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<front>
<journal-meta>
<journal-id journal-id-type="nlm-ta">OR</journal-id>
<journal-title-group>
<journal-title>Oncology Reports</journal-title>
</journal-title-group>
<issn pub-type="ppub">1021-335X</issn>
<issn pub-type="epub">1791-2431</issn>
<publisher>
<publisher-name>D.A. Spandidos</publisher-name>
</publisher>
</journal-meta>
<article-meta>
<article-id pub-id-type="doi">10.3892/or.2025.8959</article-id>
<article-id pub-id-type="publisher-id">OR-54-4-08959</article-id>
<article-categories>
<subj-group>
<subject>Review</subject>
</subj-group>
</article-categories>
<title-group>
<article-title>Advances in the chemo-preventive effects and mechanisms of ursolic acid against lung cancer (Review)</article-title>
</title-group>
<contrib-group>
<contrib contrib-type="author"><name><surname>Lin</surname><given-names>Zhanyu</given-names></name>
<xref rid="af1-or-54-4-08959" ref-type="aff">1</xref></contrib>
<contrib contrib-type="author"><name><surname>Chen</surname><given-names>Qingze</given-names></name>
<xref rid="af1-or-54-4-08959" ref-type="aff">1</xref></contrib>
<contrib contrib-type="author"><name><surname>Chen</surname><given-names>Zhaoyue</given-names></name>
<xref rid="af2-or-54-4-08959" ref-type="aff">2</xref></contrib>
<contrib contrib-type="author"><name><surname>Peng</surname><given-names>Tianyang</given-names></name>
<xref rid="af2-or-54-4-08959" ref-type="aff">2</xref></contrib>
<contrib contrib-type="author"><name><surname>Bai</surname><given-names>Jinglu</given-names></name>
<xref rid="af1-or-54-4-08959" ref-type="aff">1</xref></contrib>
<contrib contrib-type="author"><name><surname>Ma</surname><given-names>Fengjun</given-names></name>
<xref rid="af2-or-54-4-08959" ref-type="aff">2</xref>
<xref rid="c1-or-54-4-08959" ref-type="corresp"/></contrib>
</contrib-group>
<aff id="af1-or-54-4-08959"><label>1</label>Department of Traditional Chinese College, Shandong University of Traditional Chinese Medicine, Jinan, Shandong 250000, P.R. China</aff>
<aff id="af2-or-54-4-08959"><label>2</label>Department of Acupuncture and Massage College, Shandong University of Traditional Chinese Medicine, Jinan, Shandong 250000, P.R. China</aff>
<author-notes>
<corresp id="c1-or-54-4-08959"><italic>Correspondence to</italic>: Dr Fengjun Ma, Department of Acupuncture and Massage College, Shandong University of Traditional Chinese Medicine, 4655 University Road, Changqing, Jinan, Shandong 250000, P.R. China, E-mail: <email>mfjsunshine@126.com</email></corresp>
</author-notes>
<pub-date pub-type="collection"><month>10</month><year>2025</year></pub-date>
<pub-date pub-type="epub"><day>25</day><month>07</month><year>2025</year></pub-date>
<volume>54</volume>
<issue>4</issue>
<elocation-id>126</elocation-id>
<history>
<date date-type="received"><day>08</day><month>05</month><year>2025</year></date>
<date date-type="accepted"><day>23</day><month>06</month><year>2025</year></date>
</history>
<permissions>
<copyright-statement>Copyright: &#x00A9; 2025 Lin et al.</copyright-statement>
<copyright-year>2025</copyright-year>
<license license-type="open-access">
<license-p>This is an open access article distributed under the terms of the <ext-link ext-link-type="uri" xlink:href="https://creativecommons.org/licenses/by-nc-nd/4.0/">Creative Commons Attribution-NonCommercial-NoDerivs License</ext-link>, which permits use and distribution in any medium, provided the original work is properly cited, the use is non-commercial and no modifications or adaptations are made.</license-p></license>
</permissions>
<abstract>
<p>Ursolic acid (UA), a natural pentacyclic triterpenoid carboxylic acid, exhibits diverse biological activities and notable antitumor properties. Lung cancer (LC), a leading malignancy of the respiratory system, is predominantly classified into small cell LC and non-small cell LC. The increasing incidence and mortality rates of LC have spurred considerable interest in the chemo-preventive potential of UA. Accumulating evidence demonstrates that UA markedly inhibits LC cell proliferation and induces apoptosis. Mechanistically, UA induces cell cycle arrest at the G0/G1 phase, thereby suppressing LC cell invasion, migration and tumor growth. Furthermore, UA has shown synergistic effects when combined with other therapeutic agents, including mitotic kinase inhibitors and multifunctional nanomedicines, effectively overcoming drug resistance in LC cells. These multifaceted mechanisms collectively contribute to the chemo-preventive efficacy of UA against LC. Consequently, UA represents a promising candidate for LC prevention and therapy. The present review comprehensively summarizes the anticancer effects and molecular mechanisms of UA in LC, offering insights to guide future research and facilitate the development of innovative therapeutic strategies.</p>
</abstract>
<kwd-group>
<kwd>ursolic acid</kwd>
<kwd>lung cancer</kwd>
<kwd>chemoprevention</kwd>
<kwd>respiratory diseases</kwd>
<kwd>phytomedicine</kwd>
</kwd-group>
<funding-group>
<award-group>
<funding-source>Youth Program of the Shandong Provincial Natural Science Foundation</funding-source>
<award-id>ZR2023QH079</award-id>
</award-group>
<funding-statement>The present study was supported by the Youth Program of the Shandong Provincial Natural Science Foundation (grant no. ZR2023QH079).</funding-statement>
</funding-group>
</article-meta>
</front>
<body>
<sec sec-type="intro">
<label>1.</label>
<title>Introduction</title>
<p>Lung cancer (LC) is among the most prevalent and lethal malignancies worldwide, ranking as the leading cause of cancer-related mortality (<xref rid="b1-or-54-4-08959" ref-type="bibr">1</xref>). Early-stage LC is often asymptomatic and difficult to detect, resulting in delayed diagnosis. For patients diagnosed at advanced stages, the five-year survival rate remains dismally low at &#x007E;6&#x0025; (<xref rid="b2-or-54-4-08959" ref-type="bibr">2</xref>). Globally, &#x007E;1.6 million new LC cases are reported annually (<xref rid="b3-or-54-4-08959" ref-type="bibr">3</xref>). In men, LC constitutes the primary cause of both cancer incidence and mortality, whereas among women, its incidence ranks second only to breast and colorectal cancers (<xref rid="b4-or-54-4-08959" ref-type="bibr">4</xref>). LC poses a significant public health burden, with major risk factors including exogenous environmental exposures such as tobacco exposure, occupational and environmental carcinogens, and air pollution, as well as endogenous biological factors such as genetic predisposition, chronic lung disease, and hormonal and metabolic factors (<xref rid="b5-or-54-4-08959" ref-type="bibr">5</xref>,<xref rid="b6-or-54-4-08959" ref-type="bibr">6</xref>). Despite substantial advancements in diagnostic and therapeutic modalities in recent years, the overall prognosis of LC remains poor, particularly for patients with advanced disease (<xref rid="b7-or-54-4-08959" ref-type="bibr">7</xref>,<xref rid="b8-or-54-4-08959" ref-type="bibr">8</xref>).</p>
<p>Chemoprevention, defined as the use of natural or synthetic agents to prevent, inhibit, delay, or reverse carcinogenesis, has attracted considerable attention as a strategy to combat LC (<xref rid="b9-or-54-4-08959" ref-type="bibr">9</xref>). Although various candidate chemo-preventive agents such as vitamin E, isotretinoin and aspirin have been evaluated, none have demonstrated definitive clinical efficacy (<xref rid="b10-or-54-4-08959" ref-type="bibr">10</xref>). Natural bioactive compounds, characterized by diverse pharmacological activities and relatively low toxicity, have emerged as promising candidates in cancer prevention and treatment, thereby becoming a central focus of chemoprevention research (<xref rid="b11-or-54-4-08959" ref-type="bibr">11</xref>). Ursolic acid (UA; PubChem Compound ID: 64945) is a pentacyclic triterpenoid compound (C<sub>30</sub>H<sub>48</sub>O<sub>3</sub>) widely distributed in various plants, including calendula, lavender, oregano, Melaleuca, sage, apple, rosemary and pear. It has garnered significant scientific interest due to its diverse biological activities (<xref rid="b12-or-54-4-08959" ref-type="bibr">12</xref>,<xref rid="b13-or-54-4-08959" ref-type="bibr">13</xref>). Previous studies have revealed that UA possesses multifaceted biological activities, including anti-inflammatory (<xref rid="b14-or-54-4-08959" ref-type="bibr">14</xref>), antioxidant (<xref rid="b15-or-54-4-08959" ref-type="bibr">15</xref>), and anti-obesity effects (<xref rid="b16-or-54-4-08959" ref-type="bibr">16</xref>). Additionally, UA exhibits therapeutic potential in a variety of conditions, including diabetes (<xref rid="b17-or-54-4-08959" ref-type="bibr">17</xref>), liver diseases (<xref rid="b18-or-54-4-08959" ref-type="bibr">18</xref>), cardiovascular diseases (<xref rid="b19-or-54-4-08959" ref-type="bibr">19</xref>), gastrointestinal disorders (<xref rid="b20-or-54-4-08959" ref-type="bibr">20</xref>) and neurodegenerative diseases (<xref rid="b21-or-54-4-08959" ref-type="bibr">21</xref>). Of particular note is its remarkable anticancer potential (<xref rid="b22-or-54-4-08959" ref-type="bibr">22</xref>). UA has been demonstrated to inhibit tumor cell proliferation, induce apoptosis, and suppress tumor invasion and metastasis across multiple cancer types, including breast (<xref rid="b23-or-54-4-08959" ref-type="bibr">23</xref>), pancreatic (<xref rid="b24-or-54-4-08959" ref-type="bibr">24</xref>), prostate (<xref rid="b25-or-54-4-08959" ref-type="bibr">25</xref>), colorectal (<xref rid="b26-or-54-4-08959" ref-type="bibr">26</xref>), cervical (<xref rid="b27-or-54-4-08959" ref-type="bibr">27</xref>) and renal cancers (<xref rid="b28-or-54-4-08959" ref-type="bibr">28</xref>).</p>
<p>In LC chemoprevention, UA exerts its effects through multiple molecular mechanisms. Although extensive preclinical evidence supports the potential role of UA in LC prevention, the precise molecular pathways remain to be fully elucidated. Moreover, challenges related to the bioavailability, safety, and clinical efficacy of UA must be addressed to facilitate its translational application. The present review aims to comprehensively summarize the chemo-preventive effects and molecular mechanisms of UA in LC, thereby providing new insights and a theoretical framework for its future application in LC prevention and therapy.</p>
</sec>
<sec>
<label>2.</label>
<title>UA and its derivatives</title>
<p>UA is a pentacyclic triterpenoid compound that naturally occurs either as triterpene saponins or in its free acid form (<xref rid="b29-or-54-4-08959" ref-type="bibr">29</xref>,<xref rid="b30-or-54-4-08959" ref-type="bibr">30</xref>). It is also referred to as urson, malol, prunol, or 3&#x03B2;-3-hydroxy-urs-12-en-28-oic acid (<xref rid="b31-or-54-4-08959" ref-type="bibr">31</xref>). UA has the molecular formula C<sub>30</sub>H<sub>48</sub>O<sub>3</sub>, a molecular weight of 456.68 g/mol, and a melting point ranging from 283&#x2013;285&#x00B0;C (<xref rid="b12-or-54-4-08959" ref-type="bibr">12</xref>,<xref rid="b32-or-54-4-08959" ref-type="bibr">32</xref>). Its chemical structure comprises five rings-four six-membered and one five-membered-along with multiple hydroxyl and carboxyl functional groups. This distinctive molecular framework confers a broad spectrum of biological activities, including anti-inflammatory, antioxidant, antimicrobial and anticancer effects (<xref rid="b33-or-54-4-08959" ref-type="bibr">33</xref>&#x2013;<xref rid="b35-or-54-4-08959" ref-type="bibr">35</xref>). Numerous studies have demonstrated that UA exerts potent anticancer effects across various malignancies (<xref rid="b36-or-54-4-08959" ref-type="bibr">36</xref>,<xref rid="b37-or-54-4-08959" ref-type="bibr">37</xref>). Its mechanisms of action extend beyond conventional pathways such as apoptosis induction and proliferation inhibition, encompassing unique molecular targets and biological processes. Importantly, UA selectively targets cancer stem cells (CSCs), impairing their self-renewal capacity, which is critical for tumor initiation and recurrence (<xref rid="b38-or-54-4-08959" ref-type="bibr">38</xref>). Moreover, UA exhibits context-dependent modulation of autophagy, a process highly relevant to cancer therapy. At low concentrations, UA activates the AMP-activated protein kinase/mammalian target of rapamycin pathway, inducing protective autophagy that facilitates the clearance of damaged cellular components and enhances chemoresistance. Conversely, at high concentrations, UA inhibits autophagy by blocking autophagosome-lysosome fusion, thereby promoting autophagic cell death and augmenting its anticancer efficacy. Beyond autophagy regulation, UA exerts precise anticancer effects by modulating glycolytic metabolism (<xref rid="b39-or-54-4-08959" ref-type="bibr">39</xref>), inducing structural modifications (<xref rid="b40-or-54-4-08959" ref-type="bibr">40</xref>), and remodeling the tumor microenvironment (<xref rid="b41-or-54-4-08959" ref-type="bibr">41</xref>). These multifaceted actions underscore UA as a promising candidate for cancer therapy.</p>
<p>To improve the pharmacological activity and therapeutic potential of UA, various derivatives have been synthesized through chemical modifications targeting its hydroxyl, carboxyl and cyclic backbone moieties. Most reported UA derivatives fall into two principal categories: modifications at C-3/C-28, C-11, C-17 and C-28 positions, and structural alterations involving C-2/C-3 and the A-ring (<xref rid="b13-or-54-4-08959" ref-type="bibr">13</xref>,<xref rid="b42-or-54-4-08959" ref-type="bibr">42</xref>). Representative examples include UA-piperazine-dithio-carbamate ruthenium (II) polypyridyl complexes, which induce antitumor activity via necrosis (<xref rid="b43-or-54-4-08959" ref-type="bibr">43</xref>); corosolic acid (CA), a natural UA derivative that inhibits cancer cell proliferation through &#x03B2;-catenin downregulation (<xref rid="b44-or-54-4-08959" ref-type="bibr">44</xref>); UA232, which promotes apoptosis by inducing cell cycle arrest and endoplasmic reticulum (ER) stress (<xref rid="b45-or-54-4-08959" ref-type="bibr">45</xref>); and compound 17, a UA-derived small molecule that triggers cancer cell death through macropinocytosis (<xref rid="b46-or-54-4-08959" ref-type="bibr">46</xref>). Collectively, these findings suggest that UA derivatives exert anticancer effects through multi-target and multi-pathway mechanisms, enhancing the pharmacological potency and drug-like properties of UA. This not only reinforces its therapeutic efficacy but also offers novel insights for the development of innovative anticancer agents.</p>
</sec>
<sec>
<label>3.</label>
<title>Chemo-preventive effects of UA on LC</title>
<sec>
<title/>
<sec>
<title>Induction of autophagy and apoptosis in LC cells</title>
<p>Apoptosis plays a pivotal role in tumor development, progression and metastasis, yet cancer cells often evade apoptotic mechanisms to sustain survival (<xref rid="b47-or-54-4-08959" ref-type="bibr">47</xref>). Induction of apoptosis facilitates the elimination of potentially harmful or precancerous cells, whereas inhibition of apoptotic pathways contributes to uncontrolled cell proliferation and malignant transformation (<xref rid="b48-or-54-4-08959" ref-type="bibr">48</xref>). UA primarily induces apoptosis in LC cells through mitochondria-dependent (MD) pathways, ER stress pathways, and modulation of associated signaling cascades (<xref rid="f1-or-54-4-08959" ref-type="fig">Fig. 1</xref>).</p>
<p>Multiple studies have demonstrated that UA inhibits the proliferation of non-small cell LC (NSCLC) cells in a dose- and time-dependent manner while promoting apoptosis. UA activates caspase-3 and caspase-9, downregulates the anti-apoptotic protein Bcl-2, and upregulates the pro-apoptotic protein Bax, collectively inducing apoptotic cell death in LC cells (<xref rid="b49-or-54-4-08959" ref-type="bibr">49</xref>). Matrix metalloproteinases (MMPs), a family of zinc-dependent endopeptidases, mediate extracellular matrix (ECM) remodeling, which is implicated in various pathological processes (<xref rid="b50-or-54-4-08959" ref-type="bibr">50</xref>). Notably, upregulation of MMP gene expression has been associated with apoptosis induction in NSCLC cells. Lai <italic>et al</italic> (<xref rid="b51-or-54-4-08959" ref-type="bibr">51</xref>) reported that treatment of H460 cells with UA for 24 h led to increased expression of MMP-1, &#x2212;2, &#x2212;3, &#x2212;9, and &#x2212;10, concomitant with activation of caspase-3, nuclear morphological changes, and DNA fragmentation, thereby promoting apoptosis. Additionally, Gou <italic>et al</italic> (<xref rid="b45-or-54-4-08959" ref-type="bibr">45</xref>) demonstrated that the UA derivative UA232 induces apoptosis in A549 and H460 cells by causing G0/G1 phase cell cycle arrest and upregulating C/EBP-homologous protein, which triggers apoptosis via the ER stress pathway. Consistently, UA has been shown to exert anticancer effects in both A549 and H460 cells by inducing G0/G1 arrest and apoptosis, thereby suppressing tumor growth and progression (<xref rid="b52-or-54-4-08959" ref-type="bibr">52</xref>).</p>
<p>Mitochondria are essential organelles involved in regulating cellular functions such as autophagy and apoptosis under stress conditions (<xref rid="b53-or-54-4-08959" ref-type="bibr">53</xref>). Chen <italic>et al</italic> (<xref rid="b54-or-54-4-08959" ref-type="bibr">54</xref>) observed that UA increases the expression of apoptosis-inducing factor and endonuclease G in NCI-H292 cells, promoting their release via the MD pathway and triggering apoptosis. To address UA&#x0027;s limited solubility and lack of tumor specificity, Ma <italic>et al</italic> (<xref rid="b55-or-54-4-08959" ref-type="bibr">55</xref>) developed a hyaluronic acid-liposome UA delivery system (HA-Lipo/UA). Their results showed that HA-Lipo/UA upregulated apoptosis-related protein in the TGF-&#x03B2; signaling pathway and p53 expression in A549 cells, activated caspase-3, and enhanced mitochondrial apoptosis, suggesting a promising strategy for targeted LC therapy.</p>
<p>Mitophagy, a selective autophagic process that degrades damaged mitochondria via lysosomal pathways, is another mechanism by which UA exerts anticancer effects. Castrejon-Jim&#x00E9;nez <italic>et al</italic> (<xref rid="b56-or-54-4-08959" ref-type="bibr">56</xref>) reported that UA induces mitophagy in A549 cells through a Parkin-independent mechanism, leading to p62 overexpression and subsequent apoptosis. Furthermore, Song <italic>et al</italic> (<xref rid="b57-or-54-4-08959" ref-type="bibr">57</xref>) demonstrated that UA significantly enhances radiosensitivity in NSCLC cells, especially in radiation-resistant cells overexpressing hypoxia-inducible factor 1 alpha (HIF-1&#x03B1;). By reducing the glutathione ratio and downregulating HIF-1&#x03B1; in H1299/M-HIF-1&#x03B1; cells, UA increases radiosensitivity and promotes radiation-induced cell death.</p>
<p>DNA damage repair (DDR) is critical for maintaining genomic stability (<xref rid="b58-or-54-4-08959" ref-type="bibr">58</xref>). A strong correlation exists between DNA damage and the initiation of cell death pathways (<xref rid="b59-or-54-4-08959" ref-type="bibr">59</xref>). When DNA repair mechanisms are compromised, apoptosis acts as a safeguard to eliminate damaged cells (<xref rid="b60-or-54-4-08959" ref-type="bibr">60</xref>). Vaccinia-related kinase 1 (VRK1), a mitotic kinase frequently overexpressed in lung adenocarcinoma, belongs to the nuclear serine-threonine chromatin kinase family (<xref rid="b61-or-54-4-08959" ref-type="bibr">61</xref>). UA has been shown to bind the catalytic domain of VRK1, inhibiting its kinase activity. This interference impairs VRK1-mediated 53BP1 foci formation, thereby disrupting DDR and contributing to the therapeutic efficacy of UA against LC (<xref rid="b62-or-54-4-08959" ref-type="bibr">62</xref>).</p>
</sec>
<sec>
<title>Inhibition of LC cell invasion and migration</title>
<p>Tumor metastasis is a major contributor to the high morbidity and mortality associated with cancer (<xref rid="b63-or-54-4-08959" ref-type="bibr">63</xref>). Dysregulation of cancer cell migration critically influences the ability of tumor cells to detach from the primary site and invade surrounding tissues, thereby facilitating metastasis (<xref rid="b63-or-54-4-08959" ref-type="bibr">63</xref>).</p>
<p>Proteases play a vital role in cancer progression not only by mediating ECM remodeling but also by regulating the bioavailability of growth factors, pro-angiogenic factors, and cytokines, which collectively promote tumor development through both direct and indirect mechanisms (<xref rid="b64-or-54-4-08959" ref-type="bibr">64</xref>). However, the clinical application of UA is limited by its poor water solubility and insufficient tumor-targeting capability (<xref rid="b65-or-54-4-08959" ref-type="bibr">65</xref>). To address these challenges, Xu <italic>et al</italic> (<xref rid="b66-or-54-4-08959" ref-type="bibr">66</xref>) developed a novel multifunctional nanoparticle formulation [HA-modified UA and astragaloside IV (AS-IV)-loaded polydopamine nanoparticles (NPs; UA/(AS-IV)@PDA-HA)]. This delivery system significantly enhanced the cytotoxicity of UA and improved its anti-metastatic efficacy in NSCLC cells. Furthermore, UA has been shown to inhibit LC cell invasion in a concentration-dependent manner, with notable suppression of cell migration observed at concentrations between 4 and 16 &#x00B5;mol/l (<xref rid="b67-or-54-4-08959" ref-type="bibr">67</xref>).</p>
<p>Epithelial-mesenchymal transition (EMT) is a fundamental cellular program involved in embryonic development, tissue repair and stem cell plasticity, but it also contributes pathologically to fibrosis and cancer metastasis by enhancing cellular motility and invasiveness (<xref rid="b68-or-54-4-08959" ref-type="bibr">68</xref>). Experimental studies demonstrated that UA reduces EMT induction in H1975 LC cells triggered by transforming growth factor-&#x03B2;1, thereby inhibiting metastatic potential (<xref rid="b69-or-54-4-08959" ref-type="bibr">69</xref>). Additionally, investigations in human NSCLC A549 cells revealed that UA suppresses EMT by inhibiting the nuclear factor Kappa-light-chain-enhancer of activated B Cells (NF-&#x03BA;B) signaling pathway, downregulating astrocyte-elevated gene-1 (AEG-1), and modulating key EMT markers-upregulating epithelial marker E-cadherin while downregulating mesenchymal markers N-cadherin and vimentin. This mechanism effectively curtails tumor cell migration and invasion, underscoring the promise of UA as an anti-metastatic agent in LC treatment (<xref rid="f2-or-54-4-08959" ref-type="fig">Fig. 2</xref>) (<xref rid="b70-or-54-4-08959" ref-type="bibr">70</xref>).</p>
</sec>
<sec>
<title>Inhibition of LC cell proliferation and growth</title>
<p>Cell proliferation is fundamental to the normal development and homeostasis of multicellular organisms. Dysregulated cell proliferation is a hallmark of tumorigenesis and can also contribute to congenital malformations (<xref rid="b71-or-54-4-08959" ref-type="bibr">71</xref>).</p>
<p>Cancer/Testis Antigen Family 45 Member A2 (CT45A2) is implicated as an oncogene in NSCLC and is associated with Epidermal Growth Factor Receptor (EGFR) T790 mutations. The antitumor effects of UA in NSCLC predominantly depend on CT45A2 expression in H1975 cells. UA inhibits CT45A2 transcription by targeting the &#x03B2;-catenin/transcription factor 4 (TCF4) signaling pathway. Specifically, UA negatively regulates the &#x03B2;-catenin/TCF4/CT45A2 axis, thereby suppressing the proliferation of H1975 cells (<xref rid="b72-or-54-4-08959" ref-type="bibr">72</xref>). Autophagy-related gene 5 (ATG5) plays a pivotal role in autophagy by participating in the formation of autophagic complexes and autophagosomes, thus amplifying the autophagic response and offering potential therapeutic avenues (<xref rid="b73-or-54-4-08959" ref-type="bibr">73</xref>,<xref rid="b74-or-54-4-08959" ref-type="bibr">74</xref>). Mutations in ATG5 have been linked to various pathologies. Notably, inhibition of ATG5 via chloroquine (CQ) or siRNA enhances UA&#x0027;s anti-proliferative effects by suppressing autophagy, suggesting that autophagy may serve as a protective mechanism in cancer cells under UA treatment (<xref rid="b75-or-54-4-08959" ref-type="bibr">75</xref>).</p>
<p>Cell proliferation involves the biosynthesis of macromolecules such as proteins, lipids and nucleic acids, as well as an increase in cell size and mass. Aberrant regulation of cell proliferation and division contribute to tumor development. Wu <italic>et al</italic> (<xref rid="b76-or-54-4-08959" ref-type="bibr">76</xref>) demonstrated that UA suppresses NSCLC cell proliferation by inducing phosphorylation of stress-activated protein kinase/c-Jun N-terminal kinase and subsequently downregulating Sp1 expression. Furthermore, Way <italic>et al</italic> (<xref rid="b49-or-54-4-08959" ref-type="bibr">49</xref>) reported that UA inhibits LC cell proliferation through modulation of key signaling proteins, including mTOR and AMPK. Their findings indicate that UA activates AMPK in a dose- and time-dependent manner, which in turn suppresses mTOR activity-a central regulator of protein synthesis and cellular proliferation (<xref rid="f3-or-54-4-08959" ref-type="fig">Fig. 3</xref>).</p>
</sec>
<sec>
<title>Combination with other anticancer drugs</title>
<p>Chemotherapy remains a cornerstone in the treatment of LC (<xref rid="b77-or-54-4-08959" ref-type="bibr">77</xref>,<xref rid="b78-or-54-4-08959" ref-type="bibr">78</xref>). However, the emergence of drug resistance constitutes a significant barrier to successful chemotherapy outcomes (<xref rid="b79-or-54-4-08959" ref-type="bibr">79</xref>). Cisplatin resistance, in particular, is a major cause of therapeutic failure in patients with LC (<xref rid="b80-or-54-4-08959" ref-type="bibr">80</xref>). Recently, UA has attracted increasing attention for its potential to overcome cisplatin resistance in LC (<xref rid="f4-or-54-4-08959" ref-type="fig">Fig. 4</xref>).</p>
<p>Fan <italic>et al</italic> (<xref rid="b81-or-54-4-08959" ref-type="bibr">81</xref>) utilized the A549 human LC cell line as a model for cisplatin-resistant cells and demonstrated that UA treatment inhibited the activation of the Janus kinase 2/signal transducer and activator of transcription 3 (Jak2/Stat3) signaling pathway. This inhibition led to downregulation of pluripotency-associated transcription factors and suppression of CSC enrichment, thereby attenuating chemoresistance.</p>
<p>To improve UA delivery and targeting, Li <italic>et al</italic> (<xref rid="b82-or-54-4-08959" ref-type="bibr">82</xref>) developed a hydrogel-based drug delivery system co-loaded with UA and cisplatin. This platform enhances the targeting of UA to LC cells by facilitating its binding to the LC-specific membrane protein TMEM16A, effectively inhibiting lung adenocarcinoma progression. The hydrogel system thus provides a promising strategy to potentiate UA&#x0027;s therapeutic efficacy in resistant LC.</p>
<p>Furthermore, Chen <italic>et al</italic> (<xref rid="b83-or-54-4-08959" ref-type="bibr">83</xref>) identified the miRNA-149-5p/MyD88 signaling axis as a critical mediator of chemoresistance in NSCLC cells. Their study revealed that UA suppresses this signaling pathway, thereby reducing cancer stemness, overcoming chemotherapy resistance, and ultimately enhancing treatment efficacy in LC.</p>
</sec>
</sec>
</sec>
<sec>
<label>4.</label>
<title>Novel drug carriers</title>
<p>Currently, most anticancer drugs have the drawback of poor targeting, which can cause irreversible damage to the body during treatment. New drug delivery systems aimed at ensuring drug safety and efficient therapy may become key to enhancing the efficacy of anticancer drugs (<xref rid="b84-or-54-4-08959" ref-type="bibr">84</xref>). Research indicates that nanoparticle-based drug delivery systems (Nano-DDS) could potentially resolve the challenges associated with drug administration in cancer therapy (<xref rid="b85-or-54-4-08959" ref-type="bibr">85</xref>).</p>
<p>In an experiment by Wu <italic>et al</italic> (<xref rid="b79-or-54-4-08959" ref-type="bibr">79</xref>), a biomimetic red blood cell membrane (RBCM) nano-carrier, UA-loaded NPs coated with RBCM, was developed. This novel biomimetic drug delivery platform enhanced the tumor targeting, stability and biocompatibility of the UA NPs. It addressed the clinical limitations of UA and improved its bioavailability. This innovative biomimetic delivery system significantly improved the anticancer efficacy in advanced NSCLC model, offering a promising strategy for enhancing UA-based treatments. In addition, Xu <italic>et al</italic> (<xref rid="b66-or-54-4-08959" ref-type="bibr">66</xref>) developed a HA-modified UA/AS-IV-loaded polydopamine (PDA) nanomedicine (UA/(AS-IV)<sup>@</sup>PDA-HA). This nanomedicine effectively enhanced the water solubility and targeting ability of UA. It allows UA to specifically bind to the overexpressed cluster of differentiation 44 on the surface of NSCLC cells. Moreover, the modified nanomedicine significantly improved the cytotoxicity mediated by UA and enhanced its ability to inhibit NSCLC cell proliferation and metastasis. These findings suggest that UA has great potential as an effective targeted anticancer drug for LC therapy. Novel drug delivery systems have greatly enhanced the ability of UA to target LC, enabling precise control that reduces systemic toxicity and improves anticancer efficacy. However, the integration and interaction between targeted therapies and UA in addiction-related oncogenes of NSCLC remain unclear and require further investigation.</p>
</sec>
<sec>
<label>5.</label>
<title>Pharmacokinetics of UA</title>
<p>According to the Biopharmaceutics Classification System (BCS), UA is classified as a Class IV drug, characterized by low solubility and low permeability. Although UA demonstrates unique advantages in the treatment of cancers such as LC, its pharmacological efficacy is limited. Due to its lipophilic nature, UA exhibits poor oral bioavailability and has difficulty penetrating biological membranes, thereby reducing its therapeutic effectiveness against tumors (<xref rid="b86-or-54-4-08959" ref-type="bibr">86</xref>). To overcome these challenges, Antonio <italic>et al</italic> (<xref rid="b87-or-54-4-08959" ref-type="bibr">87</xref>) developed chitosan (CS)-modified polylactic acid NPs encapsulating UA. Their study showed that this nanoparticle system reduced the average particle size and promoted the amorphous transformation of UA, enabling sustained release. This significantly reduced cytotoxicity in tumor cells and enhanced UA&#x0027;s oral absorption, clearance rate and metabolic efficiency in rat models. Furthermore, Yang <italic>et al</italic> (<xref rid="b88-or-54-4-08959" ref-type="bibr">88</xref>) demonstrated that amorphous UA NPs prepared using the supercritical antisolvent technique effectively improved UA&#x0027;s supersaturation, solubility and absorption. In another study, Yu <italic>et al</italic> (<xref rid="b89-or-54-4-08959" ref-type="bibr">89</xref>) formulated a supramolecular co-amorphous system combining UA and piperine. Through differential scanning calorimetry and scanning electron microscopy, it was confirmed that the co-amorphous system significantly enhanced UA&#x0027;s oral bioavailability and solubility in physiological media compared to its crystalline form.</p>
<p>Regarding drug absorption, high-performance liquid chromatography-mass spectrometry was used to analyze the tissue distribution of UA in rats 1 h after oral administration. The study revealed that UA concentrations were highest in the lungs, followed by the spleen, liver, brain, heart and kidneys, in descending order (<xref rid="b90-or-54-4-08959" ref-type="bibr">90</xref>). Additionally, Wang <italic>et al</italic> (<xref rid="b91-or-54-4-08959" ref-type="bibr">91</xref>) found that a novel CS-coated UA liposome achieved significantly higher accumulation at tumor sites in mice compared with conventional UA liposomes and free UA. These findings offer new insights and strategies for enhancing UA&#x0027;s therapeutic efficacy against LC.</p>
<p>In terms of drug metabolism and excretion, research on UA remains relatively limited. Available studies indicate that UA is primarily metabolized in the human body by the hepatic cytochrome P450 (CYP450) enzyme system, along with phase II conjugation reactions. In Caco-2 cells, CYP3A4 and CYP2C9 play key roles in UA metabolism, and the PXR-RXR&#x03B1; pathway has been shown to significantly upregulate CYP2C9 expression, thereby promoting UA biotransformation (<xref rid="b92-or-54-4-08959" ref-type="bibr">92</xref>).</p>
<p>In summary, although UA shows promising pharmacokinetic behavior, further studies are needed to fully elucidate its absorption, metabolism and elimination profiles, which will be essential for advancing its clinical application.</p>
</sec>
<sec sec-type="conclusion">
<label>6.</label>
<title>Conclusion and outlook</title>
<p>LC, a malignant tumor originating from lung tissue, is one of the most common cancers worldwide and a leading cause of cancer-related mortality (<xref rid="b93-or-54-4-08959" ref-type="bibr">93</xref>,<xref rid="b94-or-54-4-08959" ref-type="bibr">94</xref>). UA plays a significant role in the treatment of LC, with mechanisms that include inhibiting cell proliferation, invasion and migration, and reducing drug resistance. These effects involve signaling pathways such as &#x03B2;-catenin, &#x03B2;-catenin/TCF4/CT45A2, NF-&#x03BA;B, Jak2/Stat3, and the regulation of related genes such as ATG5, CT45A2, MMP and AEG-1, as well as the expression of proteins such as Bcl-2, Bax, upregulation of E-cadherin, downregulation of N-cadherin, vimentin, mTOR and sp1, alongside the involvement of proteases and kinases such as caspase-3, caspase-9, urokinase, cathepsin B, AMPK and VRK1 (<xref rid="tI-or-54-4-08959" ref-type="table">Table I</xref>).</p>
<p>Due to the limited water solubility, poor targeting ability, and drug resistance of UA (<xref rid="b95-or-54-4-08959" ref-type="bibr">95</xref>), the development of novel DDS, including Nano-DDS and hydrogel-based delivery systems, has greatly addressed these issues. These innovations significantly enhance the delivery efficiency, targeting ability and bioavailability of UA, improving the effectiveness of monotherapy and boosting the antitumor effect through synergistic strategies. Furthermore, Ram Kumar Pandian <italic>et al</italic> (<xref rid="b96-or-54-4-08959" ref-type="bibr">96</xref>) found that polyhydroxybutyrate NPs could deliver UA, enhancing its stability and bioactivity, thus improving the treatment of tumors. In another study by Sharma <italic>et al</italic> (<xref rid="b97-or-54-4-08959" ref-type="bibr">97</xref>), HA-UA conjugates were used to prepare PTX-loaded HA-UA NPs, which significantly inhibited tumor cell proliferation in experimental models, offering new ideas and methods for combined chemotherapy delivery. If these two delivery systems are applied to the treatment of LC, they might yield unforeseen effects and become a new direction for future research. In addition, smoking as an important factor affecting LC is detrimental to the whole process of carcinogenesis. It has been identified that polycyclic aromatic hydrocarbons in cigarettes can affect the metabolism of drugs by key drug-metabolizing enzymes of cytochrome P450 and isoforms of the glucuronosyltransferase family, shortening the duration of drug action by accelerating the metabolism of related drugs and thus affecting therapeutic efficacy (<xref rid="b98-or-54-4-08959" ref-type="bibr">98</xref>). In addition, Zevin <italic>et al</italic> (<xref rid="b99-or-54-4-08959" ref-type="bibr">99</xref>) found that smoking significantly upregulated CYP2E1 activity, increasing the rate of metabolizing drugs while activating carcinogens and increasing the risk of disease. Whether smoking affects the metabolism and utilization of natural active ingredients, such as UA, has not been confirmed by relevant experiments, and the authors will further explore this issue in future studies.</p>
<p>Although UA shows remarkable therapeutic potential in LC treatment, there are still some limitations: First, low bioavailability: Its poor water solubility results in low absorption and bioavailability in the body. Second, lack of clinical trial data: Most studies on UA in LC remain at the laboratory stage, lacking large-scale clinical trials to support its safety and efficacy. In particular, clinical evidence for UA combination chemotherapy in non-small cell carcinoma remains low and a distant dream. Third, Dose and administration challenges: In clinical application, determining the appropriate dose is crucial. A very low dose may result in ineffective treatment, while a very high dose could cause toxicity. Further experimental research is needed to optimize dosing and administration methods. Fourth, drug interactions: UA may interact with other drugs, influencing their metabolism and therapeutic effects. Identifying interactions with other drugs is one of the future research directions. Fifth, side effects and toxicity: While UA is considered a relatively safe natural compound, high doses or prolonged use may still produce toxicity and side effects, which need further investigation. Sixth, individual differences: Patients may have different responses to UA based on factors such as genetic background, tumor type, stage and overall health. Hence, it is essential to avoid generalizing treatment approaches.</p>
<p>In conclusion, while UA has made significant progress in non-clinical research, some issues and limitations remain. In the future, the authors will focus research on the cultivation of real animal cells, to deepen the analysis of their multi-target regulatory networks and develop efficient delivery systems, to promote the clinical translation of UA and its derivatives, and ultimately to realize the leap from cellular evidence to human disease intervention (<xref rid="f5-or-54-4-08959" ref-type="fig">Fig. 5</xref>).</p>
</sec>
</body>
<back>
<ack>
<title>Acknowledgements</title>
<p>Not applicable.</p>
</ack>
<sec sec-type="data-availability">
<title>Availability of data and materials</title>
<p>Not applicable.</p>
</sec>
<sec>
<title>Authors&#x0027; contributions</title>
<p>ZL wrote the manuscript and drew the pictures. QC and ZC collected and organized literature. TP and JB proofread the manuscript. FM are fully responsible for the study designing, research fields, drafting, and finalizing the manuscript. All authors read and approved the final version of the manuscript. Data authentication is not applicable.</p>
</sec>
<sec>
<title>Ethics approval and consent to participate</title>
<p>Not applicable.</p>
</sec>
<sec>
<title>Patient consent for publication</title>
<p>Not applicable.</p>
</sec>
<sec sec-type="COI-statement">
<title>Competing interests</title>
<p>The authors declare that they have no competing interests.</p>
</sec>
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<floats-group>
<fig id="f1-or-54-4-08959" position="float">
<label>Figure 1.</label>
<caption><p>Molecular targets regulated by UA and their effects on cellular autophagy and apoptosis. UA, ursolic acid; HA-Lipo/UA, hyaluronic acid-liposome UA; GSH, glutathione; MMP, matrix metalloproteinase; ARTS, apoptosis-related protein in the TGF-&#x03B2; signaling pathway; HIF, hypoxia-inducible factor; PD-L1, programmed death-ligand 1; VRK1, vaccinia-related kinase 1; Chop, C/EBP-homologous protein. Figure created using Adobe Illustrator 2024 (v28.0), Adobe Inc.</p></caption>
<alt-text>Figure 1. Molecular targets regulated by UA and their effects on cellular autophagy and apoptosis. UA, ursolic acid; HA&#x2013;Lipo / UA, hyaluronic acid&#x2013;liposome UA; GSH, glutathione; MMP, matrix metallopro...</alt-text>
<graphic xlink:href="or-54-04-08959-g00.jpeg"/>
</fig>
<fig id="f2-or-54-4-08959" position="float">
<label>Figure 2.</label>
<caption><p>Molecular targets regulated by UA and their effects on cell invasion and migration. UA, ursolic acid; MMP, matrix metalloproteinase; AEG-1, astrocyte-elevated gene-1. Figure created using Adobe Illustrator 2024 (v28.0), Adobe Inc.</p></caption>
<alt-text>Figure 2. Molecular targets regulated by UA and their effects on cell invasion and migration. UA, ursolic acid; MMP, matrix metalloproteinase; AEG&#x2013;1, astrocyte&#x2013;elevated gene&#x2013;1. Figure created using Ad...</alt-text>
<graphic xlink:href="or-54-04-08959-g01.jpeg"/>
</fig>
<fig id="f3-or-54-4-08959" position="float">
<label>Figure 3.</label>
<caption><p>Molecular targets regulated by UA and their effects on cell proliferation. UA, ursolic acid. Figure created using Adobe Illustrator 2024 (v28.0), Adobe Inc.</p></caption>
<alt-text>Figure 3. Molecular targets regulated by UA and their effects on cell proliferation. UA, ursolic acid. Figure created using Adobe Illustrator 2024 (v28.0), Adobe Inc.</alt-text>
<graphic xlink:href="or-54-04-08959-g02.jpeg"/>
</fig>
<fig id="f4-or-54-4-08959" position="float">
<label>Figure 4.</label>
<caption><p>Molecular targets regulated by UA and their impact on attenuating drug resistance. UA, ursolic acid; miR, microRNA. Figure created using Adobe Illustrator 2024 (v28.0), Adobe Inc.</p></caption>
<alt-text>Figure 4. Molecular targets regulated by UA and their impact on attenuating drug resistance. UA, ursolic acid; miR, microRNA. Figure created using Adobe Illustrator 2024 (v28.0), Adobe Inc.</alt-text>
<graphic xlink:href="or-54-04-08959-g03.jpeg"/>
</fig>
<fig id="f5-or-54-4-08959" position="float">
<label>Figure 5.</label>
<caption><p>Mechanisms associated with the chemoprotective effect of UA for the treatment of lung cancer. UA, ursolic acid. Figure created using Adobe Illustrator 2024 (v28.0), Adobe Inc.</p></caption>
<alt-text>Figure 5. Mechanisms associated with the chemoprotective effect of UA for the treatment of lung cancer. UA, ursolic acid. Figure created using Adobe Illustrator 2024 (v28.0), Adobe Inc.</alt-text>
<graphic xlink:href="or-54-04-08959-g04.jpeg"/>
</fig>
<table-wrap id="tI-or-54-4-08959" position="float">
<label>Table I.</label>
<caption><p>Mechanism of action of ursolic acid in lung cancer.</p></caption>
<table frame="hsides" rules="groups">
<thead>
<tr>
<th align="left" valign="bottom">First author/s, year</th>
<th align="center" valign="bottom">Disease</th>
<th align="center" valign="bottom">Real modules (Animal/Cell/Patient)</th>
<th align="center" valign="bottom">Possible mechanisms</th>
<th align="center" valign="bottom">Targets</th>
<th align="center" valign="bottom">Doses</th>
<th align="center" valign="bottom">Treatment period</th>
<th align="center" valign="bottom">(Refs.)</th>
</tr>
</thead>
<tbody>
<tr>
<td align="left" valign="top">Kang <italic>et al</italic>, 2021</td>
<td align="left" valign="top">Lung cancer</td>
<td align="left" valign="top">Cell: A549, H460</td>
<td align="left" valign="top">Inducing apoptosis, inhibiting</td>
<td align="left" valign="top">MMP2&#x2193;, MMP3&#x2193;,</td>
<td align="left" valign="top">10 &#x00B5;M,</td>
<td align="left" valign="top">24 h</td>
<td align="center" valign="top">(<xref rid="b52-or-54-4-08959" ref-type="bibr">52</xref>)</td>
</tr>
<tr>
<td/>
<td/>
<td/>
<td align="left" valign="top">cell proliferation, and concen-</td>
<td align="left" valign="top">MMP9&#x2193;, PD-L1&#x2193;,</td>
<td align="left" valign="top">20 &#x00B5;M</td>
<td/>
<td/>
</tr>
<tr>
<td/>
<td/>
<td/>
<td align="left" valign="top">trating on blocking the cell cycle.</td>
<td align="left" valign="top">CDK4&#x2193;, CCND1&#x2193;</td>
<td/>
<td/>
<td/>
</tr>
<tr>
<td/>
<td/>
<td/>
<td/>
<td align="left" valign="top">CCNE1&#x2193;, CDKN1A&#x2191;,</td>
<td/>
<td/>
<td/>
</tr>
<tr>
<td/>
<td/>
<td/>
<td/>
<td align="left" valign="top">CDKN1B&#x2191;, VEGF&#x2193;,</td>
<td/>
<td/>
<td/>
</tr>
<tr>
<td/>
<td/>
<td/>
<td/>
<td align="left" valign="top">pSTAT3&#x2193;</td>
<td/>
<td/>
<td/>
</tr>
<tr>
<td align="left" valign="top">Way <italic>et al</italic>, 2014</td>
<td/>
<td align="left" valign="top">Cell: A549, H460</td>
<td align="left" valign="top">Induces apoptosis and inhibits</td>
<td align="left" valign="top">Caspase-3&#x2191;, Caspase-9&#x2191;,</td>
<td align="left" valign="top">30 &#x00B5;M</td>
<td align="left" valign="top">24; 48 h</td>
<td align="center" valign="top">(<xref rid="b49-or-54-4-08959" ref-type="bibr">49</xref>)</td>
</tr>
<tr>
<td/>
<td/>
<td/>
<td align="left" valign="top">cell proliferation.</td>
<td align="left" valign="top">Bax&#x2191;, Bcl-2&#x2193;, p-mTOR&#x2193;,</td>
<td/>
<td/>
<td/>
</tr>
<tr>
<td/>
<td/>
<td/>
<td/>
<td align="left" valign="top">FASN&#x2193;</td>
<td/>
<td/>
<td/>
</tr>
<tr>
<td align="left" valign="top">Lai <italic>et al</italic>, 2007</td>
<td/>
<td align="left" valign="top">Cell: H460</td>
<td align="left" valign="top">Induces apoptosis of tumor cells.</td>
<td align="left" valign="top">MMP-1&#x2191;, MMP-2&#x2191;,</td>
<td align="left" valign="top">10 &#x00B5;M</td>
<td align="left" valign="top">24 h</td>
<td align="center" valign="top">(<xref rid="b51-or-54-4-08959" ref-type="bibr">51</xref>)</td>
</tr>
<tr>
<td/>
<td/>
<td/>
<td/>
<td align="left" valign="top">MMP-3&#x2191;, MMP-9&#x2191;,</td>
<td/>
<td/>
<td/>
</tr>
<tr>
<td/>
<td/>
<td/>
<td/>
<td align="left" valign="top">MMP-10&#x2191;, Caspase-3&#x2191;</td>
<td/>
<td/>
<td/>
</tr>
<tr>
<td align="left" valign="top">Gou <italic>et al</italic>, 2020</td>
<td/>
<td align="left" valign="top">Cell: H460, A549</td>
<td align="left" valign="top">Induces apoptosis by activating</td>
<td align="left" valign="top">CHOP&#x2191;, Cyclin D1&#x2193;,</td>
<td align="left" valign="top">0-50 &#x00B5;M</td>
<td align="left" valign="top">24, 48,</td>
<td align="center" valign="top">(<xref rid="b45-or-54-4-08959" ref-type="bibr">45</xref>)</td>
</tr>
<tr>
<td/>
<td/>
<td/>
<td align="left" valign="top">the endoplasmic reticulum stress</td>
<td align="left" valign="top">CDK4&#x2193;p-PERK&#x2191;,</td>
<td/>
<td align="left" valign="top">72 h</td>
<td/>
</tr>
<tr>
<td/>
<td/>
<td/>
<td align="left" valign="top">pathway, arresting the cell cycle.</td>
<td align="left" valign="top">p-eIF2&#x03B1;&#x2191;, eIF2&#x03B1;&#x2191;</td>
<td/>
<td/>
<td/>
</tr>
<tr>
<td align="left" valign="top">Chen <italic>et al</italic>, 2019</td>
<td/>
<td align="left" valign="top">Cell: NCI-H292</td>
<td align="left" valign="top">Induces apoptosis through</td>
<td align="left" valign="top">AIF&#x2191;, Endo G&#x2191;,</td>
<td align="left" valign="top">3, 6, 9, 12</td>
<td align="left" valign="top">Respectively</td>
<td align="center" valign="top">(<xref rid="b54-or-54-4-08959" ref-type="bibr">54</xref>)</td>
</tr>
<tr>
<td/>
<td/>
<td/>
<td align="left" valign="top">mitochondrial-dependent</td>
<td align="left" valign="top">BCL-Xs&#x2191;</td>
<td align="left" valign="top">and 15 &#x00B5;M</td>
<td align="left" valign="top">24, 48 h</td>
<td/>
</tr>
<tr>
<td/>
<td/>
<td/>
<td align="left" valign="top">pathway.</td>
<td/>
<td/>
<td/>
<td/>
</tr>
<tr>
<td align="left" valign="top">Ma <italic>et al</italic>, 2023</td>
<td/>
<td align="left" valign="top">Cell: A549</td>
<td align="left" valign="top">Induces mitochondrial apoptosis,</td>
<td align="left" valign="top">ARTS&#x2191;, p53&#x2191;,</td>
<td align="left" valign="top">20 &#x00B5;g/ml</td>
<td align="left" valign="top">24 h</td>
<td align="center" valign="top">(<xref rid="b55-or-54-4-08959" ref-type="bibr">55</xref>)</td>
</tr>
<tr>
<td/>
<td/>
<td/>
<td align="left" valign="top">create HA-Lipo/UA delivery</td>
<td align="left" valign="top">ascapase-3&#x2191;,</td>
<td/>
<td/>
<td/>
</tr>
<tr>
<td/>
<td/>
<td/>
<td align="left" valign="top">system.</td>
<td align="left" valign="top">Cyto-C&#x2191;, Bcl-2&#x2193;, Bax&#x2191;</td>
<td/>
<td/>
<td/>
</tr>
<tr>
<td align="left" valign="top">Castrejon-</td>
<td/>
<td align="left" valign="top">Cell: A549</td>
<td align="left" valign="top">Induces apoptosis, induces</td>
<td align="left" valign="top">P62&#x2191;, Parkin&#x2191;</td>
<td align="left" valign="top">10 &#x00B5;g/ml</td>
<td align="left" valign="top">24, 48 h</td>
<td align="center" valign="top">(<xref rid="b56-or-54-4-08959" ref-type="bibr">56</xref>)</td>
</tr>
<tr>
<td align="left" valign="top">Jimenez <italic>et al</italic>, 2019</td>
<td/>
<td/>
<td align="left" valign="top">mitochondrial phagocytosis.</td>
<td/>
<td/>
<td/>
<td/>
</tr>
<tr>
<td align="left" valign="top">Song <italic>et al</italic>, 2017</td>
<td/>
<td align="left" valign="top">Cell: H1299</td>
<td align="left" valign="top">Induces cell death, enhances cell radiosensitivity.</td>
<td align="left" valign="top">GSH&#x2193;, HIF-1&#x03B1;&#x2193;</td>
<td align="left" valign="top">50, 80 &#x00B5;g/ml</td>
<td align="left" valign="top">24 h</td>
<td align="center" valign="top">(<xref rid="b57-or-54-4-08959" ref-type="bibr">57</xref>)</td>
</tr>
<tr>
<td align="left" valign="top">Kim <italic>et al</italic>, 2015</td>
<td/>
<td align="left" valign="top">Cell: A549</td>
<td align="left" valign="top">Induces apoptosis and impedes</td>
<td align="left" valign="top">53BP1 foci&#x2193;,</td>
<td align="left" valign="top">50 &#x00B5;M</td>
<td align="left" valign="top">12 h</td>
<td align="center" valign="top">(<xref rid="b62-or-54-4-08959" ref-type="bibr">62</xref>)</td>
</tr>
<tr>
<td/>
<td/>
<td/>
<td align="left" valign="top">DNA damage repair capability.</td>
<td align="left" valign="top">&#x03B1;-p-CREB&#x2193;,</td>
<td/>
<td/>
<td/>
</tr>
<tr>
<td/>
<td/>
<td/>
<td/>
<td align="left" valign="top">&#x03B1;-H3 p-Ser10&#x2193;</td>
<td/>
<td/>
<td/>
</tr>
<tr>
<td align="left" valign="top">Lamouille <italic>et al</italic>,</td>
<td/>
<td align="left" valign="top">Cell: HNBE,</td>
<td align="left" valign="top">Reduces cell invasion, reduce</td>
<td align="left" valign="top">MMP-9&#x2191;, MMP-2&#x2191;,</td>
<td align="left" valign="top">2, 4, 8,</td>
<td align="left" valign="top">48 h</td>
<td align="center" valign="top">(<xref rid="b68-or-54-4-08959" ref-type="bibr">68</xref>)</td>
</tr>
<tr>
<td align="left" valign="top">2014</td>
<td/>
<td align="left" valign="top">A549, H3255</td>
<td align="left" valign="top">cell migration, reduces cell</td>
<td align="left" valign="top">protein kinase C&#x2193;</td>
<td align="left" valign="top">16 &#x00B5;Mol/l</td>
<td/>
<td/>
</tr>
<tr>
<td/>
<td/>
<td align="left" valign="top">and Calu-6</td>
<td align="left" valign="top">activity.</td>
<td/>
<td/>
<td/>
<td/>
</tr>
<tr>
<td align="left" valign="top">Liu <italic>et al</italic>, 2013</td>
<td/>
<td align="left" valign="top">Cell: H1975</td>
<td align="left" valign="top">Inhibits cell invasion and</td>
<td align="left" valign="top">EMT&#x2193;, MMP-2&#x2193;,</td>
<td align="left" valign="top">0, 1, 5, 10,</td>
<td align="left" valign="top">24 h</td>
<td align="center" valign="top">(<xref rid="b70-or-54-4-08959" ref-type="bibr">70</xref>)</td>
</tr>
<tr>
<td/>
<td/>
<td/>
<td align="left" valign="top">migration.</td>
<td align="left" valign="top">MMP-9&#x2193;, Integrin</td>
<td align="left" valign="top">15, 20, 25,</td>
<td/>
<td/>
</tr>
<tr>
<td/>
<td/>
<td/>
<td/>
<td align="left" valign="top">&#x03B1;v&#x03B2;5&#x2193;</td>
<td align="left" valign="top">50, 100 ng/l</td>
<td/>
<td/>
</tr>
<tr>
<td align="left" valign="top">Jesudason <italic>et al</italic>,</td>
<td/>
<td align="left" valign="top">Cell: A549 and</td>
<td align="left" valign="top">Inhibits cell metastasis and EMT</td>
<td align="left" valign="top">AEG-1&#x2193;, E-cadherin&#x2191;,</td>
<td align="left" valign="top">5, 10, 20, 30,</td>
<td align="left" valign="top">24 h</td>
<td align="center" valign="top">(<xref rid="b71-or-54-4-08959" ref-type="bibr">71</xref>)</td>
</tr>
<tr>
<td align="left" valign="top">2000</td>
<td/>
<td align="left" valign="top">H1975</td>
<td/>
<td align="left" valign="top">N-cadherin&#x2193;, vimentin&#x2193;</td>
<td align="left" valign="top">40 &#x00B5;M</td>
<td/>
<td/>
</tr>
<tr>
<td align="left" valign="top">Higgins <italic>et al</italic>,</td>
<td/>
<td align="left" valign="top">Cell: PC9, H1299,</td>
<td align="left" valign="top">Inhibits cell proliferation.</td>
<td align="left" valign="top">Sp1&#x2193;, DNMT1&#x2193;, EZH2&#x2193;,</td>
<td align="left" valign="top">30 &#x00B5;M</td>
<td align="left" valign="top">48 h</td>
<td align="center" valign="top">(<xref rid="b77-or-54-4-08959" ref-type="bibr">77</xref>)</td>
</tr>
<tr>
<td align="left" valign="top">2009</td>
<td/>
<td align="left" valign="top">A549, H1650, H358 and H1975</td>
<td/>
<td align="left" valign="top">SAPK/JNK&#x2193;</td>
<td/>
<td/>
<td/>
</tr>
<tr>
<td align="left" valign="top">Way <italic>et al</italic>, 2014</td>
<td/>
<td align="left" valign="top">Cell: A549, H460</td>
<td align="left" valign="top">Inhibits cell proliferation.</td>
<td align="left" valign="top">AMPK&#x2191;, mTOR&#x2193;,</td>
<td align="left" valign="top">30 &#x00B5;M</td>
<td align="left" valign="top">24, 48 h</td>
<td align="center" valign="top">(<xref rid="b49-or-54-4-08959" ref-type="bibr">49</xref>)</td>
</tr>
<tr>
<td/>
<td/>
<td/>
<td/>
<td align="left" valign="top">Caspase-3&#x2193;, Caspase-9&#x2193;,</td>
<td/>
<td/>
<td/>
</tr>
<tr>
<td/>
<td/>
<td/>
<td/>
<td align="left" valign="top">Bcl-2&#x2193;, Bax&#x2191;</td>
<td/>
<td/>
<td/>
</tr>
<tr>
<td align="left" valign="top">Changotra <italic>et al</italic>,</td>
<td/>
<td align="left" valign="top">Cell: H1975</td>
<td align="left" valign="top">Inhibits cell proliferation.</td>
<td align="left" valign="top">CT45A2&#x2193;, transcription</td>
<td align="left" valign="top">25 &#x00B5;M</td>
<td align="left" valign="top">24, 48, 72 h</td>
<td align="center" valign="top">(<xref rid="b73-or-54-4-08959" ref-type="bibr">73</xref>)</td>
</tr>
<tr>
<td align="left" valign="top">2022</td>
<td/>
<td/>
<td/>
<td align="left" valign="top">factor/&#x03B2;-catenin&#x2193;,</td>
<td/>
<td/>
<td/>
</tr>
<tr>
<td/>
<td/>
<td/>
<td/>
<td align="left" valign="top">TCF4&#x2193;, siNC&#x2193;</td>
<td/>
<td/>
<td/>
</tr>
<tr>
<td align="left" valign="top">Wu et al, 2015</td>
<td/>
<td align="left" valign="top">Cell: H460, H1975,</td>
<td align="left" valign="top">Inhibits cell proliferation and</td>
<td align="left" valign="top">ATG5&#x2193;, p-SAK&#x2193;,</td>
<td align="left" valign="top">10 &#x00B5;M,</td>
<td align="left" valign="top">24, 48, 72 h</td>
<td align="center" valign="top">(<xref rid="b76-or-54-4-08959" ref-type="bibr">76</xref>)</td>
</tr>
<tr>
<td/>
<td/>
<td align="left" valign="top">A549, H1299, H520, H82 and H446</td>
<td align="left" valign="top">autophagy-related genes.</td>
<td align="left" valign="top">p-S6&#x2193;, p-AKT&#x2193;</td>
<td align="left" valign="top">15 &#x00B5;M</td>
<td/>
<td/>
</tr>
<tr>
<td align="left" valign="top">Li et al, 2024</td>
<td/>
<td align="left" valign="top">Cell: A549</td>
<td align="left" valign="top">Reduces cell resistance and</td>
<td align="left" valign="top">Oct-4&#x2193;, Sox-2&#x2193;,</td>
<td align="left" valign="top">10, 20, 30,</td>
<td align="left" valign="top">48 h</td>
<td align="center" valign="top">(<xref rid="b82-or-54-4-08959" ref-type="bibr">82</xref>)</td>
</tr>
<tr>
<td/>
<td/>
<td/>
<td align="left" valign="top">inhibits the enrichment of tumor stem cells.</td>
<td align="left" valign="top">c-Myc&#x2193;, Jak2&#x2191;, Stat3&#x2191;</td>
<td align="left" valign="top">40 &#x00B5;M</td>
<td/>
<td/>
</tr>
<tr>
<td align="left" valign="top">Chen <italic>et al</italic>, 2020</td>
<td/>
<td align="left" valign="top">Cell: LA795</td>
<td align="left" valign="top">Inhibits neural pathways, induces</td>
<td align="left" valign="top">TMEM16A&#x2193;,</td>
<td align="left" valign="top">5, 10, 15, 20,</td>
<td align="left" valign="top">24, 48, 72 h</td>
<td align="center" valign="top">(<xref rid="b83-or-54-4-08959" ref-type="bibr">83</xref>)</td>
</tr>
<tr>
<td/>
<td/>
<td/>
<td align="left" valign="top">DNA damage and cell membrane</td>
<td align="left" valign="top">p-MEK1/2&#x2193;,</td>
<td align="left" valign="top">30, 50 &#x00B5;M</td>
<td/>
<td/>
</tr>
<tr>
<td/>
<td/>
<td/>
<td align="left" valign="top">damage, and design hydrogel</td>
<td align="left" valign="top">p-ERK1/2&#x2193;, Cyclin D1&#x2193;</td>
<td/>
<td/>
<td/>
</tr>
<tr>
<td/>
<td/>
<td/>
<td align="left" valign="top">drug delivery systems to enhance</td>
<td/>
<td/>
<td/>
<td/>
</tr>
<tr>
<td/>
<td/>
<td/>
<td align="left" valign="top">targeting ability.</td>
<td/>
<td/>
<td/>
<td/>
</tr>
<tr>
<td align="left" valign="top">Perez-</td>
<td/>
<td align="left" valign="top">Cell: NSCLC, A549</td>
<td align="left" valign="top">Reduces chemical resistance,</td>
<td align="left" valign="top">miR-149&#x2193;, MyD88&#x2193;</td>
<td align="left" valign="top">5, 10, 20 &#x00B5;M</td>
<td align="left" valign="top">24, 48, 72 h</td>
<td align="center" valign="top">(<xref rid="b84-or-54-4-08959" ref-type="bibr">84</xref>)</td>
</tr>
<tr>
<td align="left" valign="top">Herrero <italic>et al</italic>,</td>
<td/>
<td/>
<td align="left" valign="top">inhibits miRNA, weakens</td>
<td/>
<td/>
<td/>
<td/>
</tr>
<tr>
<td align="left" valign="top">2015</td>
<td/>
<td/>
<td align="left" valign="top">stemness of cells.</td>
<td/>
<td/>
<td/>
<td/>
</tr>
</tbody>
</table>
<table-wrap-foot>
<fn id="tfn1-or-54-4-08959"><p>p-, phosphorylated; miRNA or miR, microRNA; CHOP, C/EBP-homologous protein; AIF, apoptosis-inducing factor; Endo G, endonuclease G; ARTS, apoptosis-related protein in the TGF-&#x03B2; signaling pathway; HIF-1&#x03B1;; hypoxia-inducible factor 1 alpha; GSH, reduced glutathione; EMT, epithelial-mesenchymal transition; AEG-1, astrocyte-elevated gene-1; CT45A2, Cancer/Testis Antigen Family 45 Member A2; TCF4, transcription factor 4; si-, small interfering; NC, negative control; ATG5, autophagy-related gene 5; SAPK/JNK, stress-activated protein kinase/c-Jun N-terminal kinase.</p></fn>
</table-wrap-foot>
</table-wrap>
</floats-group>
</article>
