A ROLE FOR PHALERIA MACROCARPA (SCHEFF) BOERL. EXTRACTS IN THE MANAGEMENT
OF WOMEN’S PATHOLOGICAL CONDITIONS: A RESEARCH REVIEW
RAYMOND RUBIANTO TJANDRAWINATA
, HANNA CHRISTABEL ROULI
Dexa Laboratories of Biomolecular Sciences, Industri Selatan V Block PP no. 7, Kawasan Industri Jababeka II, Cikarang 17550, Indonesia
Received: 02 Nov 2016 Revised and Accepted: 30 Jan 2017
Phaleria macrocarpa (Scheff) Boerl is a medicinal plant that originates from West Papua, Indonesia. The fruit of this plant is known to contain
numerous different compounds that produce different bioactivities. Many of these bioactivities are related to women pathological conditions. The
purpose of this review is to evaluate the effect of P. macrocarpa fruit extract in the management of these conditions. Different studies have proven
that P. macrocarpa extract helps regulate hormone imbalance in women with problems relating to their menstruation cycle, especially during
premenstrual syndrome. It helps alleviate symptoms of primary dysmenorrhea and endometriosis through its bioactivity as anti-inflammation,
apoptosis inducer, anti-angiogenic and anti-oxidant agent. P. macrocarpa fruit extract also showed selective anti-proliferative, anti-inflammatory,
and anti-angiogenic activity on breast and cervical cancer cells. It regulates cancer cell progression through numerous different pathways, making it
highly favourable to be developed as a cancer treatment, whether as a single treatment or as an adjunct therapy. In conclusion, P. macrocarpa
extract has great potential to be developed into treatments for women’s pathological conditions. However, further study, both preclinical and
clinical studies are needed to ascertain its use in women to be effective and safe.
Keywords: Phaleria macrocarpa, Premenstrual syndrome, Endometriosis, Breast cancer, Cervical cancer, Hormone imbalance
© 2016 The Authors. Published by Innovare Academic Sciences Pvt Ltd. This is an open access article under the CC BY license (http://creativecommons.org/licenses/by/4.0/)
DOI: http://dx.doi.org/10.22159/ijpps.2 017v9i3.16001
For many years plant extracts have been used for the management
of women’s health conditions [1, 2]. However, scientific justifications
which provide the bases for these therapeutic intents are virtualy
absent. One serious problem with investigating the use of natural
products for health benefits is the absence of acceptable clinical
study data. Majority evidence is empirical or anecdotal involving the
uncontrolled use of products of doubtful quality. Many of these
traditional herbal medicines are active biologically and could be
clinically beneficial. However, their real clinical effects are most
likely to be dose dependent and due to the secondary metabolites
contained within the product. It is likely that these active agents also
cause unwanted toxicity. Without good clinical trial data and with no
quality control of the product, it is unlikely that these agents would
consistently provide therapeutic benefits.
The Phaleria macrocarpa (Scheff) Boerl plant (known locally in
Indonesia as mahkota dewa) is a plant which originates from the West
Papua area in Indonesia and is empirically used as medicine. The ripe
fruits of P. macrocarpa have red skin, with its fruit flesh, shells and
seeds located inside the fruit. It has a smooth round surface, around 3-
5 cm in size. The fruit grows on the trunks and branches of the trees
and suspended by short stalks. The stalk is attached to the stem and is
fibrous and watery. It also has white flesh, .
The major ingredients of P. marcrocapa fruits are flavonoids,
although alkaloids, saponins, tannins, and terpenoids are also found
in the fruits in a much lower concentration. The n-hexane extract of
P. macrocarpa fruit contains terpenoids, whereas the ethanol extract
of P. macrocarpa fruit and seed contains alkaloids, flavonoids and
triterpenoids. It has also been shown that the ethyl acetate extract of
P. macrocarpa fruit contained flavonoids, triterpenoids and
coumarin groups. Other isolated constituents of the fruit include
Icariside C3, mangiferin and gallic acid .
Traditionally, the fruits of P. macrocarpa are frequently used as
traditional medicine in conjunction with other ingredients. It is used
empirically to treat a variety of chronic diseases such as diabetes
mellitus, allergies, cancer, liver problem, heart disease, kidney
failure, blood disease, hypertension and stroke [4, 5]. The fruits of P.
macrocarpa are also known to have antimicrobial activities due to
the presence of flavonoids . An experiment which investigated the
effects of P. macrocarpa fruit extract in diabetic animals exhibited an
anti-diabetic property of the extract . This is possibly due to the
inhibitory activity on α-glucosidase . In a separate study, it was
previously reported that methanol extracts of P. macrocarpa caused
anti-nephropathic action . Many of these results suggest that the
ingredients of P. macrocarpa may have properties to alleviate
chronic diseases. In conjunction to these, other studies have show
that P. macrocarpa fruit extracts and fractions may have
pharmacological properties for women health conditions, such as
premenstrual syndrome, endometriosis, breast as well as cervical
cencer. Hence, this review is made based on different international
publications on the effect of P. macrocarpa fruit extract on different
women health conditions in the last 10 years**.
Premenstrual syndrome (PMS)
Since the dawn of time, history has noted that women tend to feel
uncomfortable prior to the onset of menses. Unlike men, women of
reproductive age have a cyclical hormonal pattern. This cyclical
pattern may be associated with premenstrual syndrome (PMS) in
some women. As the research of PMS continues, new evidence
strongly lead to the involvement of endocrine system in the etiology.
There are a number of theoretical rationales for cyclic hormonal
changes causing premenstrual symptoms. PMS has been associated
to include any of a number of different symptoms, both physical and
emotional, which occur in a cyclic fashion just prior to the menstrual
flow . These symptoms should begin to lessen with the
menstrual flow. Some women may get some symptoms and not
others. Many patients have predominantly affective symptoms with
very mild somatic symptoms, while other patients, particularly in an
outpatient general gynecologic practice, may have somatic
symptoms with few affective symptoms. It is not known whether
these different groups have similar etiologies. However, it is entirely
not clear at this moment that these cyclic changes actually cause
PMS. Many women experience one or more symptoms such as
depression, mood swings, sleeping disorders and pain. The
imbalance of hormones which resulted in progesterone deficiency
and estrogen dominance correlates with this symptom .
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Role of estrogen and progesterone in PMS
Estrogen has been classified as regulator hormone for mood in
animals and humans. However, their effects show variations of both
anxiolytic and anxiogenic actions, depending on women’s age and
stage of the reproductive cycle . It is well known that reduced
estrogen levels in menopause can cause irritability, panic disorders,
anxiety, cognitive dissonance, depression and even sleep
disturbance [13,14]. Estrogen replacement therapy in
postmenopausal women is consistently reported to improve mood
and feelings of general well-being. It has also been reported that
women suffering from severe premenstrual dysphoric disorder
(PMDD) developed anxiety and other affective symptoms when
treated with estradiol in combination with leuprolide, an agonist
analog of Gonadothropin Releasing Hormone . Another study
was performed to measure the level of estrogen and progesterone at
the onset of menstruation . In this study, investigators quantified
plasma estrogen and progesterone concentrations during the last six
days of the menstrual cycle in women having PMS. Women with
anxiety as the main symptom had significantly higher estrogen levels
on day five, which was two days prior to the onset of menstruation.
The ratio of estrogen to progesterone was consistently higher on day
six. The PMS group also showed increased body weight during the last
days of the menstrual cycle .
As estrogen binds to estrogen receptor (ER), it directly stimulates
tissue proliferation and differentiation. ER is a member of a large
family of nuclear transcriptional regulators that can stimulate the
expression of several genes. ER has two isoforms, ER-ER-α and ß,
encoded by two distinct genes . Like that of ER, the progesterone
receptor (PR) is also an intracellular steroid receptor that binds
progesterone . Both of these hormones have receptors which
become the target for PMS treatment. When estrogen and
progesterone are affected by particular agents, it may lead to a
change in the activities and levels of estrogen and progesterone
resulting in hormone imbalance in the body .
Role of neurotransmitters
Progesterone is known to induce adverse mood swings. It is
hepatically metabolized into alloprenanolone and pregnanolone, both
of which serve as agonists on the brain γ-aminobutyric acid A (GABA-
A) receptor . This complex system works as a neurotransmitting
system in the central nervous system, which inhibits the impulse
transmission between cell nerves. Human and animal studies
suggested that in some individuals, GABA-A receptor agonists can
induce negative symptoms such as anxiety, irritability, as well as
aggression. These agonists have the capacity to be anxiolytic, sedative
and antiepileptic in which its effects depend on its steady state
concentration in the brain. It is known that progesterone metabolite
alloprenanolone can serve as an agonist to GABA-A receptor agonist,
having a bimodal effect on mood with an inverted U-shaped
relationship between concentration and effect .
Estradiol concentration is also known to play a role in mood
regulation by progesterone . The previous study showed that
estradiol treatment during the luteal phase may induce more severe
negative symptoms. This indicates that simultaneously estradiol and
progesterone provide different responses in the central nervous
system, as opposed to when each hormone acts alone. Moreover, the
estrogen receptor (ER) alpha has been shown to regulate signaling
of neurotransmitter systems associated with the ethiology and
treatment of PMDD .
Role of prostaglandins in PMS
Prostaglandins (PGs) are hormone-like compounds that function as
mediators of a variety of physiological responses such as
inflammation, vascular dilation and immunity. They are synthesized
in virtually all cells of the body, including in the brain, breast,
gastrointestinal tract, kidney and reproductive tract. The anti-
inflammatory series 1 PGs are derived from linoleic acid (LA), which
is converted to gamma-linolenic acid (GLA), while arachidonic acid,
found in animal fats, is the precursor of the pro-inflammatory series
2 PGs and leukotrienes. Imbalances in the PGs series could produce
inflammation in tissues, thus resulting into PMS [22, 23]. Studies
also shown that women with PMS have abnormal serum levels of
PGs and their precursors . Lower levels of circulating
prostaglandin E1 (PGE1) can cause increased sensitivity of
reproductive tissues to estrogen, making it more vulnerable to
normal ovarian hormone cycling.
Prostaglandins may be involved in some changes that occur in the
premenstrual period. Symptoms such as cramps, nausea, headache,
and depression occurring in the premenstrual period can be
reproduced early in the cycle by administering whole blood samples
taken during the late luteal phase from a previous cycle . This
suggests that some factors in the blood (not likely prostaglandins
themselves) may stimulate prostaglandin synthesis at distant sites.
Anti-PGs have been helpful for treating PMS although it is not quite
effective when taken up to four days prior to menses [22, 26].
Significant improvement in tension, irritability and depression was
found when mefenamic acid was administered with the onset of
premenstrual symptoms to a group of women having premenstrual
and menstrual symptoms .
P. macrocarpa fraction on the management of PMS
Our previous study evaluated the efficacy and safety of DLBS1442, a
proprietary and standardized semipolar bioactive extract of the P.
macrocarpa fruit in alleviating symptoms of PMS and primary
dysmenorrhea . This was an open study over four menstrual
cycles (with two control cycles, followed by two treatment cycles).
Women with PMS and/or primary dysmenorrhea, 18–40 years** of
age, and with a regular menstrual cycle were included in the study.
In the treatment cycles, 100 mg of DLBS1442 was given two to three
times daily (for those with mild and moderate-to-severe baseline
abdominal pain, respectively), for an average of six days, i. e, three
days before until the end of the first three days of the menstrual
period. Throughout all four study cycles, daily self-assessment of
symptoms related to PMS was made by each subject using a visual
analog scale (VAS). Data were descriptively analyzed and profiled in
curves of VAS score versus time point evaluation starting from day 5
before menstruation to day 5 of menstruation.
During the trial, twenty-three subjects of average age around 21 to
32 were evaluated for the intention to treat analysis . Most
subjects experienced primary efficacy variable (abdominal pain),
peaking on days 1–2 of the menstrual phase, with a mean VAS score
of 36.8±24.3 mm and 30.0±29.6 mm, respectively, during control
cycles. DLBS1442 markedly reduced VAS scores by 13.76±28.27 mm
(37.46%) and 13.28±29.06 mm (44.28%), respectively. Other
symptoms of PMS were also markedly alleviated by DLBS1442.
Some mild adverse events were observed and resolved by the end of
the study. This study proved the effectiveness of DLBS1442 in
alleviating primary dysmenorrhea and abdominal pain, as well as
other symptoms related to PMS. It is also safe and well tolerated in
women with PMS and/or dysmenorrhea .
Pain associated with endometriosis
Endometriosis is a non-life-threatening condition in which tissue
that normally lines a woman's uterus grows in other parts of the
body, particularly on peritoneal tissues, bladder, ovaries, fallopian
tubes, rectum and other pelvic tissues . Endometriosis has been
known as the most frequent cause of pelvic pain in women during
reproductive years. It is estimated that endometriosis affects up to
10% of reproductive-age women and about 70% of women with
infertility or chronic pelvic pain . A recent case showed that out
of 2,080 women with infertility, as many as 1,263 women (60.7%)
were diagnosed with endometriosis . When endometriosis
occurs, the eutopic endometrium experiences subtle abnormalities,
including biochemical reactions that increased production of
estrogen, prostaglandins, cytokines, and metalloproteinases .
These biological reactions resulted in pelvic pain, chronic pain and
fatigue which could lead to infertility. Research to find new remedy
for this condition are directed at finding a non-hormonal efficacious
agent as a treatment. In this regard, the use of a natural product
would be one promising method of treatment for this condition.
There are clear molecular distinctions between endometriotic tissue
and normal endometrium, such as the overproduction of estrogen,
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PGs and cytokines in endometriotic tissue . Gene expression
study of endometrium from women with endometriosis as
compared with endometrium from endometriosis-free women has
revealed the presence of genes related to infertility, progesterone
resistance and implantation failure. Inflammation which also occurs
in endometriotic tissue is associated with the overproduction of
prostaglandins, chemokines, cytokines and metalloproteinases .
In patients with endometriosis, inflammatory and immune
responses, angiogenesis and apoptosis are altered in favor of the
survival and replenishment of endometriotic tissue. These basic
pathological processes depend in part on estrogen and
progesterone. Excessive formation of estrogen and prostaglandin
and the development of progesterone resistance are regarded as
essential apsects of endometriosis treatment. This is because
therapeutic targeting of aromatase in the estrogen biosynthetic
pathway, cyclooxygenase-2 (COX-2) in the prostaglandin pathway or
the progesterone receptor helps reduce pain in the pelvic area .
PGs production in endometriosis
PGs are hormones involved in inflammation and pain that are important
in the pathogenesis of endometriosis. In particular, prostaglandin E2
(PGE2) and prostaglandin F2 (PGF2) are produced excessively in uterine
and endometriotic tissues of women with endometriosis [29-31]. The
vasoconstrictive properties of PGF2, together with its ability to cause
uterine contractions, contributes to dysmenorrhea, whereas PGE2 can
induce pain directly . These PGs are clinically relevant because the
reduction of PGs formation by nonselective cyclooxygenase (COX)
inhibitors decreases pelvic pain associated with endometriosis . Care
must be taken in the long-term administration of nonselective COX
inhibitors due to its gastrointestinal side effects. Use of older COX
inhibitors has been limited because of an increased risk of
gastrointestinal bleeding as well as cardiovascular disease (CVD) .
Excessive PGE2 production during inflammation in uterine cells
through coordinated induction of multiple enzymes, particularly
COX-2 and microsomal prostaglandin E synthase, is believed to be
the cause of pelvic pain in endometriosis cases. Endometriotic
stromal cells produce large quantities of PGE2, which induce local
estrogen biosynthesis and pelvic pain [29,30]. COX-2 is up-regulated
to a greater degree in endometriotic stromal cells as compared with
endometrial stromal cells; moreover, its expression is also increased
in the endometrium of women with endometriosis as compared
with that of disease-free women. Thus, increased synthesis of PGE2
in endometriotic tissue may be due to coordinated hyperactivity of
COX-2 and microsomal prostaglandin E synthase .
Progesterone resistance in endometriosis
In contrast to the clearly unfavourable effect of estrogen on
endometriosis, the role of progesterone has remained unclear.
Endometriotic tissue produces large quantities of progesterone and
contains much lower levels of progesterone receptors than
endometrium . Progesterone, induces much lower levels of
prolactin expression in endometriotic cells compared to endometrial
stromal cells, suggesting that progesterone resistance may lead to
endometriosis. Progesterone works by increasing formation of
retinoic acid, which induces 17alpha-hydroxysteroid dehydrogenase 2
(HSD17B2) expression in endometrial epithelial cells, in a paracrine
fashion. However, endometriotic stromal cells fail to respond to
progesterone and hence do not produce retinoic acid. In endometriotic
tissue, this lack of retinoic acid leads to the lack of epithelial HSD17B2
and the failure to inactivate estradiol. Combined with high estradiol
production, this results in the high levels of estradiol in endometriotic
tissue. These findings suggest that eutopic endometrium of women
with endometriosis also exhibits progesterone resistance.
Progesterone resistance is increased by the low progesterone-
receptor levels in endometriotic tissue. In endometriotic tissue, levels
of progesterone receptor isoform B (PR-B) is undetectable, while that
of the progesterone receptor isoform A (PR-A) isoform is markedly
reduced, in endometriotic tissues [29, 34].
Effects of P. macrocarpa extract in endometriotic cells
In our attempts to find a natural remedy for endometriosis, P.
macrocarpa which is commonly known as crown of god or mahkota
dewa, our study suggested that it was a promising candidate [35,
36]. Originated from Papua, Indonesia, P. macrocarpa has been
traditionally used by Indonesians to treat different chronic diseases
ranging from diabetes, hepatitis to cancer [35-37]. However, most of
the treatments using natural products are still based on the
empirical information. Thus obtaining scientific proof for their
biological activities will need further investigation. As described
previously, our group have conducted a clinical study on the use of
bioactive fraction DLBS1442 from P. macrocarpa to treat primary
dysmenorrhea in women experiencing PMS . Further study was
aimed at the molecular mechanism of DLBS1442 at the cellular level
of endometrial cells .
The effect of DLBS1442 was investigated particularly on the
expression of genes that encode critical enzymes associated with the
onset of endometriosis . These genes include inflammatory
enzymes such as cytoplasmic phospholipase A2 (cPLA2) and COX-2,
angiogenic vascular endothelial growth factor (VEGF), estrogen and
prostaglandin receptors and transcription factors HIF-1 and NFkB of
the human endometrial epithelial cell (RL95-2). The focus of this
research was to investigate the potential of P. macrocarpa extract in
addressing the presence of the inflammatory response, cell
proliferation, apoptosis inducer, angiogenesis regulation factor
expression and in examining its relationship with the expression of
inflammatory and sex-hormone receptor genes .
A dose-dependent decrease in cell viability and an increase in
apoptosis of the RL95-2 cells was generated by exposure to the
bioactive fraction of P. macrocarpa, DLBS1442, at a dose of 100 µg/ml
that increased sub-G1 phase cell population from 7% to 34%. (IC50
around 100 μg/m) . The expression of ERβ mRNA was suppressed
by DLBS1442 in an endometrial cell line. Apoptosis-inducing effect of
this bioactive fraction against endometrial cells might be correlated to
the ERβ related mechanism. DLBS1442 also exhibited inhibitory
activity on proliferation, migration and angiogenesis of RL95-2 cell
line in a dose-dependent manner, and significantly reduced estrogen
receptor level and inhibit eicosanoid signaling pathway by reducing
NFкB transcript level and subsequent reduction in iNOS . The free
radical scavenging activity of DLBS1442 showed that it displayed
strong antioxidative activity, with IC50 around 49,16 μg/ml. The result
of this study proved that DLBS1442 has a significant effect on
endometriosis cells, preclinically proven for its efficacy in alleviating
symptoms of primary dysmenorrhea and endometriosis through its
activity as an anti-inflammatory, apoptosis inducer, anti-angiogenic
and anti-oxidant agent .
Clinical study in endometriosis
In addition to the clinical study for PMS  and in vitro study on
endometiral cell , a pilot clinical study was conducted to evaluate
the effectiveness of DLBS1442 treatment in alleviating endometriosis
and/or adenomyosis-related pain . Ten endometriosis and/or
adenomyosis patients have recruited consecutively at Yasmin Clinic
Dr. Cipto Mangunkusumo General Hospital from January to March
2013. Pain associated with menses, including PMS pain,
dysmenorrhea, dyschezia and dysuria, was measured using the visual
analog scale (VAS) at each of the next three menstrual cycles. Patients
reporting one or more pain symptoms with a VAS score were given
100 mg of DLBS1442 three times daily for 12 w. VAS score reduction
was noted in the first post-treatment menstrual cycle (approximately
5.3 w after treatment initiation) and VAS scores continued to decline
over the final two cycles . This study suggested that DLBS1442
was effective in alleviating endometriosis and/or adenomyosis-related
pain, as demonstrated by early pain reduction after DLBS1442
According to the Centers for Disease Control and Prevention, breast
cancer is one of the most common types of cancer in women and is
the second-leading cause of cancer deaths . Increasing efforts
are made on identifying not only agents that selectively target
cancer cells but also signaling pathways that promote or inhibit
cancer progression. Targeting a specific pathway is critical to
successful treatment of breast cancer as cancer cells reflect the
balance between cell death and survival. The synergy between
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inhibition of growth promotion and stimulation of apoptotic
pathway may enhance tumor cell sensitivity to apoptosis induced by
anticancer agents. Apoptosis is a form of programmed cell death
which is precisely regulated and plays important roles during
embryogenesis and immunology [40, 41]. Alterations in the
physiological execution of apoptosis lead to the extension of cellular
survival and thereby promote cancer development. Apoptotic cell
death involves a series of biochemical events leading to a
characteristic cell morphology, including blebbing, loss of membrane
asymmetry and attachment, cell shrinkage, nuclear fragmentation,
chromatin condensation and chromosomal DNA fragmentation as
well as by cleavage of PARP (poly(ADP-ribose) polymerase). It is
well recognized that BCL-2 family proteins are central regulators of
apoptosis and act as a checkpoint through which survival and death
signals must pass before the cell fate is determined. An apoptotic
death stimulus activates caspases, the major executioners of this
process, either directly or via the activation of the mitochondrial
death program. Mitochondrial apoptosis pathway is linked to COX-2
inhibition and there has been accumulating evidence that
inflammatory tissue damage proceeds the cancer development. COX
which catalyzes the transformation of arachidonic acid into PGs and
thromboxanes (TXs), is an important enzyme involved in mediating
inflammatory process. COX-2 has been reported to be significantly
overexpressed in a variety of human malignancies. Previously, it was
shown that COX-2 was overexpressed in prostate cancer (41,42). It
is also overexpressed in breast cancer, cervical dysplasia and cancer,
hepatocellular carcinoma, pancreatic cancer, skin cancer, lung
cancer, gastric cancer, and other cancer types (43-45). In human
breast cancer, overexpression of HER-2/neu, which occurs in 20-
30% of human breast cancer, is also associated with a poor
prognosis for the patient (46).
P. macrocarpa extract effect on breast cancer cells
Anti-proliferative and induction of apoptosis conferred by a
bioactive fraction of P. Macrocarpa DLBS1425 on breast cancer cells,
MDA-MB-231 and MCF-7 cells had been investigated. DLBS1425
showed an inhibition of proliferation in both cell lines. Induction of
apoptosis was shown by DNA fragmentation, activation of caspase 9,
and regulation of Bax and Bcl-2 at the mRNA level. DLBS1425
downregulated COX-2, cPLA2, and VEGF-C mRNA expressions.
DLBS1425 also down-regulated c-fos and HER-2/neu mRNA
expression in TPA-or fatty acid-induced MDA-MB-231 cells. These
findings demonstrate that DLBS1425 has anti-proliferative, anti-
inflammatory and anti-angiogenic properties .
Another study reports that DLBS1425 exhibited inhibition of
proliferative, migratory and invasive potential of MDA-MB-231 in a
dose-dependent manner and significantly reduced phosphoinositide-3
(PI3)-kinase/protein kinase B (AKT) signalling by reducing PI3K
transcript level and subsequent reduction in AKT phosphorylation.
Further, it induced pro-apoptotic genes including BAX, Bcl-2-associated
death promoter (BAD) and p35 upregulated modulator of apoptosis
(PUMA) and consequently induces cellular death signal by caspase-9
activation, promoting poly ADP-ribose polymerase (PARP) cleavage and
DNA fragmentation. Our results suggest that DLBS1425 is a potential
anticancer agent which targets genes that are involved in both cell
survival and apoptosis in MDA-MB-231 breast cancer cells .
P. macrocarpa extract reduces cardiotoxicity when
administered with chemotherapy
Treatment of breast cancer is done through 5-fluorouracil: doxorubicin:
cyclophosphamide (FAC) regimen. The use of FAC is known to generate
severe toxicity. Study on mice showed that FAC regimen equivalent to
the dose administered in human resulted in muscular damage of the
heart. This led to animal mortality in the study. Therefore, the
administration of FAC regimen on mice has to be adjusted to one-eighth
of the initial dose in order for the mice to survive. On the contrary, the
use of DLBS1425, a bioactive fraction from P. macrocarpa fruit with a
dose equivalent to 300 mg three times daily did not induce any toxicity
effect on the mice. Furthermore, the use of DLBS1425 in adjunct with
FAC regimen is proven to exert protective property on the cardiac
muscle of the mice. It also helps increase hemoglobin level in the blood.
In light of these findings, DLBS1425 is a potential candidate for adjunct
therapy with chemotherapy .
Cervical cancer is a sexually transmitted disease that results from
infection with oncogenic human papillomavirus (HPV). It is the
leading cause of cancer mortality in developing countries due to the
high rate of HPV infection and lack of prevention steps in susceptible
women. The most common HPV genotypes found in patients with
invasive cervical cancer are 16, 18, 31, 33, 35, 45, 52 and 58. Out of
these HPV genotypes, HPV 16 and 18 are classed as high-risk
oncogenic types and are most likely to persist and progress from
premalignant cervical disease to invasive cancer. These HPV types
play a pivotal role in immortality and malignant transformation of
infected cells .
The ability of HPV in generating cervical cancer is dependent on the
transformative potential of its viral oncogenes. Cervical cancer
formation has been proven to be dependent to the expression of high-
risk HPV oncogenes, E6 and E7. These pleiotropic oncogenes are
pivotal in cervical cancer formation due to their ability to reduce the
intracellular availability of the host’s cell cycle inhibitor (onco-
suppressor) proteins; p53 and retinoblastoma (Rb). E6 proteins bind
p53 and direct its rapid degradation while E7 proteins bind and
inactivate the Rb protein. These led to the profound loss of function of
p53 and Rb proteins that cause chromosomal instability and
accumulation of oncogenic mutations resulting in cancer.
Furthermore, E6 stimulates expression of HIF-1α which in turn will
stimulate neoangiogenesis for tumor cells, providing the
vascularization necessary for cancer formation. HIF1-α mediates
angiogenesis through activation of VEGF pathway. E7 inactivates
which are a cell-cycle regulatory protein that
interacts with cyclin-CDK2 and-CDK4, inhibiting cell cycle progression
at G1. This results in growth stimulation of infected cells .
Early cervical cancer is treated by removing or destroying the
precancerous or cancerous tissue. However, this treatment is no
longer effective once the cancerous cells metastasized to other
organs. The standard treatments for cervical cancer are surgery,
chemotherapy and radiation therapy. These treatments can be
harmful to other normal tissues and may facilitate cancer cell
invasion and metastasis .
Effect of P. macrocarpa on cervical cancer
Several studies have pointed out the potential of P. macrocarpa as a
treatment for cervical cancer. As described previously, P.
macrocarpa is known to contain gallic acid which is inhibitory to the
growth of many types of cancer cells. Study on cervical cancer cell
(CaSki) showed that gallic acid, a molecule isolated from P.
macrocarpa, is able to inhibit cell proliferation of this cell . In
addition, gallic acid has also shown its anti-proliferation action on
human cervical cancer HeLa and HTB-35 cells, but not on normal
HUVEC cells . This result supported the idea that gallic acid has
selective dose-dependent cytotoxicity on cervical cancer cells only.
The study also evaluated the antiproliferative activity of gallic acid
on cervical cancer cells which showed that it inhibited cell
proliferation of both HeLA and HTB-35 cells .
Certain pre-invasive squamous intraepithelial lesions transform into
invasive squamous cell carcinoma and spread to other areas of the
body through blood and lymphocyte system. Therefore, cell migration
and invasion ability is critical in the cancer progression in the body. To
examine the effect of gallic acid on cell migration and cell invasion
ability, wound scratch assay and matrigel
invasion was performed
on HeLa and HTB-35 cervical cancer cells . The result showed that
gallic acid was able to inhibit cell migration and reduce the
invasiveness of both cell lines, although the result was more significant
in the HeLa cells . One of the most critical steps in cancer
formation is angiogenesis. Gallic acid was also proven to inhibit
angiogenesis in HUVEC cells. It significantly inhibited elongation of the
tube in HUVEC cells compared to the untreated cells .
ADAMs are ectodomain shedding that function as metalloproteases.
The disintegrin-metalloproteinases of the ADAM family are
associated with proteolytic ‘shedding’ of membrane-associated
proteins and hence the rapid modulation of key cell signaling
pathways in the tumor microenvironment. ADAM17 is an important
member of the ADAM family which is involved in the proteolysis of
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collagen IV of the ECM and also the release of several integrins from
the cell surface, indicating that ADAM17 affects the migration
activity of a variety of cells, including cervical cancer cells. It is a
primary upstream component for multiple epidermal growth factor
receptor (EGFR) pro-ligands. EGFR binds with its ligands and
subsequently activates downstream mitogen-activated protein
kinase (MAPK)/extracellular signal-regulated kinases (ERK) and
phosphatidylinositol-3-kinase (PI3K)/Akt pathways, which
contribute to invasiveness and other malignant phenotypes of a
tumor. EGFR is a 170-kDa transmembrane glycoprotein receptor
encoded by the Her-1 proto-oncogene located on chromosome 7p12.
It functions through dimerization, which activates a tyrosine kinase
domain that regulates cell growth, differentiation, gene expression
and development. EGFR is present in is expressed in a wide variety
of solid tumors, including cervical cancer. Gallic acid helps reduce
the invasiveness of cervical cancer cells through down-regulation of
ADAM17 and EGFR expression and the dephosphorylation of Erk
and Akt in the two cell lines which affected the cell’s proliferation
and invasion ability. In addition to the inhibition of protein
expression, gallic acid significantly reduced ADAM17 activity .
Gallic acid is known to exhibit a cytotoxic effect on HPV-positive
cells such as HPV-18 positive human cervical carcinoma cell line
(HeLa) and human cervical epithelial cell line containing stable HPV-
16 episomes (HPVep). Gallic acid showed anti-tumor activity on
HeLa cells containing HPV18 genome and inhibits proliferation of
HPVep cells containing stable HPV-16 episomes. Gallic acid may
have a broad-spectrum antiviral activity against cells containing
viruses. HPVep cells are human cervical keratinocyte cells containing
stable HPV-16 episomes, and exhibited episomally replicating HPV-16
genomes at an estimated copy number between 10-50 genomes per
cell. HPVep cells express HPV genes E6 and E7 stably. Compared to
normal keratinocytes, HPVep cells show partial but incomplete
degradation of p53. HPVep cells display features that are similar to
HPV-infected human keratinocytes and appear to be a suitable model
to study the mechanism by which GA reduces the viability of HPV-
positive cells. GA was shown to increase apoptosis of HPVep cells
significantly in a dose-dependent manner, without generating cell
necrosis. It is predicted that GA induces HPVep cell death by inducing
cell apoptosis. A similar result was apparent in the gallic acid treated
HeLa cells. HPVep cells contain stable HPV-16 episomes and express
early viral oncoproteins E6 and E7. It is known that HPV-16 E6 is
targeted to degrade the tumor suppressor protein p53 through the
ubiquitin pathway. Therefore, it is predicted that gallic acid may
increase the p53 expression which counteracts E6 function, leading to
an increase in apoptosis. Observation of the molecular mechanism of
apoptosis showed that gallic acid up-regulated the pro-apoptosis
protein, Bax, and induced caspase activity. It also down-regulated the
expression of anti-apoptosis proteins such as Bcl-2 and x-linked
inhibitor of apoptosis protein (Xiap). In contrast, delayed expression of
pro-apoptosis related proteins was observable in non-cancerous cells
and no reduction of survival-related protein expression was found in
the non-cancerous cells .
Phaleria macrocarpa fruit has been proven to be potential as a
treatment for many gynecological conditions such as premenstrual
syndrome (PMS), endometriosis, breast cancer, and cervical cancer.
It helps regulate hormone imbalance in women with problems
relating to their menstruation cycle, especially during PMS. It helps
alleviate symptoms of primary dysmenorrhea and endometriosis
through its bioactivity as anti-inflammation, apoptosis inducer, anti-
angiogenic and anti-oxidant agent. P. macrocarpa fruit extract also
showed selective anti-proliferative, anti-inflammatory, and anti-
angiogenic activity on breast and cervical cancer cells. It regulates
cancer cell progression through numerous different pathways,
making it highly favourable to be developed as a cancer treatment,
whether as a single treatment or as an adjunct therapy. However,
further study, both preclinical and clinical studies are needed to
ascertain its use in women to be effective and safe.
CONFLICT OF INTERESTS
Both authors declare that there is no conflict of interest in the
preparation of this manuscript.
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How to cite this article
• Raymond Rubianto Tjandrawinata, Hanna Christabel Rouli. A
role for phaleria macrocarpa (scheff) boerl. extracts in the
management of women’s pathological conditions: a research
review. Int J Pharm Pharm Sci 2017;9(3):07-12.