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REVIEW Bali Medical Journal (Bali MedJ) 2021, Volume 10, Number 2: 608-616 P-ISSN.2089-1180, E-ISSN: 2302-2914

The potential effect and delivery of piperine on chemoresistant breast cancer Published by Bali Medical Journal

Desak Made Wihandani1*, I Putu Gede Septiawan Saputra2, Ni Putu Sri Indrani Remitha2, Anak Agung Bagus Putra Indrakusuma2, Putu Anda Tusta Adiputra3, I Gede Putu Supadmanaba1

1Department of Biochemistry, Faculty of Medicine, Universitas Udayana, Bali, Indonesia ABSTRACT 2Undergraduate Student, Faculty of Medicine, Universitas Udayana, Bali, Breast cancer is the most common malignancy in women worldwide. Breast cancer is associated with a high mortality rate Indonesia and health-related economic burden. Breast cancer patients have a low 5-year life expectancy when diagnosed at advanced 3Division of Surgery Oncology, Department of Surgery, Faculty of stages. Besides, the emergence of chemoresistance in breast cancer has led to an intense search for alternative anticancer Medicine, Universitas Udayana, Sanglah agents. One of the potential anticancer compounds is Piperine. Several studies had found that Piperine has anticancer General Hospital, Denpasar, Bali, effects such as anti-proliferation, induces apoptosis, anti-migration or anti-metastasis, chemo-enhancer or chemosensitizer, Indonesia cytotoxic agents, anti-angiogenesis, immune response modulators, and self-renewal inhibitor for cancer stem cells. Several delivery agents such as PLGA, PEG-PLGA and liposomes have been studied to improve Piperine’s delivery and have shown *Corresponding to: good results. Therefore, the combination of Piperine and nanoparticles is a potential anticancer agent, especially in breast Desak Made Wihandani; Department cancer. of Biochemistry, Faculty of Medicine, Universitas Udayana, Bali, Indonesia; [email protected] Keywords: breast cancer, chemoresistance, delivery, effect, Piperine Cite This Article: Wihandani, D.M., Saputra, I.P.G.S., Remitha, N.P.S.I., Indrakusuma, A.A.B.P., Adiputra, P.A.T., Supadmanaba, Received: 2021-02-05 I.G.P, I.B.P. 2021. The potential effect and delivery of piperine on chemoresistant breast cancer.Bali Medical Journal 10(2): Accepted: 2021-06-30 608-616. DOI: 10.15562/bmj.v10i2.2247 Published:2021-07-16

INTRODUCTION characteristics that are resistant to MOLECULAR BASIS OF several types of chemotherapeutic Breast cancer is the most common CHEMORESISTANCE IN BREAST agents. Therefore, several recent studies CANCER malignancy in women, responsible for have focused on finding new anticancer 25% of all cancer worldwide. According agents that have good effectiveness or can Chemoresistance is a crucial evolution in to GLOBOCAN (IARC), in 2018, there increase the therapeutic effectiveness of cancer progression, and it heavily influences were 2,088,849 new breast cancer cases the patient’s prognosis.9 Drug resistance 1 chemotherapeutic agents when combined. with 626,679 mortality. In Indonesia, the One of the compounds that have is classified into acquired resistance and incidence of breast cancer was recorded at potential anticancer effects is Piperine. intrinsic resistance.10 Chemoresistance 40 per 100,000 populations, with mortality in breast cancer occurs due to various 2 Piperine is an class compound at 16.6 per 100,000 population. According that is found in many plants from the factors in different mechanisms, such as to Riskesdas 2018 data, the incidence of Piperaceae family. It is most commonly transport and excretion, cell metabolism, breast cancer in Bali Province reaches tumor microenvironment, cancer stem 3 found in ( nigrum 0.6 per 1000 women. Breast cancer also L), widely found in Indonesia.6 As an cells, cancer signaling pathways, the role responsible for a significant health-related anticancer agent, Piperine can induce cell of miRNA, cell membranes, and others economic burden for the patients and the cycle arrest, inhibit angiogenesis, inhibit lain.11 The relationship between the nations. According to Barron et al. and metastasis, and induce apoptosis of cancer role of miRNA, JAK / STAT3 pathway, Sun et al., the economic burden of breast cells.7 However, Piperine is unstable, has and the tumor microenvironment in cancer ranges from 29,000 - 62,000 US chemoresistance breast cancer is the focus 4,5 low bioavailability, insoluble in water, dollars. and difficult to absorb.8 Therefore, a of its considerable effect. The life expectancy of breastdelivery strategy is needed to enhance the Several miRNAs are known as cancer patients is considered good, bioavailability of Piperine. In this review, oncogenes and can influence cancer but it continues to decline as the stage progressions such as tumor initiation, 1 the potential anticancer effect of Piperine progresses. Also, treatment options will be described along with its delivery tissue invasion, and even metastasis.12 are often limited due to breast cancer mechanism for Piperine. However, evidence showed that

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decreased miRNA function increased pathway, overexpression of miR -621 and breast cancer.11 Additionally, the JAK the expression of drug resistance-related miR-383 induce FBXO11 and Gadd45g, / STAT3 pathway has an interesting genes (P-glycoprotein, ABCB1: ATP leading to chemosensitivity), epithelial- mechanism in inducing chemoresistance Binding Cassette Subfamily B Member 1; to-mesenchymal transition or EMT with intrinsic and extrinsic pathways MRP-1: Multidrug Resistance-Associated (miR-489 and miR-125b overexpress capable of regulating lipid metabolism. Protein Group 1 or ABCC1: ATP Binding Smad3 and Sema4C), cancer stem cells It also induced stemness when inhibited, Cassette Subfamily C Member 1; BCRP: (CSC) (decreased miR-34a function reset leading to chemoresistance in breast Breast Cancer Resistance Protein or genes NOCTH1, miR-7 influence CSC cancer by blocking self-renewal (Figure ABCG2: ATP Binding Cassette Subfamily for metastasis by inducing the KLF4 1B).21 G Member 2), DNA repair (miR-206 gene) (Figure 1A).12–20 Accordingly, Wnt, An enzyme essential for fatty acid increases BRCA1 expression and induces Hippo, Notch, Hedgehog s, JAK / STAT3 β-oxidation (FAO) is associated with a Cyclin D2), apoptosis resistance (miR- pathway, and PI3K / Akt / mTOR signaling diverse lipid metabolism gene expression, 149 controls NDST1 and activates HS are also overexpressed in chemoresistant carnitine palmitoyltransferase 1B (CPT1B).22 FAO produces NADH and FADH2 to reduce oxidative stress and increase ATP and Acetyl Co-A, affecting protein acetylation, the TCA cycle, and fatty acid synthesis.23,24 The enzymes are closely related to Acetyl Co-A, and decreased expression suppresses metabolic acetylation, stopping breast cancer stem cells (BCSCs) and metabolism related to proliferation.24,25 Breast adipocytes trigger leptin fatty acid to control CPT1B- induced STAT3, also reset FAO activity in BCSC (Figure 1B).21 The tumor microenvironment also plays a crucial role in determining the efficacy of chemotherapeutic agents.26 Tumor microenvironment affects interstitial tissue, extracellular matrix, and normal stromal cells. Chemoresistance in breast cancer is associated with cancer- associated fibroblast (CAF), endothelial- cell vascularization, tumor-associated macrophage (TAM), fibroblasts, and mesenchymal stromal cell (MSC). Cancer cells regulate TAM and vice versa.27,28 TAM can differentiate into M1 (anti- cancer macrophage) and M2 (pro- cancerogenic).29 Cancer cells secrete transforming growth factor-β (TGF-β) and growth factors which induce angiogenesis and affecting endothelial cells.26 Reversely, MSCs also influence cancer cells and inducing TGF-β production even further.30 Figure 1. Pathogenesis of chemoresistance breast cancer. A. Role of miRNA in chemoresistance On the other hand, T regulator (Treg) breast cancer. Decreased miRNA function increases the number of induced genes, leading to chemoresistance.12 B. JAK / STAT3 pathway. This signaling inhibits natural killer (NK) cells through 31 pathway regulates fatty acid β-oxidation (FAO) and promotes chemoresistence.21 CCL-2 and helps in cancer progression. C. Interaction of tumor microenvironment with breast cancer cells against Fibroblasts (a major component of the chemotherapy agents. NK: natural killer, APC: adenomatous polyposis coli, CAF: tumor microenvironment) are considered cancer-associated fibroblast, CXCL12: chemokine (CXC motif) ligand, NF: normal the major player in chemoresistance. fibroblast, TGF-β: transforming growth factor-beta, MSC: mesenchymal stem cells, CAF modulates normal fibroblast (NF), VEGF: vascular endothelial growth factor, IL: interleukin, CCL: chemokine (CC altering cancer vascularity and immune motif) ligand, M1 and M2: anti-tumorigenic, TAM: tumor-associated macrophage, cells (Figure 1C).32 M-CSF: macrophage colony-stimulating factor.11

Published by Bali Medical Journal | Bali Medical Journal 2021; 10(2): 608-616 | doi: 10.15562/bmj.v10i2.2247 609 REVIEW

THE CHEMISTRY NATURE OF associated amide and Piperine. Pure PLGA Nanoparticle PIPERINE Piperine can also be produced by Various literature has demonstrated supercritical fluid extraction followed by the potential of Poly (lactic-co-glycolic Piperine is one of the alkaloid compounds of ethanol. In general, the acid) (PLGA) nanoparticles as a drug commonly found in the plant from the supercritical fluid extraction of pepper delivery system for many therapeutic Piperaceae family. Piperine compounds will require high temperatures and agents, such as chemotherapy, anti- are mostly found in black paper (Piper pressures, helping to reduce the volume inflammatory, antibiotic, antioxidant, nigrum L), which contains 2% - 9% of of solvent. Other extraction methods and antiseptic, and offers advantages in 6 Piperine concentration. Piperine in the were also developed, such as microwaves tumor and/or DNA targeting.46,47 PLGA black paper has been believed as a source technique and hydrotropic dissolution, is one of the top copolymers with several of treatment for many diseases based which eliminate the need for further benefits, such as biodegradable (breaks on the ancient Indian medicinal book processing, and the products can be used down into non-toxic H O and CO ) 33 2 2 Ayurveda. Piperine also has been known directly. Other literature also showed that and easily eliminated from the body. Its to have a broad spectrum of benefits, compounds such as Piperine have been polymeric nanoparticles are degraded by including antitumor, antihypertensive, isolated extensively, fractionated, and of the ester bonds into their anti-inflammatory, anti-aggregates,identified using high-performance liquid monomeric anions in vivo (lactate and 7 antioxidant, and antidepressant. chromatography (HPLC).39 glycolate).48 Meanwhile, D-Lactate does Piperine is a phytochemistry compound Currently, there is a new technique to not undergo metabolism before being essential for spicy foods and beneficial extract organic compounds from various excreted, L-lactate is converted to CO2, pharmacologist activities, which are not samples to reduce extraction time and which is excreted through the lungs and only limited as an anti-inflammatory, optimize solvent conditions, namely the converted to pyruvate, which enters the antitumor, and anti-metastatic, but Accelerated Solvent Extractor (ASE) Krebs cycle. Glycolate will be excreted also as leishmanicidal, larvicidal, technique. This method can increase the directly through the kidney system or antimycobacterial, immunosuppressive, solvent temperature at high pressure oxidized to glyoxylate, converted into 7,34–37 and antiparasitic. In 1819, Piperine to speed up the extraction process. The serine, glycine, and pyruvate. These was first separated from pepper extract results of the research by Upadhya et al. substances can later re-enter the Krebs by Hans Christian Orsted.38 Piperine, showed that compound-based extraction cycle and be metabolized into H2O, and along with chavicine, isoPiperine, and 47,49 using ASE from a complex plant matrix, CO2. PLGA is generally produced isochavicine, belongs to the alkaloid such as Piperine, was a suitable method through the catalyzed ring-opening 38 family. Several have been for quality control or standardization copolymerization of LA and GA. PGA is approved by the US Food and Drug of herbal products. The study showed a crystalline hydrophilic polymer with a Administration (FDA) and used as a an accurate, fast, and simple extraction fast degradation rate under physiological reservoir for drug discovery infrastructure, method for the extraction of compounds conditions and low water . On such as vinblastine which interacts with from different plant materials.40 the other hand, PLA is a hydrophobic and tubulin in mitosis and camptothecin, a rigid polymer that has low mechanical 34 well-known topoisomerase I inhibitor. PIPERINE DELIVERY AGENTS strength.48 Perine also neutralized several types Research by Katiyar et al., which of cancer-causing agents, such as There are several potential delivery evaluated the effect of Piperine (PIP) as an 7,12-dimethyl benz(a)anthracene and agents that can be used in combination absorption enhancer/chemosensitizer on benzo(a)pyrene, indicating its potential as with Piperine. These agents have been the oral absorption of Rapamycin (RPM), 7 a cancer chemopreventive agent. proven both clinically and mechanistically. showed that the RPM tends to accumulate There are various extraction methods However, the nature of the delivery agents in red blood cells (RBC) (38 times more used to isolate Piperine which depend and the type of molecules that it can carry concentrated in red blood cells). PIP is on the product purpose, scale, and should be carefully considered. Table 1 a P-gp inhibitor that forms the basis of 39 operation. Extraction refers to the summarizes the potential delivery agents kinetics in the combination of two drugs. separation of the analytes from a complex for piperine. matrix.40,41 Extraction efficiency is strongly influenced by solvent composition, solvent Table 1. Summary of Piperine Delivery Agents in Breast Cancer. to solid ratio, temperature, time, and extraction method.40 Extraction of Soxhlet Delivery Agent Target Cell Reference or maceration of fruit powders with polar PLGA Nanoparticle  MDA-MB-231 42 organic solvents obtained a dark brown oily substance which was fractionated by PEG-PLGA Nanoparticle  MDA-MB-468 43,44  column chromatography using diethyl MCF-7 and hexane (2:1), producing the Liposome  MDA-MB-231 45

610 Published by Bali Medical Journal | Bali Medical Journal 2021; 10(2): 608-616 | doi: 10.15562/bmj.v10i2.2247 REVIEW

Meanwhile, RPM is a P-gp substrate like surface and the high dissolution rate of to determine the molecular interaction other anticancer drugs. Therefore, most the polymer near the surface. After the mechanism between Piperine molecules tumor cells that are rich in P-gp pump controlled initial burst release of Piperine, and DPPC (L-α-phosphatidylcholine out RPM. PIP as an absorption enhancer it was noted that the continuous release dipalmitoyl) liposomes.57 The study is expected to be able to inhibit the effect of Piperine was due to the combined reported that temperature affected the of P-gp, resulting in RPM accumulation. diffusion of Piperine from the inner core shape of the absorption band. The band Katiyar et al. showed a 1.7-fold increase in of P-PEG-PNP and degradation of the width centered at ~ 3400 cm-1, showing that bioavailability from RPM in the presence PLGA polymer. The release of Piperine the stretching of OH in water molecules of PIP suspension.42 from P-PEG-PNP is further facilitated by associated with membranes via hydrogen Drug release from the PLGA matrix hydrogen bonding between the Piperine bonds. The percentage of transmission of occurs by a diffusion-degradationPLGA matrices. The continuous release this band after incorporating Piperine into mediated process. Release occurs mainly observed in Pachauri et al. study was the DPPC liposomes decreased gradually by diffusion in the polymer matrix during in line with other drug release studies with increasing temperature. This effect the initial phase, and then during the that showed that the hydrogen bonding can be attributed to the formation of subsequent phase, the release is mediated between matrix nanoparticles and the hydrogen bonds between the DPPC through both processes (degradation of drug also facilitated the sustainable release molecule and Piperine. They also showed the polymer matrix and diffusion of the of packaged drugs.43 that an increase in temperature could drug). Generally, phosphate buffer saline As a PLGA nanoparticle, PEG-PLGA shift the band located at 1092 cm-1 to (PBS) with a pH of 7.4 is used as a drug shows a slightly faster drug release.48 a lower frequency and represented the release medium to observe the release Bertrand et al. showed that further interaction via hydrogen bonds between of nanoparticles in vitro. RPM is known increasing PEG density did not result PO2- of the lipid and Piperine molecules. to be unstable in PBS due to the alkaline in additional benefits, so that surface The percentage of Piperine release varied hydrolysis of the lactam ring, which causes modification could only change the around 3.47-4.33%, where the liposome ring opening.42 biodistribution to a certain extent.54 In release reached its maximum value after contrast, PEGylation can accelerate drug two weeks.57 PEG-PLGA Nanoparticle release due to increased degradation of In developing cancer or tumor drugs, PLGA nanoparticles and associated with PIPERINE AS AN ANTICANCER encapsulation in biodegradable the hydrophilic nature of the PEG chain, AGENT IN BREAST CANCER polymeric nanoparticles has shown a which absorbs water and stimulates the promising solution for delivering various decomposition of the PLGA chain.55 hydrophobic drugs, both through active Anti-proliferation and passive targeting, by increasing the Liposome Several prior studies have shown that permeability and retention effects.50–52 Liposomes are round vesicles Piperine has anti-proliferative effects on Piperine with stable aqueous polymeric characterized by an internal watery breast cancer both in vitro and in vivo. nanoformulation reduces the nonspecific cavity and a lipid bilayer. Liposomes have In vitro, Piperine has anti-proliferative toxicity of Piperine with targeted delivery synthetic amphiphiles or phospholipids effects on several breast cancer cell lines and increased Piperine bioavailability by structure combined with sterols, such representing the characteristics of several slowing down metabolism and systemic as cholesterol, to affect membrane types of breast cancer subtypes. Piperine elimination. Among all the biodegradable permeability.56 Liposome diameter ranges has an anti-proliferative effect on the polymers used as means of drug delivery, from 25 nm to more than 1000 nm. The SKBR3 cell line, which overexpressed 58 poly (ethylene glycol) (PEG) and PLGA diameter is relatively small to penetrate the Her2. Previous studies had also have shown an increased therapeutic endothelial tumor and extravasation into demonstrated the anti-proliferative ability effect of hydrophobic drugs.43 In fact, the tumor interstitial. As a drug delivery of Piperine in breast cancer cell lines the United States Food and Drug medium, drugs that are fat-soluble MDA-MB-468, MDA-MB-231, and BT- Administration (FDA) has approved (hydrophobic) will be deposited into the 549, which have the characteristics of 44,60 for both of these polymers to be used in double lipid layer of the liposomes, while the TNBC subtype. Piperine also has humans and has been used in clinical trials drugs that are water-soluble or hydrophilic anti-proliferative effects on MCF-7 and because of their biocompatibility and high will be covered in the center of the liquid T47D, which represent luminal subtype 43,59 bioavailability.53 liposome.57 Burande et al. showed that breast cancer. In vivo, Piperine has According to the release pattern, the efficiency of Piperine encapsulation anti-proliferative effects in mouse models 61,62 Pachauri et al. showed that Piperine (PIP) in PIP liposomes, non-targeted PTX of breast cancer 4T1 and EMT6/P. has an initial burst release in the first 5 & PIP liposomes, and CTX decorated The inhibitory ability of Piperine was hours. This initial burst release of Piperine targeted liposomes was 56% ± 2.64, 35% ± also characterized by good IC50 values, is associated with the rapid release of 2.04, and 31% ± 2.68.45 namely 50um in in-vitro studies and 58,61,62 adsorbed Piperine on the PEG-PNP Pentak et al. used the FT-IR technique 232um to 870um in in-vivo studies.

Published by Bali Medical Journal | Bali Medical Journal 2021; 10(2): 608-616 | doi: 10.15562/bmj.v10i2.2247 611 REVIEW

Table 2. Summary of Piperine Effects and Its Mechanism in Breast Cancer apoptosis in vitro in several types of breast cancer cell lines and in vivo. Piperine was Potential Effect Mechanism Reference able to induce apoptosis in the Her2- 58 Anti-proliferation  Depressed the protein-related G1 phase 43,44,58–62 overexpressed SKBR3 cancer cell line. expression (CDK4, E2F-1, cyclin D3) Additionally, Rad et al. and Greenshields  Depressed the protein-related G2 phase et al. showed that Piperine administration expression (CDK1, cyclin B, Cdc25C) caused apoptosis in the breast cancer cell  Induction of p21 protein expression line MDA-MB-468 while Khamis et al. and Pachauri et al. showed a similar effect Apoptosis induction  Activate the caspase-3 43,44,58,60–62 on MCF-7 and T47D.43,44,59,60 Meanwhile,  PARP Cleavage in vivo research by Talib et al. showed that  Mitochondrial pathway 425 um of Piperine was able to induce  Inhibition of kinase B protein signaling apoptosis in EMT6 / P breast cancer model pathway mice after 48 hours.62 Finally, research by Lai et al. showed that Piperine was able  43,58,60,61 Anti-migration or anti- Depressed of MMP-2, MMP-9, dan MMP- to induce apoptosis in the breast cancer metastasis 13 expression model 4T1.61,62 Several mechanisms explain the Chemo-enhancer or  Block EGFR signaling 42,43,45,58–61, induction of apoptosis by Piperine. chemosensitizer  Depressed the P-gp expression 63,64 One of the most common mechanisms 58  Inhibit phosphorylation of survivin and is increased caspase-3 activity. p65 Administration of Piperine decreases the integrity of the mitochondrial membrane, Cytotoxic agent  Excrete cathepsin 44,58,65 which results in cytochrome C and Smac  Depressed GLO1 activity / DIABLO release into the cytoplasm.  Depressed the potential of mitochondrial This event induces the formation of the membrane apoptosome and the activation of the caspase-9 initiator. Meanwhile, Smac / Anti-angiogenesis  Depressed the VEGF expression 62 DIABLO causes apoptosis after binding Immunity response  Increased the IFN-y and IL-2 expression 62 with the inhibitor of apoptosis proteins modulator (IAPs), eliminating the apoptosis brake. Inhibit the self-renewal  Inhibit mammosphere formation 66 The activation of caspase-3 induces degradation of the protein poly (ADP- stem cell ability  Depressed the ALDH1 expression ribose) polymerase (PARP), which then  Inhibit Wnt signaling pathway culminated in protein, nucleic acid, and membrane disintegration.58 Piperine also induces apoptosis The inhibitory effect of Piperine did not contrast, E2F-1 is required in the G1/S through the DNA damage pathway decrease even though it was delivered by phase transition process, while the CDK1 observed from the examination of nanoparticles.44 and cyclin A or B complexes are required terminal deoxynucleotidyltransferase- Piperine inhibits breast cancer cell in the G2/M phase transition. Besides, a mediated dUTP-biotin nick-end labeling proliferation by arresting the cell cycle. decrease in Cdc25C, a phosphatase that (TUNEL). Piperine induces apoptosis by Several previous studies had shown that plays a role in mitosis and phase transition suppressing FAS expression, mainly by Piperine administration resulted in cell of G1/S and G2/M and an increase in p21, blocking the ERK1 / 2 signaling pathway, cycle arrest in-vivo and in-vitro, which a CDK inhibitor also causes cell cycle which leads to suppression of SREBP-1c was characterized by accumulation of cells disruption in cancer cells.60 expression.58 Khamis et al. and Pachauri in the G2/M or sub G0/G1 phases and a et al. also found a similarity which was decrease in the number of cells in the S Apoptosis induction marked by an increase in the expression phase.59,61 Cell cycle arrest occurs due to Cancer cells are known to have immortal of the pro-apoptotic protein Bax and a decreased expression of crucial proteins properties due to their ability to regulate decrease in the expression of the anti- in cell cycle regulation such as CDK4, intracellular regulation and their apoptotic protein Bcl2.43,59 Furthermore, E2F-1, cyclin D3, cyclin B, Cdc25C, and environment to support their growth. So Rad et al. and Greenshields et al. showed increased p21 expression to Piperine that the targeted anticancer agents can that Piperine reduced the expression administration.43,60 Cell cycle activity in induce apoptosis in cancer cells. Several of phosphatidylinositol-3-kinase/Akt the G1 phase requires a bond between previous studies supporting this potency (protein kinase B), which is a pro-survival type D cyclin and CDK4 and CDK6. In have shown that Piperine can induce signaling pathway in cancer cells.44,60

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Anti-Metastatic Effect increased anti-proliferative, cytotoxic, was even able to increase the effectiveness Piperine also has the ability as an anti- and apoptotic effects of on the of TRAIL-based anticancer agents by migration and anti-metastatic agent SKBR3 breast cancer cell line compared to suppressing survivin expression and p65 in breast cancer. Do et al. showed that the cell line treated with paclitaxel alone.58 phosphorylation.63 adding 25 to 50um Piperine could inhibit Pachauri et al. reported that Piperine the migration of breast cancer cells in the increased the effectiveness of paclitaxel Cytotoxic Effect SKBR3 breast cancer by 35.6% to 57.6%.58 therapy in both paclitaxel-sensitive and Piperine can induce cytotoxic effects on Greenshields et al. showed that 50um paclitaxel-resistant breast cancer cell line cancer cells through several mechanisms. Piperine inhibited metastasis in breast MCF-7. This combination provided a Research by Do et al. showed that Piperine cancer cell line MDA-MB-231, while good proliferation inhibitory effect but induced cytotoxicity in the SKBR3, BT- Pachauri et al. showed that it inhibited at a lower dose, thereby reducing the 474, and MDA-MB-231 cancer cell lines the migration of MCF-7 breast cancer risk of toxicity to paclitaxel therapy.43 On with basal Her2 expression.58 Rad et al. cell lines with an IC50 at 130um.43,60 the other hand, Motiwala et al. showed also showed that Piperine had a cytotoxic Molecularly, the metastasis in breast that Piperine has a synergistic effect with effect on the breast cancer cell line MDA- cancer cell lines can be inhibited by paclitaxel as a chemotherapeutic agent MB-468, while Schmidt et al. reported a

Piperine due to decreased expression of in breast cancer. This was demonstrated similar effect on MCF-7 with an IC50 value MMP-2 and MMP-9.43,58,60 by their ability to inhibit the growth of of 94.5 um.44 There were also 27.41% of In-vivo studies also showed similar breast cancer cell line MCF-7.64 Burande cells whose growth was inhibited which findings. Lai et al.’s study demonstrated et al. also showed that the combination was marked by a decrease in mitochondrial the ability of Piperine as an anti- of Piperine and paclitaxel had a better membrane potential by 1.17 times.65 metastatic agent through the inhibition of cytotoxic effect than paclitaxel alone.45 The ability of Piperine to induce migration of the 4T1 breast cancer model The mechanism of the synergistic effect cytotoxic effects in breast cancer resulted mice caused by decreased expression of of Piperine and paclitaxel is not clearly through several mechanisms. Piperine can MMP-13 and MMP-9 proteins. In this understood, but it seems to be associated induce cytotoxic effects through its entry study, pulmonary metastasis was also with EGFR blockade.43,58,64 into the lysosomal membrane of cancer successfully inhibited. The ability of Khamis et al. reported that Piperine cells, which in turn causes the release of Piperine to inhibit metastases in vivo is had a synergistic effect with tamoxifen cytotoxicity-inducing cathepsins. Besides, due to the inhibitory effect of Piperine with a good combination index (CI) Piperine also reduces the potential of the on the expression of cycloxygenase-1, (0.279), indicating good anti-proliferative mitochondrial membrane by increasing oxygenase, and p450 isoenzyme.61 and cytotoxic effects on breast cancer cell ROS production. This condition causes The inhibition of metastasis and lines MCF-7 and T47D.59 Piperine also DNA damage and apoptosis induction migration by Piperine is largely due to enhances the effect of an interventional which lead to cell death. Piperine also decreased MMP protein expression. MMP radiology agent such as gamma-ray reduces Glyoxalase I (GLO1) activity by is one of the important proteins involved radiation. Greenshields et al. reported that 1.24 times. GLO1 is an enzyme that plays in the metastasis process of cancer Piperine increased the anti-proliferative a role in converting MG to D-lactate. cells. MMP plays a role in degrading effect of gamma-ray radiation on TNBC Several previous studies have shown that the extracellular matrix in the basal cancer cells.60 Additionally, Piperine this enzyme plays a role in regulating the membrane layer of cancer cells, allowing also has a synergistic effect on the proliferation, migration, metabolism, cancer cells to migrate to other organs developmental chemotherapy agent and survival of cancer cells. Therefore, via blood vessels.61 Piperine suppresses rapamycin as reported by Katiyar et al. the inhibition of GLO1 reduces the pro- EGF-induced MMP-9 by suppressing Piperine was able to increase rapamycin tumorigenesis activity of cancer cells.44,58,60 transcriptional activation of the MMP-9 absorption by decreasing P-gp expression. promoter consisting of an Nf-Kb site and The administration of rapamycin with Anti-angiogenic two AP-1 sites. Piperine suppressed the Piperine also showed potent cytotoxic Angiogenesis is a potential therapeutic transcriptional activity of Nf-Kb and AP-1 activity in the breast cancer cell line MDA- target in cancer therapy by limiting the through inhibition of Akt expression and MB-231 at a lower than standard dose.42 number of nutrients and oxygen supply the MAPK and phosphatidylinositol-3- Also, Abdelhamad et al. demonstrated to cancer cells. Talib et al. showed kinase signaling pathways.58,60 the effect of Piperine in combination with that Piperine capable of inducing a TRAIL-based anticancer agent. This anti-angiogenic activity, which was Chemosensitizer combination produced a synergistic effect characterized by a significant reduction in Piperine can also increase the effect that manifested as growth inhibition and vascular endothelial growth factor (VEGF) of some chemotherapeutic agents or apoptosis induction through increased level to 177.5 pg / mL to the control group interventional radiology on breast expression of caspase-3 and PARP (890.4 pg / mL). VEGF is a protein that is cancer therapy. Several previous studies cleavage, inducing cell cycle arrest in the responsible for the angiogenesis process. have shown that Piperine increased the G2 / M phase MDA-MB-468 and MDA- Expressed VEGF will attach to the VEGF- effectiveness of paclitaxel. Do et al. showed MB-231 breast cancer cell lines. Piperine 1 and VEGF-2 receptors that are attached

Published by Bali Medical Journal | Bali Medical Journal 2021; 10(2): 608-616 | doi: 10.15562/bmj.v10i2.2247 613 REVIEW

to the vascular endothelial cells. These by inhibiting the Wnt signaling pathway. http://stacks.iop.org/1751-8121/44/ bonds will initiate the migration and As is well known, Wnt signaling pathways i=8/a=085201?key=crossref. abc74c979a75846b3de48a5587bf708f proliferation of endothelial cells, which are often dysregulated in breast cancer. 4. Barron JJ, Quimbo R, Nikam PT, Amonkar 67,68 then form new blood vessels. The Wnt signaling pathway induces MM. Assessing the economic burden of breast The ability of Piperine to provide breast tissue tumor cells originating from cancer in a US managed care population. Breast anti-angiogenesis effects indicates an stem cells or progenitor cells through the Cancer Res Treat. 2008;109(2):367–77. anticancer mechanism in inhibiting LRP5/6-mediated beta-catenin activation 5. Sun L, Legood R, Dos-Santos-Silva I, Gaiha SM, Sadique Z. Global treatment costs of breast 69 the supply of nutrients and oxygen to pathway and the mTOR pathway. So, cancer by stage: A systematic review. PLoS One. tumor cells so that it can suppress tumor the suppression effect of Piperine works 2018;13(11):1–14. cell growth. However, the findings of specifically on stem cells/progenitor cells 6. Stojanović-Radić Z, Pejčić M, Dimitrijević M, Piperine’s anti-angiogenesis ability in this of breast tissue so that it does not affect Aleksić A, Anil Kumar N V., Salehi B, et al. 66 Piperine-A Major Principle of Black Pepper: A study were unable to provide complete differentiated breast tissue cells. review of its bioactivity and studies. Appl Sci. 62 tumor regression. 2019;9(20):1–29. CONCLUSIONS 7. Rather RA, Bhagat M. Cancer chemoprevention Immuno-modulatory Effect and piperine: Molecular mechanisms and The immune system is one factor that Piperine is a potential anticancer agent therapeutic opportunities. Front Cell Dev Biol. 2018;6(FEB):1–12. plays a role in cancer progression, in breast cancer because it has anti- proliferative effects, induces apoptosis, 8. Lingli Q. Advance on delivery nanocarriers especially breast cancer. In general, the of piperine: Nanoparticles. E3S Web Conf. cancer condition will encourage a shift in anti-migration or anti-metastasis, 2019;131:3–6. the immune system’s balance to be more chemosensitizers, cytotoxic agents, 9. Yardley DA. Drug Resistance and the Role of Combination Chemotherapy in Improving inclined towards a Th2 response which is anti-angiogenesis, immune response modulators, and inhibits self-renewal Patient Outcomes. Int J Breast Cancer. dominated by the cytokine IL-4. Several 2013;2013:1–15. previous studies have shown that Piperine abilities. The potential delivery agents for 10. Nikolaou M, Pavlopoulou A, Georgakilas AG, could act as a modulator of the immune Piperine administration include PLGA, Kyrodimos E. 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