Figure 1 An overview of the TIMER microbiota–host

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Figure 1 An overview of the TIMER microbiota–host interactions that modulate chemotherapy efficacy and toxicity Figure 1 | An overview of the TIMER microbiota–host interactions that modulate chemotherapy efficacy and toxicity. Chemotherapeutics can exert their influence through multiple pathways, which are outlined here. Translocation: cyclophosphamide can cause shortening of the intestinal villi and damage to the mucosal barrier, permitting commensal microorganisms to cross the intestinal barrier and enter secondary lymphoid organs. Immunomodulation: intestinal microbiota facilitate a plethora of chemotherapy-induced immune and inflammatory responses. For example, Lactobacillus and segmented filamentous bacteria mediate the accumulation of type 17 T helper (TH17) cell and type 1 T helper (TH1) cell responses26. Bifidobacteria also modify tumour-specific T-cell induction and increase T-cell numbers in the tumour microenvironment in patients treated with anti-PD-L1 immunomodulator. Metabolism and enzymatic degradation: direct and indirect bacterial modification of pharmaceuticals might potentiate desirable effects, abrogate efficacy or liberate toxic compounds. The microbiota harbour a large suite of indirect metabolic processes (such as reduction, hydrolysis, dehydroxylation, dealkylation, etc.) which could be used for drug metabolism. These secondary metabolites are secreted into the circulation and excreted by the kidney, which might in turn cause toxicity. Gut bacteria possess β-glucuronidases that cleave the glucuronide from the inactive metabolite of irinotecan (SN-38G), releasing active metabolite (SN-38) in the gut causing diarrhoea. Reduced diversity: chemotherapy induces changes in the diversity of the mucosal and faecal microbiota through altered biliary excretion and secondary metabolism or associated antibiotic use and dietary modifications. As a result, pathobionts might predominate, leading to deleterious effects such as diarrhoea and colitis. PRR, pattern-recognition receptor; TAMC, tumour-associated myeloid cell; TLR, Toll-like receptor; Treg cell, regulatory T cell. Alexander, J. L. et al. (2017) Gut microbiota modulation of chemotherapy efficacy and toxicity Nat. Rev. Gastroenterol. Hepatol. doi:10.1038/nrgastro.2017.20