Evaluating Synergistic Anti-Cancer Efficacy of Graviola Plant Extracts

癌症仍然是全球最严重的健康风险和死亡原因之一。国际癌症研究机构(IARC)记录了2012年全球超过1400万新癌症病例和800多万癌症死亡病例，预测到2030年全球将有超过2100万新病例和1300万新癌症死亡(Ferlay等人，2015)。世界卫生组织(WHO)和GLOBOCAN都报告了2018年全球960万与癌症有关的死亡，与2012年的数据相比，死亡率增加了20%(Stewart，2014和Ferlay等人，2018)。对于传统的临床干预措施，高昂的治疗成本、副作用、多病因病因和包括内在和获得性耐药在内的癌症复杂的病理生理机制正变得越来越成问题(袁等人，2015、2017和2019年)。与植物提取物(PES)相关的协同特性已被证明可以有效地解决上述问题，利用协同多靶点效应、药代动力学/物理化学特性，以及在体外和体内对抗耐药性和消除或中和不利作用物质的机制(Wagner和Ulrich-Merzen，2009和Nandi等人，2019)。PES的增效作用通常由广泛使用的贝伦鲍姆等效法确定，该方法能够相对定量地确定相互作用的成分相对于PES各自分离的单一成分的总和的药理和治疗优势程度(Berenbaum 1997)。就与传染病、肿瘤学和免疫性炎症性疾病相关的常规临床干预措施而言，常见的方法是在资本密集型模式的指导下，广泛应用配体特定的单一靶点药物。虽然在许多情况下非常成功，但也注意到效果在下降(Petrelli和Giordano，2008和Wagner 2010)。多组分联合疗法提供了一种新的替代或补充方法，PE尤其令人感兴趣，因为一些癌症类型已经显示出对化疗药物的多药耐药(MDR)，占治疗期间癌症死亡的90%(RISTER等人，2013：Cercek等，2020)。番荔枝的种子、叶、果肉和树皮提取物，又称番荔枝、番石榴叶或番荔枝(等等)，已被证明具有临床上显著的抗癌作用，对甚至对化疗药物具有耐药性的癌症细胞具有显著的抗癌作用(Chang等人，2001年和Moghadamtousi等人，2015年)。葡萄粗品(GPES)和部分分离的GPES在体外和体内对乳腺、前列腺、胰腺、皮肤和肝癌细胞具有细胞毒作用。许多关于从GPES中提纯和鉴定近100种化合物的报告表明，GPES富含黄酮类、异喹啉、生物碱和番荔枝内酯(Moghadamtousi等人2015年，Sawant和Donre 2014年)。Chan等人在对西洋菜叶提取物(GLE)进行系统的安全性和耐受性审查后，得出了良好的安全性和耐受性概况。番荔枝内酯被认为是GPES中的主要植物化学物质，主要通过抑制线粒体复合体1对培养细胞产生细胞毒性(McLaughlin 2008)。然而，从GPES中获得的许多其他化合物还没有详细的功能。值得注意的是，GPES的神经毒性作用和在提取/分离过程中体内某些药物治疗作用的丧失限制了其开发为新的药物实体(露娜，JDE等，2006年)。此外，使用单一或多个GPE衍生的乙酰生成素会导致毒副作用，并最终导致细胞死亡，尽管表现出更好的疗效(Sun等人，2014年)。然而，这只是促进了对GPES的协同研究的需要，其中含有乙酰生素的黄酮类化合物最近被证明具有更大的意义

Cancer remains one of the most serious health risks and cause of death worldwide. The International Agency Research for Cancer (IARC) documented over 14 million new cancer cases and over 8 million cancer deaths worldwide for 2012, forecasting over 21 million new cases and 13 million new cancer deaths worldwide for 2030 (Ferlay et al, 2015). World Health Organisation (WHO) and GLOBOCAN both reported 9.6 million cancer related deaths worldwide for 2018, showing a 20% increase in mortality as compared with 2012 data (Stewart, 2014 and Ferlay et al, 2018). High treatments costs, side-effects, multicausal etiology and the complex pathophysiology of cancer inclusive of an intrinsic and acquired resistance are becoming increasingly problematic for conventional clinical interventions (Yuan et al, 2015, 2017 and 2019). Characteristics of synergy relative to plant extracts (PEs) have been shown to combat the above-mentioned problem effectively utilizing synergistic multi-target effects, pharmacokinetic/physiochemical properties, alongside mechanisms that antagonize resistance and eliminate or neutralize adversely acting substances in vitro and in vivo (Wagner and Ulrich-Merzenic, 2009 and Nandi et al, 2019). The synergistic efficacy of PEs is commonly determined by the widely used Berenbaum's isobole method, able to comparatively determine quantitatively the degree of pharmacological and therapeutic superiority of interacting components relative to the sum of the respective isolate mono constituent of the PEs (Berenbaum 1997). In terms of conventional clinical interventions relative to infectious disease, oncology and immunoinflammatory disease - the common approach is widespread application of ligand specific single target drugs directed by a capital-intensive model. Although highly successful in many cases, a decreasing effectiveness has been noted (Petrelli and Giordano, 2008 and Wagner 2010). Multi component combination therapy provides a novel alternative or complementary approach, where PEs are of particular interest as some cancer types have already shown multi drug resistance (MDR) to chemotherapeutics accounting for 90% of cancer deaths during treatment (Rather et al 2013: Cercek et al 2020). Seed, leaf, fruit-pulp and bark extracts from Annona muricata otherwise known as Graviola, guanabana or soursop (amongst other names) have been shown to possess clinically significant anticancer effects against malignant cells, successful at inducing cell death/apoptosis in cancers resistant to even chemotherapeutic drugs (Chang et al, 2001 and Moghadamtousi, et al 2015). Crude Graviola PEs (GPEs) and partially fractionated GPEs exhibit cytotoxic effects on breast, prostate, pancreas, skin and liver cancer cells in-vitro and in-vivo. Many reports on the purification and characterisation of almost 100 compounds from GPEs are available shown GPEs to be rich in in flavonoids, isoquinoline, alkaloids and annonoaceous acetogenins (Moghadamtousi et al 2015, Sawant and Dongre 2014). Chan et al 2019, after a systematic safety and tolerability review of Graviola leaf extract (GLE) concluded favourable safety and tolerability profile. Annonaceous acetogenins are considered to be the major groups of phytochemicals in GPEs that induce cytotoxicity in cultured cells, mainly via inhibition of mitochondrial complex 1 (McLaughlin 2008). However, many other compounds obtained from GPEs have not been functionally detailed. To note, GPEs development into new drug entities is restricted by its neurotoxic effects and loss in some pharmacotherapeutic effects in vivo effects during extraction/separation processes (Luna Jde et al, 2006). Also use of single or several GPE derived acetogenins lead to toxic side effects and eventually cell death despite expressing greater efficacy (Sun et al, 2014). However, this only fuels the need to synergistic studies on GPEs where flavonoids in presence of acetogenins have recently been shown to have greater significant