Introduction
Review methodology
A brief overview on HHT: from natural origins to synthetic derivatives—structural, physicochemical and biosynthetic aspects
Natural sources and traditional uses of HHT
Structural features of HHT
Physio-chemical properties of HHT
Biosynthesis of HHT
Synthetic derivatives of HHT
Methodology | Precursor-intermediate | Synthesized compound | Yield | Refs. |
---|---|---|---|---|
p-Nitrobenzenesulfonate ester reaction | p-Nitrobenzenesulfonate ester | (−) Cephalotaxine | N/A | [43] |
Eight-step synthesis from 1-Prolinol | 1-Prolinol methylenedioxyphenylacetyl chloride | (−) Cephalotaxine | N/A | [44] |
Aryne insertion reaction | Aryne | (−) Cephalotaxine | 10% | [45] |
Nine-step oxidative furan opening | Various intermediates including furan derivatives | HHT | N/A | [46] |
Lactone reaction with cephalotaxine | α-Tetrasubstituted lactone | HHT | High | [47] |
Partial esterification | Cephalotaxine | Homoharringtonine 2 Dehydrodesoxy Homoharringtonine 4 | N/A | [48] |
Alkylidene Carbene 1,5-CH insertion reaction | Alkylidene carbene | (−) Cephalotaxine | N/A | [49] |
Palladium-Catalyzed Enantioselective Tsuji Allylation | Allyl enol carbonate | (−) Cephalotaxine | N/A | [50] |
Ester Enolate Claisen rearrangement | α-Amino allylic esters | (−) Cephalotaxine | N/A | [50] |
Gold(I)-catalyzed cascade reaction | Norhydrastinine | DemethylCephalotaxinone, Cephalotaxine | N/A | [33] |
Facile stevens rearrangement | Weinreb amide | ( ±) cephalotaxine | N/A | |
Hydrogenation | β-Substituted itaconic acid monoesters | HHT | N/A | [51] |
HHT’s anticancer effects in hematological malignancies
Chronological development and clinical advancement of HHT
Years | Milestone | Description | Significance | References |
---|---|---|---|---|
2006 | Initial Discovery and Preclinical Studies | Identification of HHT’s cytotoxic properties against lymphoid and myeloid cells | Foundation for the clinical potential of HHT | [52] |
2007 | Confirmation of Apoptotic Efficacy | HHT shown effective in various tumors, including primary leukemic cells from AML patients | Broadened therapeutic scope of HHT | [54] |
2011 | Regulatory Approval of Omacetaxine (OM) | OM, a semi-synthetic HHT derivative, approved by EMA and FDA for CML treatment | Marked HHT's entry into clinical use for CML | [53] |
2011–2016 | Advanced Efficacy Studies | Studies highlighted OM’s mechanism in rapid protein degradation and the up-regulation of myosin-9 | Reinforced HHT’s effectiveness in hematologic malignancies | |
2014 | Elucidation of Mechanism of Action | Detailed understanding of how HHT and OM inhibit protein translation in cancer cells | Clarified the molecular basis of HHT's anticancer action | [53] |
The impact of HHT on AML treatment
Disease overview
Pre-clinical studies
Clinical studies
Types of studies | |||
---|---|---|---|
Preclinical studies using cell lines (in vitro) or animal model (in vivo) | |||
Experimental model | Mechanisms | Results | References |
HL-60 cells (In vitro) | ↓ Protein synthesis Synergy with l-β-d-arabinofuranosylcytosine | ↓ Protein synthesis Synergistic effect with DNA synthesis inhibitor | [67] |
AML cells (In vitro) | ↑ Bax | ↑ Apoptosis No cross-resistance with DNR and cytarabine | [68] |
HL60 HL60/MRP cells (In vitro) | ↑MCL-1 turnover ↑Mitochondrial disruption ↑Caspases | ↑ Apoptosis through mitochondrial pathway | [69] |
AML cell lines Xenograft mice (In vitro/In vivo) | ↓ MMP ↓ Mcl-1 ↓ c-KIT levels ↑Caspase-3 | ↑ Apoptosis Prolonged t(8;21) leukemia mouse survival ↑Synergy with oridonin | [61] |
AML cells (In vitro) | ↓ PI3K/AKT ↓WNT/β‐catenin signalling | ↑ Apoptosis ↑Caspase-3 mediated cleavage of AML1–ETO oncoprotein ↑synergy with aclarubicin | |
AML cell lines Primary AML cells (In vitro) | ↑ ROS synthesis Restriction of antioxidant defence | Synergistic cytotoxicity with etoposide ↑ Apoptosis | [73] |
FLT3–ITD positive cell lines Primary leukemia cells (In vitro) | ↓STAT5/Pim-2/C-Myc ↑ Cell cycle arrest | ↑ Apoptosis Alone or in combination: ↑ Sensitivity to chemotherapeuthic drugs | |
AML cells Xenograft mice (In vitro/In vivo) | : ↓ MMP, ↓ Mcl-1, ↓ PI3K–AKT/MAPK/ERK pathways | ↓ AML progression Prolonged survival in mice Synergistic effect with venetoclax | [70] |
Clinical studies | |||
---|---|---|---|
Cancer type | Study design | Primary outcomes | References |
R/R-AML | Combination of HHT with venetoclax and azacitidine (HVA) Focus on patients with allo-HSCT | Better treatment response Well tolerated | [79] |
R/R-AML | Single-center Phase II study with 46 patients HHT with aclarubicin and cytarabine (HAA) | 80% achieved Complete Remission (CR) 42% OS rate | [80] |
De Novo AML | National, multicenter, randomized, double-blinded, prospective Phase III clinical trial; HAA regimen | High CR rate Prolonged OS Suggested as a treatment option for young and newly diagnosed patients |
The impact of HHT on CML treatment
Disease overview
Disease characteristics | AML | CML | References |
---|---|---|---|
Nature of disease | Originates from leukemia stem cells; marked by increased myeloid cells in bone marrow | Slow-progressing expansion of pluripotent bone marrow stem cells | |
Prevalence | Most common acute leukemia in adults; 70% of acute leukemias | Accounts for 15–20% of adult leukemia cases | |
Clinical features | Hematopoietic insufficiency with/without leukocytosis | Leucocytosis, basophilia, splenomegaly | |
Risk factors | Genomic heterogeneity, selective treatment pressure | Smoking, radiation, pesticides, obesity, solvents | |
Age of onset | Higher prevalence in patients ≤ 60 years | Median age 53 years, affects all age groups | |
Cytogenetic markers | t(8;21) translocation, FLT3 mutations | Philadelphia chromosome from BCR–ABL gene fusion | |
Initial treatment approaches | Induction chemotherapy, “3 + 7” regimen, allo-HSCT | IFN-α, BCR–ABL TKIs (e.g., imatinib) | |
Challenges and resistance | Disease relapse, drug resistance | Resistance via BCR–ABL kinase domain mutations | |
Advanced treatment options | Exploration of novel, less toxic strategies | Ponatinib for T315I mutation; exploration of new therapies | |
Role of HHT | Effective in enhancing apoptosis, reducing proliferation | Alternative therapy for BCR–ABL TKI-resistant cases |
Pre-clinical studies
Clinical studies
Types of studies | |||
---|---|---|---|
Preclinical studies using cell lines (in vitro) or animal model (in vivo) | |||
Experimental model | Mechanisms | Results | References |
CP CML cells (In vitro) | Cytotoxicity comparison with normal bone marrow | ↑ Cytotoxicity against CP CML cells compared to normal bone marrow | [95] |
Ponatinib-resistant BCR–ABL + cell lines (In vitro) | Activity against Y253H, E255K, and T315I mutations | OM demonstrated efficacy in ponatinib-resistant BCR–ABL + cell lines | [96] |
CD34 + CD38–LICs from CML patients (In vitro) | Targeting leukemia initiating cells | OM effectively killed BCR−ABL + LICs | [55] |
BCR–ABL + cell line with E255K mutation and CML BP cells (In vitro) | Synergistic/additive effect with imatinib | HHT showed synergistic effects with imatinib in resistant CML cell lines | |
DLBCL and mantle cell lymphoma cells (In vitro) | Combination with bortezomib: ↓ MCL-1, ↑ NOXA, ↑ BAK | ↑ Apoptosis anti-proliferative activity against K562 cells | |
Ph + CML animal models (In vivo) | Targeting BCR–ABL + LICs; ↓ BCR–ABL; ↑ HSP-90 and MCL-1 levels | Substantial survival benefit in leukemic mice | [97] |
Clinical studies | |||
---|---|---|---|
Cancer Type | Study design | Primary outcomes | References |
CML | Phase II: Continuous infusion of HHT for remission induction and maintenance | 72% CHR, 31% CG response rate, 15% complete CG response | [102] |
Phase II: Six courses of HHT followed by IFN-α maintenance in 90 early CP CML patients | Higher CHR and CG rates compared to IFN-α alone | [103] | |
Phase II: HHT with IFN-α in 47 CP CML patients | 66% CG responses | [104] | |
Phase II: HHT and ara-C combination in 100 CML patients failing IFN-α therapy | Similar response rates with HHT and ara-C vs. HHT alone; longer survival with combination | [105] | |
Phase II: HHT plus cytarabine in 44 untreated Ph chromosome positive CP CML patients | 82% achieved hematologic remission; 17% MCyR | [8] | |
Phase II: HHT with ongoing imatinib therapy in 13 patients with suboptimal response to imatinib | 50% decrease in BCR–ABL transcript levels | [106] | |
Phase II: HHT after imatinib failure in 5 evaluable CML patients | CG response in 60%; undetectable BCR−ABL mutations in 40% | [107] | |
Phase II: Triple therapy with HHT, INF-α, and cytarabine, followed by imatinib | Estimated 5-year survival rate of 88% | [69] | |
Phase II: OM in 46 CML patients failing two or more prior TKIs | 67% hematologic responses; 22% MCyR | [91] | |
Phase II: OM in 62 CML patients with T315I mutation | CHR in 48 patients; MCyR in 14 patients | [89] | |
Phase II: Triple combination of IFN-α, ara-C, and HHT, followed by imatinib | Improved prognosis with an estimated 5-year survival rate of 88% | [108] |
Efficacy of HHT in other hematological malignancies
Effects of HHT on other types of cancers
Breast cancer
Cancer type | Model | Mechanisms | Results | References |
---|---|---|---|---|
Breast cancer (TNBC) | In vitro MDA-MB-157 MDA-MB-468 CAL-51 MDA-MB-231 | ↑ Bax/Bcl-2, ↑ Caspase 3, − 9 ↑ PARP ↓ STAT3/Nanog | ↓ Proliferation ↑ Apoptosis synergy with paclitaxel | |
Lung cancer | In vitro A549 H1975 A549B/VP29 | ↓ TMEM16A, ↓ MAPK pathway ↓MEK1/2, ↓ERK1/2 ↓ IL-6/JAK/STAT3 | ↓ Tumor cells growth ↑ Cell cycle arrest ↑ Apoptosis | |
Hepatocellular carcinoma | In vitro HepG2, Hep3B SMMC-7721 Bel-7402, Bel-7404 In vivo Mice | ↑ Cell cycle arrest at S phase ↑ Hippo pathway ↑ EphB4/β-catenin | ↓ Tumor growth ↑ Apoptosis ↓ Colony formation ↓ Cell invasion/migration | |
Colon cancer | In vitro LoVo SW480 HCT116 HCTl16/VP48 | ↓ EphB4, ↓ p-MEK ↓ p-ERK1/2 ↓ Wnt/β-catenin ↑ Caspases ↓ Bcl-2/Mcl-1, ↑ Bax/Bad | ↓ Cell viability ↓ Colony formation ↑ Apoptosis ↑ Sensitivity in drug-resistant cell lines |
Lung cancer
Hepatocellular carcinoma
Colon cancer
Other pharmacological applications of HHT
Anti-inflammatory activity
Anti-parasitic activity
Neuroprotective activity
Antiallergic activity
Cardioprotective effect in diabetes-induced ischemic heart disease
Anti-viral activity
Pharmacological property | Model | Molecular Mechanisms | Results | References |
---|---|---|---|---|
Anti-inflammatory | In vitro In vivo | ER stress signaling pathway | ↓ Fibroblast Proliferation ↑ Apoptosis ↓ Epidural fibrosis | [75] |
Anti-parasitic | In vitro | Disruption of mitochondrial membrane potential, ↑ Cell cycle arrest | ↓ Tumor growth ↓ Protein biosynthesis of Trypanosoma brucei, not affecting trypanothione reductase | [131] |
Neuroprotective | In vivo APP/PS1 mice | ↓ Neuroinflammation ↑SOCS3 ↑ STAT3 | ↓ Cognitive deficits ↓ Amyloid β peptide | [19] |
Anti-allergic | In vitro In vivo | ↑NF-κB-miR-183-5p-BTG1 axis | ↓ Allergic reactions ↓ Symptoms of atopic dermatitis | [141] |
Cardioprotective effect in diabetes-induced ischemic heart disease | In vivo ND-fed and HFD-induced diabetic mice | ↓ Ribosomal function ↑ Cardiomyocyte apoptosis | ↓ Cardiomyocyte apoptosis ↓ Protective against ischemia/reperfusion injury | [145] |
Anti-viral | In vitro In vivo | ↓ Viral replication ↓ Lytic gene expression ↓ RNA viruses | ↓ Viral load in multiple viruses, including SARS-CoV-2 reduced disease symptoms |