Serum diamine oxidase activity derived from responce to chemotherapy affects adverse events and serum amino acid levels

doi:10.21203/rs.3.rs-1460065/v1

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Research Article

Serum diamine oxidase activity derived from responce to chemotherapy affects adverse events and serum amino acid levels

https://doi.org/10.21203/rs.3.rs-1460065/v1

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Purpose The relation between activity of the small intestinal villi and the effectiveness of chemotherapy remains unclear. This study aimed to investigate how serum diamine oxidase (DAO) activity affects antitumor effects, adverse events, and amino acid absorption.

Methods We performed a single-center prospective cohort study that enrolled 50 patients with esophageal cancer (EC) receiving docetaxel, cisplatin, and 5-fluorouracil therapy. We determined the cut-off value of serum DAO activity contributing to a response to chemotherapy using a generalized additive model. Additionally, we compared adverse events, inflammatory markers, blood amino acid levels, and quality of life between the high and low DAO activity groups during chemotherapy.

Results The cut-off value of serum DAO activity at the first visit that contributed to a chemotherapy response was 6.5 units/L. Leukopenia and neutropenia of Grade ≥3 were significantly higher in the DAO low (<6.5 units/L) group (p = 0.044, 0.017, respectively). Interleukin-6 was significantly lower in the DAO high (≥6.5 units/L) group at the first visit and at 4 weeks after the end of chemotherapy (p = 0.039, 0.011, respectively). Glutamine was higher in the DAO high group at all measurement points during chemotherapy. Fatigue was significantly lower in the DAO high group (p = 0.001).

Conclusion Serum DAO activity may be a predictor of the response to chemotherapy in patients with EC. The absorption capacity of amino acids was maintained in the group with high DAO activity, which may have contributed to the anti-inflammatory effect and provided a background for reducing adverse events.

Esophageal cancer

Chemotherapy

Adverse events

Diamine oxidase activity

Inflammation markers

Amino acids

Diamine oxidase (DAO) is an enzyme found in high concentrations in the intestinal mucosa [1, 2], and serum DAO activity is known as an indicator of the histological integrity and maturity of the small intestinal mucosa [3, 4]. Several studies have shown that serum DAO activity is decreased by anticancer drugs [5, 6] and correlates with small intestinal mucosal damage [7] and gastrointestinal symptoms [8, 9].

Although the relationship between serum DAO activity and gastrointestinal toxicity caused by anticancer drugs has been reported, to our knowledge, there has been no report examining the relationship between the level of small intestinal villi and antitumor effect, or the mechanism of adverse events caused by gastrointestinal absorption. Therefore, we performed a single-center prospective cohort study focused on serum DAO activity and antitumor effects in patients receiving chemotherapy for esophageal cancer (EC) and investigated how small intestinal villi are involved in the anti-inflammatory effect, amino acid absorption, adverse events, and patient quality of life (QoL).

Patient eligibility

This study enrolled patients who were at least 18 years of age at the time of registration and had histologically or cytologically confirmed esophageal squamous cell carcinoma or Siewert type I adenocarcinoma and agreed to the docetaxel (TXT), cisplatin (CDDP) and 5-florouracil (5-FU) [10, 11] (DCF) chemotherapy as preoperative chemotherapy for EC or who had unresectable (clinical T4 cases or distant metastasis) EC and also agreed to DCF chemotherapy. Disease staging was defined according to the International Union Against Cancer TNM classification system, 8th edition [12]. To determine the response rate, metastatic lymph nodes and distant metastatic lesions with a minor axis of 10 mm or more were targeted. Patients also had to have an Eastern Cooperative Oncology Group performance status of 0–1 [13], adequate liver, bone marrow, renal, and cardiovascular function (serum bilirubin ≤ 1.2 mg/dL, 4000 ≤ leucocyte count ≤ 12,000, neutrophil count ≥ 2000/mm³, serum aspartate aminotransferase and alanine aminotransferase levels ≤ 100 IU/L, platelet count ≥ 10 × 10⁴/mm³, hemoglobin ≥ 8.0 g/dL, and creatinine ≤ 1.2 mg/dL or creatinine clearance > 50 mL/min). In addition, all patients had a Dysphasia score ≤ 2 [14]. The major exclusion criteria included symptomatic infectious disease, symptomatic peripheral neuropathy, diabetes mellitus controlled by insulin, pregnant or lactating women, hypersensitivity to TXT, CDDP, and 5-FU, habitual steroids users, severe interstitial pneumonia, a large amount of pleural effusion or ascites, and symptomatic bone metastasis/brain metastasis.

Study drugs

Patients received TXT diluted in 250 mL of normal saline at a dose of 35 mg/m². Then, CDDP was prepared in normal saline at a dose of 40 mg/m² and administered intravenously (iv) over 2 hours (h) on day 1. 5-FU was prepared in normal saline at a dose of 400 mg/m² and administered iv continuously on days 1–5. TXT and CDDP were given on days 1 and 15, and 5-FU was given on days 1–5 and 15–19 of every 28-day cycle (one cycle). All included patients were scheduled to receive two cycles. All patients were premedicated with granisetron 2 mg iv. Hypersensitivity reactions were treated with prophylactic use of dexamethasone 8 mg iv, which was infused 1 hour prior to the administration of TXT. To prevent fever due to neutropenia, ciprofloxacin 500 mg was administered for 5 days after chemotherapy.

Treatment assessment

Except for the primary tumor, measurable lesions were evaluated with computed tomography or magnetic resonance imaging and were assessed in accordance with the Response Evaluation Criteria in Solid Tumors Criteria version 1.0 [15]. Response was confirmed 4 weeks after completion of the two cycles of chemotherapy. The antitumor effect was determined and confirmed by two physicians. All adverse events were defined using the National Cancer Institute’s Common Terminology Criteria for Adverse Events (CTCAE) version 4.0. The method of measuring serum DAO activity was based on the method described by Takagi et al. [16]. EORTC QLQ-C30 (version 3) was used to asses the patients’ QoL. The QLQ-C30 consists of a global health and QoL scale, five functional scales (physical, role, cognitive, emotional, and social function), three symptom scales (fatigue, pain, and nausea/vomiting), and six single items: dyspnea, insomnia, anorexia, constipation, diarrhea, and economic difficulties [17]. In all cases, no oral nutritional supplements were used, and blood sampling at 6 am with the patient on an empty stomach was strictly adhered to. Cases requiring oral nutritional support due to tumor progression were excluded during the study period.

Main objective

As this was a prospective cohort study, the cut-off value of serum DAO activity that contributes to the response of EC to chemotherapy was determined by generalized additive models (GAM). Patients evaluated as achieving complete response (CR) and partial response (PR) were defined as responding cases, and patients evaluated as having stable disease (SD) and progressive disease (PD) were defined as non-responding cases.

In addition, according to this cut-off value, we classified serum DAO activity into a high group (≥ 6.5 units/L) and low group (< 6.5 units/L). We investigated hematological toxicity, non-hematological toxicity, measured levels of blood amino acids and inflammatory markers (interleukin-6 [IL-6], tumor necrosis factor α [TNF-α], and neutrophil elastase), and assessed QoL scores between the two groups at the time of the first visit, after 1 cycle, after 2 cycles, and 4 weeks after that (Online Resource 1).

Statistical analysis

The effect of serum DAO activity on antitumor efficacy was evaluated using the GAM, with response status (CR or PR) as the response variable and age, sex, tumor localization, and stage at initial diagnosis as covariates. Patient background was summarized for each group using the mean (standard deviation [SD]) for continuous measures and frequency (percentage) for categorical measures. A two-sample t-test was used to compare anti-inflammatory effects and amino acid absorption. Odds ratios and 95% confidence intervals were calculated for each adverse event and compared using Fisher’s exact test. Two-sided p-values < 0.05 were considered statistically significant. All analyses were performed using R version 4.1.0 (The R Foundation for Statistical Computing, Vienna, Austria), and the “GAM” package was used to calculate the generalized additive model.

From October 2020 to December 2022, 50 patients were enrolled in this prospective cohort study. The baseline characteristics of the patients are shown in Table 1. The results of the confirmed response to the chemotherapy were 5/30/15/0 for each of CR/PR/SD/PD. No patients were withdrawn from the study due to the need for oral nutritional support. A cut-off value of 6.5 units/L was selected for serum DAO activity, which resulted in an adjusted odds ratio of 1.5 for the estimated GAM (Online Resource 2). The relationship between the background factors classified into the DAO high group and the DAO low group according to the cut-off value is shown in Table 2. There was no significant difference in the background characteristics between the two groups. As for the value of serum DAO activity, the DAO high group was higher than the DAO low group at all points (the first visit, after 1 cycle, after 2 cycles, and after 4 weeks) (all p < 0.001). The mean (SD) of the total dose of anticancer drug was 2806.2 (364.47) mg/m² in the DAO high group and 2605.3 (382.33) mg/m² in the DAO low group, and there was no significant difference between the two groups (p = 0.064). The results of the response rates to chemotherapy can be compared in Table 3, which showed that the response rate was significantly higher in the DAO high group at initial diagnosis. Multivariate analysis showed that the group classified by the cut-off value of serum DAO activity at initial diagnosis was an independent factor involved in the response rate to chemotherapy (p = 0.033). The results of subgroup analysis for each of the DAO high and low groups are shown in Table 3. Female sex, Stage IV, N0-1 group, and tumor location in the upper-middle esophagus had a significant effect on the response to chemotherapy (p = 0.043, 0.012, 0.017, and 0.004, respectively) (Online Resource 3).

Table 1

Baseline characteristics of the patients
Characteristics	Number of patients (n = 50)
Sex
Male	41 (82.0)
Female	9 (18.0)
Age (years) [range]	72.00 [46.00–88.00]
Stage
1	1 (2.0)
2	7 (14.0)
3	18 (36.0)
4a	21 (42.0)
4b	3 (6.0)
T	6 (12.0)
1b
2	17 (34.0)
3	6 (12.0)
4a	2 (4.0)
4b	19 (38.0)
N
0	8 (16.0)
1	14 (28.0)
2	20 (40.0)
3	3 (6.0)
4	5 (10.0)
Location
Ce/Ut	12 (24.0)
Mt	24 (48.0)
Lt/Ae	14 (28.0)
SCC/Adeno
SCC	49 (98.0)
Adeno	1 (2.0)
Ce cervical esophageal site, Ut upper esophageal site, Mt middle esophageal site, Lt lower esophageal site, Ae abdominal esophageal site, SCC squamous cell carcinoma, Adeno adenocarcinoma Values or number (%) unless otherwise noted

Table 2

Patient background factors classified according to DAO cut-off value
Characteristics		Serum DAO activity		p-Value
Characteristics		DAO ≥ 6.5 units/L (n = 27)	DAO < 6.5 units/L (n = 23)	p-Value
Sex
Male	4 (14.8)		5 (21.7)	0.715
Female	23 (85.2)		18 (78.3)
Age (years) [range]	72.00 [46.00, 86.00]		72.00 [57.00, 88.00]	0.354
Stage
1	1 (3.7)		0 (0.0)	0.409
2	4 (14.8)		3 (13.0)
3	10 (37.0)		8 (34.8)
4a	9 (33.3)		12 (52.2)
4b	3 (11.1)		0 (0.0)
TMN
T
1b	4 (14.8)		2 (8.7)	0.752
2	10 (37.0)		7 (30.4)
3	4 (14.8)		2 (8.7)
4a	1 (3.7)		1 (4.3)
4b	8 (29.6)		11 (47.8)
M
0	24 (88.9)		23 (100.0)	0.240
1	3 (11.1)		0 (0.0)
N
0	4 (14.8)		4 (17.4)	0.913
1	7 (25.9)		7 (30.4)
2	12 (44.4)		8 (34.8)
3	1 (3.7)		2 (8.7)
4	3 (11.1)		2 (8.7)
Location
Ce/Ut	7 (25.9)		5 (21.7)	0.936
Mt	13 (48.1)		11 (47.8)
Lt/Ae	7 (25.9)		7 (30.4)
SCC/Adeno
SCC	26 (96.3)		23 (100.0)	1.000
Adeno	1 (3.7)		0 (0.0)
DAO diamine oxidase Ce cervical esophageal site, Ut upper esophageal site, Mt middle esophageal site, Lt lower esophageal site, Ae abdominal esophageal site, SCC squamous cell carcinoma, Adeno adenocarcinoma

Table 3

Response rates to chemotherapy
DAO units/L	N = 50	CR (%)	PR (%)	SD (%)	PD (%)	Responding cases	Response rate [95% CI]
≥ 6.5	27	5 (18.5%)	18 (66.7%)	4 (14.8%)	0 (0.0%)	23	85.2% [66.3%, 95.8%]
< 6.5	23	0 (0.0%)	12 (52.2%)	11 (47.8%)	0 (0.0%)	12	52.2% [30.6%, 73.2%]
DAO diamine oxidase, CR complete response, PR partial response, SD stable disease, PD progressive disease, CI confidence interval

Hematological and non-hematological adverse events

A comparison can be made between the two groups regarding hematological and non-hematological adverse events during chemotherapy in Table 4. Leukopenia and neutropenia of Grade 3 or higher were significantly higher in the DAO low group (p = 0.044 and 0.017, respectively). Grade 3 or higher diarrhea was significantly more common in the DAO low group (p = 0.038), and any grade fatigue and nausea were also significantly more common in the DAO low group (p = 0.043 and 0.046, respectively).

Table 4

Hematological and non-hematological adverse events during chemotherapy
	DAO ≥ 6.5 units/L		DAO < 6.5 units/L		OR [95% CI]	p-Value*
	E (N)	Proportion [95% CI]	E (N)	Proportion [95%CI]	OR [95% CI]	p-Value*
Hematological adverse events
Leukopenia	3 (27)	11.1 [2.4, 29.2]	9 (23)	39.1 [19.7, 61.5]	0.201 [0.030, 0.981]	0.044*
Neutropenia	5 (27)	18.5 [6.3, 38.1]	12 (23)	52.2 [30.6, 73.2]	0.216 [0.047, 0.861]	0.017*
Thrombocytopenia	1 (27)	3.7 [0.1, 19.0]	0 (23)	0.0 [0.0, 14.8]	-	1.000
Anemia	0 (27)	0.0 [0.0, 12.8]	3 (23)	13.0 [2.8, 33.6]	-	0.090
Hypokalemia	1 (27)	3.7 [0.1, 19.0]	0 (23)	0.0 [0.0, 14.8]	-	1.000
Hypomagnesemia	1 (27)	3.7 [0.1, 19.0]	0 (23)	0.0 [0.0, 14.8]	-	1.000
All events	8 (27)	29.6 [13.8, 50.2]	15 (23)	65.2 [42.7, 83.6]	0.232 [0.057, 0.853]	0.022*
Non-hematological adverse events
Alopecia	23 (27)	85.2 [66.3, 95.8]	18 (23)	78.3 [56.3, 92.5]	1.582 [0.293, 9.219]	0.715
Fatigue	7 (27)	25.9 [11.1, 46.3]	13 (23)	56.5 [34.5, 76.8]	0.277 [0.069, 1.025]	0.043*
Constipation	12 (27)	44.4 [25.5, 64.7]	8 (23)	34.8 [16.4, 57.3]	1.488 [0.415, 5.548]	0.569
Appetite loss	16 (27)	59.3 [38.8, 77.6]	16 (23)	69.6 [47.1, 86.8]	0.642 [0.165, 2.377]	0.559
Nausea	9 (27)	33.3 [16.5, 54.0]	15 (23)	65.2 [42.7, 83.6]	0.274 [0.070, 0.992]	0.046*
Vomiting	1 (27)	3.7 [0.1, 19.0]	4 (23)	17.4 [5.0, 38.8]	0.189 [0.004, 2.106]	0.167
Swelling	5 (27)	18.5 [6.3, 38.1]	1 (23)	4.3 [0.1, 21.9]	4.862 [0.486, 246.695]	0.199
Oral mucositis	13 (27)	48.1 [28.7, 68.1]	12 (23)	52.2 [30.6, 73.2]	0.854 [0.242, 2.979]	1.000
Diarrhea (Grade 3>)	0 (27)	0.0 [0.0, 12.8]	4 (23)	17.4 [5.0, 38.8]	-	0.038*
DAO diamine oxidase, E event number, N number of patients, OR odds ratio, CI confidence interval *p < 0.05

Serum amino acid levels

Table 5 shows the serum amino acid amounts at 4 weeks after the end of chemotherapy. Glutamine was higher in the DAO high group than in the low group at all timings during chemotherapy (p = 0.001, 0.015, 0.043, and 0.021, respectively). At 4 weeks after chemotherapy, threonine, alpha aminobutyric acid, valine, leucine, tryptophan, lysine, and arginine were significantly higher in the DAO high group than in the low group. Among the essential amino acids (EAA) and branched-chain amino acids, there was no difference between the two groups at the first visit, but the values at 4 weeks after the end of chemotherapy were significantly higher in the DAO high group (p = 0.001 and 0,011, respectively).

Table 5

Serum amino acid amounts at 4 weeks after the end of chemotherapy
Amino acids	Average (SD)		p-Value
Amino acids	DAO ≥ 6.5 units/L	DAO < 6.5 units/L	p-Value
EAA	932 (149.7)	771.7 (166.7)	0.001*
BCAA	416.5 (94.15)	349.9 (81.22)	0.011*
Glutamine	567.4 (104.4)	496.1 (105.6)	0.021*
Histidine	55.50 (22.28)	49.43 (15.06)	0.310
Taurine	60.21 (22.74)	67.41 (28.37)	0.324
Threonine	130.4 (36.62)	98.94 (34.15)	0.003*
Serine	107.5 (28.01)	97.83 (27.44)	0.224
Asparagine	42.83 (10.23)	39.46 (10.56)	0.259
Glutamic acid	63.22 (25.99)	53.35 (18.94)	0.137
Proline	186.6 (81.7)	148.9 (48.16)	0.058
Glycine	220.8 (50.26)	192.3 (74.32)	0.114
Alanine	337.9 (91.19)	305.9 (96.44)	0.235
Citrulline	29.53 (11.86)	24.24 (8.657)	0.083
Alpha aminobutyric acid	16.56 (7.489)	12.87 (3.15)	0.037*
Valine	231.6 (55.71)	190.1 (45.25)	0.006*
Cystine	31.8 (11.76)	33.63 (14.31)	0.623
Methionine	21.98 (5.972)	19.05 (5.589)	0.081
Isoleucine	67.16 (17.75)	60.15 (14.72)	0.139
Leucine	118.8 (25.07)	99.67 (24.21)	0.009*
Tyrosine	60.74 (15.96)	54.95 (19.25)	0.250
Phenylalanine	59.97 (8.906)	55.16 (13.1)	0.130
Tryptophan	50.19 (13.56)	39.3 (10.89)	0.003*
Ornithine	85.05 (26.39)	69.98 (34.28)	0.089
Lysine	186.6 (32.76)	147 (37.13)	< 0.001*
Arginine	89.07 (36.86)	62.03 (21.11)	0.003*
SD standard deviation, DAO diamine oxidase, EAA essential amino acids, BCAA branched-chain amino acids *p < 0.05

Table 6

Inflammatory markers
	Average (SD) [95% CI]		p-Value
	DAO ≥ 6.5 units/L	DAO < 6.5 units/L
Neutrophil elastase
First visit	2076 (947.6) [1701, 2451]	2415 (1022) [1973, 2857]	0.230
After 1 course	2027 (969.1) [1643, 2410]	2226 (978.2) [1803, 2649]	0.474
After 2 courses	2041 (943.8) [1668, 2415]	2018 (854.4) [1649, 2388]	0.929
After 4 weeks	2100 (948.8) [1725, 2476]	2186 (820.9) [1831, 2541]	0.735
Neutrophil count
First visit	5017 (1734) [4331, 5703]	4917 (1754) [4158, 5675]	0.840
After 1 course	2550 (1444) [1979, 3122]	2035 (1719) [1292, 2778]	0.254
After 2 courses	2248 (1402) [1693, 2802]	1962 (1996) [1099, 2825]	0.556
After 4 weeks	3355 (1457) [2779, 3932]	3431 (1541) [2764, 4097]	0.860
IL-6
First visit	3.551 (2.596) [2.524, 4.578]	5.31 (3.541) [3.778, 6.841]	0.039*
After 1 course	3.982 (2.827) [2.864, 5.1]	5.439 (4.063) [3.682, 7.196]	0.143
After 2 courses	3.257 (2.055) [2.444, 4.07]	7.002 (9.541) [2.877, 11.13]	0.052
After 4 weeks	3.459 (2.427) [2.498, 4.419]	6.681 (5.728) [4.204, 9.158]	0.011*
TNF-α
First visit	6.058 (2.909) [4.907, 7.208]	5.543 (1.838) [4.748, 6.338]	0.467
After 1 course	6.231 (2.782) [5.13, 7.331]	6.235 (2.546) [5.107, 7.364]	0.995
After 2 courses	6.503 (3.318) [5.191, 7.816]	5.97 (2.395) [4.935, 7.006]	0.525
After 4 weeks	6.651 (3.335) [5.332, 7.971]	5.751 (2.227) [4.788, 6.714]	0.276
SD standard deviation, CI confidence interval, DAO diamine oxidase, IL-6 interleukin-6, TNF-α tumor necrosis factor α *p < 0.05

Inflammatory markers

The inflammatory markers can be compared in Table 6. IL-6 showed significantly lower values in the DAO high group at the first visit and at 4 weeks after the end of chemotherapy (p = 0.039 and 0.011, respectively). There was no significant difference between the two groups in the values of TNF-α and neutrophil elastase.

QoL

Fatigue was significantly suppressed in the DAO high group at the first visit and at 4 weeks after the end of chemotherapy (p = 0.001 and 0.025, respectively) (Online Resource 4).

This is the first prospective cohort study, to our knowledge, to examine the relationship between serum DAO activity and the response to chemotherapy in patients with EC. In this study, we determined the cut-off value of serum DAO activity according to the antitumor effect and found that adverse events were significantly suppressed in the DAO high group. It is reported that about 70% of all lymphocytes in the human body are concentrated in the intestinal intra-epithelial and subepithelial layers, and the largest pool of tissue macrophages is located in the intestinal wall [18]. Given these findings, serum DAO activity at the first visit would appear to be related to the immunity and absorptive capacity of small intestinal villi, which may affect the efficacy and adverse events of chemotherapy, so we measured markers of inflammation and blood amino acid levels related to absorption capacity. The present study showed that the DAO high group had significantly lower IL-6 associated with C reactive protein (CRP) than the low group. Additionally, myelosuppression was significantly reduced in the DAO high group. Cytotoxic chemotherapy damages the villi of the small intestine, where lymphocytes are concentrated throughout the body, and raises the levels of inflammatory cytokines [19]. Besides, chemotherapy causes mucosal barrier damage, and its disruption of highly controlled host-microbial interactions can result in resident microorganisms causing bloodstream infections that lead to a strong inflammatory response due to cytokine release. In this paradigm, chemotherapy-induced “neutropenia” and “villi disorder” are complementary [20]. In the present study, it is possible that inflammatory cytokines derived from villous disorders were suppressed in the DAO high group by maintaining relatively high activity even after chemotherapy-induced damage to the villi.

According to Tanaka et al., an elemental diet is easily absorbed even in diminished small intestinal villi, and an elemental diet plus normal meal resulted in a low CRP level during chemotherapy and significantly reduced the frequency of myelosuppression [21, 22]. In the present study, we eliminated the effects of oral nutritional supplements and observed clinical outcomes purely due to serum DAO activity. The clinical findings of the suppression of inflammation and myelosuppression in patients receiving chemotherapy by taking an elemental diet were supported by the fact that the same condition occurred in the population with higher villus activity in this study. We further investigated the difference in amino acid absorption capacity due to high DAO activity. Looking at the types of amino acids that could be maintained with a significant difference 4 weeks after the end of the second course of chemotherapy, glutamine, threonine, alpha aminobutyric acid, valine, leucine, tryptophan, lysine, and arginine showed significantly higher values in the DAO high group. Macrophages and lymphocytes consume more glutamine when the human body is in an inflamed state. Glutamine utilization is said to be 10-fold greater in proliferating lymphocytes than in resting cells [23]. Moreover, for malignant disease, mitochondrial glutaminase was reported to be more active in tumor than in normal cells [24]. Glutamine is used for immunity throughout the body, including the intestinal tract, and for in vivo synthesis and degradation in the liver and kidneys. It is a major fuel for rapidly dividing cells in the intestinal mucosa, and in mammals it plays an important role in carbon metabolism and the proliferation of lymphocytes, fibroblasts, and intestinal cells [25, 26]. This point also suggests that glutamine absorption capacity was maintained in the group with relatively high small intestinal villi, which may have contributed to the anti-inflammatory effect. Considering that the EAA showed significantly higher values in the DAO high group, it is thought that the absorption capacity was also maintained. Very interesting findings have been reported for valine. Mouse and human hematopoietic stem cells are particularly vulnerable compared to other amino acids, and feeding mice a valine-restricted diet causes a decrease in bone marrow hematopoietic stem cells [27]. Thus, several EAA including glutamine, may be involved in neutropenia.

In regard to QoL, fatigue was significantly less in the DAO high group. Decreased blood lysine and arginine levels have been implicated in mental fatigue [28], and supplementation with valine and arginine has been reported to improve physical fatigue [29]. In the present study, the blood concentration of these amino acids was significantly higher in the DAO high group. Further, a low incidence of diarrhea has also been reported in patients with high serum DAO activity [9], and this was also the case in the present study.

Currently, many anti-cancer drugs are calculated based on the body surface area of the patient [30]; however, there are also some skeptical reports. In fact, we frequently experience clinical differences in the appearance of adverse events with anticancer drugs and may feel that some patients may be given higher dose intensities. Th cut-off value of 6.5 units/L for DAO could be used to adjust the dose and intensity of anticancer drugs and to predict side effects.

This study has several limitations. First, this study was conducted in single institution, and the number of enrolled patients was low. Second, we did not evaluate the histological response in surgical specimens or in progression-free survival and overall survival. In the future, it will be desirable to investigate whether the dose of an anticancer drug can be adjusted based on the serum DAO activity at the first visit, and as a result, whether the response rate of preoperative chemotherapy, the histopathological response rate, and the prognosis of the patient can be improved. It will be necessary to investigate these effects in a large-scale prospective study.

Our cut-off value for DAO activity of 6.5 units/L may be a predictor of the response to chemotherapy in patients with EC. This study also showed that blood levels of amino acids may be maintained in the DAO high group, thus providing a background for a reduced number of adverse events.

Funding The authors declare that no funds, grants, or other support were received during the preparation of this manuscript.

Conflicts of interest The authors have no relevant financial or non-financial interests to disclose.

Availability of data and material Not applicable.

Code availability Not applicable.

Author contributions All authors contributed to the study conception and design. Material preparation, data collection and analysis were performed by Yuta Sato, Takeharu Imai, Yoshihiro Tanaka, and Toshio Shimokawa. The first draft of the manuscript was written by Yuta Sato, and all authors commented on previous versions of the manuscript. All authors read and approved the final manuscript.

Ethics approval This study was conducted in accordance with the World Medical Association Declaration of Helsinki and was registered with the University Hospital Medical Information Network (UMIN ID: R000050782). The study protocol was approved by ethics committees of Gifu University School of Medicine (ID: 2020-215), and written informed consent was obtained from all of the patients before all study-related procedures.

Consent to participate Informed consent was obtained from all individual participants included in the study.

Consent for publication Written informed consent was obtained from the patient for publication of this manuscript. A copy of the patient’s written consent is available for review by the Editor-in-Chief of this journal.

Maintz L, Novak N (2007) Histamine and histamine intolerance. Am J Clin Nutr 85(5):1185–1196. https://doi.org/10.1093/ajcn/85.5.1185
Seiler N (2004) Catabolism of polyamines. Amino Acids 26(3):217–233. https://doi.org/10.1007/s00726-004-0070-z
Luk GD, Bayless TM, Baylin SB (1980) Diamine oxidase (histaminase). A circulating marker for rat intestinal mucosal maturation and integrity. J Clin Invest 66(1):66–70. https://doi.org/10.1172/JCI109836
Luk GD, Bayless TM, Baylin SB (1983) Plasma postheparin diamine oxidase. Sensitive provocative test for quantitating length of acute intestinal mucosal injury in the rat. J Clin Invest 71(5):1308–1315. https://doi.org/10.1172/jci110881
Tanaka Y, Takahashi T, Yamaguchi K, Osada S, Shimokawa T, Yoshida K (2015) Elemental diet plus glutamine for the prevention of mucositis in esophageal cancer patients receiving chemotherapy: a feasibility study. Support Care Cancer 24(2):933–941. https://doi.org/10.1007/s00520-015-2864-9
Tsujikawa T, Uda K, Ihara T, Inoue T, Andoh A, Fujiyama Y, Bamba T (1999) Changes in serum diamine oxidase activity during chemotherapy in patients with hematological malignancies. Cancer Lett 1147(1–2):195–198. https://doi.org/10.1016/s0304-3835(99)00307-9
Moriyama K, Kouchi Y, Morinaga H, Irimura K, Hayashi T, Ohuchida A, Goto T, Yoshizawa Y (2006) Diamine oxidase, a plasma biomarker in rats to GI tract toxicity of oral fluorouracil anti-cancer drugs. Toxicology 16(2–3):233–239. https://doi.org/10.1016/j.tox.2005.09.017
Namikawa T, Fukudome I, Kitagawa H, Okabayashi T, Kobayashi M, Hanazaki K (2012) Plasma diamine oxidase activity is a useful biomarker for evaluating gastrointestinal tract toxicities during chemotherapy with oral fluorouracil anti-cancer drugs in patients with gastric cancer. Oncology 82(3):147–152. https://doi.org/10.1159/000336799
Miyoshi J, Miyamoto H, Goji T, Taniguchi T, Tomonari T, Sogabe M, Kimura T, Kitamura S, Okamoto K, Fujino Y, Muguruma N, Okahisa T, Takayama T (2015) Serum diamine oxidase activity as a predictor of gastrointestinal toxicity and malnutrition due to anticancer drugs. J Gastroenterol Hepatol 30(11):1582–1590. https://doi.org/10.1111/jgh.13004
Tanaka Y, Yoshida K, Sanada Y, Osada S, Yamaguchi K, Takahashi T (2010) Biweekly docetaxel, cisplatin, and 5-fluorouracil (DCF) chemotherapy for advanced esophageal squamous cell carcinoma: a phase I dose-escalation study. Cancer Chemother Pharmacol 66(6):1159–1165. https://doi.org/10.1007/s00280-010-1447-1
Tanaka Y, Yoshida K, Yamada A, Tanahashi T, Okumura N, Matsuhashi N, Yamaguchi K, Miyazaki T (2016) Phase II trial of biweekly docetaxel, cisplatin, and 5-fluorouracil chemotherapy for advanced esophageal squamous cell carcinoma. Cancer Chemother Pharmacol 77(6):1143–1152. https://doi.org/10.1007/s00280-016-2985-y
Brierley JD, Gospodarowicz MK, Wittekind C (2016) TNM Classification of Malignant Tumours, 8th edn. Wiley-Blackwell
Oken MM, Creech RH, Tormey DC, Horton J, Davis TE, McFadden ET, Carbone PP (1982) Toxicity and response criteria of the Eastern Cooperative Oncology Group. Am J Clin Oncol 5(6):649–655
Knyrim K, Wagner HJ, Bethge N, Keymling M, Vakil N (1993) A controlled trial of an expansile metal stent for palliation of esophageal obstruction due to inoperable cancer. N Engl J Med 28(18):1302–1307. https://doi.org/10.1056/NEJM199310283291803
Therasse P, Arbuck SG, Eisenhauer EA, Wanders J, Kaplan RS, Rubinstein L, Verweij J, Van Glabbeke M, van Oosterom AT, Christian MC, Gwyther SG (2000) New guidelines to evaluate the response to treatment in solid tumors. European Organization for Research and Treatment of Cancer, National Cancer Institute of the United States, National Cancer Institute of Canada. J Natl Cancer Inst 2(3):205–216. https://doi.org/10.1093/jnci/92.3.205
Takagi K, Nakao M, Ogura Y, Nabeshima T, Kunii A (1994) Sensitive colorimetric assay of serum diamine oxidase. Clin Chim Acta 226(1):67–75. https://doi.org/10.1016/0009-8981(94)90103-1
Aaronson NK, Ahmedzai S, Bergman B, Bullinger M, Cull A, Duez NJ, Filiberti A, Flechtner H, Fleishman SB, de Haes JC et al (1993) The European Organization for Research and Treatment of Cancer QLQ-C30: a quality-of-life instrument for use in international clinical trials in oncology. J Natl Cancer Inst 3(5):365–376. https://doi.org/10.1093/jnci/85.5.365
Schenk M, Mueller C (2008) The mucosal immune system at the gastrointestinal barrier. Best Pract Res Clin Gastroenterol 22(3):391–409. https://doi.org/10.1016/j.bpg.2007.11.002
van der Velden WJ, Blijlevens NM, Feuth T, Donnelly JP (2009) Febrile mucositis in haematopoietic SCT recipients. Bone Marrow Transplant 43(1):55–60. https://doi.org/10.1038/bmt.2008.270
van der Velden WJ, Herbers AH, Feuth T, Schaap NP, Donnelly JP, Blijlevens NM (2010) Intestinal damage determines the inflammatory response and early complications in patients receiving conditioning for a stem cell transplantation. PLoS ONE 20(12):e15156. https://doi.org/10.1371/journal.pone.0015156
Tanaka Y, Ueno T, Yoshida N, Akutsu Y, Takeuchi H, Baba H, Matsubara H, Kitagawa Y, Yoshida K (2018) The effect of an elemental diet on oral mucositis of esophageal cancer patients treated with DCF chemotherapy: a multi-center prospective feasibility study (EPOC study). Esophagus 15(4):239–248. https://doi.org/10.1007/s10388-018-0620-1
Tanaka Y, Takeuchi H, Nakashima Y, Nagano H, Ueno T, Tomizuka K, Morita S, Emi Y, Hamai Y, Hihara J, Saeki H, Oki E, Kunisaki C, Otsuji E, Baba H, Matsubara H, Maehara Y, Kitagawa Y, Yoshida K (2021) Effects of an elemental diet to reduce adverse events in patients with esophageal cancer receiving docetaxel/cisplatin/5-fluorouracil: a phase III randomized controlled trial-EPOC 2 (JFMC49-1601-C5). ESMO Open 6(5):100277. https://doi.org/10.1016/j.esmoop.2021.100277
Brand K, Leibold W, Luppa P, Schoerner C, Schulz A (1986) Metabolic alterations associated with proliferation of mitogen-activated lymphocytes and of lymphoblastoid cell lines: evaluation of glucose and glutamine metabolism. Immunobiology 173(1):23–34. https://doi.org/10.1016/S0171-2985(86)80086-9
Gómez-Fabre PM, Aledo JC, Del Castillo-Olivares A, Alonso FJ, Núñez De Castro I, Campos JA, Márquez J (2000) Molecular cloning, sequencing and expression studies of the human breast cancer cell glutaminase. Biochem J 15(345 Pt 2):365–375
Neu J, Shenoy V, Chakrabarti R (1996) Glutamine nutrition and metabolism: where do we go from here ? FASEB J 10(8):829–837. https://doi.org/10.1096/fasebj.10.8.8666159
Newsholme P, Procopio J, Lima MM, Pithon-Curi TC, Curi R (2003) Glutamine and glutamate–their central role in cell metabolism and function. Cell Biochem Funct 21(1):1–9. https://doi.org/10.1002/cbf.1003
Taya Y, Ota Y, Wilkinson AC, Kanazawa A, Watarai H, Kasai M, Nakauchi H, Yamazaki S (2016) Depleting dietary valine permits nonmyeloablative mouse hematopoietic stem cell transplantation. Science 2(6316):1152–1155. https://doi.org/10.1126/science.aag3145
Mizuno K, Tanaka M, Nozaki S, Yamaguti K, Mizuma H, Sasabe T, Sugino T, Shirai T, Kataoka Y, Kajimoto Y, Kuratsune H, Kajimoto O, Watanabe Y (2007) Mental fatigue-induced decrease in levels of several plasma amino acids. J Neural Transm (Vienna) 114(5):555–561. https://doi.org/10.1007/s00702-006-0608-1
Tsuda Y, Yamaguchi M, Noma T, Okaya E, Itoh H (2019) Combined effect of arginine, valine, and serine on exercise-induced fatigue in healthy volunteers: a randomized, double-blinded, placebo-controlled crossover study. Nutrients 17(4):862. https://doi.org/10.3390/nu11040862
Sawyer M, Ratain MJ (2001) Body surface area as a determinant of pharmacokinetics and drug dosing. Invest New Drugs 19(2):171–177. https://doi.org/10.1023/a:1010639201787

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Online Resource 1: Timing of the measurements of serum DAO activity, blood amino acid levels, inflammation markers, and QoL.
OnlineResource2.pptx
Online Resource 2: A cut-off value of 6.5 units/L was selected for serum DAO activity, which resulted in an adjusted odds ratio of 1.5 for the estimated GAM
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OnlineResource4.docx

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Reviewers agreed at journal
26 May, 2022
Reviewers invited by journal
08 Apr, 2022
Editor invited by journal
08 Apr, 2022
Editor assigned by journal
21 Mar, 2022
First submitted to journal
16 Mar, 2022

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Serum diamine oxidase activity derived from responce to chemotherapy affects adverse events and serum amino acid levels

Status:

Version 1

Abstract

Introduction

Material And Methods

Patient eligibility

Study drugs

Treatment assessment

Main objective

Statistical analysis

Results

Hematological and non-hematological adverse events

Serum amino acid levels

Inflammatory markers

QoL

Discussion

Conclusion

Declarations

References

Supplementary Files

Status:

Version 1