molecules

Review
Suppressive Effects of EGCG on Cervical Cancer
Ying-Qi Wang, Jian-Liang Lu, Yue-Rong Liang and Qing-Sheng Li *
Tea Research Institute, Zhejiang University, # 866 Yuhangtang Road, Hangzhou 310058, China;
[email protected] (Y.-Q.W.); [email protected] (J.-L.L.); [email protected] (Y.-R.L.)
* Correspondence: [email protected]; Tel.: +86-571-8898-2704

Academic Editor: Helieh S. Oz




Received: 9 August 2018; Accepted: 11 September 2018; Published: 12 September 2018

Abstract: Cervical cancer is the fourth most common gynecological cancer worldwide. Although
prophylactic vaccination presents the most effective method for cervical cancer prevention,
chemotherapy is still the primary invasive intervention. It is urgent to exploit low-toxic natural
anticancer drugs on account of high cytotoxicity and side-effects of conventional agents. As a natural
product, (-)-epigallocatechingallate (EGCG) has abilities in anti-proliferation, anti-metastasis and
pro-apoptosis of cervical cancer cells. Moreover, EGCG also has pharmaceutical synergistic effects
with conventional agents such as cisplatin (CDDP) and bleomycin (BLM). The underlying mechanisms
of EGCG suppressive effects on cervical cancer are reviewed in this article. Further research directions
and ambiguous results are also discussed.

Keywords: Camellia sinensis; EGCG; cervical cancer; human papillomavirus (HPV); anticancer

1. Introduction
Cervical cancer is the fourth most common female cancer in terms of both incidence and mortality
rates worldwide, with an estimated 528,000 new cases in 2012, including 266,000 deaths (85% occurring
in developing countries) [1]. Although screening methods and early detection programs have been
established, invasive cervical cancer still represents a major concern for public health. Risk factors
of cervical cancer include human papillomavirus (HPV), sexual behavior beginning at a young age
(<16 years old), multiple sexual partners (more than four), history of genital warts, HIV positive,
and cigarette smoking or environmental tobacco smoke [2]. More than 99% of cervical cancer patients
carry at least one genotype of oncogenic HPV [3], since persistent infection with HPV is the prominent
etiological reason in the formation of cervical cancer [4]. However, more than 200 types of identified
HPVs can be classified as low-risk HPVs and high-risk HPVs [5]. Low-risk HPVs induce inconspicuous
infection or benign papilloma which could eventually be resolved by the immune system and rarely
cause neoplasia and carcinogenesis [6]. On the contrary, high-risk HPVs are related to the propensity of
malignant progression of virus-mediated lesions [7,8]. Among them, HPV 16 and HPV18 are the two
major viruses responsible for approximately 70% of all cervical carcinomas worldwide. HPV has two
vital transcriptional units, E6 and E7, that encoded oncoproteins primarily attribute to its oncogenic
function [9]. E6 protein inhibits the activity of tumor suppressor P53, and E7 protein targets other tumor
suppressors of the retinoblastoma family [10,11]. A series of human cervical cancer cell lines have been
used to study the potential anticancer ability of chemo therapeutic agents, including HPV18-positive
HeLa cell lines, HPV16-positive CaSki and SiHa cell lines, etc. Similar to other cancers, cervical
cancer harms the human body mainly due to the proliferation and metastasis of cancer cells. Current
treatments in curing cancers aim at anti-proliferation, anti-metastasis of cancer cells, and inducing
cancer cell apoptosis.
Until now, prophylactic vaccination is the primarily effective prevention strategy for cervical
malignancies [12]. Although these vaccines could prevent approximately 90% of cervical carcinoma,

Molecules 2018, 23, 2334; doi:10.3390/molecules23092334 www.mdpi.com/journal/molecules

Molecules 2018, 23, x FOR PEER REVIEW 2 of 17

the prohibitive
Molecules price
2018, 23, 2334 is incubus especially in developing countries [13,14]. Besides prophylactic 2 of 17
vaccination, cervical cancer remains curable if detected at early stage, but hard to remedy in
metastatic or recurrent carcinoma [5]. Among conventional therapies including surgery,
the prohibitive price is incubus especially in developing countries [13,14]. Besides prophylactic
radiotherapy, chemotherapy and immunotherapy [15], chemotherapy is the first option for patients
vaccination, cervical cancer remains curable if detected at early stage, but hard to remedy in
that could effectively promote the apoptosis of cancer cells. Nevertheless, due to its high
metastatic or recurrent carcinoma [5]. Among conventional therapies including surgery, radiotherapy,
chemoresistance ability and toxicity on normal cells, more effective methods using less toxic
chemotherapy and immunotherapy [15], chemotherapy is the first option for patients that could
anticancer drugs and novel therapeutic intervention strategies are required nowadays. Polyphenols
effectively promote the apoptosis of cancer cells. Nevertheless, due to its high chemoresistance
such as catechins, curcumin and ferulic acid with low side effects are potential safe anticancer
ability and toxicity on normal cells, more effective methods using less toxic anticancer drugs and
strategies for cervical cancer intervention.
novel therapeutic intervention strategies are required nowadays. Polyphenols such as catechins,
Tea is one of the three most widely consumed non-alcohol beverages in the world. The
curcumin and ferulic acid with low side effects are potential safe anticancer strategies for cervical
prominent catechins in teas are (-)-epigallocatechingallate (EGCG), (-)-epicatechingallate (ECG), (-)-
cancer intervention.
epigallocatechin (EGC), and (-)-epicatechin (EC) [16]. EGCG accounts for more than 40% of total
Tea is one of the three most widely consumed non-alcohol beverages in the world. The prominent
catechins in green tea [17], and plays a critical role in cancer chemoprevention, diabetes,
catechins in teas are (-)-epigallocatechingallate (EGCG), (-)-epicatechingallate (ECG), (-)-epigallocatechin
neurodegenerative diseases, stroke, obesity and other biochemical disorders [18]. The cancer
(EGC), and (-)-epicatechin (EC) [16]. EGCG accounts for more than 40% of total catechins in green
prevention ability of EGCG is widely supported by results from epidemiological, in vivo and in vitro
tea [17], and plays a critical role in cancer chemoprevention, diabetes, neurodegenerative diseases,
studies [19–22], especially in breast cancer [23], liver cancer [24], and prostate cancer [25,26].
stroke, obesity and other biochemical disorders [18]. The cancer prevention ability of EGCG is widely
However, the effects of EGCG on the prevention of cervical cancer are still inconclusive and
supported by results from epidemiological, in vivo and in vitro studies [19–22], especially in breast
controversial [27]. This review summarizes recent research data mainly focused on the effects of
cancer [23], liver cancer [24], and prostate cancer [25,26]. However, the effects of EGCG on the prevention
EGCG on cervical cancer, including in vivo and in vitro studies, and offers directions for further
of cervical cancer are still inconclusive and controversial [27]. This review summarizes recent research
study.
data mainly focused on the effects of EGCG on cervical cancer, including in vivo and in vitro studies,
and offers directions for further study.
2. Anti-Proliferation of Cervical Cancer Cells
2. Anti-Proliferation
The mechanism of of tumor
Cervical Cancer Cells
progression is based on the proliferation and metastasis of cancer cells
[28]. The
Onemechanism
of the characteristics
of tumor progression is malignancies
in advanced based on the isproliferation
infinite proliferation of cancer
and metastasis cells.
of cancer
Inhibiting
cells proliferation
[28]. One of cervical cancer
of the characteristics cells could
in advanced stabilize the
malignancies symptoms
is infinite of a patient
proliferation and extend
of cancer cells.
Inhibiting proliferation of cervical cancer cells could stabilize the symptoms of a patient andcancer
the treatment duration with higher curative potential. EGCG can reduce cervical extend cell
the
proliferation in various ways (Figure 1), including: (1) inducing cancer cell cycle arrest;
treatment duration with higher curative potential. EGCG can reduce cervical cancer cell proliferation (2) regulating
cancer
in variouscell ways
growth; (3) inducing
(Figure cellular
1), including: microtubule
(1) inducing depolymerization
cancer cell cycle arrest;and(2) inhibiting
regulating tubulin
cancer
assembly; (4) inhibiting angiogenesis; and (5) restraining HPV oncoproteins.
cell growth; (3) inducing cellular microtubule depolymerization and inhibiting tubulin assembly;
(4) inhibiting angiogenesis; and (5) restraining HPV oncoproteins.

Figure 1. Molecular mechanisms of (-)-epigallocatechingallate (EGCG) suppressing the proliferation

of cervical cancer cells. EGCG down-regulated the expressions of E6, E7, EGFR, IGF-1 and HIF-1,
Figure 1. Molecular mechanisms of (-)-epigallocatechingallate (EGCG) suppressing the proliferation
then the expressions of downstream targets such as the AKT/PI3K pathway, mTOR pathway and
of cervical cancer cells. EGCG down-regulated the expressions of E6, E7, EGFR, IGF-1 and HIF-1, then
ERK1/2 also declined. The decline of E6 could up-regulated P53 expression resulting in P21 and P27
the expressions of downstream targets such as the AKT/PI3K pathway, mTOR pathway and ERK1/2
up-regulations, then CDK2 was down-regulated. The down-regulation of the mTOR pathway led to
also declined. The decline of E6 could up-regulated P53 expression resulting in P21 and P27 up-
VEGF reduction. Eventually, the reduced expressions of ERK1/2, VEGF and CDK2 suppressed the
regulations, then CDK2 was down-regulated. The down-regulation of the mTOR pathway led to
proliferation of cervical cancer cells (broken lines mean indirect approaches). AKT: protein kinase B;
VEGF reduction. Eventually, the reduced expressions of ERK1/2, VEGF and CDK2 suppressed the
CDK2: cyclin-dependent kinase 2; E6: one of human papillomavirus (HPV) oncogenes; E7: another
proliferation of cervical cancer cells (broken lines mean indirect approaches). AKT: protein kinase B;
HPV oncogene; EGFR: epidermal growth factor receptor; ERK: extracellular signal-regulated kinase;
CDK2: cyclin-dependent kinase 2; E6: one of human papillomavirus (HPV) oncogenes; E7: another
HIF-1: hypoxia-inducible factor 1; IGF-1: insulin-like growth factor 1; mTOR: mammalian target of
HPV oncogene; EGFR: epidermal growth factor receptor; ERK: extracellular signal-regulated kinase;
rapamycin; P21: tumor suppressor protein; P27: tumor suppressor protein; P53: tumor suppressor
HIF-1: hypoxia-inducible factor 1; IGF-1: insulin-like growth factor 1; mTOR: mammalian target of
protein; PI3K: phosphoinositide-3-kinase; VEGF: vascular endothelial growth factor.
Molecules 2018, 23, 2334 3 of 17

2.1. Inducing Cancer Cell Cycle Arrest

Mitosis consists of G1, S, G2 and M phases. EGCG-induced mitosis arrest at low concentration
(0–25 µg/mL) in squamous cervical carcinoma Me180 cells [29]. EGCG also could arrest cell division
during different phases of the cell cycle in various cell lines. In HeLa cells, EGCG and theaflavins
induced sub-G1 phase arrest in a dose-dependent manner and showed a time-dependent inhibition of
their proliferations [30]. EGCG induced G1 phase arrested in HPV16-related CaSki cells and regulated
related gene expressions [31]. In G2/M phases, EGCG could arrest the cell growth of the HeLa cell line
and SiHa cell line in a time-dependent and dose-dependent manner, respectively.
Organisms secrete tumor suppressors to arrest the cell cycle in tumor cells, such as P53 protein
and cyclin-dependent kinases inhibitors (CKI) [32]. During cancer cell proliferation, the activation of
epidermal growth factor receptor (EGFR) and its downstream target, extracellular signal regulated
protein kinases ERK1/2, are also required. By increasing the level of P53 and CKIs (P21/WAF-1,
P27/KIP-1), EGCG inactivated EGFR and ERK1/2 protein kinases, resulting in G1 arrest and increasing
cell apoptosis in several cervical cancer cell lines finally [33]. Moreover, EGCG increased the expression
of P53 dose-dependently. Besides, insulin-like growth factor receptor (IGF-1R) is a tyrosine kinase
receptor which could activate the ERK signaling pathway by recruiting the Src homolog-2 domain
transforming protein, and has been confirmed to induce mitosis, transformation and anti-apoptosis
of cancer cells [34]. EGCG effectively decreased the phosphorylation of ERKs in a dose-dependent
manner, meanwhile, reduced activity of IGF-1R and decreased its binding ability with insulin-like
growth factor (IGF-1), result in inhibiting the proliferation and anchorage-independent transformation
of HeLa cells [35]. In G2 arrest, the potential mechanism was that EGCG upregulated the expression
of P21, an inhibitor of cyclin/cyclin-dependent kinase complexes, which induced mitosis arrest [36].
Otherwise, Polo-like kinase 1 (PLK1) plays a key role in mitotic progression and cell-cycle control [37],
which is confirmed to be one of the potential drug targets for cancer therapy [38]. By inhibiting the
binding of phosphopeptide to C-terminal of polo-box domain (PBD), green tea catechin containing
EGCG was found to be the potent inhibitor of PBD in PLK1. In addition, EGC, as another kind of
catechins, also could lead cell-cycle arrest in S and G2/M phases by disturbing the proper cellular
localization of PLK1, finally inducing apoptosis in several cancer cells including HeLa cells [39].

2.2. Regulating Cancer Cell Growth

Current research reveals that EGCG could regulate cancer cell growth through telomerase and
RNA polymerase III. Telomerase, as a reverse transcriptase, adds new DNA onto the telomeres that
are located at the ends of chromosomes [40]. Recent studies manifested that the telomerase-regulated
telomeres’ length stability might correlated with this phenomenon [41]. Thus, inhibiting the expression
of telomerase has been considered as an effective method for anticancer protection. EGCG inhibited
telomerase activity and more than 90% of the growth rate of both primary human endocervical cells
and ectocervical cells [42]. Telomeric repeat amplification protocol assay showed EGCG could also
suppress the telomerase activity in OMC-4 and TMCC-1 cervical adenocarcinoma cell lines [43].
RNA polymerase III (RNA pol III) transcribes RNA processing and related RNA molecules,
such as U6 snRNA and tRNA, and dictates the growth rate of a cell [44]. It has been proved that the
activity of RNA pol III will be deregulated in multiple cancer cells including cervical cancer cells [45].
RNA pol III proper initiation is decided by transcription factor TF III B, while TF III B is initiated
from both internal [46] and external [47] RNA pol III promoters. By inhibiting the expression of TF III
B subunits Brf1, Brf2 and its promoter, EGCG modulate the RNA pol III transcription and regulate
the cell growth of HeLa cell line [48]. Another study showed the combination therapy of EGCG and
retinoic acid also seemed to be effective through inducing apoptosis and inhibiting telomerase activity
in cervical adenocarcinoma cells [49]. Those results suggest that EGCG may be beneficial in early
cervical lesions and cervical adenocarcinoma prevention.
Molecules 2018, 23, x FOR PEER REVIEW 4 of 17

cervical adenocarcinoma cells [49]. Those results suggest that EGCG may be beneficial in early
Molecules 2018, 23, 2334 4 of 17
cervical lesions and cervical adenocarcinoma prevention.

2.3. Inducing
2.3. Inducing Cellular
Cellular Microtubule
Microtubule Depolymerization
Depolymerization andand Inhibiting
Inhibiting Tubulin
TubulinAssembly
Assembly
Microtubules are
Microtubules are dynamic
dynamic filamentous
filamentous cytoskeletal
cytoskeletal protein
protein structures
structures [50]
[50] composed
composed of of tubulins
tubulins
including α and β subunits [50]. Some key roles of microtubules are in proliferation,
including α and β subunits [50]. Some key roles of microtubules are in proliferation, signaling and signaling and
migration in cancer cells, hence both microtubule and tubulin are crucial therapeutic
migration in cancer cells, hence both microtubule and tubulin are crucial therapeutic targets for targets for
anticancer drugs.
anticancer drugs. A A recent
recent study
study found
found that
that EGCG
EGCG could
could inhibit
inhibit proliferation
proliferation ofof HeLa
HeLa cells
cells through
through
depolymerizing cellular microtubule and restraining tubulin assembly both
depolymerizing cellular microtubule and restraining tubulin assembly both in cells and cell-free in cells and cell-free
system (IC50
system (IC50 ofof 39.6
39.6±±0.63 μM)
0.63 µM) [36]. EGCG
[36]. EGCG andand
theaflavins also also
theaflavins prevented the reformation
prevented the reformationof cold-
of
treat cellular microtubule network distortion in HeLa cells [51]. The mechanism
cold-treat cellular microtubule network distortion in HeLa cells [51]. The mechanism of microtubule of microtubule
depolymerizationby
depolymerization byEGCG
EGCG is aissimilar
a similar anti-proliferation
anti-proliferation function
function to colchicine
to colchicine (a well-known
(a well-known tubulin
tubulin drug) through bounding to the α subunit of tubulin, and ultimately leading
drug) through bounding to the α subunit of tubulin, and ultimately leading to apoptosis in cervical to apoptosis in
cervical cancer
cancer cells [36]. cells [36].

2.4. Inhibiting
2.4. Inhibiting Angiogenesis
Angiogenesis
Angiogenesis consists
Angiogenesis consists of
of vascular
vascular endothelial
endothelial degradation,
degradation, adhesion
adhesion and
and migration
migration procedures,
procedures,
thatprovide
that provide nutrients
nutrients and and
oxygenoxygen in growth
in tumor tumor andgrowth and proliferation.
proliferation. Therefore,
Therefore, inhibiting inhibiting
angiogenesis
angiogenesis could effectively suppress the growth and proliferation of tumor cells. Recent
could effectively suppress the growth and proliferation of tumor cells. Recent work revealed that EGCG work
revealed that EGCG could interfere with cell signaling pathways of angiogenesis in ovarian, lung,
could interfere with cell signaling pathways of angiogenesis in ovarian, lung, breast and cervical cancer
breast
cells and cervical
(Figure cancer cells (Figure 2) [52–54].
2) [52–54].

Figure 2. Molecular mechanisms of EGCG inhibiting angiogenesis. EGCG down-regulated the

Figure 2. Molecular
expressions mechanisms
of HIF-1, E7 of EGCGininhibiting
and EGF, resulting angiogenesis. through
VEGF down-regulation EGCG down-regulated
AKT/PI3K/mTOR the
expressions
signaling of HIF-1,The
pathways. E7 decline
and EGF, resulting
of VEGF in VEGF
could inhibitdown-regulation throughline
angiogenesis (a broken AKT/PI3K/mTOR
means indirect
signaling pathways.
approach). Thekinase
AKT: protein declineB;of VEGF
E7: could
another HPVinhibit angiogenesis
oncogene; (a brokengrowth
EGF: epidermal line means
factor;indirect
HIF-1:
approach). AKT: protein kinase B; E7: another HPV oncogene; EGF: epidermal growth factor;
hypoxia-inducible factor 1; mTOR: mammalian target of rapamycin; PI3K: phosphoinositide-3-kinase; HIF-1:
hypoxia-inducible
VEGF: factor 1;growth
vascular endothelial mTOR: mammalian target of rapamycin; PI3K: phosphoinositide-3-
factor.
kinase; VEGF: vascular endothelial growth factor.
Vascular endothelial growth factor (VEGF) is the key regulator of physiological angiogenesis [55]
whichVascular
can significantly
endothelial stimulate
growth proliferation
factor (VEGF)and division
is the of vascular
key regulator of endothelial
physiological cells, resulting
angiogenesis
in enhancing the formation of new blood vessels. The expression of VEGF
[55] which can significantly stimulate proliferation and division of vascular endothelial cells, in a tumor is activated
by hypoxia-inducible
resulting in enhancingfactor 1 (HIF-1)ofunder
the formation cellular
new blood hypoxia
vessels. Thecondition
expression [56]
ofand
VEGFupregulated
in a tumorby is
protooncogene RAS, SRC, HER2. Hypoxia-inducible
activated by hypoxia-inducible factor 1 (HIF-1) factor-1α (HIF-1α)
under cellular is the subunit
hypoxia of HIF-1
condition [56] [57],
and
which plays aby
upregulated critical role in tumor
protooncogene RAS,growth, angiogenesis
SRC, HER2. [58] and apoptosis
Hypoxia-inducible factor-1α [59].(HIF-1α)
In cervical carcinoma
is the subunit
HeLa cells,
of HIF-1 EGCG
[57], which and green
plays tea extract
a critical roleeffectively inhibited
in tumor growth, the accumulation
angiogenesis [58] andof hypoxia-induced
apoptosis [59]. In
HIF-1α
cervicalprotein
carcinoma through
HeLablocking PI3K/Akt
cells, EGCG and ERKs
and green signal pathways,
tea extract effectivelyand promoted
inhibited the degradation
the accumulation of
of HIF-1α protein HIF-1α
hypoxia-induced via the proteasome
protein through systemblocking
[60]. Moreover,
PI3K/Akt byand
reducing
ERKsdownstream substrates’
signal pathways, and
phosphorylation or inhibiting
promoted the degradation Akt activation
of HIF-1α protein directly, EGCG couldsystem
via the proteasome modulate[60].the activity by
Moreover, level of Akt
reducing
to inhibit epidermal growth factor (EGF)-dependent signaling pathway transportation
downstream substrates’ phosphorylation or inhibiting Akt activation directly, EGCG could modulate and restrict
HeLa cell proliferation
the activity level of Akt [33].toAs a result,
inhibit EGCG and
epidermal greenfactor
growth tea extract reduced the expression
(EGF)-dependent signaling of VEGF
pathway
at both protein and
transportation andmRNA
restrictlevels
HeLa[61].
cellFunctionally,
proliferationEGCG
[33]. Asandagreen teaEGCG
result, extractand abolish thetea
green migration
extract
of hypoxia-stimulated
reduced the expression HeLa cells. at both protein and mRNA levels [61]. Functionally, EGCG and
of VEGF
greenModulating the expression
tea extract abolish of the of
the migration angiogenesis signalingHeLa
hypoxia-stimulated cascade may be one of the potential
cells.
anticancer
Modulating the expression of the angiogenesis signaling cascade that
mechanisms of EGCG. Transcriptional analysis revealed may EGCGbe one modulated the
of the potential
transcription level of 11 genes
anticancer mechanisms of EGCG.in angiogenesis process.
Transcriptional Amongrevealed
analysis them, EGCG that down-regulated
EGCG modulated 7 gene
the
expressions
transcriptionincluding
level of 11PDGFA
genes in (platelet-derived growthAmong
angiogenesis process. factor α, promoting
them, angiogenesis through
EGCG down-regulated 7 gene
paracrine mechanism [62,63]), THBS-1 (thrombospondin 1, promoting vascular adhesion, migration
and invasion through integrin pathways [64]), CCL2 (monocyte chemoattractant protein 1, related to the
Molecules 2018, 23, 2334 5 of 17

recruitment of tumor-infiltrating macrophages [65]), EFNA1 (ephrin A1, a prototype ligand [66]),
TGF-β2 (transforming growth factor β 2), TNFAIP2 (tumor necrosis factor α-induced protein 2),
and CXCL6 (granulocyte chemotactic protein 2); meanwhile, EGCG up-regulated 4 gene expressions
consisting of ANGPTL4 (angiopoietin-like 4, inhibiting vascular invasion [67]), IFN-β1 (interferon β 1,
reducing pro-angiogenic factors [68] and blocking endothelial cell migration [69]), IL-1β (interleukin
1 β, decreasing the secretion of matrix metalloproteinase (MMP)-2 in cervical cancer [70]), and ID1
(inhibitor of DNA binding 1). These genes are known as mediating multiple mechanisms in proliferation,
adhesion, migration and invasion of vascular endothelial cells [71]. The results suggest that EGCG may
act as an important anti-angiogenic agent in cervical cancer.

2.5. Restraining Human Papillomavirus (HPV) Oncoproteins

Since persistent infection with HPV is the prominent etiological reason in the formation of cervical
cancer [4], seeking drugs for restraining HPV-related oncoproteins is essential. EGCG has a positive
effect on suppressing HPV oncogenes and oncoproteins.
E6 and E7 of HPV are two main encoded oncoproteins in cervical cancer. In conjunction with
the cellular ubiquitin ligase E6AP, E6 oncoprotein could degrade tumor suppressor protein P53
via the ubiquitin-proteasome pathway; meanwhile, E7 oncoprotein could induce retinoblastoma
tumor suppressor gene product pRb degradation [72], resulting in disrupting cell cycle regulation
and inhibiting apoptosis of cervical carcinoma [73]. Thus, restraining the expressions of E6 and E7
oncoproteins and their proteasome pathways could inhibit HPV infection and the development of
cervical cancer. By accumulating ubiquitinated proteins and natural proteasome targets including
tumor suppressor protein P27, IκB-α and Bcl-2 associated X protein (BAX) in HeLa cells [74], EGCG
potently inhibited the degradation ability of E7 on pRb through restraining ubiquitin-proteasomal
activity and suppressing tumor growth [75,76]. Estrogen also has been confirmed to play a critical
role in HPV positive cervical cancer. Aromatase, as the key enzyme in estrogen biosynthesis,
could upregulate the expression of estrogen receptor (ER). EGCG could suppress the mRNA and
protein expression levels of estrogen receptor-α (ER-α) and aromatase, hence restraining E6 and E7
expressions. As a result, EGCG indirectly inhibits the proliferation and induces the apoptosis of cervical
cancer cells [77]. Immunohistochemistry study shows a similar result in both HeLa cells and HPV
immortalized cervical epithelial TCL-1 cells [29].

3. Anti-Metastasis of Cervical Cancer Cells

The metastasis of cancer cells includes three key steps, adhesion, migration and invasion. EGCG
shows an inhibitory effect on the migratory and invasive ability of cervical cancer cells by regulating
the activities of proteolytic enzymes, signal pathways, growth factors/receptors and angiogenesis.
Moreover, EGCG could inhibit the spreading of HeLa cells through keeping their round shape from
changing to multiple filopodia and lamellipodia, which were the characteristics of spreading cells,
hence reducing the adherence rate and migration ability of HeLa cells by 40% and 68% after 48 h
respectively [71].
Matrix metalloproteinases (MMPs) are related to several proteolytic events [78] and the tissue
inhibitor of metalloproteinase-1 (TIMP-1) is confirmed to directly regulate MMPs activity. Both MMPs
and TIMP-1 can be used as tumor therapeutic targets in the clinic [79]. By treating HeLa cells with
EGCG, the expression of MMP-9 was down-regulated; in an opposite way, the expression of TIMP-1
was significantly increased in a time-dependent manner [80]. Another study also confirmed that
EGCG decreased the expressions of both MMP-2 and MMP-9 in HeLa cells and completely abolished
their expressions at 50 µg/mL of EGCG, illustrating the inhibition ability of EGCG on MMP-driven
migration in cervical cancer cells. A mixture therapy combined with doxycycline, EGCG had a better
effect on inhibiting MMP-2 expression in HeLa cells [81]. VEGF, as a crucial regulator for physiological
angiogenesis, also plays a key role in cancer cell metastasis. By interfering in hypoxia-mediated
Molecules 2018, 23, x FOR PEER REVIEW 6 of 17

in hypoxia-mediated activation of PI3K/Akt and ERK1/2 signaling pathways, EGCG and green tea
Molecules 2018, 23, 2334 6 of 17
extract down-regulated the mRNA and protein levels of VEGF that results in inhibiting HeLa cell
migration [61].
activation of PI3K/Akt and ERK1/2 signaling pathways, EGCG and green tea extract down-regulated
4. Pro-Apoptosis
the of Cervical
mRNA and protein Cancer
levels of VEGFCells
that results in inhibiting HeLa cell migration [61].
Anti-proliferation and anti-metastasis of cancer cells stand for restraining malignancies, while
4. Pro-Apoptosis of Cervical Cancer Cells
pro-apoptosis of cancer cells could cure cancer eventually. EGCG can induce apoptosis of cervical
Anti-proliferation
cancer and anti-metastasis
cells (Figure 3) through of cancer
(1) inducing caspase cells stand
secretion, forinduced
(2) ROS restraining malignancies,
apoptosis of cancer
while pro-apoptosis of cancer cells could cure cancer
cells, and (3) inducing lysosomal proteases secretion. eventually. EGCG can induce apoptosis of
cervical cancer cells (Figure 3) through (1) inducing caspase secretion, (2) ROS induced apoptosis of
cancer cells, and (3) inducing lysosomal proteases secretion.

Figure 3. Molecular mechanisms of EGCG promoting apoptosis of cervical cancer cells. EGCG
down-regulated E6 through estrogen, then the expressions of P53 and casp8 were up-regulated. EGCG
also could
Figure increase P53
3. Molecular expression
mechanisms of by AKT/PI3K
EGCG promoting pathways. BAX
apoptosis and casp3
of cervical would
cancer cells.promote their
EGCG down-
expressions
regulated E6with up-regulation
through of P53
estrogen, then and
the casp8 respectively.
expressions of P53 andThe up-regulation
casp8 of BAX EGCG
were up-regulated. and casp3
also
could promote apoptosis of cervical cancer cells in the end (broken lines mean indirect
could increase P53 expression by AKT/PI3K pathways. BAX and casp3 would promote their approaches).
AKT: protein with
expressions kinase B; BAX: Bcl-2ofassociated
up-regulation X protein;
P53 and casp8 Casp3: caspase
respectively. 3; Casp8: caspase
The up-regulation of BAX 8; E6:
andone of
casp3
HPV oncogenes; P53: tumor suppressor protein; PI3K: phosphoinositide-3-kinase.
could promote apoptosis of cervical cancer cells in the end (broken lines mean indirect approaches).
AKT: protein kinase B; BAX: Bcl-2 associated X protein; Casp3: caspase 3; Casp8: caspase 8; E6: one of
4.1. Inducing Caspase Secretion
HPV oncogenes; P53: tumor suppressor protein; PI3K: phosphoinositide-3-kinase.
Caspases are a series of proteases which have been verified as involved in tumor cell apoptosis,
necrosis and Caspase
4.1. Inducing inflammation.
SecretionThe deficiency of caspase would lead to tumor proliferation. EGCG
induced cancer cells apoptosis at high concentration (25–50 µg/mL) in squamous cervical carcinoma
Caspases are a series of proteases which have been verified as involved in tumor cell apoptosis,
Me180 cells [29]. In the meantime, EGCG improved the expression of caspase-3 in cervical carcinoma
necrosis and inflammation. The deficiency of caspase would lead to tumor proliferation. EGCG
cells [82]. Black tea polyphenol theaflavins and green tea catechins hydrate could also induce the
induced cancer cells apoptosis at high concentration (25–50 μg/mL) in squamous cervical carcinoma
expressions of caspase-3, -8, -9 and P53 in HeLa [30] or SiHa cells [83]. Eventually, EGCG could
Me180 cells [29]. In the meantime, EGCG improved the expression of caspase-3 in cervical carcinoma
promote caspase-mediated cancer cell apoptosis.
cells [82]. Black tea polyphenol theaflavins and green tea catechins hydrate could also induce the
expressions
4.2. of caspase-3,
Reactive Oxygen Species -8, -9 and
(ROS) P53 Apoptosis
Induced in HeLa of [30] or SiHa
Cancer Cellscells [83]. Eventually, EGCG could
promote caspase-mediated cancer cell apoptosis.
Reactive oxygen species (ROS) are a series of chemical-reactive molecules, containing hydrogen
peroxide, superoxide
4.2. Reactive anion (ROS)
Oxygen Species radical,Induced
singletApoptosis
oxygen, and hydroxyl
of Cancer Cells radical, which are associated with
the decreased antioxidant capability of cells and multiple stages of carcinogenesis [84]. In cancer cells,
a lowReactive
ROS level oxygen species
supports (ROS)pathways
survival are a series
thatofmakes
chemical-reactive molecules,
a positive impact in cellcontaining hydrogen
proliferation, but a
peroxide,orsuperoxide
medium high level anion
of ROS radical,
causessinglet oxygen,
oxidative stressandthathydroxyl
could leadradical,
to cellwhich are associated
apoptosis, necrosis with
and
the decreased
genotoxic damageantioxidant
[85]. capability of cells and multiple stages of carcinogenesis [84]. In cancer cells,
a low ROS level
EGCG is notsupports survival
only a natural pathwaysagent
antioxidant that makes a positive
in normal impact
cells but alsoin cell proliferation,
exhibits prooxidantbut anda
medium or high level
apoptosis-inducing of ROS in
properties causes
canceroxidative stressHigh
cells [86,87]. that concentrations
could lead to cell apoptosis,
of EGCG (50 µgnecrosis
to 200and
µg
genotoxic damage [85].
gallic acid equivalents GAE/mL) induced formation of intracellular superoxide anion radical, H2 O2 and
EGCG
hydroxyl is notasonly
radical, a natural antioxidant
a consequence of increasingagent in normal
oxidative stress cells but cells
in HeLa also [88].
exhibits prooxidant and
High-concentration
apoptosis-inducing properties in cancer cells [86,87]. High concentrations
(100 µg gallic acid equivalents GAE/mL) green tea induced the formation of intracellular of EGCG (50 μg ROS
to 200 μg
and
gallic acid equivalents GAE/mL) induced formation of intracellular superoxide
inhibited the activity of catalase, while increasing the production of superoxide anion radicals and anion radical, H2O2

and hydroxyl radical, as a consequence of increasing oxidative stress in HeLa cells [88]. High-
reducing glutathione. Thioredoxin (Trx) and thioredoxin reductase (TrxR) presenting in all living cells
concentration (100 μg gallic acid equivalents GAE/mL) green tea induced the formation of
act as antioxidant and apoptotic resistance proteins, which are often overexpressed in drug-resistant
intracellular ROS and inhibited the activity of catalase, while increasing the production of superoxide
cancer cells. Both of them are critical regulators of cellular redox homeostasis. The increased level
anion radicals and reducing glutathione. Thioredoxin (Trx) and thioredoxin reductase (TrxR)
of ROS induced by EGCG has proven to be an effective regulator for both Trx and TrxR [89].
presenting in all living cells act as antioxidant and apoptotic resistance proteins, which are often
The inactivation of Trx/TrxR by a high concentration of EGCG was linked to elevation of ROS
overexpressed in drug-resistant cancer cells. Both of them are critical regulators of cellular redox
levels in HeLa cells. By autoxidation, EGCG oxidized into EGCG (semi) quinones and released H2 O2 ,
Molecules 2018, 23, 2334 7 of 17

then inactivated Trx/TrxR through binding with them separately and formed irreversible EGCG-Trx
and EGCG-TrxR conjugates, thus inducing prooxidant cytotoxicity and apoptosis of HeLa cells.
Mitochondria, which play an important role in energy production, are major sites of ROS
generation [90]. Excessive generation of ROS could lead to the opening of a mitochondrial permeability
transition pore with decline in mitochondrial membrane potential (∆Ψm) and consequent release
of cytochrome-C from the inter-membrane space into the cytosol, culminating in activation of the
caspase cascade and apoptotic cell death pathways [91]. Treating SiHa cells with green tea polyphenols
consisting of EGCG decreased ∆Ψm of mitochondria and disrupted mitochondrial function, finally
inducing apoptosis of SiHa cells [92]. The mitochondrial perturbation ability of EGCG and tea
polyphenols may because they can induce the excess hydrogen peroxide.

4.3. Inducing Lysosomal Proteases Secretion

Lysosomes are cytoplasmic membrane-enclosed organelles containing hydrolytic enzymes that
control the intracellular turnover and degradation of macromolecules [93]. Under lysosomal membrane
permeabilization (LMP), lysosomal proteases leak into the cytosol and induce cell death. EGCG was
able to trigger LMP supported by Lyso-Tracker Red staining, cathepsin-D cytosolic translocation and
cytosolic acidulation, and then lysosomal proteases were released into cytosol and inducing death of
HeLa cells [94]. ROS is known to be the principle inducer of LMP. In cancer cell lines, 60 µM EGCG
led to intracellular ROS formation which resulted in LMP onset and cytosolic acidification, eventually
promoting cell death [94].

5. Pharmaceutical Synergistic Effect

Chemotherapy is the most important cancer treatment. But the side-effects of certain
chemotherapeutic agents make the human body unbearable before they cure cancers. Chemotherapeutic
agents with low side-effects are urgently needed, while seeking chemical compounds with
pharmaceutical synergistic effect to reduce the side-effects of chemotherapeutic agents is another
effective approach, such as EGCG. Besides, EGCG also has the ability to inhibit cancer cell proliferation,
metastasis, and promoting their apoptosis (Table 1).

Table 1. Pharmaceutical synergistic effects of EGCG and tea polyphenols.

Ingredient Drug Cell Line Cytotoxic Action Reference

Attenuated the toxicity and
enhanced the sensitivity of
cisplatin, decreased cellular Kilic et al. (2014)
cisplatin HeLa
EGCG survival and induced apoptosis, Singh et al. (2011)
regulated NF-kB p65, Akt and
mTOR pathways
Prevented carcinogenesis and
Yokoyama et al.
retinoic acid HEN induced apoptosis, inhibited
(2008)
telomerase activity
Induced G2/M phase cell cycle
Alshatwi et al.
platinum SiHa arrest, increased subG0 cell death
(2015)
Tea polyphenols phase and inhibited proliferation
Enhanced the therapeutic
properties of bleomycin (BLM),
bleomycin Alshatwi et al.
SiHa activated caspase-3, -8, -9,
hydrochloride (2016)
upregulated Bcl-2 and P53
expression and induced apoptosis
Increased the chemosensitivity and
cisplatin HeLa, SiHa Singh et al. (2013)
minimized the toxicity of cisplatin

Cisplatin (cisdiamminedichloroplatinum II, CDDP) is one of the traditional chemotherapeutic

agents in the treatment of several types of cancer [95]. The clinical use of CDDP is always limited to its
Molecules 2018, 23, 2334 8 of 17

undesirable side-effects, such as nephrotoxicity, gastrointestinal toxicity, neurotoxicity, bone marrow

toxicity and ototoxicity [96]. Oxidative stress induced by the strong electrophilic nature of activated
CDDP is another common adverse effect of CDDP [97]. Additionally, CDDP-based chemotherapy with
concurrent radiation therapy is the commonly used strategy in cervical carcinoma, but the result is
unsatisfactory due to its chemoresistance. Therefore, novel combination strategies are required. EGCG
has synergistic anticancer activity with CDDP. EGCG could enhance the efficacy of CDDP in inhibiting
proliferation of HeLa cells than CDDP alone [98]. Using EGCG combined with CDDP to treat HeLa
and SiHa cell lines exhibited significant inhibition of cell growth through blocking kappa-Bα inhibitor
phosphorylation, resulting in inhibiting the activation of Akt and NF-κB signaling pathways [99].
Meanwhile, encapsulated polyphenols consisting of EGCG exhibit a higher effect in enhancing the
sensitivity of CDDP [100]. TPP@Pt, a nanoparticle synthesized by tea polyphenols with EGCG and
platinum, was tested with ability of inducing cell cycle arrest in G2/M phase and increased cell
quantity in subG0 death phase in SiHa cells [101]. These findings highlight the synergistic anticancer
activity of tea components with CDDP.
Bleomycin (BLM) is another anti-neoplastic chemotherapeutic agent which made by Streptomyces
verticillus. By inducing DNA oxidative damage and inhibiting cancer cell proliferation [102], BLM is
used in redox-related cancer, including testicular cancer and cervical squamous cell cancer [103].
However, BLM also causes several side effects in normal cells, such as immune system damage,
hyperpigmentation, pneumonitis and pulmonary fibrosis, which are mediated by redox status
disturbances [104,105]. The combination of tea polyphenols with EGCG and BLM could overcome the
side effects of BLM and have therapeutic benefits for uterine cervical cancer patients. The combination
therapy induced stronger cancer cell apoptosis ability than treated either tea polyphenols or BLM
alone, by activating caspase-3, -8, -9 and up-regulating the expressions of P53 and Bcl-2 [106].

6. Ambiguous Potential Functions of (-)-Epigallocatechingallate (EGCG) on Cervical Cancer

DNA methylation and histone deacetylase are important epigenetic mechanisms for the
inactivation of many genes related to tumor suppressors. Epigenetic alterations are mainly mediated
by DNA methyltransferases (DNMT), histone deacetylase (HDAC), and other classes of enzymes [107].
Through targeting epigenetic alterations consisting of DNA methylation, EGCG acts as an epigenetic
modifier in bounding the process of carcinogenesis in tumors [108,109]. EGCG significantly reduced
the enzymatic activity of DNMT and HDAC in a time-dependent manner in HeLa cells; furthermore,
molecular modeling data also supported the result. It was interesting that the expression of DNMT3B
normally increased in various cancer tissues and cell lines [110], was decreased in EGCG-treated HeLa
cells, whereas there were no significant changes in the expression of HDAC1 [108]. Thus, further
studies are needed to determine the efficacy of EGCG for therapeutic purposes as an epigenetic drug.
The 67KD laminin receptor (67LR) is a non-integrin cell surface receptor for extracellular matrix
with higher expressions in tumor cells [111]. It is widely related to several processes of cancer
cells metastasis [112]. As a major surface receptor of EGCG [113], 67LR could coordinate with
EGCG in regulation of several signal pathways and inhibition of tumor growth and promotion
of apoptosis. Through 67LR mediation, EGCG inhibited HeLa cells growth by inducing myosin
regulatory light chain dephosphorylation [114]. Both eukaryotic translation elongation factor-1A
and myosin phosphatase-targeting subunit-1 were considered to be the mediators for EGCG-induced
cancer prevention through 67LR in HeLa cells [115]. The sensitivity of 67LR to EGCG would be
influenced by the tumor oxidative conditions, high O2 pressure suppressed the degradation of
ubiquitin/proteasome-mediated 67LR and enhanced the sensitivity of cancer cells [116].

7. Further Suggestions
Based on its anti-proliferation, anti-metastasis, pro-apoptosis and pharmaceutical synergistic
effects, EGCG shows suppressive effects on cervical cancer. An overview of suppressive effects of
Molecules 2018, 23, 2334 9 of 17
Molecules 2018, 23, x FOR PEER REVIEW 9 of 17

EGCG
EGCG on on cervical
cervical cancer
cancer isis illustrated
illustrated in
in Figure
Figure 4. 4. Meanwhile,
Meanwhile, the the cytotoxic
cytotoxic activities
activities of
of EGCG
EGCG on on
human cervical cancer cell lines are summarized
human cervical cancer cell lines are summarized in Table 2. in Table 2.
Among
Among anti-proliferation
anti-proliferationof ofcervical
cervicalcancer
cancercells,
cells,EGCG
EGCG depolymerizes
depolymerizes the the cellular
cellular microtubule
microtubule
and
and binds
binds on
on tubulin
tubulin identical
identical to to colchicine.
colchicine. However,
However, the the IC50
IC50 ofof EGCG
EGCG is is 1000-fold
1000-fold higher
higher than
than
colchicine. This indicates that
colchicine. This indicates that EGCG EGCG may not only target on tubulin of microtubule but also
on tubulin of microtubule but also other other
targets
targetsinincellular
cellular or extracellular
or extracellular regions [36]. Therefore,
regions further studies
[36]. Therefore, further should
studiesfocus on the
should mechanism
focus on the
of EGCG on depolymerizing
mechanism cellular microtubule.
of EGCG on depolymerizing cellularIn addition, EGCGIncan
microtubule. inhibit telomerase
addition, EGCG canin inhibit
breast
cancer [117],inesophageal
telomerase carcinoma
breast cancer [118], endocervical
[117], esophageal carcinoma cells andendocervical
[118], ectocervical cells
cells [42], but shows much
and ectocervical cells
milder
[42], butcytotoxic
shows much effects in cervical
milder cancer
cytotoxic cells
effects in [119].
cervicalThe activity
cancer cellsof[119].
telomerase is related
The activity to DNA
of telomerase
methylation
is related to DNA[120],methylation
and thus whether EGCG
[120], and thuscan inhibitEGCG
whether telomerase activity
can inhibit throughactivity
telomerase reducing DNA
through
methylation
reducing DNA is amethylation
promising research project. research project.
is a promising

effects of
Figure 4. Overview of suppressive effects of EGCG
EGCG on
on cervical
cervical cancer.
cancer.

EGCG
EGCG can can induce
induce non-apoptotic
non-apoptotic cell cell death
death through
through LMP LMP in in cervical
cervical cancer
cancer cells.
cells. But
But the
the
potential mechanism of cervical cancer cell death through upregulating ROS formation
potential mechanism of cervical cancer cell death through upregulating ROS formation has not been has not been
certified
certified in
in HeLa
HeLa cells
cells [88].
[88]. There
There isis only
only oneone study
study focused
focused on on the
the potency
potency of of tea
tea components
components in in
lysosome-associated
lysosome-associatedcell celldeath
deathpathways
pathways[121].
[121]. Further
Further studies
studies could
could work
work on on the
the mechanism
mechanism of of LMP
LMP
induced
induced byby EGCG
EGCG in in cervical
cervical cancer
cancer cells.
cells.
DNMT
DNMT and andHDAC
HDAC areare
twotwo
promising
promisingtargets for anticancer
targets drugs. Adrugs.
for anticancer series of
A effective
series ofepigenetic
effective
targeting
epigeneticdrugs in clinical
targeting drugstrials has been
in clinical proved,
trials but proved,
has been adverse butreactions
adversesuch as marrow
reactions suchsuppression
as marrow
and gastrointestinal
suppression symptoms also
and gastrointestinal appeared also
symptoms during treatment
appeared [122].treatment
during Thus, a low toxicity
[122]. Thus,natural
a low
inhibitor for epigenetic
toxicity natural inhibitor modification
for epigeneticis an attractive research
modification direction.
is an attractive EGCGdirection.
research as a dietary agentasina
EGCG
cancer
dietarytreatment has the
agent in cancer ability tohas
treatment inhibit the enzymatic
the ability to inhibitactivity of DNMT
the enzymatic and of
activity HDACDNMT in and
HeLa cells.
HDAC
However, the inhibition
in HeLa cells. However, mechanism
the inhibition needs more research
mechanism needs moreto support and
research tothe efficacy
support andofthe
EGCG for
efficacy
therapeutic
of EGCG forpurpose as anpurpose
therapeutic epigenetic drug
as an should be
epigenetic tested
drug in the
should befuture
tested[108].
in the future [108].
Molecules 2018, 23, 2334 10 of 17

Table 2. Cytotoxic activities of EGCG on human cervical cancer cell lines.

Cell Line Function Cytotoxic Action Reference

Induced G1 phase cell cycle arrest and apoptosis, inhibited EGFR signaling pathway Sah et al. (2004)
Induced G2/M phase cell cycle arrest and apoptosis, depolymerized microtubule Chakrabarty et al. (2011)
Reduced IGF-1R activity and inhibited proliferation of cells Li et al. (2007)
Anti-proliferation Inhibited Akt and NF-kB activation, inhibited cell growth Singh et al. (2011)
Inhibited the expression of Brf1, Brf2 and its promoter, inhibited RNA polIII transcription Jacob et al. (2007)

HeLa Depolymerized cellular microtubule Chakrabarty et al. (2015)

Inhibited HIF-1α protein accumulation, decreased VEGF expression, blocked P3K/Akt,
Zhang et al. (2006)
ERK1/2 signaling pathway
Inhibited HPV E6, E7, ERα, and aromatase expression Qiao et al. (2009)
Inhibited proteasome functionality, induced apoptosis Bonfili et al. (2011)
Reduced enzymatic activity of DNMT and HDAC, inhibited carcinogenesis Khan et al. (2015)
Inhibited invasion and migration, decreased MMP-9 and TIMP-1 expression Sharma et al. (2012)
Anti-metastasis Reduced proliferation, adhesion, invasion of tumor cell, exhibited anti-angiogenesis effect Tudoran et al. (2012)
Inhibited invasion and migration, decreased MMP-2, -9 expression Roomi et al. (2010)
Inactivated Trx/TrxR, induced prooxidant cytotoxicity and apoptosis Zhang et al. (2010)
Pro-apoptosis
Induced LMP secretion Zhang et al. (2012)
Induced formation of intracellular ROS Krstic et al. (2015)
Induced G1 phase cell cycle arrest and apoptosis, regulated gene expression Ahn et al. (2003)
Caski Anti-proliferation
Induced G1 phase cell cycle arrest and apoptosis, inhibited EGFR signaling pathway Sah et al. (2004)
Inhibited HPV E6/7, ERα, and aromatase expression Qiao et al. (2009)
Anti-proliferation Induced G1 phase cell cycle arrest and apoptosis, inhibited EGFR signaling pathway Sah et al. (2004)
SiHa
Pro-apoptosis Increased caspase-3, -8, -9 secretion and inhibited cell growth Al-Hazzani et al. (2011)
OMC-1 Anti-proliferation Inhibited telomerase activity, induced cell cycle dysregulation and apoptosis Noguchi et al. 2006)
HEN, HEC Anti-proliferation Inhibited telomerase activity and cell growth, induced apoptosis Yokoyama et al. (2004)
Molecules 2018, 23, 2334 11 of 17

Although chemoprevention effects and molecular mechanisms of EGCG have been illustrated
in cervical cancer, there is only one piece of epidemiological evidence and only one clinical study
has been undertaken until now. A case control study in central China showed that green tea intake
was identified as a protective factor against cervical cancer or cervical intraepithelial neoplasia [123].
Compared with other cancers [18–20], epidemiological research on the suppressive effects of EGCG in
cervical cancer is extremely rare.

8. Conclusions
EGCG has abilities in the anti-proliferation, anti-metastasis and pro-apoptosis of cervical cancer
cells. Although little epidemiological and clinical research supports the suppressive effects of EGCG
on cervical cancer, molecular evidence shows positive results of EGCG in inhibiting cervical cancer.
Moreover, EGCG could reduce the side-effects of traditional chemotherapy agents, such as CDDP and
BLM. Knowledge of more precise and deeper mechanisms of how EGCG restrains cervical cancer cells
is required. Overall, EGCG shows a potential role in suppressing cervical cancer.

Author Contributions: Y.-Q.W.: Figures 1–4; Tables 1 and 2; Section 4: Pro-apoptosis of cervical cancer
cells; Section 5: Pharmaceutical synergistic effect; J.-L.L.: Section 1: Introduction; Section 6: Ambiguous
potential functions of EGCG on cervical cancer; Y.-R.L.: Section 7: Further suggestions; Section 8: Conclusions;
Q.-S.L.: Section 2: Anti-proliferation of cervical cancer cells; Section 3: Anti-metastasis of cervical cancer cells;
modifying manuscript.
Funding: This work was financially supported by National Natural Science Foundation of China (No. 31470687).
Acknowledgments: The authors appreciate the advice of Xiao-Chang Wang, Xin-Qiang Zheng and Jian-Hui Ye.
Conflicts of Interest: The authors declare no conflict of interest.

Abbreviations
AKT: protein kinase B; ANGPTL4: angiopoietin-like 4; BAX: Bcl-2 associated X protein; BLM: bleomycin;
Casp3: caspase 3; Casp8: caspase 8; CCL2: chemoattractant protein 1; CDDP: cisdiamminedichloroplatinum II;
CDK2: cyclin-dependent kinase 2; CKI: cyclin-dependent kinases inhibitor; CXCL6: granulocyte chemotactic
protein 2; DNMT: DNA methyltransferase; EC: epicatechin; ECG: epicatechingallate; EFNA1: ephrin A1; EGC:
epigallocatechin; EGCG: epigallocatechingallate; EGF: epidermal growth factor; EGFR: epidermal growth factor
receptor; ER: estrogen receptor; ERK: extracellular signal-regulated kinase; ER-α: estrogen receptor-α; HDAC:
histone deacetylase; HIF-1: hypoxia-inducible factor 1; HIV: human immunodeficiency virus; HPV: human
papillomavirus; ID1: inhibitor of DNA binding 1; IFN-β1: interferon β 1; IGF-1: insulin-like growth factor
1; IGF-1R: insulin-like growth factor receptor; LMP: lysosomal membrane permeabilization; MMPs: matrix
metalloproteinases; mTOR: mammalian target of rapamycin; PBD: polo-box domain; PDGFA: platelet-derived
growth factor α; PI3K: phosphoinositide-3-kinase; PLK1: Polo-like kinase 1; RNA pol III: RNA polymerase III;
ROS: reactive oxygen species; TGF-β2: transforming growth factor β 2; THBS-1: thrombospondin 1; TIMP-1:
tissue inhibitor of metalloproteinase-1; TNFAIP2: tumor necrosis factor α-induced protein 2; Trx: thioredoxin;
TrxR: thioredoxin reductase; VEGF: vascular endothelial growth factor; 67LR: 67KD laminin receptor.

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Sample Availability: Samples of the compounds are not available from the authors.

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