PHYTOTHERAPY RESEARCH

Phytother. Res. (2017)

Published online in Wiley Online Library
(wileyonlinelibrary.com) DOI: 10.1002/ptr.5809

REVIEW
Anticancer Properties of Solamargine: A
Systematic Review

Fatemeh Kalalinia1 and Iman Karimi-Sani2*

1
Biotechnology Research Center, Mashhad University of Medical Sciences, Mashhad, Iran
2
Department of Biotechnology, Ferdowsi University of Mashhad, Mashhad, Iran

Cancers are usually treated by anticancer agents that are toxic for both normal and cancer cells, so these drugs
have major side effects and they are not suitable and enough effective for cancer prevention. Solamargine, a
steroidal alkaloid glycoside found in Solanum species such as Solanum nigrum, displayed several therapeutic
activities. We aim to review the use of solamargine in experimental cancer studies. Articles published in biology
journals between 1975 and 2017 were retrieved from PubMed, Scopus, and Web of Science using relevant
keywords. The scientific papers mainly focusing on solamargine with therapeutic efficacies against cancers were
identified and tabulated. In addition, the reliability of experimental findings was determined under “Risk of
Bias” criteria. The author manually reviewed 33 articles; 27 articles were found concerning the anti-cancer
potential in cancer cells. Solamargine has been found to possess anticancer activities via its effect on a variety
of biological pathways including cell survival pathways, tumor suppressor pathways, caspase activation pathway,
mitochondrial pathways, death receptor pathways, protein kinase pathways, and signal pathways, which promote
invasion/migration and multi drug resistance. Solamargine can be an anticancer agent candidate when
complementary scientific evidences become available. Copyright © 2017 John Wiley & Sons, Ltd.
Keywords: solamargine; cytotoxicity; apoptosis; drug resistance; cell cycle arrest; invasion.

Abbreviations: ABC, ATP-binding cassette; Apaf-1, apoptotic protease activating factor 1; CAFs, cancer-associated fibroblasts; CDKIs,
cyclin-dependent kinases inhibitors; COX, cyclooxygenase; DNMT1, DNA methyltransferase 1; ECM, extracellular matrix; EGF,
epidermal growth factor; FADD, fas-associated protein with death domain; FDA, Food and Drug Administration; MDR, multidrug
resistance; MMPs, matrix metalloproteinases; MTX, methotrexate; MUC1, mucin 1; PGE2, prostaglandin E2; RBL, rhamnose binding
lectin; RGP, radial growth phase; RIP, receptor interacting protein; TME, tumor microenvironment; TNFs, tumor necrosis factors;
TRADD, TNFRSF1A associated via death domain; VGP, vertical growth phase

chemotherapeutic agents with very low or even no

INTRODUCTION
cytotoxicity and side effects are needed for favorable
treatment.
Based on GLOBOCAN 2016 report, about 1,685,210 Plants compounds are assumed as major sources of
new cancer cases and 595,690 cancer-related deaths new chemical entities, new drugs, and new drug leads.
occurred in the United States (Siegel et al., 2016). A large number of herbal products have been studied
Although, advanced detection methods and treatment for their possible anticancer activity, and plant-based
technologies are available (DeSantis et al., 2014), cancer agents have been used in the development of anticancer
accounts for about 23% of the total deaths (Anand et al., drugs or as lead compounds for new pharmaceuticals
2008) and is the second most common cause of death (Lin et al., 2016; Safe and Kasiappan, 2016; Chen et al.,
after cardiovascular disease in developed and 2016a,b). Solanum nigrum Linn. [English name; Black
developing countries (Wang et al., 2014). A lot of Nightshade (Sani et al., 2015), Indian name; Makoi
chemotherapeutic agents have been evaluated during (Jainu and Devi, 2006)] is a dicot weed in the
the last half century, and some of them have an Solanaceae family. Although S. nigrum is a rich source
established place in the management of cancers. Most of toxins, such as solanine that inhibit proliferation and
of anticancer drugs have a level of toxicity and well induced apoptosis in various cancer cells, which
above compared with other group of drugs, and nearly demonstrated as an reservoir of agents that have
all of them do not discriminate between normal and hepatoprotective, antitumor, cytostatic, anti-
cancer cells, so these drugs are particularly harmful to ulcerogenic, anti-inflammatory, and anti-convulsant
normal tissues such as bone marrow, lymphoid tissues, effects (Atanu et al., 2011; Lv et al., 2014). Solamargine,
and the epithelium of the gastrointestinal tract a steroidal alkaloid glycoside from S. nigrum, displayed
(Urushizaki, 1990). Thus, new more effective cancer several therapeutic applications such as antileishmanial
activity (Abreu Miranda et al., 2013), antitrypanosomal
* Correspondence to: Iman Karimi-Sani, Department of Biotechnology, activity (Moreira et al., 2013), anti Trypanosoma cruzi
Ferdowsi University of Mashhad, P. O. Box 91775-1365, Mashhad, Iran.
E-mail: im_ka897@mail.um.ac.ir
activity (Hall et al., 2006), and especially superior
Chemical compounds studied in this review: Solamargine (Pubchem CID: anticancer effect against various human cancer cell lines
73611). (Sun et al., 2010).

Received 05 January 2017

Revised 10 March 2017
Copyright © 2017 John Wiley & Sons, Ltd. Accepted 14 March 2017
 F. KALALINIA AND I. KARIMI-SANI

In order to contribute to the development of effective

agents derived from medicinal plants in the
management of cancers, this review will discuss the
anticancer properties of solamargine, accomplished by
content of published articles in the period between
1975 and 2017, with emphasis on the molecular
pathways modulated by this agent that may be useful
in the preclinical and clinical trials.

MATERIALS AND METHODS

This systematic review was carried out and reported in

accordance with preferred reporting items for
systematic reviews and meta-analysis (Moher et al.,
2009).

Search strategy. A comprehensive literature search

strategy was carried out including searching PubMed
(1975 to February 2017), Scoops (1975 to February
2017), and Web of Science (1975 to February 2017).
The search for suitable papers in internet databases
was carried out using diverse combinations of the Figure 1. Trial selection and analysis for the presence of published
following keywords: “Solamargine,” “Cancer,” articles.
“Phytotherapy,” “Natural Products,” and “Medicinal
Plants.” The ultimate goal of this review was to explore
papers that investigated the therapeutic approaches of
solamargine in cancer treatment using in vitro and allocation concealment (selection bias), blinding of
in vivo experimental systems. The bibliographies of all outcome assessment (detection bias), blinding of
literatures thus located were scanned for further participants and personnel (performance bias),
relevant references. incomplete outcome data (attrition bias), and selective
reporting (reporting bias).

Study selection. The titles, abstracts, and keywords of

records (46 articles) retrieved were scanned to Data analysis. Data were extracted for each study
determine whether to be assessed further. Full content including study design, sample and settings, summary
of related articles (38 articles) was retrieved for further details of intervention, outcomes and measurements,
assessment if the information met the inclusion criteria. and results. Then, summarized results were tabulated
Finally, the shortlisted and relevant studies (33 articles and used to generate summary descriptions across key
include 27 original studies) were independently assessed characteristics. A qualitative analysis was conducted
by two authors of this study (Fig. 1). Disagreement was across the different interventions reported to describe
resolved by discussion and reached consensus through a intervention types and contexts. This analysis was
third party (Javad Behravan). conducted in smaller groups in the research team but
further enriched through discussion of process and
emerging findings among all group members. Because
Data extraction. We imported the search results into a of heterogeneity of studies in terms of interventions,
bibliographic citation management software (EndNote meta-analyses have not been performed for the
X7). Two authors extracted data into a standardized accessed data.
form that identified the study methodology and
characteristics of each study. Data were extracted and
synthesized separately for experimental studies and
observational studies. The following items were
extracted from each study, if available: study substances, RESULTS AND DISCUSSION
animal models, doses or concentrations, cell lines,
biochemical assays, molecular mechanisms, and The 27 original articles, summarized in the Table 1, that
histological assessments. Finally, a narrative synthesis fulfilled the inclusion criteria were divided into five
of all studies was produced. groups: (a) structural insight; (b) in vitro cytotoxicity
studies of solamargine on cancer cells; (c) in vitro
studies of solamargine on cancer cell migration and
Methodological quality and assessment of studies. The invasion; (d) in vitro studies of solamargine on cancer
risk of bias of in vivo studies was assessed following cell multidrug resistance (MDR); (e) in vivo
Hooijmans et al. (2014) recommendations, considering cytotoxicity studies of solamargine in experimental
random sequence generation (selection bias), animals.
Copyright © 2017 John Wiley & Sons, Ltd. Phytother. Res. (2017)
 ANTICANCER PROPERTIES OF SOLAMARGINE: A SYSTEMATIC REVIEW

Table 1. In vitro studies of solamargine on different cancer cell lines and normal cell lines

References Inhibitory concentration Cell Line Treatment time (h) Improved characteristics

(Hsu et al., 1996) 1.9 μg/mL (IC50) Hep3B 16 Solamargine triggers gene expression of human
TNFR I
(Kuo et al., 2000) 5 μg/mL (IC50) Hep3B 16 TNFR-I and -II are involved in the mechanism of
solamargine-mediated apoptosis
(Ding et al., 2012) 9.21 μg/mL (IC50) SMMC-7721 72 Activation of caspase-3 and the regulation of the
cell cycle progression to induce apoptosis and
inhibit hepatoma cells proliferation
(Ding et al., 2013) 8.77 μg/mL (IC50) MGC-803 72 Decrease of mutation p53, the increase of the
19.88 μg/mL (IC50) HepG2 72 ratio of Bax to Bcl-2 and the activation of
caspase-3 to induce apoptosis
(Tang et al., 2011) 2.4 mg/kg (IC50) H22 Data not inhibition on mice with H22 liver cancer or
available ehrlich ascites tumor
(Liang et al., 2004) 2.9 μM (IC50) A549 18 Sensitizes cancer cells through TNFRs and
mitochondria-mediated pathways and anticancer
potential against TNFs- and cisplatin-resistance
cancer cells
(Liu et al., 2004) 11.8 μM (IC80) H441 16 Enhancement of the susceptibility of cancer
12.5 μM (IC80) H520 16 cells to TNFs
H661
H69
(Liang et al., 2008) 2.41, 3.58, and H661 18 Up-regulation of HER2 and TOP2A expressions
6.83 μM, simultaneously augmented trastuzumab and
,
(ED25, ED50 and ED75) epirubicin-induced deaths of cancer cells
(Zhou et al., 2014) 6.185 μM (GC50) H1650 48 Inhibit proliferation and induce apoptosis in cancer
7.024 μM (GC50) A549 48 cells through p38 MAPK-mediated suppression of
phosphorylation and protein expression of Stat3,
followed by inducing Stat3 downstream effector p21
(Shiu et al., 2009) 0.91, 1.81 and HBL-100 16 Co-regulates HER2/neu and TopoIIα expression
3.00 μM markedly, and enhances TopoII inhibitor–EPI
(IC25, IC50 and IC75) (epirubicin)-induced cytotoxicity to breast cancer cells
1.08, 1.98 and MCF-7 16
2.38 μM
(IC25, IC50 and IC75)
1.40, 3.13 and SK-BR-3 16
4.38 μM
(IC25, IC50 and IC75)
(Shiu et al., 2008) 1.67 μM (IC50) ZR-75-1 16 Downregulation of HER2/neu and enhancement of
drug susceptibility of breast cancer cells
(Munari et al., 2014) 4.58 to 18.23 MCF-7 24 Antiproliferative activity against the tumor cell lines
μM (IC50) HT29
HeLa
HepG2
MO59J
U343
U251
(Sun et al., 2010) 8.5, 8.04, 7.86, K562 2, 4, 6, 8 Induction of apoptosis by a lysosomal–mitochondrial
7.68 and and 24 death pathway
7.54 μM (IC50)
(Sun et al., 2011) 8.0 μM (IC50) K562 24 Initiate acute injury and bursting by damaging to
7.8 μM (IC50) KB 24 cellular membrane
5.9 μM (IC50) PC3 24
(Li et al., 2011b) 8.9 μM (IC50) MG-63 24 Activation of mitochondria-mediated apoptotic
8.6 μM (IC50) 48 pathway via both p53 transcription-dependent
9.6 μM (IC50) Saos-2 24 and -independent mechanisms
9.8 μM (IC50) 48
5.8 μM (IC50) U2OS 24
6.0 μM (IC50) 48
20.1 μM (IC50) RPE1 24
21.5 μM (IC50) 48
23.2 μM (IC50) HL7702 24

(Continues)

Copyright © 2017 John Wiley & Sons, Ltd. Phytother. Res. (2017)
 F. KALALINIA AND I. KARIMI-SANI

Table 1. (Continued)

References Inhibitory concentration Cell Line Treatment time (h) Improved characteristics

22.9 μM (IC50) 48
(Hsu et al., 1996) 1.7 μg/mL (IC50) normal fibroblast 16 Upregulation of TNFR I gene expression
(Xiang et al., 2016) 7.0 and 6.5 μM (IC50) PC3 24 Activation of AMPKα mediates
DU145 Suppressing MUC1 expression in castration-resistant
C4-2B prostate cancer cells
BPH-1
(Xie et al., 2015) 12.27, 11.86, SMMC7721 and 3, 6, 12, 24 The activation of the Bcl-2/Bax and caspase
11.57, 12.17 and HepG2 and 48 signaling pathways
10.48 μM (IC50)
(Lee et al., 2004) 100 μg/mL (IC80) HT29 4 The effectiveness against the liver cells was
HepG2 greater than against the colon cells
(Chen et al., 2015a) 4.09 μM (IC50) H1299 24 Inactivation of PI3-K/Akt and reduction of SP1 and
3.40 μM (IC50) A549 p65 expression increase the effect of solamargine
on suppressing EP4 expression
(Li et al., 2011a) 4.30 μM (IC50) K562/A02 24 Trigger apoptosis in MDR tumor cells, which is
8.50 μM (IC50) KB/VCR associated with actin disruption and downregulation
7.42 μM (IC50) H460/paclitaxel of MDR1 expression
(Shiu et al., 2007) 2.07 μM (IC50) HBL-100 16 The combined treatment of solamargine and cDDP
2.15 μM (IC50) ZR-75-1 significantly reduced Bcl-2 and Bcl-xL expressions,
3.00 μM (IC50) SK-BR-3 and enhanced Bax, cytochrome c, caspase-9 and
-3 expressions in breast cancer cells
(Sani et al., 2015) HepG2 24 Inhibition of migration and invasion of HepG2 cells
by down-regulating MMP-2 and MMP-9 expression
and activity
(Al Sinani et al., 2016) 8 μM (IC50) WM239 2 Trigger cellular necrosis through extrinsic lysosomal
6 μM (IC50) WM115 mitochondrial death pathway
(Liang et al., 2007) 5.46 μM (IC50) A549 18 Downregulation of the HER2 and TOP2A expression
5.85 μM (IC50) H441 by solamargine with epirubicin may partially explain
the solamargine and epirubicin cytotoxicity synergy
effect
(Chen et al., 2016c) Data not available H1650 48 The inter-correlations between EP4, DNMT1 and
H1975 c-Jun and feedback regulation of ERK1/2 by c-Jun
PC9 contribute to the overall responses of solamargine
A549
H1299
(Chang et al., 1998) 3.0 μg/mL (IC50) Hep3B 24 The carbohydrate moieties of steroidal alkaloids might
alter the binding specificity to steroid receptors
(Chen et al., 2016c) 6 μM ( IC50) H1650 48 Targeting EP4 downstream c-Jun through
H1975 ERK1/2-mediated reduction of DNMT1
PC9
A549
H1299

Structural insight

Solamargine [IUPAC name: (3β,22α,25R)-Spirosol-5-

en-3-yl 6-deoxy-α-L-mannopyranosyl-(1 → 2)-[6-
deoxy-α-L-mannopyranosyl-(1 → 4)]-β-D-glucopyrano-
side, C45H73NO15, 868.05882 g/mol] is a steroidal
glycoalkaloid, isolated and purified from the fruits of
Solanum species such as S. nigrum (Fig. 2) (Atanu et al.,
2011). Solamargine is structurally composed of two
major parts: solasodine (an oxaza-spiro steroidal
aglycone) and a chacotriose (2,4-bis-a-L-
rhamnopyranosyl-b-D-glucopyranose) that attached to
the 3-hydroxy group of solasodine (C3 side chain).
Figure 2. Chemical structure of solamargine. The C3 side chain of
Nowadays, solamargine has been synthesized in 13 steps solamargine is shown with purple circle. L-Rhamnopyranosyl (Rha)
from the naturally abundant diosgenin in chemical and D-glucopyranosyl (Glc). [Colour figure can be viewed at
laboratory (Wei et al., 2011). wileyonlinelibrary.com]

Copyright © 2017 John Wiley & Sons, Ltd. Phytother. Res. (2017)
 ANTICANCER PROPERTIES OF SOLAMARGINE: A SYSTEMATIC REVIEW

Rhamnose binding lectin receptor may be connected 2004; Liang et al., 2008; Shiu et al., 2009; Sun et al.,
with solamargine’s anticancer activity. Lectins, from 2011; Tang et al., 2011; Li et al., 2011a, b; Ding et al.,
the Latin legere “to select,” are a diverse group of 2012; Munari et al., 2014; Zhou et al., 2014). As noted in
biomolecules binding proteins that contain Table 1, the IC50 value, the concentration that inhibits
carbohydrate groups, including lipids, sugars, and 50% of cell proliferation, of solamargine on different
sugar-modified proteins. This characterization allows cells varied from 0.91 to 26.66 μM. In addition, cytotoxic
to influence a wide range of biological processes by effects of solamargine and several conventional
lectins (Ghazarian et al., 2011). Rhamnose binding lectin chemotherapeutic agents, e.g., paclitaxel, cisplatin,
(RBL) is able to recognize rhamnose specifically in etoposide, and gemcitabine, have been compared in
some species of animals and was also found on the cell human lung cancer cell lines (H441, H520, H661, and
surface of human umbilical venous endothelial cells H69). The IC50s of solamargine, paclitaxel, cisplatin,
and normal human dermal fibroblasts (Tateno et al., etoposide, and gemcitabine were approximately 6.7,
1998; Faury et al., 2008). A natural glycoside formed 21, >250, >250, and >250 μM for H520, 7.2, 23.4, 136,
by rhamnose and aglycone, rhamnoside, is widely >250, and >250 μM for H661, 3, 45, >250, >250, and
distributed in higher plant species (Koulman et al., >250 μM for H441, and 5.8, 22.4, 240, >250, and
2008). The C3 side chain of solamargine contains L- >250 μM for H69 cells, respectively. Solamargine is
Rhamnopyranosyl (Rha) and D-glucopyranosyl (Glc). the most sensitive agent compare with paclitaxel,
The remarkable anticancer properties of solamargine cisplatin, etoposide, and gemcitabine in all lung cancer
(specially triggering cell death by apoptosis) may be cell lines. (Liu et al., 2004). However, acute or chronic
associated with 20 -Rhamnopyranosyl moiety of toxicity of solamargine is not determined well (Sun
solamargine (Chang et al., 1998). Wang et al. (2011) et al., 2011).
showed that rhamnose plays an important role in the Anticancer agents typically damage both normal and
solamargine’s anticancer activity, because RBL receptor cancer cells which known as adverse effect for affects
of tumor cells could conjugate with rhamnose to therapeutic modality. The ideal anticancer drugs are
mediate the transportation of rhamnosides. As regards expected to exert minimal or even no side effects to
to the different levels of RBL in cancer cells, increased normal cells and a maximum ability to sacrifice cancer
RBL receptor expression on cell surfaces or higher cells (Nawab et al., 2012). Generally, growing and
numbers of rhamnose moieties in the structure of dividing of cancer cells are much faster than normal
rhamnosides could mediate more effective cancer cell cells, so agents that can quickly stop cancer cells
elimination. The molecular model analysis of proliferation have high demand for oncology
solamargine indicated that this moiety is adjacent to therapeutic protocols. For the first time, Al Sinani
the rigid steroid structure and considerably changed et al. (2016) demonstrated the selective effects of
the dihedral angle of the glycosidic bond. It implied that solamargine in causing cytotoxicity on human cancer
the carbohydrate moieties of steroidal alkaloids such as cells [Human melanoma cell line WM35 (radial growth
20 -Rhamnopyranosyl moiety of solamargine might alter phase), primary melanoma cell line WM115, metastatic
the binding specificity to steroid hormone receptors melanoma cell line WM239 (vertical growth phase) in
and consequently regulate the downstream genes comparison with normal cell lines (primary bovine
expression in different manners (Chang et al., 1998). aortic endothelial cells and rat fibroblast and epithelial
cells)]. The results showed that solamargine has
potential features as a promising anticancer agent
In vitro cytotoxicity studies of solamargine on cancer because it selectively and rapidly caused necrosis in
cells the high proliferative melanoma cells (WM115 and
WM239), while it had minimum necrotic effects on the
Cytotoxicity can be defined as the direct killing of cells benign radial growth phase melanoma (WM35) and
and/or the inhibition of cell proliferation (Yuen and normal cells (Al Sinani et al., 2016). The previous
Gohel, 2005). Solamargine is the most active cytotoxic evidences indicated higher cytotoxicity of solamargine
compounds of Solanaceae plant family against cancer in all lung cancer cell lines with minimal effect on
cells (Shiu et al., 2009; Chen et al., 2010). Using different normal cells.
methods, cytotoxicity of solamargine has been shown in
various cancer cell lines, including human liver cancer
(Hep3B, HepG2, H22, and SMMC-7721), human lung Induction of cell death. Historically, three types of
cancer (A549, H441, H520, H661, H69, and H1650), mammalian cell death have been characterized by
human breast cancer (HBL-100, SK-BR-3, ZR-75-1, morphological criteria: apoptosis, oncosis, and necrosis
and MCF-7), human myelogenous leukemia (K562), (Trump et al., 1997). The process of programmed cell
squamous carcinoma (KB), human prostate cancer death that called apoptosis is distinguished by distinct
(PC3), osteosarcoma (U2OS, MG-63, Saos-2), murine morphological characteristics and its energy-dependent
melanoma (B16F10), human colon carcinoma (HT29), biochemical mechanisms (Elmore, 2007). Apoptosis is
human cervical adenocarcinoma (HeLa), human characterized by cell shrinkage followed by breakup,
glioblastoma cell lines (MO59J, U343 and U251), and but oncosis involves cell swelling and coagulation of
low toxicity on normal cell lines including Chinese the cytoplasm (Weerasinghe and Buja, 2012).
hamster lung fibroblasts (V79), human lung fibroblasts Nowadays, it is accepted that apoptosis and oncosis
(GM07492A), human liver (HL-7702 cells), and human may not be the only forms of mammalian cell death.
retinal pigment epithelium (RPE1). The results of these Necrosis manifests itself by passive, accidental cell death
studies indicated that the cytotoxic effects of resulting from abnormal environmental conditions with
solamargine are dose and time dependent (Hsu et al., uncontrolled release of inflammatory cellular contents
1996; Kuo et al., 2000; Liang et al., 2004; Liu et al., (Fink and Cookson, 2005).
Copyright © 2017 John Wiley & Sons, Ltd. Phytother. Res. (2017)
 F. KALALINIA AND I. KARIMI-SANI

Figure 3. Regulation of apoptotic cell death mediators by solamargine. Unregulated mediators are shown with red color, and downregulated
mediators are shown with green color. [Colour figure can be viewed at wileyonlinelibrary.com]

Induction of apoptosis. Apoptosis, from a Greek word solamargine-mediated apoptosis in Hep3B cells (Kuo
meaning falling off, is necessary for normal cell et al., 2000; Liu et al., 2004). Solamargine significantly
turnover, normal organism development, normal upregulated the protein expressions of Fas and the
hormone-dependent atrophy, embryonic development, other downstream signal proteins including TRADD
and normal immune system function (Elmore, 2007). and FADD in HBL-100, SK-BR-3, ZR-75-1 (Shiu
There are two principal pathways of apoptosis: the et al., 2007), A549 (Liang et al., 2004), H441, H520,
transmembrane (extrinsic) pathway and the H661, H69 (Liu et al., 2004), A549, H441 (Liang et al.,
mitochondrial (intrinsic) pathway. Solamargine can 2007), B16F10, HT29, MCF-7, HeLa, HepG2, MO59J,
induce apoptosis through regulating the expression of U343, and U251 cells (Munari et al., 2014). Activation
apoptosis-related genes and proteins (Fig. 3) or via of caspase-3 and -8 in solamargine-treated A549 (Liang
direct activation of apoptosis pathways (Table 2) in et al., 2004), SMMC-7721 (Ding et al., 2012), H44, H520,
cancer cells. H661 H69 (Liu et al., 2004), HBL-100, ZR-75-1, and SK-
The extrinsic transmembrane pathway of apoptosis. BR-3 cells (Shiu et al., 2007) evidenced the activation of
Treatment with solamargine upregulated the gene TNFRs signal transduction.
expression of TNF-R1 in A549 (Liang et al., 2004), The intrinsic mitochondrial pathway of apoptosis.
Hep3B (Hsu et al., 1996; Kuo et al., 2000; Liu et al., Solamargine can trigger intrinsic apoptosis through
2004), HBL-100, SK-BR-3, ZR-75-1 (Shiu et al., 2007), regulation of intrinsic apoptotic death mediators. The
B16F10, HT29, MCF-7, HeLa, HepG2, MO59J, U343 enzyme cytochrome c oxidase (Cyt c or Complex IV,
and U251 cell lines (Munari et al., 2014), and TNF-R2 EC 1.9.3.1) is associated with the inner membrane of
in A549 and Hep3B cell lines (Fig. 3) (Kuo et al., the mitochondrion as a key participant in the life-
2000). TNF-R2 was involved in the mechanism of supporting function of ATP synthesis. However, during

Table 2. A list of apoptotic and growth inhibitory pathways activated by solamargine in tumor cells

Pathways References

Caspase activation (Li et al., 2011b; Xie et al., 2015; Al Sinani et al., 2016)
Induction of death receptors (Liang et al., 2007; Shiu et al., 2007; Al Sinani et al., 2016)
Fas receptor aggregation (Liang et al., 2007; Shiu et al., 2007)
Induction of p53/p21 pathway (Li et al., 2011b; Ding et al., 2013; Lv et al., 2014)
Induction of DNA fragmentation (Kuo et al., 2000; Liu et al., 2004)
Suppression of antiapoptotic proteins (Liu et al., 2004; Li et al., 2011b; Xie et al., 2015; Al Sinani et al., 2016)
Mitochondrial activation (Li et al., 2011b; Al Sinani et al., 2016)
Inhibition of IL6/STAT3 activation (Lv et al., 2014)
p38 MAPK pathway (Zhou et al., 2014)
Inhibition of NF-κB (Chen et al., 2015a)
Inhibition of PI3K-AKT activation (Chen et al., 2015b)
Inhibition of growth factors and their receptors (Shiu et al., 2009)

Copyright © 2017 John Wiley & Sons, Ltd. Phytother. Res. (2017)
 ANTICANCER PROPERTIES OF SOLAMARGINE: A SYSTEMATIC REVIEW

apoptosis, cytochrome c is released into the cytosol and permobilization of lysosomal membranes in cancer cells,
triggers programmed cell death (Ow et al., 2008). which cause increase in influx of water and finally
Alternately, solamargine caused the release of resulted in lysosomes swell and vacuoles formation
cytochrome c from mitochondria of the H44, H520, (Sun et al., 2010). Large lysosomes lead to an increase
H661, H69 (Liu et al., 2004), A549 (Liang et al., 2004), in surface tension, a decrease in lysosome integrity,
K562 (Sun et al., 2010), HBL-100, ZR-75-1, SK-BR-3 and finely broke down. Moreover, when damage occurs
(Shiu et al., 2007), and U2OS (Li et al., 2011b) cells in in cells, repair of the enlarged lysosomes is more
a dose-dependent manner. A balance between pro- difficult than smaller ones (Proskuryakov et al., 2003).
apoptotic and anti-apoptotic members of the Bcl-2
family regulates the intrinsic mitochondrial pathway of Induction of oncosis. Oncosis, derived from a Greek
apoptosis (Dhar and St Clair, 2009). The anti-apoptotic word “oncos” meaning swelling, is a specific pattern
Bcl-xL and Bcl-2 genes were downregulated in of cell infarcts and zonal killing following chemical
solamargine-treated A549 (Liang et al., 2004), H44, toxicity (Majno and Joris, 1995). During this process,
H520, H661, H69 (Liu et al., 2004), K562 (Sun et al., the earliest step is formation of abnormal cell shape
2010) HBL-100, ZR-75-1, SK-BR-3 (Shiu et al., 2007) and cell volume that frequently occur within seconds
B16F10, HT29, MCF-7, HeLa, HepG2, MO59J, U343, to minutes. In addition, oncosis is characterized by
and U251 cells (Munari et al., 2014). Instead, there was membrane blebbing, nuclear chromatin clumping,
an appreciable increase in the expression of cleaved mitochondria swelling, and changing in the
caspase-3 and 9 in solamargine-treated K562 (Sun cytoskeleton elements including actin and tubulin
et al., 2010), B16F10, HT29, MCF-7, HeLa, HepG2, (Sun et al., 2011). Solamargine can induce cellular
MO59J, U343, and U251 cells (Munari et al., 2014). oncosis in cancer cells. The blebs occur within 35–50 s
Overall, it seems that solamargine can induce the of stimulation and last as long as 6 and 2 min in K562
intrinsic mitochondrial pathway of apoptosis via and KB cells, respectively. Decreased actin solubility
downregulation of anti-apoptotic mediators and was observed during ATP-depletion, as well as
upregulation of pro-apoptotic mediators. breakdown of the actomyosin network, a change in lipid
The Bcl-2 family proteins have a critical role in order of the plasma membrane and membrane blebs. A
mitochondrial control of apoptosis. The p53 tumor major decline in ATP levels can lead cell death from
suppressor protein regulates this family of proteins; apoptosis to a necrotic, and it shows that ATP levels in
however, the exact mechanisms underlying kindling the cells regulate the mode of cell death (Eguchi et al.,
remain unknown (Schuler and Green, 2001). The Bcl-2 1997). ATP levels decreased within 2 h in solamargine-
family proteins possess mitochondrial membrane treated KB and K562 cells. In addition, solamargine
permeability and composed of two related groups, pro- exposure led to a rapid, dramatic change of the normal
apoptotic or anti-apoptotic. Some of the pro-apoptotic architecture in KB cells through decreasing the β-tubulin
proteins are Bcl-10, Bak, Bax, Bik, Bid, Bim, and Bad, and microtubules networks and simultaneous formation
and some of the anti-apoptotic proteins are Bcl-2, Bcl- of actin stress fibers (Sun et al., 2011).
XS, Bcl-XL, Bcl-x, Bcl-w, and BAG (Elmore, 2007).
Tumor protein p53 could directly activate Bax proteins Induction of necrosis. Necrosis has always been
via a transcription independent pathway to enhance characterized as accidental cell death, and for a long
per-mobilization of mitochondria and engage the time, necrosis was considered as a random, uncontrolled
apoptotic program (Chipuk and Green, 2004). Li et al. process. Necrosis lacks some features of autophagy and
(2011b) showed that solamargine induced apoptosis by apoptosis and characterized by the absence of
increasing the expression of Bax and p53. Cleavage of cytochrome c release, caspase activation, and DNA
chromosomal DNA into oligonucleosomal-size oligonucleosomal fragmentation (Krysko et al., 2008).
fragments is an integral part of apoptosis process Although this type of cell death was considered for
(Zhang and Xu, 2000). Activated caspase-3 can cleave many years as an uncontrolled form, recent advances
DNA into oligonucleosomal fragments from 180 to 200 in cell death biology suggest that its occurrence might
base pairs. Treatment of H441, H520, H661, H69 (Liu be tightly regulated (Golstein and Kroemer, 2007). It is
et al., 2004), SMMC-7721 (Ding et al., 2012), U2OS (Li demonstrated that solamargine can trigger cancer cell
et al., 2011b), and Hep3B (Kuo et al., 2000) cells with necrosis. Al Sinani et al. (2016) showed that solamargine
solamargine produces a ladder of oligonucleosomal effectively, selectively, and rapidly inhibited the growth
fragments (180 to 200 BP). of the melanoma cancer cell lines, WM239 (metastatic)
Lysosomal membrane per-mobilization-mediated cell and WM115 (primary), with a low cytotoxicity on
death. Recently, a new lysosomal pathway of apoptosis normal cells and benign melanoma cells, WM35.
has emerged. This pathway induced by lysosomotropic Cellular necrosis was induced by solamargine in
photosensitizer agents, oxidative stress, oxidized lipids, malignant melanoma cell lines WM115 and WM239,
serum starvation, DNA damage, or Fas and TNF-α through induction of lysosomal membrane per-
ligation involves release of lysosomal cathepsins. mobilization. In addition, solamargine upregulated the
Lysosomal-membrane permobilization can mediate expression of cathepsin B that triggered the extrinsic
caspase-dependent and caspase-independent apoptosis- mitochondrial death pathway represented by the release
like cell death or even necrosis (Fehrenbacher and of cytochrome c and upregulation of TNFR1.
Jaattela, 2005; Terman et al., 2006). A previous
experiment revealed that solamargine induced Cell cycle arrest. Cell proliferation occurs by a
apoptosis in K562 cells via early lysosomal successive cell division cycle, which tightly regulates by
destabilization and subsequent mitochondrial damage cell survival and cell death; otherwise, cells grow out of
by overload of Ca2+, decrease of membrane potential control and result in “tumors.” The cell cycle has four
and release of Cyt c. Solamargine can also induce recognized phases that include G1, S, G2, and M phase
Copyright © 2017 John Wiley & Sons, Ltd. Phytother. Res. (2017)
 F. KALALINIA AND I. KARIMI-SANI

(Williams and Stoeber, 2012). Solamargine can increase In vitro studies of solamargine on cancer cell migration
the ratio of the apoptotic sub-G1 peak of A549 (Liang and invasion
et al., 2004; Zhou et al., 2014), H441, H520, H661, H69
(Liu et al., 2004), HBL-100, MCF-7, SK-BR-3 (Shiu Metastasis is the general term used to describe the
et al., 2009), and Hep3B cells (Hsu et al., 1996; Kuo spread of primary tumor cells to secondary tissues and
et al., 2000) in a time- and concentration-dependent distant body organs, which is more common cause
manner. Instead, G2/M phase was reduced in MCF-7, cancer morbidity and mortality (Bacac and
HBL-100, SK-BR-3 (Shiu et al., 2007; Shiu et al., 2009), Stamenkovic, 2008; Tarin, 2008; Lazebnik, 2010; Tarin,
ZR-75-1 (Shiu et al., 2007), Hep3B (Kuo et al., 2000), 2011). It seems that metastasis is responsible for about
SMMC-7721 (Xie et al., 2015), and A549 cells under 90% of cancer deaths in the world (Chaffer and
treatment with solamargine (Fig. 4) (Liang et al., 2004; Weinberg, 2011). We evaluated the inhibitory effects of
Zhou et al., 2014). In addition, no significant changes solamargine on hepatocellular carcinoma cell migration
in G0/G1 phase were found in HBL-100, ZR-75-1, and and invasion. We showed that treatment with
SK-BR-3 cells (Shiu et al., 2007). In contrast to previous solamargine significantly decreased the invasion and
results, another recent study results showed that migration ability of HepG2 cells in a concentration-
solamargine did not cause cell-cycle arrest in K562 cells dependent manner (Sani et al., 2015).
(Sun et al., 2011). In the tumor microenvironment, extracellular
Uncontrolled cell cycle engine underlies abnormal proteinases (or proteases), such as the matrix
cell growth and proliferation that characterizes as the metalloproteinases (MMPs), also known as matrixins,
malignant phenotype of cancer cells. Brakes of cell cycle mediate many of the microenvironment changes
progression can cause by mitogens through stimulating during tumor progression (Kessenbrock et al., 2010).
G1–S CDK activities, which trigger pRB These metalloproteinases play a central role in
phosphorylation. The pRB functions are often defective extracellular matrix remodeling, during wound repair
in cancer cells with abnormal cells proliferation processes, inflammation, and development. MMPs
(Harbour and Dean, 2000). Defective brakes in cell are also important contributors to cancer initiation,
cycle progression can result from tumorigenic development, and progression. In a close relationship
mutations, which have been identified in diverse tumors to metastasis, MMPs degrade basement membranes
and in the different mitogenic signaling pathways such and expose cryptic peptide epitopes in extracellular
as HER2 gene, downstream signaling networks matrix that stimulate cellular invasion (Stamenkovic,
(including Ras–Raf–MAPK or PI3K–Akt signaling 2003; Parks et al., 2004; Kessenbrock et al., 2010;
pathways) and also the cell cycle-regulated genes Gialeli et al., 2011). Our observation indicates that
themselves (Huang et al., 2002; Freier et al., 2003; Zhang solamargine can decrease both MMP-2 and -9 protein
et al., 2009). Several investigations demonstrated the expression in HepG2 cells. In addition, gelatin
tumoricidal effects of solamargine with the regulation zymography results showed that solamargine reduced
of cancer cell cycling and signaling mediators. The the enzymatic activity of the secreted MMP-2 and -9
proto-oncogene HER-2/neu is an important from these cells in a concentration-dependent
proliferation regulator. It is demonstrated that manner (Fig. 5). Overall, these evidences strongly
solamargine upregulated HER2/neu and indicated that solamargine can inhibit migration and
Topoisomerase II α (Topo-IIα) expression in HBL-100, invasion of HepG2 cells through downregulation of
MCF-7, and SK-BR-3 cells (Shiu et al., 2009). MMP-2 and -9 expression and activity in vitro (Sani
et al., 2015).
Cyclooxygenase (COX), officially known as
prostaglandin-endoperoxide synthase, an enzyme that
catalyzes the conversion of arachidonic acid to
prostaglandins, is involved in several physiological
and pathogenetic pathways. Two isoforms of COX
are known, COX-1 and COX-2. Overexpression of
COX-2 is noted in different cancers, for instance, in
half of all breast cancer patients. This enzyme is
overexpressed by inflammatory and mitogenic stimuli
such as cytokines and growth factors, which results in
enhanced synthesis of prostaglandin E2 in neoplastic
and inflamed tissues (Kalalinia et al., 2011), which
promotes cancer metastasis through multiple events:
tumor angiogenesis and lymphangiogenesis,
inactivation of host immune cells, and stimulation of
tumor cell migration/invasive ability (Majumder
et al., 2014). Chen et al. (2015b) showed that
solamargine can inhibit the growth of lung cancer
cells through inhibition of prostaglandin E2 receptor
EP4. In other study, they indicated that solamargine
increased phosphorylation of ERK1/2 and inhibited
expression of c-Jun and DNA methyltransferase 1
Figure 4. The G0/G1 and G2/M cell cycle arrest by solamargine in
(DNMT1) at protein level, which were abrogated in
various cancer cell lines. [Colour figure can be viewed at cells transfected with exogenously expressed DNMT1
wileyonlinelibrary.com] gene and treated with MEK/ERK1/2 inhibitor,
Copyright © 2017 John Wiley & Sons, Ltd. Phytother. Res. (2017)
 ANTICANCER PROPERTIES OF SOLAMARGINE: A SYSTEMATIC REVIEW

Figure 5. Downregulation of metastasis mediators by solamargine. [Colour figure can be viewed at wileyonlinelibrary.com]

respectively. Interestingly, overexpressed DNMT1 transduction in solamargine-treated A549 cells (Liang

antagonized the effect of solamargine on c-Jun et al., 2004). Thus, these results proposed that
protein expression. Overexpression of c-Jun could solamargine sensitized A549 cells to cell death through
block solamargine-inhibited lung cancer cell growth, TNFRs signal transduction and mitochondria-mediated
and feedback resisted the solamargine-induced pathways and might have anticancer potential against
phosphorylation of ERK1/2 (Chen et al., 2016c). TNFs and cisplatin-resistance cancer cells (Liang et al.,
Finally, evidences indicate that solamargine inhibits 2004; Liu et al., 2004; Shiu et al., 2007).
the growth of cancer cells through reduction of EP4 Solamargine displayed significant cytotoxicity in the
protein levels, followed by increasing ERK1/2 examined MDR sublines (human leukemic cell lines
phosphorylation. K562/A02, oral cancer cell lines KB/VCR, and non-
small cell lung cancer cells H460/Taxol). These cell lines
were nearly as sensitive as to cytotoxic effects of
In vitro studies of solamargine on cancer cell multidrug solamargine as the corresponding non-resistant parental
resistance cell lines (K562, KB, and H460) (Li et al., 2011a).
Solamargine-treated K562/A02 cells exhibited a
Some of human cancers are resistant or become significant dose-dependent increase in the number of
resistant to treatment with chemotherapy drugs. This apoptotic cells. Bcl-2 protein expression was
phenomenon is called MDR and can limit the prolonged significantly reduced, and Bax was upregulated in this
and effective use of chemotherapeutic agents solamargine-treated cell line (Li et al., 2011a).
(Kunjachan et al., 2013). Cisplatin can be toxic to a wide The overexpression of P-gp, also named as MDR1, is
variety of cancers by inducing apoptosis via lethal DNA one of the major mechanisms underlying MDR, which
damage. Several mechanisms including intrinsic and functions as a drug efflux pump (Robinson et al., 1997;
acquired resistance are responsible for cisplatin Tainton et al., 2004). K562/A02 cells have been shown
resistance, which is a big challenge for cancer treatment to express high levels of P-gp on their plasma
(He et al., 2015). Originally, resistant to cisplatin at high membrane. Compared with untreated K562/A02 cells,
concentration occurred in most of the breast and lung solamargine significantly inhibited the overexpression
cancer cells. Solamargine can enhance the cell death of of P-gp in treated cells (Li et al., 2011a). Solamargine
A549, HBL-100, ZR-75-1, and SK-BR-3 cells in the exposure also leads to a rapid, dramatic disruption of
presence of cisplatin. Solamargine can increase the ratio normal cellular architecture and reduction of actin
of Bax to Bcl-2 and Bcl-xL. This may overcome the Bcl- expression in K562/A02 and KB/VCR cells that can be
2- and Bcl-xL-mediated drug resistance, which results in interpreted in attention to the close relationship
the increase of susceptibility of the breast cancer cells to between P-gp and cytoskeletal actin in MDR tumor cells
cisplatin. Combination of solamargine with cisplatin also (Fu and Roufogalis, 2007; Li et al., 2011a). On the other
can increase the activities of caspase-3, -8, and -9 and hand, it has been shown that induction of MDR1 gene
Bax expression in A549 cells (Liu et al., 2004; Shiu expression did not significantly alter the activity of
et al., 2007). Solamargine overcame the resistance of solamargine against human myelogenous leukemia
A549 cells to TNF-α and β through upregulation of MDR cells (K562 and K562/A02) and squamous cell
TNF-R1 and TNF-R2 expression. Activation of carcinoma (KB and KB/VCR) (Sun et al., 2011).
TRADD, FADD recruitment, and caspase-8 and -3 is Upregulation of HER-2/neu receptor, a member of
the evidences of the activation of TNFRs signal the epidermal growth factor receptor family, is
Copyright © 2017 John Wiley & Sons, Ltd. Phytother. Res. (2017)
 F. KALALINIA AND I. KARIMI-SANI

Figure 7. Classification of two in vivo studies based on the

different levels of risks and types of bias. [Colour figure can be
viewed at wileyonlinelibrary.com]

Figure 6. Classification of two in vivo studies based on the exhibited significantly greater cooperative growth
different risks of bias. [Colour figure can be viewed at inhibition than did each alone in the H661 and H69 cells
wileyonlinelibrary.com] (Liang et al., 2008). After treatment of SKBR-3, HBL-
100, and MCF-7 cells with trastuzumab, only SK-BR-3
cells exhibited sensitivity towards trastuzumab. Instead,
associated with cell division and growth that have been the combination of solamargine with trastuzumab
reported in numerous cancer types. For instance, about further inhibited cell proliferation in HBL-100, MCF-7,
30% of breast cancers have upregulation of HER-2/neu and SK-BR-3 cells. These experimental results indicated
protein, which induces resistance to chemotherapy that solamargine may enhance the susceptibility to
agents through promoting cell proliferation and opposes trastuzumab by overexpression of HER2 in breast
apoptosis (Cui et al., 2014). A significant correlation also cancer cells (Shiu et al., 2009).
was obtained between the expression of HER2/neu and Mucin 1 (MUC1), a heterodimeric cell surface-
Topo-IIα (topoisomerase IIα, an enzyme that regulates associated protein, is aberrantly overexpressed in
the overwinding or underwinding of DNA) (Hengstler human cancers with aggressive features. The functional
et al., 1999). ZR-75-1 and SKBR-3 cell lines express high role of this protein is not well defined; however, studies
levels of HER2, whereas HBL-100 and MCF-7 cells have provided insights into a role for MUC1 in
express low levels of this protein (Hager et al., 2005; activation of intracellular signaling pathways (Tagde
Shiu et al., 2009). Treatment of ZR-75-1, A549, and et al., 2016). For instance, in MUC1-overexpressed
H441 cells with solamargine downregulates HER2/neu cancer cells, both PI3K and Erk1/2 pathways are
mRNA and HER2/neu protein expression. Topo-IIα overstimulated, and MUC1 stimulates AMPK
expression was also decreased significantly in ZR-75-1, activation. These indicate a possible role for these
A549, and H441 cells under treatment with solamargine pathways in conferring drug resistance in MUC1-
(Liang et al., 2007; Shiu et al., 2008). In addition, overexpressing cancer cells (Nath et al., 2013). A study
downregulation of HER2/neu expression by by Xiang et al. (2016) showed that solamargine is able
solamargine enhanced the susceptibility of ZR-75-1 cells to significantly reduce the protein expression and
to methotrexate, 5-florouracil (5-Fu), and cisplatin, but promoter activity of MUC1, whereas increasing
not to epirubicin (Shiu et al., 2008). However, phosphorylation of AMPKα. Moreover, solamargine
combination of solamargine with epirubicin also reduced NF-κB subunit p65 protein expression.
considerably increased their cytotoxicity in H661 and Interestingly, exogenous overexpression of MUC1
H69 cells. The ratios of HER2 expression to β-actin attenuated solamargine-stimulated phosphorylation of
gene expression revealed that the cells treated with AMPKα and more importantly reversed solamargine-
solamargine exhibited markedly higher HER2 than the inhibited cancer cell growth. Overall, these evidences
untreated control in H661 and H69 cells. A similar demonstrated that solamargine inhibits cancer cell
result was obtained concerning the HER2 receptor growth through AMPKα-mediated inhibition of p65,
expression upon exposure to solamargine in H661 and followed by reduction of MUC1 expression.
H69 cell lines (Liang et al., 2008). Trastuzumab
(Herceptin™) is an HER2/neu-targeted therapy
approved by the Food and Drug Administration for In vivo cytotoxicity studies of solamargine in
treating metastatic breast cancers, which overexpress experimental animals
HER2/neu. Incubation with Trastuzumab had no
cytotoxicity effect on the H661 and H69 cell lines. In The study of Al Chami et al. (2003) verified the
addition, combinations of solamargine with trastuzumab toxicological properties of solamargine in rats and
Copyright © 2017 John Wiley & Sons, Ltd. Phytother. Res. (2017)
 ANTICANCER PROPERTIES OF SOLAMARGINE: A SYSTEMATIC REVIEW

mice. Results showed that solamargine had the similar

CONCLUSIONS AND FUTURE PROSPECTS
toxicity range to other Solanaceae glycoalkaloids.
Solamargine LD50 value was similar to those obtained
for solanine (Nishie et al., 1975) and a standard mixture For decades, the researchers tried to find more effective
of solasodine glycosides (Cham et al., 1991). Although and less toxic chemotherapeutic agents for cancer
solamargine did not cause animal death earlier than treatment. There is no doubt that solamargine has
6 h, using of very high dose of solamargine (over exhibited significant anticancer activity on numerous
60 mg/kg BW), they lead to death within 3 h after a cancer cell lines through different mechanisms, for
single intraperitoneal injection. Animal death in the instance, induction of apoptosis, inhibition of cell
high-dose recipient could be mainly attributed to cell proliferation, and differentiation, inhibition of MDR.
membrane disruption and acetylcholinesterase Several molecular pathways have been shown to be
inhibition. On the other hand, any bleeding from the deregulated in cancer cells by solamargine such as the
animal eyes or nose was not observed after MAP kinase cascade, TNFR, and Bcl-2 signaling
solamargine administration. These evidences, together pathway. In addition, solamargine has a potential
with the histology evidences, which did not show renal features as a promising anticancer agent because it
and hepatic congestion, suggest that solamargine has a selectively and rapidly cytotoxic to human cancer cells
low effect on cell membrane disruption in doses below compared with normal cell lines in vitro. However,
the LD50 value. In addition, solamargine at low-to- complementary in vitro investigations require expertise
medium doses (15–35 mg/kg BW) did not affect the in understanding the underlying mechanism involved
weight of the testicle and epididymis or the number in inhibition of tumor growth by solamargine, for
of spermatozoa, while high doses of solamargine (45 instance, angiogenesis mechanism. Based on the
and 50 mg/kg BW) could induce subcapsular scientific evidence available so far, solamargine is a
congestion that is possibly produced by hyperemia powerful agent against cancer cells, but in vivo
(Al Chami et al., 2003). anticancer potential of solamargine remains unclear.
Moreover, clinical trials are needed to assess effect of
solamargine. In conclusion, solamargine could be a very
promising adjunct to traditional cancer treatments.
METHODOLOGICAL QUALITY/RISK OF BIAS

Healthcare systematic reviews can include non- Acknowledgement

randomized studies, which are prone to many “biases”
that affect the accuracy of their findings. In order to The authors are indebted to the Research Council of Mashhad
University of Medical Sciences, Iran, for the approval and financial
minimize these biases, measurement of the risk of bias
support of this project.
is considerable in the individual studies that are being
included in systematic reviews. This measurement
enables exclusion of studies that have high risk of bias
from the overall estimate, or during sensitivity analyzes Conflict of Interest
(Bilandzic et al., 2016). Three out of two live studies
randomly allocated the experimental animals, but none The authors whose names are listed certify that they have no
affiliations with or involvement in any organization or entity with any
of the studies reported the detailed protocol of
financial interest (such as honoraria; educational grants; participation
allocation concealment, and none of them adhered to in speakers’ bureaus; membership, employment, consultancies, stock
appropriate blinding of assessments, either during drug ownership, or other equity interest; and expert testimony or patent-
intervention or during the assessment of the outcome. licensing arrangements), or non-financial interest (such as personal or
Figures 6 and 7 provide an overview of methodological professional relationships, affiliations, knowledge or beliefs) in the
quality/risk of bias of each study. subject matter or materials discussed in this manuscript.

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