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Anti-cancer natural products isolated from Chinese medicinal herbs
© 2011 Tan et al. ; licensee BioMed Central Ltd.
This is an open access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0),
which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.
© 2011 Tan et al. ; licensee BioMed Central Ltd.
This is an open access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0),
which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.
Anti-cancer natural products isolated from Chinese medicinal herbs
Wen Tan 1, 2 §, Jinjian Lu 1, 2, 3 §, Mingqing Huang 1, 2, 4, Yingbo Li 1, 2, Meiwan Chen 1,
2, Guosheng Wu 1, 2, Jian Gong 1, 2, Zhangfeng Zhong 1, 2, Zengtao Xu 1, 2, Yuanye
Dang 1, 2, Jiajie Guo 1, 2, Xiuping Chen 1, 2 *, Yitao Wang 1, 2 *
1 State Key Laboratory of Quality Research in Chinese Medicine, University of
Macau, Av. Padre Toma's Pereira S.J., Taipa, Macao SAR, China
2 Institute of Chinese Medical Sciences, University of Macau, Av. Padre Toma's
Pereira S.J., Taipa, Macao SAR, China
3 College of Life Sciences, Zhejiang Chinese Medical University, 548 Binwen Rd.,
Binjiang Dist., Hangzhou 310053, Zhejiang, China
4 College of Pharmacy, Fujian University of Traditional Chinese Medicine, No.1
Huatuo Rd., Shangjie University Town, Fuzhou 350108, Fujian, China
§ These authors contributed equally to this work
* Corresponding authors:
Xiuping Chen and Yitao Wang
State Key Laboratory of Quality Research in Chinese Medicine
University of Macau
Av. Padre Toma's Pereira S.J.
Taipa, Macao SAR
In recent years, a number of natural products isolated from Chinese herbs have been
found to inhibit proliferation, induce apoptosis, suppress angiogenesis, retard
metastasis and enhance chemotherapy, exhibiting anti-cancer potential both in vitro
and in vivo. This article summarizes recent advances in in vitro and in vivo research
on the anti-cancer effects and related mechanisms of some promising natural
products. These natural products are also reviewed for their therapeutic potentials,
including flavonoids (gambogic acid, curcumin, wogonin and silibinin), alkaloids
(berberine), terpenes (artemisinin, β-elemene, oridonin, triptolide, and ursolic acid),
quinones (shikonin and emodin) and saponins (ginsenoside Rg3), which are isolated
from Chinese medicinal herbs. In particular, the discovery of the new use of
artemisinin derivatives as excellent anti-cancer drugs is also reviewed.
Surgery, chemotherapy and radiotherapy are the main conventional cancer treatment
often supplemented by other complementary and alternative therapies in China .
While chemotherapy is one of the most extensively studied methods in anti-cancer
therapies, its efficacy and safety remain a primary concern as toxicity and other side
effects of chemotherapy are severe. Moreover, multi-drug resistant cancer is even a
bigger challenge. Medicinal herbs are main sources of new drugs. Newman et al.
reported that more than half of the new chemicals approved between 1982 and 2002
were derived directly or indirectly from natural products . Some active compounds
have been isolated from Chinese medicinal herbs and tested for anti-cancer effects.
For example, β-elemene, a compound isolated from Curcuma wenyujin Y. H. Chen et
C. Ling (Wenyujin), is used as an anti-cancer drug in China. For this study, we
searched three databases, namely PubMed, Scopus and Web of Science, using
keywords “cancer”, “tumor”, “neoplastic” and “Chinese herbs” or “Chinese
medicine”. Publications including research and review papers covered in this review
were dated between 1987 and 2011, the majority of which were published between
2007 and 2011. Chinese herb-derived ingredients, including flavonoids, alkaloids,
terpenes, quinones and saponins, were found.
Gambogic acid (GA)
GA (Figure 1A) is the principal active ingredient of gamboges which is the resin from
various Garcinia species including Garcinia hanburyi Hook.f. (Tenghuang) . GA
has various biological effects, such as anti-inflammatory, analgesic and anti-pyretic 
as well as anti-cancer activities [4, 5]. In vitro and in vivo studies have demonstrated
its potential as an excellent cytotoxicity against a variety of malignant tumors,
including glioblastoma, as well as cancers of the breast, lung and liver. GA is
currently investigated in clinical trials in China [6-8].
GA induces apoptosis in various cancer cell types and the action mechanisms of GA
remain unclear. Transferrin receptor (TfR) significantly over-expressed in a variety of
cancers cells may be the primary target of GA . The binding of GA to TfR in a
manner independent of the transferrin binding site, leading to the rapid apoptosis of
tumor cells . Proteomics analysis suggests that stathmin may be another molecular
target of GA . The importance of the role of p53 in GA-induced apoptosis remains
controversial [5,10]. Furthermore, GA antagonizes the anti-apoptotic B-cell
lymphoma 2 (Bcl-2) family of proteins and inhibits all six human Bcl-2 proteins to
various extents, most potently inhibiting myeloid cell leukemia sequence 1 (Mcl-1)
and Bcl-B, as evidenced by a half maximal inhibitory concentration (IC50) lower than
1μM . Moreover, GA also influences other anti-cancer targets, such as nuclear
factor-kappa B (NF-κB)  and topoisomerase IIα .
GA causes a dose-dependent suppression of cell invasion and inhibits lung metastases
of MDA-MB-435 cells in vivo through protein kinase C (PKC)-mediated matrix
metalloproteinase-2 (MMP-2) and matrix metallopeptidase-9 (MMP-9) inhibition .
GA also exhibits significant anti-metastatic activities on B16-F10 melanoma cancer
cells partially through the inhibition of the cell surface expression of integrin α4 in
C57BL/6 mice .
Notably, the combination of GA with other compounds enhances their anti-cancer
activities [15-17]. For example, He et al.  reports that proliferative inhibition and
apoptosis induction are much more visibly increased when Tca8113 cells are treated
with combined GA and celastrol, indicating that the combination of GA and celastrol
can be a promising modality for treating oral squamous cell carcinoma. Another study
showed that GA in combined use with 5-fluorouracil (5-FU) induced considerably
higher apoptosis rates in BGC-823 human gastric cells and inhibited tumor growth in
human xenografts . Furthermore, low concentrations of GA were found to cause a
dramatic increase in docetaxel-induced cytotoxicity in docetaxel-resistant
BGC-823/Doc cells . Magnetic nanoparticles of Fe3O4 (MNPs-Fe3O4) were
reported to enhance GA-induced cytotoxicity and apoptosis in K562 human leukemia
Curcumin (Figure 1B) is the main active flavonoid derived from the rhizome of
Curcuma longa (Jianghuang), with its dry herb weight consisting of up to 3.08%
curcumin . Curcumin has been used to treat cardiovascular disease, inflammation
and arthritis . Epidemiological studies have found that incidence of several
cancers is low in India where curcumin is widely consumed, suggesting that curcumin
intake plays a role in cancer prevention . Other studies have also indicated that
curcumin inhibits cell proliferation and survival in breast cancer, colon cancer,
prostate cancer, gastric cancer, leukemia, lymphoma and melanoma . Curcumin
induces cell apoptosis through complex intrinsic and extrinsic pathways. Curcumin
binds to more than 30 different protein targets, including transcript factors (NF-κB
and activator protein-1), growth factor receptors [epidermal growth factor receptor
(EGFR), human epidermal growth factor receptor 2 (HER2)], kinases
[mitogen-activated protein kinase (MAPK), PKC and protein kinase A (PKA)],
inflammatory cytokines [tumor necrosis factor (TNF) and interleukins], cell
cycle-related proteins (p53 and p21), matrix metalloproteinases (MMPs) and
urokinase plasminogen activators (u-PA) [20, 22, 23]. Daily oral administration of
curcumin suppresses metastasis in breast, colon, lung and medulloblastoma cancers.
The suppression involves the regulation of metastatic proteins, such as vascular
endothelial growth factor (VEGF), MMP-2, MMP-9 and intercellular adhesion
molecules [24, 25].
Curcumin induces non-apoptotic cell death, such as autophagic cell death, which
involves the degradation of the cell’s own components through lysosomal machinery
. In vitro and in vivo studies have demonstrated that curcumin induces autophagic
cell death, as evidenced by the immunoreactivity of microtubule-associated protein
light chain 3 (LC3) in myeloid leukemia cells. The action mechanism is attributed to
the inhibition of the Akt/mammalian target of rapamycin/p70 ribosomal protein S6
kinase pathway and activation of extracellular signal-regulated kinase 1/2 by
curcumin in malignant glioma cells [26, 27]. In addition, autophagic inhibitor
bafilomycin A1 suppresses curcumin-induced cell death . Another type of
non-apoptotic cell death induced by curcumin is paraptosis which is observed in
malignant breast cancer cells but not in normal breast cells. Curcumin induces
paraptotic events (eg the promotion of vacuolation accompanied with mitochondrial
and/or endoplasmic reticular swelling and fusion) and decreases the level of paraptotic
inhibitor protein AIP-1/Alix . These paraptotic events are attributed to superoxide
anion and proteasomal dysfunction .
Curcumin reduces toxicity induced by anti-cancer agents , sensitizes
chemo-resistant cancer cells and demonstrates synergic effects with different
chemotherapeutic agents such as doxorubicin, 5-FU, paclitaxel, vincristine,
melphalan, butyrate, cisplatin, celecoxib, vinorelbine, gemcitabine, oxaliplatin,
etoposide, sulfinosine, thalidomide, suberoylanilide hydroxamic acid, dasatinib and
bortezomib . Prior administration of curcumin reduces the DNA damage and
oxidative stress induced by cyclophosphamide (CXC) , improves uroprotective
efficacy in the CXC hemorrhagic cystitis model  and suppresses early lung
damage in CXC-treated rats . Curcumin alleviates the side effects of mitomycin
C, as evidenced by decreased lipid peroxidation and DNA damage . Furthermore,
curcumin reduces weight loss and improves kidney function and bone marrow
suppression in animal studies . When combined with oxaliplatin, curcumin
decreases the proliferative capacity of oxaliplatin-resistant cell lines and enhances the
cytotoxicity of oxaliplatin in an in vitro oxaliplatin-resistant model . Additionally,
curcumin protects healthy cells against radiation and sensitizes tumor cells to
radiation therapy [37, 38].
Clinical trials have been or are currently being conducted to evaluate the tolerance,
safety, pharmacokinetics and efficiency of curcumin as well as its combination
therapy with current anti-cancer drugs . A phase I clinical trial found no
dose-limiting toxicity in patients treated with an oral-dose of up to 8g/day of
curcumin. The recommendation is seven consecutive doses (6g/day) of curcumin
every three weeks in combination with a standard dose of docetaxel .
Improvements in biological and clinical responses were observed in most treated
patients . A phase II trial of gemcitabine-resistant pancreatic cancer found
chemotherapeutic drugs in combined use with curcumin to be sufficiently safe,
feasible and efficient. While the bioavailability of curcumin is relatively poor, two out
of 21 patients in the phase II trial showed clinical biological responses; one patient
exhibited marked tumor regression coupled with a significant increase in serum
cytokine levels [41, 42].
Wogonin (Figure 1C) is one of the flavonoids isolated from Scutellaria baicalensis
Georgi (Huangqin), with its dry herb weight consisting of up to 0.39mg/100mg of
wogonin . Wogonin has been widely used in the treatment of various
inflammatory diseases owing to its inhibition of nitric oxide (NO), prostaglandin E2
and pro-inflammatory cytokines production, as well as its reduction of
cyclooxygenase-2 (COX-2). In vitro studies [44-48] have shown wogonin to possess
cytostatic and cytotoxic activities against several human tumor cell lines.
Wogonin induces apoptosis through the mediation of Ca2+ and/or inhibition of NF-κB,
- to H2O2 to some extent; H2O2, in turn, serves as a signaling molecule that
activates phospholipase Cγ. Ca2+ efflux from the endoplasmic reticulum is then
regulated, leading to the activation of Bcl-2-associated agonist of cell death .
Wogonin may also directly activate the mitochondrial Ca2+ channel uniporter and
enhance Ca2+ uptake, resulting in Ca2+ overload and mitochondrial damage .
Furthermore, wogonin induces cell type-dependent cell cycle inhibitions in cancer
cells, such as those observed in human cervical carcinoma HeLa cells at the G1 phase
 and in THP-1 cells at the G2/M phase  respectively. Unlike the inhibitory
effect of baicalein and baicalin on normal human fetal lung diploid TIG-1 cells ,
wogonin imposes minor or almost no toxicity on normal peripheral T cells ,
TIG-1 cells  and human prostate epithelial cells . This selective inhibition of
wogonin is due to a high expression of L-type voltage dependent Ca2+ channels in
cancer cells . In addition, wogonin suppresses VEGF-stimulated migration and
tube formation in HUVEC by inhibiting VEGF receptor 2 (VEGFR2) instead of
VEGFR1 phosphorylation .
The synergistic effect of wogonin on chemotherapy drugs, such as etoposide, has also
been investigated. Wogonin significantly improves etoposide-induced apoptosis in
cancer cells in a similar capacity as the typical P-glycoprotein (P-gp) inhibitors
verapamil and cyclosporine A [50-52]. However, other P-gp substrates, such as
doxorubicin and vinblastine, do not show any synergistic effect . Similar effect
was also found when combination treatment with 5-FU in human gastric MGC-803
cells and in MGC-803 transplanted nude mice . The underlying mechanisms
might be due to its pro-apoptotic effect and inhibition of NF-κB nuclear translocation
Anti-inflammatory and anti-viral activities of wogonin may also contribute to tumor
prevention . Wogonin is a good anti-cancer candidate due to its broad toxicities to
various types of tumor cell lines and the low toxicities to normal tissues, as well as the
Silibinin (Figure 1D), a mixture of flavonoids derived from Silybum marianum
(Shuifeiji), is therapeutically used for the treatment of hepatic diseases in China,
Germany and Japan. Silibinin has effects on many cancers, such as prostate, colon,
bladder and lung cancers [55,56], particularly the migration, invasion and metastasis
of cancer cells . In a transgenic adenocarcinoma of the mouse prostate (TRAMP)
mouse model, silibinin inhibits tumor growth, progression, local invasion and distant
metastasis . Silibinin induces both death receptor-mediated and
mitochondrial-mediated apoptosis in human breast cancer MCF-7 cells . Silibinin
also reduces hepatocellular carcinoma xenograft growth through the inhibition of cell
proliferation, cell cycle progression, as well as phosphatase and tensin homolog/P-Akt
and extracellular signal-regulated kinase (ERK) signaling. These effects induce
apoptosis and increase histone acetylation and superoxide dismutase-1 (SOD-1)
expression on human hepatocellular carcinoma xenografts . Not only does
silibinin inhibit primary prostatic tumor progress but also protects against
angiogenesis and late-stage metastasis. Therefore, silibinin may have a potential for
improving survival and reducing morbidity in prostate cancer patients .
Silibinin exerts anti-cancer activity mainly by blocking cell cycle progression and
induces G1 cell cycle arrest in a dose- and time-dependent manner in large cell
carcinoma H1299 and H460 cells and bronchioalveolar carcinoma H322 cells .
Silibinin modulates the protein levels of cyclin-dependent kinases (CDKs; 4, 6 and 2),
cyclins (D1, D3 and E), and CDK inhibitors (p18/INK4C, p21/Waf1 and p27/Kip1) in
a differential manner in the above-mentioned cell lines . Silibinin also regulates
multiple cellular proliferative pathways in cancer cells, including receptor tyrosine
kinases (RTKs), androgen receptors, signal transducers and activators of transcription
(STATs), NF-κB . Moreover, silibinin inhibits the constitutive activation of
STAT3 and causes caspase activation and apoptotic cell death in human prostate
carcinoma DU145 cells .
The combined use of silibinin with 1,25-dihydroxyvitamin D3 promotes the
expression of both differentiation-promoting and -inhibiting genes in acute
myelogenous leukemia cells and the latter can be neutralized by a highly specific
pharmacological inhibitor, suggesting the therapeutic potential of silibinin .
Berberine (Figure 1E) is an isoquinoline alkaloid isolated from Coptidis Rhizoma
(Huanglian), which is a Chinese medicinal herb for heat dissipation and
detoxification, with its dry herb weight consisting of up to 7.1mg/100mg of berberine
. Berberine has diverse pharmacological activities [66-70] and is especially used
as an antibacterial and anti-inflammatory gastrointestinal remedy in China .
Berberine has anti-proliferative effects on cancer cells has been documented [72-78].
Multiple targets of berberine have been identified, including mitochondria, DNA or
RNA, DNA topoisomerases, estrogen receptors, MMPs, p53 and NF-κB [74, 79-82].
Berberine exerts cytotoxicity and inhibits telomerase and topoisomerase in cancer
cells by specifically binding to oligonucleotides or polymorphic nucleic acid and by
stabilizing DNA triplexes or G-quadruplexes [81,83,84]; the electrostatic interactions
may be quantified in terms of the Hill model of cooperative interactions .
Cell cycle regulation is a common target mechanism in anti-cancer therapies. A
low-dose (12.5–50μM) berberine treatment induces G1 phase arrest whereas doses
higher than 50μM induce G2 phase arrest in mouse melanoma K1735-M2 and human
melanoma WM793 cells . Moreover, 50μM berberine decreases cyclin B1 levels
and induces cycle arrest at the G1 phase in human lung cancer H1299 and A549 cell
lines . Even in anoikis-resistant human breast cancer MDA-MB-231 and MCF-7
cells, 10 or 20μM doses of berberine is superior to 5 or 10nM of doxorubicine
respectively by inducing cell cycle arrest at the G0/G1 phase .
In human breast cancer MCF-7 cells, berberine induces apoptosis through a
mitochondrial dependent pathway by increasing the Bcl-2-associated X protein
(Bax)/Bcl-2 protein ratio, activating caspases and inducing poly (ADP-ribose)
polymerase (PARP) cleavage . These apoptotic processes also occur in human
tongue squamous carcinoma cancer-4 and human glioblastoma T98G cells [73, 88].
Accumulation of berberine on mitochondrial membranes alters the binding between
adenine nucleotide translocator and bongkrekic acid, thereby inducing depolarization
and fragmentation which may contribute to mitochondrial respiration inhibition and
mitochondrial dysfunction . In the p53-expressing human neuroblastoma
SK-N-SH and p53-deficient SK-N-MC cells, the role of p53 in berberine’s
anti-neoplastic function is highlighted by the cytotoxic effects and apoptotic gene
expression accompanied by caspase-3 activation .
In addition to apoptotic alteration induced by berberine, recent findings are about
anti-cancer mechanisms that have a higher propensity to cause autophagy. Berberine
induces autophagic cell death in human hepatocellular liver carcinoma cell lines
(HepG2) and MHCC97-L cells, which may be diminished by cell death inhibitor
3-methyladenine through beclin-1 activation and mammalian target of rapamycin
(mTOR) signaling pathway inhibition . In addition, berberine also modifies LC3,
an autophagic marker, in human lung cancer A549 cells, indicating that autophagy
may play a crucial role in berberine-induced cancer cell death .
Berberine also inhibits tumor metastasis and invasion. For example, berberine inhibits
12-O-Tetradecanoylphorbol 13-acetate (TPA)-induced cell migration and blocks
prostaglandin E (EP) receptor 4 agonist-induced migration by reducing EP receptors 2
and 4 in A375 and Hs294 cells . Even at low doses, berberine suppresses Rho
GTPase activation and induces migration and motility inhibition in HONE1 cells .
Berberine also inhibits Rho kinase-mediated Ezrin phosphorylation at Thr (567) in
5-8F cells, leading to a 51.1 % inhibition of tumor metastasis to the lymph nodes in
vivo . A combination of As2O3 (5μM) and berberine (10μM) inhibit the formation
of a cell confluent layer by blocking PKCα and ξ, consistent with reduced levels of
myelocytomatosis oncogene (Myc), Jun proto-oncogene, metallothionein 1-MMP and
Berberine enhances chemo- and radio-sensitivity, implying its potential as an adjuvant
in cancer therapy. Combined with chemotherapy drugs such as cisplatin or As2O3,
berberine exhibits significant cytotoxicity in HeLa and SH-SY5Y cells compared with
monotherapy [96, 97]. When combined with γ radiation, the apoptotic effect is
significantly enhanced in HepG2 cells . Berberine also alleviates
chemo-resistance by down-regulating overexpressed transformed mouse 3T3 cell
double minute-2 and activating p53 in acute lymphoblastic leukemia cells .
Berberine’s poor bioavailability makes it less likely to be an independent anti-tumor
agent [100-102]. Berberine is nevertheless a potential natural compound for
alternative cancer therapy.
Artemisinin and its derivatives (ARTs)
Artemisinin (Figure 1F) is an active terpene of the Chinese medicinal herb Artemisia
annua L. (Huanghuahao) used in China to treat malaria and fever. ARTs, such as
dihydroartemisinin (DHA) and artesunate (Figure 1G), exhibit anti-cancer activities in
vitro and in vivo [103-106]. DHA is one of the main metabolites of ARTs and
artesunate is a semi-synthesized derivative of ARTs; both compounds exhibit
The anti-cancer potential of ARTs has been demonstrated in various cancer cells
including those of leukemia and other cancer cells of breast, ovary, liver, lung,
pancreas and colon [104, 105]. The selective anti-cancer potential of ARTs was
related with the expression of different molecules such as c-MYC, cdc25A, EGFR,
γ-glutamycysteine synthetase (GLCLR) [105, 106]. ARTs also exert anti-cancer
effects in vivo in multiple cancer types [103, 107, 108]. For example, either DHA or
artesunate has anti-cancer activity against pancreatic cancer xenografts [107, 109].
The anti-cancer mechanism of ARTs is likely to be related to the cleavage of the
iron- or heme-mediated peroxide bridge, followed by the generation of reactive
oxygen species (ROS) [110-112]. According to Efferth et al. , CCRF-CEM
and U373 cells are sensitive to a combined treatment of ARTs and iron (II)-glycine
sulfate or holotransferring. Pretreatment with deferoxamine mesylate salt (an iron
chelator) visibly reduces DHA-induced apoptosis in HL-60 leukemia cells .
The anti-cancer potential of ARTs is possibly connected to the expression of TfR.
The synergism of artesunate and iron (II)-glycine sulfate co-treatment is unsuitable
for all types of tumor cells . Endoplasmic reticulum stress is partially involved
in some cases of ARTs-mediated anti-proliferation [115, 116].
ARTs induce cell cycle arrest in various cell types [103, 115, 117]. For example,
DHA and artesunate effectively mediate G1 phase arrest in HepG2 and Hep3B cells
. DHA reduces cell number in the S phase in HCT116 colon cancer cells
. Interestingly, DHA also arrests the G2 phase in OVCA-420 ovarian cancer
cells . Thus, ART-mediated cell cycle arrest is possibly cell type dependent.
ARTs also induce apoptotic cell death in a number of cell types, in which the
mitochondrial-mediated apoptotic pathway plays a decisive role [104, 106]. For
instance, DHA enhances Bax and reduces Bcl-2 expression in cancer cells
[103,107]. DHA-induced apoptosis is abrogated by the loss of Bak and is largely
reduced in cells with siRNA-mediated downregulation of Bak or NOXA .
However, DHA activates caspase-8, which is related to the death receptor-mediated
apoptotic pathway in HL-60 cells . DHA enhances Fas expression and
activates caspase-8 in ovarian cancer cells . DHA also enhances death receptor
5 and activates both mitochondrial- and death receptor-mediated apoptotic
pathways in prostate cancer cells . ARTs-induced apoptosis in cancer cells
may involve p38 MAPK rather than p53 [103, 104].
ARTs inhibit angiogenesis which is a vital process in metastasis [121-124]. DHA
inhibits chorioallantoic membrane angiogenesis at low concentrations and decreases
the levels of two major VEGF receptors on HUVEC . Conditioned media from
K562 cells pre-treated with DHA inhibits VEGF expression and secretion in chronic
myeloid leukemia K562 cells, leading to angiogenetic activity decrease [121,124].
Artemisinin inhibits cell migration and concomitantly decreases the expression of
MMP2 and the αvβ3 integrins in human melanoma cells . ARTs also regulate
the levels of u-PA, MMP2, MMP7 and MMP9 all of which are related to metastasis
ARTs exert synergistic effects with other compounds. Combination of DHA and
caboplatin significantly reduces the development of ovarian cancer as compared with
DHA only . Combined use of DHA or artesunate with gencitabine inhibits the
growth of HepG2 and Hep3B transplanted tumors . Supra-additive inhibition of
cell growth in some glioblastoma multiforme cells is observable when artesunate is in
combined use with EGFR inhibitor OSI-774 . DHA not only up-regulates death
receptor 5 expression but also cooperates with TNF-related apoptosis-inducing ligand
(TRAIL) to induce apoptosis in human prostate cancer cells . Therefore, either
used alone or in combination with other compounds, ARTs are promising compounds
Elemene (Figure 1H) is a sesquiterpene mixture isolated from more than 50 Chinese
herbs and plants, such as Curcuma wenyujin Y. H. Chen et C. Ling (Wenyujin) .
Elemene is mainly composed of β- and δ- and γ-elemene, with β-elemene accounting
for 60 %–72 % of all three isoforms. β-elemene exerts anti-cancer potential in brain,
laryngeal, lung, breast, prostate, cervical, colon and ovarian carcinomas [128-130].
Elemene shows synergistic effects in combination with other chemotherapeutic drugs
, leading to the blockade of cell cycle progression by modulating the G2 cell
cycle checkpoint and inducing G2/M arrest in human non-small cell lung cancer
(NSCLC) and ovarian carcinoma cells while inducing G0/G1 phase arrest in
glioblastoma cell lines through phosphorylation of p38 MAPK [129, 130, 132]. In
NSCLC cells, β-elemene induces cell arrest at the G2/M phase by increasing
phospho-Cdc2 (Tyr15) and p27/Kip1, and by decreasing phospho-Cdc2 (Thr161) and
cyclin B1. Moreover, elemene reduces the expression of Cdc25C, activates Cdc2 and
increases Chk2 . β-elemene combined with cisplatin also mediate G2/M cell
cycle arrest in chemo-resistant ovarian carcinoma cells through down-regulation of
cyclin B1 and Cdc2 by elevating the levels of phosphorylation of Cdc2, Cdc25C, p53,
p21/Waf1, p27/Kip1 and GADD45 . β-elemene also induces
mitochondrial-mediated apoptosis in prostate cancer and NSCLC cells [128, 129].
Combining β-elemene with cisplatin, docetaxel and taxanes significantly increases its
inhibitory effect in androgen-independent prostate carcinoma DU145 and PC-3 cells,
as well as in NSCLC H460 and A549 cells . β-elemene enhances cellular uptake
of taxanes due to the alteration of cell membrane permeability may partly account for
its synergistic effects with taxanes . Elemene inhibits the growth of human
epidermoid and thyroid cancer cells in vivo , and passes through the blood-brain
barrier , suggesting its potential for treating cerebral malignancy.
β-elemene has been approved by China’s State Food and Drug Administration as a
second class innovative drug and is prescribed as an adjuvant drug for some tumor
therapies in China.
Oridonin (Figure 1I) is a diterpenoid isolated from Rabdosia rubescens (Hemsl.) Hara
(Donglingcao), with its dry raw herb consisting of up to 0.35 % of oridonin .
Rabdosia rubescens (Hemsl.) Hara has long been used to treat sore throat, tonsillitis,
and esophageal cancer by native residents of Henan Province. Oridonin was included
in the Chinese Pharmacopoeia in 1977. Main chemical constituents of Rabdosia
rubescens (Hemsl.) Hara are ent-Kaurene diterpenoids, which have multiple
biological activities, such as anti-inflammatory, anti-bacterial and anti-tumor effects.
Oridonin significantly inhibits tumor cell proliferation, induces cell cycle arrest and
promotes cell death. In anti-proliferation tests, different cell lines exhibited similar
sensitivity to oridonin with an IC50 of about 40–80μM after 24 hours of treatment
[136-141]. Oridonin induces G2/M cell cycle arrest by up-regulation of heat shock 70
kDa protein 1, serine-threonine kinase receptor-associated protein, translationally
controlled tumor protein, stress-induced phosphoprotein 1, trifunctional purine
biosynthetic protein adenosine-3 and inorganic pyrophosphatase as well as
down-regulation of poly(rC)-binding protein 1  in a p53-independent and
p21/Waf1-dependent manner . Induction of apoptosis contributes to
oridonin-induced cell death, mainly through mitochondrial-mediated pathways. The
up-regulation of Fas, Fas ligand (FasL) and Fas (TNFRSF6)-associated via death
domain (FADD) expression, as well as the down-regulation of pro-caspase-8
expression suggests that the activation of the Fas/FasL pathway may also be partially
involved in oridonin-induced apoptosis . Possible downstream responses include
the induction of loss of mitochondrial transmembrane potential , the activation
of several caspases [136,146], the down-regulation of Bcl-2, the up-regulation of Bax
and Bid [136,147] as well as the promotion of cytochrome c release  and PARP
cleavage . However, the regulation of Bcl-xL and participation of caspase-3/9
remain controversial [136,143,146,148-150]. Oridonin-induced intracellular ROS
formation may be an initiator of this process [143, 151]. Other proteins may also be
involved in oridonin-induced cell cycle arrest and apoptosis; these proteins include
ERK [144, 152], p38MAPK , insulin-like growth factor 1 receptor , EGFR
, NF-κB , as well as p16, p21/Waf1, p27/Kip1 and c-MYC . Oridonin
induce cell death by affecting the balance of apoptosis and necrosis. In A375-S2 cells,
low concentrations (34.3μM) of oridonin induce p53 and ERK-dependent apoptosis
whereas high concentrations (137.4μM) induce necrosis . In L929 cells, oridonin
induces a caspase-independent and mitochondria- or MAPK-dependent cell death
through both apoptosis and necrosis [139, 149]. Similar results are also observed in
A431 cells . Oridonin also induces simultaneous autophagy and apoptosis in
MCF-7  and HeLa cells . This autophagy may be attributed to the
inactivation of Ras, changes in mitochondrial membrane potential , activation of
PKC, Raf-1 or c-jun N-terminal kinase (JNK) signaling  and even NF-κB
signaling pathways . Inhibition of autophagy is attributed to apoptotic
up-regulation because oridonin-induced apoptosis augmentation is accompanied by
reduced autophagy  whereas oridonin-induced autophagy inhibits ROS-mediated
apoptosis by activating the p38 MAPK-NF-κB survival pathways in L929 cells .
Oridonin inhibits DNA, RNA, and protein syntheses , decrease telomerase, as
well as down-regulate human telomerase reverse transcriptase mRNA expression
. The in vivo anti-tumor activities of oridonin have been demonstrated in
different tumors such as Ehrlich ascites carcinoma, sarcoma-180 solid tumors and in
leukemic mice models [163,164].
Triptolide (Figure 1J) is a diterpenoid triepoxide and the principal active ingredient of
Tripterygium wilfordii Hook. f. (Leigongteng) used in Chinese medicine to treat
inflammation and autoimmune diseases . Triptolide exhibits potent
anti-inflammation, immunomodulation and anti-tumor activities [166-170]. Triptolide
exerts multiple effects on apoptosis, angiogenesis, metastasis and drug-resistance
Triptolide is active in pro-apoptosis in diverse tumor cell types including ovarian
cancer , myeloma , myeloid leukemia , thyroid carcinoma  and
pancreatic tumor cells . Many in vitro and in vivo studies have tried to elucidate
the potential mechanism of triptolide; however, conclusions have been inconsistent.
Triptolide seems to induce apoptosis via different pathways in various cell lines. For
example, triptolide induces apoptosis by the overexpression of cytomembrane death
receptor in a caspase-8-dependent manner in pancreatic tumor  and
cholangiocarcinoma cells . Triptolide also promotes apoptosis in leukemic and
hepatocarcinoma cells by the mitochondrial-mediated pathway [172, 173].
Triptolide is a potent inhibitor of tumor angiogenesis in a zebrafish embryo model and
demonstrates potent activities against vessel formation by nearly 50 % at 1.2μM
. In a xenograft model, triptolide (0.75mg/kg/day) blocks tumor angiogenesis
and progression in a murine tumorigenesis assay possibly correlated with the
down-regulation of proangiogenic Tie2 and VEGFR-2 expression . In vitro
studies have shown that triptolide inhibits the proliferation of HUVEC. A chick
embryo chorioallantoic membrane test shows that triptolide inhibits angiogenesis as
well. Triptolide impairs VEGF expression in thyroid carcinoma TA-K cells and
down-regulates NF-κB pathway activity; the target genes of triptolide are associated
with endothelial cell mobilization in HUVEC . The down-regulation of NF-κB
signaling , in combination with the inhibition of VEGF expression , may be
the anti-angiogenesis action of triptolide.
Furthermore, triptolide inhibits tumor metastasis, reducing basal and stimulated colon
cancer cell migration through collagen by 65 % to 80 % and decreasing the expression
of VEGF and COX-2 . Triptolide inhibits the expression of multiple cytokine
receptors potentially involved in cell migration and cancer metastasis, including the
thrombin receptor, CXCR4, TNF receptors and TGF-β receptors . Triptolide also
inhibits interferon-γ-induced programmed death-1-ligand 1 surface expression whose
up-regulation is an important mechanism of tumor immune evasion in human breast
cancer cells . Triptolide inhibits the experimental metastasis of melanoma cells
to the lungs and spleens of mice . Moreover, triptolide inhibits the migration of
lymphoma cells via lymph nodes, a result which may be related to its
anti-proliferative effects and blockage of the SDF-1/CXCR4 axis .
Triptolide enhances the anti-neoplastic activity of chemotherapy [180, 181]. The
combination index-isobologram indicates that the effect of triptolide on 5-FU is
synergistic on colon carcinoma . In a tumor xenograft model, the combined
effects of triptolide (0.25mg/kg/day) and 5-FU (12mg/kg/day) on the growth of colon
carcinoma are superior to those of individual agents . Triptolide is synergistic
with other anti-cancer agents or therapies including hydroxycamptothecin ,
idarubicin, AraC , TRAIL  and ionizing radiation . These results
indicate the therapeutic potential of triptolide in treating cancer.
Ursolic acid (UA)
UA (Figure 1K) is a ubiquitous pentacyclic triterpenoid compound from many plants
such as Ligustrum lucidum Ait. (Nuzhen). UA exerts proliferation inhibition in human
ovarian cancer CAOV3 cells and doxorubicin-resistant human hepatoma R-HepG2
cells [185,186]. UA disrupts cell cycle progression and induces necrosis in a clonal
MMTV-Wnt-1 mammary tumor cell line . Eight novel UA derivatives with
substitutions at positions C-3, C-11, and C-28 of UA show cytotoxicity to some
degree in HeLa, SKOV3 and BGC-823 in vitro; only one derivative exhibits more
potent cytotoxicity than UA .
UA induces apoptosis via both extrinsic and intrinsic signaling pathways in cancer
cells . In PC-3 cells, UA inhibits proliferation by activating caspase-9 and JNK
as well as FasL activation and Akt inhibition . A significant proliferation
inhibition and invasion suppression in both a dose- and time-dependent manner is
observed in highly metastatic breast cancer MDA-MB-231 cells; this inhibition is
related to the down-regulation of MMP2 and u-PA expression . Moreover, UA
reduces IL-1β- or TNF-α-induced rat C6 glioma cell invasion and inhibits the
interaction of ZIP/p62 and PKC-ζ . Nontoxic UA concentrations inhibit vessel
growth in rat aortic ring and down-regulate matrix MMPs such as MMP2 and MMP9
. In other cancer cell lines, such as Hep3B, Huh7 and HA22T cells, UA exerts a
potential anti-angiogenic effect by decreasing HIF-1α, VEGF and IL-8 gene
Shikonin (Figure 1L) is a natural anthraquinone derivative isolated from the roots of
Lithospermum erythrorhizon (Zicao) and exerts anti-tumor effects mainly by
inhibiting cell growth and inducing apoptosis. The underlying molecular mechanisms
vary with cell types and treatment methods. Shikonin induces apoptosis in a classic
caspase-dependent pathway in cervical, bladder and melanoma cancer cells. [195-198].
Shikonin induces necroptosis regardless of the drug concentration in
caspase-3-negative MCF-7 cells . Different concentrations of shikonin induce
either apoptosis or necroptosis, and necroptosis converts to apoptosis in the presence
of Nec-1 in HL-60 and K562 cells . The growth inhibition and apoptosis induced
by shikonin in some cancer cells may be attributed to the inactivation of NF-κB
activity or increasing Annexin V signal and CD95 (Fas/APO) expression [201, 202].
Shikonin also induces apoptosis via ROS production in osteosarcoma and
Bcr/Abl-positive CML cells [203, 204].
Several different mechanisms contribute to the anti-cancer activities of shikonin. For
example, shikonin suppresses proteasomal activities thereby inhibiting tumor growth
in both H22 allografts and PC-3 xenografts . Shikonin also inhibits
topoisomerase II  and down-regulates ER2 and activates NFE2-related factor 2
as an anti-estrogen agent in human breast cancer [207, 208]. Shikonin modulates an
estrogen enzyme by down-regulating the expression of steroid sulfatase which is
important for estrogen biosynthesis . Shikonin inhibits tumor invasion via the
NF-κB signaling pathway in human high-metastatic adenoid cystic carcinoma cells
. Therefore, shikonin may directly or indirectly inhibit or modulate
disease-related cellular targets in cancer.
Emodin (Figure 1M) is a natural anthraquinone derivative isolated from Rheum
palmatum L. (Zhangyedahuang), with its dry raw herb consisting of up to
0.20mg/100mg of emodin . Emodin exerts anti-tumor activity against various
human cancers . Emodin induces cell cycle arrest and apoptosis in cancer cells
[212-214] and the oxidative injury acts upstream of anti-proliferation. Emodin inhibits
IL-6-induced Janus-activated kinase 2/STAT3 pathways and induces apoptosis in
myeloma cells via the down-regulation of Mcl-1 . Emodin down-regulates
androgen receptors and inhibits prostate cancer cell growth . Moreover, emodin
stabilizes topoisomerase II-DNA cleavage complexes, thereby inducing DNA
double-strand breaks . The suppression of excision repair cross complementation
1 (ERCC1) and Rad51 expression through ERK1/2 inactivation is vital in
emodin-induced cytotoxicity in human NSCLC cells .
Emodin inhibits basic fibroblast growth factor (bFGF)-induced proliferation and
migration in HUVEC and VEGF-A-induced tube formation . Emodin inhibits
tumor cell migration through suppression of the phosphatidylinositol
3-kinase-Cdc42/Rac1 pathway . The disruption of the membrane lipid
raft-associated integrin signaling pathway by emodin may inhibit cell adhesion and
Emodin sensitizes chemotherapy associated with ROS production [221, 222]. In
combined use with cisplatin, emodin elevates ROS generation and enhances
chemosensitivity in DU-145 cells, accompanied by the down-regulation of MDR1
expression and suppression of HIF-1α transactivation . Emodin enhances the
sensitivity of gallbladder cancer SGC996 cells to platinum drugs via glutathione
depletion and multidrug resistance-related protein 1 down-regulation . The
mechanisms of the synergistic effects of emodin with cisplatin or gencitabin may be
attributed to the emodin-induced down-regulation of ERCC1 and Rad51 expression,
respectively [225,226]. These results suggest that emodin may be used as an adjuvant
to enhance the anti-cancer effects of chemotherapeutic agents.
Extracted from Panax ginseng C.A. Mey. (Renshen) and Panax quinquefolius L.,
Araliaceae (Xiyangshen), ginsenoside Rg3 (Figure 1N) is a biologically active
component with both in vitro and in vivo anti-cancer activities [227, 228]. The
anti-proliferative mechanism of ginsenoside Rg3 is associated with the inactivation of
NF-κB [229, 230], modulation of MAPKs  and the down-regulation of
Wnt/β-catenin signaling . Ginsenoside Rg3 affects the ephrin receptor pathway
in HCT-116 human colorectal cancer cells . The anti-proliferative mechanism of
ginsenoside Rg3 is also associated with the molecules of mitotic inhibition, DNA
replication, repair, and growth factor signaling .
Ginsenoside Rg3 inhibits the proliferation of HUVEC and suppresses the capillary
tube formation of HUVEC on a matrigel at nanomole scales in the presence or
absence of VEGF. Ginsenoside Rg3 attenuates VEGF-induced chemo-invasion of
HUVEC and ex vivo microvascular sprouting in rat aortic ring. bFGF-induced
angiogenesis may be abolished by ginsenoside Rg3 . In lung metastasis models
of ovarian cancer, ginsenoside Rg3 decreases the number of tumor colonies in the lung
and vessels oriented toward the tumor mass . This effect may be partially due to
the inhibition of angiogenesis and the decrease in MMP9 expression .
Ginsenoside Rg3 increases the efficacy of cancer chemotherapy. Combined treatments
with ginsenoside Rg3 enhance the susceptibility of colon cancer cells to docetaxel,
paclitaxel, cisplatin and doxorubicin; the mechanism of such an enhancement is
related to the inhibition of the constitutively activated NF-κB . A similar
phenomenon has been observed in prostate cancer cells, in which the combination of
ginsenoside Rg3 and docetaxel more effectively induces apoptosis and G1 cell cycle
arrest, accompanied by the inhibition of NF-κB activity . Low-dose
administration of cyclophosphamide (CTX) with ginsenoside Rg3 increases the
efficacy of targeting the tumor microvasculature and the two-drug combination
treatment results demonstrate the longest patient survival rates . Ginsenoside Rg3
combined with gemcitabine not only enhances the efficacy of tumor growth
suppression and survival prolongation, but also decreases VEGF expression and
microvessel density in tumors .
Natural products such as GA, curcumin, β-elemene et al. derived from Chinese
medicinal herbs are potential candidates for anti-cancer therapeutic drugs.
5-FU: 5-fluorouracil; AIF: apoptosis inducing factor ; AP-1: activator protein-1;
ARTs: artemisinin and its derivatives; ATRA: all-trans retinoic acid; bFGF: basic
fibroblast growth factor; CDKs: cyclin-dependent kinases; CTX: cyclophosphamide
DHA: dihydroartemisinin; DPD: dihydropyrimidine dehydrogenase; EGFR:
epidermal growth factor receptor; ERK1/2: extracellular signal-regulated kinase 1/2;
FasL: Fas ligand; GA: gambogic acid; HDMEC: human dermal microvascular
endothelial cells; HUVEC: human umbilical vascular endothelial cells; ICAM-1:
intercellular cell adhesion molecule-1; IL-1β: interleukin-1β; LC3: light chain 3;
MMP2: matrix metalloproteinase-2; MMP9: matrix metalloproteinase9; MRP1:
multidrug resistance-associated protein 1; NF-κB: nuclear factor-kappa B; P-gp:
P-glycoprotein; PI3K: phosphoinositide 3-kinase; ROS: reactive oxygen species;
STAT: signal transducer and activator of transcription; STS: steroid sulfatase; TfR:
transferrin receptor; TPA: 12-O-tetradeca noylphorbol-13-acetate; TRAMP:
transgenic adenocarcinoma of the mouse prostate; UA: ursolic acid; u-PA: urokinase
plasminogen activators; VCAM-1: vascular cell adhesion molecule-1; VEGF:
vascular endothelial growth factor; VEGFR1:vascular endothelial growth factor
receptor 1; VEGFR2: vascular endothelial growth factor receptor 2
The authors declare that they have no competing interests.
WT, JJL, MQH, YBL, MWC, GSW, JG, ZFZ, ZTX, YYD and XPC wrote the
manuscript (WT wrote berberine; JJL wrote GA and ARTs; MQH wrote emodin and
ginsenoside Rg3; YBL wrote cucurmin; MWC wrote silibinin; GSW wrote shikonin;
JG wrote wogonin; ZFZ wrote β-elemene; ZTX wrote triptolide; YYD wrote UA;
XPC wrote oridonin. ). JJG drew the chemical structures in Figure 1. WT, JJL and
XPC revised the manuscript. YTW designed and supervised this work. All authors
read and approved the final version of the manuscript.
The work was supported by the grant (029/2007/A2) from the Science and
Technology Development Fund of Macau Special Administrative Region, China and
supported in part by the National Natural Science of China (No. 81001450) awarded