Natural biomolecules and derivatives as anticancer immunomodulatory agents.

Introduction

Cancer remains one of the leading causes of global mortality despite improved diagnostic techniques, identification of novel disease-predictive markers and the approval of a myriad of new therapeutics. Surgical removal, radiotherapy and chemotherapy remain the cornerstones of treatment, each with their own limitations. Chemotherapy has two main limitations, the occurrence of resistance in over 90% of patients and the blunt targeting of pathways also required for normal cellular development and homeostasis ( 1 ). Radiotherapy also induces healthy tissue injury, inflammation and oxidative stress with up to 85-95% of patients experiencing skin lesions and 60% experiencing lung injury ( 2 , 3 ). Both modalities offer a broadly-targeted approach to cancer treatment leaving behind cell death, debris and damage-associated molecular patterns (DAMPs) in both cancer and healthy cells. Alleviating collateral damage, overcoming resistance and finding more targeted approaches are central goals to improving cancer treatment and quality of life. We believe that synergism between natural biomolecules and conventional therapeutics could be a step to achieve these goals for several reasons, which will be discussed later on.

Collateral damage can be lessened by targeting inflammation, a double-edged sword in cancer as chronic inflammation itself promotes tumorigenesis and cancer progression ( 2 ). At the same time, wielding the power of the immune system by stimulating cancer cell recognition from the host defense and by inducing immunogenic cell death ( 4 – 7 ) is also an attractive approach for several reasons. As this immune-cancer interplay and particularly evasion of immune recognition is what cancer cells need in order to develop, proliferate and acquire resistance.

The cancer-immunity cycle aims to unmask, locate and kill cancer cells. The first step of the cycle is the release of tumor-derived antigens that are created as a result of genomic instability. Dendritic cells capture tumor-associated antigens and upon full maturation and activation become antigen presenting cells (APCs) to T lymphocytes in the lymph nodes. Dendritic cell maturation includes the increased cell-surface expression of antigen peptides on major histocompatibility complex (MHC) class I components, and of co-stimulatory receptor ligands including CD80 and CD86. Engagement of T cell receptors (TCRs) by MHC class I, as well as of co-stimulatory receptors such as CD28, results in T cell activation, differentiation into tumor-specific cytotoxic T cells and clonal expansion. Proinflammatory mediators including tumor necrosis factor alpha (TNF-α), interferon alpha (IFN-α), IFN-γ, interleukin-2 (IL-2) and IL-12 promote T cell activation. Chemokines such as C-X-C Motif Chemokine Ligand 9 (CXCL9) and CXCL10 stimulate T cell trafficking and infiltration into the tumor, where T-cell-mediated cytotoxicity liberates more tumor-associated antigens to further propagate the cancer-immunity cycle ( 4 , 5 , 8 ).

Antigen-dependent cytotoxicity can be inhibited as effector T cells become exhausted especially when chronic inflammation in the TME leads to continuous activation of TCRs and co-stimulatory receptors ( 9 , 10 ). This occurs via the upregulation of immune checkpoints including the programmed cell death protein 1 (PD-1) ( 10 , 11 ) and cytotoxic T-lymphocyte-associated protein 4 (CTLA-4) ( 12 , 13 ). Like CD28, CTLA-4 binds to dendritic CD80 and CD86, but with markedly higher affinity, and CTLA-4 competitively inhibits CD28-induced effector T cell responses ( 13 ). Checkpoint inhibitors, which are aimed at reactivating T cells and re-establishing cytotoxicity, are emerging as the most prominent immunomodulatory agents in cancer chemotherapy ( 14 ). They have already shown success in metastatic melanoma, urothelial and non-small cell lung (NSCL) carcinomas ( 12 , 15 ), but have been associated with the development of immune-related adverse events in 70-90% of patients ( 16 , 17 ). This necessitates the development of novel agents with improved safety profiles. Natural biomolecules including berberine, triptolide, epigallocatechin gallate (EGCG) and curcumin, reviewed here, have been shown to reduce cancer cell expression of the PD-1 ligand, PD-L1. Could these phytochemicals emerge as novel checkpoint inhibitors with improved safety profiles?

Nonspecific cytotoxicity is primarily executed by natural killer (NK) cells, whose activity is potentiated upon stress-induced stimulation of natural cytotoxicity receptors (NCR). NK cell activity is, however, inhibited upon MHC-class-I-dependent stimulation of killer cell inhibitory immunoglobulin-like receptors (KIR). Cancer cells lacking MHC class I can be recognized as ‘non-self’ and lysed by NK cells. The importance of immune surveillance and cytotoxicity in tumorigenesis and cancer progression is highlighted by findings that increased numbers of antitumor cells such as mature dendritic cells, NK, cytotoxic T, T helper (Th) and B cells in the TME are associated with improved prognosis ( 18 – 21 ) ( Figure 1 ).

Cancer cells can escape immune surveillance and through proliferation of immune-escapee clones give rise to established tumors via immunoediting ( 7 , 22 ). Malignant cells can lose their antigenicity and evade detection by NK cells or APCs through downregulation of tumor-specific antigens or dysregulated antigen presentation via MHC class I and II. In fact, 20-60% of solid cancers show decreased expression of MHC class I, and reduced MHC I and II expression levels predict poor prognosis in cancers such as breast ( 23 ), colorectal ( 24 ) and bladder ( 25 ). Tumor-specific expression of MHC class II, however, improves immune checkpoint inhibitor efficacy ( 26 , 27 ). Cancer cells can also take advantage of negative feedback mechanisms that promote immune tolerance including the expression of ligands for immune checkpoint receptors (e.g. PD-L1) that promote T cell exhaustion ( 28 ). Cancer cells may also secrete inhibitory, Th2-type cytokines including transforming growth factor β (TGF-β), interleukin 4 (IL-4) and IL-10 that in turn stimulate the recruitment, generation and propagation of tumorsupportive immune cells including Foxp3+ regulatory T (Treg) and B (Breg) cells, M2-polarized tumor associated macrophages (TAMs) and myeloid derived suppressor cells (MDSCs). These tumorsupportive cells promote cancer progression by promoting angiogenesis, migration and metastasis ( 29 – 31 ), and by inhibiting T- and NK-cell-mediated cytotoxicity ( 32 – 34 ) ( Figure 2 ).

One of the additional targets that have emerged is STAT3 (signal transducer and transcription activator 3). STAT3 is a downstream effector of cytokines including IL-6 and IL-4, growth factors such as EGF, and hypoxia. Phosphorylated STAT3 dimers in cancer cells promote the transcription of genes associated with proliferation, cell cycle regulation, adhesion, metastasis and angiogenesis. Persistent activation of STAT3 is poor prognostic indicator in some cancers. In immune cells, IL-6 induces STAT-3 phosphorylation to promote IL-10 secretion leading to autocrine activation of immune STAT-3 and maintenance a strong immunosuppressive microenvironment. Additionally, IL-6-mediated activation of JAK2/STAT3 within cancer cells promotes the expression of PD-L1 and PD-L2 and checkpoint inhibition. STAT3 has emerged as important target as it promotes tumor cell stemness, malignant transformation, uncontrolled proliferation, evasion of apoptosis, metastasis and most importantly for this scope of this review, immune evasion ( 35 ) ( Figure 3 ).

About half of the clinically-utilized cancer chemotherapeutics ranging from topoisomerase inhibitors, cancer chemotherapeutic antibiotics to microtubule-stabilizing agents, are derived from or inspired from natural sources ( 36 ). As new therapeutic targets emerge, interest in the incorporation of novel biomolecules as adjuncts to conventional therapy has increased. While initial investigations focused on dietary compounds which through their antioxidant and anti-inflammatory properties may be cancer preventative, proapoptotic and antiproliferative effects have also been identified, leading to clinical trials. As the spotlight has moved into the development of immunomodulatory cancer chemotherapies, so has the identification of anti-inflammatory and immunomodulatory phytochemicals. In this review, we will highlight phytochemicals with anticancer and immunomodulatory properties ( Figures 4 , 5 ). We will focus on evaluating anticancer efficacy demonstrated in clinical trials, immunomodulatory roles, and will only summarize the antineoplastic effects identified in preclinical studies.

Artemisinin and artemisinin derivatives

Artemisinin is a semisynthetic isoprenoid (alternatively sesquiterpene or terpene) from Artemisia annua . It was rediscovered as an antimalarial drug by Chinese chemist and Nobel Laureate Tu Youyou in 1972. Qinghaosu, or artemisinin, was isolated from A. annua by low-temperature, ethanol-based extraction. An inactive, acidic moiety was removed to increase efficacy but reduce toxicity and yield artemisinin. Further structure-activity studies resulted in the discovery of three artemisinin derivatives: artemether, a methyl-ether derivative; artesunate, a hydrophilic derivative; and dihydro-artemisinin, an intermediate and active metabolite of the last two. Artemisinin derivatives, from here on referred to as ACTs, are currently being investigated for cancer therapy. So far, their efficacy has mostly been demonstrated in vitro and in vivo with relatively few human trials, a focus of this review. But, ACTs are ideal drugs for repurposing due to a 50-year safety record as monotherapy or adjunct therapy for malaria. And, the availability of a stable supply chain of semi-synthetic ACTs with a predicable cost, which has been established through the Semi-synthetic Artemisinin Project ( 37 ).

Clinical trials of artemisinin and artemisinin derivatives

To date, human clinical trials for the use of ACTs as cancer chemotherapeutics are limited to small cohorts of breast, colorectal and cervical cancer patients. Nonetheless, results are promising with indications of reduced disease progression in the absence of serious side effects.

Artesunate, a more stable and bioavailable analogue of artemisinin, was utilized as an add-on to guidance-based chemotherapy in patients with metastatic breast cancer. No significant side effects were reported and artesunate exhibited improved safety profile when compared to selective estrogen receptor modifiers (SERMs) ( 38 , 39 ). Notably, SERMs (e.g. tamoxifen), a staple in breast cancer chemotherapy, are associated with side effects like hepatotoxicity, nephrotoxicity, neurotoxicity, cardiotoxicity, and increased thromboembolic risk ( 40 ). Artesunate addition aided in disease stability in some patients. But, the small cohort size and confounders hindered differentiation between drug- and disease-related symptoms. Overall artesunate was found to be safe with unclear benefits ( 38 , 39 ). Artesunate did reduce expression of Ki67 in colorectal carcinoma, a proliferation marker associated with poor prognosis ( 41 ), and resulted in an overall reduction of tumor cell proliferation. No deaths occurred in the artesunate-treated group, but 27.3% of controls had died at the time of analysis ( 42 ).

Cervical cancer is one of the most common cancers in women worldwide with 90% of deaths occurring in low-income countries due to lack of screening. Standard-of-care for low-grade lesions and early stage cancer include surgery combined with radio- and chemotherapy ( 43 ). Non-surgical treatment could be of significant benefit for all women, but in particular for women with limited access to healthcare. A self-administered and affordable therapeutic option along with the currently-available self-performed screening methods could prove extremely beneficial.

Encouraging results for the use of ACTs in cervical cancer have emerged from clinical trials with intravaginal artesunate ( 44 ) or oral artenimol ( 45 ). Self-administration of intravaginal artesunate led to regression of cervical intraepithelial neoplasia (CIN) and clearance of human papillomavirus (HPV) ( 44 ), the main cause of cervical cancer ( 43 ). Oral artenimol induced a 6-month remission in 10 advanced metastatic cervical cancer patients, with sufficient remission to allow hysterectomy in one patient. Importantly, study participates survived for a minimum of 12 months, far longer than the 4-month survival of patients with similar level of care ( 43 , 45 ). No significant adverse effects were reported. Biopsy analysis revealed reduced vascularization, and reduced expression of p53, epidermal growth factor receptor (EGFR) and Ki-67. But, expression of transferrin receptor 1 (TfR1), a poor prognostic indicator in cervical cancer ( 46 ), was increased ( 45 ).

ACTs may prove excellent candidates for cervical cancer therapy because; 1) Cervical cancer is a slow growing cancer that is treated by local resection or hysterectomy so pharmacotherapeutic options can be tested without delaying or interfering with standard-of-care treatment. 2) ACTs have demonstrated cytotoxic effects against HPV infected cells with relative selectivity ( 44 , 47 ). 3) Clinical trials, although with limited number of patients, have shown extremely promising results ( 44 , 45 ). The results of all clinical trials discussed in this review, including those utilizing ACTs, are presented in ( Table 1 ) below.

Immunomodulatory effects of artemisinin and artemisinin derivatives

ACT-mediated control of the immune response to cancer is yet to be examined in patients, so we summarize the in vitro and in vivo evidence. Artemisinin caused a dose-dependent increase in CD107a, a marker of increased activity and degranulation, in primary human NK cells ( 70 ). While, artemisinin pre-treated leukemia and lymphoma cells became more susceptible to cytolysis by human primary NK cells ( 71 ). This suggests, that artemisinin employs two independent mechanisms in increasing NK-dependent cytotoxicity; by directly increasing the cytolytic activity of the NK cell predator, while simultaneously increasing the susceptibility of the cancer cell prey to NK-mediated destruction.

ACTs may reprogram immune cells to increase tumorsuppression and tumorlysis. Artesunate inhibited JAK2/STAT3 in human primary monocytes to decrease CD163+/CD206+ M2 macrophage numbers and polarize monocytes to a tumoricidal phenotype, which induced leukemia cell apoptosis ( 72 ). ACTs promoted γδ T cell proliferation and cytolytic activity by inducing granzyme B expression ( 73 – 75 ). Immune-derived granzymes enter cancer cells via perforin-formed pores to induce DNA fragmentation and caspase-3-dependent apoptosis. ACT-dependent induction of granzyme B indirectly induced apoptosis of pancreatic ( 74 ), liver ( 75 ) and breast ( 73 ) cancer cells. Concomitantly, artesunate increased hepatocarcinoma susceptibility to γδ T cytolysis by inhibiting STAT3-mediated downregulation of Fas ( 75 ). Artesunate suppressed naïve CD4+ T cell proliferation and induced their differentiation into a predominantly Th1 tumoricidal phenotype with increased expression of IFN-γ ( 76 ). Artesunate also reduced the expression of IL-2 ( 76 ), an anti-inflammatory cytokine produced by Th2 cells that can promote cancer progression by inhibiting IFN-γ release ( 77 ). These findings were extended by Chen et al. who, in a murine model of ovarian cancer, showed that artesunate induced Th1 differentiation of CD4+ via miR-142-mediated downregulation of sirtuin 1, resulting in enhanced ovarian cancer apoptosis ( 78 ).

In addition to enhancing immune-mediated cytolysis, ACTs can significantly remodel the TME. Artemisinin remodeled breast cancer TME by increasing the numbers of tumorsuppressive CTLs and CD4+/IFN-γ+ Th1 cells, while concomitantly decreasing the numbers of tumorsupportive FOXP3+ Treg and T-bet+ MDSCs ( 73 ). Similarly, Yu et al. showed that dihydroartemisinin decreased phosphorylated STAT3, but increased STAT1 phosphorylation in melanoma cells to decrease tumor growth, proliferation and metastasis but induce apoptosis in melanoma-bearing mice. Importantly, dihydroartemisinin-mediated decrease of IL-10 and IL-6 in melanoma inhibited Treg polarization and infiltration in the TME ( 79 ). Tregs are an additional source of immunosuppressive cytokines ( 5 , 8 ), and by decreasing Treg numbers, dihydroartemisinin treatment allowed for increased infiltration of CD8+ CTLs and promoted antitumor immunity ( 79 ).

In summary, in vitro and in vivo studies have identified a number of immunomodulatory roles for ACTs that lead to an overall increase of the antitumor response. ACTs directly polarize immune cells towards tumoricidal, and away from tumorsupportive populations. Concomitantly, ACTs act on cancer cells to increase their susceptibility to immune-mediated cytolysis. It remains to be seen whether these promising results translate to the clinic ( Table 2 ).

Summary of the antineoplastic mechanisms of artemisinin and artemisinin derivatives

In addition to altering immunosurveillance, ACTs target cancer cells directly. They induce ROS generation, autophagy and cell death, but inhibit proliferation, growth and migration in vitro and in vivo ( 83 ). Here, we will only summarize the major mechanistic insights into the direct antineoplastic effects of ACTs.

ACTs have recently emerged as potential inhibitors of STAT3 in cancer cells in vitro. Ilamathi et al. demonstrated that artesunate exhibited similar potency to the established STAT3 blocker S31-201 in inhibiting both constitutive and IL-6-dependent dimerization of STAT3 to induce apoptosis of hepatocellular carcinoma ( 84 ). Dihydroartemisinin inhibited both IL-6-mediated and EGFR-mediated activation of JAK2/STAT3 in head and neck squamous cell carcinoma (HNCC) in vivo and in vitro . Dihydroartemisinin-dependent inhibition of STAT3 decreased the levels of antiapoptotic (Bcl-xL, Mcl-1), proproliferative (cyclin D1), prometastatic (MMP-2/9) and proangiogenic (VEGF) proteins resulting in inhibited xenograft tumor growth ( 85 ). Similar results were observed with artesunate-dependent inhibition of STAT3 in AML ( 81 ), diffuse large B cell lymphoma ( 82 ) and melanoma ( 86 ) cell lines. HNCC resistance to cisplatin is associated with STAT3 phosphorylation ( 87 ). Importantly, dihydroartemisinin sensitized HNCC cells to cisplatin and acted synergistically with cisplatin to arrest HNCC in G0/G1 ( 85 ). Two independent studies have demonstrated that by inhibiting STAT3, dihydroartemisinin acted synergistically with the Bcl-2 inhibitor ABT-263 ( 88 ) and with the tyrosine kinase inhibitor gefitinib ( 89 ) to induce apoptosis in EGFR and RAS mutant NSCLC cells. In addition to inhibiting STAT3 activity, dihydroartemisinin has emerged as an inhibitor of STAT3 translation. Dihydroartemisinin increased miR-130b-3p to reduce STAT3 protein expression and block IL-6-dependent EMT of laryngeal squamous cell carcinoma ( 90 ). These findings identify ACTs as novel regulators of STAT3 expression and activity that can target a variety of cancers both alone and in combination with established chemotherapy.

Cancer cells evade apoptosis and many traditional chemotherapeutics are aimed at inducing this form of cell death. Efferth et al. were the first to report that ACTs promote leukemia apoptosis in vitro ( 91 ). Since, ACTs have been shown to induce apoptosis in numerous cancer cell lines via activation of both intrinsic and extrinsic factors ( 83 ). Importantly, immune cells are spared from ACT-induced apoptosis ( 73 , 74 , 92 ), suggesting that side effects such as lymphopenia, which has been associated with poor responses to chemotherapy and prognosis ( 93 , 94 ), may be avoided. However, apoptosis was unaltered in artesunate-treated colorectal cancer patients ( 42 ). A reason for the discrepancy could be that in vitro ACTs are used in concentrations far beyond those achievable in human plasma. Alternatively, ACTs do cause cell death, but via alternative pathways.

Ferroptosis is a caspase-independent programmed cell death that can be triggered through intracellular Fe 2+ accumulation and dysregulation of iron homeostasis ( 95 ). Cancer cells are enriched in iron. Additionally, increased abundance of transferrin receptors indicates poor prognosis and correlates with immune infiltration ( 96 ) suggesting that ferroptosis may selectively kill cancer cells while sparing healthy tissue. ACTs induced intracellular iron accumulation and triggered ferroptosis in NSCL, colon, renal, ovarian, CNS, leukemia, melanoma, prostate, and breast cancer cell lines by altering the mRNA expression of over 20 genes regulating iron homeostasis ( 80 ). Canonical ferroptosis is triggered by lipid ROS generated through lipid peroxidation and opposed by of glutathione peroxidase 4 (GPX4), a promising chemotherapeutic target that reduces toxic lipid peroxides by oxidizing glutathione ( 96 ). Dihydroartemisinin inhibited GPX4 to trigger ferroptosis in glioblastoma in vitro ( 97 ). Ferroptosis is an attractive alternative in inducing cell death especially in apoptosis-resistant, and conventional chemotherapy resistant cancers. ACTs have been shown to induce cell death through ferroptosis in cisplatin-resistant bladder and head and neck cancer cells ( 98 ) in addition to various other cancer subtypes. The emergence of ACTs as inducers of ferroptosis may therefore confer selectivity of these natural biomolecules against cancer with decreased side effect profile compared to conventional chemotherapy. To date, the effect of ACTs on ferroptosis has never been examined in humans, but we propose that it should not be ignored in future ACT therapy clinical trials.

A number of preclinical studies have identified that ACTs inhibit tumor cell growth and viability via autophagy. Autophagy occurs when microtubule-associated protein 1A/1B-light chain 3 (LC3) is incorporated in pre-autophagosomal membranes, where it is acted upon by autophagy related proteins (ATG) to generate LC3-I, LC3-II and mature autophagosomes ( 99 ). ACTs increased LC3, LC3-I, LC3-II and autophagosome maturation in cancer cell lines including, but not limited to, leukemia, esophageal, ovarian, pancreatic, and colon. Target recognition in autophagy is accomplished through autophagy receptors including P62/SQSTM1 (sequestosome 1), whose sustained upregulation or decreased degradation have been linked to tumorigenesis ( 99 ). Dihydroartemisinin decreased P62/SQSTM1 to induce autophagy-mediated death of tongue squamous cell carcinoma ( 100 ). P62/SQSTM1 is a target gene of NF-E2-related factor 2 (Nrf2). The dihydroartemisinin derivative DC32 ( 101 ) and a (NHC)gold(I)–artemisinin hybrid complex ( 102 ) inhibited Nrf2-mediated P62/SQSTM1 transcription. Artesunate activated AMPK (AMP-activated protein kinase) to induce autophagy-dependent apoptosis in bladder cancer cell lines ( 103 ), and suppressed Akt-mTOR signaling to induce in hepatoblastoma senescence ( 104 ). In summary, numerous in vitro studies have established a role for ACTs in increasing autophagy. But, given that autophagy can be either tumorsupportive or tumorsuppressive ( 99 ), caution should be taken when considering ACTs as adjuncts to chemotherapy.

Since resistance to conventional chemotherapeutics is a major contributing factor to patient mortality, agents that sensitize resistant cells to chemotherapy or circumvent resistance altogether are of therapeutic value. Artemisinin acted synergistically with oxaliplatin to decrease tumor growth, migration and invasion of esophageal carcinoma ( 105 ). It also induced DNA damage, autophagy, cell cycle arrest and apoptosis in cisplatin-resistant breast cancer cells ( 106 ). Interestingly, artemisinin-free A. annua extract exhibited potency against triple-negative human breast cancer cells ( 83 ) suggesting that not just artemisinin but A. annua as a whole may be of chemotherapeutic interest. Drug resistance can be circumvented by the covalent linking of two bioactive molecules via hybridization. In two studies, Fröhlich et al. reported that tamoxifen-artemisinin or estrogen-artemisinin hybrids were more potent than the parent drugs or cisplatin against human prostate, breast and cervical cancer cell lines ( 107 ). These results highlight the utility of ACTs not only as adjunct therapy, but as a natural biomolecule that can be utilized in drug hybridization to improve the potency and potentially reduce the resistance of standard chemotherapeutic agents. Furthermore, artemisinin and oxaliplatin synergistically decreased invasion, migration, and tumor growth of esophageal cancer cells ( 105 ).

Berberine

Berberine is an alkaloid found in Berberidaceae and thus the barberry fruit ( Berberis vulgaris ). Berberine use as an antioxidant, chemoprotective and anthelminthic agent in the treatment of infections and skin conditions dates back to 650BC. In modern medicine, berberine is primarily investigated for its potential in controlling metabolic syndrome and associated conditions like obesity, diabetes, hyperglycemia, hyperlipidemia, and cancer ( 108 , 109 ). But low oral bioavailability and complicated pharmacokinetics, which are significantly influenced intestinal microflora, need to be considered. Importantly, the bioactivity of berberine does not stem from the parent molecule, but from its primary metabolites which bioaccumulate ( 110 , 111 ). Thus, despite its low bioavailability, oral berberine could be of therapeutic value through its bioaccumulating metabolites, but perhaps with a loading dose.

Clinical trials of berberine

To date, several clinical trials have examined the effects of berberine, however only a few have done so in the context of cancer and none have tested its cancer chemotherapeutic efficacy. Chen et al. used berberine or placebo in patients with confirmed colorectal adenomas (not carcinomas) who had undergone a complete polypectomy. Berberine reduced risk of recurrent adenoma in the absence of side effects other than constipation ( 48 ). Given that colorectal adenomas are benign, but demonstrate potential for malignant transformation into carcinomas especially in patients with metabolic syndrome and inflammatory conditions ( 41 ), berberine could be effective in preventing the development of these tumors. Notably, none of the adenoma study participants developed carcinoma during the follow-up period ( 48 ) ( Table 1 ).

Potential clinical benefits of phytochemicals are not limited to antineoplastic effects, but include chemo- and radioprotective potential. Berberine exerted protective effects against radiation-induced injury without significant side effects ( 112 , 113 ). Berberine or placebo were administered to patients treated from seminoma, lymphoma and cervical cancer via abdominal radiotherapy. Although the study was small, it did demonstrate that berberine significantly delayed onset and reduced the incidence and severity of radiation-induced acute abdominal syndrome ( 112 ). Berberine also reduced the incidence of radiation-induced lung injury, the abundance of TGF-β and intercellular adhesion molecule-1 (ICAM-1), and thus inflammation in radiotherapy-treated NSCL patients ( 113 ). Neither clinical trial included mechanistic insight, but they did provide a proof-of-principle for the protective role of berberine as an adjunct to radiation. Clinical evidence of the protective role of berberine and other biomolecules discussed here is presented in ( Table 3 ).

Immunomodulatory effects of berberine

Radiation therapy leads to inflammasome activation in macrophages, dendritic, NK, B and T cells. Moreover, NLRP3 inflammasome activation accelerates inflammation and fibrosis, induces pyroptosis and is necessary for radiation-induced injury ( 122 ). Berberine inhibited NLRP3 inflammasome activation and pyroptosis in nonalcoholic steatohepatitis, a condition associated with liver cancer development ( 123 ). It inhibited influenza-induced NLRP3 inflammasome activation in macrophages by inhibiting mitophagy and mitochondrial ROS production ( 124 ). Berberine also inhibited AMPK-dependent autophagy in adipose tissue macrophages, which reduced palmitate-induced inflammasome activation, IL-1β release, insulin resistance ( 125 ). Beneficial effects of berberine-mediated inflammasome inhibition have been reported in Parkinson’s disease, endovascular injury, drug-induced hepatotoxicity and diabetic nephropathy (by suppressing epithelial to mesenchymal transition (EMT) ( 126 ). Given the inhibitory effects of berberine on inflammasome activation and the importance of this pathway in radiation-induced injury, we propose that berberine may protect patients from radiation-induced lung and abdominal injury ( 112 , 113 ) by inflammasome inhibition. Studies on the effects of berberine on cancer through inflammasome modulation are still limited. However, Yao et al. reported the berberine inhibited the NLRP3 inflammasome; reduced secretion of proinflammatory interleukins and TNF-α; and inhibited tumor colony formation and migration in triple-negative breast cancer cells in vitro ( 127 ).

Molecular docking analysis revealed that berberine binds STAT3 directly to inhibit STAT3 phosphorylation and dimerization. Berberine-mediated STAT3 inhibition reduced IL-10 expression in melanoma cells; reprogrammed M2 tumor-associated macrophages to a tumorsuppressive M1 phenotype; increased tumor cell recognition by T cells; and ultimately reduced tumor burden in melanoma-bearing mice ( 128 ). Berberine also inhibits the expression of protein arginine deaminase 4 (PADI4) in macrophages. Overexpression of PADI4 induces macrophage activation and promotes EMT. PADI4 expression is directly correlated to the number of lung nodules in a murine model of lung cancer. By reducing PADI4 expression, berberine dose-dependently reduced lung nodules and improved lung function suggesting a putative tumor-preventative role of berberine ( 129 ). Inflammation, oxidative stress and intestinal flora imbalance are associated with colitis and colorectal cancer development and progression. Given that fecal excretion is the predominant route of berberine excretion, berberine can reach the colon in sufficient concentrations to achieve efficacy against inflammation and malignancy ( 130 ). Berberine remodeled intestinal microflora to favor beneficial over pathogenic bacteria and reduce proinflammatory cytokine secretion. Berberine-induced inhibition of the TLR4/NF-κB/IL-6/STAT3 pathway reduced malignant transformation and cancer recurrence in colitis-associated colorectal carcinoma models ( 131 , 132 ).

Tumor progression is associated with immunoediting, which is promoted by increased PD-L1 expression within tumors. Liu et al. recently reported a novel function for berberine as a PD-1/PD-L1 checkpoint inhibitor. Berberine directly bound to the fifth subunit of the COP9 signalosome complex (CSN5) and inhibited CSN5-mediated PD-L1 deubiquitylation and stabilization within NSCL cells. Berberine-induced PD-L1 degradation increased cancer cell susceptibility to tumor-infiltrating T cells in mouse xenografts. Additionally, berberine limited the tumorsupportive functions of Treg and MDSCs further solidifying its potential as a chemotherapeutic and immunomodulating agent ( 133 ) ( Table 4 ).

Summary of the antineoplastic mechanisms of berberine

Berberine has been shown to promote tumor cell apoptosis, cell cycle arrest, mitochondrial dysfunction, ROS generation, apoptosis and autophagy in a variety of in vitro and in vivo cancer models ( 109 , 134 ). A detailed examination of these studies has been performed recently ( 109 ), and is beyond the scope of this review.

Berberine inhibited colorectal adenoma transformation to colorectal cancer by binding to pyruvate kinase isozyme type M2 (PKM2) and inhibiting the Warburg effect ( 137 ). Berberine-mediated inhibition of STAT3 decreased MMP2/9 expression to inhibit metastasis of established colorectal carcinomas ( 138 ). Protective effects of berberine have also been reported for other gastrointestinal cancers including gastric ( 139 ) and cholangiocarcinoma ( 140 , 141 ). Notably, molecular docking experiments identified STAT3, Akt, Erk and EGFR as putative berberine binding partners ( 141 ), suggesting that berberine may act as a multi-kinase inhibitor.

Berberine targets nine different oncomiRs including miR-17-5p and miR-21 which upregulate oncogenic pathways including STAT3, NF-κB, PI3K/Akt, PTEN and downregulate tumorsuppressive programmed cell death 4 (PDCD4) among others ( 136 , 142 , 143 ). Berberine downregulated miR-21 to induce expression of PDCD4, which in turn promoted multiple myeloma apoptosis by suppressing p53 ( 136 ). Similarly, berberine induced cytotoxicity in bladder cancer cells via miR-17-5p upregulation. Notably, p53 expression determined the type of berberine-induced cell death, such that p53-expressing cells underwent senescence, while p53-deficient cells – apoptosis ( 143 ), suggesting that berberine exhibits context-dependent pleiotropy. miR-17-5p is downregulated in cervical cancer and malignant pleural mesothelioma. But increased miR-17-5p expression is a poor prognostic indicator for colon, colorectal, gastric, pancreatic, nasopharyngeal, and lung cancers ( 142 ). Thus miR-17-5p acts as a double-edge sword in cancer progression and the cell-specific effects of berberine on this miRNA may determine the efficacy of berberine against different malignancies.

Berberine protected against intestinal injury induced by the conventional chemotherapeutic methotrexate. Mechanistically, berberine protected against methotrexate-induced upregulation of JAK1, STAT3 and Gsk-3β, downregulation of Akt/mTOR, oxidative stress and inflammation ( 144 ). Similarly, berberine ameliorated doxorubicin toxicity, and a berberine/doxorubicin nanoformulation synergistically decreased tumor growth and metastasis in breast cancer xenografts ( 145 ). But berberine also demonstrated synergistic effects with conventional chemotherapeutics. Berberine and 5-fluoruracil synergistically inhibited STAT3 and surviving to induce gastric cancer cell death ( 146 ). Berberine induced autophagy in NSCL cells with resistance to EGFR inhibitors like icotinib. Berberine synergized with icotinib to decrease EGFR expression and activity, induce autophagy and apoptosis, and reduce metastasis in xenograft models ( 147 ). Similarly, berberine inhibited EGFR-induced STAT3 activity to increase gastric cancer sensitivity to the EGFR inhibitors cetuximab and erlotinib ( 148 ). Moreover, berberine reversed resistance to cisplatin ( 149 ) of gastric cancer ( 149 ); to doxorubicin of lung ( 150 ) and breast cancers ( 145 , 151 , 152 ); and to temozolomide of glioblastoma ( 153 ). The rapidly mounting evidence of the chemosensitizing potential of berberine warrants the inclusion of this phytochemical as an adjunct to conventional chemotherapy.

Bioavailability and efficacy of berberine have been enhanced through novel formulations. 9-O-substitutted berberine derivatives decreased leukemia cell proliferation 30 fold in comparison to non-substituted berberine and enhanced apoptosis 6 fold ( 135 ). 9-/13-dodecyl berberine derivatives displayed selective photocytotoxicity, destabilized the mitochondrial membrane potential and increased ROS production, cell cycle arrest and apoptosis of liver, colon and bladder cancer cell lines. Notably efficacy was proportional to alkyl-chain length and lipophilicity. Importantly, substituted derivatives exhibited cytotoxicity against colon cancer, but not healthy cells ( 154 ).

Clinical safety and efficacy for berberine have been established in diabetes and metabolic syndrome ( 108 , 155 ), but as of today its antineoplastic efficacy has not be tested in patients. The promising effects of berberine in metabolic syndrome together with the correlation between obesity and metabolic syndrome with carcinogenesis ( 108 , 155 ) establish a role for berberine in preventative medicine ( 123 ). Berberine could be of great promise in several stages of tumorigenesis. It is a novel PD-L1 checkpoint inhibitor with direct immunomodulatory actions that can promote T-cell-mediated cytolysis in resistant cancers ( 133 ). It has demonstrated synergistic and sensitizing effects with traditional chemotherapeutics. But, berberine is also protective and has already proven efficacious in preventing radiation-induced injury in patients ( 112 , 113 ). We conclude that berberine is of great promise as a chemotherapeutic or radiotherapy add on.

Triptolide and triptolide analogues

Triptolide is a diterpene triepoxide derived from Tripterygium wilfordii with antimicrobial, anti-inflammatory, immunomodulatory and antitumor effects. However, its therapeutic potential is hindered by water insolubility and a narrow therapeutic index due to substantial hepato-, cardio- and nephrotoxicity. An array of triptolide derivatives aimed at improving bioavailability, limiting toxicity, but retaining efficacy has been synthesized. Modifications at C14 of triptolide have yielded the most promise and notable examples are (5R)-5-hydroxytriptolide (LLDT-8) and the prodrug minnelide ( 156 ).

Clinical trials of triptolide analogues

LLDT-8 has not yet been tested on cancer patients, but has yielded promising phase II results in rheumatoid arthritis patients with poor responses to the standard-of-care methotrexate ( 156 ). Minnelide is currently undergoing a phase I in patients with advanced GI tumors ( NCT01927965 ) and a multicenter phase II trial in patients with refractory pancreatic cancer ( NCT03117920 ). Recruiting is ongoing for a phase II trial for advanced refractory pancreatic adenosquamous carcinoma ( NCT04896073 ), as well as for phase I trials for EGFR-mutant NSCL ( NCT05166616 ), for relapsed or refractory leukemia ( NCT03760523 ) and in conjunction with paclitaxel for solid tumors ( NCT03129139 ). There is limited trial reporting, but so far sufficient bioavailability of minnelide and its metabolite triptolide were achieved, with complete elimination of triptolide within 6 hours. A common side effect was reversible, rapid onset neutropenia, while reversible acute cerebellar toxicity was reported in two patients ( 157 ). Not all triptolide derivatives are suitable for clinical use as exemplified by F60008, whose high pharmacokinetic variability between patients with advanced solid tumors led to two fatalities, resulting in the termination of a phase I clinical trial ( Table 1 ).

Immunomodulatory effects of triptolide and triptolide analogues

Despite the sparse clinical trial data, triptolide and its analogues are included in this review for their immunomodulatory potential. Triptolide is an immune checkpoint inhibitor. It inhibits IFN-γ-induced expression of PD-L1 on the surface of glioma ( 158 ), breast ( 159 ) and oral cancer cells ( 160 ). Triptolide-mediated repression of PD-L1 reduced tumor growth of patient-derived tumor xenografts and was mediated via inhibition of JAK2/STAT ( 160 ). Triptolide-induced downregulation of glioma PD-L1 increased IFN-γ and IL-2 and reversed glioma-induced inhibition of CD4+ helper T cells ( 158 ). Taken together these findings suggest a therapeutic potential of triptolide in reversing T cell exhaustion, and thus, immune evasion of tumor cells. Further studies are needed to elucidate the effect of triptolide, if any, on other immune checkpoints such as CTLA-4.

Triptolide can also remodel the TME in vivo . Triptolide inhibited melanoma growth by reducing Foxp3 mRNA levels in the spleen and auxiliary lymph nodes, as well as TGF-β, IL-10, VEGF and Tregs within the TME ( 161 ). Triptolide significantly increased the populations of monocytes, macrophages, B and T cells in a murine leukemia model ( 162 ). Recently, triptolide downregulated CXCL12 in subcutaneous colon cancer tumors, which in turn reduced TAM infiltration, reduced tumorsupportive M2 polarization, and decreased the expression of CD206 and IL-10 ( 163 ).

By reversing immune checkpoint inhibition and tumorsupportive immunity in the TME, triptolide analogues are attractive adjuncts to cancer chemotherapeutics especially for advanced-stage, chemotherapy-resistant cancers. Despite this, traditionally triptolide is used as an immunosuppressor with therapeutic potential in autoimmune diseases, which are linked to predisposition to leukemia and lymphoma ( 164 ). Triptolide inhibited IL-6/STAT3 to reduce ascites formation and organ infiltration of primary effusion lymphoma ( 165 ). Mutations in FIP1L1-PDGFRα (FIP1-Like-1 (FIP1L1)-platelet-derived growth factor receptor α (PDGFRα) confers resistance to imatinib in hypereosinophilic syndrome. Triptolide suppressed FIP1L1-PDGFRα expression, as well as downstream activation of STAT3, Erk and Akt to induce apoptosis of imatinib-resistant hypereosinophilic syndrome cells ( 166 ). Additionally, triptolide was cytotoxic to acute myeloid leukemia cells carrying the oncogenic fusion gene UBA2-WTIP ( 167 ). Since fusion gene expression is inherently limited to cancer cells, by targeting fusion gene function triptolide may exhibit selective toxicity against chemotherapy-resistant malignancies.

Promising radioprotective effects of triptolide have emerged from preclinical studies. Triptolide inhibited of IKKβ/NF-κB-mediated lysyl oxidase (LOX) production to reduce profibrotic IL-1β, IL-13 and TGF-β to diminish radiation-induced pulmonary fibrosis, and to improve mouse survival following radiation ( 168 , 169 ). Triptolide additionally reduced pulmonary fibrosis by reducing alveolar macrophage infiltration, phagocytosis and proinflammatory cytokine and chemokine production ( 170 ). Thoracic radiation shows therapeutic benefit in the treatment of breast, lung and esophageal cancers, but is accompanied by pneumonitis in early stages and pulmonary fibrosis in late stages, which reduce quality of life and patient survival. To date, effective therapy is lacking highlighting the urgent need for novel therapeutic modalities ( 3 ). Triptolide itself is too toxic to be a viable therapeutic option, but if less toxic triptolide analogues show similar radioprotective roles, they may prove viable candidates for translational medicine ( Table 5 ).

Summary of the antineoplastic effects of triptolide and triptolide analogues

In vitro an in vivo studies have established that triptolide is capable of eliciting direct antitumor effects by inhibiting proliferation, dysregulating metabolism, promoting ROS generation and autophagy, apoptosis and pyroptosis ( 156 , 173 – 176 ). Although preclinical effects are clear and have led to clinical trials, the limiting parameter of human triptolide use is its toxicity, which should not be ignored. For chemotherapeutic success, studies on triptolide should focus on its synergistic and chemosensitizing actions, as well as, on reformulation aimed at minimizing systemic toxicity and targeted-tumor release. We focus on such preclinical studies in our discussion below.

Minnelide and triptolide demonstrated synergistic effects with gemcitabine and Nab-paclitaxel pancreatic cancer animal models and cell lines. Specifically for pancreatic cancer, both have been described as inhibitors of super-enhancers, which are tumorigenic regulatory DNA sequences that function as binding platforms for transcription factors and coactivators ( 177 , 178 ). Triptolide/paclitaxel and minnelide/paclitaxel/gemcitabine combinations decreased cell viability, increased apoptosis, and cell cycle arrest in vitro and in vivo respectively ( 179 , 180 ). Notably, synergistic effects were absent in cells with silenced NF-κB suggesting that triptolide-mediated inhibition of NF-κB is necessary for synergism ( 179 ). Triptolide-induced sensitization of pancreatic cancer cell lines to gemcitabine was similarly dependent on NF-κB inhibition by triptolide ( 181 ). Addition of minnelide to gemcitabine-paclitaxel therapy allowed for the administration of lower conventional-chemotherapeutic doses, while decreasing cancer progression and metastasis, but increasing survival of tumor-bearing mice ( 180 ). Synergistic effects of triptolide have also been observed with idarubicin in acute myeloid leukemia ( 171 , 172 ); with cisplatin in gastric ( 182 ); with 5-fluorouracil ( 183 ) and with oxaliplatin ( 184 ) in colon; with paclitaxel in lung ( 185 ); and with gemcitabine in bladder cancers ( 186 ).

Triptolide potentially sensitizes resistant cancers to conventional chemotherapeutics in vivo . Minnelide inhibited DNA repair and reversed resistance to oxaliplatin of pancreatic adenocarcinoma ( 187 ) and to cisplatin in triple-negative breast cancer cells ( 188 ). Triptolide inhibited Toll-like receptor 4 (TLR4)/NF-κB signaling to enhance pancreatic-cancer-cell-line sensitivity to gemcitabine, which resulted in decreased tumor cell proliferation, viability and xenograft tumor volume ( 181 ). Similarly, triptolide-induced inhibition of NF-κB reversed resistance to taxol in lung adenocarcinoma ( 189 ). Taken together these findings identify NF-κB pathway inhibition as a key mediator of triptolide-induced sensitization of malignant cells to conventional cancer chemotherapy. Similar effects of chemotherapy sensitization were observed when using triptolide on doxorubicin-resistant breast ( 190 ), cisplatin-resistant ovarian ( 175 , 191 ) and bladder ( 192 ), and cisplatin- and 5-fluoruracil-resistant liver ( 193 ) cancers.

Triptolide derivatives with improved toxicity and bioavailability like minnelide are currently in clinical trials. However, minnelide is a prodrug of triptolide, and although its bioavailability has convincingly been improved, serious side effects have been reported in humans. Targeted drug delivery strategies take advantage of features that are unique to cancer cells. Recently, Kong et al. took advantage of the increased micropinocytosis and lysosomal activity of KRAS-mutant pancreatic cancer cells to directly deliver triptolide encapsulated in ultra-pH-sensitive micelles (T-UPSM). T-UPSM demonstrated rapid intratumor drug release with superior safety and antitumor efficacy in KRAS mutant mice ( 194 ). Triptolide conjugated to a generation-4 hydroxyl-terminated PolyAMidoAMine dendrimer was targeted to TAMs in an orthotopic glioblastoma model. Dendrimer-conjugated triptolide repolarized TAMs to a tumorsuppressive phenotype, decreased glioblastoma burden, while simultaneously limiting triptolide-associated cardiac and hepatic toxicity ( 195 ). Safety and efficacy of various dendrimers is currently being evaluated for a number of diseases with optimistic results ( 196 ) suggesting that dendrimer-triptolide conjugates may enter clinical testing soon. A nanocarrier system carrying triptolide and the active metabolite of irinotecan, SN38 inhibited NF-κB in both gastric cancer cells and cancer-associated fibroblasts (CAF) to inhibit CAF-induced cancer cell proliferation, migration and SN38-resistance, resulting in significant reduction in tumor burden in vivo ( 197 ). A biomimetic triptolide-paclitaxel nanodelivery system also caused significant antineoplastic effects against gastric cancer ( 198 ). Biomimetic nanotriptolide was also used with sorafenib in the treatment of hepatocellular carcinoma in vivo resulting in potent proapoptotic synergy resulting in reduced tumor burden ( 199 ).

Graviola

Graviola ( Annona muricata ) is a fruit tree of the tropical and subtropical regions of the Americas. It is used in indigenous medicine against cancer, parasites, malaria, and depression. A. muricata extracts can be derived from the fruit, the seeds, the roots or the leaves of the plant and consist of over 200 phytochemicals including but not limited acetogenins, flavonols, phenolic compounds and glycopeptides ( 200 ). We will first review studies utilizing graviola extracts and then we will focus on the anticancer properties of select graviola phytochemicals.

Clinical trials of graviola

As of today, graviola has been utilized in only one clinical trial, while two more – are currently recruiting. Graviola leaf extract or placebo was ingested by colorectal carcinoma patients who had already undergone surgical treatment. Safety was established as bone marrow, weight, nutritional status, liver and kidney function were not affected ( 49 ). Serum from study participants decreased colorectal carcinoma cell populations in vitro , demonstrating antineoplastic effects of bioavailable graviola phytochemicals and metabolites ( 50 ). However, no pharmacokinetic data, mechanistic insight, nor long-term effects of graviola on disease outcome or patient quality of life were reported ( 49 , 50 ). Anecdotal evidence of the antitumor effects of graviola comes from a case report of a patient with refractory metastatic breast cancer, who achieved disease stability for 5 years after self-medicating with a daily ingestion of graviola leaf extract ( 201 ). As of right now, the clinical evidence of the anticancer efficacy of graviola is inconclusive. But, a combination of graviola and ellagic acid may prevent preneoplastic cervical lesion development as lower incidence of abnormal Pap smears was reported HPV-infected women treated for 1 year ( 202 ) ( Table 1 ).

Immunomodulatory effects of graviola

Graviola extracts have demonstrated immunomodulatory potential in vitro and in vivo . Graviola extracts increased TNF-α and IL-1β expression in cultured macrophages via MAPK activation suggesting that graviola may boost macrophage immune activity ( 203 ). Najmuddin et al. showed that graviola extracts increased CD8+, CD4+ and Nk1.1 cells in a breast cancer mouse model suggesting that graviola may potentiate anticancer immunity. In breast cancer cells, graviola reduced Fas ligand, proinflammatory IL-1β, TNF-α, nitric oxide and malondialdehyde, a biproduct of lipid peroxidation associated with DNA damage. Graviola-extract treatment increased tumor cell apoptosis, reduced tumor cell proliferation and metastasis, reduced angiogenesis and tumor burden in vivo ( 204 ). Taken together these results demonstrate that graviola exerts direct effects on breast cancer cells, as well as increases antitumor immunity ( Table 6 ).

Summary of the antineoplastic effects of graviola

The antineoplastic effects of graviola have been elucidated in a plethora of in vitro and in vivo studies and have been extensively reviewed elsewhere ( 200 ). Graviola has demonstrated significant potency against breast cancer in vitro and in vivo . In vitro , it induced apoptosis in breast cancer, but not normal kidney cells ( 205 ), suggesting that graviola exhibits selective anticancer cytotoxicity. Similar findings were observed with ionic liquid, leaf-methanol, as well as seed-methanol extracts of graviola, which additionally induced G0/G1 cell cycle arrest ( 206 , 207 ). Furthermore, Daddaiouaissa et al. showed that although less potent, ionic liquid graviola extract was more efficacious than taxol in inducing growth arrest ( 206 ). Graviola decreased estrogen receptor (EGFR) expression, tumor marker (CA15-3) antigenicity, ROS production and lipid peroxidation, but promoted apoptosis in 7,12-dimethylbenz[a]anthracene (DMBA)-induced breast cancer in vivo ( 208 ). Graviola acted alone, but also synergistically, with doxorubicin to induce cell cycle arrest and decrease viability of triple-negative breast cancer in vitro ( 209 ). Graviola-mediated effects in triple-negative breast cancer cells may be through inhibition of EGFR signaling ( 210 ).

Antiproliferative and proapoptotic activities of various graviola extracts have been observed against prostate cancer cells. Graviola pulp fruit extract decreased HIF-1α expression and NADPH oxidase activity to inhibit proliferation and colony formation of prostate cancer cell lines ( 211 ). Graviola leaf extract gavage of male rats increased apoptosis in the testes and glandular epithelium, decreased seminal index and reduced prostate size ( 212 ). Graviola synergized with doxorubicin to induce ROS production, apoptosis and potentially inhibit metastasis by downregulating VEGF ( 213 ). Furthermore, synergistic effects of graviola and low-dose radiation resulted in reduced TGF-β and CD44 expression, increased apoptosis, and overall reduced solid tumor burden in mouse xenografts ( 214 ). Graviola suppressed mucin 4 (MUC4) and HIF-1α-mediated expression of glycolytic genes and VEGF to promote tumor cell necrosis, but decrease metastasis, of orthotopically-implanted pancreatic tumors ( 215 ). MUC4 is selective tumor antigen of pancreatic, ovarian and head and neck carcinoma MUC4 vaccines are investigated as novel anticancer therapies ( 216 ). MUC4 has also been implicated in antitumor immunity, however, its exact function in this context is still unclear ( 216 ).

Over 200 phytochemicals have been identified in graviola extracts with most of the antitumor effects being attributed to flavonoids and acetogenins. Acetogenins are cytotoxic against carcinomas of the breast, pancreas, prostate, colon, liver and kidney in vitro and in vivo ( 200 ). Annonacin, a potent complex 1 inhibitor, inhibited EGFR activity when used alone, and sensitized multidrug-resistance breast cancer cells to tamoxifen to reduce xenograft tumor burden ( 217 ). Annosquacin and bullatacin targeted multidrug-resistance breast cancer by modulating MAPK and depleting ATP respectively ( 218 , 219 ). But, acetogenins exhibit significant neurotoxicity induce atypical Parkinsonism in humans ( 220 ). Thus, although acetogenins are largely responsible for the antitumor efficacy of graviola, utilization of these in the clinic may lead to significant toxicity. Acetogenin-enriched graviola extracts exhibited superior potency and efficacy to flavonoid-enriched extracts, but with significant lethality. Importantly, co-administration of the two extracts did result in antitumor cytotoxicity, but with reduced side effects and lethality. The authors attributed the protective role of flavonoid-enriched extracts to rutin-mediated induction of P glycoprotein, which promoted acetogenin efflux from the brain ( 221 ). This seminal study demonstrates that the temptation to utilize the most active ingredients of graviola in developing novel chemotherapeutics should be avoided, and that whole extracts should be favored instead. Perhaps nature knows best.

Graviola extract has been recently formulated with silver nanoparticles aiming at targeted drug delivery with limited toxicity. Graviola-silver nanoparticles (GRANAg) promoted apoptosis, decreased proliferation and increased autophagy via IL-1β reduction and NLRP3 inflammasome activation ( 222 ). GRANAg peel extract demonstrated superior potency than graviola leaf extract on colon, breast and melanoma cell lines ( 223 ). Furthermore, GRANAg induced cell cycle arrest in NSCLC ( 224 ) and promoted apoptosis in cervical and prostate cancer cell line ( 225 ). In vivo studies are still needed to establish GRANAg potency, efficacy and safety before ascertaining its suitability for clinical translation.

Despite the limited clinical trial data, graviola has demonstrated safety and bioavailability in cancer patients. Graviola has consistently demonstrated proapoptotic, antiproliferative and immunomodulatory antitumor activity, but large-scale clinical trials are urgently needed in order to fully elucidate its chemotherapeutic potential.

Epigallocatechin gallate

A number of epidemiological studies and meta-analyses have linked green tea consumption to reduced prostate, breast, thyroid, colorectal and stomach cancer risk ( 226 ). Although green tea is a complex mixture of phytochemicals, EGCG has been documented as the most abundant and most bioactive ( 227 ), and thus has been studied extensively for its chemopreventative and chemotherapeutic effects ( 226 ).

Clinical trials of EGCG and EGCG-enriched green tea extracts

A number of clinical trials have identified green tea extract, and EGCG in particular as a potential cancer chemopreventative phytochemical.

Green-tea-extract supplementation for 1 year in over 1000 healthy postmenopausal women with increased risk of breast cancer significantly reduced percent mammographic density (PMD) (i.e. proportion of fibroglandular tissue within the breast) in younger women ( 51 ). Importantly, women with more than 75% PMD are 4-6fold more likely to develop breast cancer ( 228 ), and the age-dependent EGCG effect was similar to what had been previously reported for tamoxifen ( 40 , 51 ). EGCG demonstrated antiproliferative effects in patients with early breast cancer, where decreased Ki-67 correlated with high plasma EGCG levels ( 229 ). EGCG is metabolized by catechol-O-methyl transferase (COMT) and UDP-glucuronosyltransferase (UGT). Epidemiological studies revealed that green tea drinkers, especially those with low COMT-mediated catechin metabolism, exhibit lower PMD and lower breast cancer risk ( 52 ). Notably, COMT-mediated metabolism also reduced anticarcinogenic efficacy against prostate cancer ( 230 ). This findings are contradicted by a small phase II trial of EGCG-containing polyphenol formulation of green tea (Polyphenon E) in bladder cancer patients, where the pharmacogenomic relationship between EGCG pharmacokinetics and COMT or UGT1A1 polymorphisms was absent ( 53 ). Polyphenon E reduced PCNA ( 53 ) warranting further investigation of EGCG efficacy against bladder cancer. However, lack of EGCG efficacy has been reported in patients with high-grade prostatic intraepithelial neoplasia and/or atypical small acinar proliferation ( 54 ), in patients of high risk of recurrent colonic neoplasia ( 55 ), and in patients with colorectal adenomas ( 56 ). EGCG-enriched double-brewed green tea also did not protect against recurrence women with advance-stage ovarian cancer who had previously achieved complete response with surgical and chemotherapeutic interventions ( 57 ). EGCG did show promising results in chronic lymphocytic leukemia (CLL). EGCG supplementation resulted in a sustained decline in lymphocyte numbers and/or lymphadenopathy in asymptomatic Rai stage 0-II CLL patients ( 58 ). Furthermore, in Rai stage 0 CLL patients, EGCG reduced circulating Tregs, suggesting that EGCG may control lymphocytosis and delay disease progression at early disease stages ( 59 ). In summary, clinical trial data demonstrate EGCG-mediated chemoprotection against CLL, breast and bladder cancers, but not against prostate, colorectal or ovarian cancers ( Table 1 ).

EGCG has also demonstrated radioprotective potential in the clinic. It alleviated acute radiation-induced esophagitis in advanced, unresectable lung ( 114 ) and in esophageal cancer patients ( 115 ). Similar results were observed for post-resection radiotherapy-induced dermatitis in breast cancer patients ( 116 ). EGCG mouthwash reduced radiation-induced oral mucosal injury in radiotherapy-treated head and neck cancer patients in phase I ( 117 ). Overall, EGCG has demonstrated significant efficacy in reducing the incidence and severity of radiation-induced injury without significant adverse effects suggesting that it should be considered as an adjuvant to radiotherapy ( Table 3 ).

Immunomodulatory effects of EGCG

EGCG-mediated radioprotection likely stems from its anti-inflammatory effects, which have ameliorated inflammatory conditions including multiple sclerosis, lupus nephritis, rheumatoid arthritis and colitis in vivo ( 227 ). EGCG binds to the extracellular domain of the 67-kDa laminin receptor (67LR) ( 231 ), a non-integrin cell surface receptor, to inhibit TLR4 signaling via EGCG/67-kDa-induced expression of Tollip, a negative regulator of TLR4. This inhibited MAPK and NF-κB-mediated expression of proinflammatory cytokines and dendritic cell maturation ( 232 ). EGCG can also inhibit NF-κB activity directly, through a covalent interaction with NF-κB-p65 sulfhydryls ( 233 ). Some additional anti-inflammatory functions of EGCG include inhibition of LPS-induced M1-to-M2 macrophage polarization ( 234 ), and inhibition of activator-protein-1-mediated proinflammatory cytokine production in lymphocytes ( 235 ). Molecular docking studies have identified that EGCG, and also curcumin, directly bind NRLP3 components to inhibit inflammasome assembly ( 236 ), which can be triggered by radiation. EGCG exhibited radioprotective effects in both rat hippocampi and intestinal epithelia. These effects were mediated by ROS scavenging, activation of the Nrf2- antioxidant pathway and Bcl-2 ( 237 , 238 ).

EGCG also promotes anticancer immunity by inhibiting STAT3 activity in immune cells. EGCG reduced STAT3 and CXCL8 expression in colon-cancer-patient-derived neutrophils to inhibit the formation of neutrophil extracellular traps and suppress colon cancer migration in vitro ( 239 ). EGCG remodeled breast cancer TME in vivo by increasing the numbers of tumorsuppressive lymphocytes, but inducing MDSC apoptosis and alleviating MDSC-mediated tumorsuppression ( 240 ). Another mode by which ECGG promotes anticancer activity and immunotherapy is through the inhibition of PD-L1 as shown in NSCL mouse xenografts ( 241 ) ( Table 7 ).

Summary of the antineoplastic effects of EGCG

A critical target of EGCG is 67LR, which is overexpressed in cancers including of the blood, prostate, breast, bile duct, pancreas, and colon, and has been associated with tumor cell migration, invasion, and metastasis ( 244 ). EGCG inhibited EMT-like transition of glioblastoma ( 245 ) It inhibited melanoma growth and proliferation via 67LR-mediated activation of the tumor suppressor merlin ( 246 ). EGCG/67LR-mediated dephosphorylation and activation of myosin phosphatase target subunit (MYPT1) results in myosin II regulatory light chain (MRLC) inactivation and overall inhibition of cancer cell cytokinesis ( 247 ). EGCG suppressed STAT3 transcription in colorectal cancer cell in vitro to inhibit migration, but promote apoptosis ( 248 ) EGCG/67LR promoted apoptosis of multiple myeloma, acute and chronic myeloid leukemias via multiple downstream signaling cascades including p38-MAPK/JNK and JAK2/STAT3 ( 242 – 244 ). EGCG/67LR inhibited phosphodiesterase 5 (PDE5) to increase cGMP levels and induce multiple myeloma cell death via PKCδ and acid sphingomyelinase ( 243 ). Notably, PDE-overexpressing breast, pancreatic, and gastric cancer cells are resistant to EGCG-induced apoptosis. Co-administration of PDE5 inhibitors, including sildenafil and vardenafil, sensitized cells to EGCG and inhibited xenograft tumor growth. EGCG/PDE5-inhibitor combination therapy also reduced EGCG dosage requirements and decreased EGCG-induced hepatotoxicity ( 243 , 249 ). Finally, EGCG reduced metastasis of nasopharyngeal carcinoma cells through Src-mediated downregulation of MMPs ( 250 ). EGCG also remodels the TME to inhibit cancer development and progression. Notably, it inhibited adipogenesis and homing of triple-negative breast cancer cells ( 251 ). EGCG also synergized with curcumin to reduce tumor-supportive endothelial transition. EGCG/curcumin also inhibited JAK/STAT3 in tumor endothelial cells to inhibit angiogenesis and colon cancer metastasis ( 252 ).

EGCG targeted STAT3 to downregulate multidrug resistance 1 (MDR1) or c-Myb and increase sensitivity to cisplatin of cisplatin-resistant oral and ovarian cancers ( 253 , 254 ). EGCG reduced cisplatin-induced ototoxicity ( 255 ). Taken together, these data demonstrate that EGCG could act as an adjunct to cisplatin to reduce chemotherapeutic resistance and cisplatin-induced hearing loss.

Curcumin

Curcumin is a polyphenol derived from turmeric, a spice made from the roots of Curcuma longa . Turmeric has a long history of use as a remedy in Ayurveda and traditional Chinese medicine. Perhaps it is the historical significance of turmeric which sparked the very large volume of research aimed at evaluating the potential of curcuminoids as antioxidant, anti-inflammatory, immunomodulatory and anticancer agents ( 256 – 258 ). Given the overwhelming number of studies and significant anticancer activity against different cancers types in vitro and in vivo ( 257 ), curcumin cannot be ignored in this review. Due to its preclinical success and safety even in relatively high doses ( 259 ), curcumin has been clinically tested as an adjuvant for chemotherapy ( 61 , 63 , 64 ). Despite extensive research and a total of 75 human clinical trials, the clinical efficacy of curcumin against cancer is still inconclusive. We will briefly discuss these findings here, and attempt to identify reasons for the difficulty in translating curcumin into clinical use.

Clinical trials have examined the effects of curcumin as an adjuvant to radiotherapy. Curcumin was an effective alternative to radiosensitizing agents in cervical cancer ( 60 ). Curcumin was also examined for its radioprotective potential. In head and neck cancer patients, nanomicellar curcumin significantly reduced pain, severity and occurrence of radiotherapy-induced oral mucositis ( 120 ), while curcumin mouthwash was as effective as benzydamine and delayed oral mucositis occurrence ( 121 ). Results from trials the effects of curcumin in ameliorating radiotherapy-induced dermatitis in breast cancer patients have been lacklustre at best. Topical curcumin administration reduced radiotherapy-induced dermatitis only in a limited number of large breast separation patients ( 118 ), while a much larger trial found no difference between oral curcumin and placebo ( 119 ).

Curcumin has also been used as an adjuvant. Curcumin was found safe in a small cohort of metastatic colorectal cancer patients receiving folinic acid/5-fluorouracil/oxaliplatin (FOLFOX) ± bevacizumab, with half additionally receiving curcumin. It did not significantly affect quality of life and neurotoxicity scores, but did significantly improve overall patient survival. However, caution is warranted as significantly fewer patients in the curcumin arm had more than two metastatic loci, which have been shown to increase the likelihood of death ( 61 ). Again in colorectal cancer, supplementation with curcuminoids improved quality of life and inflammatory markers ESR and CRP ( 62 ), with the latter also noted in breast cancer patients ( 260 ). In metastatic castration-resistant prostate cancer (CRPC), curcumin/docetaxel combination demonstrated safety along with a response in PSA ( 66 ), a prostate cancer marker which may also predict recurrence of it post treatment ( 261 ). Synergy of curcumin and docetaxel in promoting autophagy and apoptosis via PI3K/Akt/mTOR downregulation has been demonstrated in oesophageal carcinoma in vitro ( 262 ). Yet, another human trial showed no significant benefit and was discontinued due to futility ( 67 ). No significant differences were found in off treatment duration, levels of PSA or testosterone, quality of life scores and adverse drug reactions when curcumin was added to intermittent androgen deprivation. However, adverse events and notably PSA progression were reduced in the curcumin treatment group ( 68 ). Coadministration of curcumin and gemcitabine in advanced pancreatic cancer patients yielded inconclusive results, significant gastrointestinal symptoms and forced several patients to decrease or discontinue curcumin ( 63 ). Dhillon et al. also obtained lacklustre results with only 2 of 21 patients demonstrating activity and variable plasma curcumin concentrations highlighting the problem of low oral bioavailability ( 65 ). Interestingly a similar trial (with no controls) using patented curcumin along with gemcitabine found it to be safe with a good response rate in pancreatic cancer ( 64 ) ( Table 1 ).

It can be argued that inconclusive results are due to poor pharmacokinetics and that the safety along with the volume of in vitro evidence, prompt the development of different formulations and not the abandonment of curcumin. Indeed, these problems were circumvented by a clinical trial assessing the tolerability, safety and efficacy of patented IV liposomal curcumin on 32 patients with metastatic cancer. No adverse effects were reported for 26 patients at doses of 100-300mg. However even at that dose, which is significantly lower than in vitro dosing, hemolysis and a decrease in hemoglobin occurred in one and three patients respectively. Furthermore, curcumin plasma concentrations became undetectable rapidly after the infusion. There was no tumor reduction but there was a response in tumor markers ( 69 ).

Perhaps clinical trial focus should be shifted to more potent and bioavailable analogues which can be standardized and have shown greater potency in vitro and in vivo ( 263 – 269 ). Promising analogues include GO-Y30 and WZ30. GO-Y30 modulated TGF-β and Treg function, supressed STAT3 in breast and pancreatic cancer cells, and inhibited the PD-1 immune checkpoint to increase the efficacy of cancer immunotherapy ( 263 – 265 , 267 ). WZ30 demonstrated superior activity to curcumin and synergy with cisplatin ( 266 ). Nanomicellar curcumin/docetaxel achieved targeted and sustained delivery and synergy to reduce cancer cell viability, proliferation and angiogenesis in ovarian cancer xenografts ( 268 ). A similar combination of curcumin and docetaxel synergistically reduced tumor volume in chemoresistant breast and ovarian cancer cells ( 269 ).

Through analogues like GO-Y30, perhaps the immunomodulatory aspect of curcumin can be clarified. Overall curcumin (non-analogue) has been shown to reduce STAT3 activation in both immune and cancer cells and potentiate anticancer immunity. It also exhibited synergy with chemotherapy and decreased resistance. Curcumin inhibited tumor-derived IL-6 to inhibit dendritic cell STAT3 and restore dendritic cell-mediated stimulation of T cell immunity. Coadministration of PD-1/PD-L1 antibodies with curcumin achieved further therapeutic benefit in colon cancer xenografts ( 270 ). Curcumin decreased 5-fluorouracil resistance of gastric carcinoma by suppressing STAT3 in cancer associated fibroblasts ( 271 ). Again, in gastric cancer cells curcumin (and also berberine) given alone or with fluorouracil downregulated pSTAT3, survivin and synergistically decreases cancer cell viability of cancer ( 146 ). Curcumin/IFN-β/retinoic acid combination also showed synergistic antiproliferative effects by suppressing STAT3, Bcl-2, COX-2, MMP-9 and survivin, but upregulating GADD153 and GRIM-19 ( 272 ). Similarly in haematological malignancies curcumin has decreased STAT3 activation in multiple myeloma cells, acute myeloid leukaemia and chronic myelogenous leukemia ( 273 – 275 ). Curcumin also establishes a tumorsuppressive TME by TAM and CTL repolarization. Curcumin-induced TAM1 repolarization to tumoricidal M1 phenotype increase MCP-1 secretion and NK cell recruitment. NK cells in turn secrete IFN-γ and further support M2-to-M1 TAM repolarization. In addition, curcumin-mediated decrease in TGF-β and IL-10 reduced Treg, but increased CTL numbers and antitumor immunity ( 258 ) ( Table 8 ).

In conclusion, curcumin has successfully demonstrated antitumor activity in vivo and in vitro , but clinical trial efficacy, if any, was limited to reduced inflammatory markers, which are not always corelated to improved outcomes. The chasm between preclinical potential and the clinical failure could be attributed to a troubled compound or study design. Variability in curcumin extraction, curcuminoid mixture, poor and unpredictable pharmacokinetics hinder data reproducibility ( 257 ).

Curcumin has been classified as Pan Assay Interference (PAINS) compound and an Invalid Metabolic Panacea (IMPS). PAINS and IMPs are compounds that give false leads through various types of assay interference due to their high reactivity, indiscriminate-binding to substrates, inherent fluorescence or denaturation properties ( 276 ). These issues along with questionable efficacy, bring the utility of curcumin for cancer treatment and its use in further trials into question. Despite this, repeated successful preclinical studies ( 257 ) have led researches to invest in improving the delivery and pharmacokinetics of the molecule, rather than abandoning it. Novel curcumin formulations and analogues are still being made perhaps in hopes of salvaging such an expensive and potentially false lead. While both these avenues appear very promising the pitfalls of curcumin research (PAINS, IMPS, non-standardization) may be lurking yet again and caution is advised for the yellow powder that may have cried wolf.

Concluding paragraph

Natural phytochemicals are known to mediate multiple cancer pathways and reduce tumor growth. This is done through well-known processes such as the induction of ROS and apoptosis, but also through novel targets such as immune modulation, including PD-L1 and STAT3 inhibition. Apart from immunomodulatory agents, natural biomolecules are also able to act synergistically with or offer protection from chemo- and radiotherapy. They are able to augment the tumoricidal capacity of immune cells while also decreasing proinflammatory responses that promote tumorigenesis or injury ( Figures 2 , 4 ). Therefore phytochemicals possess a lot of qualities rendering them attractive as adjuvants to established therapeutic modalities. They also possess some advantages over monoclonal therapies, such as wide sources, less toxic side effects, and diverse immunomodulatory activities. One important area that needs to be resolved, is that phytochemicals have a wide range of pharmacological effects, but their targets and molecular mechanisms relevant to tumor immunity have not been fully researched. Further research for screening natural plant-derived biomolecules for targeted antitumor effects having immunomodulatory properties could be performed with the aid of advanced novel drug delivery technologies, and computer-aided design techniques. Both the guidance of computer assisted drug design and the trojan-horse of drug encapsulation are ideal tools for furthering this field of research and the efficacy of natural biomolecules. We believe that the role of natural biomolecules in tumor immunotherapy and as therapeutic adjuvants is emerging, has great potential and will hopefully lead to clinically applied pharmaceuticals.

Author contributions

All authors listed have made a substantial, direct, and intellectual contribution to the work and approved it for publication.

Conflict of interest

The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

Publisher’s note

All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.

References

1 Emran TB Shahriar A Mahmud AR Rahman T Abir MH Siddiquee Mohd FR . Multidrug resistance in cancer: Understanding molecular mechanisms, immunoprevention and therapeutic approaches . Front Oncol ( 2022 ) 12 : 891652 . doi: 10.3389/fonc.2022.891652 35814435 PMC9262248

2 Nepon H Safran T Reece EM Murphy AM Vorstenbosch J Davison PG . Radiation-induced tissue damage: Clinical consequences and current treatment options . Semin Plast Surg ( 2021 ) 35 ( 3 ): 181–8 . doi: 10.1055/s-0041-1731464 PMC8432995 34526866

3 Arroyo-Hernández M Maldonado F Lozano-Ruiz F Muñoz-Montaño W Nuñez-Baez M Arrieta O . Radiation-induced lung injury: Current evidence . BMC Pulmon Med ( 2021 ) 21 ( 1 ): 9 . doi: 10.1186/s12890-020-01376-4 PMC7788688 33407290

4 Ahmed A Tait SWG . Targeting immunogenic cell death in cancer . Mol Oncol ( 2020 ) 14 ( 12 ): 2994 – 3006 . doi: 10.1002/1878-0261.12851 33179413 PMC7718954

5 Greten FR Grivennikov SI . Inflammation and cancer: Triggers, mechanisms and consequences . Immunity ( 2019 ) 51 ( 1 ): 27 – 41 . doi: 10.1016/j.immuni.2019.06.025 31315034 PMC6831096

6 Valle ASd Naval J Anel A Marzo I . Novel forms of immunomodulation for cancer therapy . Trends Cancer ( 2020 ) 6 ( 6 ): 518–32 . doi: 10.1016/j.trecan.2020.02.015 32460005

7 Schreiber RD Old LJ Smyth MJ . Cancer immunoediting: Integrating immunity’s roles in cancer suppression and promotion . Science ( 2011 ) 331 ( 6024 ): 1565–70 . doi: 10.1126/science.1203486 21436444

8 Chen DS Mellman I . Oncology meets immunology: The cancer-immunity cycle . Immunity ( 2013 ) 39 ( 1 ): 1 – 10 . doi: 10.1016/j.immuni.2013.07.012 23890059

9 Day CL Kaufmann DE Kiepiela P Brown JA Moodley ES Reddy S . PD-1 expression on HIV-specific T cells is associated with T-cell exhaustion and disease progression . Nature ( 2006 ) 443 ( 7109 ): 350–4 . doi: 10.1038/nature05115 16921384

10 Baitsch L Baumgaertner P Devêvre E Raghav SK Legat A Barba L . Exhaustion of tumor-specific CD8+ T cells in metastases from melanoma patients . J Clin Invest ( 2011 ) 121 ( 6 ): 2350–60 . doi: 10.1172/JCI46102 PMC3104769 21555851

11 Ishida Y Agata Y Shibahara K Honjo T . Induced expression of PD-1, a novel member of the immunoglobulin gene superfamily, upon programmed cell death . EMBO J ( 1992 ) 11 ( 11 ): 3887–95 . doi: 10.1002/j.1460-2075.1992.tb05481.x PMC556898 1396582

12 Curran MA Montalvo W Yagita H Allison JP . PD-1 and CTLA-4 combination blockade expands infiltrating T cells and reduces regulatory T and myeloid cells within B16 melanoma tumors . Proc Natl Acad Sci U S A ( 2010 ) 107 ( 9 ): 4275–80 . doi: 10.1073/pnas.0915174107 PMC2840093 20160101

13 Krummel MF Allison JP . CD28 and CTLA-4 have opposing effects on the response of T cells to stimulation . J Exp Med ( 1995 ) 182 ( 2 ): 459–65 . doi: 10.1084/jem.182.2.459 PMC2192127 7543139

14 Kraehenbuehl L Weng CH Eghbali S Wolchok JD Merghoub T . Enhancing immunotherapy in cancer by targeting emerging immunomodulatory pathways . Nat Rev Clin Oncol ( 2022 ) 19 ( 1 ): 37 – 50 . doi: 10.1038/s41571-021-00552-7 34580473

15 Necchi A Joseph RW Loriot Y Hoffman-Censits J Perez-Gracia JL Petrylak DP . Atezolizumab in platinum-treated locally advanced or metastatic urothelial carcinoma: Post-progression outcomes from the phase II IMvigor210 study . Ann Oncol: Off J Eur Soc Med Oncol ( 2017 ) 28 ( 12 ): 3044–50 . doi: 10.1093/annonc/mdx518 PMC5834063 28950298

16 Trinh S Le A Gowani S La-Beck NM . Management of immune-related adverse events associated with immune checkpoint inhibitor therapy: A minireview of current clinical guidelines . Asia Pac J Oncol Nurs ( 2019 ) 6 ( 2 ): 154–60 . doi: 10.4103/apjon.apjon_3_19 PMC6371672 30931360

17 Pillai RN Behera M Owonikoko TK Kamphorst AO Pakkala S Belani CP . Comparison of the toxicity profile of PD-1 versus PD-L1 inhibitors in non-small cell lung cancer: A systematic analysis of the literature . Cancer ( 2018 ) 124 ( 2 ): 271–7 . doi: 10.1002/cncr.31043 PMC5761314 28960263

18 Imai K Matsuyama S Miyake S Suga K Nakachi K . Natural cytotoxic activity of peripheral-blood lymphocytes and cancer incidence: An 11-year follow-up study of a general population . Lancet ‘ ( 2000 ) 356 ( 9244 ): 1795–9 . doi: 10.1016/S0140-6736(00)03231-1 11117911

19 Truxova I Kasikova L Hensler M Skapa P Laco J Pecen L . Mature dendritic cells correlate with favorable immune infiltrate and improved prognosis in ovarian carcinoma patients . J Immunother Cancer ( 2018 ) 6 ( 1 ): 139 . doi: 10.1186/s40425-018-0446-3 30526667 PMC6288908

20 Hwang WT Adams SF Tahirovic E Hagemann IS Coukos G . Prognostic significance of tumor-infiltrating T cells in ovarian cancer: A meta-analysis . Gynecol Oncol ( 2012 ) 124 ( 2 ): 192–8 . doi: 10.1016/j.ygyno.2011.09.039 PMC3298445 22040834

21 Kroeger DR Milne K Nelson BH . Tumor-infiltrating plasma cells are associated with tertiary lymphoid structures, cytolytic T-cell responses, and superior prognosis in ovarian cancer . Clin Cancer Res ( 2016 ) 22 ( 12 ): 3005–15 . doi: 10.1158/1078-0432.CCR-15-2762 26763251

22 Teng MWL Galon J Fridman WH Smyth MJ . From mice to humans: Developments in cancer immunoediting . J Clin Invest ( 2015 ) 125 ( 9 ): 3338–46 . doi: 10.1172/JCI80004 PMC4588291 26241053

23 Forero A Li Y Chen D Grizzle WE Updike KL Merz ND . Expression of the MHC class II pathway in triple-negative breast cancer tumor cells is associated with a good prognosis and infiltrating lymphocytes . Cancer Immunol Res ( 2016 ) 4 ( 5 ): 390–9 . doi: 10.1158/2326-6066.CIR-15-0243 PMC4878913 26980599

24 Sconocchia G Eppenberger-Castori S Zlobec I Karamitopoulou E Arriga R Coppola A . HLA class II antigen expression in colorectal carcinoma tumors as a favorable prognostic marker . Neoplasia ( 2014 ) 16 ( 1 ): 31 – 42 . doi: 10.1593/neo.131568 24563618 PMC3924546

25 Yi R Hong S Zhang Y Lin A Ying H Zou W . MHC-II signature correlates with anti-tumor immunity and predicts anti-PD-L1 response of bladder cancer . Front Cell Dev Biol ( 2022 ) 10 : 757137 . doi: 10.3389/fcell.2022.757137 35223828 PMC8873787

26 Roemer MGM Redd RA Cader FZ Pak CJ Abdelrahman S Ouyang J . Major histocompatibility complex class II and programmed death ligand 1 expression predict outcome after programmed death 1 blockade in classic Hodgkin lymphoma . J Clin Oncol ( 2018 ) 36 ( 10 ): 942–50 . doi: 10.1200/JCO.2017.77.3994 PMC5877802 29394125

27 Rodig SJ Gusenleitner D Jackson DG Gjini E Giobbie-Hurder A Jin C . MHC proteins confer differential sensitivity to CTLA-4 and PD-1 blockade in untreated metastatic melanoma . Sci Trans Med ( 20180 ) 10 ( 450 ): eaar3342 . doi: 10.1126/scitranslmed.aar3342 30021886

28 Buchbinder EI Desai A . CTLA-4 and PD-1 pathways: Similarities, differences, and implications of their inhibition . Am J Clin Oncol ( 2016 ) 39 ( 1 ): 98 – 106 . doi: 10.1097/COC.0000000000000239 26558876 PMC4892769

29 Chen Y Song Y Du W Gong L Chang H Zou Z . Tumor-associated macrophages: An accomplice in solid tumor progression . J Biomed Sci ( 2019 ) 26 ( 1 ): 78 . doi: 10.1186/s12929-019-0568-z 31629410 PMC6800990

30 Verma A Mathur R Farooque A Kaul V Gupta S Dwarakanath BS . T-Regulatory cells in tumor progression and therapy . Cancer Manag Res ( 2019 ) 11 : 10731–47 . doi: 10.2147/CMAR.S228887 PMC6935360 31920383

31 Shang J Zha H Sun Y . Phenotypes, functions, and clinical relevance of regulatory b cells in cancer . Front Immunol ( 2020 ) 11 : 582657 . doi: 10.3389/fimmu.2020.582657 33193391 PMC7649814

32 Ruffell B Coussens LM . Macrophages and therapeutic resistance in cancer . Cancer Cell ( 2015 ) 27 ( 4 ): 462–72 . doi: 10.1016/j.ccell.2015.02.015 PMC4400235 25858805

33 Ostrand-Rosenberg S Fenselau C . Myeloid-derived suppressor cells: Immune-suppressive cells that impair antitumor immunity and are sculpted by their environment . J Immunol ( 2018 ) 200 ( 2 ): 422–31 . doi: 10.4049/jimmunol.1701019 PMC5765878 29311384

34 Togashi Y Shitara K Nishikawa H . Regulatory T cells in cancer immunosuppression — implications for anticancer therapy . Nat Rev Clin Oncol ( 2019 ) 16 ( 6 ): 356–71 . doi: 10.1038/s41571-019-0175-7 30705439

35 Zou S Tong Q Liu B Huang W Tian Y Fu X . Targeting STAT3 in cancer immunotherapy . Mol Cancer ( 2020 ) 19 : 145 . doi: 10.1186/s12943-020-01258-7 32972405 PMC7513516

36 Newman DJ Cragg GM . Natural products as sources of new drugs from 1981 to 2014 . J Nat Prod ( 2016 ) 79 ( 3 ): 629–61 . doi: 10.1021/acs.jnatprod.5b01055 26852623

37 Lu F He XL Richard C Cao J . A brief history of artemisinin: Modes of action and mechanisms of resistance . Chin J Nat Med ( 2019 ) 17 ( 5 ): 331–6 . doi: 10.1016/S1875-5364(19)30038-X 31171267

38 von Hagens C Walter-Sack I Goeckenjan M Osburg J Storch-Hagenlocher B Sertel S . Prospective open uncontrolled phase I study to define a well-tolerated dose of oral artesunate as add-on therapy in patients with metastatic breast cancer (ARTIC M33/2) . Breast Cancer Res Treat ( 2017 ) 164 ( 2 ): 359–69 . doi: 10.1007/s10549-017-4261-1 28439738

39 von Hagens C Walter-Sack I Goeckenjan M Storch-Hagenlocher B Sertel S Elsässer M . Long-term add-on therapy (compassionate use) with oral artesunate in patients with metastatic breast cancer after participating in a phase I study (ARTIC M33/2) . Phytomedicine ( 2019 ) 54 : 140–8 . doi: 10.1016/j.phymed.2018.09.178 30668363

40 Cuzick J Warwick J Pinney E Warren RML Duffy SW . Tamoxifen and breast density in women at increased risk of breast cancer . J Natl Cancer Inst ( 2004 ) 96 ( 8 ): 621–8 . doi: 10.1093/jnci/djh106 15100340

41 Kuipers EJ Grady WM Lieberman D Seufferlein T Sung JJ Boelens PG . Colorectal cancer . Nat Rev Dis Primers ( 2015 ) 1 ( 1 ): 1 – 25 . doi: 10.1038/nrdp.2015.65 PMC4874655 27189416

42 Krishna S Ganapathi S Ster IC Saeed MEM Cowan M Finlayson C . A randomised, double blind, placebo-controlled pilot study of oral artesunate therapy for colorectal cancer . EBioMedicine ( 2015 ) 2 ( 1 ): 82 – 90 . doi: 10.1016/j.ebiom.2014.11.010 26137537 PMC4484515

43 Ferrall L Lin KY Roden RBS Hung CF Wu TC . Cervical cancer immunotherapy: Facts and hopes . Clin Cancer Res ( 2021 ) 27 ( 18 ): 4953–73 . doi: 10.1158/1078-0432.CCR-20-2833 PMC8448896 33888488

44 Trimble CL Levinson K Maldonado L Donovan MJ Clark KT Fu J . A first-in-human proof-of-concept trial of intravaginal artesunate to treat cervical intraepithelial neoplasia 2/3 (CIN2/3) . Gynecol Oncol ( 2020 ) 157 ( 1 ): 188–94 . doi: 10.1016/j.ygyno.2019.12.035 32005582

45 Jansen FH Adoubi I Kouassi Commoe JC De Cnodder T Jansen N Tschulakow A . First study of oral artenimol-r in advanced cervical cancer: Clinical benefit, tolerability and tumor markers . Anticancer Res ( 2011 ) 31 ( 12 ): 4417–22 . 22199309

46 Xu X Liu T Wu J Wang Y Hong Y Zhou H . Transferrin receptor-involved HIF-1 signaling pathway in cervical cancer . Cancer Gene Ther ( 2019 ) 26 ( 11–12 ): 356–65 . doi: 10.1038/s41417-019-0078-x 30651591

47 Disbrow GL Baege AC Kierpiec KA Yuan H Centeno JA Thibodeaux CA . Dihydroartemisinin is cytotoxic to papillomavirus-expressing epithelial cells in vitro and in vivo . Cancer Res ( 2005 ) 1;65 ( 23 ): 10854–61 . doi: 10.1158/0008-5472.CAN-05-1216 16322232

48 Chen YX Gao QY Zou TH Wang BM Liu SD Sheng JQ . Berberine versus placebo for the prevention of recurrence of colorectal adenoma: A multicentre, double-blinded, randomised controlled study . Lancet Gastroenterol Hepatol ( 2020 ) 5 ( 3 ): 267–75 . doi: 10.1016/S2468-1253(19)30409-1 31926918

49 Indrawati L Purwantyastuti P Abdullah M Surono IS Basir I . Safety of annona muricata extract supplementation for colorectal cancer patients . InaJGHE ( 2017 ) 17 ( 3 ): 170–5 . doi: 10.24871/1732016170-175

50 Indrawati L Ascobat P Bela B Abdullah M Surono IS . The effect of an annona muricata leaf extract on nutritional status and cytotoxicity in colorectal cancer: a randomized controlled trial . Asia Pac J Clin Nutr ( 2017 ) 26 ( 4 ): 606–12 . doi: 10.6133/apjcn.062016.02 28582808

51 Samavat H Ursin G Emory TH Lee E Wang R Torkelson CJ . A randomized controlled trial of green tea extract supplementation and mammographic density in postmenopausal women at increased risk of breast cancer . Cancer Prev Res (Phila) ( 2017 ) 10 ( 12 ): 710–8 . doi: 10.1158/1940-6207.CAPR-17-0187 PMC7337967 28904061

52 Wu AH Tseng CC Van Den Berg D Yu MC . Tea intake, COMT genotype, and breast cancer in Asian-American women . Cancer Res ( 2003 ) 63 ( 21 ): 7526–9 . 14612555

53 Gee JR Saltzstein DR Kim K Kolesar J Huang W Havighurst TC . A phase II randomized, double-blind, presurgical trial of polyphenon e in bladder cancer patients to evaluate pharmacodynamics and bladder tissue biomarkers . Cancer Prev Res (Phila) ( 2017 ) 10 ( 5 ): 298 – 307 . doi: 10.1158/1940-6207.CAPR-16-0167 28325826 PMC5503683

54 Kumar NB Pow-Sang J Egan KM Spiess PE Dickinson S Salup R . Randomized, placebo-controlled trial of green tea catechins for prostate cancer prevention . Cancer Prev Res (Phila) ( 2015 ) 8 ( 10 ): 879–87 . doi: 10.1158/1940-6207.CAPR-14-0324 PMC4596745 25873370

55 Sinicrope FA Viggiano TR Buttar NS Song LMWK Schroeder KW Kraichely RE . Randomized phase II trial of polyphenon e versus placebo in patients at high risk of recurrent colonic neoplasia . Cancer Prev Res (Phila) ( 2021 ) 14 ( 5 ): 573–80 . doi: 10.1158/1940-6207.CAPR-20-0598 PMC8102407 33648940

56 Seufferlein T Ettrich TJ Menzler S Messmann H Kleber G Zipprich A . Green tea extract to prevent colorectal adenomas, results of a randomized, placebo-controlled clinical trial . Am J Gastroenterol ( 2022 ) 117 ( 6 ): 884–94 . doi: 10.14309/ajg.0000000000001706 35213393

57 Trudel D Labbé DP Araya-Farias M Doyen A Bazinet L Duchesne T . A two-stage, single-arm, phase II study of EGCG-enriched green tea drink as a maintenance therapy in women with advanced stage ovarian cancer . Gynecol Oncol ( 2013 ) 131 ( 2 ): 357–61 . doi: 10.1016/j.ygyno.2013.08.019 23988418

58 Shanafelt TD Call TG Zent CS Leis JF LaPlant B Bowen DA . Phase 2 trial of daily, oral polyphenon e in patients with asymptomatic, rai stage 0-II chronic lymphocytic Leukemia(CLL) . Cancer ( 2013 ) 119 ( 2 ): 363–70 . doi: 10.1002/cncr.27719 PMC3902473 22760587

59 D’Arena G Simeon V De Martino L Statuto T D’Auria F Volpe S . Regulatory T-cell modulation by green tea in chronic lymphocytic leukemia . Int J Immunopathol Pharmacol ( 2013 ) 26 ( 1 ): 117–25 . doi: 10.1177/039463201302600111 23527714

60 Hidayat YM Wagey F Suardi D Susanto H Laihad BJ Tobing MDL . Analysis of curcumin as a radiosensitizer in cancer therapy with serum survivin examination: Randomised control trial . Asian Pac J Cancer Prev ( 2021 ) 22 ( 1 ): 139–43 . doi: 10.31557/APJCP.2021.22.1.139 PMC8184198 33507691

61 Howells LM Iwuji COO Irving GRB Barber S Walter H Sidat Z . Curcumin combined with FOLFOX chemotherapy is safe and tolerable in patients with metastatic colorectal cancer in a randomized phase IIa trial . J Nutr ( 2019 ) 149 ( 7 ): 1133–9 . doi: 10.1093/jn/nxz029 PMC6602900 31132111

62 Panahi Y Saberi-Karimian M Valizadeh O Behnam B Saadat A Jamialahmadi T . Effects of curcuminoids on systemic inflammation and quality of life in patients with colorectal cancer undergoing chemotherapy: A randomized controlled trial . Adv Exp Med Biol ( 2021 ) 1328 : 1 – 9 . doi: 10.1007/978-3-030-73234-9_1 34981467

63 Epelbaum R Schaffer M Vizel B Badmaev V Bar-Sela G . Curcumin and gemcitabine in patients with advanced pancreatic cancer . Nutr Cancer ( 2010 ) 62 ( 8 ): 1137–41 . doi: 10.1080/01635581.2010.513802 21058202

64 Pastorelli D Fabricio ASC Giovanis P D’Ippolito S Fiduccia P Soldà C . Phytosome complex of curcumin as complementary therapy of advanced pancreatic cancer improves safety and efficacy of gemcitabine: Results of a prospective phase II trial . Pharmacol Res ( 2018 ) 132 : 72–9 . doi: 10.1016/j.phrs.2018.03.013 29614381

65 Dhillon N Aggarwal BB Newman RA Wolff RA Kunnumakkara AB Abbruzzese JL . Phase II trial of curcumin in patients with advanced pancreatic cancer . Clin Cancer Res ( 2008 ) 14 ( 14 ): 4491–9 . doi: 10.1158/1078-0432.CCR-08-0024 18628464

66 Mahammedi H Planchat E Pouget M Durando X Curé H Guy L . The new combination docetaxel, prednisone and curcumin in patients with castration-resistant prostate cancer: A pilot phase II study . Oncology ( 2016 ) 90 ( 2 ): 69 – 78 . doi: 10.1159/000441148 26771576

67 Passildas-Jahanmohan J Eymard JC Pouget M Kwiatkowski F Van Praagh I Savareux L . Multicenter randomized phase II study comparing docetaxel plus curcumin versus docetaxel plus placebo in first-line treatment of metastatic castration-resistant prostate cancer . Cancer Med ( 2021 ) 10 ( 7 ): 2332–40 . doi: 10.1002/cam4.3806 PMC7982628 33666378

68 Choi YH Han DH Kim SW Kim MJ Sung HH Jeon HG . A randomized, double-blind, placebo-controlled trial to evaluate the role of curcumin in prostate cancer patients with intermittent androgen deprivation . Prostate ( 2019 ) 79 ( 6 ): 614–21 . doi: 10.1002/pros.23766 30671976

69 Greil R Greil-Ressler S Weiss L Schönlieb C Magnes T Radl B . A phase 1 dose-escalation study on the safety, tolerability and activity of liposomal curcumin (LipocurcTM) in patients with locally advanced or metastatic cancer . Cancer Chemother Pharmacol ( 2018 ) 82 ( 4 ): 695 – 706 . doi: 10.1007/s00280-018-3654-0 30074076 PMC6132848

70 Houh YK Kim KE Park S Hur DY Kim S Kim D . The effects of artemisinin on the cytolytic activity of natural killer (NK) cells . Int J Mol Sci ( 2017 ) 18 ( 7 ): E1600 . doi: 10.3390/ijms18071600 PMC5536087 28737711

71 Lu Z Bi J Wan X . Artemisinin sensitizes tumor cells to NK cell-mediated cytolysis . Biochem Biophys Res Commun ( 2020 ) 524 ( 2 ): 418–23 . doi: 10.1016/j.bbrc.2020.01.094 32007276

72 Mancuso RI Olalla Saad ST Azambuja JH . Artesunate switches monocytes to an inflammatory phenotype with the ability to kill leukemic cells . Int J Mol Sci ( 2021 ) 22 ( 2 ): E608 . doi: 10.3390/ijms22020608 PMC7827848 33435371

73 Cao Y Feng YH Gao LW Li XY Jin QX Wang YY . Artemisinin enhances the anti-tumor immune response in 4T1 breast cancer cells in vitro and in vivo . Int Immunopharmacol ( 2019 ) 70 : 110–6 . doi: 10.1016/j.intimp.2019.01.041 30798159

74 Zhou ZH Chen FX Xu WR Qian H Sun LQ Lü XT . Enhancement effect of dihydroartemisinin on human γδ T cell proliferation and killing pancreatic cancer cells . Int Immunopharmacol ( 2013 ) 17 ( 3 ): 850–7 . doi: 10.1016/j.intimp.2013.09.015 24103581

75 Qian P Zhang YW Zhou ZH Liu JQ Yue SY Guo XL . Artesunate enhances γδ T-cell-mediated antitumor activity through augmenting γδ T-cell function and reversing immune escape of HepG2 cells . Immunopharmacol Immunotoxicol ( 2018 ) 40 ( 2 ): 107–16 . doi: 10.1080/08923973.2017.1386212 29405080

76 Lee SH Cho YC Kim KH Lee IS Choi HJ Kang BY . Artesunate inhibits proliferation of naïve CD4(+) T cells but enhances function of effector T cells . Arch Pharm Res ( 2015 ) 38 ( 6 ): 1195–203 . doi: 10.1007/s12272-014-0491-5 25370606

77 Narsale A Moya R Davies JD . Human CD4+ CD25+ CD127hi cells and the Th1/Th2 phenotype . Clin Immunol ( 2018 ) 188 : 103–12 . doi: 10.1016/j.clim.2018.01.003 PMC5826897 29330114

78 Chen X Zhang XL Zhang GH Gao YF . Artesunate promotes Th1 differentiation from CD4+ T cells to enhance cell apoptosis in ovarian cancer via miR-142 . Braz J Med Biol Res ( 2019 ) 52 ( 5 ): e7992 . doi: 10.1590/1414-431x20197992 31038546 PMC6489539

79 Yu R Jin L Li F Fujimoto M Wei Q Lin Z . Dihydroartemisinin inhibits melanoma by regulating CTL/Treg anti-tumor immunity and STAT3-mediated apoptosis via IL-10 dependent manner . J Dermatol Sci ( 2020 ) 99 ( 3 ): 193 – 202 . doi: 10.1016/j.jdermsci.2020.08.001 32859456

80 Ooko E Saeed MEM Kadioglu O Sarvi S Colak M Elmasaoudi K . Artemisinin derivatives induce iron-dependent cell death (ferroptosis) in tumor cells . Phytomedicine ( 2015 ) 22 ( 11 ): 1045–54 . doi: 10.1016/j.phymed.2015.08.002 26407947

81 Tan M Rong Y Su Q Chen Y . Artesunate induces apoptosis via inhibition of STAT3 in THP-1 cells . Leuk Res ( 2017 ) 62 : 98 – 103 . doi: 10.1016/j.leukres.2017.09.022 29031126

82 Chen Y Wang F Wu P Gong S Gao J Tao H . Artesunate induces apoptosis, autophagy and ferroptosis in diffuse large b cell lymphoma cells by impairing STAT3 signaling . Cell Signal ( 2021 ) 88 : 110167 . doi: 10.1016/j.cellsig.2021.110167 34628002

83 Lang SJ Schmiech M Hafner S Paetz C Steinborn C Huber R . Antitumor activity of an artemisia annua herbal preparation and identification of active ingredients . Phytomedicine ( 2019 ) 62 : :152962 . doi: 10.1016/j.phymed.2019.152962 31132755

84 Ilamathi M Santhosh S Sivaramakrishnan V . Artesunate as an anti-cancer agent targets stat-3 and favorably suppresses hepatocellular carcinoma . Curr Top Med Chem ( 2016 ) 16 ( 22 ): 2453–63 . doi: 10.2174/1568026616666160212122820 26873192

85 Jia L Song Q Zhou C Li X Pi L Ma X . Dihydroartemisinin as a putative STAT3 inhibitor, suppresses the growth of head and neck squamous cell carcinoma by targeting Jak2/STAT3 signaling . PloS One ( 2016 ) 11 ( 1 ): e0147157 . doi: 10.1371/journal.pone.0147157 26784960 PMC4718674

86 Berköz M Özkan-Yılmaz F Özlüer-Hunt A Krośniak M Türkmen Ö Korkmaz D . Artesunate inhibits melanoma progression in vitro via suppressing STAT3 signaling pathway . Pharmacol Rep ( 2021 ) 73 ( 2 ): 650–63 . doi: 10.1007/s43440-021-00230-6 33609273

87 Gu F Ma Y Zhang Z Zhao J Kobayashi H Zhang L . Expression of Stat3 and Notch1 is associated with cisplatin resistance in head and neck squamous cell carcinoma . Oncol Rep ( 2010 ) 23 ( 3 ): 671–6 . doi: 10.3892/or_00000683 20127005

88 Yan X Li P Zhan Y Qi M Liu J An Z . Dihydroartemisinin suppresses STAT3 signaling and mcl-1 and survivin expression to potentiate ABT-263-induced apoptosis in non-small cell lung cancer cells harboring EGFR or RAS mutation . Biochem Pharmacol ( 2018 ) 150 : 72 – 85 . doi: 10.1016/j.bcp.2018.01.031 29360439

89 Jin H Jiang AY Wang H Cao Y Wu Y Jiang XF . Dihydroartemisinin and gefitinib synergistically inhibit NSCLC cell growth and promote apoptosis via the Akt/mTOR/STAT3 pathway . Mol Med Rep ( 2017 ) 16 ( 3 ): 3475–81 . doi: 10.3892/mmr.2017.6989 28713965

90 Sun Y Lu X Li H Li X . Dihydroartemisinin inhibits IL-6-induced epithelial–mesenchymal transition in laryngeal squamous cell carcinoma via the miR-130b-3p/STAT3/β-catenin signaling pathway . J Int Med Res ( 2021 ) 49 ( 11 ): 03000605211009494 . doi: 10.1177/03000605211009494 34755560 PMC8586195

91 Efferth T Rücker G Falkenberg M Manns D Olbrich A Fabry U . Detection of apoptosis in KG-1a leukemic cells treated with investigational drugs . Arzneimittelforschung ( 1996 ) 46 ( 2 ): 196 – 200 . 8720313

92 Cabello CM Lamore SD Bair WB Qiao S Azimian S Lesson JL . The redox antimalarial dihydroartemisinin targets human metastatic melanoma cells but not primary melanocytes with induction of NOXA-dependent apoptosis . Invest New Drugs ( 2012 ) 30 ( 4 ): 1289–301 . doi: 10.1007/s10637-011-9676-7 PMC3203350 21547369

93 Verma R Foster RE Horgan K Mounsey K Nixon H Smalle N . Lymphocyte depletion and repopulation after chemotherapy for primary breast cancer . Breast Cancer Res ( 2016 ) 18 : 10 . doi: 10.1186/s13058-015-0669-x 26810608 PMC4727393

94 Ménétrier-Caux C Ray-Coquard I Blay JY Caux C . Lymphopenia in cancer patients and its effects on response to immunotherapy: An opportunity for combination with cytokines ? J ImmunoTher Cancer ( 2019 ) 7 ( 1 ): 85 . doi: 10.1186/s40425-019-0549-5 30922400 PMC6437964

95 Dixon SJ Lemberg KM Lamprecht MR Skouta R Zaitsev EM Gleason CE . Ferroptosis: An iron-dependent form of nonapoptotic cell death . Cell ( 2012 ) 149 ( 5 ): 1060–72 . doi: 10.1016/j.cell.2012.03.042 PMC3367386 22632970

96 Wei J Nai GY Dai Y Huang XJ Xiong MY Yao XY . Dipetidyl peptidase-4 and transferrin receptor serve as prognostic biomarkers for acute myeloid leukemia . Ann Trans Med ( 2021 ) 9 ( 17 ): 1381–1 . doi: 10.21037/atm-21-3368 PMC8506534 34733933

97 Yi R Wang H Deng C Wang X Yao L Niu W . Dihydroartemisinin initiates ferroptosis in glioblastoma through GPX4 inhibition . Biosci Rep ( 2020 ) 40 ( 6 ): BSR20193314 . doi: 10.1042/BSR20193314 32452511 PMC7313443

98 Roh JL Kim EH Jang H Shin D . Nrf2 inhibition reverses the resistance of cisplatin-resistant head and neck cancer cells to artesunate-induced ferroptosis . Redox Biol ( 2017 ) 11 : 254–62 . doi: 10.1016/j.redox.2016.12.010 PMC5198738 28012440

99 Yun CW Lee SH . The roles of autophagy in cancer . Int J Mol Sci ( 2018 ) 19 ( 11 ): 3466 . doi: 10.3390/ijms19113466 30400561 PMC6274804

100 Shi X Wang L Ren L Li J Li S Cui Q . Dihydroartemisinin, an antimalarial drug, induces absent in melanoma 2 inflammasome activation and autophagy in human hepatocellular carcinoma HepG2215 cells . Phytother Res ( 2019 ) 33 ( 5 ): 1413–25 . doi: 10.1002/ptr.6332 30873702

101 Fan M Li Y Yao C Liu X Liu J Yu B . DC32, a dihydroartemisinin derivative, ameliorates collagen-induced arthritis through an Nrf2-p62-Keap1 feedback loop . Front Immunol ( 2018 ) 9 : 2762 . doi: 10.3389/fimmu.2018.02762 30538709 PMC6277526

102 Zhang C Fortin PY Barnoin G Qin X Wang X Fernandez Alvarez A . An Artemisinin-Derivative–(NHC)Gold(I) hybrid with enhanced cytotoxicity through inhibition of NRF2 transcriptional activity . Angewandte Chemie Int Edition ( 2020 ) 59 ( 29 ): 12062–8 . doi: 10.1002/anie.202002992 32304346

103 Zhou X Chen Y Wang F Wu H Zhang Y Liu J . Artesunate induces autophagy dependent apoptosis through upregulating ROS and activating AMPK-mTOR-ULK1 axis in human bladder cancer cells . Chem Biol Interact ( 2020 ) 331 : 109273 . doi: 10.1016/j.cbi.2020.109273 33002460

104 Zou J Ma Q Sun R Cai J Liao H Xu L . Dihydroartemisinin inhibits HepG2.2.15 proliferation by inducing cellular senescence and autophagy . BMB Rep ( 2019 ) 52 ( 8 ): 520–5 . doi: 10.5483/BMBRep.2019.52.8.058 PMC6726210 31383247

105 Wang T Wang J Ren W Liu ZL Cheng YF Zhang XM . Combination treatment with artemisinin and oxaliplatin inhibits tumorigenesis in esophageal cancer EC109 cell through wnt/β-catenin signaling pathway . Thorac Cancer ( 2020 ) 11 ( 8 ): 2316–24 . doi: 10.1111/1759-7714.13570 PMC7396387 32657048

106 Guan X Guan Y . Artemisinin induces selective and potent anticancer effects in drug resistant breast cancer cells by inducing cellular apoptosis and autophagy and G2/M cell cycle arrest . J BUON ( 2020 ) 25 ( 3 ): 1330–6 . 32862573

107 Fröhlich T Mai C Bogautdinov RP Morozkina SN Shavva AG Friedrich O . Synthesis of tamoxifen-artemisinin and estrogen-artemisinin hybrids highly potent against breast and prostate cancer . Chem Med Chem ( 2020 ) 15 ( 15 ): 1473–9 . doi: 10.1002/cmdc.202000174 PMC7496903 32374071

108 Neag MA Mocan A Echeverría J Pop RM Bocsan CI Crişan G . Berberine: Botanical occurrence, traditional uses, extraction methods, and relevance in cardiovascular, metabolic, hepatic, and renal disorders . Front Pharmacol ( 2018 ) 9 : 557 . doi: 10.3389/fphar.2018.00557 30186157 PMC6111450

109 Rauf A Abu-Izneid T Khalil AA Imran M Shah ZA Emran TB . Berberine as a potential anticancer agent: A comprehensive review . Molecules ( 2021 ) 26 ( 23 ): 7368 . doi: 10.3390/molecules26237368 34885950 PMC8658774

110 Zuo F Nakamura N Akao T Hattori M . Pharmacokinetics of berberine and its main metabolites in conventional and pseudo germ-free rats determined by liquid chromatography/ion trap mass spectrometry . Drug Metab Dispos ( 2006 ) 34 ( 12 ): 2064–72 . doi: 10.1124/dmd.106.011361 16956957

111 Cao S Zhou Y Xu P Wang Y Yan J Bin W . Berberine metabolites exhibit triglyceride-lowering effects via activation of AMP-activated protein kinase in hep G2 cells . J Ethnopharmacol ( 2013 ) 149 ( 2 ): 576–82 . doi: 10.1016/j.jep.2013.07.025 23899453

112 Li Gh Wang Dl Hu Y Pu P Li Dz Wang Wd . Berberine inhibits acute radiation intestinal syndrome in human with abdomen radiotherapy . Med Oncol ( 2010 ) 27 ( 3 ): 919–25 . doi: 10.1007/s12032-009-9307-8 19757213

113 Liu Y Yu H Zhang C Cheng Y Hu L Meng X . Protective effects of berberine on radiation-induced lung injury via intercellular adhesion molecular-1 and transforming growth factor-beta-1 in patients with lung cancer . Eur J Cancer ( 2008 ) 44 ( 16 ): 2425–32 . doi: 10.1016/j.ejca.2008.07.040 18789680

114 Zhao H Jia L Chen G Li X Meng X Zhao X . A prospective, three-arm, randomized trial of EGCG for preventing radiation-induced esophagitis in lung cancer patients receiving radiotherapy . Radiother Oncol ( 2019 ) 137 : 186–91 . doi: 10.1016/j.radonc.2019.02.022 30898322

115 Li X Xing L Zhang Y Xie P Zhu W Meng X . Phase II trial of epigallocatechin-3-Gallate in acute radiation-induced esophagitis for esophagus cancer . J Med Food ( 2020 ) 23 ( 1 ): 43–9 . doi: 10.1089/jmf.2019.4445 31747326

116 Zhao H Zhu W Zhao X Li X Zhou Z Zheng M . Efficacy of epigallocatechin-3-Gallate in preventing dermatitis in patients with breast cancer receiving postoperative radiotherapy: A double-blind, placebo-controlled, phase 2 randomized clinical trial . JAMA Dermatol ( 2022 ) 158 ( 7 ): 779–86 . doi: 10.1001/jamadermatol.2022.1736 PMC9161122 35648426

117 Zhu W Mei H Jia L Zhao H Li X Meng X . Epigallocatechin-3-gallate mouthwash protects mucosa from radiation-induced mucositis in head and neck cancer patients: A prospective, non-randomised, phase 1 trial . Invest New Drugs ( 2020 ) 38 ( 4 ): 1129–36 . doi: 10.1007/s10637-019-00871-8 31701429

118 Ryan Wolf J Gewandter JS Bautista J Heckler CE Strasser J Dyk P . Utility of topical agents for radiation dermatitis and pain: a randomized clinical trial . Support Care Cancer ( 2020 ) 28 ( 7 ): 3303–11 . doi: 10.1007/s00520-019-05166-5 PMC7242117 31758326

119 Ryan Wolf J Heckler CE Guido JJ Peoples AR Gewandter JS Ling M . Oral curcumin for radiation dermatitis: A URCC NCORP study of 686 breast cancer patients . Support Care Cancer ( 2018 ) 26 ( 5 ): 1543–52 . doi: 10.1007/s00520-017-3957-4 PMC5876157 29192329

120 Delavarian Z Pakfetrat A Ghazi A Jaafari MR Homaei Shandiz F Dalirsani Z . Oral administration of nanomicelle curcumin in the prevention of radiotherapy-induced mucositis in head and neck cancers . Spec Care Dentist ( 2019 ) 39 ( 2 ): 166–72 . doi: 10.1111/scd.12358 30761565

121 Shah S Rath H Sharma G Senapati SN Mishra E . Effectiveness of curcumin mouthwash on radiation-induced oral mucositis among head and neck cancer patients: A triple-blind, pilot randomised controlled trial . Indian J Dent Res ( 2020 ) 31 ( 5 ): 718–27 . doi: 10.4103/ijdr.IJDR_822_18 33433509

122 Wei J Wang H Wang H Wang B Meng L Xin Y . The role of NLRP3 inflammasome activation in radiation damage . BioMed Pharmacother ( 2019 ) 118 : 109217 . doi: 10.1016/j.biopha.2019.109217 31302424

123 Mai W Xu Y Xu J Zhao D Ye L Yu G . Berberine inhibits nod-like receptor family pyrin domain containing 3 inflammasome activation and pyroptosis in nonalcoholic steatohepatitis via the ROS/TXNIP axis . Front Pharmacol ( 2020 ) 11 : 185 . doi: 10.3389/fphar.2020.00185 32194416 PMC7063468

124 Liu H You L Wu J Zhao M Guo R Zhang H . Berberine suppresses influenza virus-triggered NLRP3 inflammasome activation in macrophages by inducing mitophagy and decreasing mitochondrial ROS . J Leukoc Biol ( 2020 ) 108 ( 1 ): 253–66 . doi: 10.1002/JLB.3MA0320-358RR 32272506

125 Zhou H Feng L Xu F Sun Y Ma Y Zhang X . Berberine inhibits palmitate-induced NLRP3 inflammasome activation by triggering autophagy in macrophages: A new mechanism linking berberine to insulin resistance improvement . BioMed Pharmacother ( 2017 ) 89 : 864–74 . doi: 10.1016/j.biopha.2017.03.003 28282788

126 Sarbadhikary P George BP Abrahamse H . Inhibitory role of berberine, an isoquinoline alkaloid, on NLRP3 inflammasome activation for the treatment of inflammatory diseases . Molecules ( 2021 ) 26 ( 20 ): 6238 . doi: 10.3390/molecules26206238 34684819 PMC8537060

127 Yao M Fan X Yuan B Takagi N Liu S Han X . Berberine inhibits NLRP3 inflammasome pathway in human triple-negative breast cancer MDA-MB-231 cell . BMC Complement Altern Med ( 2019 ) 19 ( 1 ): 216 . doi: 10.1186/s12906-019-2615-4 31412862 PMC6694465

128 Shah D Challagundla N Dave V Patidar A Saha B Nivsarkar M . Berberine mediates tumor cell death by skewing tumor-associated immunosuppressive macrophages to inflammatory macrophages . Phytomedicine ( 2022 ) 99 : 153904 . doi: 10.1016/j.phymed.2021.153904 35231825

129 Gu W Zhang M Gao F Niu Y Sun L Xia H . Berberine regulates PADI4-related macrophage function to prevent lung cancer . Int Immunopharmacol ( 2022 ), 110:108965 . doi: 10.1016/j.intimp.2022.108965 35764017

130 Ashrafizadeh M Najafi M Mohammadinejad R Farkhondeh T Samarghandian S . Berberine administration in treatment of colitis: A review . Curr Drug Targets ( 2020 ) 21 ( 13 ): 1385–93 . doi: 10.2174/1389450121666200621193758 32564751

131 Yan S Chang J Hao X Liu J Tan X Geng Z . Berberine regulates short-chain fatty acid metabolism and alleviates the colitis-associated colorectal tumorigenesis through remodeling intestinal flora . Phytomedicine ( 2022 ) 102 : 154217 . doi: 10.1016/j.phymed.2022.154217 35660350

132 Deng J Zhao L Yuan X Li Y Shi J Zhang H . Pre-administration of berberine exerts chemopreventive effects in AOM/DSS-induced colitis-associated carcinogenesis mice via modulating inflammation and intestinal microbiota . Nutrients ( 2022 ) 14 ( 4 ): 726 . doi: 10.3390/nu14040726 35215376 PMC8879943

133 Liu Y Liu X Zhang N Yin M Dong J Zeng Q . Berberine diminishes cancer cell PD-L1 expression and facilitates antitumor immunity via inhibiting the deubiquitination activity of CSN5 . Acta Pharm Sin B ( 2020 ) 10 ( 12 ): 2299–312 . doi: 10.1016/j.apsb.2020.06.014 PMC7745128 33354502

134 Liu J Liu P Xu T Chen Z Kong H Chu W . Berberine induces autophagic cell death in acute lymphoblastic leukemia by inactivating AKT/mTORC1 signaling . Drug Des Devel Ther ( 2020 ) 14 : 1813–23 . doi: 10.2147/DDDT.S239247 PMC7229801 32494123

135 Milata V Svedova A Barbierikova Z Holubkova E Cipakova I Cholujova D . Synthesis and anticancer activity of novel 9-O-Substituted berberine derivatives . Int J Mol Sci ( 2019 ) 20 ( 9 ): 2169 . doi: 10.3390/ijms20092169 31052469 PMC6539820

136 Luo X Gu J Zhu R Feng M Zhu X Li Y . Integrative analysis of differential miRNA and functional study of miR-21 by seed-targeting inhibition in multiple myeloma cells in response to berberine . BMC Syst Biol ( 2014 ) 8 : 82 . doi: 10.1186/1752-0509-8-82 25000828 PMC4096730

137 Yan SH Hu LM Hao XH Liu J Tan XY Geng ZR . Chemoproteomics reveals berberine directly binds to PKM2 to inhibit the progression of colorectal cancer . iScience ( 2022 ) 25 ( 8 ): 104773 . doi: 10.1016/j.isci.2022.104773 35992091 PMC9386086

138 Liu X Ji Q Ye N Sui H Zhou L Zhu H . Berberine inhibits invasion and metastasis of colorectal cancer cells via COX-2/PGE2 mediated JAK2/STAT3 signaling pathway . PloS One ( 2015 ) 10 ( 5 ): e0123478 . doi: 10.1371/journal.pone.0123478 25954974 PMC4425560

139 Xu M Ren L Fan J Huang L Zhou L Li X . Berberine inhibits gastric cancer development and progression by regulating the JAK2/STAT3 pathway and downregulating IL-6 . Life Sci ( 2022 ) 290 : 120266 . doi: 10.1016/j.lfs.2021.120266 34968467

140 Puthdee N Seubwai W Vaeteewoottacharn K Boonmars T Cha’on U Phoomak C . Berberine induces cell cycle arrest in cholangiocarcinoma cell lines via inhibition of NF-κB and STAT3 pathways . Biol Pharm Bull ( 2017 ) 40 ( 6 ): 751–7 . doi: 10.1248/bpb.b16-00428 28566619

141 Obchoei S Detarya M Boonnate P Saranaruk P Vaeteewoottacharn K Mahalapbutr P . Low dose berberine suppresses cholangiocarcinoma cell progression as a multi-kinase inhibitor . Asian Pac J Cancer Prev ( 2022 ) 23 ( 10 ): 3379–86 . doi: 10.31557/APJCP.2022.23.10.3379 PMC9924321 36308362

142 Bobbili MR Mader RM Grillari J Dellago H . OncomiR-17-5p: alarm signal in cancer ? Oncotarget ( 2017 ) 8 ( 41 ): 71206–22 . doi: 10.18632/oncotarget.19331 PMC5642632 29050357

143 Xia Y Chen S Cui J Wang Y Liu X Shen Y . Berberine suppresses bladder cancer cell proliferation by inhibiting JAK1-STAT3 signaling via upregulation of miR-17-5p . Biochem Pharmacol ( 2021 ) 188 : 114575 . doi: 10.1016/j.bcp.2021.114575 33887260

144 Hassanein EHM Kamel EO Ali FEM Ahmed MAR . Berberine and/or zinc protect against methotrexate-induced intestinal damage: Role of GSK-3β/NRF2 and JAK1/STAT-3 signaling pathways . Life Sci ( 2021 ) 281 : 119754 . doi: 10.1016/j.lfs.2021.119754 34174323

145 Zheng X Zhao Y Jia Y Shao D Zhang F Sun M . Biomimetic co-assembled nanodrug of doxorubicin and berberine suppresses chemotherapy-exacerbated breast cancer metastasis . Biomaterials ( 2021 ) 271 : 120716 . doi: 10.1016/j.biomaterials.2021.120716 33621894

146 Pandey A Vishnoi K Mahata S Tripathi SC Misra SP Misra V . Berberine and curcumin target survivin and STAT3 in gastric cancer cells and synergize actions of standard chemotherapeutic 5-fluorouracil . Nutr Cancer ( 2015 ) 67 ( 8 ): 1293–304 . doi: 10.1080/01635581.2015.1085581 26492225

147 Chen P Dai CH Shi ZH Wang Y Wu JN Chen K . Synergistic inhibitory effect of berberine and icotinib on non-small cell lung cancer cells via inducing autophagic cell death and apoptosis . Apoptosis ( 2021 ) 26 ( 11–12 ): 639–56 . doi: 10.1007/s10495-021-01694-w 34743246

148 Wang J Yang S Cai X Dong J Chen Z Wang R . Berberine inhibits EGFR signaling and enhances the antitumor effects of EGFR inhibitors in gastric cancer . Oncotarget ( 2016 ) 7 ( 46 ): 76076–86 . doi: 10.18632/oncotarget.12589 PMC5342797 27738318

149 Kou Y Tong B Wu W Liao X Zhao M . Berberine improves chemo-sensitivity to cisplatin by enhancing cell apoptosis and repressing PI3K/AKT/mTOR signaling pathway in gastric cancer . Front Pharmacol ( 2020 ) 11 : 616251 . doi: 10.3389/fphar.2020.616251 33362566 PMC7756080

150 Zhu T Li LL Xiao GF Luo QZ Liu QZ Yao KT . Berberine increases doxorubicin sensitivity by suppressing STAT3 in lung cancer . Am J Chin Med ( 2015 ) 43 ( 07 ): 1487–502 . doi: 10.1142/S0192415X15500846 26503561

151 Qian K Tang CY Chen LY Zheng S Zhao Y Ma LS . Berberine reverses breast cancer multidrug resistance based on fluorescence pharmacokinetics in vitro and In vivo . ACS Omega ( 2021 ) 6 ( 16 ): 10645–54 . doi: 10.1021/acsomega.0c06288 PMC8153757 34056218

152 Pan Y Zhang F Zhao Y Shao D Zheng X Chen Y . Berberine enhances chemosensitivity and induces apoptosis through dose-orchestrated AMPK signaling in breast cancer . J Cancer ( 2017 ) 8 ( 9 ): 1679–89 . doi: 10.7150/jca.19106 PMC5535724 28775788

153 Qu H Song X Song Z Jiang X Gao X Bai L . Berberine reduces temozolomide resistance by inducing autophagy via the ERK1/2 signaling pathway in glioblastoma . Cancer Cell Int ( 2020 ) 20 ( 1 ): 592 . doi: 10.1186/s12935-020-01693-y 33298057 PMC7727240

154 Lin HJ Ho JH Tsai LC Yang FY Yang LL Kuo CD . Synthesis and In vitro photocytotoxicity of 9-/13-Lipophilic substituted berberine derivatives as potential anticancer agents . Molecules ( 2020 ) 25 ( 3 ): 677 . doi: 10.3390/molecules25030677 32033326 PMC7036939

155 Zhang Y Gu Y Ren H Wang S Zhong H Zhao X . Gut microbiome-related effects of berberine and probiotics on type 2 diabetes (the PREMOTE study) . Nat Commun ( 2020 ) 11 ( 1 ): 5015 . doi: 10.1038/s41467-020-18414-8 33024120 PMC7538905

156 Hou W Liu B Xu H . Triptolide: Medicinal chemistry, chemical biology and clinical progress . Eur J Med Chem ( 2019 ) 176 : 378–92 . doi: 10.1016/j.ejmech.2019.05.032 31121546

157 Khanipour Roshan S Spano AD McKinney AM Nascene DR . Potentially reversible acute cerebellar toxicity associated with minnelide . Neuroradiology ( 2017 ) 59 ( 4 ): 419–21 . doi: 10.1007/s00234-017-1809-z 28303374

158 Zhang L Yu JS . Triptolide reverses helper T cell inhibition and down-regulates IFN-γ induced PD-L1 expression in glioma cell lines . J Neurooncol ( 2019 ) 143 ( 3 ): 429–36 . doi: 10.1007/s11060-019-03193-0 PMC6628928 31152305

159 Liang M Fu J . Triptolide inhibits interferon-gamma-induced programmed death-1-ligand 1 surface expression in breast cancer cells . Cancer Lett ( 2008 ) 270 ( 2 ): 337–41 . doi: 10.1016/j.canlet.2008.05.025 18572307

160 Kuo CS Yang CY Lin CK Lin GJ Sytwu HK Chen YW . Triptolide suppresses oral cancer cell PD-L1 expression in the interferon-γ-modulated microenvironment in vitro, in vivo , and in clinical patients . Biomed Pharmacother ( 2021 ) 133 : 111057 . doi: 10.1016/j.biopha.2020.111057 33378962

161 Liu B Zhang H Li J Lu C Chen G Zhang G . Triptolide downregulates treg cells and the level of IL-10, TGF-β, and VEGF in melanoma-bearing mice . Planta Med ( 2013 ) 79 ( 15 ): 1401–7 . doi: 10.1055/s-0033-1350708 23975869

162 Chan SF Chen YY Lin JJ Liao CL Ko YC Tang NY . Triptolide induced cell death through apoptosis and autophagy in murine leukemia WEHI-3 cells in vitro and promoting immune responses in WEHI-3 generated leukemia mice in vivo . Environ Toxicol ( 2017 ) 32 ( 2 ): 550–68 . doi: 10.1002/tox.22259 26990902

163 Jiang X Cao G Gao G Wang W Zhao J Gao C . Triptolide decreases tumor-associated macrophages infiltration and M2 polarization to remodel colon cancer immune microenvironment via inhibiting tumor-derived CXCL12 . J Cell Physiol ( 2021 ) 236 ( 1 ): 193 – 204 . doi: 10.1002/jcp.29833 32495392

164 Yuan K Li X Lu Q Zhu Q Jiang H Wang T . Application and mechanisms of triptolide in the treatment of inflammatory diseases–a review . Front Pharmacol ( 2019 ) 10 : 1469 . doi: 10.3389/fphar.2019.01469 31866868 PMC6908995

165 Long C Guo W Zhou H Wang J Wang H Sun X . Triptolide decreases expression of latency-associated nuclear antigen 1 and reduces viral titers in kaposi’s sarcoma-associated and herpesvirus-related primary effusion lymphoma cells . Int J Oncol ( 2016 ) 48 ( 4 ): 1519–30 . doi: 10.3892/ijo.2016.3353 26821279

166 Jin Y Chen Q Lu Z Chen B Pan J . Triptolide abrogates oncogene FIP1L1-PDGFRalpha addiction and induces apoptosis in hypereosinophilic syndrome . Cancer Sci ( 2009 ) 100 ( 11 ): 2210–7 . doi: 10.1111/j.1349-7006.2009.01283.x PMC11159907 19671059

167 Lu X Zhuang H Yu Q Zhang X Wu Z Zhang L . Identification of the UBA2-WTIP fusion gene in acute myeloid leukemia . Exp Cell Res ( 2018 ) 371 ( 2 ): 409–16 . doi: 10.1016/j.yexcr.2018.08.035 30179602

168 Guo K Chen J Chen Z Luo G Yang S Zhang M . Triptolide alleviates radiation-induced pulmonary fibrosis via inhibiting IKKβ stimulated LOX production . Biochem Biophys Res Commun ( 2020 ) 527 ( 1 ): 283–8 . doi: 10.1016/j.bbrc.2020.04.023 32446381

169 Yang S Zhang M Chen C Cao Y Tian Y Guo Y . Triptolide mitigates radiation-induced pulmonary fibrosis . Radiat Res ( 2015 ) 184 ( 5 ): 509–17 . doi: 10.1667/RR13831.1 26488756

170 Chen C Yang S Zhang M Zhang Z Zhang SB Wu B . Triptolide mitigates radiation-induced pneumonitis via inhibition of alveolar macrophages and related inflammatory molecules . Oncotarget ( 2017 ) 8 ( 28 ): 45133–42 . doi: 10.18632/oncotarget.16456 PMC5542172 28415830

171 Liu Y Chen F Wang S Guo X Shi P Wang W . Low-dose triptolide in combination with idarubicin induces apoptosis in AML leukemic stem-like KG1a cell line by modulation of the intrinsic and extrinsic factors . Cell Death Dis ( 2013 ) 4 ( 12 ): e948 . doi: 10.1038/cddis.2013.467 24309935 PMC3877540

172 Shi P Zha J Feng J Jiang Z Zhao H Deng M . Low-dose triptolide enhanced activity of idarubicin against acute myeloid leukemia stem-like cells via inhibiting DNA damage repair response . Stem Cell Rev Rep ( 2021 ) 17 ( 2 ): 616–27 . doi: 10.1007/s12015-020-10054-1 33078278

173 Cai J Yi M Tan Y Li X Li G Zeng Z . Natural product triptolide induces GSDME-mediated pyroptosis in head and neck cancer through suppressing mitochondrial hexokinase-II . J Exp Clin Cancer Res ( 2021 ) 40 ( 1 ): 190 . doi: 10.1186/s13046-021-02100-8 34108030 PMC8188724

174 Dai H Jiang Y Luo Y Bie P Chen Z . Triptolide enhances TRAIL sensitivity of pancreatic cancer cells by activating autophagy via downregulation of PUM1 . Phytomedicine ( 2019 ), 62:152953 . doi: 10.1016/j.phymed.2019.152953 31128486

175 Zhong Y Le F Cheng J Luo C Zhang X Wu X . Triptolide inhibits JAK2/STAT3 signaling and induces lethal autophagy through ROS generation in cisplatin−resistant SKOV3/DDP ovarian cancer cells . Oncol Rep ( 2021 ) 45 ( 5 ): 69 . doi: 10.3892/or.2021.8020 33760192 PMC8020210

176 Yu D Liu Y Zhou Y Ruiz-Rodado V Larion M Xu G . Triptolide suppresses IDH1-mutated malignancy via Nrf2-driven glutathione metabolism . Proc Natl Acad Sci U S A ( 2020 ) 117 ( 18 ): 9964–72 . doi: 10.1073/pnas.1913633117 PMC7211987 32312817

177 Noel P Hussein S Ng S Antal CE Lin W Rodela E . Triptolide targets super-enhancer networks in pancreatic cancer cells and cancer-associated fibroblasts . Oncogenesis ( 2020 ) 9 ( 11 ): 1 – 12 . doi: 10.1038/s41389-020-00285-9 33168807 PMC7653036

178 Lovén J Hoke HA Lin CY Lau A Orlando DA Vakoc CR . Selective inhibition of tumor oncogenes by disruption of super-enhancers . Cell ( 2013 ) 153 ( 2 ): 320–34 . doi: 10.1016/j.cell.2013.03.036 PMC3760967 23582323

179 Wang W Lin W Wang Q Zhuang X Luo J . The enhanced antitumor effect of combined triptolide and paclitaxel on pancreatic cancer cell lines . JCO ( 2014 ) 32 ( 3_suppl ): 335–5 . doi: 10.1200/jco.2014.32.3_suppl.335

180 Modi S Giri B Gupta VK Lavania S Sethi V Sharma NS . Minnelide synergizes with conventional chemotherapy by targeting both cancer and associated stroma components in pancreatic cancer . Cancer Lett ( 2022 ) 537 : 215591 . doi: 10.1016/j.canlet.2022.215591 35398530

181 Ma JX Sun YL Yu Y Zhang J Wu HY Yu XF . Triptolide enhances the sensitivity of pancreatic cancer PANC-1 cells to gemcitabine by inhibiting TLR4/NF-κB signaling . Am J Transl Res ( 2019 ) 11 ( 6 ): 3750–60 . PMC6614654 31312385

182 Li CJ Chu CY Huang LH Wang MH Sheu LF Yeh JI . Synergistic anticancer activity of triptolide combined with cisplatin enhances apoptosis in gastric cancer in vitro and in vivo . Cancer Lett ( 2012 ) 319 ( 2 ): 203–13 . doi: 10.1016/j.canlet.2012.01.006 22306340

183 Tang X Zhu Y Tao W Wei B Lin X . Synergistic effect of triptolide combined with 5-fluorouracil on colon carcinoma . Postgrad Med J ( 2007 ) 83 ( 979 ): 338–43 . doi: 10.1136/pgmj.2006.055426 PMC2600066 17488865

184 Liu Y Xiao E Yuan L Li G . Triptolide synergistically enhances antitumor activity of oxaliplatin in colon carcinoma in vitro and in vivo . DNA Cell Biol ( 2014 ) 33 ( 7 ): 418–25 . doi: 10.1089/dna.2014.2356 24720675

185 Liu J Cheng H Han L Qiang Z Zhang X Gao W . Synergistic combination therapy of lung cancer using paclitaxel- and triptolide-coloaded lipid–polymer hybrid nanoparticles . DDDT ( 2018 ), 12:3199–209 . doi: 10.2147/DDDT.S172199 PMC6161729 30288024

186 Yang Y Zhang LJ Bai XG Xu HJ Jin ZL Ding M . Synergistic antitumour effects of triptolide plus gemcitabine in bladder cancer . BioMed Pharmacother ( 2018 ) 106 : 1307–16 . doi: 10.1016/j.biopha.2018.07.083 30119201

187 Modi S Kir D Giri B Majumder K Arora N Dudeja V . Minnelide overcomes oxaliplatin resistance by downregulating DNA repair pathway in pancreatic cancer . J Gastrointest Surg ( 2016 ) 20 ( 1 ): 13 – 24 . doi: 10.1007/s11605-015-3000-3 26503259 PMC4698020

188 Zhang Z Sun C Zhang L Chi X Ji J Gao X . Triptolide interferes with XRCC1/PARP1-mediated DNA repair and confers sensitization of triple-negative breast cancer cells to cisplatin . BioMed Pharmacother ( 2019 ) 109 : 1541–6 . doi: 10.1016/j.biopha.2018.11.008 30551406

189 Jiang N Dong XP Zhang SL You QY Jiang XT Zhao XG . Triptolide reverses the taxol resistance of lung adenocarcinoma by inhibiting the NF-κB signaling pathway and the expression of NF-κB-regulated drug-resistant genes . Mol Med Rep ( 2016 ) 13 ( 1 ): 153–9 . doi: 10.3892/mmr.2015.4493 PMC4686042 26531258

190 Deng Y Li F He P Yang Y Yang J Zhang Y . Triptolide sensitizes breast cancer cells to doxorubicin through the DNA damage response inhibition . Mol Carcinog ( 2018 ) 57 ( 6 ): 807–14 . doi: 10.1002/mc.22795 29500880

191 Huang G Hu H Zhang Y Zhu Y Liu J Tan B . Triptolide sensitizes cisplatin-resistant human epithelial ovarian cancer by inhibiting the phosphorylation of AKT . J Cancer ( 2019 ) 10 ( 13 ): 3012–20 . doi: 10.7150/jca.30669 PMC6590046 31281478

192 Ho JN Byun SS Lee S Oh JJ Hong SK Lee SE . Synergistic antitumor effect of triptolide and cisplatin in cisplatin resistant human bladder cancer cells . J Urol ( 2015 ) 193 ( 3 ): 1016–22 . doi: 10.1016/j.juro.2014.09.007 25229559

193 Li Y Hu S . Triptolide sensitizes liver cancer cell lines to chemotherapy in vitro and in vivo . Panminerva Med ( 2014 ) 56 ( 3 ): 211–20 . 24352031

194 Kong C Li Y Liu Z Ye J Wang Z Zhang L . Targeting the oncogene KRAS mutant pancreatic cancer by synergistic blocking of lysosomal acidification and rapid drug release . ACS Nano ( 2019 ) 13 ( 4 ): 4049–63 . doi: 10.1021/acsnano.8b08246 30912923

195 Liaw K Sharma R Sharma A Salazar S Appiani La Rosa S Kannan RM . Systemic dendrimer delivery of triptolide to tumor-associated macrophages improves anti-tumor efficacy and reduces systemic toxicity in glioblastoma . J Control Release ( 2021 ) 329 : 434–44 . doi: 10.1016/j.jconrel.2020.12.003 PMC7904646 33290796

196 Caminade AM . Dendrimers, an emerging opportunity in personalized medicine ? J Pers Med ( 2022 ) 12 ( 8 ): 1334 . doi: 10.3390/jpm12081334 36013283 PMC9409959

197 Zheng S Wang J Ding N Chen W Chen H Xue M . Prodrug polymeric micelles integrating cancer-associated fibroblasts deactivation and synergistic chemotherapy for gastric cancer . J Nanobiotechnol ( 2021 ) 19 ( 1 ): 381 . doi: 10.1186/s12951-021-01127-5 PMC8607732 34802453

198 Wang S Jiang H Wang J Wu H Wu T Ni M . Superior in vitro anticancer effect of biomimetic paclitaxel and triptolide co-delivery system in gastric cancer . J BioMed Res ( 2021 ) 35 ( 4 ): 327–38 . doi: 10.7555/JBR.35.20210102 PMC8383169 34421008

199 Li Z Yang G Han L Wang R Gong C Yuan Y . Sorafenib and triptolide loaded cancer cell-platelet hybrid membrane-camouflaged liquid crystalline lipid nanoparticles for the treatment of hepatocellular carcinoma . J Nanobiotechnol ( 2021 ) 19 ( 1 ): 360 . doi: 10.1186/s12951-021-01095-w PMC8576878 34749742

200 Ilango S Sahoo DK Paital B Kathirvel K Gabriel JI Subramaniam K . A review on annona muricata and its anticancer activity . Cancers ( 2022 ) 14 ( 18 ): 4539 . doi: 10.3390/cancers14184539 36139697 PMC9497149

201 Hansra DM Silva O Mehta A Ahn E . Patient with metastatic breast cancer achieves stable disease for 5 years on graviola and xeloda after progressing on multiple lines of therapy . Adv Breast Cancer Res ( 2014 ) 3 ( 3 ): 84–7 . doi: 10.4236/abcr.2014.33012

202 Morosetti G Criscuolo AA Santi F Perno CF Piccione E Ciotti M . Ellagic acid and annona muricata in the chemoprevention of HPV-related pre-neoplastic lesions of the cervix . Oncol Lett ( 2017 ) 13 ( 3 ): 1880–4 . doi: 10.3892/ol.2017.5634 PMC5403706 28454338

203 Kim GT Tran NKS Choi EH Song YJ Song JH Shim SM . Immunomodulatory efficacy of standardized annona muricata (Graviola) leaf extract via activation of mitogen-activated protein kinase pathways in RAW 264.7 macrophages . Evidence-Based Complement Altern Med ( 2016 ) 2016 : e2905127 . doi: 10.1155/2016/2905127 PMC5209628 28096884

204 Syed Najmuddin SUF Romli MF Hamid M Alitheen NB Nik Abd Rahman NMA . Anti-cancer effect of annona muricata Linn leaves crude extract (AMCE) on breast cancer cell line . BMC Complement Altern Med ( 2016 ) 16 ( 1 ): 311 . doi: 10.1186/s12906-016-1290-y 27558166 PMC4997662

205 Hadisaputri YE Habibah U Abdullah FF Halimah E Mutakin M Megantara S . Antiproliferation activity and apoptotic mechanism of soursop (Annona muricata l.) leaves extract and fractions on MCF7 breast cancer cells . Breast Cancer (Dove Med Press) ( 2021 ) 13 : 447–57 . doi: 10.2147/BCTT.S317682 PMC8291383 34295188

206 Daddiouaissa D Amid A Kabbashi NA Fuad FAA Elnour AM Epandy MAKMS. Antiproliferative activity of ionic liquid-graviola fruit extract against human breast cancer (MCF-7) cell lines using flow cytometry techniques . J Ethnopharmacol ( 2019 ) 236 : 466–73 . doi: 10.1016/j.jep.2019.03.003 30853648

207 Naik AV Sellappan K . In vitro evaluation of annona muricata l. (Soursop) leaf methanol extracts on inhibition of tumorigenicity and metastasis of breast cancer cells . Biomarkers ( 2020 ) 25 ( 8 ): 701–10 . doi: 10.1080/1354750X.2020.1836025 33048613

208 Zeweil MM Sadek KM Taha NM El-Sayed Y Menshawy S . Graviola attenuates DMBA-induced breast cancer possibly through augmenting apoptosis and antioxidant pathway and downregulating estrogen receptors . Environ Sci pollut Res Int ( 2019 ) 26 ( 15 ): 15209–17 . doi: 10.1007/s11356-019-04920-w 30924043

209 Salsabila IA Nugraheni N Ahlina FN Haryanti S Meiyanto E . Synergistic cotreatment potential of soursop (Annona muricata l.) leaves extract with doxorubicin on 4T1 cells with antisenescence and anti-reactive-oxygen-species properties . Iran J Pharm Res ( 2021 ) 20 ( 2 ): 57 – 67 . doi: 10.22037/ijpr.2020.112485.13788 PMC8457719 34567146

210 Alshaeri HK Alasmari MM Natto ZS Pino-Figueroa A . Effects of annona muricata extract on triple-negative breast cancer cells mediated through EGFR signaling . Cancer Manag Res ( 2020 ) 12 : 12519–26 . doi: 10.2147/CMAR.S278647 PMC7723033 33304106

211 Deep G Kumar R Jain AK Dhar D Panigrahi GK Hussain A . Graviola inhibits hypoxia-induced NADPH oxidase activity in prostate cancer cells reducing their proliferation and clonogenicity . Sci Rep ( 2016 ) 6 : 23135 . doi: 10.1038/srep23135 26979487 PMC4793251

212 Asare GA Afriyie D Ngala RA Abutiate H Doku D Mahmood SA . Antiproliferative activity of aqueous leaf extract of annona muricata l. on the prostate, BPH-1 cells, and some target genes . Integr Cancer Ther ( 2015 ) 14 ( 1 ): 65 – 74 . doi: 10.1177/1534735414550198 25411208

213 Foster K Oyenihi O Rademan S Erhabor J Matsabisa M Barker J . Selective cytotoxic and anti-metastatic activity in DU-145 prostate cancer cells induced by annona muricata l. bark extract and phytochemical, annonacin . BMC Complement Med Ther ( 2020 ) 20 ( 1 ): 375 . doi: 10.1186/s12906-020-03130-z 33302945 PMC7727144

214 El Tawiil GA Noaman EA Askar MA El Fatih NM Mohamed HE . Anticancer and apoptogenic effect of graviola and low-dose radiation in tumor xenograft in mice . Integr Cancer Ther ( 2020 ) 19 : 1534735419900930 . doi: 10.1177/1534735419900930 32493124 PMC7273578

215 Torres MP Rachagani S Purohit V Pandey P Joshi S Moore ED . Graviola: A novel promising natural-derived drug that inhibits tumorigenicity and metastasis of pancreatic cancer cells in vitro and in vivo through altering cell metabolism . Cancer Lett ( 2012 ) 323 ( 1 ): 29 – 40 . doi: 10.1016/j.canlet.2012.03.031 22475682 PMC3371140

216 Gautam SK Kumar S Dam V Ghersi D Jain M Batra SK . MUCIN-4 (MUC4) is a novel tumor antigen for pancreatic cancer immunotherapy . Semin Immunol ( 2020 ) 47 : 101391 . doi: 10.1016/j.smim.2020.101391 31952903 PMC7160012

217 Ko YM Wu TY Wu YC Chang FR Guh JY Chuang LY . Annonacin induces cell cycle-dependent growth arrest and apoptosis in estrogen receptor-α-related pathways in MCF-7 cells . J Ethnopharmacol ( 2011 ) 137 ( 3 ): 1283–90 . doi: 10.1016/j.jep.2011.07.056 21840388

218 Oberlies NH Croy VL Harrison ML McLaughlin JL . The annonaceous acetogenin bullatacin is cytotoxic against multidrug-resistant human mammary adenocarcinoma cells . Cancer Lett ( 1997 ) 115 ( 1 ): 73–9 . doi: 10.1016/S0304-3835(97)04716-2 9097981

219 Yuan F Bai G Miao Y Chen Y Li X Chen J . Annosquacin b induces mitochondrial apoptosis in multidrug resistant human breast cancer cell line MCF-7/ADR through selectively modulating MAPKs pathways . Pharm Biol ( 2016 ) 54 ( 12 ): 3040–5 . doi: 10.1080/13880209.2016.1200634 27450387

220 Höllerhage M Rösler TW Berjas M Luo R Tran K Richards KM . Neurotoxicity of dietary supplements from annonaceae species . Int J Toxicol ( 2015 ) 34 ( 6 ): 543–50 . doi: 10.1177/1091581815602252 26405269

221 Yang C Gundala SR Mukkavilli R Vangala S Reid MD Aneja R . Synergistic interactions among flavonoids and acetogenins in graviola (Annona muricata) leaves confer protection against prostate cancer . Carcinogenesis ( 2015 ) 36 ( 6 ): 656 . doi: 10.1093/carcin/bgv046 25863125 PMC4566098

222 Jabir MS Saleh YM Sulaiman GM Yaseen NY Sahib UI Dewir YH . Green synthesis of silver nanoparticles using annona muricata extract as an inducer of apoptosis in cancer cells and inhibitor for NLRP3 inflammasome via enhanced autophagy . Nanomaterials (Basel) ( 2021 ) 11 ( 2 ): 384 . doi: 10.3390/nano11020384 33546151 PMC7913157

223 González-Pedroza MG Argueta-Figueroa L García-Contreras R Jiménez-Martínez Y Martínez-Martínez E Navarro-Marchal SA . Silver nanoparticles from annona muricata peel and leaf extracts as a potential potent, biocompatible and low cost antitumor tool . Nanomaterials (Basel) ( 2021 ) 11 ( 5 ): 1273 . doi: 10.3390/nano11051273 34066096 PMC8151560

224 Meenakshisundaram S Krishnamoorthy V Jagadeesan Y Vilwanathan R Balaiah A . Annona muricata assisted biogenic synthesis of silver nanoparticles regulates cell cycle arrest in NSCLC cell lines . Bioorg Chem ( 2020 ) 95 : 103451 . doi: 10.1016/j.bioorg.2019.103451 31927333

225 Gavamukulya Y Maina EN El-Shemy HA Meroka AM Kangogo GK Magoma G . Annona muricata silver nanoparticles exhibit strong anticancer activities against cervical and prostate adenocarcinomas through regulation of CASP9 and the CXCL1/CXCR2 genes axis . Tumour Biol ( 2021 ) 43 ( 1 ): 37 – 55 . doi: 10.3233/TUB-200058 33935122

226 Aggarwal V Tuli HS Tania M Srivastava S Ritzer EE Pandey A . Molecular mechanisms of action of epigallocatechin gallate in cancer: Recent trends and advancement . Semin Cancer Biol ( 2022 ) 80 : 256–75 . doi: 10.1016/j.semcancer.2020.05.011 32461153

227 Kochman J Jakubczyk K Antoniewicz J Mruk H Janda K . Health benefits and chemical composition of matcha green tea: A review . Molecules ( 2020 ) 26 ( 1 ): 85 . doi: 10.3390/molecules26010085 33375458 PMC7796401

228 McCormack VA dos Santos Silva I . Breast density and parenchymal patterns as markers of breast cancer risk: A meta-analysis . Cancer Epidemiol Biomarkers Prev ( 2006 ) 15 ( 6 ): 1159–69 . doi: 10.1158/1055-9965.EPI-06-0034 16775176

229 Lazzeroni M Guerrieri-Gonzaga A Gandini S Johansson H Serrano D Cazzaniga M . A presurgical study of lecithin formulation of green tea extract in women with early breast cancer . Cancer Prev Res (Phila) ( 2017 ) 10 ( 6 ): 363–70 . doi: 10.1158/1940-6207.CAPR-16-0298 28400479

230 Wang P Aronson WJ Huang M Zhang Y Lee RP Heber D . Green tea polyphenols and metabolites in prostatectomy tissue: Implications for cancer prevention . Cancer Prev Res (Phila) ( 2010 ) 3 ( 8 ): 985–93 . doi: 10.1158/1940-6207.CAPR-09-0210 PMC3163459 20628004

231 Tachibana H Koga K Fujimura Y Yamada K . A receptor for green tea polyphenol EGCG . Nat Struct Mol Biol ( 2004 ) 11 ( 4 ): 380–1 . doi: 10.1038/nsmb743 15024383

232 Byun EB Choi HG Sung NY Byun EH . Green tea polyphenol epigallocatechin-3-gallate inhibits TLR4 signaling through the 67-kDa laminin receptor on lipopolysaccharide-stimulated dendritic cells . Biochem Biophys Res Commun ( 2012 ) 426 ( 4 ): 480–5 . doi: 10.1016/j.bbrc.2012.08.096 22960171

233 Lakshmi SP Reddy AT Kodidhela LD Varadacharyulu NC . The tea catechin epigallocatechin gallate inhibits NF-κB-mediated transcriptional activation by covalent modification . Arch Biochem Biophys ( 2020 ) 695 : 108620 . doi: 10.1016/j.abb.2020.108620 33038311

234 Hu Y Gu J Lin J Wang Y Yang F Yin J . (-)-Epigallocatechin-3-gallate (EGCG) modulates polarized macrophages to suppress M1 phenotype and promote M2 polarization in vitro and in vivo . J Funct Foods ( 2021 ) 87 : 104743 . doi: 10.1016/j.jff.2021.104743

235 Huang SC Kao YH Shih SF Tsai MC Lin CS Chen LW . Epigallocatechin-3-gallate exhibits immunomodulatory effects in human primary T cells . Biochem Biophys Res Commun ( 2021 ) 550 : 70–6 . doi: 10.1016/j.bbrc.2021.02.132 33689882

236 Jena AB Dash UC Duttaroy AK . An in silico investigation on the interactions of curcumin and epigallocatechin-3-gallate with NLRP3 inflammasome complex . BioMed Pharmacother ( 2022 ) 156 : 113890 . doi: 10.1016/j.biopha.2022.113890 36270255

237 El-Missiry MA Othman AI El-Sawy MR Lebede MF . Neuroprotective effect of epigallocatechin-3-gallate (EGCG) on radiation-induced damage and apoptosis in the rat hippocampus . Int J Radiat Biol ( 2018 ) 94 ( 9 ): 798 – 808 . doi: 10.1080/09553002.2018.1492755 29939076

238 Xie LW Cai S Zhao TS Li M Tian Y . Green tea derivative (-)-epigallocatechin-3-gallate (EGCG) confers protection against ionizing radiation-induced intestinal epithelial cell death both in vitro and in vivo . Free Radic Biol Med ( 2020 ) 161 : 175–86 . doi: 10.1016/j.freeradbiomed.2020.10.012 33069855

239 Zhang Z Zhu Q Wang S Shi C . Epigallocatechin-3-gallate inhibits the formation of neutrophil extracellular traps and suppresses the migration and invasion of colon cancer cells by regulating STAT3/CXCL8 pathway . Mol Cell Biochem ( 2022 ). doi: 10.1007/s11010-022-04550-w 36112238

240 Xu P Yan F Zhao Y Chen X Sun S Wang Y . Green tea polyphenol EGCG attenuates MDSCs-mediated immunosuppression through canonical and non-canonical pathways in a 4T1 murine breast cancer model . Nutrients ( 2020 ) 12 ( 4 ): 1042 . doi: 10.3390/nu12041042 32290071 PMC7230934

241 Rawangkan A Wongsirisin P Namiki K Iida K Kobayashi Y Shimizu Y . Green tea catechin is an alternative immune checkpoint inhibitor that inhibits PD-L1 expression and lung tumor growth . Molecules ( 2018 ) 23 ( 8 ): 2071 . doi: 10.3390/molecules23082071 30126206 PMC6222340

242 Xiao X Jiang K Xu Y Peng H Wang Z Liu S . (-)-Epigallocatechin-3-gallate induces cell apoptosis in chronic myeloid leukaemia by regulating Bcr/Abl-mediated p38-MAPK/JNK and JAK2/STAT3/AKT signalling pathways . Clin Exp Pharmacol Physiol ( 2019 ) 46 ( 2 ): 126–36 . doi: 10.1111/1440-1681.13037 30251267

243 Kumazoe M Sugihara K Tsukamoto S Huang Y Tsurudome Y Suzuki T . 67-kDa laminin receptor increases cGMP to induce cancer-selective apoptosis . J Clin Invest ( 2013 ) 123 ( 2 ): 787–99 . doi: 10.1172/JCI64768 PMC3561824 23348740

244 Negri A Naponelli V Rizzi F Bettuzzi S . Molecular targets of epigallocatechin–gallate (EGCG): A special focus on signal transduction and cancer . Nutrients ( 2018 ) 10 ( 12 ): 1936 . doi: 10.3390/nu10121936 30563268 PMC6315581

245 Djediai S Gonzalez Suarez N El Cheikh-Hussein L Rodriguez Torres S Gresseau L Dhayne S . MT1-MMP cooperates with TGF-β receptor-mediated signaling to trigger SNAIL and induce epithelial-to-Mesenchymal-like transition in U87 glioblastoma cells . Int J Mol Sci ( 2021 ) 22 ( 23 ): 13006 . doi: 10.3390/ijms222313006 34884812 PMC8657819

246 Tsukamoto S Huang Y Umeda D Yamada S Yamashita S Kumazoe M . 67-kDa laminin receptor-dependent protein phosphatase 2A (PP2A) activation elicits melanoma-specific antitumor activity overcoming drug resistance . J Biol Chem ( 2014 ) 289 ( 47 ): 32671–81 . doi: 10.1074/jbc.M114.604983 PMC4239619 25294877

247 Umeda D Yano S Yamada K Tachibana H . Green tea polyphenol epigallocatechin-3-gallate signaling pathway through 67-kDa laminin receptor . J Biol Chem ( 2008 ) 283 ( 6 ): 3050–8 . doi: 10.1074/jbc.M707892200 18079119

248 Luo KW Xia J Cheng BH Gao HC Fu LW Luo XL . Tea polyphenol EGCG inhibited colorectal-cancer-cell proliferation and migration via downregulation of STAT3 . Gastroenterol Rep (Oxf) ( 2021 ) 9 ( 1 ): 59 – 70 . doi: 10.1093/gastro/goaa072 33747527 PMC7962736

249 Fujimura Y Kumazoe M Tachibana H . 67-kDa laminin receptor-mediated cellular sensing system of green tea polyphenol EGCG and functional food pairing . Molecules ( 2022 ) 27 ( 16 ): 5130 . doi: 10.3390/molecules27165130 36014370 PMC9416087

250 Ho HC Huang CC Lu YT Yeh CM Ho YT Yang SF . Epigallocatechin-3-gallate inhibits migration of human nasopharyngeal carcinoma cells by repressing MMP-2 expression . J Cell Physiol ( 2019 ) 234 ( 11 ): 20915–24 . doi: 10.1002/jcp.28696 31012106

251 Gonzalez Suarez N Rodriguez Torres S Ouanouki A El Cheikh-Hussein L Annabi B Inhibits Adipose-Derived Mesenchymal Stem Cells Differentiation into Adipocytes EGCG . And prevents a STAT3-mediated paracrine oncogenic control of triple-negative breast cancer cell invasive phenotype . Molecules ( 2021 ) 26 ( 6 ): 1506 . doi: 10.3390/molecules26061506 33801973 PMC7998295

252 Jin G Yang Y Liu K Zhao J Chen X Liu H . Combination curcumin and (-)-epigallocatechin-3-gallate inhibits colorectal carcinoma microenvironment-induced angiogenesis by JAK/STAT3/IL-8 pathway . Oncogenesis ( 2017 ) 6 ( 10 ): e384 . doi: 10.1038/oncsis.2017.84 28967875 PMC5668882

253 Yuan CH Horng CT Lee CF Chiang NN Tsai FJ Lu CC . Epigallocatechin gallate sensitizes cisplatin-resistant oral cancer CAR cell apoptosis and autophagy through stimulating AKT/STAT3 pathway and suppressing multidrug resistance 1 signaling . Environ Toxicol ( 2017 ) 32 ( 3 ): 845–55 . doi: 10.1002/tox.22284 27200496

254 Tian M Tian D Qiao X Li J Zhang L . Modulation of myb-induced NF-kB -STAT3 signaling and resulting cisplatin resistance in ovarian cancer by dietary factors . J Cell Physiol ( 2019 ) 234 ( 11 ): 21126–34 . doi: 10.1002/jcp.28715 31037726

255 Borse V Al Aameri RFH Sheehan K Sheth S Kaur T Mukherjea D . Epigallocatechin-3-gallate, a prototypic chemopreventative agent for protection against cisplatin-based ototoxicity . Cell Death Dis ( 2017 ) 8 ( 7 ): e2921 . doi: 10.1038/cddis.2017.314 28703809 PMC5550861

256 Nelson KM Dahlin JL Bisson J Graham J Pauli GF Walters MA . The essential medicinal chemistry of curcumin . J Med Chem ( 20170 ) 60 ( 5 ): 1620–37 . doi: 10.1021/acs.jmedchem.6b00975 PMC5346970 28074653

257 Amalraj A Pius A Gopi S Gopi S . Biological activities of curcuminoids, other biomolecules from turmeric and their derivatives - a review . J Tradit Complement Med ( 2017 ) 7 ( 2 ): 205–33 . doi: 10.1016/j.jtcme.2016.05.005 PMC5388087 28417091

258 Mukherjee S Baidoo JNE Fried A Banerjee P . Using curcumin to turn the innate immune system against cancer . Biochem Pharmacol ( 2020 ) 176 : 113824 . doi: 10.1016/j.bcp.2020.113824 31987852

259 Lao CD Ruffin MT Normolle D Heath DD Murray SI Bailey JM . Dose escalation of a curcuminoid formulation . BMC Complement Altern Med ( 2006 ) 6 : 10 . doi: 10.1186/1472-6882-6-10 16545122 PMC1434783

260 Martínez N Herrera M Frías L Provencio M Pérez-Carrión R Díaz V . A combination of hydroxytyrosol, omega-3 fatty acids and curcumin improves pain and inflammation among early stage breast cancer patients receiving adjuvant hormonal therapy: Results of a pilot study . Clin Transl Oncol ( 2019 ) 21 ( 4 ): 489–98 . doi: 10.1007/s12094-018-1950-0 30293230

261 Kohaar I Petrovics G Srivastava S . A rich array of prostate cancer molecular biomarkers: Opportunities and challenges . Int J Mol Sci ( 2019 ) 20 ( 8 ): E1813 . doi: 10.3390/ijms20081813 PMC6515282 31013716

262 Deng L Wu X Zhu X Yu Z Liu Z Wang J . Combination effect of curcumin with docetaxel on the PI3K/AKT/mTOR pathway to induce autophagy and apoptosis in esophageal squamous cell carcinoma . Am J Transl Res ( 2021 ) 13 ( 1 ): 57 – 72 . 33527008 PMC7847521

263 Hutzen B Friedman L Sobo M Lin L Cen L De Angelis S . Curcumin analogue GO-Y030 inhibits STAT3 activity and cell growth in breast and pancreatic carcinomas . Int J Oncol ( 2009 ) 35 ( 4 ): 867–72 . doi: 10.3892/ijo_00000401 19724924

264 MaruYama T Kobayashi S Nakatsukasa H Moritoki Y Taguchi D Sunagawa Y . The curcumin analog GO-Y030 controls the generation and stability of regulatory T cells . Front Immunol ( 2021 ) 12 : 687669 . doi: 10.3389/fimmu.2021.687669 34248973 PMC8261301

265 Sato A Kudo C Yamakoshi H Uehara Y Ohori H Ishioka C . Curcumin analog GO-Y030 is a novel inhibitor of IKKβ that suppresses NF-κB signaling and induces apoptosis . Cancer Sci ( 2011 ) 102 ( 5 ): 1045–51 . doi: 10.1111/j.1349-7006.2011.01886.x 21272158

266 He W Xia Y Cao P Hong L Zhang T Shen X . Curcuminoid WZ35 synergize with cisplatin by inducing ROS production and inhibiting TrxR1 activity in gastric cancer cells . J Exp Clin Cancer Res ( 2019 ) 38 ( 1 ): 207 . doi: 10.1186/s13046-019-1215-y 31113439 PMC6528260

267 MaruYama T Kobayashi S Shibata H Chen W Owada Y . Curcumin analog GO-Y030 boosts the efficacy of anti-PD-1 cancer immunotherapy . Cancer Sci ( 2021 ) 112 ( 12 ): 4844–52 . doi: 10.1111/cas.15136 PMC8645716 34529884

268 Hu Y Ran M Wang B Lin Y Cheng Y Zheng S . Co-Delivery of docetaxel and curcumin via nanomicelles for enhancing anti-ovarian cancer treatment . IJN ( 2020 ) 15 : 9703–15 . doi: 10.2147/IJN.S274083 PMC7721301 33299312

269 Kim CH Kim BD Lee TH Kim HK Lyu MJ Yoon YI . Synergistic co-administration of docetaxel and curcumin to chemoresistant cancer cells using PEGylated and RIPL peptide-conjugated nanostructured lipid carriers . Cancer Nanotechnol ( 2022 ) 13 ( 1 ): 17 . doi: 10.1186/s12645-022-00119-w

270 Hayakawa T Yaguchi T Kawakami Y . Enhanced anti-tumor effects of the PD-1 blockade combined with a highly absorptive form of curcumin targeting STAT3 . Cancer Sci ( 2020 ) 111 ( 12 ): 4326–35 . doi: 10.1111/cas.14675 PMC7734012 33006786

271 Ham IH Wang L Lee D Woo J Kim TH Jeong HY . Curcumin inhibits the cancer−associated fibroblast−derived chemoresistance of gastric cancer through the suppression of the JAK/STAT3 signaling pathway . Int J Oncol ( 2022 ) 61 ( 1 ): 85 . doi: 10.3892/ijo.2022.5375 35621145 PMC9170354

272 Ren M Wang Y Wu X Ge S Wang B . Curcumin synergistically increases effects of β-interferon and retinoic acid on breast cancer cells in vitro and in vivo by up-regulation of GRIM-19 through STAT3-dependent and STAT3-independent pathways . J Drug Targeting ( 2017 ) 25 ( 3 ): 247–54 . doi: 10.1080/1061186X.2016.1242132 27677346

273 Bharti AC Donato N Aggarwal BB . Curcumin (diferuloylmethane) inhibits constitutive and IL-6-inducible STAT3 phosphorylation in human multiple myeloma cells . J Immunol ( 2003 ) 171 ( 7 ): 3863–71 . doi: 10.4049/jimmunol.171.7.3863 14500688

274 Mohammadi Kian M Salemi M Bahadoran M Haghi A Dashti N Mohammadi S . Curcumin combined with thalidomide reduces expression of STAT3 and bcl-xL, leading to apoptosis in acute myeloid leukemia cell lines . Drug Des Devel Ther ( 2020 ) 14 : 185–94 . doi: 10.2147/DDDT.S228610 PMC6970263 32021103

275 Blasius R Reuter S Henry E Dicato M Diederich M . Curcumin regulates signal transducer and activator of transcription (STAT) expression in K562 cells . Biochem Pharmacol ( 2006 ) 72 ( 11 ): 1547–54 . doi: 10.1016/j.bcp.2006.07.029 16959222

276 Baell JB . Feeling nature’s PAINS: Natural products, natural product drugs, and pan assay interference compounds (PAINS) . J Nat Prod ( 2016 ) 79 ( 3 ): 616–28 . doi: 10.1021/acs.jnatprod.5b00947 26900761