Special Reviews

Juntendo Medical Journal 2021. 67(2),131-139 The Potential as New Treatment Agent of -A Metabolized from by Gut Microbiota in Cancer

TOSHIYUKI OKUMURA＊1) 2)

＊1)Department of Womenʼs Health,Eberhard Karls University of Tuebingen,Land Baden-Württemberg,Germany, ＊2)Department of Obstetrics and Gynecology,Juntendo University Faculty of Medicine,Tokyo,Japan

Cancer is the leading cause of death in Japan. Cancer is treated by multidisciplinary therapy such as surgery, chemotherapy,molecular target therapy and radiotherapy. However,almost of advanced cancer relapse after treatment. The relapsed cancer acquires resistance to the therapeutic agents we already used. The prognosis of relapsed cancer is very poor. Therefore,new treatment agents are needed urgently. In recent years metabolites derived from natural foods are focused as new therapeutic agents of cancer diseases. The metabolites are expected to cause less side effect than chemotherapy and have same effect as chemotherapy to cancer. Furthermore therapeutic agents from natural foods are Ellagic acid is metabolite derived from nuts,berries,and . Ellagic acid is known to have anticancer effects,due to affecting apoptosis,cell proliferation and cell cycle regulation. Some of metabolites from ellagic acid also have anticancer effect. are gut derived bacterial metabolites from ellagic acid. Many articles reported that Urolithin-A has anticancer effect for many cancers. Urolithin-A was reported to regulate p53 protein, caspase 3, caspase 7, AKT, aromatase and PARP in some cancers. Actin polymerization is regulated via Rac1 pathway by Urolithin-A in endometrial cancer. Furthermore, proliferation of many cancer cell lines is suppressed by UA. Safety of UA was investigated by using Rat model. The article suggested Urolithin-A has less genotoxicity compared with cyclophosphamide. Thus,Urolithin-A might be able to have a role as new treatment agent to cancer. Key words: cancer,gut microbiota,ellagic acid,Urolithin-A,new cancer therapeutic agent

Cancer growth after adjuvant chemo therapy. However almost of all advanced cancer will be relapsed after The cause of cancer has not yet been clarified. treatment. The prognosis of advanced or relapse However population of cancer patient is increasing cancer is poor still now. The new treatment agent is year by year. It is common that staging of cancer is needed to be identified urgently. divided according to spread of cancer. Treatment plan for cancer is choose depends on progress of Ellagic acid cancer. Almost of all cancers are treated by surgery,chemotherapy,radiotherapy,molecular Recently component purified from natural food is target therapy,or combination of these therapeutic expected to be used as new treatment agent to approaches. These molecular target therapies are cancers. Ellagic acid is known as a metabolite derived used as treatment agent or maintenance agent. from seeds (walnuts,almonds),fruits (persimmons, Maintenance agent is used to suppress tumor berries,peaches,palms,and ) and

Toshiyuki Okumura Department of Obstetrics and Gynecology,Juntendo University Faculty of Medicine 2-1-1 Hongo,Bunkyo-ku,Tokyo 113-8421,Japan TEL: +81-3-3813-3111 E-mail: [email protected] Triannual Meeting of the Juntendo Medical Society“MedicalResearch Update”〔The meeting was originally scheduled to be held on May 16, 2020,but was canceled due to COVID-19 pandemic〕 〔Received July 30, 2020〕〔Accepted Jan. 22,2021〕

Copyright © 2021 The Juntendo Medical Society. This is an open access article distributed under the terms of Creative Commons Attribution Li- cense (CC BY),which permits unrestricted use,distribution,and reproduction in any medium,provided the original source is properly credited. doi: 10.14789/jmj.2021.67.JMJ20-R17

131 Okumura T: The potential as new treatment agent of Urolithin-A metabolized from ellagic acid by gut microbiota in cancer

Ellagitannins Seeds（walnuts, almonds）, Fruits（berries, palms, pomegranate, etc.） GM Vegetables Vescalagin

Urolithin－D Unknown Urolithin－M5 GM DE GM Urolithin－M6 Unknown DE Ellagic acid

Urolithin－C Urolithin－E Urolithin－M7

Unknown DE

GM：Gut microbiota Urolithin－A DE：Dehydroxylase enzyme CYP：Cytochrome P450 DE CYP enzyme

Urolithin－B

Figure-1 Metabolite way of seeds,fruits and vegetables to Urolithin-A Some gut microbiotas involved in metabolite way are clarified,but not all. The gut microbiota which produces Urolithin-A from Urolithin-M7 is not found.

vegetables. 1) Ellagic acid derived from Ellagitan- on antioxidant function of Ellagic acid to investigate nins (Punicalagin,Corilagin and Vescalagin) 2)(Fig- neuroprotective function of Ellagic acid. The ure-1). Ellagic acid is known to have antioxidant symptom of dementia and brain damage induced by function,anti-inflammatory activity,neuroprotec- streptozotocin was decreased by Ellagic acid in tive function and anticancer effect. Ascorbic acid rats. 12) Motor impairment is improved by Ellagic and α-tocopherol are well known as antioxidant. acid due to reducing neuroinflammatory bio- Indeed,articles shows that Ellagic acid is able to markers (IL-1β and TNF-α) in lesioned rats. On eliminate activation of peroxyl radicals,nitrogen the other hand,the brain is protected against free dioxide,hydroxyl radical and peroxynitrite. 3) 4) radical induced neural damage by Ellagic acid. 13) Intriguingly,Ellagic acid is shown to reduce the Studies have shown that Ellagic acid might be able amount of 8-oxo-2ʼ-deoxyguanosine which is one of to have role as anticancer agent by regulating marker of oxidative DNA damage after DNA carcinogenesis,apoptosis,induced DNA damage damage induced by oxidative stress. 5) 6) Pathophy- due to oxidative stress and angiogenesis in various siological event of inflammation is related to cancers. Ellagic acid increased IL-6 and downregu- oxidative stress. 7) Ellagic acid deactivates AP-1 lated the expression level of pERK1/2,pSTAT3 and and MAPK that are induced by TNF-α and IL-1β. pAkt in PC3 cells which is androgen-independent However,NF- κB is activated by Ellagic acid. 8) 9) prostate cancer cell line. 14) Ellagic acid induced Furthermore,Ellagic acid regulates COX-2 mRNA apoptosis by caspase-3 activation in the transgenic expression by inhibition of ROS production that rat for prostate adenocarcinoma model. Ellagic acid inhibits NF-κB activity. 10) The regulator of COX-2 induced apoptosis by increasing Bax/Bcl-2 ratio expression is NF-κB. 11) The effect of Ellagic acid as and cell cycle related proteins cdk-2,cyclin E,p21 a neuroprotective agent has been investigated by and p27,but not cdk-1 and cyclin D1 in androgen using various assays. Almost of all articles focused dependent prostate cancer cell line,LNCaP. 15) Cell

132 Juntendo Medical Journal 67(2),2021

proliferation of HCT-15 colon adenocarcinoma cells the lactone rings to produce luteic acid. Three was decreased by Ellagic acid. Ellagic acid tetrahydroxy-urolithins,Urolithin-D,Urolithin-M6 decreased cell viability and induced cell cycle arrest and Urolithin-E are produced from Urolithin-M5. in G2/M. Cyclin D1 is decreased by Ellagic acid in Trihydroxy-urolithins,Urolithin-C and Urolithin- HCT-15 cells. Furthermore,Ellagic acid inhibited M7 are then transformed from tetrahydroxy-uroli- the PI3K/Akt pathway in HCT-15 cells. The thins. Trihydroxy-urolithins finally lead to the main expression level of caspase-3, cytochrome C and Bax metabolites,the dihydroxy-urolithin which is were increased by Ellagic acid. 16) Ellagic acid had known as Urolithin-A and the mono-hydroxy antiproliferative effect by inducing cell cycle arrest urolithin that is known as Urolithin-B 23)(Figure-1). in G0/G1 in MCF7 cells,a human breast cancer cell The literature about the bacterial species responsi- line through regulation of TGF-β/Smads signaling ble for urolithin production from ETs,or other pathway. 17) Ellagic acid showed decrease of chemo- EA-derived compounds are deficient. Recently, resistance to cisplatin in A2780CisR,a human Gordonibacter urolithinfaciens (DSM 27213T) and ovarian cancer cell line acquired resistance to G. pamelaeae (DSM 19378T) producing urolithin cisplatin by intermittent treatment with cisplatin were found in human feces. These bacteria for 26 weeks. 18) Ellagic acid inhibited growth of belonged to the family Coriobacteriaceae. 24) 25) human endometrial cancer cell line by decreasing These microbes generated Urolithin-M5,Urolithin- sodium-hydrogen antiporter 1 expression level, M6,and Urolithin-C. However,Urolithin-A and activity of Na+/H+ exchanger,glucose uptake, Urolithin-B were not produced in pure cultures. 24) lactate release and cytosolic pH. 19) HeLa cells, Other bacteria which are needed to produce human cervical cancer cell line was decreased cell Urolithin-A and Urolithin-B from precursor are proliferation by Ellagic acid by downregulation of still unknown. Studies had shown that absorption of Akt/mTOR signaling pathway via increase of Ellagic acid was poor. (Figure-1) However,Uroli- IGFB7. 20) Ellagic acid had a role as anticancer effect thin-A and -B were reported to be distributed in glioblastoma. Ellagic acid decreased cell prolifera- throughout colon,urine,feces,plasma and prostate tion and viability in U118 and U87,human glioblas- tissues following intake of foods or juices enriched toma cell line. Ellagic acid induced cell cycle arrest Ellagic acid. 26) 27) Urolithin-A and -B decreased in S phase in those cell lines. Furthermore,Ellagic endometrial cancer cell proliferation compared with acid showed same effect in glioblastoma xenograft other compounds derived from ,antho- model. Ellagic acid inhibited tumor growth by cyanin,sugar,lignan and fiber. 28) Therefore,respon- decreasing MMP-2, MMP-9, Snail, Bcl-2, cdk-2, sibility for the health effect of Ellagic acid have been cdk6 and cyclinD1 and increasing E-cadherin suggested to be Urolithin-A and -B. expression level. Ellagic acid inhibited Notch and Akt signaling pathway. 21) Ellagic acid increased The effect of Urolithin-A apoptosis mediated ROS in B-lymphocytes taken from patients had chronic lymphocytic leukemia by 1. Urolithin-A induces cell cycle arrest in cancer regulating mitochondrial pathway. 22) cell Cell growth and proliferation are controlled by Urolithins cell cycle. Cell cycle is divided two main cycle. One is interphase which is subdivided into G1,S,and G2 Urolithins are derived from Ellagic acid by gut phase. The other is mitosis phase (M). Cell microbiota and divided into some subtypes. How- prepares for DNA synthesis in G1 phase. DNA ever,it is not clarified if urolithins are able to be replication is occurred in S phase following G1 derived from directly or needed to be phase. Cell prepares for M phase in G2 phase. In derived via Ellagic acid. In the metabolite pathway addition,there is one more phase,G0. Cell in G0 of urolithins from Ellagic acid,the first step is the keeps proliferation ability and starts to progress cell producing pentahydroxy-urolithin (Urolithin-M5) cycle from G1 phase again by growth factor. Cell that is a key intermediate product in the process of cycle is regulated via many pathways. The path- different urolithins production by opening one of ways regulating cell cycle are controlled by

133 Okumura T: The potential as new treatment agent of Urolithin-A metabolized from ellagic acid by gut microbiota in cancer

phosphorylation and dephosphorylation of many Urolithin-A had a role similar to estrogen agonist in proteins. Cyclin A,Cyclin D1 and Cyclin E have role endometrial cancer cell line by binding to ERE. 28) to enter cell into S phase from G1 phase. Cyclin D1 Intriguingly,Urolithin-A had both effect estrogenic activates Retinoblastoma (Rb) protein by phos- and antiestrogenic in an estrogen receptor positive phorylation. Cyclin A and Cyclin E that are induced human breast cancer cell line,MCF7. 31) Further- by E2F transcriptional factor released by phos- more,Urolithin-A and Urolithin-B showed anti- phorylated Rb protein activate Cdk2 by phosphory- aromatase activity in a human estrogen receptor lation on T160. After activation of Cdk2,Cyclin A positive aromatase-overexpressing breast cancer and Cyclin E make complex with Cdk2 cell line,MCF7aro. These two compounds respectively. 29) Activated Cdk2 by Cyclin A and decreased elevation of cell proliferation of MCF7aro Cyclin E induce cell cycle progression into S phase by treatment with testosterone or estrogen. 32) from G1 phase. A protein complex called origin Urolithin-A increased CDKN1A and p21 protein recognition complex,ORC binds to the origin of expression level in human prostate cancer cell, replication site. Furthermore,chromatin licensing LNCaP. The cell cycle of LNCaP treated with and DNA replication factor 1 (CDT1),cell division Urolithin-A was arrested in G1. 33) On the other cycle 6 (CDC6) and minichromosomal maintenance hand,the cell cycle of human androgen independent family proteins (MCM2-7) bind to the ORC. This prostate cancer cell lines,DU-145 and PC-3 cells protein complex is called Pre-ORC. This complex is were arrested in G2/M phase by treatment with inactivated during G1 phase. Therefore,DNA Urolithin-A. 34) The difference between these stud- replication is not occurred in G1 phase. Cyclin E- ies was cell line. One study used androgen Cdk2 complex phosphorylates MCM2-7 and dependent cell line. The other used androgen recruits Cdc45 known as MCM helicase activator to independent cell line. Furthermore,the concentra- unwind DNA in transition between G1 and S. tion of Urolithin-A also was difference between Furthermore,the complex recruits DNA polymer- these studies. The effect of Urolithin-A on arresting ase to replication site. After DNA replication,Cyclin cell cycle might vary depending on whether the cell A-Cdk2 complex phosphorylates CDT1. Phos- line is hormone dependent or independent. How- phorylated CDT1 is not able to bind to ORC. 30) ever,the effect of Urolithins on hormone is still Cyclin B1 is important protein to regulate G2/M unclear. More studies will be needed to clarify the cell cycle. During S phase,Cyclin B1 protein is function of Urolithin-A on hormone. Urolithin-A accumulating. Cyclin B1 binds to Cdk1 in the end of inhibited cell growth in colorectal cancer cell lines, G2. This complex is inactivated by phosphorylation W480 and HT-29. Urolithin-A upregulated gene on T14 and 15 of Cdk1 protein. Wee1 and Myt1 are expression of CDKN1A encoding p21 protein. 35) kinases. These kinases inactivate Cdk1. The activa- Increase of p21 protein is known to arrest cell cycle tion of Cyclin B1-Cdk1 complex is indispensable for in G1 and block cell cycle progression into S1 phase. progression cell cycle from G2 to M phase. Cdc25c p53-dependent G1 cell cycle arrest participates dephosphorylates phosphorylation of T14 in Cdk2 with p21 protein. 36) Urolithin-A demonstrated anti- to activate Cyclin B1-Cdk2 complex. Furthermore, proliferative effects in both p53-dependent and the activated complex can activate Cdc25c by independent human colorectal cancer cell line, phosphorylation. Phosphorylated Cdc25c inacti- HCT116 p53 WT and HCT116 p53 -/-. Urolithin-A vates Wee1. This activated Cyclin B1-Cdk2 com- induced cell cycle arrest in G2/M phase in these cell plex regulates formation of the mitotic structure line. However,absence of p53 inhibited anti-prolif- such as mitotic spindle formation. Urolithin-A erative effect in HCT116 cell. 37) Urolithin-A inhib- induced cell cycle arrest in G2/M in human ited cell proliferation compared with other uroli- endometrial cancer cell line,Ishikawa cell and thins,Urolithin-B and Urolithin-C by inducing cell HEC1A cell. Urolithin-A upregulated the expres- cycle arrest at G2/M phase in human bladder sion of cyclin-B1,p21,phosphorylated-Cdk1 (on cancer cell line,UMUC3. The best treatment time T15) and CDC25B. Urolithin-A suppressed ERα, point to arrest cell cycle at G2/M phase was 24 but enhanced ERβ expression level. On the other hours,not 48 hours. In this study,the effect of hand,ER α and ERβ were inhibited by E2 treatment. Urolithin-A on PI3K/AKT and MAPKs signaling

134 Juntendo Medical Journal 67(2),2021

pathway which were implicated in cell survival and carcinoma and prevented pathway reactivation in proliferation was investigated in UMUC3 cells. vivo and invitro . 43) Phosphorylated-Akt,phosphorylated-ERK,phos- phorylated-SAPK/JUK and phosphorylated-p38 3. Urolithin-A inhibits cancer metastasis were evaluated by western-blotting. 38) The PI3K/ In recent years,some studies showed autophagy Akt pathway assists cell to survive by permitting might promote MMP-9 and regulate cancer incompetent cells to overcome cell cycle check- metastasis. 44)-46) Urolithin-A decreased MMP-9 points and inhibits apoptosis. 39) Cellular processes, activity in human colorectal cancer cell line,sw620. proliferation,survival and prevention of apoptosis Indeed,this study showed that motility and are regulated by ERKs. On the other hand, invasion of sw620 cell were inhibited by Urolithin-A apoptosis and cell differentiation are induced by treatment. Furthermore,Urolithin-A induced JNKs and p38 MAPKs. 40) Phosphorylation of Akt autophagy in sw620 cell. This study showed and ERK were decreased by treatment with metastasis inhibition by Urolithin-A was sup- Urolithin-A in UMUC3 cell. pressed by inhibition of autophagy by 3-methylade- nine (3-MA). 47) Rac1 is well known as regulator of 2. Urolithin-A induces apoptosis in cancer cell actin polymerization to form lamellipodia that is Cells are kept healthy condition by some mecha- essential for cell motility. 48) 49) Urolithin-A nism. One of mechanism keeping cell healthy increased globular actin/filamentous actin ratio condition is apoptosis. Apoptosis is induced when (G/F actin ratio) in human endometrial cancer cell cell has problems such as DNA damage. Eliminating line,Ishikawa cell. Elevation of G/F actin ratio cells which have DNA damage prevents that cell means that actin depolymerization is induced and growth is disordered. Urolithin-A increased apop- lamellipodia formation is inhibited. Urolithin-A totic cell in human androgen independent prostate inactivated Rac1 protein in Ishikawa cell. The cancer cell line,in DU-145. 34) The elevation of cell function of Urolithin-A on actin dynamics was same proliferation by dihydrotestosterone (DHT) was as NSC,which was Rac1 inhibitor. PAK1 is one of decreased by Urolithin-A in human androgen protein existing in downstream of Rac1 pathway. dependent prostate cancer cell line,LNCaP. Intrigu- Urolithin-A inactivated PAK1 as well in Ishikawa ingly,Urolithin-A inhibited recruitment androgen cell. Furthermore,wound healing assay showed receptor from cytosolic to nucleus. 41) Urolithin-A that Urolithin-A inhibited cell motility in Ishikawa decreased cell proliferation in human anaplastic cell. 50) Urolithin-A inhibited cell motility by regulat- large cell lymphoma cell lines,KARPAS-299 and ing Akt pathway in human pancreatic cancer cell MAC-2A,and human leukemia cell lines,MOLT-4 line,BxPC3,MiaPaCa2 and PANC1. 43) and HL-60. Urolithin-A increased apoptotic cells in KARPAS-299 and MOLT-4 cells. Phosphorylated 4. Antioxidant effects of Urolithin-A in cancer Akt was decreased by Urolithin-A treatment in Ellagic acid and urolithins are well known to have these cell lines. The inactivation of Akt was antioxidant effects. β-catenin known to trigger an occurred by CK2 inhibition. Furthermore,cleaved- inflammatory response was decreased in human PARP was increased after treatment with Uroli- hepatocellular cancer cell line,HepG2. Inflamma- thin-A. 42) In MiaPaCa2,BxPC3 and PANC1 that are tory factors such as IL6,IL1 β,NF- κB,COX2 and human pancreatic cancer cell lines,Urolithin-A iNOS were decreased by Urolithin-A treatment in decreased cell proliferation and induced apoptosis. HepG2. The elevation of ROS formation by H2 O2 The elevation of apoptic cell was induced by treatment was decreased by Urolithin-A treatment decrease of phosphorylated Akt. Treatment with in HepG2 cell. This study demonstrated that Urolithin-A inhibited increase of tumor volume in Urolithin-A can inhibit the NF-κB signaling path- mice xenograft model by using MiaPaCa2 or way and suppress the release of inflammatory PANC1. In this xenograft model,cleaved-caspase 3 factors. 51) was increased by Urolithin-A treatment. This study demonstrated that Urolithin-A inhibited 5. Safety of Urolithin-A PI3K/AKT activation in pancreatic ductal adeno- Some studies reported safety of Ellagitannin

135 Okumura T: The potential as new treatment agent of Urolithin-A metabolized from ellagic acid by gut microbiota in cancer

containing foods. 52) 53) One study reported safety of Ellagic acid due to existing plentiful throughout Urolithin-A. The study measured body weight of colon,urine,feces,plasma and prostate tissues rats and weight of organs (adrenal,brain,heart, following intake of foods or juices enriched Ellagic kidney,liver,spleen,thymus,thyroid,ovary and acid. Some studies showed that Urolithin-A exerted uterus) after feeding with diet including Urolithin- anticancer effect through similar function to hor- A. Furthermore,this study investigated intake of mones. Some cancers are estrogen dependent. Urolithin-A by measuring radioactivity into blood, Intriguingly,one study showed Urolithin-A plasma,liver,kidney,carcass and GI tract. The induced cell cycle arrest in G2/M phase via study found that majority of Urolithin-A was regulation of important proteins that controlled cell located in GI tract. Genotoxicity assay was per- cycle in human endometrial cancer cell line. formed in this study. The experiments showed that Furthermore,Urolithin-A had role similar to Urolithin-A didnʼt have genotoxicity. 54) estrogen. 28) One study showed Urolithin-A inhib- ited actin polymerization by inactivation of Rac1 Summary pathway in human endometrial cancer cell. The study showed Urolithin-A inhibited cell motility as The patient has cancer is increasing year by year. well. 50) A lot of studies demonstrated that Uroli- Recently new treatment agents such as molecular thin-A induced cell cycle arrest and apoptosis in target therapy has been clarified. Indeed,progres- various type of cancer. Cell cycle regulation and sion free survival of cancers is extended by apoptosis regulation are intimately connected each maintenance by using new molecular target ther- other. One of major factor regulating cell cycle and apy. However,advanced cancer is replaced after apoptosis is DNA damage. 55) However,according to undergoing therapeutic approach. The prognosis of my knowledge,the study which can verify how to replaced cancer is very poor due to less options of Urolithin-A controls factor regulating cell cycle and therapeutic approach. Thus,new therapeutic agent apoptosis doesnʼ t exist. Thus,more studies are is needed to be developed urgently. Ellagic acid has needed to clarify how Urolithin-A regulates pro- anticancer effect in various cancer cell through teins that control cell cycle arrest and apoptosis. regulating various pathways. Ellagic acid is metabo- lized into some compounds. Urolithin-A is expected to be the most effective compound derived from

Fruits Seeds Vegetables

Gut microbiota

Ellagic acid

Gut microbiota

DNA damage？ Factor arresting cell cycle Urolithin－A Cell cycle arrest Factor inducing apoptosis Apoptosis

Cancer cell Other way？ Figure-2 How dose Urolithin-A regulate factor arresting cell cycle and inducing apoptosis? Many studies showed Urolithin-A induced cell cycle arrest and apoptosis in cancer cell. However,the studies couldnʼt refer the detail of mechanism to regulate factors of arresting cell cycle and inducing apoptosis. More studies should be performed to clarify the detail.

136 Juntendo Medical Journal 67(2),2021

Conclusion radical studies of ellagic acid,a natural phenolic antioxidant. J Agric Food Chem,2002; 50: 2200-2206. 4) Galano A,Misaela Francisco Marquez MF,Pérez-Gonzá- Urolithin-A might be able to become new lez A: Ellagic acid: an unusually versatile protector therapeutic agent for cancers. However,we need to against oxidative stress. Chem Res Toxicol,2014; 27: know how Urolithin-A controls proteins to regulate 904-918. cell cycle and apoptosis. The major factor regulat- 5) Böyük A,Onder A,Kapan M, et al: Ellagic acid ameliorates lung injury after intestinal ischemia-reper- ing cell cycle is DNA damage. Dose Urolithin-A fusion. Pharmacogn Mag,2011; 7: 224-228. cause DNA damage in cancer cell? Or can 6) Srinivasan P,Vadhanam MV,Arif JM,Gupta RC: A Urolithin-A induce cell cycle arrest and apoptosis rapid screening assay for antioxidant potential of natural by another way (Figure-2)? More studies have to and synthetic agents in vitro. Int J Oncol,2002; 20: 983- 986. be carried out to clarify detail role of Urolithin-A. 7) Biswas SK: Dose the interdependence between oxida- tive stress and inflammation explain the antioxidant Limitation paradox? Oxid Med Cell Longev,2016; 2016: 5698931. 8) Masamune A,Satoh M,Kikuta K,Suzuki N,Satoh K, Shimosegawa T: Ellagic acid blocks activation of I researched the function of Urolithin-A in pancreatic stellate cells. Biochem Pharmacol,2005; 70: endometrial cancer at Tuebingen University using 869-878. grant from Juntendo University. However I couldnʼt 9) González-Sarrías A,Larrosa M,Tomás-Barberán FA, show my data in this review because my article has Dolara P,Espín JC: NF- κB-dependent anti-inflamma- tory activity of urolithins,gut microbiota ellagic acid- not yet been published. I wrote this review to show derived metabolites,in human colonic fibroblasts. Br J the function of Urolithin-A for cancers. Nutr,2010; 104: 503-512. 10) El-Shitany N,El-Bastawissy EA,El-desoky K: Ellagic Acknowledge acid protects against carrageenan-induced acute inflam- mation through inhibition of nuclear factor kappa B, inducible cyclooxygenase and proinflammatory cyto- I thank Juntendo University,Faculty of Medicine, kines and enhancement of interleukin-10 via an antioxi- Graduatesʼ Association for the opportunity to dant mechanism. Int Immunopharmacol,2014; 19: 290- review my research. I would like to express my 299. 11) Chun KS,Cha HH,Shin JW, et al: Nitric oxide induces sincere gratitude to Juntendo University Graduatesʼ expression of cyclooxygenase-2 in mouse skin through Association for their grant that made it possible for activation of NF-κB. Carcinogenesis,2004; 25: 445-454. me to continue studying in Germany with my 12) Bansal N,Yadav P,Kumar M: Ellagic acid administra- family. I also thank distinguish professor Satoru tion negated the development of streptozotocin-induced memory deficit in rats. Drug Res (Stuttg),2017; 67: Takeda for supporting my research in Tübingen 425-431. University. Furthermore,I thank department of 13) Farbood Y,Sarkaki A,Dolatshahi M,Taqhi Mansouri obstetrics and gynecology staff in Juntendo Univer- SM,Khodadadi A: Ellagic acid protects the brain sity. I thank my wife and children for supporting against 6-hydroxydopamine induced neuroinflammation in a rat model of Perkinsonʼs disease. Basic Clin Neurosci, my life in Tübingen. 2015; 6: 83-89. 14) Eskandari E,Heidarian E,Amini SA,Saffari-Chaleshtori Disclosure statement J: Evaluating the effects of ellagic acid on pSTAT3, pAkt,and pERK1/2 signaling pathways in prostate cancer PC3 cells. J Cancer Res Ther,2016; 12: 1266- The author has nothing to disclose. 1271. 15) Kowshik J,Giri H,Kishore TK,Kesavan R,Vankudavath Reference RN,Reddy GB,Dixit M,Nagini S: Ellagic acid inhibits VEGF/VEGFr2,PI3K/Akt and MAPK signaling cas- cades in the hamster cheek pouch carcinogenesis model. 1) Derosa G,Maffioli P,Sahebkar A: Ellagic acid and its Anticancer Agents Med Chem,2014; 14: 1249-1260. role in chronic diseases. Adv Exp Med Biol,2016; 928: 16) Umesalma S,Sudhandiran Ganapasam S: Beneficial 473-479. influence of ellagic acid on biochemical indexes associ- 2) Aguilar-Zarate P,Cruz-Hernández MA,Montañez JC, ated with experimentally induced colon carcinogenesis. J Belmares-Cerda RE,Aguilar CN: Bacterial tannases: Cancer Res Ther,2017; 13: 62-68. Pro- duction,properties and applications. Revista 17) Chen HS,Bai MH,Zhang T,Li GD,Liu M: Ellagic acid Mexicana de Ingeniería Química,2014; 13: 63-74. induces cell cycle arrest and apoptosis through TGF-β/ 3) Priyadarsini KI,Khopde SM,Kumar SS,Mohan H: Free Smad3 signaling pathway in hu- man breast cancer

137 Okumura T: The potential as new treatment agent of Urolithin-A metabolized from ellagic acid by gut microbiota in cancer

MCF-7 cells. Int J Oncol,2015; 46: 1730-1738. 33) Sánchez-González C,Ciudad CJ,Izquierdo-Pulido M, 18) Engelke LH,Hamacher A,Proksch P,Kassack MU: Noé V: causes p21 up-regulation in prostate Ellagic acid and resveratrol prevent the development of cancer cells. Eur J Nutr,2016; 55: 1099-1112. cisplatin resistance in the epithelial ovarian cancer cell 34) Vicinanza R,Zhang Y,Henning SM,Heber D: Pome- line A2780. J Cancer,2016; 7: 353-363. granate Juice Metabolites,Ellagic Acid and Urolithin A, 19) Abdelazeem KNM,Singh Y,Lang F,Salker MS: Synergistically Inhibit Androgen-Independent Prostate Negative effect of ellagic acid on cytosolic pH regulation Cancer Cell Growth via Distinct Effects on Cell Cycle and glycolytic flux in human endometrial cancer cells. Control and Apoptosis. Evid Based Complement Alter- Cell Physiol Biochem,2017; 41: 2374-2382. nat Med,2013; 2013: 247504. 20) Guo H,Zhang D,Fu Q: Inhibition of cervical cancer by 35) González-Sarrías A,Núñez-Sánchez MÁ,Tomé-Carneiro promoting IGFBP7 expression using ellagic acid from J,Tomás-Barberán FA,García-Conesa MT,Espín JC: pomegranate peel. Med Sci Monit,2016; 22: 4881-4886. Comprehensive characterization of the effects of ellagic 21) Wang D,Chen Q,Tan Y,Liu B,Liu C: Ellagic acid acid and urolithins on colorectal cancer and key- inhibits human glioblastoma growth in vitro and in vivo. associated molecular hallmarks: MicroRNA cell specific Oncol Rep,2017; 37: 1084-1092. induction of CDKN1A (p21) as a common mechanism 22) García-Villalba R,Beltrán D,Espín JC,Selma MV, involved. Mol Nutr Food Res,2016; 60: 701-716. Tomás-Barberán FA: Time course production of uroli- 36) Piccolo MT,Crispi S: The dual role played by p21 may thins from ellagic acid by human gut microbiota. J Agric influence the apoptotic or anti-apoptotic fate in cancer. Food Chem,2013; 61: 8797-8806. Journal of Cancer Research Updates,2012; 1: 189-202. 23) Salimi A,Roudkenar MH,Sadeghi L, et al: Ellagic acid,a 37) Norden E,Heiss EH: Urolithin A gains in antiprolifera- polyphenolic compound,selectively induces ROS-medi- tive capacity by reducing the glycolytic potential via the ated apoptosis in cancerous B-lymphocytes of CLL p53/TIGAR axis in colon cancer cells. Carcinogenesis, patients by directly targeting mitochondria. Redox Biol, 2019; 40: 93-101. 2015; 6: 461-471. 38) Liberal J,Carmo A,Gomes C,Cruz MT,Batista MT: 24) Selma MV,Beltrán D,García-Villalba R,Espín JC, Urolithins impair cell proliferation,arrest the cell cycle Tomás-Barberán FA: Description of urolithin produc- and induce apoptosis in UMUC3 bladder cancer cells. tion capacity from ellagic acid of two human intestinal Invest New Drugs,2017; 35: 671-681. Gordonibacter species. Food Funct,2014; 5: 1779-1784. 39) Chang F,Lee JT,Navolanic PM, et al: Involvement of 25) Selma MV,Tomás-Barberán FA,Beltrán D,García- PI3K/Akt pathway in cell cycle progression,apoptosis, Villalba R,Espín JC: Gordonibacter urolithinfaciens sp. and neoplastic transformation: a target for cancer nov.,a urolithin-producing bacterium isolated from the chemotherapy. Leukemia,2003; 17: 590-603. human gut. Int J Syst Evol Microbiol,2014; 64 (Pt 7): 40) Wada T,Penninger JM: Mitogen-activated protein 2346-2352. kinases in apoptosis regulation. Oncogene,2004; 23: 26) Seeram NP,Henning SM,Zhang Y,Suchard M,Li Z, 2838-2849. Heber D: Pomegranate juice ellagitannin metabolites 41) Stanisławska IJ,Granica S,Piwowarski JP, et al: The are present in human plasma and some persist in urine Activity of Urolithin A and M4 Valerolactone,Colonic for up to 48 hours. J Nutr,2006; 136: 2481-2485. Microbiota Metabolites of Polyphenols,in a Prostate 27) Nuñez-Sánchez MA,García-Villalba R,Monedero-Saiz Cancer In Vitro Model. Planta Med,2019; 85: 118-125. T, et al: Targeted metabolic profiling of pomegranate 42) Cozza G,Gianoncelli A,Bonvini P, et al: Urolithin as a polyphenols and urolithins in plasma,urine and colon converging scaffold linking ellagic acid and tissues from colorectal cancer patients. Mol Nutr Food analogues: design of potent protein kinase CK2 inhibi- Res,2014; 58: 1199-1211. tors. ChemMedChem,2011; 6: 2273-2286. 28) Zhang W,Chen JH,Aguilera-Barrantes I, et al: Urolithin 43) Totiger TM,Srinivasan S,Jala VR, et al: Urolithin A,a A suppresses the proliferation of endometrial cancer Novel Natural Compound to Target PI3K/AKT/mTOR cells by mediating estrogen receptor-α-dependent gene Pathway in Pancreatic Cancer. Mol Cancer Ther,2019; expression. Mol Nutr Food Res,2016; 60: 2387-2395. 18: 301-311. 29) Donjerkovic D,Scott DW: Regulation of the G1 phase of 44) Tyagi N,Vacek JC,Givvimani S,Sen U,Tyagi SC: the mammalian cell cycle. Cell Res,2000; 10: 1-16. Cardiac specific deletion of N- methyl-d-aspartate 30) Lodish HF,Berk A,Kaiser CA, et al: Molecular Cell receptor 1 ameliorates mtMMP-9 mediated autophagy/ Biology,8th Edition. US: W.H. Freeman and Company, mitophagy in hyperhomocysteinemia. J Recept Signal 2016. Transduct Res,2010; 30: 78-87. 31) Larrosa M,González-Sarrías A,García-Conesa MT, 45) Dong Y,Yin S,Jiang C, et al: Involvement of autophagy Tomás-Barberán FA,Espín JC: Urolithins,ellagic acid- induction in penta-1,2,3,4,6-O-galloyl-β-D-glucose-induced derived metabolites produced by human colonic micro- senescence-like growth arrest in human cancer cells. flora,exhibit estrogenic and antiestrogenic activities. J Autophagy,2014; 10: 296-310. Agric Food Chem,2006; 54: 1611-1620. 46) Filomeni G,Desideri E,Cardaci S, et al: Carcinoma cells 32) Adams LS,Zhang Y,Seeram NP,Heber D,Chen S: activate AMP-activated protein kinase-dependent -derived compounds exhibit autophagy as survival response to kaempferol-mediated antiproliferative and antiaromatase activity in breast energetic impairment. Autophagy,2010; 6: 202-216. cancer cells in vitro. Cancer Prev Res (Phila),2010; 3: 47) Zhao W,Shi F,Guo Z,Zhao J,Song X,Yang H: Metabo- 108-113. lite of ellagitannins,urolithin A induces autophagy and

138 Juntendo Medical Journal 67(2),2021

inhibits metastasis in human sw620 colorectal cancer Repeated oral administration of high doses of the cells. Mol Carcinog,2018; 57: 193-200. pomegranate ellagitannin punicalagin to rats for 37 days 48) Bosco EE,Mulloy JC,Zheng Y: Rac1 GTPase: a“Rac”of is not toxic. J Agric Food Chem,2003; 51: 3493-501. all trades. Cell Mol Life Sci,2009; 66: 370-374. 53) Patel C,Dadhaniya P,Hingorani L,Soni MG: Safety 49) Nobes CD,Hall A: Rho,rac,and cdc42 GTPases regulate assessment of pomegranate fruit extract: acute and the assembly of multimolecular focal complexes associ- subchronic toxicity studies. Food Chem Toxicol,2008; ated with actin stress fibers,lamellipodia,and filopodia. 46: 2728-2735. Cell,1995; 81: 53-62. 54) Heilman J,Andreux P,Tran N,Rinsch C,Blanco-Bose 50) Alauddin M,Okumura T,Rajaxavier J, et al: Gut W: Safety assessment of Urolithin A,a metabolite Bacterial Metabolite Urolithin A Decreases Actin produced by the human gut microbiota upon dietary Polymerization and Migration in Cancer Cells. Mol Nutr intake of plant derived ellagitannins and ellagic acid. Food Res,2020; 64: e1900390. Food Chem Toxicol,2017; 108 (Pt A): 289-297. 51) Wang Y,Qiu Z,Zhou B, et al: In vitro antiproliferative 55) Jang JY,Kang YJ,Sung B, et al: MHY440,a Novel and antioxidant effects of urolithin A,the colonic Topoisomerase I Inhibitor,Induces Cell Cycle Arrest metabolite of ellagic acid,on hepatocellular carcinomas and Apoptosis via a ROS-Dependent DNA Damage HepG2 cells. Toxicol In Vitro,2015; 29: 1107-1115. Signaling Pathway in AGS Human Gastric Cancer Cells. 52) Cerdá B,Cerón JJ,Tomás-Barberán FA,Espín JC: Molecules,2018; 24: 96.

139