Intestinal mucositis represents a common complication and dose-limiting toxicity of many anticancer drugs. The overall incidence of mucositis varies and frequencies up to 89% have been reported for patients undergoing bone marrow transplantation who were receiving high-dose chemotherapy . The condition may affect the entire alimentary tract and cause a wide range of symptoms, including severe pain, mouth ulceration, abdominal bloating, nausea/vomiting, diarrhea/constipation and malnutrition with weight loss. Furthermore, patients with gastrointestinal mucositis are at increased risk of infection and episodes of bleeding . Costs of treatment increase significantly with mucositis severity . Unscheduled chemotherapy dosage and timing adjustments because of poor treatment tolerance are common clinical practice, but may negatively affect cancer outcome. Thus, chemotherapy-mediated gastrointestinal toxicity can have a severe adverse impact on the quality of life, morbidity and mortality of cancer patients. Although practice guidelines are available to help clinicians in the selection of effective management strategies , there is so far no therapeutic intervention that successfully prevents or treats all symptoms of disease.
The precise pathophysiology underlying chemotherapy-induced intestinal mucositis has not been clarified in detail yet. Current understanding suggests the culmination of a dynamic five-phase sequence of complex inflammatory events that are initiated by direct or indirect processes of chemotherapy-induced damages to crypt cells and cells in the underlying mucosal tissue . In brief, mucosal injury by chemotherapy and drug metabolites induce DNA damage, excessive reactive oxygen species (ROS) production and apoptosis. Endogenous danger signals are released by injured cells, which imbalance mucosal homeostasis by triggering aberrant innate immune activation of nuclear factor (NF)-κB (and other transcription factors). A proinflammatory ‘storm’ of cytokines and matrix metalloproteinases accelerates intestinal mucosal damage and barrier dysfunction. Gut bacteria may colonize ulcers and translocate, resulting into expansion of specific mucosal immune cells that further exaggerate destructive inflammatory responses. Finally, mucosal healing spontaneously occurs upon cessation of chemotherapy. Recent findings [6▪] suggest that type 3 innate lymphoid cells are required for complete mucosal regeneration and restitutio ad integrum by shielding small intestinal Lgr5+ stem cells and progenitors from the adverse effects of chemotherapeutic insults via STAT3–IL-22 signaling.
Growing evidence implies that multidirectional interactions between gut microbiota and the host innate immune system may influence the development and progression of chemotherapy-induced intestinal inflammation. Within the healthy gastrointestinal tract, the microbial community (microbiota) has a mutually beneficial relationship with the host. Although the resident intestinal microbiota helps to maintain mucosal barrier homeostasis through limited inflammatory and accelerated healing responses, immune cells of the intestinal mucosa influence the commensal composition and function . Metabolic products of anaerobic bacterial fermentation, such as butyrate, may exert anti-inflammatory effects, which protect against chemotherapy-induced mucosal damage . During chemotherapy exposure, severe disruption of this fine-tuned symbiotic partnership may occur, resulting in loss of commensal tolerance and inappropriate immune responses with increased barrier permeability, which perpetuate mucositis.
Commensal microbiota affect anticancer drug metabolism by multiple mechanisms [9▪▪]. The gut microbiota may have impact on pharmacology and host (de)toxification of drugs and related metabolites by modifying delivery, absorption and availability and altering biotransformation through induction of host drug-metabolizing enzymes and transporters [10▪▪], thus either increasing or decreasing toxicity of cancer chemotherapy. In addition, chemotherapy drugs may compromise the protective colonic mucus layer, impairing antimicrobial host defense mechanisms and thus diminishing bacterial clearance . Furthermore, xenobiotics may directly shape the bacterial community structure and activity. Chemotherapeutic agents can reduce the number and diversity of microbiota  and cause dysbiosis , an alteration in the composition of the microbiota, which allows rare microbial species to overgrow, turning the gut microbiota into a disease-accelerating entity that may promote aberrant innate immune signaling in the intestinal mucosa during the development of gastrointestinal mucositis.
Conserved structures from gut microbes, so-called pathogen-associated molecular patterns (PAMPs) are recognized by Toll-like receptors (TLRs), a class of innate pattern recognition receptors (PRRs) present in various cell types of the intestinal mucosa. TLRs also sense danger signals from dead or injured host cells. Upon activation, TLRs recruit diverse adaptor proteins (MyD88, TRIP, TIRAP/MAL, TRAM and SARM). Subsequent transcriptional activation of TLR target genes encoding pro-inflammatory and anti-inflammatory cytokines and chemokines, effector molecules and type I interferons initiate the activation of antigen-specific and nonspecific adaptive immune responses . Recent findings, mainly derived from murine colitis models, have shown that the net outcome of TLR signaling in the gut is entirely context-dependent and cell/tissue-type specific . Genotoxic stress induced by chemotherapeutic agents elicits different changes in TLR expression that are cell line-specific and damage-specific . Paradoxically, TLRs may mediate both protective and destructive responses in the intestinal mucosa. Tight control of basal TLR signaling in the healthy gut is essential to avoid otherwise deleterious activation and ensure rapid tissue repair. Failure of control deregulates basal TLR signaling that imbalances commensal-dependent mucosal barrier homeostasis, facilitating inflammatory injury. This review focuses on recent advances in our understanding of the ambivalent microbial-innate immune influences via distinct TLRs in the pathophysiology of chemotherapy-induced intestinal mucositis.
TOLL-LIKE RECEPTOR 2-MEDIATED MUCOSAL PROTECTION AGAINST INTESTINAL CHEMOTOXICITY
TLR2, a member of the TLR family, recognizes conserved molecular patterns associated with both gram-negative and gram-positive bacteria, including lipopeptides/proteins. In general, triacylated lipopeptides are recognized by TLR2/TLR1, whereas diacylated lipopeptides use TLR2/TLR6 heteromers for signaling. TLR2 is differentially expressed by many distinct cell types throughout the healthy gastrointestinal tract, including enterocytes, goblet cells and different subsets of lamina propria mononuclear cells . Recent reports have identified several TLR2-dependent mechanisms that promote intestinal epithelial cell (IEC) wound healing (barrier integrity, survival, cell-cell communication and restitution) and limit proinflammatory immune responses during acute and chronic murine colitis [17,18]. The probiotic Lactobacillus rhamnosus GG, which may modulate immune functions through direct activation of TLR2, has been shown to protect mice against radiation-induced or chemotherapy-induced small intestinal IEC injury by enhancing crypt survival through COX-2-dependent  and Nrf2-dependent [20▪] signaling pathways.
The ABC transporter P-glycoprotein (P-gp; ABCB1 or MDR1) actively pumps a broad range of chemically diverse compounds out of the cell, protecting the intestinal mucosa against xenobiotics and metabolites, including chemotherapy drugs. Absence of drug-transporting P-gp can result in cellular accumulation of xenobiotics and increased toxicities with severe side-effects . Gut bacteria may modulate host P-gp function . Stimulation of TLR2 induces sustained P-gp synthesis and activity in monocytes and macrophages of the lamina propria, thus essentially reducing drug-mediated cell death [23▪]. Absence of TLR2 signaling (by either genetic deletion or depletion of the indigenous gut microbiota by antibiotics) dramatically aggravates chemotherapy-induced intestinal mucositis, which correlates with loss of P-gp in the inflamed mucosa. However, oral supplementation with a specific TLR2 agonist during chemotherapy preserves P-gp expression and limits genotoxic stress-induced damage in the small intestine. Taken together, this recent study [23▪] implies that commensal-mediated innate immune modulation via TLR2 signaling may accelerate host detoxification by instructing cells to expel harmful chemotherapy drugs, thus critically controlling the severity of cancer therapy-induced mucosal damage in the gastrointestinal tract.
Future studies will need to investigate whether manipulating TLR2 may indeed represent a useful therapeutic approach in order to ameliorate side-effects in the gut during high-dose chemotherapy. So far, only one specific chemotherapy drug (methotrexate – MTX) has been tested in this context [23▪]. It remains to be shown whether TLR2 signaling could be efficiently targeted for the prevention and treatment of intestinal mucositis induced by other chemotherapy drugs that are P-gp substrates. TLR2 may also regulate the expression of many other ATP-dependent drug transporters in a tissue-specific manner. For instance, activation of constitutive androstane receptor (CAR), a xenosensor that induces the ABCC2 and ABCC3 genes, is inhibited by TLR2 signaling in the liver , while activation of pregnane X receptor (PXR), another xenosensor which is involved in transcriptional activation of ABCB1/MDR1, may increase gene expression of TLR2 (and other PRRs) in vascular endothelial cells . These findings suggest that multidirectional signaling pathways between drug metabolism and innate immunity exist. However, the exact signaling mechanisms via TLR2 (and other TLRs) remain to be determined.
An additional concern has arisen: induction of P-gp represents the principal mechanism underlying multidrug resistance, which is a key cause of treatment failure in cancer . TLR2 is expressed on many types of cancer cells. Thus, excessively activated TLR2 could lead to an undesirable dose reduction of the anticancer drug via P-gp, which would hamper therapeutic effectiveness and compromise survival outcome. It will be pivotal to rule out the possibility that using TLR2 agonists in the treatment of chemotherapy-induced intestinal mucositis may drive manifestation of multidrug resistance and subsequent tumor progression.
TOLL-LIKE RECEPTOR 4-MEDIATED MUCOSAL DESTRUCTION IN INTESTINAL CHEMOTOXICITY
Cancer chemotherapy drugs exert cytotoxic and pro-immunogenic effects in normal and malignant cells. Dead or injured cells release numerous endogenous damage-associated molecular patterns (DAMPs), such as HMGB1 , ROS  and uric acid , which induce sustained innate immune activation, significantly contributing to uncontrolled mucosal inflammation during repeating cycles of chemotherapy treatment. The main host receptor that senses DAMPs and responds to tissue damage is TLR4. In addition, TLR4 is the major receptor for lipopolysaccharide (LPS) recognition, which requires the presence of accessory receptors (MD-2, CD14 and LPS-binding-protein). Abnormal or deficient TLR4 signaling may impair the antibacterial host response, facilitating colonization and invasion of the intestinal mucosa by gut bacteria . Acute endotoxemia, experimentally induced by systemic administration of LPS, has been shown to exacerbate MTX-induced intestinal mucositis in mice . Gene expression of TLR4 is significantly upregulated in the inflamed small intestinal mucosa after exposure to the chemotherapeutic agent MTX [23▪,31]. Sterile injury resulting from chemotherapy may prime mucosal immune cells to hypersensitivity through upregulation of TLR4 mediated by augmented release of DAMPs and production of proinflammatory cytokines, like IFNγ . Excessive activation of TLR4 may further enhance mucosal production of inflammatory cytokines/chemokines, proteases and ROS, leading to a vicious cycle that causes self-tissue destruction through increased inflammation. Lack of signaling via PXR [33▪] or TLR2 [23▪] may also lead to mucosal hyperresponsiveness to LPS via TLR4, implying that defects in xenobiotic defense via ABCB1/MDR1 P-gp signaling may be involved in triggering compromised tolerance to LPS. Mice deficient in the essential TLR4-coreceptor MD-2 [23▪] or mice that harbour a defective TLR4 (C3H/HeJ)  are indeed resistant to MTX-induced gastrointestinal damage. Collectively, these data suggest that aberrant innate immune signaling via MD-2/TLR4 is required for the severity of chemotherapy-induced intestinal damage, at least in the case of MTX.
So far, only indirect proof exists that aberrant TLR4 signaling may also be involved in the pathogenesis of mucositis induced by other chemotherapy drugs. CPT-11 (irinotecan) represents a first-line chemotherapeutic drug for metastatic colorectal cancer . TLR4 signaling has been linked to the IL-33/ST2 pathway. TLR4 activation increases production of interleukin-33  and inhibition of interleukin-33 attenuates CPT-11-mediated mucositis [36▪]. CPT-11 causes a loss in mucosal TLR4 protein expression in the jejunum 4 days after administration , which potentially delays mucosal healing after chemotherapy . It will be essential to use mice deficient in TLR4 to dissect functionally the precise molecular mechanisms of cause and effect in CPT-11-mediated toxic damage in the gut. In addition, it has been shown that the mRNA levels of TLR9 and MyD88 are increased in the intestinal mucosa after CPT-11 exposure . Genetic deletion of TLR9 and MyD88 seems to decrease CPT-11-mediated toxic injury in the small intestine , but baseline villus length was already lower in untreated TLR9-knockout compared with untreated wild-type (WT) mice, which makes interpretation difficult.
Chemotherapy drugs can cause persistent nociceptive pain associated with intestinal mucositis. It has recently been hypothesized that neuropathy and gastrointestinal toxicity may be systemically linked via a common TLR4-dependent pathway [40▪]. LPS or DAMPs may trigger peripheral hyperalgesia via TLR4 [41,42]. The chemotherapeutic agent paclitaxel directly binds TLR4 and shares its downstream signaling pathway . Local toxicities of paclitaxel include peripheral neuropathy and mucositis. Pharmacological inhibition of TLR4 reduces paclitaxel-induced behavioural hypersensitivity, preventing the increase of TRPV1-mediated capsaicin responses [44▪]. Future studies must demonstrate whether TLR4 blockade also alleviates paclitaxel-induced intestinal mucositis (and other side-effects, such as fatigue or hypersensitivity reactions).
INVOLVEMENT OF OTHER PATTERN RECOGNITION RECEPTORS IN INTESTINAL CHEMOTOXICITY
The functional effects of innate immune signaling seem to be chemotherapy drug-dependent. It is likely that each chemotherapy drug differentially modulates host immunity and microbiota function. Only little evidence exists whether (in addition to TLRs) other PRRs, such as NOD-like receptors (NLRs), may also be involved in the pathophysiology of gastrointestinal chemotoxicity.
Doxorubicin represents an example of a chemotherapy drug that impairs commensal-mucosal homeostasis by subverting the innate immune system on multiple levels. Doxorubicin-induced massive oxidative stress causes severe side-effects, including cardiomyopathy and intestinal mucositis. It affects gut microbiota-related metabolism  and reversely, soil microbes, such as environmental Actinomycetes, are capable to degrade and inactivate this anticancer drug . Doxorubicin induces rapid and profound bacterial community shifts in cancer patients, with, for example, increases in Gemella haemolysans and Streptococcus parasanguinis in the oral cavity after chemotherapy . Of note, Gemella species has been associated with cardiovascular disease  and S. parasanguinis with mucositis and gastrointestinal symptoms , respectively. Although the TLRs involved in functional recognition have not yet been defined, it is possible that PAMPs of G. haemolysans and S. parasanguinis may activate pro-inflammatory and anti-inflammatory responses via TLR2, TLR4 and TLR9 signaling, as shown for other Streptococcus species . Of note, mice that are deficient in TLR2 or TLR9 seem to be protected against doxorubicin-mediated cardiac dysfunction  and intestinal mucosal damage . Interestingly, NOD2 stimulation by muramyl dipeptide, a peptidoglycan motif common to all bacteria (including Streptococcus species), preserves intestinal stem cells against doxorubicin-mediated damage [53▪]. Future studies must address whether aberrant expansion of G. haemolysans and S. parasanguinis is indeed a common feature in doxorubicin-induced tissue damage and whether these species are functionally the real culprits that launch gut tissue-destructive host responses and drive detrimental side-effects via TLR2 and/or TLR9. Because doxorubicin itself is derived from Streptomyces bacterium and Streptomyces peucetius var. caesius, it may even act as a direct TLR2/TLR9 ligand, but proof has not been provided yet.
TOLL-LIKE RECEPTOR GENOTYPES ASSOCIATED WITH CHEMOTOXICITY
Variations in TLR genes may impair host–microbial communication. TLR gene dysfunction may alter ligand recognition and signaling pathways, modify commensal community structure and impair mucosal immune tolerance. The presence of the TLR2-Arg753Gln and TLR4-Asp299Gly polymorphisms has been associated with increased incidence of infections in patients with acute myeloid leukemia undergoing induction chemotherapy . Yet, it remains to be proven whether selected candidate TLR gene variants may indeed influence an individual's capacity to process different chemotherapeutic drugs. A preliminary report [55▪] suggests that the TLR2-1350T>C polymorphism may help to predict the potential risk of severe gastrointestinal toxicity in response to 5-fluorouracil-based chemotherapies. Based on recent research in mice, as outlined above [23▪], loss-of-function deletion of the TLR2 gene may significantly alter a key step of xenobiotic metabolism which may maximize the adverse effects of distinct chemotherapy drugs (P-gp substrates). In-vitro experiments have recently suggested that the TLR2-R753Q polymorphism impairs intestinal epithelial restitution  and gap junctional intercellular communication , which could delay mucosal healing after the conclusion of the anticancer treatment. In contrast, the more common gain-of-function TLR4-D299G gene variant may promote an auto-inflammatory microenvironment  with enhanced bacterial colonization , which would increase susceptibility to pathogenic infections  in cancer patients and aggravate chemotherapy-induced intestinal mucositis. However, chemotherapy-induced genotoxicity probably represents a multigenic and multifactorial trait . It remains to be shown in large studies with genome-wide approaches whether genetic testing of TLRs may indeed be useful (in combination with other genetic factors, such as NOD2 polymorphisms ) to unambiguously identify cancer patients with an increased risk for chemotoxic side-effects in the gastrointestinal tract. TLR polymorphisms with rare variant alleles alone may only point towards possible inter-individual variability in the sensitivity to certain chemotherapeutic drugs and associated complications in some cancer patients, but may not represent a valid genetic biomarker for overall risk stratification.
GUT MICROBIOTA DEPLETION BY ANTIBIOTICS MODULATES INTESTINAL CHEMOTOXICITY
Chemotherapy-induced toxic damage to the intestinal mucosal barrier increases the risk of infection for cancer patients by facilitating bacterial translocation and systemic inflammatory responses. As mentioned, chemotherapy may alter the gut microbiota composition favouring dysbiosis. For instance, imbalances in taxonomic composition and metabolic capacity in the gut microbial community have been associated with intestinal inflammation in lymphoma patients receiving high-dose combination chemotherapy [62▪]. Certain facultative-pathogenic species may especially prevail in seriously ill, hospitalized and immune-compromised cancer patients. To avoid life-threatening infections, antibiotics are routinely administered to patients during anticancer therapy. Antibiotic prophylaxis may be advantageous to prevent intestinal mucositis induced by a number of chemotherapeutic drugs in which gut bacterial enzymes generate highly toxic metabolites. For instance, bacterial β-glucuronidase deconjugates SN-38G to the toxic metabolite SN-38, which is responsible for CPT-11-mediated intestinal damage . Accordingly, mice that are germ-free  or ablated from gut microbiota by antibiotics  are protected against CPT-11-induced intestinal mucositis.
However, antibiotics strip away not only the ‘bad’ bacteria, but also the ‘good’ ones. Antibiotics broadly deplete many populations of beneficial commensal microbiota (at least in mice), thus reducing beneficial TLR signaling and negatively affecting downstream regulation of innate host defenses. The surviving antibiotic-resistant microbes may deregulate mucosal homeostasis by exhibiting enhanced inflammatory potential. Ablation of gut microbiota using antibiotics reduces host–microbial interactions, leading to a decline in immune gene expression and decrease in T lymphocyte numbers in the lamina propria as well as inhibition of mitochondrial gene expression and increase in IEC death [66▪]. Thus, antibiotic treatment may promote susceptibility to chemotherapy-induced intestinal mucositis in mice that are otherwise chemotoxicity-resistant [23▪]. Yet, oral supplementation of a TLR2 ligand rescues these mice from exacerbated DNA damage-associated mucosal inflammation induced by chemotherapy after antibiotic treatment [23▪]. In addition, two recent studies suggested that gut microbiota depletion by antibiotics compromises the antitumor efficacy of chemotherapy with cyclophosphamide or platinum [67,68]. Chemotherapy-induced barrier dysfunction allows microbes to gain entry into deeper host tissues and circulating TLR ligands may provide essential adjuvant antitumor effects . Oral administration of selective intestinal microbes, such as Bifidobacterium or Bacteroides, seems to improve efficacy of cancer immunotherapy with antibodies that block immune inhibitory pathways, specifically the CTLA-4 and PD-L1 axes, in mice models of melanoma [70▪,71▪]. Taken together, antibiotics may put patients who are being treated for cancer at increased risk of gastrointestinal toxicity and chemotherapy inefficacy. Future studies will need to investigate whether modulating microbial activities by, for example, probiotic supplementation during antibiotic treatment may alleviate mucosal chemotoxicity and boost drug efficacy via TLR signaling. So far, large, controlled, randomized, double-blinded clinical trials using probiotics in cancer patients are lacking.
The gut microbiota, which represents a rich source of TLR ligands, may modify xenobiotic metabolism of chemotherapy drugs, resulting in their activation or inactivation. The outcome of TLR-mediated innate immune responses during chemotherapy exposure appears to be ambivalent – depending on the pharmacology and toxicology of individual chemotherapeutic agents, distinct changes in gut microbial community structure and function as well as dynamic cellular kinetics of induction and resolution phases during genotoxic inflammation. Therefore, targeting microbial–TLR interactions for preventing or treating chemotherapy-induced gastrointestinal toxicity will be a major challenge. Future studies must investigate in more detail whether manipulating the delicate balance between gut microbiota and host immune responses by either monotherapy or combinations of different TLR agonists and antagonists may be indeed useful to limit the toxic side-effects of complex chemotherapy regimens, accelerate mucosal tissue regeneration and improve the anticancer treatment response.
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Conflicts of interest
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REFERENCES AND RECOMMENDED READING
Papers of particular interest, published within the annual period of review, have been highlighted as:
- ▪ of special interest
- ▪▪ of outstanding interest
1. McGuire DB, Altomonte V, Peterson DE, et al. Patterns of mucositis and pain in patients receiving preparative chemotherapy
and bone marrow transplantation. Oncol Nurs Forum 1993; 20:1493–1502.
2. Elting LS, Cooksley C, Chambers M, et al. The burdens of cancer therapy. Clinical and economic outcomes of chemotherapy
-induced mucositis. Cancer 2003; 98:1531–1539.
3. Murphy BA. Clinical and economic consequences of mucositis induced by chemotherapy
and/or radiation therapy. J Support Oncol 2007; 5:13–21.
4. Lalla RV, Bowen J, Barasch A, et al. MASCC/ISOO clinical practice guidelines for the management of mucositis secondary to cancer therapy. Cancer 2014; 120:1453–1461.
5. Villa A, Sonis ST. Mucositis: pathobiology and management. Curr Opin Oncol 2015; 27:159–164.
6▪. Aparicio-Domingo P, Romera-Hernandez M, Karrich JJ, et al. Type 3 innate lymphoid cells maintain intestinal epithelial stem cells after tissue damage. J Exp Med 2015; 212:1783–1791.
Type 3 innate lymphoid cells (ILC3) are regulated by various environmental and microbial factors. This study reports that intestinal ILC3 are essential in protecting Lgr5+ stem cells from chemotherapy-induced damage through production of interleukin-22, which activates anti-apoptotic pathways in epithelial cells.
7. Kamada N, Nunez G. Regulation of the immune system by the resident intestinal bacteria
. Gastroenterology 2014; 146:1477–1488.
8. Ramos MG, Bambirra EA, Cara DC, et al. Oral administration of short-chain fatty acids reduces the intestinal mucositis caused by treatment with Ara-C in mice fed commercial or elemental diets. Nutr Cancer 1997; 28:212–217.
9▪▪. Klaassen CD, Cui JY. Review: Mechanisms of how the intestinal microbiota alters the effects of drugs and bile acids. Drug Metab Dispos 2015; 43:1505–1521.
See annotation to 10.
10▪▪. Carmody RN, Turnbaugh PJ. Host-microbial interactions in the metabolism of therapeutic and diet-derived xenobiotics
. J Clin Invest 2014; 124:4173–4181.
Collectively, references 9 and 10 provide an excellent overview on our current knowledge of how gut microbiota may influence the pharmacology and toxicity of xenobiotics (drugs, chemicals) and related host responses.
11. Stringer AM, Gibson RJ, Logan RM, et al. Gastrointestinal microflora and mucins may play a critical role in the development of 5-fluorouracil-induced gastrointestinal mucositis. Exp Biol Med (Maywood) 2009; 234:430–441.
12. Fijlstra M, Ferdous M, Koning AM, et al. Substantial decreases in the number and diversity of microbiota during chemotherapy
-induced gastrointestinal mucositis in a rat model. Support Care Cancer 2015; 23:1513–1522.
13. Touchefeu Y, Montassier E, Nieman K, et al. Systematic review: the role of the gut microbiota in chemotherapy
- or radiation-induced gastrointestinal mucositis – current evidence and potential clinical applications. Aliment Pharmacol Ther 2014; 40:409–421.
14. Iwasaki A, Medzhitov R. Control of adaptive immunity by the innate immune system. Nat Immunol 2015; 16:343–353.
15. Cario E. Microbiota and innate immunity in intestinal inflammation
and neoplasia. Curr Opin Gastroenterol 2013; 29:85–91.
16. Shatz M, Menendez D, Resnick MA. The human TLR innate immune gene family is differentially influenced by DNA stress and p53 status in cancer cells. Cancer Res 2012; 72:3948–3957.
17. Ey B, Eyking A, Gerken G, et al. TLR2 mediates gap junctional intercellular communication through connexin-43 in intestinal epithelial barrier injury. J Biol Chem 2009; 284:22332–22343.
18. Ey B, Eyking A, Klepak M, et al. Loss of TLR2 worsens spontaneous colitis in MDR1A deficiency through commensally induced pyroptosis. J Immunol 2013; 190:5676–5688.
19. Ciorba MA, Riehl TE, Rao MS, et al. Lactobacillus probiotic protects intestinal epithelium from radiation injury in a TLR-2/cyclo-oxygenase-2-dependent manner. Gut 2012; 61:829–838.
20▪. Jones RM, Desai C, Darby TM, et al. Lactobacilli modulate epithelial cytoprotection through the Nrf2 pathway. Cell Rep 2015; 12:1217–1225.
Nrf2 senses oxidative stress and toxicity. This study provides first evidence that commensal lactobacilli protect the host from chemotherapy-induced genotoxic damage by activating the xenobiotic responsive Nrf2-pathway in intestinal epithelial cells.
21. Borst P, Schinkel AH. P-glycoprotein ABCB1: a major player in drug handling by mammals. J Clin Invest 2013; 123:4131–4133.
22. Mercado-Lubo R, McCormick BA. The interaction of gut microbes with host ABC transporters. Gut Microbes 2010; 1:301–306.
23▪. Frank M, Hennenberg EM, Eyking A, et al. TLR signaling modulates side effects of anticancer therapy in the small intestine. J Immunol 2015; 194:1983–1995.
Here, the authors identify TLR2 as a central regulator of xenobiotic defense via the multidrug transporter ABCB1/MDR1 P-gp. This novel mechanism may allow the innate immune system to respond to harmful xenobiotics and instruct their immediate cellular clearance, thus efficiently protecting the host from the genotoxicity of high-dose chemotherapy and its adverse effects in the intestinal mucosa. Furthermore, the study implies that gut microbiota-depletion by oral antibiotic treatment exacerbates chemotherapy-elicited toxicity in the murine small intestine, which can be alleviated by TLR2 ligand supplementation.
24. Shah P, Guo T, Moore DD, Ghose R. Role of constitutive androstane receptor in Toll-like receptor
-mediated regulation of gene expression of hepatic drug-metabolizing enzymes and transporters. Drug Metab Dispos 2014; 42:172–181.
25. Wang S, Lei T, Zhang K, et al. Xenobiotic pregnane X receptor (PXR) regulates innate immunity via activation of NLRP3 inflammasome in vascular endothelial cells. J Biol Chem 2014; 289:30075–30081.
26. Kim J. Poly(ADP-ribose) polymerase activation induces high mobility group box 1 release from proximal tubular cells during cisplatin nephrotoxicity. Physiol Res 2015; 8:8.
27. Sonis ST. The pathobiology of mucositis. Nat Rev Cancer 2004; 4:277–284.
28. Crews KR, Zhou Y, Pauley JL, et al. Effect of allopurinol versus urate oxidase on methotrexate pharmacokinetics in children with newly diagnosed acute lymphoblastic leukemia. Cancer 2010; 116:227–232.
29. Cario E. Toll-like receptors in inflammatory bowel diseases: a decade later. Inflamm Bowel Dis 2010; 16:1583–1597.
30. de Koning BA, van Dieren JM, Lindenbergh-Kortleve DJ, et al. Contributions of mucosal immune cells to methotrexate-induced mucositis. Int Immunol 2006; 18:941–949.
31. Hamada K, Kakigawa N, Sekine S, et al. Disruption of ZO-1/claudin-4 interaction in relation to inflammatory responses in methotrexate-induced intestinal mucositis. Cancer Chemother Pharmacol 2013; 72:757–765.
32. Bosisio D, Polentarutti N, Sironi M, et al. Stimulation of Toll-like receptor
4 expression in human mononuclear phagocytes by interferon-gamma: a molecular basis for priming and synergism with bacterial lipopolysaccharide. Blood 2002; 99:3427–3431.
33▪. Venkatesh M, Mukherjee S, Wang H, et al. Symbiotic bacterial metabolites regulate gastrointestinal barrier function via the xenobiotic sensor PXR and Toll-like receptor
4. Immunity 2014; 41:296–310.
Microbial-derived indoles regulate small intestinal barrier function through the xenobiotic sensor PXR which signals via TLR4.
34. Fujita K, Kubota Y, Ishida H, Sasaki Y. Irinotecan, a key chemotherapeutic drug for metastatic colorectal cancer. World J Gastroenterol 2015; 21:12234–12248.
35. Polumuri SK, Jayakar GG, Shirey KA, et al. Transcriptional regulation of murine IL-33 by TLR and non-TLR agonists. J Immunol 2012; 189:50–60.
36▪. Guabiraba R, Besnard AG, Menezes GB, et al. IL-33 targeting attenuates intestinal mucositis and enhances effective tumor chemotherapy
in mice. Mucosal Immunol 2014; 7:1079–1093.
Interleukin-33 signals via its cognate receptor ST2, which is part of the IL-1R/TLR superfamily. The authors show that interleukin-33 blockade markedly attenuates CPT-11-mediated intestinal mucositis in mice, implying a novel therapeutic approach to limit irinotecan-induced intestinal mucositis.
37. Gibson RJ, Coller JK, Wardill HR, et al. Chemotherapy
-induced gut toxicity and pain: involvement of TLRs. Support Care Cancer 2015; [Epub ahead of print].
38. Ungaro R, Fukata M, Hsu D, et al. A novel Toll-like receptor
4 antagonist antibody ameliorates inflammation but impairs mucosal healing in murine colitis. Am J Physiol Gastrointest Liver Physiol 2009; 296:G1167–1179.
39. Wong DV, Lima-Junior RC, Carvalho CB, et al. The adaptor protein Myd88 is a key signaling molecule in the pathogenesis of irinotecan-induced intestinal mucositis. PLoS One 2015; 10:e0139985.
40▪. Wardill HR, Van Sebille YZ, Mander KA, et al. Toll-like receptor
4 signaling: a common biological mechanism of regimen-related toxicities: an emerging hypothesis for neuropathy and gastrointestinal toxicity. Cancer Treat Rev 2015; 41:122–128.
The authors hypothesize an interesting concept of a possible common signal transduction mechanism via TLR4 that may induce simultaneously different toxic effects at multiple organ sites in response to selected chemotherapy drugs, such as neuropathy and gastrointestinal mucositis.
41. Agalave NM, Larsson M, Abdelmoaty S, et al. Spinal HMGB1 induces TLR4-mediated long-lasting hypersensitivity and glial activation and regulates pain-like behavior in experimental arthritis. Pain 2014; 155:1802–1813.
42. Calil IL, Zarpelon AC, Guerrero AT, et al. Lipopolysaccharide induces inflammatory hyperalgesia triggering a TLR4/MyD88-dependent cytokine cascade in the mice paw. PLoS One 2014; 9:e90013.
43. Kawasaki K, Akashi S, Shimazu R, et al. Mouse Toll-like receptor
4.MD-2 complex mediates lipopolysaccharide-mimetic signal transduction by Taxol. J Biol Chem 2000; 275:2251–2254.
44▪. Li Y, Adamek P, Zhang H, et al. The cancer chemotherapeutic paclitaxel increases human and rodent sensory neuron responses to TRPV1 by activation of TLR4. J Neurosci 2015; 35:13487–13500.
This work demonstrates that the chemotherapy drug paclitaxel, a known TLR4 agonist, induces neuropathy through cellular hypersensitivity to TRPV-1-mediated capsaicin responses via aberrant TLR4 signaling. It is likely that other paclitaxel-induced side-effects may also depend on the TLR4 pathway.
45. Niu QY, Li ZY, Du GH, Qin XM. H NMR based metabolomic profiling revealed doxorubicin-induced systematic alterations in a rat model. J Pharm Biomed Anal 2015; 118:338–348.
46. Westman Erin L, Canova Marc J, Radhi Inas J, et al. Bacterial inactivation of the anticancer drug doxorubicin. Chem Biol 2012; 19:1255–1264.
47. Napeñas JJ, Brennan MT, Coleman S, et al. Molecular methodology to assess the impact of cancer chemotherapy
on the oral bacterial flora: a pilot study. Oral Surg Oral Med Oral Pathol Oral Radiol Endodontol 2010; 109:554–560.
48. La Scola B, Raoult D. Molecular identification of Gemella
species from three patients with endocarditis. J Clin Microbiol 1998; 36:866–871.
49. Han XY, Kamana M, Rolston KVI. Viridans streptococci isolated by culture from blood of cancer patients: clinical and microbiologic analysis of 50 cases. J Clin Microbiol 2006; 44:160–165.
50. Koppe U, Suttorp N, Opitz B. Recognition of Streptococcus pneumoniae
by the innate immune system. Cell Microbiol 2012; 14:460–466.
51. Nozaki N, Shishido T, Takeishi Y, Kubota I. Modulation of doxorubicin-induced cardiac dysfunction in Toll-like receptor
-2-knockout mice. Circulation 2004; 110:2869–2874.
52. Kaczmarek A, Brinkman BM, Heyndrickx L, et al. Severity of doxorubicin-induced small intestinal mucositis is regulated by the TLR-2 and TLR-9 pathways. J Pathol 2012; 226:598–608.
53▪. Nigro G, Rossi R, Commere PH, et al. The cytosolic bacterial peptidoglycan sensor Nod2 affords stem cell protection and links microbes to gut epithelial regeneration. Cell Host Microbe 2014; 15:792–798.
Besides TLRs, NLRs comprise another major class of pattern recognition receptors which may be involved in the pathophysiology of chemotherapy-induced intestinal mucositis. This study demonstrates that microbiota-derived muramyl dipeptide triggers NOD2 signaling in Lgr5+ intestinal epithelial stem cells to enhance crypt regeneration after doxorubicin-mediated mucosal injury.
54. Schnetzke U, Spies-Weisshart B, Yomade O, et al. Polymorphisms of Toll-like receptors (TLR2 and TLR4) are associated with the risk of infectious complications in acute myeloid leukemia. Genes Immun 2015; 16:83–88.
55▪. Coller JK, White IA, Logan RM, et al. Predictive model for risk of severe gastrointestinal toxicity following chemotherapy
using patient immune genetics and type of cancer: a pilot study. Support Care Cancer 2015; 23:1233–1236.
Genetic alterations in TLRs may alter host–commensal interactions in xenobiotic metabolism. This pilot study (retrospective, small cohort) suggests that carriers of the TLR2 +1350 T>C polymorphism may be more likely to develop severe chemotherapy-induced gastrointestinal toxicity.
56. Podolsky DK, Gerken G, Eyking A, Cario E. Colitis-associated variant of TLR2 causes impaired mucosal repair because of TFF3 deficiency. Gastroenterology 2009; 137:209–220.
57. Eyking A, Ey B, Runzi M, et al. Toll-like receptor
4 variant D299G induces features of neoplastic progression in Caco-2 intestinal cells and is associated with advanced human colon cancer. Gastroenterology 2011; 141:2154–2165.
58. Vuononvirta J, Peltola V, Mertsola J, He Q. Risk of repeated Moraxella catarrhalis colonization is increased in children with Toll-like receptor
4 Asp299Gly polymorphism. Pediatr Infect Dis J 2013; 32:1185–1188.
59. Nachtigall I, Tamarkin A, Tafelski S, et al. Polymorphisms of the Toll-like receptor
2 and 4 genes are associated with faster progression and a more severe course of sepsis in critically ill patients. J Int Med Res 2014; 42:93–110.
60. Hartford CM, Dolan ME. Identifying genetic variants that contribute to chemotherapy
-induced cytotoxicity. Pharmacogenomics 2007; 8:1159–1168.
61. Yomade O, Spies-Weisshart B, Glaser A, et al. Impact of NOD2 polymorphisms on infectious complications following chemotherapy
in patients with acute myeloid leukaemia. Ann Hematol 2013; 92:1071–1077.
62▪. Montassier E, Gastinne T, Vangay P, et al. Chemotherapy
-driven dysbiosis in the intestinal microbiome. Aliment Pharmacol Ther 2015; 42:515–528.
This study performed high-throughput DNA-sequencing analysis from faecal samples before and after chemotherapy in lymphoma patients receiving myeloablative conditioning treatment prior to hematopoietic stem cell transplantation (no antibiotics). The findings imply that dysbiosis is associated with chemotherapy-induced intestinal mucositis. For instance, the authors demonstrated a decrease in anti-inflammatory Bifidobacterium, but an increase in proinflammatory Citrobacter after chemotherapy.
63. Wallace BD, Wang H, Lane KT, et al. Alleviating cancer drug toxicity by inhibiting a bacterial enzyme. Science 2010; 330:831–835.
64. Brandi G, Dabard J, Raibaud P, et al. Intestinal microflora and digestive toxicity of irinotecan in mice. Clin Cancer Res 2006; 12:1299–1307.
65. Alimonti A, Satta F, Pavese I, et al. Prevention of irinotecan plus 5-fluorouracil/leucovorin-induced diarrhoea by oral administration of neomycin plus bacitracin in first-line treatment of advanced colorectal cancer. Ann Oncol 2003; 14:805–806.
66▪. Morgun A, Dzutsev A, Dong X, et al. Uncovering effects of antibiotics on the host and microbiota using transkingdom gene networks. Gut 2015; 64:1732–1743.
Cancer patients receiving chemotherapy are often treated with antibiotics. Here, the authors found that general intestinal alterations resulting from antibiotic treatment in mice may be explained by three major influences: microbiota depletion, direct effects on host mucosa (repression in mitochondrial gene expression) and effects of microbiota shifts (overgrowth of antibiotic-resistant species).
67. Iida N, Dzutsev A, Stewart CA, et al. Commensal bacteria
control cancer response to therapy by modulating the tumor microenvironment. Science 2013; 342:967–970.
68. Viaud S, Saccheri F, Mignot G, et al. The intestinal microbiota modulates the anticancer immune effects of cyclophosphamide. Science 2013; 342:971–976.
69. Paulos CM, Wrzesinski C, Kaiser A, et al. Microbial translocation augments the function of adoptively transferred self/tumor-specific CD8+ T cells via TLR4 signaling. J Clin Invest 2007; 117:2197–2204.
70▪. Sivan A, Corrales L, Hubert N, et al. Commensal Bifidobacterium
promotes antitumor immunity and facilitates anti-PD-L1 efficacy. Science 2015; 350:1084–1089.
See annotation to 71.
71▪. Vetizou M, Pitt JM, Daillere R, et al. Anticancer immunotherapy by CTLA-4 blockade relies on the gut microbiota. Science 2015; 350:1079–1084.