Therapeutic effects of medicinal plants and their constituents on lung cancer, in vitro, in vivo and clinical evidence

Abstract The most common type of cancer in the world is lung cancer. Traditional treatments have an important role in cancer therapy. In the present review, the most recent findings on the effects of medicinal plants and their constituents or natural products (NP) in treating lung cancer are discussed. Empirical studies until the end of March 2022 were searched using the appropriate keywords through the databases PubMed, Science Direct and Scopus. The extracts and essential oils tested were all shown to effect lung cancer by several mechanisms including decreased tumour weight and volume, cell viability and modulation of cytokine. Some plant constituents increased expression of apoptotic proteins, the proportion of cells in the G2/M phase and subG0/G1 phase, and Cyt c levels. Also, natural products (NP) activate apoptotic pathways in lung cancer cell including p‐JNK, Akt/mTOR, PI3/ AKT\ and Bax, Bcl2, but suppressed AXL phosphorylation. Plant‐derived substances altered the cell morphology, reduced cell migration and metastasis, oxidative marker production, p‐eIF2α and GRP78, IgG, IgM levels and reduced leukocyte counts, LDH, GGT, 5′NT and carcinoembryonic antigen (CEA). Therefore, medicinal plant extracts and their constituents could have promising therapeutic value for lung cancer, especially if used in combination with ordinary anti‐cancer drugs.

history of chronic exposure to smoke and autoimmune diseases 13 are helpful for early diagnosis of lung cancer.The two main types of lung cancer are small cell lung cancer (SCLC) and non-small cell lung cancer (NSCLC).SCLC occurs mainly in the central airways including bronchioloalveolar cells, whereas NSCLC types originate in the neuroendocrine system. 4Radiotherapy, chemotherapy and surgery are common treatments, depending on the stage of the cancer.For example, in the early stages of cancer surgery is best, and in advanced stages, a combination of radiotherapy and surgery are appropriate treatment methods.Cisplatin or carboplatin-based combination therapies are standard treatments of metastatic lung cancer. 19ternative treatments in complement with traditional methods have been shown to be helpful in the treatment of various types of cancer, and more recently, medicinal plants [20][21][22] are reported as effective alternative treatments of lung cancer.Their anti-cancer properties include cytotoxicity (being toxic to cancer cells), inducing cancer cell apoptosis, inhibiting tumour angiogenesis and inhibiting cancer cell proliferation and growth.These impacts on cancer cells by medicinal plants and their derivatives occur through a variety of cellulare pathways and molecular processes, including: altering reactive oxygen species (ROS) generation, modulating transcriptional activators, causing mitochondrial membrane potential loss by P53 (promoter of apoptosis), inhibiting the proliferation of the transformed cell by CD95, Cyt.c and Smac release, down-regulating Nuclear factor kappa B (NFk-B), activator protein 1 (AP-1), early growth response protein 1 (EGR-1), cyclooxygenase 2 (COX-2), lipoxygenase (LOX), matrix metallopeptidase 9 (MMP-9), tumour necrosis factor (TNF), chemokine, epidermal growth factor receptor (EGFR), human epidermal growth factor receptor 2 (HER2) and inhibiting c-Jun Nterminal kinases (JNK) and serine/threonine kinase (STK4) pathway.Furthermore, medicinal plant extracts have been found to inhibit metastasis in various tumour cancers (breast, hepatic, colon and stomach cancer) by reducing MMP-2 release of cytochrome c (Cyt c), activating Cas-3 and -9, down-regulating anti-apoptotic proteins Bcl-XL and integrin associated proteins and altering the ratio of Bcl2 family proteins. 23 the present article, we discuss the 11 medicinal plants and their components or natural products (NP) that have proven most effective against lung cancer.We collate findings from in vitro and in vivo studies and clinical trials and provide the proposed molecular and cellular mechanisms of action.The biochemical properties of each plant and its constituents are described before exploring their potential as an alternative and complementary treatment of lung cancer.

| ME THODS
In vivo and in vitro reports regarding the effect of NP on lung cancer were explored using the databases PubMed, Science Direct and Scopus until the end of March 2022.Accordingly, keywords including lung cancer, medicinal plants, plant constituents, NP, in vivo, in vitro and clinical studies were used.
Several criteria were used to select eligible studies for this review: (1) in vitro, in vivo (animal) and human studies, (2) NP supplementation and their dosage, (3) the effect of NP on lung cancer, (5)   English language articles published in well-known international journals.The reference classification is depicted in Figure 1.

| RE SULTS
3.1 | The effect of various medicinal herbs and their constituents on lung cancer
Regarding the safety and efficacy of Z. multiflora, the results of two animal studies indicated that, due to phenol components including carvacrol and thymol, reduction of ROS levels in tissue but in doses more than 0.4 mL/kg for 14 days, Z. multiflora reduced the safety but increased toxicity. 34,35However, in healthy human carvacrol at doses of 1 and 2 mg/kg/day for 1 month did not show any side effects. 36The effects of Z. multiflora extract and carvacrol on lung cancer are summarized in Table 1.

Extract preparation
For the preparation of methanolic extract of Z. multiflora its dried powder was mixed with 85% methanol for 48 h and filtered and the F I G U R E 1 Flowchart of the selecting studies in the current review.cells by improving cell rounding, causing cytoplasmic blebbing and irregularity in shape, leading to fewer cells and inhibiting rates of cell growth. 42Carvacrol nanoemulsion (25, 50 and 100 μg/mL) also decreased ROS and regulated apoptosis via p-JNK, Bax and Bcl2 and increased Cyt c and activated Cas cascades in human lung adenocarcinoma A549 cells.Following administration of carvacrol, an MTT assay revealed increased A549 cell viability and further testing found increases in ROS production, a decrease in Ca2+ release, down-regulation of CHOP, p-eIF2α, GRP78 and apoptotic markers. 43stern blots and reverse transcription polymerase chain reaction (RT-PCR) tests found that 24 h administration of carvacrol inhibited the expression of AXL proteinase and suppressed AXL phosphorylation upon stimulation of neuronal NSCLC cells with ligands. 44In addition, carvacrol treatment led to inhibited cell proliferation and migration of the NSCLC cells. 44Finally, CN treatment was found to reduce the number of cell proliferation enzymes: cyclin-dependent kinase 2 (CDK2), CDK4, CDK6, Cyclin E, Cyclin D1 and enhanced expression of p21 protein in the doxorubicin resistant-A549 cell line. 45ti-tumour activity in vivo Z. multiflora essential oil (500 mg/kg) reduced tumour weight and balanced T helper 1 levels by increasing the secretion of TNFα, Interferon-gamma (IFNγ) and IL-2 and decreasing IL-4 levels.However, no significant effects on aminotransferase and alanine aminotransferase activity were found. 38o doses of carvacrol nanoemulsion (CANE, and 100 mg/Kg) over 4 weeks in an athymic nude mouse model significantly reduced tumour growth and tumour weight by 34.2% and 62.1%, respectively, and increased the expression of p-JNK, Bax, Bcl2, Cyt C, Cas-3, Cas-9 and βactin in lung tissue. 43In vivo indicated that CN treatment (50,100 mg/ kg) decreased cell growth and levels of MMP, decreased the activation of MAPK p38 and ERK, decreased the expression of VEGF and CD31 and decreased anti-angiogenesis effects. 39erall, treatment with Z. multiflora extract, and its main constituent carvacrol, reduced lung cancer virality by decreasing tumour weight and volume, increasing the expression of apoptotic proteins, modulating cytokine levels and cancer cell viability, as well as regulating specific pathways and cancer tumour cell numbers.Therefore, Z. multiflora extract and carvacrol are worth testing as a part of contemporary treatment strategies for lung cancer.

| Nigella sativa
A variety of diseases have been treated with Nigella sativa (N.sativa) seeds for thousands of years across the African and Asian continents.For example, in the south-west of Asia, this plant has been used both as a food additive and herbal medicine. 46A powerful anticancer compound extracted from N. sativa seeds is thymoquinone (TQ). 47[50][51] Regarding the safety and toxicity of black seeds and TQ, dependent on the type of animal model and administration manner, the results demonstrated that the toxicity effects of oral administration were lower than intraperitoneal injection and administration of more than 2 and 3 g/kg in the mice increased the risk of the organ toxicity of N. sativa extract and TQ. 52The results of a phase I clinical trial to evaluate the safety of thymoquinone-rich black cumin oil (BlaQmax®) on healthy subjects consuming black cumin oil formulation containing 5% at a dose of 200 mg/adult/day for 90 days showed a well-safe profile of the plant. 53As shown in Table 1, N. sativa and TQ are both potential treatments for lung cancer.

Extract preparation
Cleaned and dried seeds of N. sativa were extracted with 95% aqueous methanol for 24 h.The extract was filtered by a Buchner funnel and re-extracted with 0% methanol for an additional 2 h and methanol was removed with a rotatory evaporator at 40°C. 49N. sativa volatile oil used in Salim's study was purchased from Kahira Pharm.

Growth-inhibitory activity in cell culture
The administration of essential oil N. sativa gold nanoparticles (NsEO-AuNPs) decreased the hydrophobicity index causing significant suppression of S. aureus (78%) and V. harveyi (46%) biofilm formation, which are common infections in patients with lung cancer. 54A study using N. sativa plant seed extract (NSE) treatment found it caused a significant down-regulation of cancer cell viability and altered their morphology.Similarly, NSE treatment (0.01, 0.025, 0.05, 0.1, 0.25, 0.50, 1 mg/mL for 24 h) on human lung cancer cells significantly reduced their viability. 49TQ treatment ratio, whilst down-regulating Bcl2 proteins, inflammatory markers, ROS, cyclin D, NF-kappa B and IKK1 expression. 56Treatment with TQ-loaded soy-phospholipid-based phytosomes (0.5, 1.0, 2.0, 4.0, 6.0, 8.0 and 12.0 h) was found to activate Cas-3 and reduce oxidative stress markers in A549 cells using the annexin V staining technique. 57Combined application of indirubin-3-monoxime and TQ on A549 cancer cells did increase apoptosis markers and also reduced the Bcl-2/Bax ratio, inhibiting migration and metastasis of the cancer cells. 58Administration of TQ also increased natural killer (NK) cell tumoricidal activity and enhanced IFNγ secretion via NK cells and NK cell-mediated killing of NSCLC cells. 59In addition, inhibition of GTPase KRas, Sir-2, ALK5 and β-catenin were shown when TQ was applied to lung cancer cells. 60

Anti-tumour activity in vivo
The use of honey and N. sativa (0.2 g N. sativa or 5 g honey/day) as supplements in Sprague Dawley rats showed protection against oxidative carcinogenesis induced by methyl nitrosourea in lung, skin and colon tissues. 61Oral administration of N. sativa volatile oil (1000 or 4000 ppm) for 30 weeks to male Wistar rats reduced the size of some tumours, including in the lungs. 54The above in vitro and in vivo results indicate that N. sativa and its constituent TQ could be promising candidates for treating lung cancer.Their therapeutic actions involve decreasing cancer cell viability and altering their morphology and levels of Bcl2 proteins, inflammatory markers, oxidative stress parameters and NF-kappa whilst increasing Bax/Bcl2 ratio and levels of apoptosis.

| Crocus sativus
Crocus sativus L (C. sativus) is mainly cultivated in Iran and is a member of the Iridaceae family.Chemical analyses of C. sativus extract indicate that the most critical constituents are carotenoids, crocin, crocetin and the monoterpene aldehydes crocin and safranal. 63[66] Regarding the safety of C. sativus, its oral administration of 200 and 400 mg/day for 7 days, indicated the changes in some haematological and biochemical parameters but, these changes were in normal ranges which were not important clinically. 67e effect of C. sativus and its constituents on lung cancer and their potential mechanism was also reported in numerous studies (Table 2).

Extract preparation
For the preparation of ethanolic extract, 1 g of the dried saffron stigma was extracted with 10 mL ethanol (96%) for 2 h in an ultrasonic bath.Then the extract was filtered and concentrated in a vacuum evaporator. 68

Growth-inhibitory activity in cell culture
Treatment with ethanolic saffron extract (500, 1000, 1500 and 2000 μg/mL for 24 and 48 h) reduced cell number and viability of L929 lung cancer cells. 68The increased apoptotic level was indicated using annexin V-fluorescein isothiocyanate in A549 cancer cells that had been treated with C. sativus extract. 69Furthermore, administration of saffron extract (100 mg/kg for 28 days) decreased xenograft tumour size and reduced Cas-3, −8 and −9 expression. 70eatment of lung cancer cells with crocin (1, 2, 4, 8 and 16 mg/ mL) markedly enhanced the mRNA levels of p53 and Bax and significantly down-regulated Bcl-2 mRNA expression. 71

Anti-tumour activity in vivo
Albino mice with B(a)P-induced lung cancer were treated with crocetin (50 mg/kg) and cancer cell proliferation was reduced by 68% and 45% in weeks 8 and 18 respectively, and glycoproteins and polyamines were significantly altered. 71e above results suggest that C. sativus, crocin and crocetin down-regulate mRNA levels of major proteins of apoptosis in lung cancer cells.Therefore, C. sativus, crocin and crocetin could be considered as treatment strategies for lung cancer.including Iran and Pakistan. 48,73Previous studies indicated that linalool is the medicinal constituent of O. basilicum. 74The anti-cancer effects of O. basilicum and its constituents have been demonstrated [78] Safety results demonstrated that acute effects of O. basilicum were shown in the LD50 > 5 mg/kg such as haematocrit, platelets and RBC decreasing and oral toxicity in patients. 79It was shown that O. basilicum consumption in food and drug preparations is safe.
However, a concentration limit for alkylbenzenes should be considered, and the plant chemotypes with equal or lower levels of these alkylbenzenes should be used. 80The effects of O. basilicum on lung tumours are summarized in Table 2.

Growth-inhibitory activity in cell culture
Treatment of A549 cancer cells with linalool (0-2.0 mM) inhibited cell proliferation and migration but increased the G0/G1 cell cycle arrest.Linalool treatment also sensitized cancer cells and antimetastatic markers were recorded in the treated A549 cells. 81Finally, linalool significantly decreased cancer cell viability even if only administered for 4 h. 81The above in vitro studies support the hypothesis that O. basilicum and its constituent linalool are a natural therapeutic against lung cancer cells and support further research to test the hypothesis.

| Ferula assa-foetida and F. Szowitsiana
The genus Ferula are perennial flowering plants belonging to the Apiaceae (Umbelliferae) family.Ferula growth spans the eastern Mediterranean regions all the way to central Asia. 82This genus consists of about 170 species of which 30 are found in Iran.
The anti-tumour and cytotoxic effects against multifarious cancer cell lines, anti-inflammatory, antioxidant, immunomodulatory and anti-bacterial activities, reduced lipid peroxidation and down-regulation of matrix metalloprotease expression caused by F. szowitsiana and its constituents have been reported in several studies (75-82).As well as F. szowitsiana, studies have found F. persica and its derivative coumarin may possess therapeutic properties.
Administration F. persica known as food additive until 1.5-2 mg/kg incresed the fibroblast cells in male patients and improved libido but did not report serious or acute side effects. 83,84e effects of F. persica and coumarin on lung cancer are summarized in Table 2.

Extract preparation
Total plant extracts were obtained by extraction of dried and milled aerial parts of the plants with 80% methanol (1:10) using the maceration method for 4 days.After every 24 h, the mixture was filtered and a new solvent was added to the plant powder.The combined extracts were concentrated to dryness under vacuum pressure. 85 the other study, the extract of the air-dried roots of F. szowitsiana (100 g) was prepared using the Soxhlet-extracted method with dichloromethane and methanol (1 L of each) and then was dried by evaporator. 86

Growth-inhibitory activity in cell culture
Treatment of A549 cells with F. szowitsiana extract (400 μg/mL for 48 and 72 h) altered anti-apoptosis, pro-apoptosis and tumour suppressor gene expression, up-regulated P53, Bax and Cas-9 and also activated multiple apoptotic pathways and antiproliferation activity. 86Treatment with F. persica extract (100 μg/mL) decreased cell viability and cell proliferation in MDBK, A549, HT29, HepG2 and MCF7 cell lines. 85ll proliferation, invasion, metastasis and autophagy were reduced in lung cancer cells treated with terpenoids.The inhibitory effects of terpenoids on cyclins and CDK were shown. 81Triterpenoids (25 mg/kg) inhibited the ROS accumulation via cytotoxicity of cisplatin by blocking autophagic flux. 87Human lung cancer cells treated with F. szowitsiana extract showed decreased cytotoxicity via SK-LU-1, SPC-A-1 and 95D tests and were also less viable. 88Inhibition of cell growth via increasing G1 cell cycle arrest, morphological cells and annexin were reported in NSCLC cell lines treated with coumarin (10-160 μg/m). 89The level of ROS and glutathione (GSH) in human alveolar epithelial A549 cancer cells was decreased and thiobarbituric acid reactive substance (TBARS) was markedly increased when they were treated with coumarin. 90Coumarin derivatives (12 μM) significantly decreased the migration of IL-1β-stimulated cells and IL-1β levels and inhibited F-actin reorganization in A549 cell lines. 91An earlier study found that administration of coumarin-based benzopyranone derivatives (20 μM) up-regulated the apoptotic pathway via Bax protein expression but down-regulated Bcl-2 protein expression in human lung (A549) cancer cells. 92sed on the above findings, further investigation in F. persica and its main constituent coumarin as a possible treatment for lung cancer via the inhibition of cyclins and CDK, their reducing effects on cancer cell migration and metastasis mediated by cytokines such as IL-1β, oxidative marker production, cell viability and cytotoxicity warrant further investigation.

| Curcuma longa
Turmeric, also known as Curcuma longa (C.longa), is a part of the Zingiberaceae family found in some regions of Asia, being particularly abundant in India.In addition to its multiple health benefits, C. longa is an important ingredient in recipes. 93,94Previous studies demonstrate various pharmacological properties of C. longa and curcumin (CUR) including: antioxidant ( 7), anti-inflammatory, 95 anti-tumour, 96 anti-tussive, 97 anti-diabetic, 98 anti-convulsant 99 and hepatoprotective effects. 100The anti-inflammatory, antioxidant and immunomodulatory effects of CUR have also been reported in experimental lung disorders. 101Some studies have looked at the potential anti-tumour mechanisms that C. longa and CUR adopt but further investigation is still needed to ascertain how they work.
Clinical results indicated that administration of C. longa and curcumin for 3 months, up to 8000 mg/d did not show side effects in patients, thus, it was recommended that using 2500 mg of C. longa was safe in humans. 102Table 3 summarizes the effects of C. longa and CUR on lung cancer.

Extract preparation
C. longa rhizome powder (100 g) was dissolved in 200 mL n-hexane and the solution was shaken for 4 h at 45°C.Then, the supernatant was transferred to a tube.This step was performed three times.Then, the residue of n-hexane extraction was dissolved in 200 mL dichloromethane instead of n-hexane and the same steps were repeated.The debris of extraction with dichloromethane was dissolved in 200 mL methanol and in the same way, supernatant was collected.Finally, the solvents of all three phases were dried by rotatory-evaporator and the remaining powders were stored at-20°C until used. 103owth-inhibitory activity in cell culture N-hexane extract of C. longa at concentrations of 0.114, 0.142, 0.171 and 0.199 mg/mL inhibited telomerase in A549 lung cancer cells dose-dependently. 103Administration of CUR (1%), in diet before and during weekly NTHi exposure in mice, significantly decreased lung tumours number in the absence of NTHi exposure and in the presence of NTHi exposures (85% and 53% respectively).In addition, direct anti-tumoral effects of CUR was reported in in vitro of murine K-ras-induced lung adenocarcinoma cell lines (LKR-10 and LKR-13) through reduction of cell viability, colony formation and apoptosis induction. 104In addition, tumour size and weight, Notch and HIF1 mRNA and tumour VEGF and NFB expression were all decreased by CUR (100 mg/kg).VEGF signalling was also inhibited by CUR, consequently inhibiting cancer cell growth. 105R (0, 5,10, 20 and 40 μM) applied to lung cancer stem cells for 7 days acted as an interventional agent by inhibiting both the Wnt/ß-catenin and the Sonic Hedgehog pathways. 106CUR inhibits Wnt and mTOR pathways by down-regulating urothelial cancerassociated 1 (UCA1). 107CUR (25-100 μM, for 6-48 h) also inhibited lung cancer cell growth by down-regulating UCA1, and by enhancing miRNA-98 activity. 108th pure CUR and nanoencapsulated CUR (CUR-Fe3O4) (0-120 mM, 24 and 48 h) reduced proliferation and hTERT gene expression in lung cancer cells but CUR-Fe3O4 was most effective. 109ditionally, CUR-Fe3O4 decreased migration of human lung cancer cells and ROS-mediated apoptosis. 110Lung cancer cells in 160 mM CUR for 12 to 72 h showed increased p53, BCL-2 (promoter of apoptosis), BCL-XL (promoter of apoptosis), Bak (promoter of apoptosis) and Cas gene expression. 111CUR (10 M) has also been found to regulate axon guidance, glioma, ErbB tyrosine kinase receptor signalling pathways and reduce metastasis in lung cancer cells. 112 a result of increasing FOXA2 expression and modulating STAT3 signalling pathways, CUR treatment (40 μ M, 4 h) inhibited human NCI-H292 cell growth. 113In NCI-H460 cells, CUR causes DNA repair and DNA damage. 114CUR (20 and 40 mM) reduced tumorspheres formed by H460 lung cancer cells and also inhibited proliferation and colony formation of the cancer cells.The inhibitory action of CUR on the JAK2/STAT3 pathway is implicated in the reduction of tumour spores and the suppression of tumour growth in mice bearing lung cancer xenografts. 115fitinib is a medication for cancer that inhibits EGFR in target cells.In primary NSCLC cell lines that are gefitinib-resistant (H157 and H1294), CUR reinstated the anti-cancer effects of gefitinib. 116R also inhibited SCLC cells, up-regulated the cyclin-dependent kinase inhibitors: p27 and p21 and down-regulated cyclin D1. 117 Additionally, CUR activated the ERK1/2 signalling pathway to increase the expression of forkhead box protein O1 (FOXO1).117 PI3K/ Akt/mTOR was also inhibited by CUR, consequently inhibiting the growth of NSCLC cells by inducing autophagy and apoptosis [118][119][120][121] and modulating calcium signalling.122 CUR also inhibits adiponectin receptor 1, preventing cancer cells from migrating and invading their host.
In expression and invasion in mice. 125Wang et al (123) demonstrated that CUR-induced reduction in NSCLC (A549) viability is related to oxidative stress and its cytotoxicity by causing ROS accumulation. 126 the same study, CUR prevented NSCLC proliferation by modulating the Wnt/ß-catenin pathway (123).Furthermore, by reducing mitochondrial transmembrane potential, CUR (0, 10, 20 and 30 μM, for 2 h) activated the mitochondrial apoptosis and DNA damage repair pathways. 127MHMM-41 (8 μM and 16 μM for 12 h) exerted even better antiproliferative effects on A549 cancer cells and also induced ROS-mediated apoptosis and migration of A549 cells. 128CUR (30 μM) inhibited migration and tube formation in NCI-H460 cells but this could be reversed by infecting the cells with the dominantactive variant STAT3C.This result suggests that CUR's inactivation of STAT3 is responsible for its effect on tumour angiogenesis. 129LC 801D cells were effectively inhibited from migrating and invasively spreading by low-toxic levels of CUR that disrupted Rac1/ PAK1 signalling pathways and MMP-2 and MMP-9 expression. 130study was performed using CUR dry powders and liposomal (MDA) and Cas-3 levels in lung tissue and expression of VEGF and B-cell lymphoma 2 (BCL-2).However, CUR powder showed a much stronger anti-cancer effect than LCDs.131 Treatment with CUR also reduced activation of HLJ1 via activation of the JNK/JunD pathway and also led to increased expression of E-cadherin in lung cancer cells.132

Anti-tumour activity in vivo
In an animal model of lung cancer, the anti-carcinogenic effect of CUR (100 mg/kg, 0.2 mL, once every other day) was shown by reduced tumour volume and weight, down-regulated Notch and HIF1 mRNA expression and inhibited VEGF and NFB. 105In another study conducted on mice, CUR administration reduced the number of visible lung tumours and inhibited NTH's ability to increase neutrophil chemokine levels. 133In a rat model of lung cancer, administration of CUR and resveratrol decreased Cyt c activity and oxidative enzymes, increased lipid peroxidation, SOD and CAT activities and reduced LPO. 134CUR liposomes increased apoptosis in cells and adiponectin expression and tumour growth in vivo were both inhibited by CUR treatment.CUR inhibited adiponectin expression by inhibiting NF-ĸ B/MMP pathways, resulting in decreased migration and invasiveness of the A549 cancer cells. 135 both in vitro and in vivo studies, C. longa and CUR have been

| Achillea millefolium
Achillea millefolium (A.millefolium), also known as yarrow, is a member of the Asteraceae family and found across Europe, Asia, North Africa and North America. 136,137e anti-inflammation and antioxidant and improvement effects of A. millefoliumi on pain and estrogenical wounds were reported and chronic administration (ED50 = 32 mg/kg، p.o) increased above the affects in rats for 90 days but it did not show any serious side effect or toxicity. 138In review articles, it was stated that A. millefolium extracts are safe in the concentrations used in cosmetics. 139Several in vitro studies have explored the anti-tumour potential of A. millefolium and its constituents, and the findings of A. millefolium effects on lung cancer are summarized in Table 3.

Extract preparation
The lyophilized powder (1 g) of the plant was extracted with 40 mL of methanol by stirring (25°C, at 10,000 x g) for 1 h and filtered through filter paper.The extract was evaporated at 40°C in rotary to dryness.The ethanolic extract was prepared using the dry fruiting bodies (1 g) with 30 mL of 90% ethanol by stirring for 48 h at 70°C.
The extract was filtered and centrifuged to get a clear liquid and evaporated at 40°C. 140oly ADP-ribose polymerase (PARP) activity in A549 cells.142 In addition, kaempferol (10, 25, 50 μM) treatment of A549 lung cancer cells, followed by TGFß-1 stimulation, resulted in phosphorylation of Smad3 (although phosphorylation at residue Thr179 was down-regulated) and the formation and nuclear translocation of Smad4 complexes.143 Kaempferol treatment combined with radiation therapy to kill tumours increased the amount of tumour death, both in vitro and in vivo, by suppressing the AKT/PI3K and ERK pathways and activating the mitochondria apoptosis pathway.144 In the same study, kaempferol was also found to induce

| Portulaca oleraceae
Portulaca oleracea (P.oleracea) belongs to the Portulacaceae family and grows in Iran, India, Japan, China and southern Europe. 148nistein and luteolin 149 are natural flavonoid constituents of P. oleracea with potential anti-cancer, antioxidant and anti-inflammatory properties. 150][153] Results were reported that administration P. oleracea did not show cytotoxic effects in in vitro studies and the IC 50 value of more than 10 μg/mL but moderate toxic effects were shown in LD 50 value of 1853 mg/kg. 154It was also reported that human consumption of P.
oleracea poses minimal dangers in humans. 155Several studies have reported a therapeutic effect of P. oleracea, genistein and luteolin on lung cancer cells, which are discussed below and summarized in Table 4.

Extract preparation
The oil from dried and grounded P. oleracea seeds was extracted by continuous extraction in Soxhlet apparatus for 12 h using petroleum ether (60-80°C boiling range) as a solvent.Then the solvent was evaporated and kept at −4°C. 156,157owth-inhibitory activity in cell culture Following treatment of HepG2 and A-549 cells with P. oleracea treatment (10-1000 ng/mL m for 24 h), a dose-dependent reduction in cell viability and changes in cell morphology were recorded.In addition, the lung adenocarcinoma cell line (A549) showed decreased proliferation and a higher apoptotic rate compared to controls. 156nsidering mRNA and protein levels, glutein therapy increased Bax but decreased Bcl-2 (anti-apoptotic factor) in A549 cells. 158milarly, genistein may enhance the production of Bax and downregulate Bcl-2, as well as inhibit lung cancer cell proliferation and induce their apoptosis.
The treatment resulted in inhibited tumour growth by activating miR-128 in the tumour cells.P. oleracea cytotoxic effects on human lung (K562 and A549) and breast cancer (MCF-7 and MDA-MB-435) cells were examined using four alkaloids isolated from air-dried aerial parts.The alkaloids isolated from P. oleracea showed moderate cytotoxic activity against A549 cells and only weak cytotoxic activity against K562 cells. 157The alkaloids did not appear to have any cytotoxic effects on MCF-7 and MDA-MB-435 (breast cancer) cells.

TA B L E 4
The effects of Portulaca oleracea, Allium cepa, Brassica juncea and Aloe Vera their constituents, on lung cancer.

Study type
Typ of lung cancer Preparations Dose Effects Ref.

| Allium cepa
5][166] Also, Garlic (Allium sativum) is a member of the onion (Amaryllidaceae) family and is classified in the same genus to which onion, leek, chive and shallot belong. 167The plant grows all over the world but is most common in zones with moderate climates and originates from central Asia. 168,169Anti-fungal, 170 anti-cancer, antiinflammatory, 171 antioxidant, antispasmodic, 168,172 antimicrobial, anti-mutagenic, 173 antidiabetic, 174,175 antiplatelet 176 and antiasthmatic properties 177 of its main constituent quercetin (QT) have been reported.
To our knowledge, there is no published data regarding the safety of A. cepa in humans.Several studies have found A. cepa and CUR works against lung cancer cells and the potential mechanisms are explored below and summarized in Table 4.

Extract preparation
Onion bulbs (100 g) was peeled, washed, cut into pieces and crushed and percolated in 500 mL of distilled water for 3 days with intermittent shaking.Using Whattman no.1 filter paper the extract was filtered to get fine. 178owth-inhibitory activity in cell culture NCI-H209 lung cancer cells treated with QT (5 μM) glucuronides are less likely to survive but they exhibit a higher percentage of cells in the G2/M phase, subG0/G1 phase and in the G2/M phase over time. 179Raising cyclin B expression and glucuronic acid, Cdc25c-ser-216-pand Wee1 levels were also reduced, indicating G2/M arrest.Several features of apoptosis were also observed after QT treatment, including the release of Cyt c, the induction of Bax and Bcl-2, the activation of Cas-3 and the cleavage of poly (ADP-ribose) polymerase. 179Increases in Bax, Bad and Bcl-x (L) levels occurred dose-dependently following treatment with QT (14.5, 29, 43.5, 58 μM). 180In the same study, QT was also found to inhibit Akt-1 and p-Akt-1, phosphorylated ERK and MEK1/2 in a dose-dependent manner.Several studies have indicated that QT is capable of causing apoptosis via activation of caspase-3 in A549 lung carcinoma cells. 180Researchers found that consumption of QT-rich foods negatively correlated with lung cancer risk in nontumour lung tissue from 38 adenocarcinoma patients.This correlation was not different between genotypes of P450s or GSTs, gender or subtypes of lung cancer, and the correlation was strongest in smoker subjects (who smoked >20 cigarettes per day). 179rthermore, high consumption of QT-rich foods led to higher expression of GSTM1, GSTM2, GSTT2 and GSTP1 relative to the low consumption group, but there was a lower expression of some P450 genes.According to these findings, QT intake is able to reduce smoking-induced lung cancer risk. 179QT-containing diet is also associated with poorer miRNA expression profiles of the tumour suppressor let-7 family in lung cancer tissue samples from 264 cases (144 adenocarcinomas and 120 squamous cell carcinomas).181 QT-rich diet also significantly differentiates miR-

Anti-tumour activity in vivo
A. cepa extract (10 g/L) showed an antiproliferative effect and mitotic indices appeared to be reduced in association with concentrations of the extracts. 178Moreover, the extract showed no anti-mutagenic or genotoxic properties.It is possible that the effects of onion extracts are caused by phenolic compounds.An antioxidant effect of A. cepa oil (10 mg/kg for 21 days) was shown in rats that had been exposed to nicotine, with higher levels of catalase (CAT) and superoxide dismutase (SOD) noted. 182Administration of crocetin (50 mg/kg for 8 and q8 weeks) reduced cell proliferation, glycoprotein and polyamine synthesis in B(a)P-induced lung cancer in mice. 183e anti-cancer effects of A. cepa and its main constituent QT reported in the above studies indicate that A. cepa and QT could inhibit adenocarcinomas parameters by modulating the expression of B-cell lymphoma, Bax mRNA, Bcl-2 mRNA, cell viability and DNA synthesis in lung cancer cells.

| Brassica juncea
Brassica juncea (B.5][186] Different biological activities of mustard and its constituents, such as antioxidant, 185,187,188 anti-inflammatory 189 and anti-depressant activities 190 have been reported.B. juncea has also demonstrated cytotoxic effects against cancer cells from different organs, including the colon, stomach, lungs and breast. 191minstration of F. suspensa extract did not show hepatotoxicity, hemolytic activity or other side effects indicating its safety when used at the studies doses. 192The effects of mustard and its constituents on lung cancer are summarized in Table 4.

Extract preparation
Dried B. juncea powder (20 g) was dissolved in 100 mL of 100% methanol and kept in a rectangular double-walled water bath at 50°C for 4 h.
Then the excerpt was filtered with filter paper (diameter of 125 mm) and the filtrate was kept at 50°C until it turned into a semisolid form. 193owth-inhibitory activity in cell culture DPPH assay analysis found that a combination of A. deliciosa and B.
juncea extracts increased antioxidant and antiproliferation activity markers and apoptosis in human lung carcinoma cells. 193Treatment of lung cancer cells with sinapic acid decreased potential cytotoxic and apoptosis reduced ROS production levels and elevated Cas activity (Cas-3 and Cas-9). 194Similarly, administration of sinapic acid (500, 1000, 2000, 5000 and 10,000 μg/mL) to A549 cells was found to increase Cas-3 activity, as well as lactate dehydrogenase (LDH) activity and decrease necroptotic marker proteins, cyclophilin A and high mobility group box 1 (HMGB1). 195

Anti-tumour activity in vivo
In vivo results showed that treatment with sinapic acid (30 mg/kg in corn oil, orally) improved lung and body weight, reduced levels of IgG, IgM and leukocyte counts, reduced the function of neutrophils, lipid peroxidation, pro-inflammatory cytokines, AHH, LDH, GGT, 5′NT and CEA and elevated the phagocytic index, activity index and activity of antioxidant enzymes. 194e above in vitro and in vivo results indicate that mustard and its constituents could be effective in lung cancer treatment via increasing antioxidant activities and antiproliferation activity markers, apoptosis and improving levels of immunoglobulins, Cas, HMGB1, LDH and pro-inflammatory cytokines in lung cancer models.

| Aloe vera
Aloe Vera (A. vera) is used to treat wounds in traditional Chinese medicine but is also widely used as a food, a remedy for constipation, wound healing and anti-cancer purposes in Egypt, Greece and China.[198] Regarding the safety of the plant, administration of tree doses (832.5, 1665 and 3330 mg/kg/bw by gavage), did not show any toxicity and mortality. 199Several studies have indicated an effect of A.
vera and its derivatives on lung cancer and the findings are discussed below and summarized in Table 4.

Growth-inhibitory activity in cell culture
Administration of Aloe emodin (A.emodin, 20 μM) to lung cancer (H460) cells increased apoptosis, necrosis and cell death, increased MAP kinase membrane activation of a mitochondrial permeability transition pore, changed Cyt c protein expression and mediated localization of F-actin. 200In addition, treatment of A549 and NCI-H1299 cells with A. emodin (10, 20 and 40 μM) stimulated autophagy through activation of MAPK signalling, inhibition of the Akt/mTOR pathways, reduced ROS levels and mediated autophagy. 201A study looking at the impact of A. emodin on CH27 and H460 cells found apoptosis was induced via nuclear morphological changes and DNA fragmentation, cystolic Cyt c fractions were enhanced, Cas-3 was activated and protein kinase C (PKC) expression was increased. 202milarly, Lee et al 203

| Different mechanisms of natural products against lung cancer
In the present article, the effects of the most effective 11 medicinal plants and their constituents against lung cancer were reviewed.
8][209][210] Below we summarize the mode of action and molecular strategies of medicinal plants and their derivatives against lung cancer, as evidenced by empirical study.

| Cell proliferation, cell viability and tumour growth
In lung cancer, increasing cell proliferation and viability of cancer cells demonstrates the advancement of the disease.Therefore, the effect of natural products on lung cancer cell proliferation and viability is an indicator of their therapeutic effects.The in vitro and in vivo studies demonstrated the inhibitory effects of A. vera, C. longa, C. sativus, B. juncea, A. cepa, P. oleracea, Z. multiflora, N. sativa and their constituents on lung cancer cell proliferation. 43,45,68,81,115,127,156,159,180In addition to cell proliferation and viability, tumour growth rate is used to diagnose the stage and severity of cancer.A. vera, C.longa, F. szowitsiana, P. oleracea and Z. multiflora all demonstrated an ability to block or disrupt tumour growth in lung cancer models and cell lines. 39,90,131,135,211Figure 2 illustrates the effects of these natural products on cell proliferation and tumour growth in lung cancer.

| Apoptosis
Increased apoptosis reduced rates of lung cancer cell proliferation, growth and prevented metastasis, making it a powerful effect against lung cancer.Several studies reported that the natural products: O. basilicum, P. oleracea, A. vera, C. longa, A. cepa, C. sativus, N. sativa, Z. multiflora and their constituents increased the level of apoptosis in lung cancer models or cell lines. 58,86,128,142,146,161,180,20 6 ow these natural products induce apoptosis in lung cancer is shown in Figure 2.

| Growth of lung cancer
The and immune cells, are the primary proteases responsible for ECM degradation.The urokinase-type plasminogen activator (u-PA) is a key enzyme involved in ECM degradation and the activation of proMMPs, including MMP-2.Abnormal expression of membrane type 1-matrix metalloproteinase (MT1-MMP) in tumours is associated with the regulation of MMP-2 activity. 214MMP-9, another member of the MMP family, has been identified as a biomarker for various cancers. 215Therefore, inhibiting the activity or expression of MMPs may be a potential strategy to suppress tumour invasion and metastasis.In lung cancer and other cancers, overexpression of GLUT1 (glucose transporter 1) is associated with poor prognosis.CUR, a natural compound with diverse activities, has been studied for its potential therapeutic effects. 2160][221] Another important target of cancer treatments is decreasing the amount of tumour cell migration and metastasis.There are several in vitro and even in vivo studies that found A. millefolium, C. longa, Ferula spp., N. sativa and their constituents reduced lung cancer cell migration 44,58,81,91,130,143 and lung cancer metastasis. 58,81,112,125,147e effects of these natural products on migration and metastasis of lung cancer are shown in Figure 2.

| Signalling pathways underlying the growth-suppressive activity of medicinal plants and their constituents
Studies investigating various types of cancer have revealed some of the molecular events behind cancer cell proliferation, viability, migration and metastasis.For example, enhanced tumour growth correlated with increased AMPK and fatty acid oxidation in ovarian cancer cells, linked to dysregulation of mTORC1 expression in renal cell carcinoma and has been connected to the hypoxia and oncogenic HRAS or KRAS pathways in glioblastoma and bladder cancer. 222nce, p53-deficient KRasG12D NSCLC had dysfunctional mitochondria, lipid accumulation and defects in fatty acid oxidation, resulting in reduced tumour growth. 223In addition, mutations in MYC, TP53, Ros-related oncogenes, the AMPK and PI3K signalling pathways of the NSCLCs enhanced expression of GLUT1, negatively impacting cell proliferation and growth. 223[226] Increasing accumulation and expression of angiogenesis factors such as VPF and VGEF enhanced metastasis and cell growth in tumour cells.Apoxemia and realizing ROS also triggered angiogenesis factors in human glioma cells. 227,228Breast cancer cells tend to proliferate when ß-actin, FOXM1, FBXW7, Fascin, eNOS, MMP-2 and HER2-receptor are expressed or stimulated. 229Expressions of Wnt1, β-catenin and cyclin D1 at the protein level in NSCLC cells increased the risk of mutagenesis, increased cancer cell viability and decreased apoptosis. 230Activation of Signal Transducer And Activator Of Transcription 3 (STAT3) signalling induced EMT and increased miR-193a-3p, miR-210-3p and miR-5100 levels, prompting lung cancer metastasis. 231It was reported that proliferation was suppressed via inhibiting the PHLPP1/AKT pathway. 232e cancer suppression effects of N. sativa, A. emodin, F. Szowitsiana and A. millefolium extracts as well as some derivatives of medicinal plants such as CUR, TQ, carvacrol, genistein, crocin work by increasing apoptosis and authophagy, reducing cell viability or proliferation via RTK and reducing cytotoxicity via inhibition of ROS release and expression. 60,116,204The suppression effects of the above plants on P38, 39,116,206 101,113,130 Therefore natural plant products, including medicinal plants and their derivatives, are promising agents for the treatment of lung cancer by impacting apoptosis, autophagy, cell viability or proliferation, metastasis and migration.The molecular pathways of these anti-cancer effects are summarized in Figure 3.

| Chemosensitization activity
Despite the availability of numerous conventional anti-cancer drugs with diverse mechanisms of action, the majority of them ultimately induce cell death through necrosis, apoptosis or autophagy by stimulating genotoxic stress. 234However, these chemotherapeutic agents primarily target rapidly dividing cells, which often results in adverse effects on normal dividing cells, leading to a multitude of side effects. 235While some of these side effects are short-term, such as nausea, myelosuppression or alopecia, others, including infertility, weight gain, cardiac dysfunction or secondary leukaemia, are longterm and serious.Additionally, the development of chemoresistance, particularly multidrug resistance (MDR), is another significant obstacle to the success of chemotherapy. 235To overcome this challenge, researchers have conducted extensive research on molecules that may enhance the therapeutic index of anti-tumoral drugs by making tumour cells more sensitive to chemotherapeutic agents, known as chemosensitizers.[238] Given these limitations, natural compounds have emerged as a promising source of new molecules for chemosensitization due to their unique structures and mechanisms of action.Many plantderived molecules have been found to target multiple pathways involved in cancer and are consumed as food or used as traditional remedies.Natural products have played a significant role in the development of small molecules approved for cancer treatment.
For instance, between the 1940s and the end of 2014, 75% of the small molecules approved for cancer treatment were other than synthetic, with 49% being natural products or directly derived from it.
[241] Natural compounds have emerged as a promising source of new molecules for chemosensitization in cancer therapy due to their unique structures and mechanisms of action.They can be used as chemotherapeutic agents, chemopreventive agents and chemosensitizing agents to improve the effectiveness of conventional chemotherapy. 242,243Natural products, especially edible phytochemicals-nutraceuticals, are attractive partners to be used in combination with chemotherapy due to their high biodiversity, good oral bioavailability and relatively low intrinsic toxicity. 244When associated with conventional chemotherapeutics, regarding the limited bioavailability of these compounds have been discussed, and novel formulations and analogues have been developed to increase their efficacy. 52,245,246Over the past few decades, numerous studies have indicated that cancer cells can develop resistance to drugs, which can be overcome by combining multiple drugs that act on redundant signalling nodes.EGFRi can initiate various side effects, which can be alleviated by incorporating natural products into the therapeutic regimen. 247For instance, Honeysuckle, a natural product obtained from Lonicera japonica Mohammad Hossein Boskabady: Formal analysis (equal); methodology (equal); supervision (equal); writing -review and editing (equal).

ACK N O WLE D G E M ENTS
Not applicable.

3. 1 . 4 |
Ocimum basilicum Ocimum basilicum L. (O.basilicum), or basil, is the main part of the oil crop used in traditional medicine that belongs to the Lamiaceae family.It is widely found in regions of central and southeast Asia, vitro studies have shown that CUR (10 μ M for 4 days) induces the maturation of lung cancer patient-isolated regulatory cells (Treg) to T helper (Th)-1 cells by inhibiting DNA transcription of forkhead protein-3 (Foxp3) and increasing expression of IFNγ.Treatment with CUR in lung cancer patients led to a significant increase in peripheral Tregs compared to healthy subjects. 123Treatment of A549 cells with CUR (6 M, for 48 h) increased the expression of the enzyme EZH2 through microRNAs (miR)-7c and miR-101 and reduced the expression of NOTCH1 via EZH2 activation. 124CUR (0, 15, 30, 45 and 60 μ mol/L) significantly inhibited lung cancer invasion and metastasis by inhibiting GLUT1/MT1-MMP/MMP2 pathways and was also found to significantly inhibit GLUT1/MT1-MMP/MMP2 found to suppress cancer cell proliferation and induce apoptosis of lung cancer cells.Additionally, CUR altered the expression of EGFR, microRNAs and autophagy in cancer stem cells.It is believed that CUR influences the expression of different genes in the cancer cells themselves, such as NF-kB, STAT-3 and AP-1, as well as protein kinases, including MAPK and enzymes such as COX and LOX.Thus, CUR makes for a promising therapeutic target in treating lung cancer.

G2/M cell
cycle arrest, inhibit clonogenic survival and elevate tumour cell apoptosis.Administration of kaempferol-3-O-rutinoside significantly stimulated cancer cell cytoskeleton collapse, mitochondrial dysfunction and apoptosis via the calcium signalling pathway.145Kaempferol treatment (25 μM) for 48 h also decreased the expression of GST, NQO1 and HO1, triggered Nrf2 by tertbutylhydroquinone (tBHQ), reduced ROS levels and induced apoptosis in treated cells.146Finally, Hang et al147 found various doses of kaempferol (20, 40, 60, 80, 100, 120 and 140 μM) reduced migration and metastasis of cells, induced cell mortality and apoptosis and modulated EMT protein expression in human NSCLC cells.These results suggest that the anti-cancer mechanisms of A. millefolium and its constituent kaempferol are broad and lead to cancer cell immobility and death.Compared to the other plant species discussed, A. millefolium has also been reported to disrupt the cytoskeleton of lung cancer cells.

30 and 50
μM) increased Bax expression and p21 protein levels in H460 NSCLC and H322 cells, independent of the p53 pathway.160Moreover, genistein(5, 10, 25, 50, 100 and 200 μM) exerted anticancer effects on the A549 human lung cancer cell by regulating Cas-3/9 activity, miRNA27a activity and the expression of the MET protein. 161A549 cells, expressing TRAIL-resistant human adenocarcinoma genes, were treated with genistein (0, 10, 20 and 40 μM) which led to enhancing p62, activating Cas-3 and Cas-8 and increasing TRAIL-induced tumour cell death by activated autophagy. 162Apoptosis and autophagy of NSCLC cells were also increased by genistein in vitro by inhibiting Bcl-xL distribution in the cytoplasm, lowering cytoplasmic Bcl-xL levels and increasing Bcl-xL and Beclin-1 dissociation. 163Bcl-xL distribution and levels in the cytoplasm and Bcl-xL and Beclin-1 dissociation are closely associated with NSCLC radiosensitivity by facilitating DNA damageinduced apoptosis and autophagy.Therefore, genestein could be considered as a therapeutic agent for enhancing the sensitivity of radiation therapy in NSCLC patients.
found A. emodin (40 μM) treatment of CH27 cells also triggered apoptosis by DNA fragmentation and enhanced expression of Bcl-2 family proteins such as Bcl-XL, Bag-1 and Bak which increased Cyt c in the cytosolic fraction.A. emodin administration (20 μM for 2 h) to H460 cells also stimulated protein kinase Cδ (PKCδ) expression and cell death and decreased expression of cytoskeleton-related proteins, including sarcoma (RAS), RAS homologue gene family member A (RHO), p38, heat shock protein 27(HSP27), focal adhesion kinase (FAK), α-actinin and tubulin.204 Lee et al205 found the treatment of carcinoma H460 cells with A. emodin (40 μM) increased the amount of proform and fragments of nucleophosmin, inducing apoptosis.In a more recent study, apoptosisinducing proteins such as cAMP-dependent protein kinase, protein kinase C, Bcl-2, Cas-3 and p38 were also measured in carcinoma H460 cells following treatment with A. emodin nanoparticles (50 μM) for 16 h.206These A. emodin nanoparticles cleaved Cas-3, Poly (ADP-ribose) polymerase (PARP), Cas-8 and Cas-9 and simultaneously activated MAPKs and inhibited PI3K/AKT, leading to marked inhibition of cancer cell proliferation, induced cell cycle arrest and apoptosis.206Based on the above studies, A. vera and A. emodin showed anticarcinoma effects on lung cancer cells.Therefore, A. vera and A. emodin could be effective in lung cancer therapy by inhibiting cell proliferation, cytoskeleton activation, stimulated cell apoptosis as well as Cas-3 and PKC activation, MAPK signalling, inhibition of ROS production, Akt/mTOR and PI3K/AKT pathways.206 extracellular matrix (ECM) is a crucial component of the tumour microenvironment (TME) and is present in both interstitial and epithelial vessels.It plays a dual role in cancer progression, as it facilitates interactions between cancer cells and stromal cells, promoting carcinogenesis, while also acting as a barrier against tumour metastasis. 212Degradation of the ECM allows cancer cells to traverse it and enter blood vessels.Subsequently, with the assistance of certain cytokines, cancer cells can pass through vessel walls and extravasate to secondary sites, where they continue to proliferate and form metastatic lesions. 213Matrix metalloproteinases (MMPs), a family of zinc-dependent endopeptidases produced by various cell types, including fibroblasts, epithelial cells F I G U R E 2 Anti-apoptosis, cell death and anti-cell migration mechanisms of natural products on lung cancer.
Liao et al. demonstrated that CUR treatment reduced the expression of GLUT1, MT1-MMP and MMP2 in A549 lung cancer cells.Conversely, in GLUT1-overexpressing A549 cells, CUR's anti-migration and anti-invasion effects were impaired, and MT1-MMP and MMP2expression were up-regulated.Consistent with these findings, in vivo experiments using nude mice showed that CUR treatment significantly reduced metastatic rates in A549 cells, but this effect was hindered in GLUT1-overexpressing cells.The study concluded that CUR suppresses migration and invasion by modulating the GLUT1/MT1-MMP/MMP2 pathway in A549 cells.125Another compound, honokiol, derived from Magnolia officinalis, was found to inhibit migration and invasion in H1299 lung cancer cells by disrupting the expression of MMP-9 and the Hsp90/MMP-9 interactions mediated by HDAC6.Honokiol promoted the degradation of MMP-9 through the ubiquitin-proteasome pathway, rather than inhibiting its transcription.HDAC6, a deacetylase, regulates the stability of Hsp90, which is involved in the activation of MMP-2/9.Honokiol inhibited the expression of acetylαtubulin, a specific substrate of HDAC6, and further experiments confirmed the regulation of MMP-9 by HDAC6.217Other natural compounds, such as theaflavin and theaflavin digallate from black tea, were found to exert anti-metastasis effects by inhibiting type IV collagenase in mouse LLC cells.218(-)-Epigallocatechin-3-gallate (EGCG), a polyphenol found in green tea, has also been extensively studied.Deng et al. reported that EGCG inhibits invasion in CL1-5 lung cancer cells by suppressing the mRNA and protein levels of MMP-2 through the JNK pathway.EGCG was also found to enhance the anti-cancer effects of docetaxel and reduce MMP-2 expression.Additionally, EGCG was shown to suppress migration and invasion by inhibiting epithelial-mesenchymal transition plant-based chemosensitizers enhance the cytotoxic effect of the anti-cancer drugs, promoting a synergistic effect even in cells with acquired resistance.Nutraceuticals represent a specific segment of natural compounds that are consumed as part of a normal diet and are considered pharmacologically safe.However, challenges F I G U R E 3 Anti-cell proliferation, anti-oxidative and anti-tumour growth mechanisms of natural products on lung cancer.

248 4|
Thunb, was shown to reduce acneiform rash incidences and severities induced by EGFRi in lung cancer patients.Additionally, natural bioactive components can help reverse EGFRi resistance in cancer cells.Bruceine H, a derivative of Brucea javanica (L.), was found to overcome resistance to receptor tyrosine kinase (RTK)-EGFRi in non-small cell lung cancer (NSCLC) models by suppressing Notch3, EGFR activation and β-catenin expression., thereby increasing gefitinib response.This combination also induced Foxo3a expression, which correlates with better response to EGFR inhibitors and overall survival in NSLCC patients.Similarly, cryptotanshinone (CTS), a bioactive component of Salvia miltiorrhiza, was shown to sensitize gefitinib-resistant EGFR-mutant lung cancer cells by targeting catalase (CAT), heme oxygenase 1 (HMOX1) and stearoyl-CoA desaturase (SCD).These proteins were identified through proteomic analysis and suggested to be potential therapeutic targets in lung cancers.CON CLUS IONThis review article presented the potential therapeutic effects of medicinal plants and their constituents on lung cancer based on in vivo and in vitro findings.Medicinal plants and their constituents increase the anti-cancer effects of many chemotherapeutic agents and radiotherapy, as well as reverse the effects of chemotherapeutic drug resistance, which is noteworthy since the emergence of chemotherapeutic drug resistance will eventually compromise the treatment of cancer.The reviewed papers showed that the extract of Z. multiflora extract and its main constituent carvacrol, reduce lung cancer virality, increases the expression of apoptotic proteins, modulates cytokine levels, cancer cell viability and regulate specific pathways.The effect of C. sativus, crocin and crocetin on down-regulation of mRNA levels of major proteins of apoptosis in lung cancer cells was also reported.F. persica and its main constituent coumarin are shown as a possible treatment for lung cancer via the inhibition of cyclins and CDK, their reducing effects on cancer cell migration and metastasis mediated by cytokines such as IL-1β, oxidative marker production, cell viability and cytotoxicity.C. longa and CUR suppress cancer cell proliferation and induce apoptosis of lung cancer cells.CUR changed the expression of EGFR, microRNAs and autophagy in cancer stem cells and influences the expression of different genes in the cancer cells, such as NF-kB, STAT-3 and AP-1, as well as protein kinases, including MAPK and enzymes such as COX and LOX.The anti-cancer mechanisms of A. millefolium and its constituent, kaempferol by change in cancer cell immobility and death as well as disruption the cytoskeleton of lung cancer cells were shown.P. oleracea and its constituent such genestein reduce cell viability, cell proliferation, Bcl-2 level and MMP-2 expression but increase apoptotic, cytotoxicity, Bax expression, miR-128 activation and p21 protein level, inhibit NSCLC cells ERK1/2 and PI3K/ Akt phosphorylation, regulate Cas-3/9 activity, miRNA27a activity and the expression of the MET protein enhancing p62, activating Cas-3 and Cas-8 and increasing TRAIL-induced tumour cell death by activated autophagy.The anti-cancer effects of A. cepa and its main constituent QT are shown by adenocarcinomas parameters inhibition through modulating the expression of B-cell lymphoma, Bax mRNA, Bcl-2 mRNA, cell viability and DNA synthesis in lung cancer cells.The effects of B. juncea or mustard and its constituents on lung cancer treatment are shown via increasing antioxidant activities and antiproliferation activity markers, apoptosis and improving levels of immunoglobulins, Cas, HMGB1, LDH and pro-inflammatory cytokines.Based on the above studies, A. vera and A. emodin showed anti-carcinoma effects on lung cancer cells.It was shown that A. vera and A. emodin are effective in lung cancer therapy by inhibiting cell proliferation, cytoskeleton activation, stimulated cell apoptosis as well as Cas-3 and PKC activation, MAPK signalling, inhibition of ROS production, Akt/ mTOR and PI3K/AKT pathways.Therefore, promising effects of medicinal plants and their constituents on lung cancer based on many experimental findings were indicated.However, it is necessary to pay attention to the pharmacodynamic and pharmacokinetic limitations of each medicinal plant.In addition, further clinical studies of the plants and their constituents on lung cancer are needed to justify their use in clinical practice for the treatment of these diseases.AUTH O R CO NTR I B UTI O N S Arghavan Memarzia: Writing -original draft (equal).Saeideh Saadat: Writing -original draft (equal); writing -review and editing (equal).Fereshteh Asgharzadeh: Writing -original draft (equal); writing -review and editing (equal).Sepide Behrouz: Writing -original draft (equal).Gert Folkerts: Writing -review and editing (equal).

72 TA B L E 2 The effects of Crocus sativus, Ocimum basilicum, Ferula persica and Ferula szowitsiana and their constituents on lung cancer. Study type Type of lung cancer Preparations Dose Effects Ref.
The effects of Curcuma longa and Achillea millefoliumand their constituents on lung cancer.
(LCDs) against human lung cancer A549 cells and normal human bronchial epithelial BEAS-2B cells.CUR and LCDs reduced TNFα levels in bronchoalveolar lavage fluid) BALF, (malondialdehyde TA B L E 3