OSA: Integrative Palliative Management of Canine OSA Patients

This exclusive article is part of the Veterinary Professional Blog Series

This article is the property of Dr. Erin Bannink, October 2020.

Do not distribute without written permission.

Osteosarcoma is one of the most common cancers diagnosed in dogs. Because cures are rare and median survival times with amputation and chemotherapy are one year or less, many of my clients decline conventional treatment and elect palliative care. This used to be one of the most frustrating conditions to treat with herbs. After a lot of research and trial and error, as well as some excellent suggestions, brainstorming and formula modification guidance from Dr. Steve Marsden, we have found an herb combination that is much more reliably effective, at least in my hands, than anything I had in my toolbox previously. Here I'll share information on the integrative protocol that is the foundation for most of my palliative osteosarcoma patients. We will start with results I have seen in my practice to date, then summarize the standard of care conventional medicine options and conclude with published research studies that may help explain the positive results we are seeing in many patients treated with herbal interventions.

I am not accepting any more Teleconsultation requests at this time.

STATISTICS

Following are preliminary survival statistics for patients I have treated in my practice with various integrative protocols and informed consent. Patient data is still maturing. Large studies which are appropriately powered are required to define statistically significant results. For your information I have also included a general summary of published statistics with conventional interventions as well as preliminary statistics for patients treated at my practice with an integrative protocol following amputation.

(MST = median survival time)

Herbal therapies without amputation or radiation +/- zoledronate (11 patients):

Amputation and herbal therapies (7 patients):

Amputation, chemotherapy and herbal therapies (7 patients)

Published Survival statistics

PALLIATIVE OPTIONS FOR CANINE APPENDICULAR OSA

Osteosarcoma (OSA) is the most common primary bone tumor seen in dogs. At the time of diagnosis 90% of patients with osteosarcoma will have microscopic metastasis (spread to distant sites). Other bone tumors such as chondrosarcoma, fibrosarcoma, hemangiosarcoma, synovial cell sarcoma, round cell tumors or metastatic carcinoma, as well as fungal infection, cannot be ruled out without a biopsy or needle aspirate. Prognosis may vary depending on the tumor type and grade.

Amputation

Surgery alone provides an average survival of 4-6 months with <10% living to 1 year. In one report of 15 dogs treated with amputation alone, average survival time was 5.6 months with 47% 6 month survival time and 20% 1 year survival time. 14 of the dogs were euthanized due to progressive osteosarcoma. Another study of 35 dogs showed 11% 1 year survival time for dogs treated with amputation.

Conventional Course Fraction Palliative Radiation

Palliative radiation can be used to control pain associated with the local tumor but is not curative. A study of 95 dogs treated with radiation therapy, either by 8 Gy on days 0,7,21 or 10 Gy on days 0 and 7, showed a 74% response rate. Radiation given to 24 dogs with either appendicular (leg) or axial (jaw, nasal) as once weekly 8 Gy fractions for 4 treatments resulted in a 96% response rate. Median duration of response was 94.5 days for the 15 dogs with appendicular tumors. Combination with chemotherapy, resulted in an average survival of 6.9 months for dogs with no evidence of metastatic disease.

Stereotactic Radiation Followed by Chemotherapy

Stereotactic radiation is a very precise delivery of high dose radiation to the bone tumor. Depending on location, 1-3 consecutive doses of stereotactic radiation are given and general anesthesia is required for each treatment. Acute side effects associated with stereotactic radiation include localized hair loss and mild skin irritation. The most concerning risk with stereotactic radiation, is that between 20-40% of dogs will develop a pathologic fracture in the affected bone within 6 months following treatment. If a pathological fracture develops, amputation is recommended. To help decrease the potential for pathological fracture, a dose of pamidronate or zolendronate is given the week before radiation is planned to help better stabilize and strengthen the bone. The first dose of chemotherapy (carboplatin) is given at the first radiation dose to increase the effectiveness of radiation. 3-4 additional carboplatin doses are recommended after radiation which is given every three weeks. The goal of stereotactic radiation is marked improvement of lameness and return to function without amputation, although, some dogs may require continued pain medications.

Studies have shown that dogs treated with stereotactic radiation followed by chemotherapy have similar survival times compared to dogs with amputation and chemotherapy. In a recent study, stereotactic radiation and chemotherapy resulted in a median survival time of 350 days, compared to 147 days in dogs receiving conventionally planned and delivered hypofractionated radiation.

Bisphosphonates

Pamidronate/Zolendronate (bisphosphonates) are drugs used in humans with metastatic bone cancer. These drugs inhibit pathologic bone resorption without adversely affecting bone mineralization. Pamidronate is given intravenously once every 28 days and has shown subjective improvement in bone pain in 40% of the dogs receiving palliative treatment for osteosarcoma. In addition, 6 of 9 dogs evaluated showed increase in bone density at the primary tumor site. Zolendronate is a newer generation bisphosphonate and binds to the bone in much higher concentrations resulting in 100 times the anti-resorptive potency of pamidronate. Infusion of zolendronate is given over 15 minutes every 28 days. A response rate of 50% with a 4-month duration of response has been reported in dogs with appendicular osteosarcoma. Increased bone density was also documented in these dogs. Long term side effects are rare in dogs, although thorough studies on long term administration have not been published. There is one report of ostenecrosis of the jaw in one dog who received monthly infusions for 43 months. We have seen no long term toxicities in dogs receiving monthly treatments at OVRS to date.

The benefit of Pamidronate/zolendronate therapy in addition to chemotherapy and radiation is unclear. There is at least one study suggesting that survival times may be less in patients receiving Pamidronate with radiation and chemotherapy, but other studies have suggested a survival benefit.

Oral Pain Medications

Pain Medications can be given alone or in combination with any of the palliative options. Survival time with palliative options other than amputation is more variable as it depends on how long pain can be controlled. Each dog’s pain tolerance and their level of comfort at initial consult differs. The most common cause of treatment failure is no longer being able to control pain or development of a pathologic fracture. For most dogs, decline in quality of life due to pain ranges between 1-4 months. Calculated median survival time for patients treated in our practice with oral medications alone was 3 months.

Integrative and Alternative Medicine Treatments: OVRS statistics for Dr. Bannink’s patients

Herbal treatments are usually recommended as additions to more conventional pain control measures (see above). In a clinical trial we recently completed at OVRS, median survival time for 26 patients treated with oral pain medications and an herbal formula developed to address pain and inflammation was about 4 months, compared to 3 months with oral medications alone. While the overall survival times were not statistically better than historical controls (MST 3 months), subjectively patients did not experience the same degree of pain progression that is typically seen with increase in tumor size. Grade of lameness at the time of initiating herbal intervention may prove to be significant in a larger study. Median survival time for the seven patients presenting with grade 0-1 lameness at the time of study enrollment was 5.3 months (159 days; range 10 to over 21 months) compared to MST of 2.8 months (86 days; range 27-134 days) for the five patients presenting with a grade 2-4 lameness.

Following the above single herbal formula clinical trial, 11 dogs have been treated with the study formula along with other herbal formulas and supplements resulting in improved outcomes using a more aggressive multi-formula patient-specific herbal prescribing approach. Median survival time for these patients was 7.5 months (range 58 – 428 days).

There have been no other controlled clinical trials on efficacy of these treatments in dogs. However, clinical experience of safe use and encouraging survivals in patient treated at OVRS with amputation and herbal therapies, either with or without chemotherapy, provide some rationale for this treatment in motivated individuals as the treatment is well tolerated with minimal risk of side effects.

As a maintenance therapy after chemotherapy herbs may work by enhancing immune surveillance for cancer cells and also by inhibiting the blood supply to newly forming cancer masses (anti-angiogenesis) which is a similar mechanism to metronomic chemotherapy protocols which accomplish this with pharmaceuticals. There may be additional mechanisms by which herbs may provide effective palliative effects in osteosarcoma patients. Articles which illustrate some of these potential actions are presented below.

TWO PRIMARY HERBAL FORMULAS FOR USE IN PALLIATING CANINE OSA

My favored palliative approach is to use a combination of conventional and Chinese Medicine interventions. Radiation +/- chemotherapy, Zoledronate, acupuncture, oral analgesic pharmacueticals and herbal interventions are all discussed at an initial patient consultation and a plan formulated to meet the treatment goals of the family. For financial and convenience reasons many of my clients tend to opt for a combination of oral medications, herbs, acupuncture and zoledronate.

Modified Qing Gu San

The custom formula used in my practice, which will be referred to here as “OSA formula” for ease of communication, is an adaptation of the classical TCM formula Qing Gu San. That formula is indicated for treatment of the TCM pattern of “steaming bone pain” due to empty heat. The modified version used in the above mentioned clinical trial contains the following herbs: Anamarrhena asphodeloides (Zhi Mu), Scutellaria baicalensis (Huang Qin), Lithospermum erythrorhixon (Zi Cao), Artemisia annua (Qing Hao), Bupleurum chinensis (Chai Hu), Gentian (Qin Jiao), Scrophularia (Xuan Shen), Coptis (Huang Lian), Schizandra (Wu Wei Zi), Licorice (Gan Cao). The ingredient modifications were selected by Dr. Steve Marsden and I based on published research suggesting potential benefit in either pain management or anti-neoplastic action relevant to canine osteosarcoma tumor biology as well as consideration of Classical Chinese Medicine herb combining principles.

This modified formula was developed with the main goal of improving control of bone pain and thereby survival times in a palliative care setting. The secondary goal was potentially slowing disease progression.

Huo Luo Xiao Ling Dan

Huo Luo Xiao Ling Dan has been useful in my practice to provide longer term pain control for patients with OSA in concert with the custom adaptation of Qing Gu San which I just described. I often use this formulas as an "herbal NSAID" and have found it to be helpful in many patients who cannot receive NSAIDS or for whom avoidance of those types of medications is desired. I have also used this formula safely concurrent with NSAIDs and other oral pain medications.

Huo Luo Xiao Ling Dan, from a TCM perspective, moves blood and relieves Blood stasis. Patients who fit this TCM pattern would have a dark colored tongue and wiry pulse. The formula contains Myrrh (Mo Yao), Frankincense (Ru Xiang), Salvia (Dan Shen) and Angelica (Dang Gui). It is indicated for management of pain. This is a classical formula but can be hard to find. I mix it myself. It is equal parts of each of the four ingredients. A 100g prescription would be 25g of each granular 5:1 extract.

The formula has been evaluated for absorbed compounds and metabolites in rat plasma after oral ingestion and 109 compounds identified. The combination of herbs in this formula, each inhibiting different targets to achieve effect, resulted in an overall alternation in the arachidonic acid metabolic profile related to pain control. No toxicities were seen in rats receiving oral doses as high as 4.6/kg over 14 days or 2.3g/kg over 42 days.

In rats, the serum concentrations of two boswellic acid compounds were significantly higher after oral administration of Huo Luo Xiao Ling Dan compared to administration of Boswellia (Frankincense/Ru Xiang) alone. This is evidence of the beneficial impact of herb combining and illustrates why complex herb combinations can be more effective than single herb treatments.

When pharmacokinetics were evaluated in normal versus arthritic rats, different pharmacokinetics were noted between the two groups. In a rheumatoid arthritis model of rats receiving the formula orally, bone protective properties related to inhibition of osteoclastic bone remodeling and MMP inhibition were observed. The formula contains multiple compounds that show COX inhibition properties. COX-1 selective compounds were Acetyl-11-keto-beta-boswellic acid, beta-boswellic acid, acetyl-alpha-boswellic acid, acetyl-beta-boswellic acid, and betulinic acid. COX-2 selective compounds were Senkyunolide O and cryptotanshinone. And two compounds, roburic acid and phenethyl-trans-ferulate, showed equal inhibition of COX-1 and COX-2.

Given COX inhibition, the question of ulcerogenic potential naturally arises. I have used this formula and NSAID therapy concurrently with no anecdotally noted increase in gastrointestinal ulceration over that which is normally seen with NSAID therapy alone. Boswellia (Frankincense/Ru Xiang) has actually shown to protect from gastric ulceration in a number of rabbits and rat studies. While the exact mechanism for this is unknown, it has been proposed that boswellia’s gastroprotective mechanisms may be related to increases gastric mucosal resistance and local synthesis of cytoprotective prostaglandins, inhibition of leukotriene synthesis or the Nrf2/HO-1 pathway. Additionally, Salvia (Dan shen) protects against gastric ulcer development and Angelica Root (Dang Gui) and Myrrh (Mo Yao) promote gastric ulcer healing.

A randomized, blinded placebo controlled clinical trial in humans evaluating efficacy of this single formula for osteoarthritis knee pain showed no toxicity but also no significant difference between treatment groups and placebo. In the Author’s practice, this formula is not used alone but always along with the “OSA formula” for management of cancer-related bone pain.

ADDITIONAL RESEARCH ON CHINESE HERBS RELATED TO OSTEOSARCOMA AND POTENTIAL MECHANISMS OF ACTION

Epidermal Growth Factor Receptor and OSA progression

Epidermal growth factor receptor (EGFR) is important in the metastatic behavior of osteosarcoma and has been identified as a potential therapeutic target given its role in OSA cell proliferation and frequent over-expression in canine OSA tumor tissue. High EGFR expression, seen in 75% of canine pulmonary metastasis samples studied, was associated with shorter survival time and disease free interval in one study. This high EGFR expression was also seen in the primary tumor tissue in these cases.

Wogonin, isolated from Scutellaria (Huang Qin), dose-dependently inhibited the growth of tumor cells which expressed high levels of EGFR. Gomisin N, isolated from Schisandra, inhibits activation of EGFR, as well as suppresses NF-kB signaling, both of which enhance TNF-alpha induced apoptosis. Berberine, found in a number of TCM herbs (Scutellaria, Coptis, Rhubarb, Bupleurum), suppressed growth of prostate cancer cells in vitro via inhibition of EGFR signaling, leading to apoptosis and cell cycle arrest.

Scutellaria baicalensis (Huang Qin)

Scutellaria is traditionally used in TCM for it’s anti-inflammatory and antineoplastic action. Baicalein, a flavone found in the roots of Scutellaria, was found to effectively induce apoptosis in three canine OSA cell lines and did not interfere with doxorubicin’s anti-proliferative action. In vivo, baicalin retarded growth of human OSA tumors in mice.

Baicalein has exhibited the ability to inhibit the growth, migration, and invasion of OSA cell lines and induce apoptosis of OSA cell lines via numerous pathways including Ezrin, AKT, and TGF- β1 pathways. The compound also generated reactive oxygen species (ROS) in human OSA cell lines, and induced cell apoptosis via suppression of Bcl-2 and activation of caspase-9 and caspase-3.

Wogonin, isolated from Scutellaria, reduced tumor growth and incidence of metastasis, angiogenesis, lymphangiogenesis and the number of Tumor Associated Macrophages (TAM) in vivo in osteosarcoma-bearing mice models. It has shown similar anti-neoplastic and anti-angiogenic activity in other cancer cell lines. Wogonin also demonstrated the ability to increase Reactive Oxygen Species (ROS) in human OSA cells and altering mitochondrial membrane potential in vitro. These effects were time- and dose-dependent. Induction of apoptosis was observed, via increase in activity of Caspase-3. Increase in other pro-apoptotic proteins (Bad, Bax), and decrease levels of anti-apoptotic proteins (Bcl-2) was also observed. Anti-inflammatory action in human OSA cell lines expressing COX-2 was observed with a Wogonin extract in vitro. The extract also decreased edema in vivo in a mouse model of experimentally induced intra-articular swelling.

Coptis japonica (Huang Lian)

Coptis contains coptisine which has been suggested as a safe potential anti-osteosarcoma drug candidate. Coptisine significantly inhibited OSA cell proliferation in vitro, induced cell cycle arrest (G0/G1 phase) and inhibited tumor growth in vivo. Cell migration, invasion and angiogenesis were also inhibited through mechanisms involving decreased STAT3 phosphorylation (activation). Interestingly, coptisine was noted to markedly increase white blood cell, red blood cell and platelet counts while not exceeding the normal range. Columbamine, another active component of Coptis, was found to exert anti-proliferative and anti-angiogenic action in human OSA cell lines. Coptis and its major constituent, berberine, have demonstrated numerous anti-neoplastic actions via cell cycle arrest, induction of apoptosis, anti-angiogenic action, anti-metastatic action and anti-inflammatory action.

Of note, some studies have shown that Coptis had greater anti-neoplastic action than the individual components, potentially due to synergistic activity between berberine and the other compounds naturally found in this plant. Coptis extracts have also shown anti-inflammatory action, both in vivo and in vitro, through decreasing expression of inflammatory cytokines, many of which have been documented to be active in osteosarcoma, including PI3K/Akt.

Lithospermum erythrorhixon (Zi Cao)

Lithospermum contains Shikonin, which has shown anti-inflammatory and anti-neoplastic action in a number of studies. Shikonin was evaluated for it’s anti-inflammatory and anti-neoplastic action in an osteosarcoma cells line. Induction of ROS and cytotoxicity (via decreased Bcl-2 expression) were observed. These phenomena were inhibited by pre-treatment with the antioxidant N-acetyl cysteine.

Shikonin was also has a dose-dependent effect in decreasing cell survival rate in OSA cell lines in vitro. This effect was not related to caspase activation, as is the case with many other herbs, but rather through a pathway involving necroptosis mediated by RIP1 and RIP3. Decreased growth rate and lung metastasis were observe in in vivo studies.

Necroptosis is a regulated form of necrosis which occurs after DNA damage. Because necroptosis is a method of cell death which is independent from apoptosis, the common causes for treatment failure due to derangements in the apoptotic cascade and resistance to apoptosis do not impact susceptibility to Shikonin mechanisms of cell death. This has important implications in overcoming common causes of treatment failure.

Artemisia annua (Qing Hao)

Artesunate, a compound found in Artemisia, showed synergistic activity with allicin, isolated from garlic, in osteosarcoma cell lines in vitro and in vivo. Invasion, motility, and colony formation were reduced. Apoptosis rate was increased via increased caspase-3 and caspase-9 activity in vitro. In vivo, suppression of tumor growth was observed. Dihydroartemisinin was evaluated for it’s anti-neoplastic action in human and canine OSA cell lines. It was noted, in vivo, to prevent OSA development. It demonstrated anti-proliferative and pro-apoptotic action and decreased cell invasion and migration in vitro. An artemisinin extract and capillarisin, an active component of artemisinin, showed pain relieving and anti-inflammatory activity, respectively.

While older studies have evaluated individual compounds isolated from Artemisia, a more recent study from 2019 demonstrated increased anti-OSA cytotoxic potency of the whole plant extract when compared to artemisinin. This finding suggests synergism of the complex phytochemicals within the whole plant. Decreased iron concentration was noted in the treated OSA cells, supporting previous theory that iron chelation plays a role in this plant’s antineoplastic mechanism of action.

Oral administration of iron followed by an oral Artemisia annua extract product to 20 companion animals at a veterinary hospital in Germany in addition to standard of care resulted in a statistically significant increase in the likelihood of living over 18 months compared to standard of care therapy alone.

Artemisinin has demonstrated anti-angiogenic action in OSA cell lines via the p38/MAPK/CREB/TSP-1 pathways in vitro. It also inhibited OSA growth and angiogenesis in vivo through these same pathways. Artemisinin has also shown potential as an anti-resorptive therapy for treatment of osteolytic lesions. This action has been associated with inhibition of NF-κB signaling.

Bupleurum chinensis (Chai Hu)

The immunomodulatory activity of Bupleurum species has been attributed primarily to saikosaponins, which activate phagocytic activity in macrophages, suppress T cell response and increase B cell responses. These effects were largely related to down-regulation of NF-kB signaling which decreases the production of pro-inflammatory cytokines. Its anti-inflammatory action is closely associated with its immunomodulating activity, with saikosaponins (A, C and D) primarily involved in its effects to reduce both acute and chronic inflammatory responses. The anti-inflammatory effects were shown to be observable with oral administration in mouse models.

Compounds found in Bupleurum also show anti-tumor activity in various cancer cell lines including leukemia, melanoma, hepatocellular carcinoma, gastric adenocarcinoma and cervical cancer. Specific to osteosarcoma, Saikosaponin D inhibited proliferation of OSA cell lines, caused cell cycle arrest and induced apoptosis at concentrations of 80 µmol/L.

Five saikosaponins isolated from Bupleurum chinensis show the ability to inhibit osteoclast activity. Saikosaponin A specifically inhibits osteoclastogenesis through a number of pathways including inhibition of NF-κB, has demonstrated the ability to inhibit parathyroid hormone-related protein and invasive behavior in metastatic breast cancer, raising interest for its use in treatment of cancer-related bone loss. These properties of saikosaponins may be relevant to management of palliative care in OSA patients for the same reasons bisphosphonate drugs are useful in controlling bone pain, as it shares this mechanism of action.

NMDA inhibitors are often used as adjunctive therapies in management of OSA related bone pain because of their ability to treat “wind-up syndrome”. Saikosaponin A isolated from Bupleurum chinensis, has been shown to have NMDA-inhibiting activity. Saikosaponin A and Saikosaponin D, major triterpenoids derived from Bupleurum root, demonstrated anti-inflammatory activity related to the ability to inhibit activity of COX-2, nuclear factor-kB (NF-kB), and inducible nitric-oxide (iNOS), resulting in decreased nitric oxide (NO) and prostaglandin E-2 (PGE2) production. Other inflammatory cytokines including Interleukin-6 (IL-6) and Tumor Necrosis Factor-alpha (TNF-a) were

suppressed in a dose-dependent manner by these triterpenoids. These triterpenoids also showed in vivo ability to decrease acute inflammation in a murine model.

Gentian macrophylla (Qin Jiao)

Gentian root contains many anti-inflammatory compounds, justifying its traditional Tibetan and Chinese use to treat conditions such as rheumatoid arthritis, tonsillitis and urticaria. Gentian root contains 20 compounds which individually inhibit COX-1 and COX-2. One compound also inhibits Nitric Oxide production. Gentiopicroside, a compound isolated from gentian species, has anti-inflammatory and analgesic properties in mice, specifically against persistent inflammatory pain stimuli.

Anamarrhena asphodeloides (Zhi Mu)

Anamarsaponin B has anti-inflammatory activity related to COX-2 and iNOS inhibition, reduction of inflammatory cytokines (IL-6, TNF-alpha) and inhibition of NF-kB activation.65 An extract derived from Anamarrhena asphodeloides (root) and Lonicera japonica (flower), showed analgesic and anti-inflammatory activity comparable to celecoxib. Its effects were due to ability to inhibit inflammatory mediators such as NF-kB, PGE2 and NO in vitro. This same extract also showed stronger anti-inflammatory and anti-nociceptive action in vivo than celecoxib, decreasing edema and pain responses in mouse models.

Multiple compounds have recently been identified in Anamarrhena which have shown some anticancer potential in various cancer cell lines. These include glycosides (aneglycoside A-C, timosaponin), steroidal saponins (timosaponin V, timosaponin P, timosaponin Q, timosaponin BIII) and benzophenones. Timosaponin AIII from Anamarrhena is being investigated as an anticancer pharmacological agent. The compound showed synergistic action with ginsenosides against OSA cells.

Anamarrhena extract inhibited osteoclastogenesis so may be beneficial in inhibiting cancer-related bone resorption.

Scrophularia ningpoensis (Xuan Shen)

The main constituents are vanillin, eugenol, isoeugenol methyl ether, ferulic acid, benzoic acid, syringic acid, rhamnopyranosyl vanilloyl, syringic acid-4-O-alpha-L-rhamnopyr-anoside, beta-sitosterol, adenosine, and dibutyl phthalate. Eugenol exhibits anti-inflammatory and analgesic effects. It’s analgesic activity is related to GABA receptor blockade. It is effective at controlling neuropathic pain in mice. Vanillin exerts anti-nociceptive effects in mice, likely involving alpha 2-adrenergic and opioid receptor activity.

Schisandra chinensis (Wu Wei Zi)

Corosolic acid, found in many medicinal herbs including Schisandra, showed dose- and time-dependent anti-neoplastic action in OSA cell lines. The following mechanisms of action were identified: activation of caspases 3 and 9 (inducers of apoptosis). Schisandra was shown to have analgesic action in vivo. Schisandra has anti-inflammatory action related to it’s inhibition of TNF-α, and attenuation of NF-κβ activity through suppression of MAPK activity.

Epimedium (Yin Yang Huo)

Icaratin, one of the compounds with anti-neoplastic action found in Epimedium, had dose-dependent anti-proliferative action and time-dependent pro-apoptotic action in human OSA cell lines. It also decreased cell motility.

Epimedium is found in formulas such as Er Xian Tang and Zan Yu Dan which have TCM actions to warm and tonify Yang.

Panax Ginseng (Ren Shen)

Ginsenosides from Panax Ginseng have been shown in hundreds of studies to exert anti-neoplastic action on various cell lines via numerous pathways. A few studies have been published evaluating their anti-neoplastic action against OSA specifically. Ginsenoside Rb3, one of the main active constituents in Panax Ginseng, showed dose-dependent cytotoxic action against four human OSA cell lines in vitro. Ginsenoside Rf induced cell cycle arrest and apoptosis, via activation of caspase-3 and caspase-9, in a dose-dependent manner in human OSA cell lines.

Panax ginseng is a common ingredient in many TCM formulas. Formulas which include Panax Ginseng which are commonly used in the authors practice in management of cancer include: Bu Zhong Yi Qi Tang, Chai Hu Jia Long Gu Mu Li Tang, Gui Pi Tang, and Xiao Chai Hu Tang.

Sophora flavencens (Ku Shen)

Oxymatrine, a quinolizidine alkaloid isolated from Sophora, has been reported to have anti-neoplastic action in numerous studies. Specific to OSA, this compound inhibited PI3K/Akt signaling which has been identified as an important mechanism in OSA progression as discussed earlier. It promoted apoptosis through downregulation of Bcl-2 (anti-apoptotic) and upregulation of BAX (pro-apoptotic). In vitro, it suppressed tumor growth in mice models.

Salvia miltiorrhiza (Dan Shen)

Tanshinone II, found in Salvia, is effective against inflammatory and neuropathic cancer-induced bone pain. It also demonstrated antineoplastic action in OSA cells through induction of mitochondrial dysfunction and subsequent triggering of apoptotic pathways as well as anti-angiogenic action.

Salvia, in TCM, is indicated for treatment of the TCM imbalances of Blood Stasis, Heat, and Blood deficiency. It is used to treat conditions such as pain, palpitations, and swelling. It is included in the following TCM formula Huo Luo Xiao Ling Dan which may be useful in management of patients with OSA. Huo Luo Xiao Ling Dan moves blood and relieves Blood stasis. Tongue Dark. Pulse wiry. It contains Myrrh (Mo Yao), Frankincense (Ru Xiang), Salvia (Dan Shen) and Angelica (Dang Gui). It is indicated for management of pain.

REFERENCES:

Conventional Oncology Treatments

Green EM, Adams WM, Forrest LJ. Four fraction palliative radiotherapy for osteosarcoma in 24 dogs. J Am Anim Hosp Assoc. 2002;38(5):445-51.

Pagano C, Boudreaux B, Shiomitsu K. Safety and toxicity of an accelerated coursely fractionated radiation protool for treatment of appendicular osteosarcoma in 14 dogs: 10Gy x 2 fractions. Vet Radiol Ultrasound. 2016;57(5):551-6.

Kubicek L, Vanderhart D, Wirth K, et al. Association between computed tomographic characteristics and fractures following stereotactic radiosurgery in dogs with appendicular osteosarcoma. Vet Radiol Ultrasound. 2016;57(3):321-30.

Walter CU, Dernell WS, LaRue SM, et al. Curative-intent radiation therapy as a treatment modality for appendicular and axial osteosarcoma: a preliminary retrospective evaluation of 14 dogs with the disease. Vet Comp Oncol. 2005;3(1):1-7.

Nolan MW, Green NA, DiVito EM, et al. Impact of radiation dose and pre-treatment pain levels on survival in dogs undergoing radiotherapy with or without chemotherapy for presumed extremity osteosarcoma. Vet Comp Oncol. 2020 Feb 11. doi: 10.1111/vco.12576. Epub ahead of print. PMID: 32048435.

Oblak ML, Boston SE, Higginson G, et al. The impact of pamidronate and chemotherapy on survival times in dogs with appendicular primary bone tumors treated with palliative radiation therapy. Vet Surg. 2012;41(3):430-5.

Fan TM1, de Lorimier LP, O'Dell-Anderson K, et al. Single-agent pamidronate for palliative therapy of canine appendicular osteosarcoma bone pain. Vet Intern Med. 2007;21(3):431-9.

Fan TM, de Lorimier LP, Charney SC, et al. Evaluation of intravenous pamidronate administration in 33 cancer-bearing dogs with primary or secondary bone involvement. J Vet Intern Med. 2005;19(1):74-80.

Oblak ML, Boston SE, Higginson G, et al. The impact of pamidronate and chemotherapy on survival times in dogs with appendicular primary bone tumors treated with palliative radiation therapy. Vet Surg. 2012;41(3):430-5.

Fan TM, Charney SC, de Lorimier LP, et al. Double-blind placebo-controlled trial of adjuvant pamidronate with palliative radiotherapy and intravenous doxorubicin for canine appendicular osteosarcoma bone pain. J Vet Intern Med. 2009;23(1):152-60.

Fan TM, de Lorimier LP, Garrett LD, et al. The bone biologic effects of zoledronate in healthy dogs and dogs with malignant osteolysis. J Vet Intern Med. 22. 2008;22:380-387.

Huo Luo Xiao Ling Dan

Wang XF, Wang J. Icaritin suppresses the proliferation of human osteosarcoma cells in vitro by increasing apoptosis and decreasing MMP expression. Acta Pharmacol Sin. 2014;35(4):531-9

Zhang YH, Li HD, Li B, et al. Ginsenoside Rg3 induces DNA damage in human osteosarcoma cells and reduces MNNG-induced DNA damage and apoptosis in normal human cells. Oncol Rep. 2014;31(2):919-25.

Shangguan WJ, Li H, Zhang YH. Induction of G2/M phase cell cycle arrest and apoptosis by ginsenoside Rf in human osteosarcoma MG‑63 cells through the mitochondrial pathway. Oncol Rep. 2014;31(1):305-13.

Wang N, Zhao X, Li Y, et al. Identification of the absorbed components and metabolites of modified Huo Luo Xiao Ling Dan in rat plasma by UHPLC-Q-TOF/MS/MS. Biomed Chromatogr. 2018;32(6):e4195.

Wang N, Zhao X, Huai J, et al. Arachidonic acid metabonomics study for understanding therapeutic mechanism of Huo Luo Xiao Ling Dan on rat model of rheumatoid arthritis. J Ethnopharmacol. 2018;217:205–211.

Fan AY, Lao L, Zhang RX, Zhou AN, Berman BM. Preclinical safety evaluation of the aqueous acetone extract of Chinese herbal formula Modified Huo Luo Xiao Ling Dan. Zhong Xi Yi Jie He Xue Bao. 2010;8(5):438–447.

Wang H, Zhang C, Wu Y, Ai Y, Lee DY, Dai R. Comparative pharmacokinetic study of two boswellic acids in normal and arthritic rat plasma after oral administration of Boswellia serrata extract or Huo Luo Xiao Ling Dan by LC-MS. Biomed Chromatogr. 2014;28(10):1402–1408.

Ma W, Peng Y, Wang W, et al. Pharmacokinetic comparison of five tanshinones in normal and arthritic rats after oral administration of Huo Luo Xiao Ling Dan or its single herb extract by UPLC-MS/MS. Biomed Chromatogr. 2016;30(10):1573–1581.

Ma W, Wang W, Peng Y, et al. Ultra-high performance liquid chromatography with tandem mass spectrometry method for the simultaneous quantitation of five phthalides in rat plasma: Application to a comparative pharmacokinetic study of Huo Luo Xiao Ling Dan and herb-pair extract. J Sep Sci. 2016;39(11):2057–2067.

Nanjundaiah SM, Lee DY, Berman BM, Moudgil KD. Chinese Herbal Formula Huo-Luo-Xiao-Ling Dan Protects against Bone Damage in Adjuvant Arthritis by Modulating the Mediators of Bone Remodeling. Evid Based Complement Alternat Med. 2013;2013:429606.

Cao H, Yu R, Choi Y, et al. Discovery of cyclooxygenase inhibitors from medicinal plants used to treat inflammation. Pharmacol Res. 2010;61(6):519–524.

Yusif RM, Abu Hashim II, Mohamed EA, Badria FA. Gastroretentive Matrix Tablets of Boswellia Oleogum Resin: Preparation, Optimization, In Vitro Evaluation, and Cytoprotective Effect on Indomethacin-Induced Gastric Ulcer in Rabbits. AAPS PharmSciTech. 2016;17(2):328–338.

Singh S, Khajuria A, Taneja SC, et al. The gastric ulcer protective effect of boswellic acids, a leukotriene inhibitor from Boswellia serrata, in rats. Phytomedicine. 2008;15(6-7):408–415.

Zhang Y, Jia J, Ding Y, et al. Alpha-boswellic acid protects against ethanol-induced gastric injury in rats: involvement of nuclear factor erythroid-2-related factor 2/heme oxygenase-1 pathway. J Pharm Pharmacol. 2016;68(4):514–522.

Wang GZ, Ru X, Ding LH, Li HQ. Short term effect of Salvia miltiorrhiza in treating rat acetic acid chronic gastric ulcer and long term effect in preventing recurrence. World J Gastroenterol. 1998;4(2):169–170.

Mayer B, Baggio CH, Freitas CS, et al. Gastroprotective constituents of Salvia officinalis L. Fitoterapia. 2009;80(7):421–426.

Murakami S, Kijima H, Isobe Y, et al. Effect of salvianolic acid A, a depside from roots of Salvia miltiorrhiza, on gastric H+,K(+)-ATPase. Planta Med. 1990;56(4):360–363.

Ye YN, So HL, Liu ES, Shin VY, Cho CH. Effect of polysaccharides from Angelica sinensis on gastric ulcer healing. Life Sci. 2003;72(8):925–932.

Wang J, Zhu L, Zou K, et al. The anti-ulcer activities of bisabolangelone from Angelica polymorpha. J Ethnopharmacol. 2009;123(2):343–346.

Ye YN, Koo MW, Li Y, Matsui H, Cho CH. Angelica sinensis modulates migration and proliferation of gastric epithelial cells. Life Sci. 2001;68(8):961–968.

al-Harbi MM, Qureshi S, Raza M, Ahmed MM, Afzal M, Shah AH. Gastric antiulcer and cytoprotective effect of Commiphora molmol in rats. J Ethnopharmacol. 1997;55(2):141–150.

Haffor AS. Effect of myrrh (Commiphora molmol) on leukocyte levels before and during healing from gastric ulcer or skin injury. J Immunotoxicol. 2010;7(1):68–75.

"OSA Formula"

Helmerick EC, Loftus JP, Wakshlag JJ. The effects of baicalein on canine osteosarcoma cell proliferation and death. Vet Comp Oncol. 2014 Dec;12(4):299-309. doi: 10.1111/vco.12013. Epub 2012 Dec 10. PubMed [citation]PMID: 23228048

Liu Y, Hong Z, Chen P, et al. Baicalin inhibits growth and induces apoptosis of human osteosarcoma cells by suppressing the AKT pathway. Oncol Lett. 2019;18(3):3188–3194.

Wang Y, Wang H, Zhou R, et al. Baicalin Inhibits Human Osteosarcoma Cells Invasion, Metastasis, and Anoikis Resistance by Suppressing the Transforming Growth factor-β1-induced Epithelial-To-Mesenchymal Transition. Anticancer Drugs. 2017;28(6), 581-587.

Zhang J, Yang W, Zhou Y, et al. Baicalein inhibits osteosarcoma cell proliferation and invasion through the miR 183/Ezrin pathway. Mol Med Rep. Jul 2018;18(1),1104-1112.

Wan D, Ouyang H. Baicalin induces apoptosis in human osteosarcoma cell through ROS-mediated mitochondrial pathway. Nat Prod Res. 2018;32(16),1996-2000.

Kimura Y, Sumiyoshi M. Anti-tumor and anti-metastatic actions of wogonin isolated from Scutellaria baicalensis roots through anti-lymphangiogenesis. Phytomedicine. 2013 Feb 15;20(3-4):328-36. doi: 10.1016/j.phymed.2012.10.016. Epub 2012 Dec 6. PubMed [citation]PMID: 23219337

Lin CC, Kuo CL, Lee MH, et al. Wogonin triggers apoptosis in human osteosarcoma U-2 OS cells through the endoplasmic reticulum stress, mitochondrial dysfunction and caspase-3-dependent signaling pathways. Int J Oncol. 2011 Jul;39(1):217-24. doi: 10.3892/ijo.2011.1027. Epub 2011 May 3. PubMed [citation]PMID: 21573491

Chang IC, Huang YJ, Chiang TI, et al. Shikonin induces apoptosis through reactive oxygen species/extracellular signal-regulated kinase pathway in osteosarcoma cells. Biol Pharm Bull. 2010;33(5):816-24. PubMed [citation]PMID: 20460760

Isani G, Bertocchi M, Andreani G, et al. Cytotoxic Effects of Artemisia annua L. and Pure Artemisinin on the D-17 Canine Osteosarcoma Cell Line. Oxid Med Cell Longev. 2019;2019:1615758.

Saeed MEM, Breuer E, Hegazy MF, Efferth T. Retrospective study of small pet tumors treated with Artemisia annua and iron. Int J Oncol. 2020;56(1):123–138.

Li Z , Ding X, Wu H. et al. Artemisinin Inhibits Angiogenesis by Regulating p38 MAPK/CREB/TSP-1 Signaling Pathway in Osteosarcoma. J Cell Biochem 2019 Feb 11[Online ahead of print]

Cheng-Ming Wei C, Liu Q, Song F, et al. Artesunate Inhibits RANKL-induced Osteoclastogenesis and Bone Resorption in Vitro and Prevents LPS-induced Bone Loss in Vivo. Cell Physiol. 2018. 233(1),476-485

Meschini S, Marra M, Calcabrini A, et al. Voacamine, a bisindolic alkaloid from Peschiera fuchsiaefolia, enhances the cytotoxic effect of doxorubicin on multidrug-resistant tumor cells. Int J Oncol. 2003 Dec;23(6):1505-13. PubMed [citation]PMID: 14612920

Zhao L, Li J, Sun ZB, Sun C, Yu ZH, Guo X. Saikosaponin D inhibits proliferation of human osteosarcoma cells via the p53 signaling pathway. Exp Ther Med. 2019;17(1):488–494.

Gao T, Zhao P, Yu X, Cao S, Zhang B, Dai M. Use of Saikosaponin D and JNK inhibitor SP600125, alone or in combination, inhibits malignant properties of human osteosarcoma U2 cells. Am J Transl Res. 2019;11(4):2070–2080. Published 2019 Apr 15.

Yu JQ, Deng AJ, Wu LQ, et al. Osteoclast-inhibiting saikosaponin derivatives from Bupleurum chinense. Fitoterapia. 2013;85:101-8.

Zhou C, Liu W, He W, Wang H, Chen Q, Song H. Saikosaponin a inhibits RANKL-induced osteoclastogenesis by suppressing NF-κB and MAPK pathways. Int Immunopharmacol. 2015;25(1):49–54.

Shin JE, Kim HJ, Kim KR, et al. Type I saikosaponins a and d inhibit osteoclastogenesis in bone marrow-derived macrophages and osteolytic activity of metastatic breast cancer cells. Evid Based Complement Alternat Med. 2015;2015:582437.

Ye C, Han N, Teng F, et al. Extraction optimization of polysaccharides of Schisandrae Fructus and evaluation of their analgesic activity. Int J Biol Macromol. 2013 Jun;57:291-6. doi: 10.1016/j.ijbiomac.2013.03.025. Epub 2013 Mar 16. PubMed [citation]PMID: 23511049

Kim KS, Choi HM, Yang HI, Yoo MC. WIN-34B May Have Analgesic and Anti-Inflammatory Effects by Reducing the Production of Pro-Inflammatory Mediators in Cells via Inhibition of IκB Signaling Pathways. Biomol Ther (Seoul). 2012 Jan;20(1):50-6. doi: 10.4062/biomolther.2012.20.1.050. PubMed [citation]PMID: 24116274 PMCID: PMC3792201

Kang M, Jung I, Hur J, et al. The analgesic and anti-inflammatory effect of WIN-34B, a new herbal formula for osteoarthritis composed of Lonicera japonica Thunb and Anemarrhena asphodeloides BUNGE in vivo. J Ethnopharmacol. 2010 Sep 15;131(2):485-96. doi: 10.1016/j.jep.2010.07.025. Epub 2010 Jul 17. PubMed [citation]PMID: 20643199

Sun XH, Zhu FT, Zhang YW, et al. Two new steroidal saponins isolated from Anemarrhena asphodeloides. Chin J Nat Med. 2017;15(3):220–224.

Yang BY, Bi XY, Liu Y, et al. Four New Glycosides from the Rhizoma of Anemarrhena asphodeloides. Molecules. 2017;22(11):1995.

Zhao YF, Zhou J, Zhang MJ, Zhang M, Huang XF. Cytotoxic steroidal saponins from the rhizome of Anemarrhena asphodeloides [published online ahead of print, 2019 Dec 20]. Steroids. 2019;155:108557.

Wu DL, Liao ZD, Chen FF, et al. Benzophenones from Anemarrhena asphodeloides Bge. Exhibit Anticancer Activity in HepG2 Cells via the NF-κB Signaling Pathway. Molecules. 2019;24(12):2246. Published 2019 Jun 15.

Liao ZD, Chen FF, Xu FQ, et al. One new benzophenone and one new 1,3-diphenylpropane from the fibrous roots of Anemarrhena asphodeloides Bge. and their cytotoxicity [published online ahead of print, 2019 May 14]. Nat Prod Res. 2019;1–7. doi:10.1080/14786419.2019.1607856

Han FY, Song XY, Chen JJ, et al. Timosaponin AIII: A novel potential anti-tumor compound from Anemarrhena asphodeloides. Steroids. 2018;140:125–130.

Jung O, Lee SY. Synergistic anticancer effects of timosaponin AIII and ginsenosides in MG63 human osteosarcoma cells. J Ginseng Res. 2019;43(3):488–495.

Chen L, Liu JC, Zhang XN, et al. Down-regulation of NR2B receptors partially contributes to analgesic effects of Gentiopicroside in persistent inflammatory pain. Neuropharmacology. 2008 Jun;54(8):1175-81. doi: 10.1016/j.neuropharm.2008.03.007. Epub 2008 Mar 25. PubMed [citation]PMID: 18410946

Yamaguchi M, Vikulina T, Arbiser JL, et al. Suppression of NF-κB activation by gentian violet promotes osteoblastogenesis and suppresses osteoclastogenesis. Curr Mol Med. 2014;14(6):783-92. PubMed [citation]PMID: 25056540 PMCID: PMC4422508

Bao M, Cao Z, Yu D, et al. Columbamine suppresses the proliferation and neovascularization of metastatic osteosarcoma U2OS cells with low cytotoxicity.Toxicol Lett. 2012 Dec 17;215(3):174-80. doi: 10.1016/j.toxlet.2012.10.015. Epub 2012 Nov 2.