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Chemotherapy‑induced oxidative injury in pediatric acute lymphoblastic leukemia: The role of N‑acetylcysteine (Review)

  • Authors:
    • Ray Sebastian Soetadji
    • Sandjaja Soetadji
    • Timothy Jonathan
    • Ardo Sanjaya
  • View Affiliations / Copyright

    Affiliations: Department of Anatomy, Faculty of Medicine, Maranatha Christian University, Bandung, West Java 40164, Indonesia, Department of Pediatric Health, Limijati Hospital, Bandung, West Java 40115, Indonesia
    Copyright: © Soetadji et al. This is an open access article distributed under the terms of Creative Commons Attribution License.
  • Article Number: 82
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    Published online on: May 7, 2026
       https://doi.org/10.3892/br.2026.2155
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Abstract

Pediatric acute lymphoblastic leukemia (ALL) is the most common childhood malignancy. However, intensive chemotherapy frequently leads to notable organ toxicity, much of which is mediated by treatment‑induced oxidative stress. Reactive oxygen species (ROS) generated during cytotoxic therapy contribute to tissue damage, including the liver, heart and nervous system. Current adjunctive therapies provide drug‑specific protection, such as dexrazoxane for anthracycline‑induced cardiotoxicity, but they do not address the shared ROS‑generating pathway, a common mechanism of chemotherapy‑induced toxicity across multiple agents and tissues. The present narrative review synthesizes the biochemical rationale, preclinical evidence and translational considerations for N‑acetylcysteine (NAC) as a redox‑modulating adjunct therapy in pediatric ALL. NAC acts as a glutathione precursor, scavenges reactive oxygen and nitrogen species, chelates redox‑active metals, and modulates inflammatory signaling pathways. These properties have been associated with cytoprotective effects in preclinical models of chemotherapy‑induced cardiotoxicity, hepatotoxicity, neurotoxicity and oxidative injury. Available evidence suggests that NAC can reduce treatment‑related toxicity without consistently compromising antitumor efficacy, although outcomes appear to be dependent on timing, dosage and treatment context. While the favorable safety, low cost and accessibility of NAC support its potential clinical utility, current evidence remains limited, particularly in pediatric ALL populations. In conclusion, NAC represents a promising but context‑dependent adjunctive strategy for mitigating chemotherapy‑induced toxicity in pediatric ALL. Further well‑designed clinical studies are required to define its optimal use, including timing, dosing and impact on oncological outcomes.
View Figures

Figure 1

Chemotherapy-induced oxidative injury
and timing-dependent effects of NAC. Chemotherapeutic agents used
in ALL increase ROS levels, which are essential for tumor cell
killing, but also cause off-target injury in several tissues,
including the liver, heart, nervous system, bone marrow and GI
tract. NAC acts as a redox-modulating agent and its effects are
dependent on timing. Early or concurrent administration may reduce
ROS-mediated cytotoxicity and potentially attenuate antitumor
efficacy. By contrast, delayed administration may preserve
therapeutic activity while reducing treatment-related toxicity.
Thus, the application of NAC must be balanced by the potential
interference with antitumor efficacy and also by protection from
adverse effects in other organs. NAC, N-acetylcysteine; ROS,
reactive oxygen species; GI, gastrointestinal; ALL, acute
lymphoblastic leukemia.
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Copy and paste a formatted citation
Spandidos Publications style
Soetadji RS, Soetadji S, Jonathan T and Sanjaya A: Chemotherapy‑induced oxidative injury in pediatric acute lymphoblastic leukemia: The role of N‑acetylcysteine (Review). Biomed Rep 25: 82, 2026.
APA
Soetadji, R.S., Soetadji, S., Jonathan, T., & Sanjaya, A. (2026). Chemotherapy‑induced oxidative injury in pediatric acute lymphoblastic leukemia: The role of N‑acetylcysteine (Review). Biomedical Reports, 25, 82. https://doi.org/10.3892/br.2026.2155
MLA
Soetadji, R. S., Soetadji, S., Jonathan, T., Sanjaya, A."Chemotherapy‑induced oxidative injury in pediatric acute lymphoblastic leukemia: The role of N‑acetylcysteine (Review)". Biomedical Reports 25.1 (2026): 82.
Chicago
Soetadji, R. S., Soetadji, S., Jonathan, T., Sanjaya, A."Chemotherapy‑induced oxidative injury in pediatric acute lymphoblastic leukemia: The role of N‑acetylcysteine (Review)". Biomedical Reports 25, no. 1 (2026): 82. https://doi.org/10.3892/br.2026.2155
Copy and paste a formatted citation
x
Spandidos Publications style
Soetadji RS, Soetadji S, Jonathan T and Sanjaya A: Chemotherapy‑induced oxidative injury in pediatric acute lymphoblastic leukemia: The role of N‑acetylcysteine (Review). Biomed Rep 25: 82, 2026.
APA
Soetadji, R.S., Soetadji, S., Jonathan, T., & Sanjaya, A. (2026). Chemotherapy‑induced oxidative injury in pediatric acute lymphoblastic leukemia: The role of N‑acetylcysteine (Review). Biomedical Reports, 25, 82. https://doi.org/10.3892/br.2026.2155
MLA
Soetadji, R. S., Soetadji, S., Jonathan, T., Sanjaya, A."Chemotherapy‑induced oxidative injury in pediatric acute lymphoblastic leukemia: The role of N‑acetylcysteine (Review)". Biomedical Reports 25.1 (2026): 82.
Chicago
Soetadji, R. S., Soetadji, S., Jonathan, T., Sanjaya, A."Chemotherapy‑induced oxidative injury in pediatric acute lymphoblastic leukemia: The role of N‑acetylcysteine (Review)". Biomedical Reports 25, no. 1 (2026): 82. https://doi.org/10.3892/br.2026.2155
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