1

Will metastatic cancer be a curable disease ?

2

Cancer Treatment is not a success (so far..)

Overall cancer mortality, Age standardized ratio by age class in 19

western countries

MEN WOMEN

Summa et al. Submited

3

Age standardized ratio by cancer site in 19 countries

0

100

200

300

400

500

600

700

800

900

1961 1966 1971 1976 1981 1986 1991 1996 2001

ASR

Years

ASR Stomach cancer (male)

ASR Lung cancer (male)

ASR Breast cancer ( female)

ASR Prostate cancer (male)

ASR Lung cancer (female)

4

What is Cancer?

Cancer phenotype: Invariants

1- Increased pressure

2- Fractal shape

3- Increased glucose uptake

4- Intracellular alkalosis

5

What is Cancer?

Cancer phenotype: 1 - Increased pressure

Measured Interstitial Pressures

Interstitial Pressures compared to

vascular pressures

6

What is Cancer?

Cancer phenotype: 2 – Fractal shape

Fleury et al., « Fractal » 2003

Fractal image of a breast carcinoma

7

What is Cancer?

Cancer phenotype: 3 – Increased glucose uptake

Pet Scan

8Hematoxylin and eosin stains are a pH based phenomenon

Cancer phenotype: 4 – Intracellular alkalosis

9

Cancer : between glycolysis and physical constraints.

L. Schwartz Springer 2004

10

Cell Mitosis

11

The cell is an electrical machine

12

Bioenergetics of Cell Metabolism

Adenosine triphosphate (ATP) : the energetic currency exchange

Wikipedia_image

13

Bioenergetics of Cell Metabolism

ATP hydrolysis is the molecular motor of Life.

14

Glycolysis vs. Oxidative phosphorylation

Modified from Diaz-Moralli et al. (2013)

The central carbon metabolism (CCM) oscillates between biomass and energy synthesis

and times cell division.

BIOMASSGLYCOLYSIS

OXPHOS

15

Glycolysis vs. Oxidative phosphorylation

Modified from Diaz-Moralli et al. (2013)

The central carbon metabolism (CCM) oscillates between biomass and energy synthesis

and times cell division.

ATPOXPHOS

GLYCOLYSIS

16

Differentiated Cells

Differentiated cells have an oxidative metabolism based on mitochondrial respiration and energy synthesis (ATP)

17

Differentiated Cells

Differentiated cells have an oxidative metabolism based on mitochondrial respiration and energy

synthesis (ATP)

• ATP = 9 pmol

• Acidic pH = 6.8

• NAD+/NADH ratio = 8-10

18

Proliferating Cells

Rapidly proliferating cells have a glycolytic metabolism based on glucose fermentation and biomass synthesis

19

Intertwined redox oscillators

In the case of normal cells

0

1

2

3

4

5

6

7

8

9

10

pm

ole

s

[ATP]

G0 SG1 MG2 G0 0

0.02

0.04

0.06

0.08

0.1

0.12

0.14

0.16

0.18

0.2

rati

o N

AD

H/N

AD

+

NADH/NAD+

MG0 G1 S G2 G0

0

2E-08

4E-08

6E-08

8E-08

0.0000001

1.2E-07

1.4E-07

1.6E-07

1.8E-07

mo

l/L

[H+]

G0 G1 S G2 M G0

20

3. pHi Oscillation Regulates Cell Cycle

RNA polymerase [4]

Chromatin

decondensation

[1-3]

DNA polymerase [4]Chromatin

condensation

[3]

1. Lois et al. (1983)

2. Allfrey et al. (1962)

3. Guo et al. (1989)

4. Grainger et al. (1979)

5. McBrian et al. (2013)

6. Kurdistani (2014)

Histone acetylation [5-

6]

Histone deacetylation [5-6]

6.6

6.7

6.8

6.9

7

7.1

7.2

7.3

7.4

7.5

pH

i

pHi oscillation during cell cycle

G2 Early MitosisG1 S G1

21

CANCER : A DECREASE IN ENERGY YELD

21

22

Mitochondria are not functional in cancer

23

Warburg Effect : Reduced Energy Efficiency

Heiden et al. (2010)

PPP

24

Cancer Cells are ATP-deprived

0

2

4

6

8

10

12

Normal Cancer Normal Cancer Normal Cancer Normal Cancer Normal Cancer

Pro-G1 Late G1-S Early G2 Late G2-Early M M/G0

pm

ole

s/µ

g p

rot.

[ATP] in normal and cancer cells

(n=8)

25

Intertwined redox oscillators

In the case of cancer cells

0

0.5

1

1.5

2

2.5

3

3.5

4

4.5

5

pm

ole

s

[ATP]

0

1E-08

2E-08

3E-08

4E-08

5E-08

6E-08

7E-08

mo

l/L

[H+]0

0.01

0.02

0.03

0.04

0.05

0.06

0.07

0.08

rati

o N

AD

H/N

AD

+

NADH/NAD+

0

0.1

0.2

0.3

0.4

0.5

0.6

0.7

0.8

0.9

1

rati

o N

AD

PH

/NA

DP

+

NADPH/NADP+

G0G1 S G2G0 M

G0

G0

G0G1

G1

G1S

S

SG2

G2

G2M

M

M G0

G0

26

Cancer Drugs Change Cancer Metabolism

27

PET SCAN

Chemotherapy normalizes the radioactive glucose uptake

28

Can we do better than chemotherapy?

29

Our approach

Data-base

Individual screening• 5 cancer cell types

• proliferation and MTT test

• 1, 3, 5 days cultures

Combination screening(same experimental conditions)

Literature screening• Metabolic activity

• Well-known molecules

• Data on human toxicity

28 molecules

7 molecules

7 combinations

Results• High clinical efficiency

• Universal and simple mechanisms

• Low regulatory risk and low cost

30

Literature screening

Drugs Mechanism of action

Acetazolamide Anhydrase carbonic inhibition

Albendazole PEP carboxykinase inhibition

Amobarbital NADH dehydrogenase

Amrinone PDE-3 inhibition

Betaine lipotropic factor

Capsaicin NADH dehydrogenase

Dfructose 1,6 biphosphate PKM2 activation

Dichloroacetate PDHK1 inhibition

Dimercaprol PDH activation

Farnesol phospholipase D inhibition

Genistein Phospholipase Cgamma inhibition

Gossypol LDH inhibition

Hydrazine sulfate PEP carboxykinase inhibition

Hydroxycitrate ATP citrate lyase

Ketoconazole Cyt. P450 demethylase inhibition

Lipoic acid PDHK1 inhibition

Lithium chloride PEPCK inhibition

Lonidamine Hexokinase inhibition

Metformine AMPK activation

Miltefosine Choline kinase inhibition

Niacine Lipolysis inhibition

Quinacrine Phospholipase A2 inhibition

Quinine Phospholipase A2 inhibition

Silibinine IGFBP activation

Simvastatine Lipolysis inhibition

Suramine Citrate synthase inhibition

Tolbutamide Potassium channel blocker

Xylitol PP2A

31

METABLOC 1

Aim:

Identify a combination of two drugs active

against altered cancer cell metabolism

32

In vivo validation

Experiments

• Three syngeneic cancer models

– MBT-2 bladder carcinoma

– B16-F10 melanoma

– LL/2 lung carcinoma

• Analysis of tumor volume and animal survival

METABLOC 1

33

0

500

1000

1500

2000

2500

3000

3500

10 20 30 40 50 60 70 80 90 100 110 120 130

Saline 5-FU Ethanol

Contrôle DMSO I33 seul K11/A44

K11/N83 I33/ V25 I33/ A44

V25 / A44 K11 / N83 / B29 I33/V25 Low

I33/A44 Low K11/A44 K11/N83 V25/A44

Combination of molecules in bladder cancer

Vt

(mm

3)

Tumor volume evolution in bladder carcinoma model (MBT-2).

Time since

implantation (days)

Treatment Treatment

METABLOC 1

34

0

12

34

56

78

910

11

19 29 39 49 59 69 79 89 99 109 119 129 139

ALA/HCA in bladder carcinoma (MBT-2)

Time since

implantation (days)Nu

mb

er o

f al

ive

mic

e (n

=1

8)

Survival. Saline Ethanol

5-FU ALA/ HCA

Treatment Treatment

The ALA/HCA combination reduces tumor development rate

and doubles survival time as compared to untreated mice.

METABLOC 1

35

0

1

2

3

4

5

6

7

8

9

10

18 28 38 48 58 68 78 88 98 108 118

ALA/HCA in melanoma (B16-F10)

Time since

implantation (days)

Treatment

Survival.

Nu

mb

er o

f al

ive

mic

e (n

=1

0)

Saline Ethanol

Cisplatin ALA/ HCA

The ALA/HCA combination reduces tumor development rate

and doubles survival time as compared to untreated mice.

METABLOC 1

36

LLC tumor model

37

Well-known molecules

Name

Indications

Toxicity

Lipoic acid Calcium hydroxycitrate

• Anti-oxidant

• Dietary supplement

• Diabetic neuropathy

• No toxicity at

1200mg/day during 2 years

• No mutagenic or

genotoxic activity

Weight loss agent

• No toxicity at 5g/day

during 8 weeks

• No mutagenic or

genotoxic activity

ALA HCA

38

0

500

1000

1500

2000

2500

3000

3500

4000

10 15 20 25 30 35 40 45 50 55 60 65

Enhanced efficacy of chemotherapy

Vt

(mm

3)

Treatment

Tumor volume.

Addition of ALA/HCA enhanced the efficiency of

cisplatin treatment (LLC model).

Saline Ethanol Cisplatin

ALA/ HCA CIS/ ALA/ HCA

Time since

implantation (days)

39

In vivo screeningsDrugs Mechanism of action6-diazo-5-oxo-L-norleucine Glutaminase inhibition

Agmatine Polyamine synthesis inhibition

Alpha cetoglutarate Citrate synthase inhibition

Amiloride Na+/H+ antiport inhibition

Apigenine IGFBP activation

Bicalutamide IGFBP activation

Bromocriptine Hypothalamic D2 receptor agonist

Butyrate sodium HDAC inhibition

Chitosan PK-M2 inhibition

Choline Chloride lipotropic factor

Citrate Citrate synthase inhibition

Cryogenine PEP carboxykinase inhibition

Curcumin AID inhibition

D-alanine Alanine transaminase inhibition

Epigallocatechin gallate PK-M1/M2 splicing regulation

Fluoxetine Serotonine reabsorption inhibition

Ibuprofen NSAIDS

Indole 3 carbinol Triglycerides reduction

Ketoconazole Cyt. P450 demethylase inhibition

Lactoferine Oxydative stress reduction

Letrozole Aromatase inhibition

L-norvaline Arginase inhibition

Melatonine anti-oxydant, anti-proliferative

Menadione Tyr kinase receptor inhibition

Oméprazole IGFBP activation

Oxythiamine Transketolase inhibition

PEG8000 PK activation

Pegvisomant GH receptor inhibition

Pralidoxime Alanine transaminase inhibition

Retinoic acid Cellular differentiation activation

Sulpiride GH secretion inhibition

Suramine Citrate synthase inhibition

Valproate sodium HDAC inhibition

Vitamine B12 lipotropic factor

METABLOC 2

40

0

500

1000

1500

2000

2500

3000

3500

4000

4500

15 25 35 45 55

Vt

(mm

3)

Treatment

Tumor volume (LLC).

Time since

implantation (days)

Screening of 19 combinations

ALA/HCA/OCT

CisplatinALA/ HCA

Vehicles

METABLOC 2

41

Combination of ALA/ HCA/ OCT/ CAP

METABLOC 1

First report of tumor regression with a metabolic treatment Schwartz L. Invest New Drugs. 2013 Apr;31(2):256-64.

42

First patient

7/2001: Adenocarcinoma of the colon pT4 N0

10/ 2009 : Peritoneal metastasis

12/2009 : Chemotherapy at Institut Gustave Roussy

(Villejuif)

5-FU, Cisplat, Avastin

12/2009 oral ALA and HCA

3/ 2010 : Avastin discontinued because of poor tolerance

7/ 2010 : abdominal radiotherapy followed by Gemcitabine

7/ 2011: discontinuation of chemotherapy

10/2014: death

43

CT of the perirectal mass at the date of discovery (Nov. 2009)

44

CT of the same region, on June 2012

45

First italian patient

Glioblastoma multiforme started Metabloc in early

2008

Multiple relapses but alive and reasonably well in

5/2015

46

In the mean time

Dr Burt Berkson (New Mexico)

10 cases of uncurable advanced cancer :

Long term stabilization with IV Lipoic acidand low dose naltrexone

Number of patients treated not stated

Integrative Cancer Therapies 2009 (4) 416–422

47

Compassionate use in desperate patients

48

Targeting the Central Carbon Metabolism

49

Inclusion criteria

Metastatic carcinoma

Standard chemotherapy failed

Offered only palliative care

Karnofsky status between fifty and eighty

Life expectancy estimated to be between 2 and 6 months

50

Chemoresistant advanced metastatic cancer :

• lipoic acid 600 mg IV (Thioctacid® (Meda Pharma)

• hydroxycitrate 500 mg t.i.d (Solgar)

• low-dose naltrexone 5 mg (Revia) at bed time

Treatment Protocol: chemoresistant tumors

51

0

1

2

3

4

5

6

7

8

9

10

11

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21

Patient

Patient

Patient

Patient

Patient

Patient

Patient

Patient

Patient

Patient

Patient

Month survival

Life expectancy

Clinic results for the first 11 patients

52

Advanced metastatic cancer :

• lipoic acid 1, 8gr (Tiobec®)

• hydroxycitrate 500 mg t.i.d (Solgar)

• low-dose naltrexone 5 mg (Revia) at bed time

• In combination with standard chemotherapy

Treatment Protocol: chemosensitive tumors

53

Second Series of Clinical treatment

• Group I: Metabolic treatment only (n=17)

• Group II: Metabolic treatment and chemotherapy (n=27)

• 12 months treatment

Months

Pro

port

ion s

urv

ivin

g

Months

Pro

po

rtio

n s

urv

ivin

g

Group IGroup II

54

Florentine

• 3/2006 Sarcoma of the uterus : surgery + RT + chemotherapy ( TEC)

• 2008 Radiation induced enteritis

• 1/2013 multiple brain metastasis ( N sup 15)

Palliative radiatiotherapy (30gy in 10 fractions)

Sent home to die

• 3/ 2013 start metabloc

• 5/ 2015 NED

55

Yun

56 year old lady

• 3/13 Squamous cell carcinoma of the lung with bone and brain metastasis ( N sup 20)

• Treatment gifetinib, partial response

• 2/14 because of tumor progression , continue gifetinib and start metabolic treatment partial response

• 6/14 brain irradiation 30Gy/10 fractions. During radiation acute psychosis, weight loss.

• 8/14 The husband is told that she is going to die

• 9/14 starts Alimta for palliative care and metabolic treatment

• 5/ 15 She lives an almost normal life

56

Vincent’s wife

57

Marina

• 2/12 Cholangiocarcinoma partial hepatectomy

• 5/12 Lung metastasis

• 5 FU and cisplatin ineffective

Stutent ineffective

Other treatment option sent home to die

• 2/13 start LDN, LA, HCA

Tumor stabilisation for 16 months

• 2/15 Death

58

PSA in hormone resistant prostate cancer

0

2

4

6

8

10

12

14

ng/m

L

Dates

PSA concentration (ng/mL)Start metabolic treatment

12/05/11 14/11/12 24/11/13 15/10/14 06/03/15

0

100

200

300

400

500

600

700

800

900

ng/m

L

Dates

PSA concentration (ng/mL)

01/04/1520/12/1329/03/1311/05/12

Start metabolic treatment

59

Metastatic colon cancer (3 different lines of chemotherapy)

60

Decrease level of tumor markers followed by regrowth

035

287

602

641

214

175

104

159

190

153154157170

184182

237233235

276

327

397

738

701

830

000

100

200

300

400

500

600

700

800

900

0 2 4 6 8

Months of metabolic treatment

Start metabolic treatment

Ca125 (UI/mL)

Add Nivaquine

Glucophage

Death

Gemzar Zocor

Stop Zocor

Ptérostilbène

Cyclosérine

Stop metabolic treatment

Relais Crevel

61Schwartz and Israel 2005

From:

Israël and Schwartz.

2006

Targets for a combined anti-tumoral therapy

62

How to improve METABLOC?

A)Decrease glucose uptake

B)Decrease intracellular pH

63

63

PET scan

Colon carcinoma with

liver metastasis

PET scan

Regular administration

of Metabloc Digoxin

and 5 FU

(2 months later)

64

As of september 2015, it is probable that:

1) Cancer is the simple consequence of mitochondrial inactivation.

2) Alzheimer’s disease has a lot of common features with cancer

3) It is a matter of time before effective treatment will reach the market

4) There will be economical/political changes