New South Wales, Sydney, Australia.
⁸ Wake Forest Department of General Surgery, Wake Forest Organoid Research Center (WFORCE), Wake Forest University School of Medicine, Winston-Salem, NC, USA. kvotanop@wakehealth.edu.
⁹ Wake Forest Institute of Regenerative Medicine, Wake Forest University School of Medicine, Winston-Salem, NC, USA. kvotanop@wakehealth.edu.
¹⁰ Wake Forest Comprehensive Cancer Center, Wake Forest University School of Medicine, Winston-Salem, NC, USA. kvotanop@wakehealth.edu.
¹¹ Section of Surgical Oncology, Department of Surgery, Wake Forest University School of Medicine, Winston-Salem, NC, USA. kvotanop@wakehealth.edu.

PMID: 38704503
DOI: 10.1245/s10434-024-15355-0

Abstract

Introduction: Appendiceal cancer (AC) excessive mucin production is a barrier to heated intraperitoneal chemotherapy (HIPEC) drug delivery. Bromelain is a pineapple stem extract with mucolytic properties. We explored bromelain treatment effects against mucinous AC in a patient-derived tumor organoid (PTO) model and an AC cell line.

Patients and methods: PTOs were fabricated from tumor specimens obtained from patients with AC undergoing cytoreductive surgery with HIPEC. PTOs underwent HIPEC treatment with bromelain, cisplatin, and mitomycin C (MMC) at 37 °C and 42 °C with and without bromelain pretreatment.

Results: From October 2020 to May 2023, 16 specimens were collected from 13 patients with low-grade (12/16, 75%) and high-grade AC (4/16, 25%). The mucin-depleting effects of bromelain were most significant in combination with N-acetylcysteine (NAC) compared with bromelain (47% versus 10%, p = 0.0009) or NAC alone (47% versus 12.8%, p = 0.0027). Bromelain demonstrated > 31% organoid viability reduction at 60 min (p < 0.001) and > 66% in 48 h (p < 0.0001). Pretreatment with bromelain increased cytotoxicity of both cisplatin and MMC HIPEC conditions by 31.6% (p = 0.0001) and 35.5% (p = 0.0001), respectively. Ki67, CK20, and MUC2 expression decreased after bromelain treatment; while increased caspase 3/7 activity and decreased Bcl-2 (p = 0.009) and Bcl-xL (p = 0.01) suggest induction of apoptosis pathways. Furthermore, autophagy proteins LC3A/B I (p < 0.03) and II (p < 0.031) were increased; while ATG7 (p < 0.01), ATG 12 (p < 0.04), and Becline 1(p < 0.03), expression decreased in bromelain-treated PTOs.

Conclusions: Bromelain demonstrates cytotoxicity and mucolytic activity against appendiceal cancer organoids. As a pretreatment agent, it potentiates the cytotoxicity of multiple HIPEC regimens, potentially mediated through programmed cell death and autophagy.

Keywords: Appendiceal cancer; Bromelain; HIPEC; Organoids.

Abstract

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