Pilot Quasi-Randomized Controlled Study of Herbal Medicine Hochuekkito as an Adjunct to Conventional Treatment for Progressed Pulmonary <i>Mycobacterium avium</i> Complex Disease

<div><p>Introduction</p><p>Hochuekkito, a traditional herbal medicine, is occasionally prescribed in Japan to treat patients with a poor general condition. We aimed to examine whether this medicine was beneficial and tolerable for patients with progressed pulmonary <i>Mycobacterium avium</i> complex (MAC) disease.</p><p>Methods</p><p>This pilot open-label quasi-randomized controlled trial enrolled 18 patients with progressed pulmonary MAC disease who had initiated antimycobacterial treatment over one year ago but were persistently culture-positive or intolerant. All patients continued their baseline treatment regimens with (n = 9) or without (n = 9) oral Hochuekkito for 24 weeks.</p><p>Results</p><p>Baseline characteristics were generally similar between the groups. Most patients were elderly (median age 70 years), female, had a low body mass index (<20 kg/m²), and a long-term disease duration (median approximately 8 years). After the 24-week treatment period, no patient achieved sputum conversion. Although the number of colonies in sputum tended to increase in the control group, it generally remained stable in the Hochuekkito group. Radiological disease control was frequently observed in the Hochuekkito group than the control group (8/9 vs. 3/9; p = 0.05). Patients in the Hochuekkito group tended to experience increase in body weight and serum albumin level compared with those in the control group (median body weight change: +0.4 kg vs. −0.8 kg; median albumin change: +0.2 g/dl vs. ±0.0 g/dl). No severe adverse events occurred.</p><p>Conclusions</p><p>Hochuekkito could be an effective, feasible adjunct to conventional therapy for patients with progressed pulmonary MAC disease. Future study is needed to explore this possibility.</p><p>Trial Registration</p><p>UMIN Clinical Trials Registry <a href="https://upload.umin.ac.jp/cgi-open-bin/ctr/ctr.cgi?function=brows&action=brows&type=summary&recptno=R000011622&language=E" target="_blank">UMIN000009920</a></p></div

Comparison of secondary endpoints between the Hochuekkito and control groups over the 24-week treatment period.

<p>CAT  =  chronic obstructive pulmonary disease assessment test; BW  =  body weight; ALB  =  albumin; CRP  =  C-reactive protein; ESR  =  erythrocyte segmentation rate.</p><p>*Chronic obstructive pulmonary disease assessment test score ranging from 0 to 40. A higher score means more severe symptoms <a href="http://www.plosone.org/article/info:doi/10.1371/journal.pone.0104411#pone.0104411-Jones1" target="_blank">[11]</a>.</p

Comparison of treatment status at the time of registration between patients in the Hochuekkito and control groups.

<p>Data are expressed as number of patients.</p><p>RFP  =  rifampicin (10 mg/kg/day); EB  =  ethambutol (15 mg/kg/day); CAM  =  clarithromycin (15–20 mg/kg/day); LVFX  =  levofloxacin (10 mg/kg/day).</p><p>*Aminoglycosides (Kanamycin or Streptomycin: 15 mg/kg two/three times per a week) and/or fluoroquinolones.</p>†<p>Minimum inhibitory concentration to CAM >32 µg/ml by the broth microdilution method.</p

Comparison of baseline characteristics in the Hochuekkito and control groups.

<p>Data are expressed as the number of patients or median (with observed range: minimum, maximum). All p values are for comparisons between the two groups and were obtained by Fisher's exact test, Pearson's test, or Mann-Whitney U test as appropriate.</p><p>BMI  =  body mass index; CRP  =  C-reactive protein; ESR  =  erythrocyte segmentation rate; CAT  =  chronic obstructive pulmonary disease assessment test.</p><p>*Semi-quantitative scoring system: 0 (no colonies), 1 (1–9 colonies), 2 (10–49 colonies), 3 (50–99 colonies), 4 (100–199 colonies), 5 (200–299 colonies), 6 (300–399 colonies), 7 (400–499 colonies), and 8 (≥500 colonies).</p>†<p>Chronic obstructive pulmonary disease assessment test score ranging from 0 to 40. A higher score means more severe symptoms <a href="http://www.plosone.org/article/info:doi/10.1371/journal.pone.0104411#pone.0104411-Jones1" target="_blank">[11]</a>.</p

Changes in sputum findings over the 24-week treatment period.

<p>The number of MAC colonies in the sputum cultures of patients in the Hochuekkito (a) and control (b) groups. All p values were determined by using Wilcoxon signed-rank test. MAC  =  <i>Mycobacterium avium</i> complex. *Semi-quantitative scoring system: 0 (no colonies), 1 (1–9 colonies), 2 (10–49 colonies), 3 (50–99 colonies), 4 (100–199 colonies), 5 (200–299 colonies), 6 (300–399 colonies), 7 (400–499 colonies), and 8 (≥500 colonies).</p

Changes in radiological findings over the 24-week treatment period.

<p>Radiological assessment was performed by comparing chest X-ray images before and after treatment.</p

Difference in types of <i>EGFR</i> mutations between tumors with mPAP and without mPAP element.

<p>Difference in types of <i>EGFR</i> mutations between tumors with mPAP and without mPAP element.</p

Representative appearances of the major histological subtypes of lung adenocarcinoma (hematoxylin and eosin stain, ×200).

<p>A, The lepidic subtype is characterized by the extension of neoplastic cells along the surface of the alveolar walls; B, The acinar subtype is characterized by tubular or glandular structures invading a fibrous stroma; C, The papillary subtype is characterized by the extension of neoplastic cells on the surfaces of fibrovascular cores; D, The micropapillary subtype is characterized by the formation of tufted papillary structures that lack a central fibrovascular core and float in the alveolar space; E, The solid subtype is characterized by the formation of solid nests consisting of neoplastic cells.</p

Clinical characteristics of inoperable lung adenocarcinomas.

<p>Clinical characteristics of inoperable lung adenocarcinomas.</p

Hypothetical schema for histogenesis of the <i>EGFR</i>-mutated and the <i>EGFR</i> wild-type lung adenocarcinomas (LADCs).

<p>In early stages, <i>EGFR</i>-mutated LADC, which may develop from terminal respiratory units (TRU) [<a href="http://www.plosone.org/article/info:doi/10.1371/journal.pone.0166795#pone.0166795.ref022" target="_blank">22</a>], exhibits lepidic patterns consisting of neoplastic cells with hobnail or spheroid morphology. In advanced stages, they progress to form papillary and micropapillary patterns (upper panel). <i>EGFR</i> wild-type LADC, which may develop from the central airway compartment (CAC) [<a href="http://www.plosone.org/article/info:doi/10.1371/journal.pone.0166795#pone.0166795.ref022" target="_blank">22</a>], exhibits a lepidic pattern consisting of neoplastic cells with columnar morphology, and progresses to form acinar and solid patterns (lower panel). Magnification of all photographs is ×200.</p