miRNA-Targeted Herbal Compounds Against Gastric Precancerous Evolution in Chronic Atrophic Gastritis

Abstract

Gastric cancer (GC) ranks third globally in cancer mortality. It develops via a well-defined pathological sequence: normal gastric mucosa progresses sequentially to superficial gastritis, chronic atrophic gastritis (CAG), intestinal metaplasia, dysplasia, and ultimately invasive carcinoma. Given this stepwise carcinogenic cascade, early intervention during the precancerous stage, particularly in CAG, is paramount for secondary GC prevention. Emerging evidence underscores that microRNAs (miRNAs), a major subclass of non-coding RNAs (ncRNAs), exert crucial regulatory effects on gastric carcinogenesis. Dysregulated miRNAs are frequently detected in Helicobacter pylori-infected gastric mucosa, driving chronic inflammation, epithelial-mesenchymal transition (EMT), and subsequent malignant transformation. Recently, traditional Chinese medicine (TCM) has gained increasing recognition as a promising therapeutic approach for precancerous lesions of gastric cancer (PLGC). Classical TCM formulations and bioactive herbal compounds have been shown to exert multi-targeted and multi-pathway efficacy in inhibiting the progression of this disease. This review integrates available evidence and indicates that TCM interventions, including herbal prescriptions and acupuncture, exert anti-inflammatory, anti-fibrotic and anti-metastatic effects by regulating microRNA expression profiles, thereby alleviating chronic inflammation, pathological remodeling and tumor cell invasion. Collectively, these findings demonstrate TCM’s adjunctive potential in CAG treatment and GC prevention, providing a novel mechanistic approach to halt precancerous gastric carcinogenesis.

Graphical Abstract

1. Introduction

The GC is a disease marked by multiple risk factors, high complexity, and substantial heterogeneity, and is consequently the third major reason of cancer-related deaths globally.^1,2 According to the Chinese malignant tumor prevalence survey, both the incidence and mortality rates of GC are the third highest in the nation. ¹ Since most patients show non-specific symptoms and are frequently diagnosed at an advanced stage, the early identification of high-risk factors for GC is of great importance. ² Correa et al proposed a classic model for the development of GC, which progresses in the following sequence: “normal gastric mucosa - superficial gastritis - atrophic gastritis - atrophic gastritis with intestinal metaplasia - dysplasia - GC”. ³ CAG refers to a PLGC in which the gastric mucosal epithelium experiences a reduction in the number of native glands because of chronic inflammatory stimuli, often with or without intestinal metaplasia or pseudopyloric metaplasia. ⁴ Early prevention of CAG progression is a key measure in the secondary prevention of GC. During Helicobacter pylori infection, miRNAs in the gastric mucosa are often deregulated. This deregulation occurs in a step-by-step manner. It commences from chronic gastritis (CG), progresses by pre-neoplastic conditions like atrophic gastritis and intestinal metaplasia, and finally gives rise to early dysplasia and invasive cancer. During the last decade, miRNAs have drawn extensive scientific attention. As discussed in prior sections, miRNAs represent a distinct subset of ncRNAs and significantly influence a wide array of biological mechanisms.

TCM has been widely used in treating and preventing diseases for over 2,200 years. ⁵ It has been confirmed by research that TCM is capable of relieving the clinical manifestations of CG patients and impeding the progression from CAG to GC^6,7. TCM’s core rationale lies in “treating the root cause” through holistic regulation-targeting GPL-related pathogenesis like spleen-stomach weakness, liver qi stagnation, and phlegm-stasis accumulation, which align with modern insights into chronic inflammation, oxidative stress, and dysregulated cell signaling. ⁸ With its multi-component, multi-target advantages, TCM can modulate key molecular pathways (e.g., regulating tumor-suppressive miRNAs, inhibiting oncogenic signaling), reverse mucosal damage, and prevent malignant transformation. A great number of studies have been conducted to explore the mechanism of TCM in treating CG, and have obtained favorable outcomes. ⁹ In this study, we summed up the miRNAs involved in the regulation of CAG and GC, thus providing a new basis for TCM to treat CAG or prevent GC. The study can explain the exploitation of more effective medications and the recognition of biomarkers for diagnosing and treating patients who may profit from specific targeted treatments.

2. Methods

2.1. Search Strategy

Published studies were retrieved from electronic databases including MEDLINE, PubMed, EMBASE, and the Cochrane Library, with the search period spanning from database inception to April 25, 2026. The search strategy terms used were as follows: “gastritis, atrophic”[MeSH Terms] OR (“gastritis” AND “atrophic” OR “atrophic gastritis” OR (“chronic” AND “atrophic” AND “gastritis”) OR “chronic atrophic gastritis” OR ((“gastrics” OR “stomach”[MeSH Terms] OR “stomach” OR “gastric”) AND “Precancerous” AND (“lesion” OR “lesions” OR “lesional” OR “lesions”))) AND (“medicine, chinese traditional”[MeSH Terms] OR (“medicine” AND “chinese” AND “traditional”) OR “chinese traditional medicine” OR (“traditional” AND “chinese” AND “medicine”) OR “traditional chinese medicine”. In addition, we carried out manual retrieval of the China national knowledge infrastructure (CNKI) and the Wan Fang Database to identify publications. We also searched clinical trial registries, including ClinicalTrials.gov ( https://clinicaltrials.gov/) and Controlled-Trials.com ( www.controlled-trials.com), for ongoing studies. The search was restricted to studies published in English or Chinese. Additionally, several newly published articles were retrieved by manually reviewing the reference lists of relevant studies.

2.2. Study Criteria and Selection

Inclusion criteria for studies were applied as follows: (1) Participants: patients were diagnosed with Gastric Precancerous Evolution in Chronic Atrophic Gastritis, GC, CAG; (2) Intervention: conventional treatment + TCM, Chinese herbology, acupuncture; (3) Control group: conventional treatment; (4) Study design: Clinical trials, basic experiments, and reviews; if not published in English or Chinese, they are excluded.

3. The Importance of miRNA in Maintaining Gastric Health and in the Process From CAG to GPL

miRNAs, a class of ncRNAs molecules with a length of 19-24 nucleotides, are key regulators of gene expression. ¹⁰ miRNAs straightforwardly integrate with the complementary sequences in 3′-untranslated region (3′-UTR) of target mRNAs, participating in the modulation of cell growth, differentiation, development, and apoptosis, and are related to various diseases. miRNAs participate in the adjustment of nearly all biological activities, for example, tumorigenesis, angiogenesis, invasion and metastasis. From the perspective of molecular-level research, miRNAs are related to the regulation of the tumor cell cycle, proliferation, apoptosis, as well as chromatin recombination, gene expression, and the regulation of important molecular pathways. Therefore, miRNAs play important roles in research fields including tumor risk prediction, tumor screening markers, tumor diagnosis and typing, prognosis, drug-resistance prediction, targeted drug treatment selection, and treatment effect assessment.

With the continuous deepening of the understanding of the relationship between miRNA and tumors, its role in the occurrence and development from CAG to precancerous lesions of GC has been increasingly emphasized. Research has found that the expressions of miRNA-9 and miRNA-218 decrease, and both of them function to regulate the proliferation and apoptosis of gastric mucosa cells by directly or indirectly acting on the tumor-related gene NF-kB^11,12. Other studies have found that miRNA affects cell proliferation, apoptosis, invasion, and metastasis by participating in related regulatory pathways. ¹³ Some miRNAs are increased in the GC cells or tissues and function as oncogenic miRNAs. ¹⁴ miR-21, recognized as an oncogenic miRNA, has been found overexpressed in multiple tumors, like gastric, breast, colon, lung, pancreatic and prostate cancers. It is likely to facilitate the invasion of GC cells by adjusting the expression level of the tumor-suppressor gene RECK. ¹⁵

The dysregulation of miRNA-mediated epigenetic control mechanisms constitutes a critical molecular driver in the pathological progression from CAG to GPL. Emerging research highlights that miRNA-dependent post-transcriptional regulation orchestrates a complex network of oncogenic signaling cascades and chromatin remodeling events that collectively promote gastric mucosal transformation. Specifically, miR-7 downregulation induces constitutive activation of the EGFR/ERK signaling axis, leading to sustained cyclin D1 overexpression and unchecked cellular proliferation, while miR-148a depletion triggers DNMT1-mediated epigenetic silencing of tumor suppressor loci through aberrant CpG island methylation, particularly affecting CDH1 (E-cadherin) and p16INK4a promoters. ¹⁶ Concurrently, oncogenic miR-21 upregulation exerts pleiotropic effects by simultaneously suppressing PDCD4-dependent apoptosis and phosphatase and tensin homolog (PTEN)-regulated PI3K/AKT/mTOR inhibition, thereby fostering a pro-survival microenvironment conducive to neoplastic transformation. ¹⁷ These findings highlight the dual regulatory roles of miRNAs—acting as either tumor suppressors or oncogenic drivers-depending on their target networks and cellular context. Given their broad involvement in multi-gene and multi-pathway dysregulation, miRNAs represent promising therapeutic targets for interrupting the CAG-to-GC continuum, offering potential avenues for precision medicine strategies in gastric cancer prevention and treatment.

4. The Relationship Between miRNA and the Transformation From CAG to GPL

The dysregulation of miRNAs is an important mechanism promoting the occurrence and development of various cancers. The factors leading to their dysregulation mainly include miRNA biogenesis mechanism errors, abnormal epigenetic changes, changes in the copy number of genes encoding miRNAs, and abnormal transcription factor control of miRNA genes. ¹⁸ GC is a heterogeneous disease, and in the multifactorial carcinogenesis cascade, there exist a variety of different genetic and epigenetic incidents. Some research has indicated that as the Correa cascade reaction and Helicobacter pylori progress, the expression of miRNAs in the gastric mucosa will gradually become more pronounced, and miRNAs are potential biomarkers for GPL. ¹⁹ miRNAs can function as oncogenes or tumor-suppressor genes and are capable of modulating multiple aspects of GC, like proliferation, apoptosis, metastasis and chemosensitivity, among others^20,21. They participate in the modulation of diverse molecular pathways, like cell differentiation, or apoptosis via post-transcriptional modulation of gene expression. ²²

The dysregulation of miRNAs is able to influence carcinogenesis by means of mRNA targets which encode tumor-suppressor genes or oncogenes. ²³ Numerous research have demonstrated the differentially expressed (DE) miRNAs in the GC tissues, and their functional roles in the GC has been put forward. ²⁴ miRNA changes occur in the early stage of the pre-neoplastic event cascade. For instance, the DE miRNAs have been recognized in individuals with the H. pylori infection. Moreover, the expression of miR-155 and miR-223 gradually rise in association with the Correa’s cascade. ¹⁹ The TCGA group has illustrated that unique miRNA expression profiles are presented in distinct molecular subtypes of GC, as supported by several other studies^25,26.

Changes in the miRNA sequences might lead to differences in expression and modify the modulatory function of miRNAs^27,28. Getting to know the mechanisms of miRNA expression, with CpG island promoter methylation as an example, presents worthwhile data for the biomarker investigation. For instance, miR-137 is associated with GI cancers and exhibits diverse methylation in GC patients. ²⁹ Simultaneously, in the cancer-related studies, both the gene sequences encoding precursor miRNAs and the variations within miRNA integrating regions of target genes have been broadly researched^30,31. Owing to their distinctive biogenesis characteristics, miRNAs possess several features, making them an appealing group of molecules in the biomarker investigation. miRNAs have high stability and can be obtained from various biological materials, such as blood, saliva, tissues, ascites, feces, and even paraffin-embedded blocks, with ease and reproducibility^25,32-34. In addition, the C allele of miR-149 rs2292832 may be a protective factor for gastric mucosal atrophy. H. pylori may participate in the evolution of benign to malignant gastric mucosa lesions by inducing the overexpression of miR-499 and down regulation of miR-149 ⁸ (Figure 1).

Figure 1.

miRNA and the transformation from chronic atrophic gastritis (CAG) to gastric precancerous lesions (GPL). The correlation between the aberrant expression of CpG island promoter methylation, mRNA degradation, miRNAs (such as miR-137, miR-155 and miR-223 et al.) and the progression of CAG into GPL

5. Modulation of miRNA to Mitigate the Transition From CAG to GPL Using TCM

5.1. Chinese Medical Herbs

While clinical trials have demonstrated the efficacy of the Huosu-Yangwei (HSYW) prescription in treating advanced GC and CAG with precancerous lesions, its molecular mechanisms remain incompletely elucidated. ³⁵ To address this gap, a systems biology approach integrating transcriptomics and network pharmacology was employed to investigate the regulatory role of HSYW’s circRNA-miRNA-mRNA (CMM) network in gastric carcinogenesis. ³⁶ The experiments conducted on Balb/c mice carrying N87 cells have verified that HSYW has an anti-tumor effect. RNA sequencing (RNA-seq) identified 200 DE mRNAs and 119 DE circRNAs, which were subsequently analyzed through predictive miRNA target interactions. Computational modeling constructed both CMM and protein-protein interaction (PPI) networks, followed by quantitative real-time PCR (qRT-PCR) validation to ensure network reliability. ³⁷ Bioinformatic interrogation of The Cancer Genome Atlas (TCGA) and Human Protein Atlas (HPA) databases revealed significant dysregulation of key differentially expressed (DE) targets, including KLF15 and PREX1. ³⁸ Core network analysis identified four circRNAs, six mRNAs, and five miRNAs as potential biomarkers for HSYW therapeutic response. Notably, the study highlights two critical regulatory axes: circRNA_07980/miR-766-3p/PREX1 and circRNA_00240/miR-642a-5p/KLF15, which may mediate HSYW’s antitumor effects in GC. These findings underscore the utility of combining experimental and computational approaches to decipher complex herbal medicine mechanisms, providing a foundation for future biomarker-driven therapeutic strategies in GC management (Figure 2 and Table1).

Figure 2.

Traditional Chinese Medicine (TCM) modulates key miRNAs to suppress the transition from chronic atrophic gastritis (CAG) to gastric precancerous lesions (GPL). HSYW, Huosu-Yangwei; HSYW, Huosu-Yangwei; XLHZ, Xianglian Huazhuo formula; YWXY, Yiwei Xiaoyu granules; WFC, Weifuchun; TCGA, The Cancer Genome Atlas; HPA, Human Protein Atlas; TGF-β1, transforming growth factor β1; SPEM, spasmolytic polypeptide-expressing metaplasia; TFF2, trefoil factor 2; KPNA2, karyopherin subunit alpha 2

Table 1.

Modulation of miRNA to Mitigate the Transition From CAG to GPL Using TCM

Classification	Chinese herbology	Type of study	Model	Dose/Acupoint	Effects	Refs
Chinese medical herbs	HSYW	In vivo	mice	60 mL/60 kg×0.02 kg×10.0	inhibited tumor growth	36
​	YZSJD	In vivo; In vitro	Rats, MKN-45 cells	9 g/kg	mediated by microRNA-7 on apoptosis	39
​	XLHZ	In vivo; In vitro	Rats, GES-1 cells	36 g·kg-1	altering miRNA expression profiles and regulating downstream target genes	40
​	YWXY	In vivo; In vitro	mice, human	15 g/kg, 20 g/kg	Restored the expression of miR-7 by mediating TFF2	41
​	WFC	In vitro	Human GC cell	50 mg/kg; 5 to 50 μg/mL	reducing the levels of KPNA2	42
​	Zhiwei Fuwei Pills	In vivo	Rats	0. 42 g·kg-1, 0. 84 g·kg-1, 1. 67 g·kg-1	regulating the miRNA-21/Bcl-2 signaling pathway	43
Acupuncture	NA	In vivo	Rats	Zusanli (ST36), Zhongwan (CV12), Pishu (BL20)	Decreases NF-κB p65, miR-155, miR-21 and increases miR-146a	44

HSYW, Huosu-Yangwei: Pogostemon cablin, Perilla frutescens, Atractylodes macrocephala Koidz, Citrus trifoliata, Amomum kwangsiense D, Citrus medica, Prunus mume, Zingiber officinale Roscoe, Ziziphus jujuba, Glycyrrhiza uralensis Fisch, Astragalus mongholicus Bunge, Rehmannia glutinosa, Paeoni, Trichosanthes kirilowii Maxim, Angelica sinensis, Conioselinum anthriscoides, Curcuma zedoaria, Lycium chinense, Coptis chinensis Franch, Codonopsis pilosula, Taraxacum mongolicum; YZSJD, Yangzheng Sanjie Decoction: Astragali Radix, Scutellariae Barbatae Herba, Arisaematis Rhizoma Preparatum, Citri Sarcodactylis Fructus, Cremastrae Pseudobulbus and Curcumae Longae Rhizoma; XLHZ, Xianglian Huazhuo formula: Rhizoma Coptidis, Rhizoma Atractylodis Macrocephalae, Fructus Amomi Rotundus, Herba Hedyotidis, Radix Angelicae Sinensis, Rhizoma Chuanxiong, Radix Notoginseng, Poria, Radix Paeoniae Alba, Bulbus Lilii Lancifolii, Fructus Aurantii Immaturus, Rhizoma Cyperi, Radix Aucklandiae, Scorpion, Rhizoma Corydalis Yanhusuo, Herba Agastaches Rugosa, Fructus Amomi, Herba Scutellariae Barbatae; YWXY, Yiwei Xiaoyu granules: Red Ginseng, Panax Notoginseng, Atractylodis Macrocephalae Rhizoma, Coicis Semen, Angelica APA, Aesculi Semen, Fritillariae Thunbergii Bulbus et al; WFC, Weifuchun: Radix Ginseng Rubra, Rabdosia amethystoides, Fructus Aurantii; NF-κB, nuclear factor-kappa B.

Emerging evidence highlights the pivotal regulatory role of miRNAs in the molecular pathogenesis of gastric carcinogenesis, particularly during the transition from CAG to GPL, where they function as either oncogenic drivers (oncomiRs) or tumor suppressors (tumor-suppressor-miRs). ⁴⁵ Among these, miR-7 has been identified as a key tumor-suppressive miRNA in CAG-associated precancerous transformation, exerting its inhibitory effects by directly targeting the epidermal growth factor receptor (EGFR), a well-characterized oncogenic signaling hub. Yangzheng Sanjie Decoction (YZSJD), a traditional Chinese herbal formulation, has demonstrated clinical efficacy in alleviating symptoms and potentially delaying the progression of precancerous lesions, prompting mechanistic investigations into its anti-tumor properties. ⁴⁶ To elucidate the underlying molecular mechanisms, a recent study employed a YZSJD-containing serum (YCS) model to assess its effects on the GC MKN-45 cell line. ³⁹ The findings revealed that YCS significantly inhibited cellular proliferation by inducing S-phase cell cycle arrest and promoting apoptosis, while miR-7 expression was notably downregulated in GC tissues compared to normal controls. Further Western blot and qRT-PCR analyses demonstrated an inverse correlation between miR-7 and EGFR levels, suggesting that YCS-mediated suppression of GC cell proliferation and induction of apoptosis may occur, at least in part, through miR-7-dependent EGFR downregulation. ⁴⁷ These insights provide a novel mechanistic basis for YZSJD’s therapeutic potential in GC intervention, positioning miR-7/EGFR axis modulation as a promising strategy for chemoprevention and targeted therapy in gastric carcinogenesis.

This study elucidated the molecular mechanisms underlying Xianglian Huazhuo formula (XLHZ)-mediated inhibition of CAG progression to GC. ⁴⁰ Gastric mucosal pathology was assessed in a rat model, and miRNA profiling was performed via high-throughput sequencing. DE miRNAs were analyzed using miRDB, miRanda, and miRWalk to predict target genes, followed by functional enrichment analysis (GO/KEGG). Key findings were validated by qRT-PCR, while Western blot, EdU incorporation, and flow cytometry assays evaluated XLHZ’s effects on EMT markers, proliferation, migration, and cell cycle dynamics in CAG cells. Bioinformatic analysis identified four critical target genes and five DE miRNAs. ⁴⁸ GO enrichment implicated these genes in neuronal development, transcription factor regulation, and RNA polymerase activity. KEGG pathway analysis revealed significant associations with the Phospholipase D, Wnt, and MAPK signaling cascades. Experimental validation confirmed miRNA-target gene interactions consistent with sequencing data. ⁴⁹ Functionally, XLHZ upregulated E-cadherin while suppressing transforming growth factor β1 (TGF-β1), vimentin, and β-catenin expression, thereby attenuating CAG cell migration and proliferation. Cell cycle arrest at G0/G1 and G2/M phases further substantiated XLHZ’s tumor-suppressive effects. These results suggest that XLHZ impedes CAG-to-GC progression via modulation of miR-320-3p, miR-20a-3p, miR-883-3p, miR-483-3p, and miR-34b-5p and their downstream targets. This study provides novel mechanistic insights into XLHZ’s therapeutic potential, highlighting its role in miRNA-mediated pathway regulation as a strategy to mitigate gastric carcinogenesis.

Spasmolytic polypeptide-expressing metaplasia (SPEM) is an underlying PLGC. The purpose was to elucidate the preventive impacts of Yiwei Xiaoyu granules (YWXY) mediated by miR-7 in the SPEM lesions. ⁴¹ With signed informed consent, gastric mucosal tissue was gathered from healthy individuals and CAG patients. Mice in which SPEM was induced by tamoxifen were treated with YWXY. On the tenth day of the experiment, the gastric mucosa was collected. Subsequently, confirm SPEM and lesions, and study its underlying mechanism. qRT-PCR was utilized to detect RNA transcripts. In SPEM lesions, the expression of miR-7 was reduced, and the expressions of trefoil factor 2 (TFF2) and clusterin were high. ⁵⁰ Experimental research indicated that YWXY was able to suppress cell proliferation through the regulation of Ki67. At the same time, as detected by immunofluorescence, YWXY was able to restore the expression of miR-7 by regulating TFF2, suggesting its underlying machinery of targeting miR-7 via modulating TFF2. Within 3 days of YWXY administration for the SPEM lesions, the vascular endothelial growth factor-β (VEGF-β) expression and gastric intrinsic factor recovered. This led to the speculation that YWXY hinders the progression of SPEM by modulating VEGF-β and gastric intrinsic factor as its underlying mechanism. In summary, in the human gastric mucosa, the down-regulation of miR-7 occurs early in SPEM via the modulation of TFF2. ⁵¹ In the SPEM mouse model, YWXY can suppress cell proliferation and reinstate the miR-7 expression via modulating TFF2.

Weifuchun (WFC), a TCM with established efficacy in chronic gastric disorders such as atrophic gastritis and intestinal metaplasia, exhibits potential anti-tumor properties in GC, though its underlying mechanisms remain poorly characterized. ⁵² To address this gap, this study systematically evaluated WFC’s inhibitory effects on GC oncogenicity and dissected its molecular pathways. ⁴² In vitro experiments demonstrated WFC’s selective suppression of malignant phenotypes in GC cells, with minimal impact on normal gastric epithelium. Functional assays and molecular profiling revealed that WFC attenuates tumor progression primarily through downregulation of karyopherin subunit alpha 2 (KPNA2), a nuclear transport protein implicated in oncogenesis. Mechanistically, WFC modulates KPNA2 via dual pathways: (1) miR-26a-5p upregulation, inducing post-transcriptional silencing, and (2) suppression of MAPK phosphorylation dynamics, disrupting oncogenic signaling. These findings were validated in vivo, where WFC significantly impaired tumor growth in a xenograft model. ⁵³ This study identifies WFC as a multi-targeted GC therapeutic, acting through coordinated miR-26a-5p/KPNA2 axis modulation and MAPK pathway inhibition. These insights not only advance the pharmacological understanding of WFC but also support its potential integration into GC treatment regimens, particularly for therapy-resistant cases.

The present research sought to assess how Zhiwei Fuwei Pills modulate mitochondrial apoptosis in PLGC-bearing rats, centering on the regulatory role of the miRNA-21/Bcl-2 signaling pathway. ⁴³ Male SPF SD rats aged 50 weeks were selected for this study. Seventy-five of these animals were treated with N-methyl-N′-nitro-N-nitrosoguanidine (MNNG) plus multiple pathogenic factors to induce lesions, and a reliable PLGC rat model was achieved after 26 weeks of induction. Rats with successfully established PLGC models were randomly stratified into five groups, including the model control group, folic acid positive control group, and Zhiwei Fuwei Pills low-, medium-, and high-dose groups. The other 10 rats were assigned to the negative control group, with intragastric administration of normal saline at an equivalent volume. Rats received consecutive medication treatment over four weeks, followed by the collection of gastric mucosa samples for further laboratory assays. For the assessment of pathological and molecular modifications, multiple experimental methodologies were implemented: Hematoxylin-eosin (HE) staining was carried out to characterize the pathological features of gastric mucosal tissues; TUNEL assay was employed to determine the apoptotic index of gastric mucosal epithelial cells; RT-PCR was utilized to quantify the mRNA transcript levels of miRNA-21, PTEN, Bcl-2, Bax, and caspase-3; Western blot analysis was performed to assess the protein concentrations of PTEN, Bcl-2, Bax, and caspase-3; Immunohistochemistry (IHC) was applied to detect the positive expression patterns of PTEN, Bcl-2, and Bax in gastric mucosal tissues; and Transmission electron microscopy (TEM) was used to analyze mitochondrial morphological and structural changes. These data indicated that, in comparison to the model control group, rats administered Zhiwei Fuwei Pills presented with mitigated pathological alterations in the gastric mucosa, accompanied by a prominent upregulation in apoptotic cell numbers. ⁵⁴ Further molecular assays demonstrated that the drug intervention remarkably inhibited the mRNA expression of miRNA-21 and Bcl-2. Conversely, the transcriptional and protein levels of PTEN, Bax, and caspase-3 were greatly enhanced, accompanied by a distinct reduction in Bcl-2 protein expression in all medication groups. Notably, mitochondrial ultrastructural damages were substantially relieved in all intervention groups, showing alleviated swelling, reduced membrane breakage and attenuated cristae depletion. These changes further verified the activation of mitochondria-mediated apoptotic progression. In summary, these findings reveal that Zhiwei Fuwei Pills exert a potent pro-apoptotic effect on PLGC cells via the mitochondrial pathway, and this pharmacotherapeutic action may be orchestrated by regulating the miRNA-21/Bcl-2 signaling axis.

5.2. Acupuncture

For centuries, TCM has employed acupuncture as an effective therapeutic intervention for CAG^55,56. This study systematically investigated the therapeutic mechanisms of acupuncture at Zusanli (ST36), Zhongwan (CV12), and Pishu (BL20) in a CAG-induced rat model through comprehensive evaluation of body weight dynamics, gastric gland histopathology, and molecular expression profiles of NF-κB p65 and key microRNAs (miR-155, miR-21, miR-146a). ⁴⁴ The results demonstrated that acupuncture treatment significantly improved physiological parameters, as evidenced by marked increases in body weight compared to the model group, suggesting enhanced metabolic and nutritional status. Histopathological examinations further revealed substantial amelioration of gastric mucosal damage, indicating acupuncture’s protective effects on gastric tissue integrity. At the molecular level, the CAG model exhibited upregulated expression of pro-inflammatory mediators NF-κB p65, miR-155 and miR-21, with miR-21 showing a direct positive correlation with miR-155, while anti-inflammatory miR-146a was downregulated and inversely correlated with miR-155/miR-21. Notably, acupuncture intervention effectively reversed these pathological molecular patterns, downregulating NF-κB p65, miR-155 and miR-21 while upregulating miR-146a expression. ⁵⁷ These findings collectively suggest that acupuncture’s therapeutic benefits in CAG may be mediated through modulation of the NF-κB signaling pathway and restoration of microRNA homeostasis, highlighting the critical involvement of these molecular targets in acupuncture’s anti-inflammatory and immunomodulatory effects, thereby providing a scientific basis for its clinical application in CAG management.

6. Discussion

The progression from CAG to GPL represents a critical stage in gastric carcinogenesis, characterized by chronic inflammation, epithelial dysplasia, and dysregulated miRNA expression. During gastric mucosal deterioration, pro-inflammatory miRNAs including miR-21 and miR-155 are significantly upregulated, which sustain chronic inflammation via the NF-κB and STAT3 signaling pathways. In contrast, tumor-suppressive miRNAs such as miR-34a and the miR-200 family are downregulated, thereby inducing uncontrolled cell proliferation and EMT. TCM classic prescriptions have a long history of clinical application. With mild medicinal properties, few adverse reactions and favorable medication safety, they are widely used in the prevention and treatment of various diseases. To objectively evaluate the pharmacological effects and mechanism of this TCM compound, the mouse dosage was set with reference to the human clinical equivalent dose in preclinical animal experiments of this study. This design simulates the actual clinical drug exposure level, providing experimental evidence for the pharmacological research and rational clinical application of the prescription. TCM interventions include single herbs such as Huangqin (Scutellaria baicalensis) and Dangshen (Codonopsis pilosula): the former suppresses miR-21 and miR-155, while the latter restores the expression of the miR-200 family. Classical prescriptions, including Banxia Xiexin Tang and Weifuchun tablets, modulate the miR-146a/NF-κB axis and upregulate miR-148a to inhibit hypermethylation of tumor suppressor genes, respectively. These TCM regimens exert synergistic effects in restoring gene regulatory homeostasis, with their multi-target actions mediated by bioactive constituents (e.g., flavonoids, alkaloids, and polysaccharides) that modulate core signaling pathways linked to inflammation, apoptosis, and cell cycle progression.

Studies on miRNA-targeted herbal compounds for gastric precancerous lesions in chronic atrophic gastritis possess important therapeutic significance. These compounds can reverse pathological changes including gastric mucosal atrophy, intestinal metaplasia and dysplasia by regulating the abnormal expression of tumor-suppressive and oncogenic miRNAs, thereby blocking the malignant progression of gastric precancerous lesions. Based on the multi-component and multi-target advantages of TCM, herbal ingredients can modulate key miRNAs and their downstream signaling pathways, improve the gastric mucosal microenvironment, alleviate inflammatory injury, and inhibit abnormal cell proliferation and malignant transformation. Furthermore, these findings provide novel molecular targets and promising avenues for natural drug research and development, facilitating early intervention as well as precise prevention and management of gastric precancerous lesions. Moreover, they address the limitations of single Western medical intervention and lay a theoretical foundation for mechanistic research and clinical translation of TCM in restraining the progression of gastric cancer.

6.1. Limitations and future Perspectives

Lack of standardized literature retrieval strategies and methodological quality evaluation systems renders relevant studies susceptible to publication bias; The majority of included studies are preclinical basic investigations (e.g., in vitro cell assays and animal models), whereas high-quality controlled clinical trials are rare due to small sample sizes and insufficient follow-up durations, hampering the direct translation of experimental findings to human pathological conditions; In terms of mechanism exploration, existing research is mostly limited to superficial investigation of single miRNAs and linear signaling pathways, lacking targeted binding verification assays; Additionally, it fails to fully account for confounding factors including the spatiotemporal expression specificity of miRNAs, interactive regulation of non-coding RNAs, gastric mucosal microenvironment and Helicobacter pylori infection.

Future studies should prioritize clarifying the dynamic expression characteristics of tumor-suppressive miRNAs (TS-miRNAs) specific to different gastric carcinogenesis stages, such as miR-34a, miR-145, the let-7 family and miR-200c. By integrating TCM’s holistic approach with modern molecular medicine, this ancient practice may provide a novel and effective strategy for preventing gastric cancer progression through targeted miRNA modulation. Large-sample, multicenter clinical cohorts are required to verify their dual value as early warning biomarkers for malignant transformation and therapeutic targets of TCM intervention.

7. Conclusion

Recent advances in TCM have led to a holistic and methodical approach to PLGC treatment. A review of previous studies has found that in clinical practice, the TCMs commonly used to treat PLGC include Astragalus membranaceus and Ginseng which are tonic herbs, Panax notoginseng for activating blood circulation to dissipate blood stasis, and Actinidia arguta root and Hedyotis diffusa which are for clearing heat and detoxifying. Further research and analysis indicate that TCMs suppress aberrant cell proliferation, modulate apoptosis in affected regions, eliminate inflammatory reactions, and reduce oxidative stress-induced damage. These effects collectively restore gastric physiological homeostasis, ameliorate gastric mucosal status, reverse pathological alterations, and achieve effective alleviation or cure of the disease. In conclusion, TCMs have unique clinical advantages in treating PLGC and are worthy of continuous promotion. However, the development of TCM still has a long way to go and there are still some deficiencies that need to be improved: The complexity of TCM components makes the research on the mechanism of action of TCMs complicated and difficult. In the future, in - depth research on the mechanism of TCMs can be carried out; Clinical randomized trials can increase the sample size, extend the follow-up time, and unify the efficacy evaluation criteria to enhance the persuasiveness of the results; Technologies such as network pharmacology and data mining can be used to analyze the relationships between drug compatibility, drug dosage and drug efficacy, so as to carry out more accurate treatment.