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Cancer Biology & Therapy

ISSN: 1538-4047 (Print) 1555-8576 (Online) Journal homepage: http://www.tandfonline.com/loi/kcbt20

Anticancer biology of Azadirachta indica L (neem):


A mini review
Rajkumar Paul, Murari Prasad & Nand K. Sah
To cite this article: Rajkumar Paul, Murari Prasad & Nand K. Sah (2011) Anticancer biology
of Azadirachta indica L (neem): A mini review, Cancer Biology & Therapy, 12:6, 467-476, DOI:
10.4161/cbt.12.6.16850
To link to this article: http://dx.doi.org/10.4161/cbt.12.6.16850

Published online: 15 Sep 2011.

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REVIEW

review

Cancer Biology & Therapy 12:6, 467-476; September 15, 2011; 2011 Landes Bioscience

Anticancer biology of Azadirachta indica L (neem)


A mini review

Rajkumar Paul,1,* Murari Prasad2 and Nand K. Sah3


School of Biotechnology; Rajiv Gandhi Technological University; 2Environmental Chemistry Division; Advanced Material Processing Research Institute (CSIR); Bhopal, India;
3
Department of Botany; TNB College; Bhagalpur, India

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Keywords: neem, Azadirachta indica, herbal medicine, nimbolide, azadirachtin, anticancer drug

Neem (Azadirachta indica), a member of the Meliaceae family, is


a fast growing tropical evergreen tree with a highly branched
and stout, solid stem. Because of its tremendous therapeutic,
domestic, agricultural and ethnomedicinal significance, and
its proximity with human culture and civilization, neem has
been called the wonder tree and natures drug store. All
parts of this tree, particularly the leaves, bark, seed-oil and
their purified products are widely used for treatment of cancer.
Over 60 different types of biochemicals including terpenoids
and steroids have been purified from this plant. Pre-clinical
research work done during the last decade has fine-tuned our
understanding of the anticancer properties of the crude and
purified products from this plant. The anticancer properties of
the plant have been studied largely in terms of its preventive,
protective, tumor-suppressive, immunomodulatory and
apoptotic effects against various types of cancer and their
molecular mechanisms. This review aims at scanning scattered
literature on the anticancer biology of A. indica, related
toxicity problems and future perspectives. The cogent data
on the anticancer biology of products from A. indica deserve
multi-institutional clinical trials as early as possible. The
prospects of relatively cheaper cancer drugs could then be
brighter, particularly for the under-privileged cancer patients
of the world.

Arya-veppu (Malyalam), Vaypum (Tamil), Bevu (Kannad) and


Nimtree, Vepu, Vempu, Vepa (Telugu). In east Africa it is also
known as Mwarobaini (Swahili) which literally means the tree
of the 40 as it is considered as a treatment for 40 different diseases. The whole plant is full of domestic, industrial and pharmaceutical values (Tables 1 and 2). The preparations using foliar
extracts of this plant are applied as a panacea for skin problems,
such as, eczema, ringworm, acne and cancer.1 A large number of
unique chemical compounds have been purified from this plant
that are being used effectively as antiseptic, antiviral, antipyretic,
anti-inflammatory, anti-ulcer, anti-malarial, antifungal and anticancer agents (Tables 4 and 5). Some of the most studied compounds include nimbin, azadirachtin, nimbidiol, quercetin and
nimbidin, among others (Tables 3 and 4).2,3 Because of its tremendous therapeutic significance (Fig. 5), neem is also known as a
village pharmacy, particularly in India. This unique plant,
has been closer to human culture and civilization since time
immemorial.
Cancer continues to be an enigmatic challenge for cancer
biologists and medical practitioners. Several tantalizing claims
for discovering a sure cure for cancer have been made by scientists from time to time; yet a dependable cure against most cancers remains a challenge even today. One of the primary reasons
for this is the multiple pathways of survival adopted by cancer
cells. Blocking a few pathways of their survival does not ensure
their targeted elimination. That is why researchers are now trying
to target them through multiple pathways with minimum possible side effects and discomfort to patients. In recent years, certain herbal products and ethnomedicines (Table 1) have drawn
keen attention of researchers and medical practitioners primarily because of convincing anticancer properties with negligible
unpleasant side effects and discomfort to patients.4,5
During the last decade, the anticancer properties of neem
have been investigated in detail from several scientific angles.
The active ingredients obtained from the plant have been demonstrated unequivocally to induce apoptosis in several types of
tumor cells and to organize and gear up the immune system to
take on the cancer cells through cross priming. Regular use of
neem and its preparations have been found to prevent onset of
cancer through multiple mechanisms including production of
substantial levels of antioxidants and carcinogen-detoxifying
enzymes. Against a wide variety of human cancer cell lines and
animal models for human cancers including colon, stomach,
Ehrlichs carcinoma, lung, liver, skin, oral, prostate and breast

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Introduction
Neem (Azadirachta indica) is a tropical evergreen, profusely
branched tree with oblique leaves and stout trunk of timber values with insect-repellant properties. Earlier this plant was also
known as Melia azadirachta (L) and Antelaea azadirachta (L).
It is a native of Myanmar (Burma) and India. But, it may be
found in Bangladesh, Sri Lanka and African countries, as well. It
is about 20 ft tall and belongs to Meliaceae family (Fig. 1AD).
The neem tree is known by a variety of names, such as,
Indian lilac (English), Azadirakhta (Persian), Margosa and
neeb (Arabic), Tamar (Burmese), Kohomba (Sinhala), Pokok
semambu (Malaysia), Dogon yaro (some Nigerian languages),
neem (Hindi and Bangla), nimba (Sanskrit and Marathi),
*Correspondence to: Rajkumar Paul; Email: rajkumarpaul81@gmail.com
Submitted: 05/20/11; Accepted: 06/09/11
DOI: 10.4161/cbt.12.6.16850

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Figure 1. (A) A neem tree,52 (B) an inflorescence of neem,53 (C) fruits of neem54 and (D) seeds of neem.55

cancers; neem products have been demonstrated to produce


impressive anticancer results. This review aims at providing an
in-depth analysis of the scattered research work on the anticancer
therapeutic potential of neem vis--vis its toxicological problems
and future perspectives.
Anti-Carcinogenic and Anti-Mutagenic Effect
of Neem
That neem extracts possess potent ability to remove cancerous
phenotype (tumor commonly termed as nasoor), has long been
known to people in Asia, particularly in India. During the last two
decades, researchers in India and abroad have gathered convincing data to suggest that the onset of cancerous phenotype due to
certain mutagens and pro-carcinogens may be treated effectively
by extracts obtained from various parts of the neem tree. The
chemopreventive effects of dietary doses of aqueous neem leaf
extract was studied on in vivo murine system against 3H-B--P
(Benz--pyrene)-induced initiation of cancer measured in terms
of 3H-B--P-DNA adduct.6 Their results indicated that neem
leaf extract reduced the metabolic activation of 3H-B--P with

468

consequent decrease in the level of 3H-B--P-DNA adduct formation. These molecular and biochemical modulations observed
at the initiation phase of carcinogenesis highlight the chemopreventive significance of A. indica extracts. In another interesting
study, Chaimuangraj et al. observed that dietary feeding of the
neem leaf extract (20, 100, 250 mg/Kg body weight) significantly
inhibited the azoxymethane-induced aberrant crypt foci (ACF)
and also significantly decreased the proliferating cell nuclear
antigen (PCNA) labeling indices (p < 0.0006) in the colon epithelium in rats. The preventive action of neem flowers has been
demonstrated by several research groups against the neoplastic
developments due to chemicals including DMBA and BP.8-10
These results indicate that dietary use of extracts from various
parts of A. indica may play a promising role in future drug discovery and development programs as far as chemoprevention
of cancer is concerned. Most of the ethnomedicinal and early
studies on neem with respect to its anticancer properties suffered
from lack of credible mechanistic principles. Serious attempts at
unraveling the possible scientific interpretations of the chemopreventive/anticancer effects of neem extracts have been made
in recent years. O6-alkylguanines are potently mutagenic and

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Table 1. Ethnomedicinal and ritualistic significance of neem (A. indica)


S. no

Ethnomedicinal/Ritualistic uses

Scientific significance

Remarks

On the eve of Hindi New Years Day in the month of


Chaitra (MarchApril) a paste from the neem leaf or
its aqueous lysate is orally taken. This is also known
as Gudipadwa in some parts of India.

This date signifies the end of winter and


beginning of spring followed by summer.
During this seasonal change health problems
aggravate. Oral consumption of foliar paste
of neem may take care of these problems.

The ancient sages in India


enshrined these rituals in the
culture and civilization of this
region only because of its
medicinal efficacy.

Use of neem boughs with green leaves is prevalent


during Nagpanchmi, a festival for worshipping
deadly snakes. On the eve of the festival neem
leaves are consumed as a precaution against
the poisonous snakes. It is assumed that oral
consumption of neem may help to overcome
problems associated with snake bite.

Certain ingredients of neem may be acting as


an antidote for snake venom.

This ritual has been prevalent in


India, particularly in the eastern
states since time immemorial.
The antidotes against snake
venom may be worked out.

Neem twigs are hung outside the labor room


during and after the birth of a child for some days
in order to avoid the evil spirits that may otherwise
jeopardize the life of the new born.

Many times, particularly in rural India, child


birth takes place in a clean room in the
residential place. Presence of neem twigs
with leaves may help avoid viral/bacterial
infections to mother and the child.

The ancient sages understood


the significance of neem as an
antibiotic. So, it was enforced
into the social custom as a ritual
during child birth.

Soft leaves of neem are used as bed cover for


patients suffering from small pox.

Small pox used to be an epidemic. Now it


has been controlled to a large extent. During
those days, neem leaves were used as an
antiviral agent.

It is not understood how neem


acts as an antiviral.

Powdered neem leaves are used externally for healing wounds. Earlier, neem leaves were burnt into
powdered form, mixed with mustard oil and applied
on open wounds to speed healing.

The antibiotic nature of neem is exploited


still in certain parts of India, particularly by
rural populations.

This practice has been long in


use in India.

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pro-carcinogenic. O6-methylguanine-DNA methyltransferase


(MGMT) is an enzyme that detoxifies O6-alkylguanines and
thus tries to maintain genomic integrity of the cells. Recently
ethanolic and aqueous extracts of neem have been demonstrated
to enhance the activity of MGMT leading to time-dependent
demethylation of O6-methylguanine and consequent prevention of its cytotoxic lesions.11 A facilitated elimination of these
lesions by increasing the activity of MGMT is likely to be a beneficial chemoprevention strategy. More recently, development of
DMBA-induced hamster buccal pouch (HBP) carcinoma has
been observed to be inhibited by nimbolide and azadirachtin in a
concentration-dependent manner through multiple mechanisms
including prevention of activation of procarcinogen, oxidative
DNA damage and upregulation of antioxidant and carcinogen
detoxifying enzymes.12
Effect of Neem on Drug Metabolizing Enzymes
In certain cases, neem preparations have also been observed to
potentiate the antitumor activities of certain drugs besides affording protection against life threatening side effects of these chemotherapeutic agents. For example, pre-treatment of Swiss mice
with NLP not only suppressed leucopenia and neutropenia but
also potentiated the antitumor activities of cyclophosphamide
concomitantly. In an interesting observation HPLC-generated
neem leaf fractions have been shown as positive modulators of the
phase-I and phase-II xenobiotic-metabolizing enzymes, lipid and
protein oxidation and anti-oxidant defense enzymes leading to
attenuation of the DMBA-induced HBP carcinoma in the Swiss
mice.13

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Table 2. Parts of neem (A. indica) tree with medicinal uses


S. no

Parts of
neem tree

Treatable ailments

Bark

Analgesic, alternative and curative of fever

Twig

Leaf

Flower

Fruit

Piles, intestinal worms, urinary disorder,


epistaxis, phlegm, eye problem, diabetes,
wounds, leprosy

Seed

Leprosy, intestinal worms, cancer

Oil

Leprosy, intestinal worms

Gum

Scabies, wounds, ulcers, skin diseases

Cough, asthma, piles, phantom tumor,


intestinal worms, spermatorrhoea,
obstinate urinary disorder, diabetes
Leprosy, eye problem, epistaxis,
intestinal worms, anorexia, biliousness,
skin ulcers, cancer
Bile suppression, elimination of intestinal
worms, phlegm

Cisplatin (cis) and 5-fluorouracil (5-FU) are established


chemotherapeutic agents against certain forms of cancer. But,
they also cause terrible side effects including programmed cell
death of circulating blood cells. In order to reduce these side
effects granulocyte colony stimulating factor (GCSF) is often
administered while treatment with cis and 5-FU. Recently pretreatment with neem leaf preparation (NLP) has been found
to protect circulating blood of cis and 5-FU treated Swiss mice
significantly. NLP could, therefore, be a better substitute than
GCSF which is expensive and is also known to promote angiogenesis and tumor development in the experimental animals.14

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Table 3. Medicinal properties of neem (A. indica) tree preparations


S. no

Therapeutic uses

Types of preparations

Immunostimulant activity

Aqueous extracts of neem bark and leaf

45

Hypoglycaemic activity

Aqueous extracts of neem leaves

46, 56

Antiulcer effect

Aqueous extracts of neem leaf and bark

57

Antifertility effect

Seed oil

4749, 58, 59

Antimalarial activity

Seed and leaf extracts

6062

Antifungal activity

Extracts of neem leaf, neem oil seed kernels

6364

Antibacterial activity

Aqueous leaf extract

6365

Antiviral activity

Aqueous leaf extract

24, 27, 3132, 66, 67

Anticancer activity

Aqueous leaf extract

24, 27, 31, 32

10

Antioxidant activity

Leaf and seed extract

1213, 15, 16

11

Effect on central nervous system

Leaf extract

68

Skin tumor induction is often associated with upregulation


of certain marker enzymes, such as alkaline phosphatase, alanine aminotransferase and aspartate aminotransferase. Upon
treatment with aqueous A. indica leaf extract (AAILE) there
was significant decrease in the activity of these marker enzymes.
The AAILE treatment reduced oxidative stress by decreasing
lipid peroxidation levels and by enhancing the reduced glutathione contents and activities of various antioxidant enzymes.15,16
Hanachi et al. demonstrated that oral administration of 5%
(w/v) of A. indica extract suppressed the diethylnitrosamine and
acetylaminofluorene induced pre-neoplastic nodules in the male
Sprague drawly rats apparently by increasing the distribution of
antioxidant elements and GST activity. Their results suggest that
neem extract protects against onset of hepatocarcinoma with
negligible side complications on normal cells. In another interesting piece of research performed on 7-wk-old Swiss albino mice,18
80% ethanolic extract of the leaves of A. indica has been shown
to enhance the phase-II hepatic enzymes, such as, Glutathione
S Transferase and DT-diaphorase. These enzymes, which are
known to be involved in detoxification of certain chemical carcinogens, were studied vis--vis BP and DMBA (7,12 dimethyl
benz anthracene)-induced onset of carcinogenesis. The neem
extract was observed not only to induce the phase-II enzymes but
also to enhance the activity of the hepatic antioxidant enzymes
including, glutathione reductase, glutathione peroxidase and
superoxide dismutase. Similar results on the anti-oxidant activity of the aqueous foliar extract and ethanolic extracts of flower
and stem bark of Siamese neem has been made by Sithisarn et al.
Neem may, therefore, be used as a potent preventive and adjuvant
therapy against cancer.

References

of these extracts were equal to or better than the standard


anticancer agents, particularly against solid tumors. For example, ethanolic extracts (80%) of neem leaf, when administered
at doses of 250500 mg per kilogram, suppressed the average
number of papilomas as well as overall tumor burden induced
by BP and DMBA significantly (p < 0.005 and p < 0.001) in
the 7-wk-old Swiss albino mice model.18 In another interesting
molecular study, a Japanese group has demonstrated that nimbolide, a triterpenoid present in certain edible parts of A. indica,
arrested the HT-29 (human colon carcinoma cells) in G2 /M and
G0 /G1 stages apparently through upregulation of p21 which is
a well known down-stream effector of the p53 gene. p53 is a
very important anticancer protein (product of p53 gene) that
regulates a large number of genes that are involved in tumorigenesis. Nimbolide has also been shown to upregulate cyclin D2
and Chk2; and to suppress the expression of cyclin A, cyclin
E, Cdk2 and Rad17 at the same time.20 Extending these studies on the U937, HL-60, THP1 and B16 cell lines, Kumar and
authors21 have demonstrated that nimbolide exerted antiproliferative and apoptotic effects apparently through the suppression of bcl-2/bax ratio and through the mediation of increased
expression of Apaf-1 and caspase-3. These observations suggest
that neem ingredients act through molecular pathways to register
anticancer effects. Subapriya et al.22 also investigated molecular
pathways of anticancer effects of the ethanolic neem leaf extract
(ENLE) on DMBA-induced carcinogenesis in buccal pouch of
hamster. Their observations suggest involvement of the PCNA
(Proliferating cell nuclear antigen), mutant p53 and bcl2 genes.
These pro-cancer genes are upregulated during DMBA-induced
carcinogenesis. The use of ENLE has been observed by them to
suppress these genes as well as DMBA-induced cell proliferation
and differentiation. In another interesting study by Bieberich et
al, neem seed oil has been found to suppress breast tumor development in the ex vivo experimental models of female mice. They
have observed that 50 l of neem seed oil inoculated at a dilution of 1:25 every week around the ex vivo developing breast
cancer (MCF-7 cell line) for about 50 d reduced tumor burden
by 50%. These observations provide emphatic evidence to help
evolve working strategies to make use of antitumor efficacy of
neem extracts on human beings.

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Neem Arrests Tumor Cell Growth and Proliferation


There is interesting and compelling evidence to suggest that
neem may be used as a tumor suppressor. Researchers in
India, Europe and Japan have found that polysaccharides and
limonoids present in the neem bark, leaves and seed oil reduced
tumors and cancers, and showed efficacy against lymphocytic
leukemia. In Japan, hot water extracts from neem bark showed
remarkable effectiveness against several types of tumors. Some

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Table 4. Triterpenoids and steroids isolated from neem (A. indica)

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S. no

Name of constituents

Chemical formula

Melting point (C)

Isolated from

Nimbin

C30H36O9

205

Oil, trunk and root bark

Nimbinin

C28H34O6

202

Oil, trunk and root bark

Nimbidic acid (Salannic acid)

C26H34O7

228

Oil

Salannin

C34H44O9

167

Oil

Deacetyl Nimbin

C28H34O8

208

Seeds and bark

Nimbolide

C27H30O7

245

Leaves

Meliantriol

C30H50O5

176

Oil

Azadirone

C28H36O4

192

Oil

Epoxyazadiradione

C28H34O6

202

Oil

10

Azadiradione

C28H34O5

205

Oil

11

Gedunin

C28H34O7

218

Oil

12

7-Deacetyl Gedunin

C26H34O6

259

Oil

13

Meldenin

C28H38O5

240

Oil

14

Salannin-lactone

C34H44O10

244

Oil

15

Nimbin-lactone

C30H36O10

184

Oil

16

Azadirachtin

C35H44O16

155

Seeds

17

Vepinin

C28H36O5

Oil

18

Nimbolin A

C39H46O8

180

Trunk wood

19

Nimbolin B

C39H46O10

243

Trunk wood

Nimbidinin

C26H34O6

282

Oil

Vilasinin

C26H36O5

255

Leaves

20
21
22
23
24

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Nomolin

C28H34O6

205

Fruits

Nimolicin

C28H34O5

166

Fruits

17-Hydroxy-azadiradione

C28H34O6

Fruits

17-Hydroxy-azadiradione

C28H34O6

177

Fruits

26

17-Epi-azadiradione

C28H34O5

205

Fruits

27

1-Methoxy-1,2-dihydroepoxy-azadiradione

C29H38O7

235

Seeds

28

1, 2-Diepoxy-azadiradione

C28H34O7

110

Seeds

25

29

7-Acetylneotrichilenone

C28H36O5

208

Seeds

30

7-Deacetyl-7-benzoylazadiradione

C33H36O5

Amorphous

Seeds

31

7-Deacetyl-7-benzoylepoxy-azadiradione

C33H36O6

Amorphous

Seeds

32

7-Deacetyl-7-benzoylgedunin

C33H36O7

278

Seeds

33

Nimbinene

C28H34O7

134

Oil, leaves and bark

34

6-Deacetyl nimbinene

C26H32O6

141

Oil, leaves and bark

35

Nimbandiol

C26H32O7

121

Oil, leaves and bark

36

6-o-Acetyl-nimbandiol

C28H34O8

178

Oil

37

3-Deacetylsalannin

C32H42O8

214

Oil

38

Salannol

C32H44O8

208

Oil

39

1,3-Diacetyl-vilasinin

C30H40O7

157

Oil

40

Nimocinol (6-Hydroxy-azadirone)

C28H36O5

130

Leaves

41

-Sitosterol

C29H50O

140

Blossom, leaves and wood oil

42

-Sitosterol--D-glucoside

C35H60O6

283

Blossom, leaves
and heart wood

43

Cycloeucalenol

C30H50O

138

Wood oil

44

24-Methylene-cycloartanol

C31H52O

122

Wood oil

45

4,14-Dimethyl 5-ergosta-8,24 (28)-dien-3-ol

C30H50O

Heart wood

46

4-Methyl-5-ergosta-8,24 (28)-dien-3-ol

C29H48O

Heart wood

47

Neem leaf glycoprotein

Leaf

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Table 5. Non-terpenoid and non-steroid constituents of neem (A. indica)


S. no

Name of constituents

Chemical formula

Melting point (C)

Isolated from

Kaemferol

C15H10O6

276

Blossoms

Quercetin

C15H10O7

313

Blossoms and leaves

Myricetin

C15H10O8

357

Blossoms

Sugiol

C20H28O2

292

Trunk bark

Nimbiol

C18H24O2

250

Trunk bark

Glucoside of Quercetin

C21H20O12

Leaves

Glucoside of Kaemferol

C21H20O11

Leaves

Melicitrin

C20H18O12

Blossoms

Quercetin-3-galactoside (Hyperin)

C21H20O12

237

Blossoms and leaves

10

Kaemferol-3-glucoside (Astragalin)

C21H20O11

178

Blossoms

11

Quercitrin

C21H20O11

250

Leaves

12

Rutin

C27H30O16

214

Leaves

13

Isorhamnetin

C16H12O7

305

Leaves

14

Rhamnoside of Quercetin

C21H20O11

245

Leaves

15

5-Hydroxy-methyl furfural

C6H6O3

Fruit

Neem Induces Apoptosis in Cancer Cells


Apoptosis or programmed cell death is a genetically driven process
that has been kept conserved largely among the metazoans since
millions of years. This is such a fine natural method of surgery
that requires biochemical blades led by a host of caspase enzymes
to wipe out the unwanted, redundant, wayward, incorrigible and
irreparable cells of the body without shedding even a single drop
of blood and without any material loss to the body as a whole.
The medical practitioners have, therefore, accepted elimination
of cancer cells through orchestration of apoptosis as a therapy of
choice. Neem extracts and its purified products have been examined for induction of apoptosis among the cancer cells. Following
DNA fragmentation and cell viability assays, an ethanolic extract
of neem has been shown to induce apoptosis in prostate cancer
cells (PC-3) in a dose-dependent manner.21 These observations
are commensurate with the findings that treatment with neem
extract (1) suppressed the level of expression of bcl-2 protein,
which is a strong pro-survival factor in cancer cells and (2) at the
same time enhanced the level of expression of pro-apoptotic Bax
protein. The neem extract could thus be a potentially effective
treatment against prostate cancer. Working on the choriocarcinoma (BeWo) cells, Kumar et al.24 have shown that nimbolide,
which is an active anticancer principle of the neem leaf and flowers, induces apoptosis through engagement of the mitochondrial pathway. The involvement of this pathway is based on the
observation that nimbolide mediates upregulation of Apaf1 and
caspase3 and decrease in the bcl2/bax ratio. Treatment of U937,
HL-60, THP1 and B16 cells with nimbolide has been observed
to disrupt cell cycle check points (G2 /M, G0 /G1 and G/S) in
correlation to induction of apoptosis.25 The molecular connection that exists between cell cycle disruption and apoptosis is not
clearly shown by them in these cells. Sometimes, cell cycle disruption leading to arrest of cells at the cell cycle check points is
attributed to immunity against apoptosis. This is true at least

in cases where cell cycle arrest has been demonstrated to accrue


through p53 and its downstream attendant p21 gene.26 Subapriya
and coworkers22,27 have found convincing results on the apoptosis-inducing ability of ENLE on DMBA-induced cancer cells/tissues in the HBP model. They have shown that ENLE enhanced
the expression of pro-apoptotic genes, such as, bim, caspase-8
and caspase-3, and at the same time suppressed bcl2, PCNA
and mutant p53 in the DMBA-induced cancer cells (Fig. 2).
These observations are correlated reasonably well to elimination of the neoplasm. It is, thus obvious that crude extracts and
purified drugs from neem possess credible ability to induce programmed cell death among cancer/tumor cells. This therapy of
cancer may be considered for human patients, as well.

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The Role of Neem in Bioimmunotherapy of Cancer


The innate and the acquired immune systems keep vigil on the
overall defense of the body. Gearing up the immune system
against targeted attack on health risks has been contemplated as a
dependable therapy known as bioimmunotherapy. Cancer biologists and medical practitioners have accepted bioimmunotherapy
as one of the dependable therapeutic regimens against cancer.
Several drugs of immunological origin are in great demand. For
example, interferons (IFN) are well known therapeutic cytokines
that are used as anticancer agents against many types of cancer
cells in vitro and in vivo.28 It is used individually and in combination with other anticancer agents including ionizing radiations.
Subversion of the bodys immune and genetic system is often
a prelude to initiation of cancer. Some recent inputs to cancer
research demonstrate that neem exerts anticancer effects against
various types of cancers efficiently by gearing up the bodys
immune response. Neem modulated active specific immunotherapy intends to boost the hosts antitumor immune response
by proper presentation of tumor-associated antigen (TAA) or its
derivatives to B and T cells, where the role of antigen presenting cells (APC) is predominant. Closely in line with this view,

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Figure 2. Functional mechanisms of neem. 24,27,31-32

Baral et al.29 demonstrated that neem leaf preparation (NLP)


acted as an adjuvant in the course of generation of appreciable
level of anti-serum in C57BL/6 mice against B16MelSAg (vaccine). This anti-serum must show anticancer property if it is to
be dependable. Vaccination of the mice with B16MelSAg+NLP

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indeed prevented the growth of B16 melanoma tumor more


efficiently than B16MelSAg and NLP alone. This result was
adequately supported by the observation that anti-serum (raised
against B16MelSAg+NLP) when injected subcutaneously after
mixing with B16Mel tumor in the syngenic C57BL/6 mice

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reduced the tumor burden quite significantly as compared with


parallel controls. In an interesting study, Sarkar et al.30 have
shown that antiserum raised against NLP in the Swiss mice
may react with carcinoembryonic antigen (CEA) as well as
with a peptide derived from it. NLP may thus be considered
for use not only as a potential immune adjuvant but also as an
effective antigen for inducing active immunity against at least
certain tumors. These results may help evolve formal strategies for treatment of tumors, particularly CEA positive ones,
albeit a convincing explanation of this observation is yet to
come. Recent work done by Bose and Baral31 shows that NLP
enhances NK-cell mediated cytotoxicity of human cancer cells
(K562) possibly through CD40-CD40L dependent endogenous
production of IL-12 and activation of p38 MAPK pathway. It
has been suggested that these pathways critically control perforin to eliminate tumor cells. An active ingredient (Neem Leaf
Glycoprotein, NLGP) recently isolated from neem leaf preparation has been investigated for its immunomodulatory role in the
restoration of the impaired chemotactic movement of peripheral
blood mononuclear cells (PBMC) toward the head and neck
squamous cell carcinoma to exert antitumor activities.32 Their
study is actually based on an earlier finding that NLGP exerts
immunomodulation-mediated restriction of murine tumors in
vivo. They have observed that NLGP enhanced expression of
IFN which in turn downregulated CXCR3B (splice variant of
CXCR3, responsible for lymphocyte apoptosis) in the in vitro
human HNSCC-PBMC. As a result, the ratio of CXCR3A/
CXCR3B increased and restored chemotaxis of PBMCs toward
the tumor. Activation of the immune system by NLGP was
also studied in terms of upregulation of early markers, CD69
and CD45RO and downregulation of CD45RA and CD62L
(L-selectin) on the lymphocyte, monocyte and dendritic cells.33
NLGP has been observed to prompt the type I response through
activation of T cells that begin secretion of greater amount of
signature T-helper (Th) 1 cytokines, such as IFN. NLGP also
gears up type II response measured in terms of IL4 secretion but
to a comparatively less amount than type I. These workers have
further shown that NK-cells and cytotoxic T-cells isolated from
the immunosuppressed patients of HNSCC (head and neck
squamous cell carcinoma) may be activated effectively by NLGP
to kill K562 (erythroleukemia) cells and KB (oral cancer) cells,
respectively. NLGP-induced activation of CTL response was
found dependent on IFN-mediated upregulation of perforin/
granzyme B in the killer cells, but independent of this in the NK
cells.34 A similar preparation from neem (NLP) was observed to
replenish the pool of WBC, which was reduced by cyclophosphamide (CYP) in mice.35 This result was in good correlation to
significant inhibition of CYP-induced tumor growth and consequent survival rate of mice following pre-treatment with NLP.
In another interesting study, pretreatment with neem leaf preparation (NLP) suppressed murine Enrlich carcinoma and B16
melanoma in the Swiss and C57BL/6 mice. These observations
correlated well to activation of NK and NK-T cells, as well as
enhanced secretion of TNF and IFN.36 TNF is a controversial cytokine that may act as antitumor and protumor depending upon several factors including the type of cell line, external

and internal stimuli, etc. However, a large body of modern literature on cancer shows that TNF is a strong survival factor for
cancer, because it activates NFB (a strong transcription factor)
that may induce innumerous genes that support survival of cancer.37 Using BALB/-c mice as an experimental model it has been
observed that there was a significant enhancement in the peritoneal macrophage activity and expression of activation marker
CD44 following regular subcutaneous administration of aqueous neem extract. This extract was also observed to enhance the
CD4, CD8 and CD25 positive sub-population of lymphocytes.
At the same time, metastatic activity of sarcoma L-1 and lymphosarcoma RAW cells was attenuated by this extract.38 Nitric
oxide (NO), a key tumoricidal agent is known to regulate T-cell
proliferation, cytokine production, cell signaling and apoptosis.39
Several laboratories have demonstrated that the T-cell derived
cytokines IFN, along with IL-2 and/or TNF, are macrophage
activators and serve as a potent inducer of NO.40 NLGP along
with tumor antigen vaccination showed NO production and
upregulation of IL-12 and excess IFN.41 Neem leaf preparation
enhances tumor antigen presentation of the macrophages42 and
dendritic cells to the T and B cells for induction of antitumor
immunity by allowing generation of immune effector/memory
response.43 That NLGP can enable maturation of the myeloid
derived DCs and can optimize the antitumor T-cell functions is
also known. Thus, it can be used as a candidate vaccine tool for
antigen specific cancer immunotherapy.44

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474

Toxicological Risk Factors Involved


in the Use of Neem Extracts

In spite of its versatile qualities neem deserves use with care.


Indiscriminate use of its extracts, particularly when taken in
overdoses, may cause unpleasant side effects. Some people are
excessively allergic to neem products which may cause itching,
swelling of mouth and throat, wheezing and sometimes breathing difficulties. Use of neem or its products may also be a reason
for damage to liver and kidney that may result in jaundice and
in low or no urine production, respectively. Although neem has
some hematostimulatory effect as observed in mice, it may also
destroy red blood corpuscles.45 Excessive use of neem may bring
about neurotoxicity. One of the important concerns about its use
is its ability to interfere with the normal reproductive systems
fostering infertility.46-49 DNA methylation is a major epigenetic
regulatory mechanism. A statistically insignificant reduction in
methylated deoxycytidine has been observed in the infertile male
group treated with neem than in the untreated ones.50 Neem has
been in use since the dawn of civilization, yet no severe harmful effect has been reported. Since ancient times, therefore, neem
tree is kept at bay from the regular dwelling places.
Conclusion
Neem (Azadirachta indica) has been an ancient source of herbal
panacea against a variety of human health problems. Researchers
have been trying to purify the active ingredients from this plant
and to work out their mechanistic, therapeutic and clinical

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aspects on the reliable systems. Over 60 various products from


neem are available in the purified form. These products vis-vis the crude extracts of neem are being tested expediently
on suitable in vitro and in vivo systems to establish their anticancer and immunomodulation effects. There are compelling
experimental evidences to suggest that neem products e.g.,
Azadirachtin A, Nimbolide, Nimbidin etc., possess convincing
anticancer properties. Molecular mechanisms of their action
have been investigated. Due to these reasons, it is imperative
that suitable clinical trials should be conducted to pave the way
to bring these products into the market as certified anticancer
drugs. The scientific data show that suitable combinations of
drugs tempered with radiotherapy and bioimmunotherapy may
be of great promise in finding a sure cure for cancer patients.
Neem products may cause some unpleasant side effects, particularly if taken in overdoses. It is, therefore, advisable that
these products be used under the supervision and prescription
of qualified medical practitioners and physicians.
Future Perspectives
The world market for alternative medicine has increased to
about 10.895 billion USD as per a recent report by the World

Disclosure of Potential Conflicts of Interest

No potential conflicts of interest were disclosed.

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enc
e.
Donotdi
s
t
r
i
but
e.

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Cancer Biology & Therapy Volume 12 Issue 6

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