Development of artemisinin compounds for cancer treatment

Abstract

Artemisinin contains an endoperoxide moiety that can react with iron to form cytotoxic free radicals. Cancer cells contain significantly more intracellular free iron than normal cells and it has been shown that artemisinin and its analogs selectively cause apoptosis in many cancer cell lines. In addition, artemisinin compounds have been shown to have anti-angiogenic, anti-inflammatory, anti-metastasis, and growth inhibition effects. These properties make artemisinin compounds attractive cancer chemotherapeutic drug candidates. However, simple artemisinin analogs are less potent than traditional cancer chemotherapeutic agents and have short plasma half-lives, and would require high dosage and frequent administration to be effective for cancer treatment. More potent and target-selective artemisinin-compounds are being developed. These include artemisinin dimers and trimers, artemisinin hybrid compounds, and tagging of artemisinin compounds to molecules that are involved in the intracellular iron-delivery mechanism. These compounds are promising potent anticancer compounds that produce significantly less side effect than traditional chemotherapeutic agents.

Full text

REVIEW
Development of artemisinin compounds for cancer treatment
Henry C. Lai &Narendra P. Singh &Tomikazu Sasaki
Received: 20 July 2012 /Accepted: 21 August 2012 / Published online: 31 August 2012
#Springer Science+Business Media, LLC 2012
Summary Artemisinin contains an endoperoxide moiety that
can react with iron to form cytotoxic free radicals. Cancer cells
contain significantly more intracellular free iron than normal
cells and it has been shown that artemisinin and its analogs
selectively cause apoptosis in many cancer cell lines. In addi-
tion, artemisinin compounds have been shown to have anti-
angiogenic, anti-inflammatory, anti-metastasis, and growth
inhibition effects. These properties make artemisinin com-
pounds attractive cancer chemotherapeutic drug candidates.
However, simple artemisinin analogs are less potent than
traditional cancer chemotherapeutic agents and have short
plasma half-lives, and would require high dosage and frequent
administration to be effective for cancer treatment. More
potent and target-selective artemisinin-compounds are being
developed. These include artemisinin dimers and trimers,
artemisinin hybrid compounds, and tagging of artemisinin
compounds to molecules that are involved in the intracellular
iron-delivery mechanism. These compounds are promising
potent anticancer compounds that produce significantly less
side effect than traditional chemotherapeutic agents.
Keywords Artemisinins .Anticancer properties .Drug
development
Introduction
Artemisinin (Fig. 1), a chemical isolated from the sweet
wormwood Artemisia annua L, is a sesquiterpene lactone
with potent antimalarial activity. Its effectiveness on malaria
is due to its endoperoxide moiety that reacts with heme,
which is abundant in malaria parasites, leading to the for-
mation of carbon-based free radicals which in turn cause
death of the parasite. Artemisinin is also being developed
into an anticancer therapeutic agent. The rationale is that
cancer cells, like the malaria parasites, contain high concen-
tration of free iron. Cell death also results from the forma-
tion of free radicals by the artemisinin-iron reaction. The
advantage of artemisinin as an anticancer agent is not only
in its potency as a toxic agent to cancer cells, but also in its
selectivity in killing cancer cells and low toxicity to normal
cells. In a paper published in 1995 [1], we demonstrated that
dihydroartemisinin is 100 times more toxic to human leu-
kemia cells than normal lymphocytes. This was again
shown later in human breast cancer cells versus normal
breast cells [2]. In addition, we showed that an increase in
intracellular iron by preincubating cancer cells with holo-
transferrin could potentiate the toxicity of artemisinin to-
ward the cells. This gave support to the hypothesis that
artemisinin kills cancer cells via its reaction with free iron
and its selectivity toward cancer cells was due to their high
rate of uptake of iron via transferrin receptors compared to
normal cells. This property of artemisinin enables it to be
effective against many different types of cancer cells.
Over the years, various forms of molecules containing
artemisinin/endoperoxide moiety have been developed for
more effective cancer treatment. In this review, we will sum-
marize these developments and discuss some of the problems.
Artemisinin and its monomer analogs are generally not
potent enough to assure cancer cure due to their relatively
low toxicity toward cancer cells and short half lives. More
potent compounds are needed. Many attempts have been
made to increase the cancer cytotoxicity potency. These in-
clude artemisinin dimers, tetraoxanes and hybrids. Another
approach is to deliver artemisinin compounds to cancer cells
by tagging them to cancer cell targeting molecules.
H. C. Lai (*):N. P. Singh
Departments of Bioengineering, University of Washington,
Box 355061, Seattle, WA 98195, USA
e-mail: hlai@u.washington.edu
T. Sasaki
Departments of Chemistry, University of Washington,
Seattle, WA 98195, USA
Invest New Drugs (2013) 31:230–246
DOI 10.1007/s10637-012-9873-z

Artemisinin monomers
The anticancer effects of artemisinin have been reported in
the early 1990s by Woerdenbag et al.[3]. Most of the earlier
research was mainly on the monomer analogs. The most
prolific researcher in this area has been Thomas Efferth of
the Johannes Gutenberg University.
The common artemisinin monomers (artemisinin, dihy-
droartemisinin, artesuante and artemether (Fig. 1)) have been
tested on many different types of cancer cells (Table 1).
Results indicate they are toxic to cancer cells with IC
50
sin
the 10–20 μM range. Only few studies had simultaneously
tested the compounds on normal cells [1,2,4–11]. In general,
artemisinin compounds have been shown to be more toxic
toward cancer cells than their corresponding normal cells.
Many molecular mechanisms have been investigated. Artemi-
sinins affect many different cellular pathways that are in-
volved in cellular development, proliferation, and apoptosis.
Apoptosis is a commonly reported effect [6,7,12–31], as well
as arrest in cell cycle [9,11,32–37], particularly at the G
0
/G
1
phases. Thus, both cell death and growth inhibition occur.
However, the site of action is not clear. There are reports of
involvement of mitochondria and the apoptotic pathway [5,7,
9,20–22,38–41]. There are also reports suggesting extra-
mitochondrial mode of action [7,30,44]. Involvements of
iron/heme [1,2,9,14,23,38,40–45] and reactive oxidative
species [5,7,12,20,30,46–51] have also been implicated as
we had previously hypothesized [1].
Many cellular molecular pathways involved in cell
growth and processes of cancer development have been
studied. Two processes that have repeatedly been reported
to be affected by artemisinins are inhibition of nuclear factor
kappaB (NF-κB) [27,32,52–56] and decrease in vascular
endothelial growth factor (VEGF) [16,57–63] activities.
Effects on other cellular pathways have also been reported
including NOXA [5], mitogen-activated protein kinase
(MAPK) [53,64], hypoxia-inducible factor 1α(HIFα)
[59,65], Wnt/β−catenin [66,67], survivin [24], COX
[68], c-MYC oncoprotein [18,23,69], epidermal growth
factor (EGF) [70], and tumor necrosis factor α(TNFα)[56].
These molecular effects could explain the apoptotic, anti-
angiogenic [15,16,54,58–63,71–86]; anti-inflammatory
[55,56,68,87–90]; anti-metastasis [61,91–95], and cell
cycle inhibition effects of artemisinin compounds. Of
course, most of these changes in cellular molecular activities
could result from an increase in free radical activity in
cancer cells due to the reaction of artemisinins with iron.
Artemisinin monomers have been tested on many animal
models of cancer, including sarcoma, leukemia, fibrosarcoma,
glioma, oesteosarcoma, and cancers of the breast, pancreas,
ovary, liver, and colon. Studies are summarized in Table 2.A
general conclusion is that these monomers can retard cancer
growth. However, high doses up to 100 mg/kg/day are re-
quired to achieve significant effect. No significant side effects
have been reported. Several studies [6,8,96,97]haveshown
that dihydroartemisinin is synergistic with various traditional
chemotherapeutic anticancer drugs. These findings warrant
the use of artemisinin compounds as primary or adjuvant
agents for cancer treatment. However, only five human case
reports have so far been published: laryngeal squamous cell
carcinoma/artesunate [98]; metastatic uveal melanoma/artesu-
nate [99];pituitary macroadenoma/artemether [100];non-
small cell lung cancer/artesunate [101]; and cervical cancer/
dihydroartemisinin [102].
Other monomers and artemisinin hybrids
In addition to the basic monomeric compounds, other
artemisinin-like compounds have been developed. These oth-
er compounds include: artemisone, tehranolide, artemisinin-
glycolipid, deoxoartemisinin, and artemisinin deveriatives.
Deoxoartemisinin compounds have actively been studied
in Yansei University in Korea. A group of deoxoartemisi-
nins was synthesized [103] and found to be more potent
antimalarials than artemisinin. These compounds are hydro-
lytically stable and orally active. Lee et al.[104]tested
anticancer cell activity of deoxoartemisinin and carboxypro-
pyldeoxoartemisinin on cancer cell lines. Their compounds
have different profiles of toxicity on the different cell lines.
They proposed that the antitumor activity of artemisinin
compounds was not dependent on lipophilicity and ‘artemi-
sinin derivatives have specific target proteins in each type of
cancer’. However, no further information on this hypothesis
is available. Jung et al.[105] tested a series of deoxoarte-
misinin monomers, dimers and trimers on cancer cell lines.
Some of these compounds are more active in killing cancer
cells than adriamycin, mitomycin, and taxol. A trimer, par-
ticularly, was shown to be very active. However, the study
also showed that different cell lines have different
artemisinin artemether dih
y
droartemisinin
artesunate
Fig. 1 Molecular structures of
several common artemisinin
monomers
Invest New Drugs (2013) 31:230–246 231

Table 1 A list of cancer cell
lines investigated in artemisinin
in vitro studies (all cell lines
were human cells unless other-
wise specified)
Brain cancer-
Rat C6 glioma cells- dihydroartemisinin [65,85,163]
U373MG cells- dihydroartemisinin [50]
18 neuroblastoma cell lines- artemisinin, dihydroartemisinin, artesunate [51]
Glioblastoma multiforme cell lines- artesunate [162]
Breast cancer-
MDA-MB-231cells-artesunate [171]
Murine Ehrlich ascites EN2 tumor cells- artemisinin [125,172]
MCF-7, MDA-MD-231, and T47D cells- artesunate [7]
MCF-7 cells-artemisinin [173,174]
HTB-27 radio-resistant cells- dihydroartemisinin [2]
MCF-7 cells- artesunate [175]
MCF-7, MDA-MB-231, MCF-10AT, MCF-10A cells-artemisinin [11]
Cervical cancer-
HeLa cells- artesunate [27]
Colorectal cancer-
Mouse colorectal cancer cells- artesunate [176]
CLY cells- artesunate [66,67]
HCT116 cells- dihydroartemisinin [42]
HCT116 and HCT116/R cells- dihydroartemisinin [177]
Endometrial cancer-
RL95-2 endometrial carcinoma cells- artesunate [31]
Gastric cancer-
PG100 cells- artemether [4]
Hepatoma-
H22 cells- artemisinin [178]
HepG2, Huh-7, BEL-7404, Hep3B-artemisinin, dihydroartemisinin, artesunate, artemether [8]
HepG2 and SMMC-7721 hepatocellular carcinoma cells- artemisinin [94]
BEL-7402 cells-artesunate [179]
BEL-7402 cells-dihydroartemisinin [180]
Leukemia-
Multidrug-resistant human CCRF-CEM cells- artesunate [181]
Doxorubicin-resistant T leukemia cells- artesunate [12]
Molt-4 cells- dihydroartemisinin [1]
Chronic myeloid leukemia K562 cells- dihydroartemisinin [16]
K562 cells- artesunate [63]
HL60 leukemia cells- DHA [44,182]
K562/adr chemoresistant myelogenous leukemia cells- artemisinin, dihydroartemisinin, artesunate [169]
K562 cells- dihydroartemisinin [183]
CCRF-CEM and multi-drug resistant leukemia cells- artemisinin and artesunic acid [131]
Lung cancer-
ASTC-a-1 lung adenocarcinoma cells- dihydroartemisinin [19]
SPC-A-1 cells- dihydroartemisinin [24]
PC-14 cells- dihydroartemisinin [184]
GLC4/adr small cell lung cancer cells- artemisinin, dihydroartemisinin, artesunate [182]
Small cell lung cancer cells- artemisinin [185]
A549 lung adenocarcinoma cells- artesunate [186]
ASTC-a-1 lung adenocarcinoma cells-artemisinin [30]
Murine Lewis lung carcinoma cells- dihydroartemisinin [96]
Lymphoma-
Romos cells- artesunate [164]
232 Invest New Drugs (2013) 31:230–246

responsiveness to these compounds. The variation can be
hundreds of folds. For the dimers, linkages with one amide-
or one sulfur centered two ethylene groups are essential for
high anticancer activity. Antitumor activity of deoxoartemi-
sinin dimers has also been studied by Jeyadevan et al.[106]
and Posner et al. [107]. Cho et al.[108] synthesized 10-
substitured triazolylartemisinin compounds and tested them
on various cancer cell lines (human colorectal adenocarcino-
ma, human glioma, human cervical carcinoma and mouse
melanoma). The GI
50
s of most of these compounds were less
than 1 μM. However, in most of these cell lines, paclitaxel
has significantly lower GI
50
s. Nam et al.[25] tested deox-
oartemisinin and its dimers and trimers on oral cancer cells.
The deoxoartemisinin compound 12-(2′-hydroxyethyl)
deoxoartemisinin was not very active against the cancer
cells. However, the dimer and trimer showed potent antipro-
liferative effect on the cells. The trimer was actually more
potent than paclitaxel. Apoptosis was observed. Jung et al.
[109] tested C-12 non-acetal deoxoartemisinins on various
cancer cell lines and reported potent activity. However, these
compounds were significantly less potent than doxorubicin.
Oh et al.[79] (on oxo-olefinated deoxortemisinin)
andJungetal.[77] (on non-acetal deoxoartemisinin)
have reported potent anti-angiogenic activity of deox-
oartemisinin compounds. They also reported no direct
correlation of anti-angiogenic and anticancer activity of
these compounds.
Ricci et al.[81] studied artemisinin-glycolipid hybrids
and reported high antiangiogenic activity of these com-
pounds comparable to fumagillin and thalidomide. Gly-
colipids have been shown to have anti-angiogenic effects.
Recently, artemisinin-glycolipid hybrids from 12β(c-c)-
type deoxoartemisinin and glycolipids have also been
tested on cancer cells [110]. They have potent anticancer
activity above that of artemisinin or glycolipid alone on
several cancer cell lines. Notably, they are five times
more potent than cisplatin and paclitaxel on oral cancer
cells.
Melanoma-
A375, G361, LOX melanoma cells- dihydroartemisinin [5]
Myeloma-
SP2/0 cells- artesunate [17,187]
RPM18226 multiple myeloma cells- dihydroartemisinin [62]
Nasopharyngeal cancer-
CNE-1 and CNE-2 nasopharyngeal carcinoma cells- artemisinin [35]
Oral cancer-
YD-10B cells- dihydroartemisinin [25]
Oral squamous cell carcinoma (IHGK) cells- artemisinin [188]
Osteosarcoma-
Canine osteosarcoma cells- dihydroartemisinin [189]
HOS cells- artesunate [29]
Ovarian cancer-
A2780 and OVCAR-3 cells- dihydroartemisinin [6]
Ten human ovarian cancer cell lines- dihydroartemisinin, artesunate, artemether, arteether, arteannuin [10]
SKOV3 and OVCAR3 cells- dihydroartemisinin [64,190]
HO8910PM cells- dihydroartemisinin [95]
Pancreatic cancer-
BxPC-3 and AsPC-1 cells- dihydroartemisinin [191]
Panc-1 cells-artesunate [47]
BxPC-3 and PANC-1 cells- dihydroartemisinin [97]
Papillomavirus-expressed epithelial cells- dihydroartemisinin [46]
Prostate cancer-
PC-3, LNCaP, C4-2 and DU145 cells- dihydroartemisinin [23]
LNCaP (lymph node carcinoma of the prostate) cells- artemisinin [34]
PC-3 cells- Artesuante [192]
Skin cancer-
A431 human epidermoid carcinoma cells-artesunate [9]
Thyroid cancer-
8 medullary thyroid carcinoma cell lines- artesunate [193]
There are studies in which a
panel of different types of can-
cer cells was investigated, e.g.,
Beekman et al. [125], Efferth et
al. [194]
Table 1 (continued)
Invest New Drugs (2013) 31:230–246 233

Table 2 In vivo studies of artemisinin-compounds on cancer growth
Treatments Results
Bachmeier
et al.
[171]
MDA-MB231 human breast cancer mouse xenograft; started
when tumors at 5-6 mm diameter, artesuante (200 or 400 mg/
kg/day, i.p., for five consecutive days), doxorubicin (8 mg/kg,
i.v., once a week for two weeks), monitored to 38 days.
‘Marginal’growth inhibition at 400 mg/kg dose
(tumor size~60 % of control); doxorubicin was more potent.
Chen et al.
[195]
BxPC-3 human pancreatic cancer mouse xenograft; started when
tumors reached ~120 mm
3
, dihydroartemisinin (2, 10, 50 mg/
kg, i.p. for 18 days).
Inhibited tumor growth in a dose-dependent manner;
at 50 mg/kg, tumor volume on day 18 was 27 % of control.
Chen et al.
[6]
A2780 and OVCAR-3 human ovarian cancer mouse xenografts;
started when tumor reached ~70 mg, dihydroartemisinin (10 or
25 mg/kg/5 days/week for three weeks, i.p.), carboplatin
(120 mg/kg, i.p. on first day), and combined dihydrartemisi-
nin/carboplatin treatment.
Significant growth inhibition observed.
A2780 xenograft- dihydroartemisinin-24 % and 41 % inhibition
for the two dosages); carboplatin- 56 % inhibition; combine-
70 % inhibition.
OVCAR xenograft- dihydroartemisinin-14 % and 37 % inhibi-
tion for the two dosages); carboplatin- 46 % inhibition;
combine- 70 % inhibition.
Dell’Eva
et al.
[76]
Kaposi’s sarcoma mouse xenograft; started immediately after
cancer implantation, artesunate (167 mg/kg/day in drinking
water) for 27 days.
Artesunate inhibited tumor growth, at the end of the experiment,
tumor volume of artesunate –treated animals was ~30 % of control.
Disbrow
et al.
[46]
Canine oral papillomavirus tumor model; direct application of
dihydroartemisinin (2.22 mg in 100 μl (78 mM) DMSO once
daily, 5 days a week).
Dihydroartemisinimn abolished tumor formation, tumor
developed regressed faster than control.
Du et al.
[196]
Panc-1 human pancreatic cancer mouse xenograft; started when
tumors reached 130 mm
3,
artesunate (20, 50, 100 mg/kg/day,
daily i.p.), gemcitabine (100 mg/kg/day, i.p., every three days).
Retarded tumor growth dose-dependently, response to 100 mg/
kg artesunate dose similar to gemcitabine treatment. However,
body weight loss was observed in gemcitabine-treated and not
in artesunate-treated mice.
Farsam et
al.[197]
Spontaneous mammary ductal carcinoma in mice; started when
tumors reached 500 mm
3,
artemether (10 mg/kg/day, i.p.) or
cyclophosphamide (20 mg/kg/day, i.p.) given first in three
consecutive days and then on days 5, 7, and 9.
On day 10, volume of tumors of artemether-treated animals was
24 % of controls; response similar to cyclophosphamide.
Gao et al.
[198]
U937 human leukemia cell mouse xenograft; started 3 days after
inoculation, dihydroartemisinin (50 mg/kg, i.p., 5 times per week).
52, 60, and 70 % inhibition of tumor growth on days 10, 15 and 20.
Hou et al.
[8]
HepG2 and Hep3B human hepatoma mouse xenograft; started at
100 mg tumor mass, artemisinin or dihydroartemisinin (50 or
100 mg/kg/day, p.o.), artemisinin or dihydroartemisinin+
gemcitabine (80 mg/kg, i.p. on days 7, 11 and 15).
HepG2 xenograft: artemisinin and dihydrartemisinin reduced
tumor growth dose-dependently (30 %, 39.4 % for artemisi-
nin; 36.1 % and 60.6 % for dihydroartemisinin 36.1 % and
60.6 %); dihydroartemisinin more potent than artemisinin;
synergistic with gemcitabine.
Hep3B xenograft: dihydroartemisinin more potent than
artemisnin in reducing tumor growth; dihydroartemisinin
synergistic with gemcitabine, but not artemisinin.
Lai and
Singh
[170]
DMBA-induced breast cancer in rat; artemisinin mixed in food
(~8 mg/kg/day, 40 weeks).
Delayed and prevention of cancer development; fewer tumors
developed in artemisinin-treated animals.
Lai et al.
[158]
MTLn3 cell implantation-induced breast cancer in rat; started
when tumors reached 1 cm in diameter, dihydroartemisinin
(20 mg/kg/day, p.o., 5 consecutive days).
Tumor growth reduction (on day 6, tumors size of
dihydroartemisinin-treated rats was ~75 % of control).
Langroudi
et al.
[119]
Implanted mouse spontaneous mammary ductal carcinoma, started
when tumors reached 500 mm
3
, artemisinin (2.8 mg/kg/day,
i.p.) or cyclophosphamide (20 mg/kg/day, i.p.) daily for 20 days.
Artemisinin decreased tumor growth (~50 % on day 20); no
significant difference between artemisinin- and
cyclophosphamide-treated groups until day 19, when cyclo-
phosphamideshowed bigger inhibition.
Li et al.
[66]
CLY human colorectal carcinoma mouse xenograft, started when
tumors reached 100 mm
3
(stopped when control tumors
reached 1000 mm
3
); Artesunate (100 mg/kg, i.v., daily;
300 mg/kg, i.v., every 3 days), cyclophosphamide (100 mg/
kg, i.v., every 7 days).
Artesunate inhibited tumor growth at 35.4 % and 50.5 % for the
two dosages.
Cyclophosphamide at 67.1 % (with weight loss and two animals
died).
Ma et al.
[199]
A549 human non-small cell lung carcinoma mouse xenograft;
started when tumors reached 100 mm
3
, artesunate (60 or
120 mg/kg/day, p.o., 2 weeks).
Artesunate at 120 mg/kg/day significantly reduced tumor
growth (not at 60 mg/kg/day). On day 14, tumor size of
artesunate-treated animals was ~56 % of control.
Moore et
al.[200]
Implanted fibrosarcoma in rats; started with tumors reached
340 mm3, dihydroartemisinin (2 mg/kg/day for 1-3 days,
5 mg/kg/day on 4-10 days, p.o.), some animals were also
Tumor growth of dihydroartemisinin treatment alone not
different from control.
234 Invest New Drugs (2013) 31:230–246

Table 2 (continued)
Treatments Results
given ferrous sulfate (20 mg/kg, p.o.) together with dihy-
droartemisinin.
‘Dihydroartemisinin+ferrous sulfate’-treated animals: tumor
growth was retarded (70 % of control on day 11).
Noori and
Hassen
[201]
Implanted mouse spontaneous mammary ductal carcinoma,
started when tumors reached 1500 mm
3
, dihydroartemisinin
(4.85 μg/mouse/day, i.p. for 6 days). (The dosage given by the
authors was probably incorrect.)
Dihydroartemisinin reduced tumor growth (at the end of the
experiment, dihydroartemisinin-injected tumor volume was
almost the same as on day 1).
Noori et
al.[115]
Implanted mouse spontaneous mammary ductal carcinoma,
started when tumors reached 1500 mm
3
, dihydroartemisinin
(intratumoral injection, 11.28 μg/mouse/day for 9 days).
Dihydroartemisinin significantly retarded tumor growth (at the
end of the experiment, dihydroartemisinin-injected tumor vol-
ume was almost the same as on day 1).
Rasheed
et al.
[92]
Chicken embryo metastasis assay with non-small cell lung can-
cer cells placed on upper chorion-allantoic membrane (CAM),
artesunate (i.v., or applied on upper CAM).
Artesunate decreased liver metastasis and reduced primary
tumor size on upper CAM.
Soomro et
al.[82]
Zebra fish embryos angiogenesis model; various
dihydroartemisinin derivatives added to water
Some dervicatives have potent anti-angiogenesis effect- effec-
tive at 1 μg/ml.
Tin et al.
[11]
MCF-7 breast cancer mouse xenograft; started when tumors
about 35 mm
3
; artemisinin (100 mg/kg/day, SC) for two
weeks.
Inhibition of tumor growth (at the end of two weeks, tumor size
smaller than at start), anti-angiogenic effect implied.
Wang et
al.[202]
Eca109 human esophageal carcinoma cell mouse xenograft;
artesunate (100, 200, 300 mg/kg/day, i.p.; 7 days, stopped one
week and then injected for another 7 days), tumors measured
one day after last injection.
Artesunate inhibited cancer growth (maximum inhibition rate
76.4 % in the 200 mg/kg group)
Wang et
al.[61]
Mouse Lewis lung carcinoma cells inoculated in ear skin of
mice; artemisinin (50 mg/kg/day, p.o., 2 weeks) started the
day after inoculation; animals examined on day 30 after
inoculation; others for survival study up to 60 days.
Artemisinin caused no significant change in tumor growth rate;
presence and number of lung metastasis were reduced by 50
and 63.5 %, respectively; also less metastasis in lymph nodes-
metastasis in deep cervical and mediastinal lymph nodes fully
prevented; lymphangiogenisis was inhibited by 63 %; survival
prolonged from 38 days (in control) to 54 days.
Wang et
al.[97]
BxPC-3 human pancreatic cancer mouse xenograft; started when
tumors reached 120 mm
3
, dihydroartemisinin (10 mg/kg/day,
daily, i.p.), gemcitabine (100 mg/kg, i.p., 2 times a week),
dihydroartemisinin+gemcitabine, for 21 days.
Dihydroartemisinin reduced tumor growth (~30 % inhibition on
day 21), dihydroartemisinin and gemcitabine are synergistic.
Wang et
al.[54]
BxPC-3 human pancreatic cancer mouse xenograft; started when
tumors reached 120 mm
3
, dihydroartemisinin (2, 10, 50 mg/
kg/day, i.p. for 21 days).
Dose-dependent inhibition of tumor growth; on day 21, tumor
size of 50 mg/kg-group was 33 % of control.
Weifeng et
al.[94]
HepG2 human hepetocellular carcinoma orthotropic xenograft
implanted in liver of mice; artemisinin (50 or 100 mg/kg/day,
p.o., 4 weeks) beginning at 24 hr after tumor implantation.
Lung tumor (metastasis) fewer in artemisinin-treated groups
compared to control (51.8 % and 79.6 % inhibition for the two
dosages).
Wu et al.
[95]
Mouse orthotropic ovarian cancer tissue implanted on ovarian
capsule; started at two weeks after tumor inoculation,
dihydroartemisinin (50 mg/kg, i.p., 3 X a week for 4 weeks)
No significant difference in tumor size from control; metastesis
to other organs was moderately reduced in dihydroartemisinin-
treated animals.
Wu et al.
[85]
Rat orthotropic glioma model (C6 rat glioma cells injected into
brain white matter of rats); started on third day after
implantation, artemether (50, 33.3, 66.6 mg/kg/day, p.o.,
10 days), artemether (50 mg/kg/day)+ ferrous sulfate (1.5 mg/
kg/day, p.o., 10 days).
Artemether reduced tumor growth (volume ~40 % of control);
no significant different among the different dosages.
Ferrous sulfate enhanced the effect of artemether.
Xu et al.
[29]
HOS human osteosarcoma mouse xenograft; started when
tumors reached 120 mm
3
, artesunate (50, 100, 200 mg/kg/day,
i.p., 18 days), cisplatin (2 mg/kg, i.p., twice weekly).
Artesunate caused dose-dependent reduction in tumor growth. In-
hibition of artesunate at 200 mg/kg/day similar to that of cisplatin.
Zhang et
al.[203]
HepG2 hepatocellular carcinoma mouse xenograft,
dihydroartemisinin (20 mg/kg/day, i.p., 5 times a week, 27 days).
On day 26, tumor size of dihydroartemisinin-treated rats was
~40 % of control.
Zhou et al.
[96]
Lewis lung carcinoma mouse xenograft (subcutaneous
implantation of piece of tumor), started immediately after
tumor implantation, dihydroartemisinin (50, 100, 200 mg/kg/
day, i.p., 25 days), cyclophosphamide (50 mg/kg/day. i.p.,
every other day, 5X), and dihydroartemisinin+
cyclophosphamide.
Dihydroartemisinin and the chemotherapeutic drugs reduced
tumor growth. Combined treatment better than either drug
alone in both models. Spontaneous pulmonary metastasis
completely inhibited by drug combinations.
A549 non-small cell lung cancer mouse xenograft, similar
treatments as above except cisplatin (2 mg/kg, i.p) was used
instead of cyclophosphamide.
Invest New Drugs (2013) 31:230–246 235

Artemisone (Fig. 2) is being developed mainly in the
Hong Kong University of Science and Technology for use
in malaria treatment. It is structurally different from the
artemisinin derivatives currently used in malaria treatment
and has been suggested to be a possible replacement in case
resistance develops to the current artemisinin compounds
[111]. Recently, artemisone has been tested on several can-
cer cell lines [112] and found to have more potent anti-
proliferative effect (mainly in arresting cell cycling) than
artemisinin. It also acted synergistically with the chemother-
apeutic drugs oxaliplatin and gemcitabine. However, earlier
studies have shown that artemisone is less anti-angiogenic
than dihydroartemisinin [75] and has significant embryo-
and fetotoxic effects [113]. These latter effects are common
to other artemisinin compounds.
Tehranolide (Fig. 3) is a sesquiterpene lactone with an
endoperoxide moiety. It is isolated from Artemisia diffusa
and investigated mainly by researchers at the Tarbiot Medares
University in Iran. An important aspect of the research is that,
in addition to its selective toxicity to cancer cells, Tehranolide
has been shown to modify immune responses and enhance
antitumor immunity. Tehranolide decreased breast tumor
growth when injected directly into the tumor in the mouse
and attenuate Treg-cell-mediated immune suppression that the
researcher interpreted as an antitumor immunity against can-
cer [114]. A further study [115] showed that intraperitoneally
injected Tehranolide could also reduce tumor growth in mice
and caused a significant decrease in sphenic CD4(+)CD25(+)
Foxp3(+) T-lymphocytes. In vitro study showed that it
inhibited cell growth of RIN pancreatic cancer cells and had
no significant effect on normal lymphocytes. Interestingly,
similar effects of artemisinin on the immune system were also
reported by these researchers. Noori et al.[116]reportedthat
artemisinin was an immunosuppressive agent. It was shown to
suppress delayed hypersensitivity to sheep blood cells in mice.
More recently, Noori et al.[117] reported that dihydroartemi-
sinin stimulated the delayed hypersensitivity against sheep
blood cells and reduced growth of ductal carcinoma in mice.
Noori and Hassan [118] further reported that dihydroartemi-
sinin decreased IL-4 and the level of CD4(+)CD25(+)Foxp3
(+) T-lymphocytes in mice. Laugroudi et al.[119]reported
that artemisinin reduced Treg cellsin tumor and increased IFN
gamma/IL-4 ratio in splenoctye cultures. Increase in Treg cells
in tumors is correlated with tumor progression. More recently,
Noori and Hassan [120] reported that Tehranolide inhibited
proliferation of MCF-7 breast cancer cells by induction of G
0
/
G
1
cell cycle arrest and apoptosis.
Yang et al.[121] tested 15 dihydroartemisinin-chalcone
hybrids on human HL-60 leukemia and mouse P388 lym-
phoma cells. Chalcone was used to form the hybrids
because it also has been shown to have anticancer activity.
The researcher reported that the hybrids had higher toxic-
ity toward the cancer cells than dihydroartemisinin alone.
The IC
50
s were all <1 μM. Hybrids linked by ether are
more potent than those linked by ester. Xie et al.[122]
have also tested artemisinin-chalcone hybrids on five can-
cer cell lines. The IC
50
s on human HT-29 colon and HeLa
cervical cancer cells were between 0.12 and 0.85 μM. Xie
et al.[123] have also synthesized artemisinin-guanidine
hybrids. The Guanidine moiety would make the molecule
more water soluble. These hybrids were tested on human
non-small cell lung cancer, colon cancer, and breast can-
cer cells. The IC
50
s were between 0.02 and 0.53 μM,
which were significantly lower than those of dihydroarte-
misinin (IC
50
s 7.8–12 μM) on these cancer cells. Liu et
al.[124] synthesized artemisinin derivatives containing
lipophilic alkyl carbon chains. They reported that these
compounds were more cytotoxic toward cancer cells than
artemisinin (up to 200 times). The length of the carbon
chains correlated with the cytotoxicity toward human hep-
tocellular carcinoma cells. However, toxicity of these
compounds on normal cells is not known. More lipophilic
artemisinin compounds, e.g., artemether and arteether, are
in general more neurotoxic.
Fig. 2 Molecular structure of artemisone
Fig. 3 Molecular structure of Tehranolide
236 Invest New Drugs (2013) 31:230–246

More recently, Soomro et al.[82] reported the cytotoxic
effects of a group of dihydroartemisinin derivatives that they
synthesized. Some of these compounds were found to be
more potent than artesunate (EC
50
17–62 μMonacute
lymphoblastic leukemia cell lines). The compounds also
have anti-angiogenic property. Interestingly, drug-resisitant
cancer cells were more sensitive to some of these com-
pounds than the drug-sensitive wild types.
Artemisinin dimers and trimers
The first study on artemisinin dimers was reported by
Beekman et al.in 1998 [125]. The pioneer work in the
development of artemisinin dimers was carried out in the
laboratory of Gary Posner in the Johns Hopkins Univer-
sity. Artemisinin dimers (Fig. 4) have been tested in
many different cancer cell lines and found to be effective
in either retarding their growth or causing cell death
(apoptosis) (e.g. [126–129]). In general, cancer cell cyto-
toxicity of dimers is more potent than that of the mono-
mers. The increase in potency varies from 10- to 200-
fold [106,127,128,130–132]. Artemisinin dimers have
also been shown to be as or even more potent than some
chemotherapeutic agents, such as doxorubicin [133], and
much less toxic to normal cells than cancer cells [130,
134]. Posner et al.[135] reported a high therapeutic
index (>150) for some of the dimers they synthesized.
Nam et al.[25] reported that deoxoartemisinin dimers
and trimers are more potent than the monomer on cancer
cells. Deoxoartemisinin trimers are even more potent than
pacilitaxel, 5-fluorouracil, and cisplatin on oral cancer
cells. The artemisinin-guanidine dimers of Xie et al.
[123] are more potent than its monomer and have IC
50
s
of 20–60 nM against HT-29 human colon cancer cells.
The highly selective cytotoxicity of artemisinin dimers
towards cancer cells makes them an attractive option
for development for cancer treatment.
Not very many studies have been carried out to investi-
gate the effect of artemisinin-dimers in vivo. Galal et al.
[136] reported that daily subcutaneous injection (25–50 mg/
kg/day) of a dimer caused a significant growth delay of HL-
60 human leukemia xenografts in the mouse. However, one
of the dimer tested was found to be toxic to animals. Re-
cently, we [137] have shown in both in vitro and in vivo
experiments that artemisinin dimers (dimer-alcohol and
dimer-hydrazone) are more potent than dihydroartemisinin
in regard to rat mammary adenocarcinoma cancer cell
(MTLn3) toxicity and retardation of tumor growth (daily
oral administration of 20 mg/kg).
The mechanism of action of artemisinin dimers on cancer
cells is not known. However, it must be pointed out that the
presence of two endoperoxides in one molecule would not
guarantee its effectiveness towards cancer cells. Other mo-
lecular features also play a role on its potency. For example,
not all dimers tested were found to have an effective anti-
proliferative effect on cancer cells and those that do also
have different potencies towards different cancer cell lines
(e.g. 23, 133, 136). In our recent study [137], we tested two
artemisinin-dimers synthesized in our laboratories and
found that one was slight but significantly more potent
effect than the other both in vitro and in vivo.
Beekman et al.[138] speculated that the spatial positions
of the active groups are an important consideration. They
found that non-symmetric DHA dimers are more potent than
symmetric dimers in killing EN2 cancer cells. The linkers of
the dimers also play an important role. Chadwick et al.
[139], in testing their C10 carba artemisinin dimers, found
that changing the number of carbon atoms in the linker
changed the potency of the dimer in killing HL-60 cells:
dimers with more carbon atoms in their linkers were more
active. Jung et al.[105] reported that linker size affected the
potency of their artemisinin dimers. Jeyadevan et al.[106],
from their study on artemisinin phosphate ester dimers, also
concluded that the nature of the linker in the dimers played
an important role in their antiproliferative effect on cancer
Fig. 4 Molecular structures of
two artemisinin dimers (Dimer-
Sal and Dimer-OH) and the
monomer dihydroartemisinin
(DHA)
Invest New Drugs (2013) 31:230–246 237

cells. Reiter et al.[129] also reported that the nature and
length of the linkers of the artesunic acid homodimers they
synthesized are important in the biological effect and may
be involved in overcoming cross-resistance in drug-resistant
cancer cells. Furthermore, it is also not known why the
dimers are more potent than monomers. One possibility is
that dimers, with two active groups, after activation by iron,
can form cross-linking of biological molecules, which could
cause a more devastating effect on cellular functions leading
to cell death. Interestingly, Beekman et al.[125] concluded
that the ether linkage of their artemsinin dimers was the
component that kills cancer cells, whereas the endoperox-
ides only played a minor role. However, Stockwin et al.
[128] found that both the antioxidant LN-acetylcysteine and
the iron-chelator desferroxamine were able to block the
cancer cell cytotoxicity of their dimers, which would sug-
gest an involvement of the endoperoxide moieties. They
suggested that formation of reactive oxygen species causes
endoplasmic reticulum stress leading to apoptosis.
Therefore, artemisinin dimers cannot be considered as a
single group of compounds with similar general properties.
The arrangement of atoms in the molecule, the chemical
characteristics of the linkers, and the in vivo pharmacoki-
netics of a dimer can determine the cytotoxic effectiveness
and action of the compound on cancer cells.
Tetraoxanes
Tetraoxanes are structurally different from artemisinin-like
compounds. However, they also contain endoperoxide moi-
ety that can react with heme or ferrous iron to form free
radicals. They were developed mainly as antimalarials
[140]. Vennerstrom et al.[141] tested a series of tetraoxanes
on neuroblastioma cells and reported IC
50
s in the low μM
range. Opsenica et al.[142] also tested tetraoxanes on 14
cancer cell lines, including those from non-small cell lung
cancer, colon cancer, CNS cancer, melanoma, ovarian caner
and renal cancer. They also reported GI
50
and IC
50
values in
the μM range (<10 μM). There was indication that tetraox-
anes induced apoptosis in cancer cells. Two compounds
described by Terjic et al.[143] have IC
50
sof22and69
nM on melanoma cells. This low IC
50
again was reported by
Opensiac et al.[144] on melanoma and ovarian cancer cells
(60 nM). Cvijetic et al.[145] recently pointed out hydro-
phobicity and H-bond donor properties are the main factors
affecting the cytotoxic potency of tetraoxane compounds.
Apparently, tetraoxanes are generally more potent than arte-
misinin compounds on cancer cells. There is indication that
different free radical species are produced by these two
groups of compounds. A study by Kumura et al.[146]
reported oxidative degradation of unsaturated phospholipids
in the presence of Fe
2+
and absence of oxygen, whereas no
such degradation was observed with artemisinin. It must be
pointed out that not all tetraoxanes tested are toxic to cancer
cells. Kumar et al.[147] tested a series of tetraoxanes on 4
cancer and 2 non-cancer cell lines and found no significant
effects up to a concentration of 25 μM. Certain structural
requirements seem to be necessary for these compounds to
work as effective antimalarials. Similar requirements may
be needed for them to affect cancer cells. These molecular
structural considerations have been discussed in a recent
review by Kumar et al.[148]. The toxicity of these com-
pounds on normal cells needs to be investigated.
Artemisinin tagged to molecules involved in cellular iron
transport
In mammalian cells, iron is transported into the cytoplasm
via a receptor-mediated endocytosis process [149]. Binding
of the plasma iron-carrying protein transferrin to cell surface
transferrin receptors triggers endocytosis. A drop in pH in
the endosome causes the release of iron from transferrin.
Iron is then actively pumped out into the cytoplasm. Trans-
ferrin and transferrin receptors are recycled back to the cell
surface. Since cancer cells require a large amount of iron,
e.g., as a cofactor in the synthesis of deoxyriboses before
cell division, they express a high number of transferrin
receptors on their cell surface. For example, breast cancer
cells have 5–15 times more transferrin receptors on their cell
surface than normal breast cells [150], and breast cancer
cells do take up more iron than normal breast cells [151]. We
speculate that if artemisinin is covalently attached to holo-
transferrin (iron-loaded transferrin), it would be transported
in the same package into cells and react with the iron within
the endosome where iron would be released from holotrans-
ferrin. This may enhance the cytotoxic potency and selec-
tivity of artemisinin on cancer cells.
Transferrin is a glycoprotein. Its protein moiety is mainly
involved in its binding to cell surface transferrin receptors,
whereas the carbohydrate chains are not involved in receptor
binding [152]. Transferrin has two N-glycosides attached to
Asn residues in the C-terminal domain [153]. Periodate
oxidation of these carbohydrate chains generate reactive
aldehyde groups that can be modified with a variety of
hydrazine or aminoxy derivatives of artemisinin. Assuming
that all 1,2-diol moieties are oxidized to the corresponding
aldehyde group, we estimate that at least ten artemisinin
derivatives could be tagged to one molecule of transferrin.
Thus, we have tagged an artemisinin analog artelinic acid to
the gycosylate-moiety of holotransferrin using a relatively
simple process. Holotransferrin was first treated with NaIO4
to oxidize the N-glycoside chains to expose aldehyde groups
on the surface. Artelinic acid hydrazide was then reacted with
the oxidized holotransferrin to form a covalent conjugate (Art-
238 Invest New Drugs (2013) 31:230–246

Tf). On an average, more than 16 artelinic acid moieties can be
tagged to one transferrin molecule.
Using this ‘Trojan Horse’strategy, chemotherpeutic drugs
have been tagged to transferrin for specific delivery to cancer
cells. However, tagging with artemisinin offers an addition
advantage. In this situation, artemisinin is a pro-drug and
becomes activated after it is transported inside the cell when
iron is released from transferrin inside acidified endosome.
We [154] first tested the Art-Tf in human leukemia (Molt-
4) cells and normal human lymphocytes and compared it with
the effectiveness of dihydroartemisinin. We found that Art-Tf
is about two times more potent than DHA in killing cancer
cells. However, its toxicity toward normal lymphocytes was
much lower (IC
50
s: Molt-4-Tagged-compound 0.98 μM;
Molt-4-DHA 1.64 μM; lymphocyte-tagged compound
33 mM; lymphocyte-DHA 58.4 μM.) This enhanced cancer
versus normal cell toxicity ratio was further confirmed by a
more recent experiment by an independent research group
[155]. They tested ART-Tf on human breast cancer cell
(MCF-7) and normal breast cells (HNB) (IC
50
s: MCF-7/
ART-Tf 0.08 μM; MCF-7/DHA 0.20 μM; HNB/ART-Tf
22.89 μM; HNB/DHA 0.69 μM). Thus, in line with our data
on human leukemia cells/lymphocytes, these researchers
reported that ART-Tf was more cytotoxic and selective in
killing cancerous than normal breast cells. A further study
by the same researchers [156] reported a difference in ultra-
sturcture of plasma membrane of breast cancer cells treated
with Art-Tf or DHA. Large holes were observed on the
membrane after Art-Tf treatment, whereas small irregular
shape holes were observed with DHA treatment.
Astudy[157] has been carried out to investigate the mech-
anisms of action of Art-Tf. In prostate cancer cells (DU-145),
Art-Tf induced apoptosis via activation of mitochrondial apo-
ptotic pathways. Leakage of cytochrome c from mitochondria,
cleavages of procaspase-9 and caspase-3, and PARP-
degradation were observed. The action required expression of
transferrin receptors, thus, validating the endocytotic intake of
Art-Tf. Furthermore, the toxicity is related to the number of
artemisinin-moieties tagged and independent of the concentra-
tion of cells in the culture (whereas the effectiveness of DHA
decreased with an increase in cell concentration). Interestingly,
Art-Tf is less effective to PC-3 cells, another type of human
prostate cancer cell line, than DU-145. A recent study (Gong et
al. unpublished results) has found that transferrin tagged with
artemisinin-dimer was more potent in killing breast cancer
cells than transferrin-tagged with the monomer.
We have also tested ART-Tf on an animal model of breast
cancer and found that it (at 13 nmol/day, iv) significantly
retarded the growth of breast tumor in the rat and it was
significantly more effective than DHA (at 20 mg/kg/day, po)
[158].
A major drawback of Art-Tf is that it is large molecule
and has to be injected intravenously. This limits the dosage
that can be given at a time. In addition, Art-Tf has to
compete with endogenous transferrin for binding to trans-
ferrin receptors on cancer cells.
In another research to achieve specific delivery of artemsi-
nin to cancer cells, we [159] covalently conjugated artemisi-
nin to a transferrin-receptor targeting peptide HAIYPRH that
binds to a cavity on the surface of the transferrin receptor. This
enables artemisinin to be co-internalized with receptor-bound
transferrin. One (ART-peptide) or two (ART2-peptide) arte-
misinin moieties were covalently tagged to the peptide. The
artemisinin-peptide conjugates showed potent anti-cancer ac-
tivity against Molt-4 leukemia cells with a significantly im-
proved cancer/normal cells selectivity. (The IC
50
values of
ART-peptide and ART2-peptide on Molt-4 cells were 1.06±
0.08 and 0.61±0.05 μM at 72 h, respectively. ART2-peptide
was significantly more potent than ART-peptide, consistent
with a higher anti-cancer activity of artemisinin dimers com-
pared to monomeric artemisinin derivatives. The artemisinin-
tagged peptides were virtually non-toxic to normal leukocytes
(IC
50
>10,000 μM). Under the same assay conditions, DHA
showed IC
50
values of 5.01±0.35 and 43±22 μM for Molt-4
cells and normal leukocytes, respectively. Thus, the peptide
conjugates showed markedly improved efficacy and selectiv-
ity in killing the leukemia cells.
Artemisinin-tagged natural iron-carrying molecules can
also be used to treat other diseases. In an earlier paper [160],
we proposed the use of artemisinin-tagged transferrin and
lactoferrin for treatment of bacterial infection, because some
bacteria pick up host transferrin and lactoferrin as their
sources of iron. We also proposed that artemisinin-tagged
bacterial specific siderophores can be developed into effec-
tive antibiotics. Most bacteria use siderophores to acquire
iron from the environment. A recent study by Miller et al.
[161] showed that artemisinin-tagged mycobactin, a bacte-
rial siderophore, had selective and potent activity against
multi- and extensively drug-resistant strains of Mycobacte-
rium tuberculosis. Furthermore, in addition to artemisinin
monomers, other artemisinin-compounds, e.g., dimers,
trimers, or tetraoxanes, can also be tagged to these targeting
carriers. This may further enhance their efficacies.
Discussion
A good cancer treatment should have high specificity toward
cancer cells and not normal cells. It should have a broad
spectrum of action. Thus, it is effective against different
types of cancer and acts on different mechanisms that affect
cancer growth and development. It should be easy to admin-
ister, e.g., orally, and have a high therapeutic index. An
additional preferable quality is that it is economical, thus, it
can be available to patients who cannot afford the expensive
traditional cancer therapies. Artemisinin derivatives satisfy
Invest New Drugs (2013) 31:230–246 239

all these criteria. In particular, it is very unusual that a
chemotherapeutic agent has also antiproliferation, antiangio-
genic, and anti-inflammatory properties. All of them are
beneficial to cancer treatment. With the different types of
artemisinin-like compounds described in the above sections,
it is likely that some will eventually developed into effective
and simple cancer treatment agents. However, there are
several aspects that will require further research to under-
stand the mechanisms of action of these compounds and to
achieve this goal of a better treatment strategy.
(1) The reason why artemisinin is less toxic to normal cells
than cancer cells is still a mystery. In one of our early
experiments on breast cancer cells and normal breast
cells [2], it was found that artemisinin has virtually no
significant toxicity on normal breast cells in log phase
in culture, when uptake of iron for cell division occurs.
It can be speculated that normal cells have better reg-
ulation of free iron intracellularly, such that removal of
iron from the endosome, transfer to sites of usage, and
storage in ferritin are much more efficient than in
cancer cells. In the study of artemisinin-tagged trans-
ferrin [154],the same low toxicity to normal dividing
cells was again observed. Since iron is released from
holotransferrin inside the endosome when it acidifies,
the released iron can immediately react with the arte-
misinin moieties attached to the transferrin molecule.
This indicates a fast removal of released iron from the
endosome in normal cells.
(2) It is clear that the artemisinin monomers alone are not
effective enough for use in cancer treatment. Combi-
nation of these compounds with traditional chemother-
apeutic agents may achieve a synergistic effect with
fewer side effects. Synergism has been reported be-
tween artesunate with fotemustine and dacarbazine on
human uveal melanoma [99]; artesunate and epidermal
growth factor receptor tyrosine kinase inhibitor on
glioblastoma multiforme cells [162]; artesunate and
vinovelbine and cisplatin on human non-small cell
lung cancer [101]; dihydroartemisinin and temozolo-
mide on rat C6 glioma cells [163]; artemisinin and
dihydroartemisinin with gemcitabine on hapatoma
xenograph in mice [8]; Dihydroartemisinin and carbo-
platin on ovarian cancer cells in vitro and vivo [6];
dihydroartemisinin and gemcitabine on pancreatic can-
cer xenograft in mice [97]; dihydroartemisinin with
cisplatin and cyclophosphamide on lung cancer xeno-
graphs in mice [96]; artesuante with lenalidomide on
A549 lung cancer cells and MCF7 breast cancer cells
(not on HCT116 colon cancer cells); artemisone with
gemcitabine, oxaliplatin and thalidomide on human
colon and breast cancer cells [112]; and artesunate
and the anti-CD20 antibody rituximab [164]. However,
this interaction requires further investigation before
implementation. Gravett et al.[112] have reported an-
tagonism between artemisinin and oxaliplatin on colon
cancer cells, and Riganti et al.[165] reported that
artemisinin induced doxorubicin resistance in human
colon cancer cells. On the other hand, artemisinin com-
pounds have been shown to be toxic towards various
multiple drug-resistant cancer cell lines [131,166–168].
Interestingly, Reungpatthanaphong and Mankhetkorn
[169] reported that artemisinin, artesunate, and dihy-
droartemisinin were synergistic with pirarubicin and
doxorubicin on drug-resistant K562/adr and GLC4/adr
cells, but not in their corresponding drug-sensitive cell
lines. This further supports the use of artemisinin com-
pounds as supplements to traditional chemotherapy.
(3) Some of these compounds have not been tested ade-
quately. For example, the effects of most of these com-
pounds on normal cells have not been studied. Most
mechanism studies were carried out on monomers. It is
likely that the more complex artemisinin-compounds
may have different anticancer mechanisms. For example,
the high toxicity of dimers and trimers on cancer cells
could be due to their ability to form crosslinks among
biological molecules. In that sense an optimal length of
the linker to the two endoperoxide-moieties would affect
the effectiveness of the dimer or trimer in killing cells.
Too short a linker arm would be less effective, since
intermolecular crosslinks would be more damaging that
intramolecular crosslinks. However, if the arms are too
long, both endoperoxides would not be accessible to the
source of free iron and get activated at the same time. In
addition, the atomic composition of the linker could also
affect the effectiveness of the dimer/trimer molecule such
that negative charges in the linker could make the mol-
ecule more attracted to positive charged free iron atom.
(4) A very puzzling fact is that different artemisinin com-
pounds have different effectiveness on different types of
cancer cells. It is very important to understand this phe-
nomenon in order to develop aneffective treatment using
artemisinin drugs. This puzzle can probably be resolved
by understanding the mechanism of action of these com-
pounds. Several possibilities can be investigated. One
possibility is that differences in iron metabolism in dif-
ferent types of cancer cells [e.g., see 45] may alter the
amount and location of cellular iron available for inter-
action with artemisinin compounds in the cell. This may
also explain the observation that increase iron availabil-
ity to cells (via an iron supplement of holotransferrin)
does not always enhance the effectiveness of artemisinin
compounds. The location of a compound inside the cell
compartments can affects its effectiveness in killing the
cell. Oxidative stress is a major mechanism of action of
artemisinin compounds. Cells with different oxidative/
240 Invest New Drugs (2013) 31:230–246

antioxidative profiles will have different susceptibilities
to artemisinin compounds.
(5) The effect of long term intake of artemisinin has not yet
been investigated. In one of our experiments [170], we
gave artemisinin to rats at ~8 mg/kg/day continuously for
40 weeks. We did not observe any adverse side effects in
the animals. It is possible in the future that artemisinin
compounds could be used to turn cancer into a chronic
disease or as cancer preventive agents. However, effects
of longer period of administration at higher dosage,
particularly neurotoxicity, should be investigated.
(6) In addition to the property of selective toxicity toward
cancer cells. Artemisinin compounds have been shown to
have other properties that could be beneficial for cancer
treatment. Further studies on these properties are needed.
These properties are anti-angiogenic, anti-inflammatory,
anti-metastatic, and immunological effects.
Acknowledgments The authors’research on artemisinin was sup-
ported by the Breast Cancer Funding of California, the Akibene Foun-
dation, Holley Holdings, Susan Komen for the Cure, the Meryl and
Charles Witmer Foundation, the Washington Technology Center, and
the Life Sciences Discovery Fund of the State of Washington.
Conflict of interest statement The authors are co-inventors of tech-
nologies, of which the patents are owned by the University of Washing-
ton, related to artemisinin-tagged transferrin, artemisinin-tagged
transferrin receptor binding peptides, and artemisinin-dimer hydrazone.
These technologies are licensed to Holley Pharmaceuticals (China) and
Artemisia Biomedical (USA) for commercial development.
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