Efficacy Evaluation Of Transdermal Treatment With Wensan Tincture For Lung Nodules Based On Real World Data And Discussion On Its Mechanism

BackgroudLung cancer is the first malignancy with mortality and second with morbidity worldwide.Despite significant advances in surgical treatment,radiotherapy,chemotherapy,molecular targeting and immunotherapy,the five-year survival rate of lung cancer is still low and the prognosis is poor.Pulmonary nodules are the main manifestation of early-stage lung cancer,and the results of epidemiological investigations have shown that the detection rate of pulmonary nodules is 2.1%64.5%.The pathological changes of pulmonary nodules are complex,and the clinical manifestations vary,so far there is no specific drug treatment,and there is a great challenge in early diagnosis and treatment.AI assisted screening system applications have greatly improved the false-positive rate and the detection rate of small pulmonary nodules and pulmonary micronodules,and this kind of nodule imaging usually does not show the typical spiculation sign,pleural indentation sign,lobulation sign,bronchial inflation sign and vacuolization sign and other malignant signs,leading to difficulty in differentiating from benign lesions(such as tuberculosis,granuloma,teratoma,etc.),which brings a certain difficulty in clinical diagnosis.Because the vast majority of pulmonary nodules belong to benign lesions or indolent lung cancer nodules,and the comparison of early surgery with follow-up elective surgery does not significantly improve the overall survival of patients,regular follow-up,follow-up observation becomes the first opinion of management for the vast majority of pulmonary nodules.The trend of pulmonary nodules and their uncertainty also place a significant psychological burden on patients,and there are unique advantages to TCM in this setting.Traditional Chinese medicine(TCM)treatment has unique advantages in relieving anxiety,improving clinical symptoms,reducing the risk level of pulmonary nodules,and inhibiting the process of transformation of colon cancer,while there is a lack of sufficient evidence-based medicine in clinical decision-making.At present,most lung nodule related TCM studies set the observation time within 3 months,because lung nodules exhibit inert growth law,it is difficult to reflect the actual efficacy of TCM in clinic to some extent.The high grade of evidence developed by large,multicentre RCTs is problematic because of excessive study costs,lack of external veracity of results,and low rates of outcome conversion.Real world research data are derived from real-world clinic settings such as hospitals,communities,or families,and have the advantages of broad sources,comprehensive data,more realistic results,and better extrapolation.Real world research is based on real-world research data to explore the objective underlying laws that exist in the diagnosis and treatment setting in order to guide clinical work and the conduct of trial research.The large number of patients with lung nodules accumulated over a long period in the respiratory clinic of Guang’anmen Hospital,and therapeutic technology of Wensan tincture transdermal drug delivery is of great importance in stopping lung nodule progression at an early stage and delaying the malignant outcome.Based on this,our group conducted a retrospective cohort study based on his to control confounders using propensity score matching and explore the clinical efficacy and safety of Wensan tincture for transdermal treatment of lung nodules,in order to add new evidence-based evidence for TCM and TCM for cancer prevention and treatment.In addition,the material basis of Wensan tincture treatment of lung nodules was investigated by network pharmacology combined with molecular docking technology to preliminarily explore the mechanism of action of Wensan tincture transdermal delivery treatment technology in controlling lung nodule growth,reducing lung cancer risk,and halting the progression of nodule transformation.Objective1.To evaluate the clinical efficacy of Wensan tincture in the treatment of lung nodules based on TCM real-world data.2.To explore the material basis and potential pharmacological mechanisms of action of Wensan tincture for transdermal delivery in the treatment of lung nodules based on network pharmacology.Methods1.A retrospective cohort study of transdermal delivery of Wensan tincture for the treatment of lung nodulesThis study is a single center,retrospective cohort real-world study based on clinical data of pulmonary nodules using a whole sample design in a real-world study mode,with statistical analysis of clinical and follow-up data of patients with pulmonary nodules,and with propensity score matching to handle confounders between groups.The study data were obtained from the his database of the tertiary a hospital of Guang’anmen Hospital,Chinese Academy of Chinese Medical Sciences(CAS),and extracted 2019.01-2022.04 outpatient medical record data of pulmonary nodules,including basic information(sex,age,smoking history,family history of cancer,etc.),clinical diagnosis,imaging examination(chest CT),prescription information,etc.The observation subjects who met the criteria of nanoexclusion were divided into exposure and non exposure groups according to whether they had a record of warm dispersed tincture medication or a history of warm dispersed tincture medication.The exposure definition refers to those who received a transdermal topical treatment with Wensan tincture and had ≥ 8 treatment sessions;The non exposed group refers to those who did not receive transdermal topical treatment with Wensan tincture.Both exposed and non exposed groups were treated with traditional Chinese medicine,and the treatment of Western Medicine(such as anti infection or surgery)and the treatment of underlying diseases were not defined.Detailed records of relevant medication use and adverse effects were required during the study.The primary outcome measure of the study was lung nodule size change in chest CT,and the secondary outcome measures were occurrence of surgery,type of adverse events after medication,and occurrence of adverse events.Statistical methods were performed by propensity score matching(PSM)matching according to a 1:1 genetic matching method to balance confounders,and differences between groups were tested before and after propensity score matching.Lung nodule progression and efficacy differences between the two groups were analyzed to evaluate the role of Wensan tincture transdermal delivery therapy as an exposure factor during the treatment of lung nodules.2.To investigate the molecular mechanism of Wensan tincture transdermal delivery for the treatment of lung nodules based on network pharmacologyUsing network pharmacology,active ingredients contained in Wensan tincture were screened out,the ingredient targets of Wensan tincture collected from databases such as tcmsp and swisstargetprediction were searched through databases such as genecards to obtain the intersection of drug prediction targets and disease targets.The active ingredient target network diagram was further drawn to construct a protein interaction network(PPI),and the key target network diagram was obtained before go function and KEGG pathway enrichment analysis.Finally,the potential active ingredients and targets of Wensan tincture in the treatment of lung nodules were predicted,and the targets and component structures were retrieved in databases such as PDB for molecular docking validation.Results1.A retrospective cohort study of transdermal delivery of Wensan tincture for the treatment of lung nodules(1)During the follow-up of 1315 lung nodules,121 lung nodules appeared to shrink or disappear,128 lung nodules appeared to increase in different degrees,and 1006 lung nodules remained stable.The percentage of lung nodules that shrunk,grew,and were unchanged under TCM intervention was 9.2%,9.7%,and 76.5%,respectively.(2)After matching,the ratios of decreased,increased,and unchanged lung nodules were 21.97%,6.23%,71.80%,respectively,in 305 patients in the exposed group and 17.70%,20.66%,61.64%,respectively,in 305 patients in the non exposed group.Compared with the non exposed group,the lung nodule growth rate significantly decreased after treatment in the exposed group,and the difference was statistically significant(P<0.001).(3)When stratified by nodule size,in cases with nodule size≤8 mm,the lung nodule growth rate was 5.58%in the exposed group,which was significantly lower than 24.87%in the non exposed group(P<0.001).2.To investigate the molecular mechanism of Wensan tincture transdermal delivery for the treatment of lung nodules based on network pharmacology(1)Active ingredients and action targets of Wensan tincture:screening the eligible active ingredients in Wensan tincture yielded 14 Strychnos nux vomica,3 Chuanwu,7 Tianxing radix,7 Weilingxian,9 live alone,15 Turkish Poria cocos,7 Chuanxiong Rhizoma,2 Angelica sinensis,8 Xixin radix,13 Shengdihuang radix,and a total of 74 active ingredients were obtained after removing duplicates.Among them,62 active ingredients were able to match to the action targets in the database,and their corresponding target proteins were entered into the UniProt database,resulting in a total of 344 active ingredients action targets of Wentong cream after removing ineffective and duplicate targets.(2)Construction of TCM compound active ingredient target network:Cytoscape 3.9.1 software was used to construct the TCM compound active ingredient target network.A total of 415 nodes,904 action relationships were obtained,see Figure 1.The top 5 ranked compounds according to the degree value were:β-Sitosterol,stigmasterol,kaempferol,quercetin,salidroside.(3)Key targets of Wensan tincture in treating lung nodules:a total of 1005 disease-related targets of PN were retrieved through OMIM,genecards,and disgenet databases and intersected with 344 target mapping of active ingredients of Wensan tincture in the treatment of PN,resulting in 102 key targets(common targets)of Wensan tincture in treating PN.(4)PPI network construction:the intersection targets were imported into string,resulting in a PPI network,containing a total of 102 nodes,442 edges,and an average node degree value of 8.67.Where nodes are targets and edges represent inter target interaction relationships.The data were then imported into Cytoscape version 3.9.1 software,and the nodes with degree,betweenness centrality,and closeness centrality greater than or equal to above the mean were used as key targets,resulting in STAT3,Jun,mapk3,mapk1,PIK3R1,hsp90aa1,TP53,and AKT1 as key targets for treatment of lung nodules with Wensan tincture.(5)Go functional enrichment analysis and KEGG pathway analysis results:set P<0.05,go functional enrichment analysis resulted in 951 entries containing 728 biological processes,112 cellular components and 111 molecular functions.KEGG analysis resulted in 163 pathways,the main involved pathways were:cancer,AGE-RAGE,EGFR,PD-L1,HIF-1,TNF,MAPK and other signal pathways.(6)Molecular docking:molecular docking of the key targets in the PPI network with the main active ingredients from Wensan tincture resulted in quercetin exhibiting better binding with mapk3 binding energy of-9.1 kJ/mol.Conclusion1.Treatment with Wensan tincture transdermal delivery can effectively inhibit the growth of lung nodules and delay the progression of lung nodules.2.Treatment with Wensan tincture transdermal delivery was more effective against nodules within 8 mm,and there was a decreasing trend in the risk of progression of lung nodules with increasing number of administrations.3.The main active ingredients that Wensan tincture exerts to treat PN may be βSitosterol,stigmasterol,kaempferol,quercetin,salidroside,etc;The key targets that play a role may be STAT3,Jun,mapk3,mapk1,TP53,PIK3R1,hsp90aa1,AKT1,and others;The main pathways involved include cancer,AGE-RAGE,EGFR,TNF,MAPK,PD-L1,HIF-1 and so on.4.Wensan tincture exerts therapeutic effects through mutual coordination between multi-component,multi-target,and multi signaling pathways,which embodies the advantages of multi-link,multi pathway,and multi mechanism holistic intervention on lung nodules in traditional Chinese medicine.