Novel Use of Bromelain and Acetylcysteine (BromAc®) for Pleural Involvement in Pseudomyxoma Peritonei

Abstract

Pseudomyxoma peritonei (PMP) is a rare mucinous disease most commonly arising from the appendix. Pleural involvement arising from established PMP is seen in a small number of cases. Combined cytoreductive surgery and hyperthermic intrathoracic chemotherapy is the treatment of choice when managing intra-thoracic PMP. In cases of recurrence, surgical intervention may be technically challenging and carry higher rates of complications, morbidity, and mortality. Bromelain and acetylcysteine (BromAc<sup>®</sup>) is a novel treatment modality that has demonstrated mucolytic properties. When injected directly into mucinous disease, it facilitates tumour dissolution and allows it to be aspirated. It has recently been tested in the treatment of inoperable peritoneal mucinous disease, with an acceptable safety profile and positive objective response. Here we describe the first two cases of BromAc<sup>®</sup> administered directly into pleural adenomucinosis, with striking differences in response between the two patients likely due to differences in tumour hardness.

Anticancer properties of bromelain: State-of-the-art and recent trends

“…Tumors with soft or intermediate textures are more susceptible to the drug's action. In the first two cases reported, effectively, large response differences were reported, possibly due to the tumor consistency (Lam et al, 2021). The safety profile was however good as also the objective response.…”

“…The anti-cancer properties of bromelain, in combination with N-acetylcysteine, were used also to produce a new drug (BromAc ® ) which has been recently proved effective in the recurrent thoracic pseudomyxoma peritonei (PMP) treatment ( 154 ). According to the bromelain-based mucus-disrupting activity (see above), the mucolytic properties of BromAc ® help the tumor dissolution when it was injected directly into mucinous disease.…”

Implications of nasal delivery of bromelain on its pharmacokinetics, tissue distribution and pharmacodynamic profile—A preclinical study

“…Bromelain, a complex mixture of proteolytic cysteine proteases obtained from stem of pineapple (Ananas comosus) is a food supplement exhibiting a variety of pharmacological activities. Various studies substantiate the bromelain's mucolytic [13], wound healing [14], fibrinolytic [15], antiedematous [16], antithrombotic [17], anti-inflammatory [18], antioxidant [19], anticancer [20] as well as immunomodulatory activity [21]. Bromelain significantly decreases COX-2 and PGE-2 expression and lower the cytokines (IL-1β, IL-6 and TNF-α) secretion from immune cells in inflammatory conditions [22,23].…”

Bromelain: A Potent Phytomedicine

“…Ghensi et al [55] concluded from their study that dexamethasone sodium phosphate (20 ng/mL) when added to bromelain (20 ng/mL) activated a greater number of mesenchymal stem cells, resulting in increased hyaluronan and collagen synthesis as well as the release of anti-inflammatory cytokines. Lam et al [56] found that bromelain and acetylcysteine (BromAc) is a newer therapeutic medication that has been shown to have mucolytic characteristics. It aids tumor dissociation and enables for swallowing when injected directly into mucinous illness.…”