This study compared E-Ac versus E-Su effect on the development of hepatomegaly and aflatoxin induced hepatocellular carcinomas (HCCs) in Rainbow trout.
E-Ac promotion of HCCs and induction of hepatomegaly:
The elevation of HCC incidence and hepatomegaly caused by increased E-Ac shown in Figures 1 through 3 and Figure 6, respectively in trout are parallel to the down regulation
of the Hippo/Yap pathway signal shown by others that caused hepatomegaly of organs and tumor formation by inhibition of apoptosis, the controlled cell death of aberrant cells. Restriction of the Hippo (Mst1 & Mst2 kinases) signaling path or phosphorylation
of the YAP/TAZ factors has been shown to increase cell growth, organ size and tumor development [24, 25, 26, 27].
One of the main paths of apoptosis is via mitochondrial membrane disruption called the intrinsic path, as opposed to an extrinsic
path that starts the apoptotic signal outside the cell and bypasses any action on the mitochondria . (See more of these two pathway types in section 5.4).
E-Ac has been shown to suppress the mitochondrial gate opening thereby reducing apoptosis
and the Hippo path. 1.) It conceals the mitochondrial membrane against the Bax opening , 2.) It decreases the tumor suppressor p53 protein synthesis , 3.) It increases the bcl-2/Bax protein ratio , and 4.) It inhibits the
retinoid initiation of tumor apoptosis with mitochondrial membrane gate opening . Thus dietary E-Ac, depending on its concentration is an anti-apoptotic molecule. We have shown in this study with live animals that it causes liver hepatomegaly and
promotes aflatoxin induced liver tumor formation in proportion to the dietary dose. This study together with the above reports, indicates that inhibition of the Hippo/Yap pathway at the mitochondrial membrane gate (the intrinsic path) is one of the core
sites for the adverse outcome of E-Ac in rainbow trout liver.
5.2. E-Su preservation of liver size, and reduction of HCCs:
E-Su on the other hand, up regulates the Bax initiated
mitochondrial membrane opening that releases cytochrome C, leading to the activation of caspase 3, the final executor of apoptosis. The same mitochondrial site releases Smac/DIABLO  which counteracts the Inhibitor of Apoptosis Protein
(IAP) [33, 34], there by facilitating apoptosis. This mitochondrial gate is one of many locations in the cell control signaling pathways that are up-regulated by E-Su [13, 35, 36]. Several of the apoptotic signals are activated by the tumor
suppressor protein p53, which E-Su up-regulates . Since these sites are suppressed by E-Ac, they are points of competitive inhibition against the action of E-Su on the Hippo pathway signal. They affect both organ size and carcinogenesis
in an opposite manner as we have seen in this study. Our results show that there is in vivo trans-esterification of the tocopherol esters tending to balance the ratio of E-OH/E-Ac/E-Su which would affect the balance of the Hippo/YAP signals.
But when either of these esters is abnormally increased they would predominate in the path signaling and either cause hepatomegaly and tumors or prevent the same respectively.
It is likely that a percentage of the dietary E-Su converted to E-Ac
was responsible for some, if not all, of the HCCs shown for diet 68 in Figure 4.
Other factors that are up regulated by, but are also synergistic with E-Su in the Hippo signaling pathway [17, 36, 37] are the Tumor necrosis factor Related-Apoptosis-Inducing
ligand, (TRAIL)  and FasL  both of which require activation of cellular Death Domain receptors that are up-regulated by E-Su . In the defense system that involves this family, the tumor necrosis factor alpha (TNFα) causes cell death,
but it is not specific to cancer cells and causes inflamation and organ toxicity. Significantly, in contrast to TNFα, TRAIL is generally nontoxic to normal cells but causes apoptosis, in tumor cells including resistant malignant mesotheliomas [16,
40], in vitro gastric cancer cells , in vitrocolon cancer cells including those that are p53 negative  and others . E-Su up-regulates all of these pathway signals. E-Su is an activator for death
receptors DR4 and DR5 that are receptors for TRAIL at the cell membrane and also, like TRAIL, these receptors exhibit apoptotic selectivity to tumor cells, and are not generally adverse in normal cells [35, 43]. In one study with pancreatic cancer cell
lines the results were dubious .
Since TRAIL and FasL can by-pass the action on the mitochondria, and directly initiate apoptosis via caspases 8 and 3, E-Su therefore facilitates both intrinsic and extrinsic apoptosis.
The value of E-Su as
a cancer cell specific agent which does not affect normal cells is shown by the following list of some of the cancerous organs or cell types that have been shown by other investigators to undergo apoptosis by E-Su treatment either alone or as a synergist with
Breast [13, 42, 46, 47, 48, 49], Lymph glands [56, 57],
Cervical [18, 19],
Mesothelium [16, 40, 58],
Colon [17, 33, 50, 51], Ovaries [18, 19],
52, 53, 54], Pancreas [59, 60, 61, 62, 63],
Liver [44, 54, 55], and Prostate
[14, 64, 65, 66, 67, 68].
But like TRAIL and other activators, E-Su as a co-activator has been shown to be more effective than either factor alone [40, 41]. Hence E-Su in cancer therapy is likely to be most effective when used
in conjunction with a synergist.
5.3. Aflatoxin mechanism of action and relation to the tocopheryl esters:
Aflatoxin B1, after its conversion to AfB1-8,9-exo-epoxide [69, 70] has caused: 1. A two fold increase of the apoptotic
inhibitor, nuclear factor kappa beta (NF-κβ), [71, 72] in broiler livers. 2. Adverse activity of caspase-3 with necrotic degeneration in the rat hepatocytes . 2. Mutation of the tumor suppressor protein p53 [74, 75] in
human livers, thereby crippling regulation of apoptosis. 4. Impairment of the immune response by destruction of thymus (type II cells) and the bursa of fabricus (types I cells)  in chicken broilers. 5. Decrease in catalase and increase
in “excessive” oxidative stress in chick spleen lymphocytes . Catalase activity has been shown to be enhanced by tocopherol in Rainbow trout blood where its deficiency has been implicated in disease (http://www.healcorp.net/catalase.html
) and HCC risk in humans [78, 79]. Overall, as detailed above, elevated E-Ac alone causes hepatomegaly but in the presence of AfB1 also promotes HCC incidence. E-Su normalizes apoptosis [80, 81] and inhibits the necrosis and HCCs caused by AfB1.
It is significant that E-Su suppresses hepatomegaly and aflatoxin induced HCC induction in the light of the ubiquitous presence of aflatoxins in our society and its known contribution to HCCs in humans.
5.4. The complexity of Apoptosis
Many other proteins are involved in cell proliferation versus apoptosis such as tumor necrosis factor alpha (TNF-alpha), that activates the nuclear factor kappa beta (NF-κ β) [51, 55, 68, 82, 83], certain of the Bcl family of proteins all
that are apoptosis inhibitors. Then transforming growth factor-beta (TGF-β) [42, 46, 48], TRAIL, FasL and p53 proteins that are apoptosis activators. These are respectively inhibited or activated by E-Su and give a picture of hierarchy
of highly integrated interaction and cross talk in cell regulation. If any of the factors in one of these pathways are inhibited by mutation or toxins, apoptosis is inhibited. In some cases where such activity is inhibited, agonists have been found
that re-stabilize the activity . E-Su is such an activator [16, 46].
5.5. Type I (extrinsic) apoptosis and Type II (intrinsic) apoptosis with involvment of E-Su and E-Ac:
In both of these apoptotic
pathways, or cell type functions, α-E-Su acts at specific identified sites of the signaling pathway [29, 85].
With extrinsic type I Cells the signal for apoptosis originates outside the cell and is independent of mitochondrial
involvement. In this type, E-Su up regulates the cell surface death receptors (DR4 and DR5), of both TRAIL [17, 37] and FasL  leading to the downstream activation of the proteases, Caspase 8, then Caspase 3, the final effector of cell apoptosis but
does not directly target Caspase 9 which is a Type II Cell Caspase .
Intrinsic type II Cells involves a mitochondrial membrane change in permeability at the location of succinic dehydrogenase of the electron transport chain 
where the apoptotic signal is instigated through Bid formation of Bax proteins to act upon mitochondria and cause release of Smac/Diablo and cytochrome C. The latter then promotes the apoptosis signal with caspase 9, p53 and Caspase 3, where Smac/Diablo
intercepts the inhibitors of apoptosis proteins (IAP), and thereby is an ally to TRAIL and other apoptotic proteins as it facilitates the signal to reach Caspase 3, one of the final apoptosis actuators. E-Su facilitates the Bax, translocation for this
to happen  while E-Ac inhibits this mitochondrial change by the Bax/Bid factors [29, 30, 37].
5.6. The need for E-Su allies that are cancer cell specific.
Most chemotherapeutic drugs that have been successful in cancer treatment
are also toxic to the extent that the value of life is often compromised and the treatment has to be discontinued. Chemotherapy induced peripheral neurodegeneration [86, 87] illustrates the need to find treatments that destroy cancer cells but
not normal cells similar to both TRAIL and E-Su. Another adverse example is found in the current prostate cancer treatment methods that include the use of anti-androgen drugs to block the synthesis of testosterone or 5-hydroxy testosterone, hormones
which in turn promote growth of cancerous prostate cells. Lupron is an example of this class of drugs. Used with initial radiation treatment, it has proven effective as a periodic i.m. injection done over a period of about two years. But
it has serious side effects and like other chemotherapy drugs, it is not specific to the prostate gland, nor to cancer cells but is toxic throughout the body and after each injection causes initial sever flu like symptoms. Over the long range it causes
serious muscle debilitation and mental fatigue. http://www.lupronprostatecancer.com/sideeffects.aspx and http://www.rxlist.com/ lupron-side-effects-drug-center.html.
Most of the other drugs
used also have toxic side effects illustrated by prostate cancer treatment with antiandrogens .
E-Su on the other hand by a different mode is reported to repress the androgen receptor expression of the cancer cells instead of the androgen
itself and but it is non toxic to normal cells . Furthermore the long term ablation of androgen receptors by traditional drugs in some cases, has been found to become receptor negative, so that the cancer growth proceeds regardless of the androgen
presence or absence. Since E-Su has been found to be an agonist in several apoptosis resistant or receptor negative tumors [16, 17, 46]it could prove positive for androgen receptor treatment where traditional drugs have failed.
targeting and Cancer Cell Specific Agents:
E-Ac has been shown to prevent the mitochondrial gate opening (section 5.1 and 5.4) in contrast to E-Su. With this in mind because we find that there is in situ trans-esterification on the tocopherol
moiety of the analogue, the resulting E-Ac produced, could be the cause of a slight HCC presence and enlargement from diet 68 (Figures 4 and 6).
To prevent the trans-esterification and thereby the loss of mitochondrial gate opening, several other
analogues have been produced and found more effective than E-Su, namely tocopheryl ether acetate  which is now undergoing a clinical test , tocopheramine succinate  and triphenylphosphonium tagged E-Su . Two other synergists with E-Su
are exisulind , and TRAIL [16, 38, 40], the latter being a native member of the tumor necrosis family that is specific to cancer cells. All of these synergists induce cancer cell apoptosis but have limited affect on normal cells and do not induce necrosis.
Localized or "point" radiation  and  used with E-Su further increases treatment success.
By using these mitochondrial targeted tocopherol analogues in cohort with E-Su all of which up-regulate apoptosis in cancer cells but not in normal
cells, future treatment methods should be able to avoid the serious side effects of current drugs. One of the reviews of the cancer specific drugs and mitochondrial membrane permiabilization is noted .
The authors thank Robert R Sand, DVM, for the generous use of his fish hatchery facilities and laboratory for this study and for the technical assistance of Aaron Abbot and Dustin Tucket as well as many other volunteers.
The authors verify that there is no conflict of interest in this study.
 Center MM, Jemal A. International Trends in Liver Cancer Incidence Rates. Cancer Epid Biomarkers & Prev.
20 (2011), 2362-8. doi: 10.1158/1055-9965.EPI-11-0643. Epub 2011 Sep 15.
 Liu Y, Wu F. Global Burden of Aflatoxin-induced Hepatocellular Carcinoma: A Risk Assessment. Environ Health Perspect.
2010;118:818-24. doi: 10.1289/ehp.0901388. Epub 2010 Feb 19. See also: Centers for Disease Control; Morbidity and Mortality Weekly Report. X, 2010;May 7: 517-5203.
 Weir HK, Thompson TD, Soman A et al. Meeting the Healthy People 2020 Objectives to Reduce Cancer Mortality. Prev Chronic Dis. 2015;12:40482. DOI: 10.5888/pcd12.140482.
L, Thorgeirsson SS, Gail
MH et al. Dominant Role of Hepatitis B Virus and Cofactor Role of Aflatoxin in Hepatocarcinogenesis in Qidong, China. Hepatology. 2002;36:1214-20. http://onlinelibrary.wiley.com/doi/10.1053/jhep.2002.36366/pd.
 Ok HE, Kim HJ,
Shim WB, Chum HS. Natural occurrence of aflatoxin B1 in marketed foods and risk estimates of dietary exposure in Koreans. J Food Protect. 2007;70:2824-28.
 Muirhead, S. Pet Food varieties Recalled. Feedstuffs. 2006;16:3. Settlement
Agreement. http://recalledpetfoodsettlement.com/ (accessed 4 Jan. 2008) see also: http://www.nbcnews.com/id/10771943/ns/health-pet_health/t/toxic-pet-food-may-have-killed-dozens-dogs/#.UwKS9YXIehw
In Code of Federal Regulations: 7 CFR 983.150 Aflatoxin regulations. (a) maximum level. Wn. D.C.: US Government Publication Office. https://www.law.cornell.edu/cfr/text/7/983.150. (accessed 15 Dec. 2016)
 Giezendanner E, and
Budd B. Aflatoxins, In Search of One Health Solutions (Power Point).
Gillings School of Public Health, University of North Carolina at Chapel Hill. In Collaboration with the North Carolina One Health Collaborative. Copyright 2012. (Also
located at: www.pitt.edu/~super7/48011-49001/48591.ppt)
 Nissen SB, Tjønneeland A, Stripp C, et al. Intake of A, C, and E from diet and supplements and breast cancer in postmenopausal
women. Cancer Causes and Control. 2003;14:695-04. DOI: 10.1023/A:1026377521890
 Chen X, Mikhail SS, Ding YW, Yang G, Bondoc F, and Yang
CS. Effects of vitamin E and selenium supplementation on esophageal adenocarcinogenesis in a surgical model with rats. Carcinogenesis. 2000;21:1531-6.
 Factor VM, Laskowska D, Jensen MR et al. Vitamin E reduces chromosomal
damage and inhibits hepatic tumor formation in a transgenic mouse model. PNAS. 2000;97:2196-101.
 Fariss MW, Fortuna MB, Everett CK, Smith
JD, Trent DF, Djuric
Z. The Selective Antiproliferative Effects of α-Tocopheryl Hemisuccinate and Cholesteryl Hemisuccinate on Murine Leukemia Cells Result from the Action of the Intact Compounds. Cancer Res. 1994;54:3346-51.
 Yu W, Sander BG, Kline
K. RRR-a-tocopheryl succinate-induced apoptosis of human breast cancer cells involves Bax translocation to mitochondria. Cancer Res. 2003;63:2483-91.
 Israel K, Yu W, Sanders BG, Kline K. Vitamin E Succinate Induces Apoptosis in Human Prostate Cancer
Cells: Role for Fas in Vitamin E Succinate-Triggered Apoptosis. Nutr & Cancer. 2000;36:90-100.
 Exon JH, South EH, Taruscio TG, Clifton GD, Fariss MW. Chemopreventive Effect of Dietary d-α-Tocopheryl
Succinate Supplementation on Precancer Colon Aberrant Crypt Formation and Vitamin E Analogue Levels in Young and Old Rats. Nutr & Cancer. 2004;49:72-80. DOI:10.1207/s15327914nc4901_10
 Tomasetti M, Andera L, Alleva R, Borghi B, Neuzil J, Procopio A. α-Tocopheryl succinate induces DR4 and DR5 expression by a p53 dependent route: Implication for sensitisation of resistant cancer cells to TRAIL apoptosis. FEBS Let. 2006;580:1925-31.
 Weber T, Lu M, Andera L, Lahm H, Gellert N, Fariss MW. Vitamin E Succinate is a Potent Novel Antineoplastic Agent with High Selectivity and Cooperativity with Tumor Anti-necrosis
Factor-Related Apoptosis-inducing Ligand (Apo2 Ligand) in Vivo. Clin Cancer Res. 2002;8:863-69.
 Jha MN, Bedford JS, Cole WC, Edward-Prasad J, Prasad
KN. Vitamin E (d-a-Tocopheryl Succinate) Decreases Mitotic Accumulation in γ-irradiated Human Tumor, but Not in Normal Cells. Nutr Cancer. 1999;35:189-94. doi.org/10.1207/S15327914NC352_14.
 Kumar B, Jha MN, Cole WC. D-Alpha-Tocopheryl Succinate (Vitamin E) Enhances Radiation-Induced Chromosomal Damage Levels in Human Cancer Cells, but Reduces it in Normal Cells. J. Am. Coll. Nutr. 2002;21:339-43.
 Kline K, Yu W, Sanders BG. Vitamin E: Mechanisms of Action as Tumor Cell growth Inhibitors. In: Prasad KN, Cole WC, editors. Cancer and Nutrition, Amsterdam: IOS Press; 1998; p. 37-9.
Traber MG, Packer L. Vitamin E: beyond antioxidant function. Am J Clin Nutr. 1995;62 Suppl:1501S-9S.
 Halver JE, Crystalline Aflatoxin and Other Vectors for Trout Hepatoma. In: Halver JE, Mitchell IA, editors. Trout Hepatoma Research Conference
Papers. Wn. D.C.: Bureau of Sport Fisheries and Wildlife; 1967, 78-102.
 Yu W, Simmonson-Menchaca M, Gapor A, Sanders BG, Kline K. Induction of apoptosis in human breast cancer cells by tocopherols and tocotrienols. Nutrition & Cancer.
1999;33:26-32. Doi: 10.1080/01635589909514744.
 Camargo FC, Gokhale S, Johnnidis JB, et al. YAP1 Increases Organ Size and Expands Undifferentiated Progenitor Cells. Current Biology.
2007;17:2054-60. doi: 10.1016/j.cub.2007.10.039.
 Dong J, Feldmann G, Huang J et al. Elucidation of a Universal Size-Control Mechanism in Drosophila and Mammals. Cell. 2007;130:1120-33.
 Lu L, Li Y, Kim SM. Hippo signaling is a potent in vivo growth and tumor suppressor pathway in the mammalian liver. Proc Natl Acad Sci. 2010;107:1437-42. doi:10.1073/pnas.0911427107,
Lee K, Lee JH, Kim TS, et al. The Hippo-Salvador pathway restrains hepatic oval cell proliferation, liver size, and liver tumorigenesis. Proc Natl Acad Sci. 2010;107:8248-53. DOI: 10.1073/pnas.0912203107
 Ozoren N, El-Deiry
WS. Defining Characteristics of Types I and II Apoptotic Cells in Response to TRAIL. Neoplasia. 2002; 4:551–7. doi: 10.1038/sj.neo.7900270
 Garg NK, Mangal
S, Sahu T, Mehta A, Vyas SP, Tyagi RK. Evaluation of anti-apoptotic activity of different dietary antioxidants in renal cell carcinoma against hydrogen peroxide. Asian Pac J Trop Biomed. 2011;1:57-63. doi: 10.1016/S2221-1691(11)60069-5.
Azizova YV, Teplyi DL, Bazhanova ED, Pozdnyakova ON. The effect of water deprivation and α-tocopherol acetate on the expression of apoptosis marker proteins. Advances in Gerontology. 2012;2:38-42. doi:10.1134/S2079057012010031.
Y, Beard RL, Chandraratna, Kang JX. Evidence of lysosomal pathway for apoptosis induced by the synthetic retinoid CD437 in human leukema HL-60cells. Cell Death Differ. 2001;8:477-85. doi: 10.1038/sj.cdd.4400843.
 Zhou LL, ZhouLY, Luo KQ, Chang DC. Smac/DIABLO and cytochrome c are released from mitochondria through a similar mechanism during UV-induced apoptosis. Apoptosis. 2005;10:289-99. DOI: 10.1007/s10495-005-0803-9.
 Aguiano-Hernandez YM, Chartier A, Huerta S. Smac/DIABLO and colon cancer. Anticancer Agents Med Chem. 2007;7:467-73. DOI: 10.2174/187152007781058631.
 Deng Y, Lin Y, Wu X. TRAIL-induced apoptosis requires Bax-dependent mitochondrial
release of Smac/DIABLO. Genes Dev. 2002;16:33-45. DOI: 10.1101/gad.949602.
 Dong L, Jameson VJA, Tilly D et al. Mitochondrial Targeting of Vitamin E Succinate Enhances
Its Pro-apoptotic and Anti-cancer Activity via Mitochondrial Complex. J Biol Chem. 2011;286:3717-28. DOI: 10.1074/jbc.M110.186643.
 Rohlena J, Dong LF, Kluckova K
et al. Mitochondrially Targeted α-Tocopheryl Succinate is Antiangiogenic: Potential Benefit Against Tumor Angiogenesis but Caution Against Wound Healing. Antioxid Redox Signal. 2011;15:2923-35. DOI: 10.1089/ars.2011.4192.
J, Tomasetti M, Zhao Y, Dong LF, Birringer M, Wang XF. Vitamin E Analogs, a Novel Group of “Mitocans,” as Anticancer Agents: The importance of Being Redox-Silent. Mol Pharmacol. 2007;71:1185-99. DOI: 10.1124/mol.106.030122.
SR, Schooley K, Smolak PJ, Din WS, Huang CP, Nicholl
JK . Identification and characterization of a new member of the TNF family that induces apoptosis. Immunity. 1995;3:673-82. DOI: 10.1016/1074-7613(95)90057-8.
 Wu K, Li Y, Zhao Y et al. Roles of Fas signaling pathway in vitamin E succinate-induced apoptosis in human gastric cancer SGC-7901 cells. World J Gastroenterol. 2002;8:982–6.
 Tomasetti M, Rippo MR, Alleva R et al. Alpha-tocopheryl succinate and TRAIL selectively synergise in induction of apoptosis in human malignant
mesothelioma cells. Br J Cancer. 2004;90:1644-53. DOI: 10.1038/sj.bjc.6601707.
 Hou L, Zhang H, Xu P et al. Effect of vitamin E succinate on expression of the tumor necrosis factor-related apoptosis-inducing ligand
(TRAIL) receptor in gastric cancer cells and CD4(+) T cells. Mol Biosyst. 2015;11:3119-28. DOI: 10.1039/c5mb00350d.
 Kline K, Yu W, Sanders BG. The Role of Nutrition in Preventing and Treating
Breast and Prostate Cancer. J Nutr. 2001:131:161S-3S.
 Neuzil J, Weber T, Gellert N, Weber C. Selective cancer cell killing by α-tocopheryl succinate. Br J Cancer. 2000;84:87-9. DOI: 10.1054/bjoc.2000.1559
 Ohlsson B, Albrechtsson E, Axelson J. Vitamins A and D but not E and K decreased the cell number in human pancreatic cancer cell lines. Scand J Gastroenterol. 2004;39:882-5. DOI:
 Kim HN, Lee JH, Jin WJ, Lee ZH. α-Tocophery Succinate Inhibits Osteoclast Formation by Suppressing Receptor Activator of Nuclear Factor-kappaB Ligand (RANKL) Expression and Bone Resorption. J Bone Metab.
2012;111-20. DOI: 10.11005/jbm.2012.19.2.111.
 Yu W, Heim K, Qian M, Simmons-Menchaca M, Sanders BG, Kline
K. Evidence for role of transforming growth factor-beta in RRR-alpha-tocopheryl succinated-induced apoptosis of human MDA-MB-435 breast cancer cells. Nutr Cancer. 1997;27:267-78. DOI: 10.1080/01635589709514537
 Turley JM, Fu T, Ruscetti FW, Mikovits JA, Bertolette
DC 3rd, Birchenall-Roberts MC. Vitamin E succinate induces Fas-mediated apoptosis in estrogen receptor-negative human
breast cancer cells. Cancer Res. 1997;57:881-90. pubmed/9041190 (See also: Malafa MP, Neitzel LT. Vitamin E succinate promotes breast cancer tumor dormancy. J. Surg Res. 2000;93:163-70. DOI: 10.1006/jsre.2000.5948.)
 Kline K, Yu W, Sanders BG. Vitamin E and breast cancer. J Nutr. 2004;134:3458S-62S. pubmed/15570054.
 Charpentier A, Simmons-Menchaca M, Yu W, Zhao B, Qian M, Heim K. RRR- α-
tocopheryl succinate enchances TGF-beta 1, -beta 2, and beta 3 and TGF-beta R-II expression by human MDA-MB-435 breast cancer cells. Nutr. Cancer. 1996;26:237-50. DOI: 10.1080/01635589609514480.
 Lim SJ, Lee YJ, Park DH et al. Alpha-tocopheryl
succinate sensitizes human colon cancer cells to exisulind-induced apoptosis. Apoptosis. 2007;12:423-31. DOI: 10.1007/s10495-006-0620-9.
 Neuzil J, Weber T, Schroder A et al. Induction of cancer cell apoptosis by α-tocopheryl succinate:
molecular pathways and structural requirements. FASEB J. 2001;15:403-15. DOI: 10.1096/fj.00-0251com.
 Sun Y, Zhao Y, Hou L, Zhang X, Zhang Z,Wu k. RRR-α-tocopheryl succinate induces apoptosis in human gastric cancer cells via the NF-κB
signaling pathway. Oncol Rep. 2014;32:1243-8. DOI: 10.3892/or.2014.3282
 Zhao Y, Li R, Xia W, Neuzil J, Lu Y, Zhang H. Bid integrates intrinsic and extrinsic signaling in apoptosis induced by alpha-tocopheryl succinate in human gastric carcinoma
cells. Cancer Let. 2010;288:42-9. DOI: 10.1016/j.canlet.2009.06.021.
 Abd-El Fattah AA, Darwish HA, Fathy N, Raafat A, Shouman SA. Promising antitumor effect of alpha-tocopheryl succinate in human colon and liver cancer cells. Med Chem Res.
2012;21:2735-2743. DOI: 10.1007/s00044-011-9801-3.
 Valis K, Prochazka L, Boura E, Chladova
J, Obsil T, Rohlena
J. Hippo/Mst1 Stimulates Transcription of the Proapoptotic Mediator NOXA in a Fox01-Dependent Manner. Cancer Res. 2011;71:946-54. DOI: 10.1158/0008-5472.CAN-10-2203.
Dalen J, Neuzil J. α-Tocopheryl succinate sensitizes a T Lymphoma cell line to TRAIL-induced apoptosis by suppressing NF-κB activation. Br J Cancer. 2003;88:153-8. DOI: 10.1038/sj.bjc.6600683.
 Turley JM, Funakoshi S, Ruscetti
FW et al. Growth inhibition and apoptosis of RL human B lymphoma cells by vitamin E succinate and retinoic acid: role for transforming growth factor beta. Cell Growth Differ. 1995;6:655-63. pubmed/7669719.
 Kovarova J, Bajzikova
M, Vondrusova M, Stursa J, Goodwin J, Nguyen M. Mitochondrial targeting of α-tocopheryl succinate enhances its anti-mesothelioma efficacy. Redox Rep. 2014;19:16-25. DOI: 10.1179/1351000213Y.0000000064
Patacsil D, Osayi S, Tran
AT et al. Vitamin E succinate inhibits survivin and induces apoptosis in pancreatic cancer cells. Genes Nutr. 2012;71:83-9. DOI:10.1007/s12263-011-0242-x.
 Heisler T, Towfigh S, Simon N, Liu
C, McFadden DW.. Peptide YY augments gross inhibition by vitamin E succinate of human pancreatic cancer cell growth. J Surg
Res. 2000;88:23-5. DOI: 10.1006/jsre.1999.5775.
 Greco E, Basso D, Fadi E et al. Analogs of vitamin E epitomized by alpha-tocopheryl succinate for pancreatic cancer treatment: in
vitro results induce caution for in vivo applications. Pancreas.2010;39:662-8. DOI: 10.1097/MPA.0b013e3181c8b48c
 Peng L, Liu X, Qian L, Tang
T, Yang Z. Vitamin E Intake and Pancreatic Cancer Risk: Meta-Analysis of Observational Studies. Med Sci Monit. 2015;21:1249-55.
 Asanuma K, Moriai R, Yajima T et al. Survivin as a radioresistance factor in pancreatic cancer. Jpn J Cancer Res. 2000;91:1204-9. PMID:
 Zhang Y, Ni J, Messing EM, Chang E, Yang
CR, Yeh S. Vitamin E succinate inhibits the function of androgen-specific antigen in prostate cancer cells. Proc Natl Acad
Sci. 2002;99:7408-13. DOI: 10.1073/pnas.102014399.
 Ni J, Chen M, Zhang Y, Li
R, Huang J, Yeh
S. Vitamin E succinate inhibits human prostate cancer cell growth via modulating cell cycle regulatory machinery. Biochem Biophys Res Comm. 2003;300:357-363. PMID: 12504091.
 Tomasetti M, Nocchi L, Neuzil J et al. Alpha-Tocopheryl
Succinate Inhibits Autophagic Survival of Prostate Cancer Cells Induced by Vitamin K3 and Ascorbate to Trigger Cell Death. PLOS One. 2012;7:52263. DOI: 10.1371/journal.pone.0052263.
Weinstein SJ, Peters U, Ahn J et al. Serum α-tocopherol and γ-tocopherol Concentrations and Prostate Cancer Risk in the PLCO Screening Trial: A Nested Case-Control Study. PLOS One. 2012;7:e40204. DOI: 10.1371/journal.pone.0040204
Basu A, Grossie B, Bennett M, Mills N, Imrhan
V. Alplha-tocopheryl succinate (α-TOS) modulates human prostate LNCap xenograft growth and gene expression in BALB/c nude mice fed two levels of dietary soybean oil. Eur J Nutr. 2007;46:34-43. DOI:
 Smela ME, Currier SS, Bailey EA, Essigmann JM. The chemistry and biology of aflatoxin B1: from mutational spectrometry to carcinogenesis. Carcinogenesis.
2001;22:535-45. PMID: 11285186.
 Kumar V. Aflatoxins, their Biosynthetic Pathway and Mechanism of Action. biotecharticles.com./Agriculture-Article/Aflatoxins-their-Biosynthetic-Pathway-and-
Mechanism-of-Action-3357.html. [accessed 16.12.16]
 Qiugang M, Li Y, Fan Y et al. Molecular Mechanisms of Lipoic Acid Protection against Aflatoxin B1-Induced Liver Oxidative Damage and Inflammatory Responses in Broilers.
Toxin. 2015;7:5435-47. DOI: 10.3390/toxins7124879.
 Leudde T, Schwabe F. NF-κβ in the liver-linking injury, fibrosis
and hepatocellular carcinoma. Nat Rev Gastroenterol Hepatol. 2011;8:108-18. DOI: 10.1038/nrgastro.2010.213.
 Meki AR, Abdel-Ghaffar SK, El-Gibaly I. Aflatoxin
B1 induces apoptosis in rat liver: protective effect of melatonin. Neuro Endocrinol Lett. 2001;22:417-26. PMID: 11781538.
 Stern MC, Umbach DM, Yu MC, London SJ, Zhang
ZQ, Taylor JA. Hepatitis B, Aflatoxin B1 and p53 Codon 249 Mutation in Hepatocellular Carcinomas from Guangxi, People's
Republic of China and a Meta-analysis of Existing Studies. Cancer Epidemiol Biomarkers Prev. 2001;10:617-25. PMID: 11401911
 Mace L, Aguilar F, Wang JS et al. Aflatoxin B1-induced DNA adduct formation and p53 mutations in
CYP450-expressing human liver cell lines. Carcinogenesis. 1997;18:1291-7. PMID: 9230270
 Peng X, Zhengqiang Y, Liang N, Chi
X, Li X, Jiang
M. The mitochondrial and death receptor pathways involved in the thymocyte’s apoptosis induced by aflatoxin B1. Oncotarget. 2016;7(11):12222–34. DOI: 10.18632/oncotarget.7731.
 Chen j, Chen K, Yuan S et al. Effects of aflatoxin B1 on oxidative stress markers and apoptosis of spleens in boilers. Toxicol Ind Health. 2016;32:278-84. DOI: 10.1177/0748233713500819.
 Hokama Y, Kimura LH, Kobara TY, et al. Variation in peroxisomal enzyme levels of peripheral leukocytes of cancer, leprosy and tuberculosis patients. Cancer Res. 1974;34:2784- 9.
Meszaros I, Goth L. Uber die katalaseaktivitat der erythrozyten von krebspatienten. In: Rapoport S, Jung F. editors. Internationales Symposium uber Struktur und Funktion der Erythrozyten. Berlin, Acadamie Verlag; 1975:403.
Alberts B , Johnson A, Lewis J et al. Cell Death. In: Molecular Biology of the Cell,6th Ed. Chap. 18. New York, NY: Garland Science; 2015, p. 1021.
 Kroemer G, Galluzzi L, Brenner C. Mitochondrial Membrane Permeabilization
in Cell Death. Physiol. Rev. 2007;87:99-163. DOI: 10.1152/physrev.00013.2006.
 Nakamura T, Goto M, Matsumoto A, Tanaka I. Inhibition of NF-kappa B transcriptional activity by alpha-tocopheryl succinate. Biofactors. 1998;7:21-30.
 Barnes PJ. Nuclear factor-kappa B. Int J Biochem Cell Biol. 1997;29:867-70. PMID: 9304801
 Wang S, El-Deiry WS. TRAIL and apoptosis induction by TNF-family death receptors. Oncogene. 2003;22:8628-33. DOI: 10.1038/sj.onc.1207232.
 Fulda S, Debatin KM. Extrinsic versus intrinsic apoptosis pathways in anticancer chemotherapy. Oncogene. 2006;25:4798–4811. DOI: 10.1038/sj.onc.1209608.
 Carozzi VA, Canta A, Chiorazzi A. Chemotherapy-induced
peripheral neuropathy: What do we know about mechanisms? Neuroscience Letters. 2015;596:90-107. DOI: 10.1016/j.neulet.2014.10.014.
 Okouchi M, Ekshyyan O, Maracine M, Aw TY. Neuronal Apoptosis in Neurodegeneration. Antioxid Redox Signal. 2007;9:1059-96. DOI: 10.1089/ars.2007.1511
Gillatt D. Antiandrogen treatments in locally advanced prostate cancer: are they all the same? J Cancer Res Clin Oncol. 2006;132 Suppl 1:S17-S26. DOI: 10.1007/s00432-006-0133-5.
Anderson K, Simmons-Menchaca M, Lawson KA, Atkinson J, Sanders BG, Kline K. Differential Response of Human Ovarian Cancer Cells to Induction of Apoptosis by Vitamin E Succinate and Vitamin E Analogue, α-TEA.
Cancer Res. 2004;64(12):4263-9. DOI: 10.1158/0008-5472.CAN-03-2327.
 Guerrouahen BS, Hahn
T, Alderman Z, Curti
B, Urba W, Akporiaye
ET. GMP-grade α-TEA lysine salt: a 28-Day oral toxicity and toxicokinetic study with a 28-Day recovery period in Beagle dogs. Cancer.2016;16:199. doi: 10.1186/s12885-016-2220-6.
 Gruber J, Stanniek K, Krewenka C et al. Tocopheramine succinate and tocopheryl succinate: Mechanism of mitochondrial inhibition
and superoxide radical production. Bioorg. Med. Chem. 2014; 22:684-691. DOI: 10.1016/j.bmc.2013.12.036.
 Griffiths GJ. Exisulind Cell Pathways. Curr Opin Invetig Drugs.
2000;1:386-91. PMID: 11249724.
Abbreviations and Definitions
AfB1: Aflatoxin B1 : Potent carcinogen produced in moldy food by Aspergillus species.
BAK1 is a pro-apoptotic Bcl-2 protein having four Bcl-2 homology (BH) domains: BH 1-4.
Bax: Apoptosis regulator BAX, also known as “bcl-2-like protein 4", is
bcl-2:This name stands for B cell lymphoma.
Bcl-2 proteins incite either anti- or pro-apoptosis. BID: The BH3 Interacting-domain Death agonist gene is a pro-apoptotic member of the Bcl-2 protein family and is upregulated by the tulmor
Caspase: cysteine-aspartic protease, or cysteine-dependent aspartate-directed protease.
signalling or literally Cell Movement
DIABLO: (Direct IAP Binding protein with Low pI) Binds caspase inhibitors and thus facilitates apoptosis
DR4, DR5 etc.: Death Domain receptors that are
required for the action of TRAIL & FasL.
E-Ac: Vitamin E acetate (d-alpha tocopheryl-acetate)
E-Su: Vitamin E succinate (d-alpha tocopoheryl-succinate)
Cell proliferation path signaling that controls apoptosis, originally seen in the Drosophila melanogaster fruit fly. The Hippo proteins phosphorylate the YAP factors inhibiting them and preventing out of control cell growth and proliferation.
IAP: Inhibitor of Apoptosis Proteins
Kinases: Enzymes that phosphorylate a target substrate
Mst 1 and Mst2: Serine/threonine protein kinases, the mammalian
homologs of the Hippo kinase from Drosophila controlling the cell proliferation, differentiation etc.
NF-κβ: Nuclear Factor kappa beta, an apoptosis inhibitor. In normal cells it acts
as modulator of cell growth and death, but in cancer cells it prevents apoptosis and therby promotes cancer growth.
p53: tumor suppressor protein that when activated is a transcription factor that regulates many downstream target
genes, including BID. However, p53 also has a transcription-independent role in apoptosis, in particular, promoting Bax activation and the insertion of Bax into the mitochondrial membrane.
Mitochondria-derived Activator of Caspases. Also called DIABLO
TNF-α: Tumor necrosis factor alpha is a cytokine that activates NF-kβ. It causes cell death, but it is not specific to
cancer cells and causes inflamation and organ toxicity.
TRAIL: Tumor necrosis factor Related-Apoptosis-Inducing Ligand. It targets only cancer cells.
YAP: Yes Associated Protein. Up regulation of the YAP signal causes organ hypertrophy and eventual tumor development.