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Vernieri C, Ligorio F, Tripathy D, Longo VD. Cyclic fasting-mimicking diet in cancer treatment: Preclinical and clinical evidence. Cell Metab 2024; 36:1644-1667. [PMID: 39059383 DOI: 10.1016/j.cmet.2024.06.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/11/2024] [Revised: 06/03/2024] [Accepted: 06/27/2024] [Indexed: 07/28/2024]
Abstract
In preclinical tumor models, cyclic fasting and fasting-mimicking diets (FMDs) produce antitumor effects that become synergistic when combined with a wide range of standard anticancer treatments while protecting normal tissues from treatment-induced adverse events. More recently, results of phase 1/2 clinical trials showed that cyclic FMD is safe, feasible, and associated with positive metabolic and immunomodulatory effects in patients with different tumor types, thus paving the way for larger clinical trials to investigate FMD anticancer activity in different clinical contexts. Here, we review the tumor-cell-autonomous and immune-system-mediated mechanisms of fasting/FMD antitumor effects, and we critically discuss new metabolic interventions that could synergize with nutrient starvation to boost its anticancer activity and prevent or reverse tumor resistance while minimizing toxicity to patients. Finally, we highlight potential future applications of FMD approaches in combination with standard anticancer strategies as well as strategies to implement the design and conduction of clinical trials.
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Affiliation(s)
- Claudio Vernieri
- Medical Oncology and Hematology-Oncology Department, University of Milan, 20122 Milan, Italy; IFOM ETS, the AIRC Institute of Molecular Oncology, 20139 Milan, Italy.
| | - Francesca Ligorio
- Medical Oncology and Hematology-Oncology Department, University of Milan, 20122 Milan, Italy; Medical Oncology Department, Fondazione IRCCS Istituto Nazionale dei Tumori, 20133 Milan, Italy
| | - Debu Tripathy
- Department of Breast Medical Oncology, The University of Texas MD Anderson Cancer Center, Unit 1354, 1515 Holcombe Blvd, Houston, TX 77030-4009, USA
| | - Valter D Longo
- IFOM ETS, the AIRC Institute of Molecular Oncology, 20139 Milan, Italy; Longevity Institute, Davis School of Gerontology and Department of Biological Sciences, University of Southern California, Los Angeles, CA 90089, USA.
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Chai X, Zhang Y, Zhang W, Feng K, Jiang Y, Zhu A, Chen X, Di L, Wang R. Tumor Metabolism: A New Field for the Treatment of Glioma. Bioconjug Chem 2024. [PMID: 39013195 DOI: 10.1021/acs.bioconjchem.4c00287] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/18/2024]
Abstract
The clinical treatment of glioma remains relatively immature. Commonly used clinical treatments for gliomas are surgery combined with chemotherapy and radiotherapy, but there is a problem of drug resistance. In addition, immunotherapy and targeted therapies also suffer from the problem of immune evasion. The advent of metabolic therapy holds immense potential for advancing more efficacious and tolerable therapies against this aggressive disease. Metabolic therapy alters the metabolic processes of tumor cells at the molecular level to inhibit tumor growth and spread, and lead to better outcomes for patients with glioma that are insensitive to conventional treatments. Moreover, compared with conventional therapy, it has less impact on normal cells, less toxicity and side effects, and higher safety. The objective of this review is to examine the changes in metabolic characteristics throughout the development of glioma, enumerate the current methodologies employed for studying tumor metabolism, and highlight the metabolic reprogramming pathways of glioma along with their potential molecular mechanisms. Importantly, it seeks to elucidate potential metabolic targets for glioblastoma (GBM) therapy and summarize effective combination treatment strategies based on various studies.
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Affiliation(s)
- Xiaoqian Chai
- School of Pharmacy, Nanjing University of Chinese Medicine, Nanjing 210023, China
- Jiangsu Provincial TCM Engineering Technology Research Center of High Efficient Drug Delivery System, Nanjing 210023, China
| | - Yingjie Zhang
- School of Pharmacy, Nanjing University of Chinese Medicine, Nanjing 210023, China
- Jiangsu Provincial TCM Engineering Technology Research Center of High Efficient Drug Delivery System, Nanjing 210023, China
| | - Wen Zhang
- School of Pharmacy, Nanjing University of Chinese Medicine, Nanjing 210023, China
- Jiangsu Provincial TCM Engineering Technology Research Center of High Efficient Drug Delivery System, Nanjing 210023, China
| | - Kuanhan Feng
- School of Pharmacy, Nanjing University of Chinese Medicine, Nanjing 210023, China
- Jiangsu Provincial TCM Engineering Technology Research Center of High Efficient Drug Delivery System, Nanjing 210023, China
| | - Yingyu Jiang
- School of Pharmacy, Nanjing University of Chinese Medicine, Nanjing 210023, China
- Jiangsu Provincial TCM Engineering Technology Research Center of High Efficient Drug Delivery System, Nanjing 210023, China
| | - Anran Zhu
- School of Pharmacy, Nanjing University of Chinese Medicine, Nanjing 210023, China
- Jiangsu Provincial TCM Engineering Technology Research Center of High Efficient Drug Delivery System, Nanjing 210023, China
| | - Xiaojin Chen
- School of Pharmacy, Nanjing University of Chinese Medicine, Nanjing 210023, China
- Jiangsu Provincial TCM Engineering Technology Research Center of High Efficient Drug Delivery System, Nanjing 210023, China
| | - Liuqing Di
- School of Pharmacy, Nanjing University of Chinese Medicine, Nanjing 210023, China
- Jiangsu Provincial TCM Engineering Technology Research Center of High Efficient Drug Delivery System, Nanjing 210023, China
| | - Ruoning Wang
- School of Pharmacy, Nanjing University of Chinese Medicine, Nanjing 210023, China
- Jiangsu Provincial TCM Engineering Technology Research Center of High Efficient Drug Delivery System, Nanjing 210023, China
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3
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Pahwa B, Leskinen S, Didia E, Huda S, D'Amico RS. Role of nutritional adjuncts in the management of gliomas: A systematic review of literature. Clin Neurol Neurosurg 2023; 231:107853. [PMID: 37390567 DOI: 10.1016/j.clineuro.2023.107853] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2023] [Accepted: 06/23/2023] [Indexed: 07/02/2023]
Abstract
BACKGROUND A variety of dietary adjuncts are known to affect the pathophysiology of glioma, making them a potential therapeutic adjunct to standard of care. We systematically reviewed clinical outcomes in glioma patients treated with one or more nutritional adjunct and/or an antimetabolite drug. METHODOLOGY A systematic review of the literature following PRISMA guidelines was performed using Pubmed from inception till February 2023. In total, 22 manuscripts on nutrition representing 828 patients were included in the review. Statistical analyses were performed to compare the outcomes of various adjuncts. RESULTS The median overall survival (OS) increased for newly diagnosed (21 months) and recurrent cases (10 months) when compared to historical data. For newly diagnosed cases, a ketogenic diet had the highest median OS of all the adjuncts (42.6 months) while in recurrent cases, a low copper diet coupled with 1 g penicillamine had the highest median OS (18.5 months). However, no statistically significant difference was observed in OS or progression-free survival (PFS) of newly diagnosed or recurrent gliomas. CONCLUSION While nutritional adjuncts may offer a therapeutic benefit in the treatment of glioma, more human subject research is needed to derive meaningful conclusions.
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Affiliation(s)
- Bhavya Pahwa
- Department of Neurosurgery, UCMS and GTB Hospital, Delhi, India
| | - Sandra Leskinen
- State University of New York Downstate Medical School, New York, USA
| | | | - Shayan Huda
- City University of New York School of Medicine, New York, USA
| | - Randy S D'Amico
- Department of Neurosurgery, Lenox Hill Hospital, Zucker School of Medicine at Hofstra/Northwell, New York, NY, USA.
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Puig-Saenz C, Pearson JRD, Thomas JE, McArdle SEB. A Holistic Approach to Hard-to-Treat Cancers: The Future of Immunotherapy for Glioblastoma, Triple Negative Breast Cancer, and Advanced Prostate Cancer. Biomedicines 2023; 11:2100. [PMID: 37626597 PMCID: PMC10452459 DOI: 10.3390/biomedicines11082100] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2023] [Revised: 07/21/2023] [Accepted: 07/24/2023] [Indexed: 08/27/2023] Open
Abstract
Immunotherapy represents an attractive avenue for cancer therapy due to its tumour specificity and relatively low frequency of adverse effects compared to other treatment modalities. Despite many advances being made in the field of cancer immunotherapy, very few immunotherapeutic treatments have been approved for difficult-to-treat solid tumours such as triple negative breast cancer (TNBC), glioblastoma multiforme (GBM), and advanced prostate cancer (PCa). The anatomical location of some of these cancers may also make them more difficult to treat. Many trials focus solely on immunotherapy and have failed to consider or manipulate, prior to the immunotherapeutic intervention, important factors such as the microbiota, which itself is directly linked to lifestyle factors, diet, stress, social support, exercise, sleep, and oral hygiene. This review summarises the most recent treatments for hard-to-treat cancers whilst factoring in the less conventional interventions which could tilt the balance of treatment in favour of success for these malignancies.
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Affiliation(s)
- Carles Puig-Saenz
- The John van Geest Cancer Research Centre, School of Science and Technology, Nottingham Trent University, College Drive, Clifton, Nottingham NG11 8NS, UK; (C.P.-S.); (J.R.D.P.); (J.E.T.)
- Centre for Systems Health and Integrated Metabolic Research, School of Science and Technology, Nottingham Trent University, College Drive, Clifton, Nottingham NG11 8NS, UK
| | - Joshua R. D. Pearson
- The John van Geest Cancer Research Centre, School of Science and Technology, Nottingham Trent University, College Drive, Clifton, Nottingham NG11 8NS, UK; (C.P.-S.); (J.R.D.P.); (J.E.T.)
- Centre for Systems Health and Integrated Metabolic Research, School of Science and Technology, Nottingham Trent University, College Drive, Clifton, Nottingham NG11 8NS, UK
| | - Jubini E. Thomas
- The John van Geest Cancer Research Centre, School of Science and Technology, Nottingham Trent University, College Drive, Clifton, Nottingham NG11 8NS, UK; (C.P.-S.); (J.R.D.P.); (J.E.T.)
- Centre for Systems Health and Integrated Metabolic Research, School of Science and Technology, Nottingham Trent University, College Drive, Clifton, Nottingham NG11 8NS, UK
| | - Stéphanie E. B. McArdle
- The John van Geest Cancer Research Centre, School of Science and Technology, Nottingham Trent University, College Drive, Clifton, Nottingham NG11 8NS, UK; (C.P.-S.); (J.R.D.P.); (J.E.T.)
- Centre for Systems Health and Integrated Metabolic Research, School of Science and Technology, Nottingham Trent University, College Drive, Clifton, Nottingham NG11 8NS, UK
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Al-Jada DN, Takruri HR, Talib WH. From antiepileptic therapy to promising adjuvant in medical oncology: A historical view of the ketogenic diet. PHARMANUTRITION 2023. [DOI: 10.1016/j.phanu.2023.100340] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/28/2023]
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Egashira R, Matsunaga M, Miyake A, Hotta S, Nagai N, Yamaguchi C, Takeuchi M, Moriguchi M, Tonari S, Nakano M, Saito H, Hagihara K. Long-Term Effects of a Ketogenic Diet for Cancer. Nutrients 2023; 15:nu15102334. [PMID: 37242217 DOI: 10.3390/nu15102334] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2023] [Revised: 05/01/2023] [Accepted: 05/13/2023] [Indexed: 05/28/2023] Open
Abstract
A ketogenic diet has been proposed as a potential supportive therapy for cancer patients, although its long-term influence on survival rates remain controversial. In our previous report, we presented promising results for 37 of 55 patients with advanced cancer enrolled between 2013 and 2018 who remained on a ketogenic diet for at least 3 months. We followed all 55 patients until March 2023 and analyzed the data up to March 2022. For the 37 patients with previously reported promising results, the median follow-up period was 25 (range of 3-104) months and 28 patients died. The median overall survival (OS) in this subset of 37 patients was 25.1 months and the 5-year survival rate was 23.9%. We also evaluated the association between the duration of the ketogenic diet and outcome in all 55 patients, except for 2 patients with insufficient data. The patients were divided into two groups: those who followed the diet for ≥12 months (n = 21) and those who followed it for <12 months (n = 32). The median duration of the ketogenic diet was 37 (range of 12-99) months for the ≥12 months group and 3 (range of 0-11) months for the <12 months group. During the follow-up period, 41 patients died (10/21 in the ≥12 months group and 31/32 in the <12 months group). The median OS was 19.9 months (55.1 months in the ≥12 months group and 12 months in the <12 months group). Following the inverse probability of treatment weighting to align the background factors of the two groups and make them comparable, the adjusted log-rank test showed a significantly better OS rate in the group that continued the ketogenic diet for a longer period (p < 0.001, adjusted log-rank test). These results indicate that a longer continuation of the ketogenic diet improved the prognosis of advanced cancer patients.
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Affiliation(s)
- Ryuichiro Egashira
- Department of Advanced Hybrid Medicine, Graduate School of Medicine, Osaka University, Osaka 565-0871, Japan
| | - Michiko Matsunaga
- Department of Advanced Hybrid Medicine, Graduate School of Medicine, Osaka University, Osaka 565-0871, Japan
- Japan Society for the Promotion of Science, Tokyo 102-0083, Japan
| | - Akimitsu Miyake
- Department of AI and Innovative Medicine, Tohoku University School of Medicine, Sendai 980-8575, Japan
| | - Sayaka Hotta
- Department of Advanced Hybrid Medicine, Graduate School of Medicine, Osaka University, Osaka 565-0871, Japan
| | - Naoko Nagai
- Division of Nutritional Management, Osaka University Hospital, Osaka 565-0871, Japan
| | - Chise Yamaguchi
- Division of Nutritional Management, Osaka University Hospital, Osaka 565-0871, Japan
| | - Mariko Takeuchi
- Department of Advanced Hybrid Medicine, Graduate School of Medicine, Osaka University, Osaka 565-0871, Japan
| | - Misaki Moriguchi
- Department of Advanced Hybrid Medicine, Graduate School of Medicine, Osaka University, Osaka 565-0871, Japan
| | - Satoko Tonari
- Department of Advanced Hybrid Medicine, Graduate School of Medicine, Osaka University, Osaka 565-0871, Japan
| | - Mai Nakano
- Department of Advanced Hybrid Medicine, Graduate School of Medicine, Osaka University, Osaka 565-0871, Japan
| | - Hitomi Saito
- Department of Advanced Hybrid Medicine, Graduate School of Medicine, Osaka University, Osaka 565-0871, Japan
| | - Keisuke Hagihara
- Department of Advanced Hybrid Medicine, Graduate School of Medicine, Osaka University, Osaka 565-0871, Japan
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Makuku R, Sinaei Far Z, Khalili N, Moyo A, Razi S, Keshavarz-Fathi M, Mahmoudi M, Rezaei N. The Role of Ketogenic Diet in the Treatment of Neuroblastoma. Integr Cancer Ther 2023; 22:15347354221150787. [PMID: 36752115 PMCID: PMC9909060 DOI: 10.1177/15347354221150787] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/09/2023] Open
Abstract
The ketogenic diet (KD) was initially used in 1920 for drug-resistant epileptic patients. From this point onward, ketogenic diets became a pivotal part of nutritional therapy research. To date, KD has shown therapeutic potential in many pathologies such as Alzheimer's disease, Parkinson's disease, autism, brain cancers, and multiple sclerosis. Although KD is now an adjuvant therapy for certain diseases, its effectiveness as an antitumor nutritional therapy is still an ongoing debate, especially in Neuroblastoma. Neuroblastoma is the most common extra-cranial solid tumor in children and is metastatic at initial presentation in more than half of the cases. Although Neuroblastoma can be managed by surgery, chemotherapy, immunotherapy, and radiotherapy, its 5-year survival rate in children remains below 40%. Earlier studies have proposed the ketogenic diet as a possible adjuvant therapy for patients undergoing treatment for Neuroblastoma. In this study, we seek to review the possible roles of KD in the treatment of Neuroblastoma.
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Affiliation(s)
- Rangarirai Makuku
- Tehran University of Medical Sciences, Tehran, Iran,Universal Scientific Education and Research Network (USERN), Harare, Zimbabwe
| | - Zeinab Sinaei Far
- Tehran University of Medical Sciences, Tehran, Iran,Universal Scientific Education and Research Network (USERN), Tehran, Iran
| | - Neda Khalili
- Tehran University of Medical Sciences, Tehran, Iran,Universal Scientific Education and Research Network (USERN), Tehran, Iran
| | - Alistar Moyo
- Universal Scientific Education and Research Network (USERN), Harare, Zimbabwe
| | - Sepideh Razi
- Tehran University of Medical Sciences, Tehran, Iran,Universal Scientific Education and Research Network (USERN), Tehran, Iran
| | - Mahsa Keshavarz-Fathi
- Tehran University of Medical Sciences, Tehran, Iran,Universal Scientific Education and Research Network (USERN), Tehran, Iran
| | | | - Nima Rezaei
- Tehran University of Medical Sciences, Tehran, Iran,Universal Scientific Education and Research Network (USERN), Stockholm, Sweden,Nima Rezaei, Research Center for Immunodeficiencies, Children’s Medical Center, Dr Qarib Street, Keshavarz Blvd, Tehran 14194, Iran. Emails: ;
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Miller C, Austin K, Fischer L, Stringer E, Sidhu S. The Ketogenic Diet: Considerations for Cancer Survivorship. Curr Nutr Rep 2022; 11:682-694. [PMID: 36224487 DOI: 10.1007/s13668-022-00439-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/28/2022] [Indexed: 01/31/2023]
Abstract
PURPOSE OF REVIEW This article aims to evaluate the current practice of the ketogenic diet (KD) in oncology by discussing feasibility, impact on quality of life, and implications for dietetic practice. Articles discussed were selected based on an adult oncology population with emphasis on publications from the last 5 years. RECENT FINDINGS There is a paucity of randomized prospective trials and articles reviewed were heterogeneous in nature, limiting the ability to draw conclusions about the KDs role in cancer care and survivorship. Despite the lack of evidence, patients with cancer are interested in KD. The authors highlight barriers to supporting implementation of KD and recommend the inclusion of a registered dietitian with experience in KD to ensure safety and support the nutrition goals of patients with cancer. Thorough, well-designed randomized control trials are needed to elucidate the potential advantages of this diet therapy in cancer care and survivorship.
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Affiliation(s)
- Cara Miller
- Oncology Nutrition, BC Cancer- Victoria, 2410 Lee Ave, Victoria, BC, V8R 6V5, Canada
| | - Karina Austin
- Oncology Nutrition, BC Cancer- Victoria, 2410 Lee Ave, Victoria, BC, V8R 6V5, Canada
| | - Lawren Fischer
- Oncology Nutrition, BC Cancer- Victoria, 2410 Lee Ave, Victoria, BC, V8R 6V5, Canada.
| | - Eleah Stringer
- Oncology Nutrition, BC Cancer- Victoria, 2410 Lee Ave, Victoria, BC, V8R 6V5, Canada.,Michael Smith Health Research BC, Vancouver, Canada
| | - Satnam Sidhu
- Oncology Nutrition, BC Cancer- Victoria, 2410 Lee Ave, Victoria, BC, V8R 6V5, Canada
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Erbani J, Boon M, Akkari L. Therapy-induced shaping of the glioblastoma microenvironment: Macrophages at play. Semin Cancer Biol 2022; 86:41-56. [PMID: 35569742 DOI: 10.1016/j.semcancer.2022.05.003] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2022] [Revised: 05/03/2022] [Accepted: 05/06/2022] [Indexed: 01/27/2023]
Abstract
The intricate cross-talks between tumor cells and their microenvironment play a key role in cancer progression and resistance to treatment. In recent years, targeting pro-tumorigenic components of the tumor microenvironment (TME) has emerged as a tantalizing strategy to improve the efficacy of standard-of-care (SOC) treatments, particularly for hard-to-treat cancers such as glioblastoma. In this review, we explore how the distinct microenvironmental niches characteristic of the glioblastoma TME shape response to therapy. In particular, we delve into the interplay between tumor-associated macrophages (TAM) and glioblastoma cells within angiogenic and hypoxic niches, and interrogate their dynamic co-evolution upon SOC therapies that fuels malignancy. Resolving the complexity of therapy-induced alterations in the glioblastoma TME and their impact on disease relapse is a stepping stone to identify targetable pro-tumorigenic pathways and TAM subsets, and may open the way to efficient combination therapies that will improve clinical outcomes.
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Affiliation(s)
- Johanna Erbani
- Division of Tumour Biology and Immunology, Oncode Institute, The Netherlands Cancer Institute, Plesmanlaan 121, 1066 CX Amsterdam, the Netherlands
| | - Menno Boon
- Division of Tumour Biology and Immunology, Oncode Institute, The Netherlands Cancer Institute, Plesmanlaan 121, 1066 CX Amsterdam, the Netherlands
| | - Leila Akkari
- Division of Tumour Biology and Immunology, Oncode Institute, The Netherlands Cancer Institute, Plesmanlaan 121, 1066 CX Amsterdam, the Netherlands.
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Feasibility and Safety of a Combined Metabolic Strategy in Glioblastoma Multiforme: A Prospective Case Series. JOURNAL OF ONCOLOGY 2022; 2022:4496734. [PMID: 36276276 PMCID: PMC9586748 DOI: 10.1155/2022/4496734] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/23/2022] [Revised: 06/08/2022] [Accepted: 06/28/2022] [Indexed: 11/18/2022]
Abstract
Background Glioblastoma multiforme (GBM) may be susceptible to metabolic strategies such as fasting and ketogenic diets, which lower blood glucose and elevate ketones. Combining these two strategies may be an ideal approach for sustaining a potentially therapeutic glucose ketone index (GKI). In this prospective case series, we observed whether a combined metabolic strategy was feasible, safe, and capable of sustaining a GKI <6 in patients with GBM. Methods We provided recommendations and guidelines to 10 GBM patients at various stages of tumour progression and treatment that enabled them to complete a 5–7-day fast every 1–2 months combined with a modified ketogenic diet during the intervening weeks. Patients monitored their blood glucose and ketone levels and body weight. Adverse effects were assessed. Results Patients completed a mean of 161 ± 74 days of the combined metabolic strategy, with 34 ± 18 (21%) days of prolonged fasting (mean fast duration: 6.0 ± 1.4 days) and 127 ± 59 (79%) days on the ketogenic diet. The mean GKI for all 10 patients was 3.22 (1.28 during the fasts, 5.10 during the ketogenic diet). Body weight decreased by 8.4 ± 6.9 kg (11.2% decrease in baseline weight). The most common adverse effects attributed to the fasts and ketogenic diet were fatigue, irritability, and feeling lightheaded. The metabolic strategy did not interfere with standard oncological treatments. Conclusion This is the first study to observe the feasibility and safety of repeated, prolonged fasting combined with a modified ketogenic diet in patients with GBM. Using minimal support, patients maintained the combined metabolic strategy for 5–6 months while sustaining a potentially therapeutic mean GKI of 3.22. Weight loss was considerable. Adverse effects attributed to the metabolic strategy were mild, and it did not interfere with standard oncological treatments. Study Registration: This study is registered on the Australia New Zealand Clinical Trials Registry, number ACTRN12620001310954. The study was registered on 4 December 2020.
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Ketogenic Diet in the Treatment of Gliomas and Glioblastomas. Nutrients 2022; 14:nu14183851. [PMID: 36145228 PMCID: PMC9504425 DOI: 10.3390/nu14183851] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2022] [Revised: 09/13/2022] [Accepted: 09/14/2022] [Indexed: 11/29/2022] Open
Abstract
In recent years, scientific interest in the use of the ketogenic diet (KD) as a complementary approach to the standard cancer therapy has grown, in particular against those of the central nervous system (CNS). In metabolic terms, there are the following differences between healthy and neoplastic cells: neoplastic cells divert their metabolism to anaerobic glycolysis (Warburg effect), they alter the normal mitochondrial functioning, and they use mainly certain amino acids for their own metabolic needs, to gain an advantage over healthy cells and to lead to a pro-oncogenetic effect. Several works in literature speculate which are the molecular targets of KD used against cancer. The following different mechanisms of action will be explored in this review: metabolic, inflammatory, oncogenic and oncosuppressive, ROS, and epigenetic modulation. Preclinical and clinical studies on the use of KD in CNS tumors have also increased in recent years. An interesting hypothesis emerged from the studies about the possible use of a ketogenic diet as a combination therapy along with chemotherapy (CT) and radiotherapy (RT) for the treatment of cancer. Currently, however, clinical data are still very limited but encouraging, so we need further studies to definitively validate or disprove the role of KD in fighting against cancer.
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Seyfried TN, Arismendi-Morillo G, Zuccoli G, Lee DC, Duraj T, Elsakka AM, Maroon JC, Mukherjee P, Ta L, Shelton L, D'Agostino D, Kiebish M, Chinopoulos C. Metabolic management of microenvironment acidity in glioblastoma. Front Oncol 2022; 12:968351. [PMID: 36059707 PMCID: PMC9428719 DOI: 10.3389/fonc.2022.968351] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2022] [Accepted: 07/15/2022] [Indexed: 11/24/2022] Open
Abstract
Glioblastoma (GBM), similar to most cancers, is dependent on fermentation metabolism for the synthesis of biomass and energy (ATP) regardless of the cellular or genetic heterogeneity seen within the tumor. The transition from respiration to fermentation arises from the documented defects in the number, the structure, and the function of mitochondria and mitochondrial-associated membranes in GBM tissue. Glucose and glutamine are the major fermentable fuels that drive GBM growth. The major waste products of GBM cell fermentation (lactic acid, glutamic acid, and succinic acid) will acidify the microenvironment and are largely responsible for drug resistance, enhanced invasion, immunosuppression, and metastasis. Besides surgical debulking, therapies used for GBM management (radiation, chemotherapy, and steroids) enhance microenvironment acidification and, although often providing a time-limited disease control, will thus favor tumor recurrence and complications. The simultaneous restriction of glucose and glutamine, while elevating non-fermentable, anti-inflammatory ketone bodies, can help restore the pH balance of the microenvironment while, at the same time, providing a non-toxic therapeutic strategy for killing most of the neoplastic cells.
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Affiliation(s)
- Thomas N. Seyfried
- Biology Department, Boston College, Chestnut Hill, MA, United States
- *Correspondence: Thomas N. Seyfried,
| | - Gabriel Arismendi-Morillo
- Instituto de Investigaciones Biológicas, Facultad de Medicina, Universidad del Zulia, Maracaibo, Venezuela
| | - Giulio Zuccoli
- The Program for the Study of Neurodevelopment in Rare Disorders (NDRD), University of Pittsburgh, Pittsburgh, PA, United States
| | - Derek C. Lee
- Biology Department, Boston College, Chestnut Hill, MA, United States
| | - Tomas Duraj
- Faculty of Medicine, Institute for Applied Molecular Medicine (IMMA), CEU San Pablo University, Madrid, Spain
| | - Ahmed M. Elsakka
- Neuro Metabolism, Faculty of Medicine, Alexandria University, Alexandria, Egypt
| | - Joseph C. Maroon
- Department of Neurosurgery, University of Pittsburgh, Medical Center, Pittsburgh, PA, United States
| | - Purna Mukherjee
- Biology Department, Boston College, Chestnut Hill, MA, United States
| | - Linh Ta
- Biology Department, Boston College, Chestnut Hill, MA, United States
| | | | - Dominic D'Agostino
- Department of Molecular Pharmacology and Physiology, University of South Florida, Tampa, FL, United States
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Guo A, Asztely F, Smits A, Jakola AS. Methodological Approaches to Ketogenic Dietary Treatments in Glioma Patients from a Nutritional Point of View. Nutr Cancer 2022; 75:112-122. [PMID: 35959770 DOI: 10.1080/01635581.2022.2108073] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Ketogenic diets (KD) have received increasing interest in neuro-oncology based on their ability to inhibit glioma growth In Vitro and their established role in medically refractory seizures. This review analyses the methodological aspects of KD treatment alongside standard care for patients with gliomas from a nutritional point of view. A literature search was performed in March 2022 searching PubMed and Scopus. We identified 13 articles including 187 patients with a histological-new or recurrent-diagnosis of glioma and treated by KD during the course of the disease. Dietary treatments were categorized as the classical ketogenic diet (CKD), the Modified Atkins diet (MAD), and the medium-chain triglyceride (MCT) diet. We identified a large variation in dietary characteristics regarding restriction of carbohydrates, ketogenic ratio, and additional dietary support. This striking heterogenicity in the methodological approaches of KD treatments made it problematic to compare effects between the included studies. Therefore, a standardized definition of KD for patients with glioma and a consensus on methodological implementation is needed. It would also be desirable to further investigate to what extent KD treatment can be optimized to secure optimal nutrient status and patient satisfaction.
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Affiliation(s)
- Annie Guo
- Institute of Neuroscience and Physiology, Department of Clinical Neuroscience, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Fredrik Asztely
- Institute of Neuroscience and Physiology, Department of Clinical Neuroscience, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Anja Smits
- Institute of Neuroscience and Physiology, Department of Clinical Neuroscience, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden.,Institute of Medicine, Neurology, Uppsala University Hospital, Uppsala, Sweden
| | - Asgeir S Jakola
- Institute of Neuroscience and Physiology, Department of Clinical Neuroscience, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden.,Department of Neurosurgery, Sahlgrenska University Hospital, Gothenburg, Sweden.,Department of Neurosurgery, St. Olavs University Hospital, Trondheim, Norway
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14
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Tyagi A, Wu SY, Watabe K. Metabolism in the progression and metastasis of brain tumors. Cancer Lett 2022; 539:215713. [PMID: 35513201 PMCID: PMC9999298 DOI: 10.1016/j.canlet.2022.215713] [Citation(s) in RCA: 14] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/01/2022] [Revised: 04/21/2022] [Accepted: 04/22/2022] [Indexed: 01/30/2023]
Abstract
Malignant brain tumors and metastases pose significant health problems and cause substantial morbidity and mortality in children and adults. Based on epidemiological evidence, gliomas comprise 30% and 80% of primary brain tumors and malignant tumors, respectively. Brain metastases affect 15-30% of cancer patients, particularly primary tumors of the lung, breast, colon, and kidney, and melanoma. Despite advancements in multimodal molecular targeted therapy and immunotherapy that do not ensure long-term treatment, malignant brain tumors and metastases contribute significantly to cancer related mortality. Recent studies have shown that metastatic cancer cells possess distinct metabolic traits to adapt and survive in new environment that differs significantly from the primary site in both nutrient composition and availability. As metabolic regulation lies at the intersection of many research areas, concerted efforts to understand the metabolic mechanism(s) driving malignant brain tumors and metastases may reveal novel therapeutic targets to prevent or reduce metastasis and predict biomarkers for the treatment of this aggressive disease. This review focuses on various aspects of metabolic signaling, interface between metabolic regulators and cellular processes, and implications of their dysregulation in the context of brain tumors and metastases.
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Affiliation(s)
- Abhishek Tyagi
- Department of Cancer Biology, Wake Forest University School of Medicine, Winston-Salem, NC, 27157, USA
| | - Shih-Ying Wu
- Department of Cancer Biology, Wake Forest University School of Medicine, Winston-Salem, NC, 27157, USA
| | - Kounosuke Watabe
- Department of Cancer Biology, Wake Forest University School of Medicine, Winston-Salem, NC, 27157, USA.
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15
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Nakamura K, Hagihara K, Nagai N, Egashira R, Takeuchi M, Nakano M, Saito H, Moriguchi M, Tonari S, Watanabe S, Miyake A, Ashida K. Ketogenic Effects of Multiple Doses of a Medium Chain Triglycerides Enriched Ketogenic Formula in Healthy Men under the Ketogenic Diet: A Randomized, Double-Blinded, Placebo-Controlled Study. Nutrients 2022; 14:nu14061199. [PMID: 35334856 PMCID: PMC8955388 DOI: 10.3390/nu14061199] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2022] [Revised: 03/02/2022] [Accepted: 03/09/2022] [Indexed: 02/04/2023] Open
Abstract
Ketogenic diets, which are carbohydrate-restricted high-fat diets, may have therapeutic effects on various diseases, including cancer. However, ketogenic diets are often not standardized and, therefore, results are difficult to interpret. We previously investigated the usefulness of ketogenic diets in cancer therapy, where ketogenic formulas (KF) were used as supplements to enhance blood ketone bodies; however, the amount of KF was determined empirically with reference to blood ketone bodies levels. Here, to determine a standardized optimal amount of KF, we investigated temporal changes in blood ketone bodies (acetoacetic acid (AcAc), β-hydroxybutyrate (BHB)) and safety in 20 healthy individuals when KF was taken repeatedly under the conditions of a ketogenic diet (UMIN000034216). The diurnal variation in total ketone bodies, and AcAc and BHB levels significantly increased after lunch and after dinner, on the 4th day of KF administration. There were no significant safety issues related to KF in the context of anthropometric, metabolic, nutritional, urological and gastrointestinal parameters. In addition, ketogenic diets lead to changes in gut microbiota. KF showed a decrease in phylum Firmicutes. Our study provides baseline data of the usefulness of KF in a ketogenic diet.
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Affiliation(s)
- Kentaro Nakamura
- Research Team 3, Co-Creation Center, Meiji Holdings Co., Ltd., Tokyo 192-0919, Japan; (K.N.); (K.A.)
| | - Keisuke Hagihara
- Department of Advanced Hybrid Medicine, Graduate School of Medicine, Osaka University, Osaka 565-0871, Japan; (R.E.); (M.T.); (M.N.); (H.S.); (M.M.); (S.T.)
- Correspondence: ; Tel.: +81-06-6210-8349; Fax: +81-06-6210-8348
| | - Naoko Nagai
- Division of Nutritional Management, Osaka University Hospital, Osaka 565-0871, Japan;
| | - Ryuichiro Egashira
- Department of Advanced Hybrid Medicine, Graduate School of Medicine, Osaka University, Osaka 565-0871, Japan; (R.E.); (M.T.); (M.N.); (H.S.); (M.M.); (S.T.)
| | - Mariko Takeuchi
- Department of Advanced Hybrid Medicine, Graduate School of Medicine, Osaka University, Osaka 565-0871, Japan; (R.E.); (M.T.); (M.N.); (H.S.); (M.M.); (S.T.)
| | - Mai Nakano
- Department of Advanced Hybrid Medicine, Graduate School of Medicine, Osaka University, Osaka 565-0871, Japan; (R.E.); (M.T.); (M.N.); (H.S.); (M.M.); (S.T.)
| | - Hitomi Saito
- Department of Advanced Hybrid Medicine, Graduate School of Medicine, Osaka University, Osaka 565-0871, Japan; (R.E.); (M.T.); (M.N.); (H.S.); (M.M.); (S.T.)
| | - Misaki Moriguchi
- Department of Advanced Hybrid Medicine, Graduate School of Medicine, Osaka University, Osaka 565-0871, Japan; (R.E.); (M.T.); (M.N.); (H.S.); (M.M.); (S.T.)
| | - Satoko Tonari
- Department of Advanced Hybrid Medicine, Graduate School of Medicine, Osaka University, Osaka 565-0871, Japan; (R.E.); (M.T.); (M.N.); (H.S.); (M.M.); (S.T.)
| | | | - Akimitsu Miyake
- Department of Medical Innovation, Osaka University Hospital, Osaka 565-0871, Japan;
| | - Kinya Ashida
- Research Team 3, Co-Creation Center, Meiji Holdings Co., Ltd., Tokyo 192-0919, Japan; (K.N.); (K.A.)
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16
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Sargaço B, Oliveira PA, Antunes ML, Moreira AC. Effects of the Ketogenic Diet in the Treatment of Gliomas: A Systematic Review. Nutrients 2022; 14:nu14051007. [PMID: 35267981 PMCID: PMC8912802 DOI: 10.3390/nu14051007] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2022] [Revised: 02/24/2022] [Accepted: 02/25/2022] [Indexed: 02/04/2023] Open
Abstract
The ketogenic diet (KD) is a restrictive therapeutic diet, distinguished by being hyperlipidic, normoproteic, and hypoglucidic. This diet simulates biochemical changes related to fasting periods to achieve systemic ketosis. The metabolic particularities of glioma tumors motivated the rise in investigations and nutritional strategies, such as KD, to modulate the glycemic response as a treatment. This systematic review followed the PRISMA recommendations and was published in PROSPERO, with the identification CRD42021264173. The databases used were EMBASE, PubMed/Medline, Scopus, and Web of Science, and the studies were analyzed using the web-based application Rayyan. To analyze the risk of bias, Cochrane RevMan 5 software was used. For the analysis and treatment of statistical data, Microsoft® Excel® was used. A total of nine original articles were included. Data on survival, symptomology, and quality of life were collected. Mean overall survival was 15.9 months. Constipation and fatigue were the most reported symptoms. In 44.4% of the studies, an improvement in the quality of life was found. The KD is supported by most published studies as an effective therapy in the treatment of malignant gliomas due to its positive effects on patient survival. It was not possible to conclude the effectiveness of KD on quality of life.
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Affiliation(s)
- Beatriz Sargaço
- Faculdade de Medicina, Universidade de Lisboa, 1649-028 Lisboa, Portugal
- ESTeSL-Escola Superior de Tecnologia da Saúde de Lisboa, Instituto Politécnico de Lisboa, 1990-096 Lisboa, Portugal; (P.A.O.); (M.L.A.); (A.C.M.)
- Correspondence:
| | - Patrícia Almeida Oliveira
- ESTeSL-Escola Superior de Tecnologia da Saúde de Lisboa, Instituto Politécnico de Lisboa, 1990-096 Lisboa, Portugal; (P.A.O.); (M.L.A.); (A.C.M.)
| | - Maria Luz Antunes
- ESTeSL-Escola Superior de Tecnologia da Saúde de Lisboa, Instituto Politécnico de Lisboa, 1990-096 Lisboa, Portugal; (P.A.O.); (M.L.A.); (A.C.M.)
- APPsyCI–Applied Psychology Research Center Capabilities & Inclusion, ISPA–Instituto Universitário, 1149-041 Lisboa, Portugal
| | - Ana Catarina Moreira
- ESTeSL-Escola Superior de Tecnologia da Saúde de Lisboa, Instituto Politécnico de Lisboa, 1990-096 Lisboa, Portugal; (P.A.O.); (M.L.A.); (A.C.M.)
- H&TRC-Health & Technology Research Center, 1990-096 Lisboa, Portugal
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17
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Harland A, Liu X, Ghirardello M, Galan MC, Perks CM, Kurian KM. Glioma Stem-Like Cells and Metabolism: Potential for Novel Therapeutic Strategies. Front Oncol 2021; 11:743814. [PMID: 34532295 PMCID: PMC8438230 DOI: 10.3389/fonc.2021.743814] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2021] [Accepted: 08/09/2021] [Indexed: 12/21/2022] Open
Abstract
Glioma stem-like cells (GSCs) were first described as a population which may in part be resistant to traditional chemotherapeutic therapies and responsible for tumour regrowth. Knowledge of the underlying metabolic complexity governing GSC growth and function may point to potential differences between GSCs and the tumour bulk which could be harnessed clinically. There is an increasing interest in the direct/indirect targeting or reprogramming of GSC metabolism as a potential novel therapeutic approach in the adjuvant or recurrent setting to help overcome resistance which may be mediated by GSCs. In this review we will discuss stem-like models, interaction between metabolism and GSCs, and potential current and future strategies for overcoming GSC resistance.
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Affiliation(s)
- Abigail Harland
- Brain Tumour Research Centre, Bristol Medical School, University of Bristol, Bristol, United Kingdom
| | - Xia Liu
- Brain Tumour Research Centre, Bristol Medical School, University of Bristol, Bristol, United Kingdom
| | - Mattia Ghirardello
- Galan Research Group, School of Chemistry, University of Bristol, Bristol, United Kingdom
| | - M Carmen Galan
- Galan Research Group, School of Chemistry, University of Bristol, Bristol, United Kingdom
| | - Claire M Perks
- IGFs and Metabolic Endocrinology Group, Bristol Medical School, Translational Health Sciences, Southmead Hospital, University of Bristol, Bristol, United Kingdom
| | - Kathreena M Kurian
- Brain Tumour Research Centre, Bristol Medical School, University of Bristol, Bristol, United Kingdom
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18
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Cortez NE, Mackenzie GG. Ketogenic Diets in Pancreatic Cancer and Associated Cachexia: Cellular Mechanisms and Clinical Perspectives. Nutrients 2021; 13:nu13093202. [PMID: 34579079 PMCID: PMC8471358 DOI: 10.3390/nu13093202] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2021] [Revised: 09/06/2021] [Accepted: 09/10/2021] [Indexed: 12/15/2022] Open
Abstract
Pancreatic ductal adenocarcinoma (PDAC) is an aggressive and extremely therapy-resistant cancer. It is estimated that up to 80% of PDAC patients present with cachexia, a multifactorial disorder characterized by the involuntary and ongoing wasting of skeletal muscle that affects therapeutic response and survival. During the last decade, there has been an increased interest in exploring dietary interventions to complement the treatment of PDAC and associated cachexia. Ketogenic diets (KDs) have gained attention for their anti-tumor potential. Characterized by a very low carbohydrate, moderate protein, and high fat composition, this diet mimics the metabolic changes that occur in fasting. Numerous studies report that a KD reduces tumor growth and can act as an adjuvant therapy in various cancers, including pancreatic cancer. However, research on the effect and mechanisms of action of KDs on PDAC-associated cachexia is limited. In this narrative review, we summarize the evidence of the impact of KDs in PDAC treatment and cachexia mitigation. Furthermore, we discuss key cellular mechanisms that explain KDs’ potential anti-tumor and anti-cachexia effects, focusing primarily on reprogramming of cell metabolism, epigenome, and the gut microbiome. Finally, we provide a perspective on future research needed to advance KDs into clinical use.
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19
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Voss M, Wenger KJ, von Mettenheim N, Bojunga J, Vetter M, Diehl B, Franz K, Gerlach R, Ronellenfitsch MW, Harter PN, Hattingen E, Steinbach JP, Rödel C, Rieger J. Short-term fasting in glioma patients: analysis of diet diaries and metabolic parameters of the ERGO2 trial. Eur J Nutr 2021; 61:477-487. [PMID: 34487222 PMCID: PMC8783850 DOI: 10.1007/s00394-021-02666-1] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2021] [Accepted: 08/19/2021] [Indexed: 12/21/2022]
Abstract
Purpose The prospective, randomized ERGO2 trial investigated the effect of calorie-restricted ketogenic diet and intermittent fasting (KD-IF) on re-irradiation for recurrent brain tumors. The study did not meet its primary endpoint of improved progression-free survival in comparison to standard diet (SD). We here report the results of the quality of life/neurocognition and a detailed analysis of the diet diaries. Methods 50 patients were randomized 1:1 to re-irradiation combined with either SD or KD-IF. The KD-IF schedule included 3 days of ketogenic diet (KD: 21–23 kcal/kg/d, carbohydrate intake limited to 50 g/d), followed by 3 days of fasting and again 3 days of KD. Follow-up included examination of cognition, quality of life and serum samples. Results The 20 patients who completed KD-IF met the prespecified goals for calorie and carbohydrate restriction. Substantial decreases in leptin and insulin and an increase in uric acid were observed. The SD group, of note, had a lower calorie intake than expected (21 kcal/kg/d instead of 30 kcal/kg/d). Neither quality of life nor cognition were affected by the diet. Low glucose emerged as a significant prognostic parameter in a best responder analysis. Conclusion The strict caloric goals of the ERGO2 trial were tolerated well by patients with recurrent brain cancer. The short diet schedule led to significant metabolic changes with low glucose emerging as a candidate marker of better prognosis. The unexpected lower calorie intake of the control group complicates the interpretation of the results. Clinicaltrials.gov number: NCT01754350; Registration: 21.12.2012. Supplementary Information The online version contains supplementary material available at 10.1007/s00394-021-02666-1.
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Affiliation(s)
- Martin Voss
- Dr. Senckenberg Institute of Neurooncology, University Hospital Frankfurt, Goethe University, Schleusenweg 2-16, 60528, Frankfurt/Main, Germany. .,University Cancer Center Frankfurt (UCT), University Hospital Frankfurt, Goethe University, Theodor-Stern-Kai 7, 60590, Frankfurt/Main, Germany. .,Partner Site Frankfurt/Mainz, German Cancer Research Center (DKFZ), German Cancer Consortium (DKTK), Stiftung Des Öffentlichen Rechts, Im Neuenheimer Feld 280, 69120, Heidelberg, Germany. .,Frankfurt Cancer Institute (FCI), Georg-Speyer-Haus, Paul-Ehrlich-Straße 42-44, 60596, Frankfurt/Main, Germany.
| | - Katharina J Wenger
- University Cancer Center Frankfurt (UCT), University Hospital Frankfurt, Goethe University, Theodor-Stern-Kai 7, 60590, Frankfurt/Main, Germany.,Partner Site Frankfurt/Mainz, German Cancer Research Center (DKFZ), German Cancer Consortium (DKTK), Stiftung Des Öffentlichen Rechts, Im Neuenheimer Feld 280, 69120, Heidelberg, Germany.,Frankfurt Cancer Institute (FCI), Georg-Speyer-Haus, Paul-Ehrlich-Straße 42-44, 60596, Frankfurt/Main, Germany.,Institute of Neuroradiology, University Hospital Frankfurt, Goethe University, Schleusenweg 2-16, 60528, Frankfurt/Main, Germany
| | - Nina von Mettenheim
- Dr. Senckenberg Institute of Neurooncology, University Hospital Frankfurt, Goethe University, Schleusenweg 2-16, 60528, Frankfurt/Main, Germany.,University Cancer Center Frankfurt (UCT), University Hospital Frankfurt, Goethe University, Theodor-Stern-Kai 7, 60590, Frankfurt/Main, Germany.,Partner Site Frankfurt/Mainz, German Cancer Research Center (DKFZ), German Cancer Consortium (DKTK), Stiftung Des Öffentlichen Rechts, Im Neuenheimer Feld 280, 69120, Heidelberg, Germany.,Frankfurt Cancer Institute (FCI), Georg-Speyer-Haus, Paul-Ehrlich-Straße 42-44, 60596, Frankfurt/Main, Germany
| | - Jörg Bojunga
- Department of Medicine 1, University Hospital Frankfurt, Goethe University, Theodor-Stern-Kai 7, 60590, Frankfurt/Main, Germany
| | - Manuela Vetter
- Dr. Senckenberg Institute of Neurooncology, University Hospital Frankfurt, Goethe University, Schleusenweg 2-16, 60528, Frankfurt/Main, Germany.,University Cancer Center Frankfurt (UCT), University Hospital Frankfurt, Goethe University, Theodor-Stern-Kai 7, 60590, Frankfurt/Main, Germany.,Partner Site Frankfurt/Mainz, German Cancer Research Center (DKFZ), German Cancer Consortium (DKTK), Stiftung Des Öffentlichen Rechts, Im Neuenheimer Feld 280, 69120, Heidelberg, Germany.,Frankfurt Cancer Institute (FCI), Georg-Speyer-Haus, Paul-Ehrlich-Straße 42-44, 60596, Frankfurt/Main, Germany
| | - Bianca Diehl
- Dr. Senckenberg Institute of Neurooncology, University Hospital Frankfurt, Goethe University, Schleusenweg 2-16, 60528, Frankfurt/Main, Germany.,University Cancer Center Frankfurt (UCT), University Hospital Frankfurt, Goethe University, Theodor-Stern-Kai 7, 60590, Frankfurt/Main, Germany.,Partner Site Frankfurt/Mainz, German Cancer Research Center (DKFZ), German Cancer Consortium (DKTK), Stiftung Des Öffentlichen Rechts, Im Neuenheimer Feld 280, 69120, Heidelberg, Germany.,Frankfurt Cancer Institute (FCI), Georg-Speyer-Haus, Paul-Ehrlich-Straße 42-44, 60596, Frankfurt/Main, Germany
| | - Kea Franz
- University Cancer Center Frankfurt (UCT), University Hospital Frankfurt, Goethe University, Theodor-Stern-Kai 7, 60590, Frankfurt/Main, Germany.,Partner Site Frankfurt/Mainz, German Cancer Research Center (DKFZ), German Cancer Consortium (DKTK), Stiftung Des Öffentlichen Rechts, Im Neuenheimer Feld 280, 69120, Heidelberg, Germany.,Frankfurt Cancer Institute (FCI), Georg-Speyer-Haus, Paul-Ehrlich-Straße 42-44, 60596, Frankfurt/Main, Germany.,Department of Neurosurgery, University Hospital Frankfurt, Goethe University, Schleusenweg 2-16, 60528, Frankfurt/Main, Germany
| | - Ruediger Gerlach
- Department of Neurosurgery, HELIOS Hospital Erfurt, Nordhäuser Straße 74, 99089, Erfurt, Germany
| | - Michael W Ronellenfitsch
- Dr. Senckenberg Institute of Neurooncology, University Hospital Frankfurt, Goethe University, Schleusenweg 2-16, 60528, Frankfurt/Main, Germany.,University Cancer Center Frankfurt (UCT), University Hospital Frankfurt, Goethe University, Theodor-Stern-Kai 7, 60590, Frankfurt/Main, Germany.,Partner Site Frankfurt/Mainz, German Cancer Research Center (DKFZ), German Cancer Consortium (DKTK), Stiftung Des Öffentlichen Rechts, Im Neuenheimer Feld 280, 69120, Heidelberg, Germany.,Frankfurt Cancer Institute (FCI), Georg-Speyer-Haus, Paul-Ehrlich-Straße 42-44, 60596, Frankfurt/Main, Germany
| | - Patrick N Harter
- University Cancer Center Frankfurt (UCT), University Hospital Frankfurt, Goethe University, Theodor-Stern-Kai 7, 60590, Frankfurt/Main, Germany.,Partner Site Frankfurt/Mainz, German Cancer Research Center (DKFZ), German Cancer Consortium (DKTK), Stiftung Des Öffentlichen Rechts, Im Neuenheimer Feld 280, 69120, Heidelberg, Germany.,Frankfurt Cancer Institute (FCI), Georg-Speyer-Haus, Paul-Ehrlich-Straße 42-44, 60596, Frankfurt/Main, Germany.,Institute of Neurology (Edinger-Institute), University Hospital Frankfurt, Goethe University, Heinrich-Hoffmann Strasse 7, 60528, Frankfurt/Main, Germany
| | - Elke Hattingen
- University Cancer Center Frankfurt (UCT), University Hospital Frankfurt, Goethe University, Theodor-Stern-Kai 7, 60590, Frankfurt/Main, Germany.,Partner Site Frankfurt/Mainz, German Cancer Research Center (DKFZ), German Cancer Consortium (DKTK), Stiftung Des Öffentlichen Rechts, Im Neuenheimer Feld 280, 69120, Heidelberg, Germany.,Frankfurt Cancer Institute (FCI), Georg-Speyer-Haus, Paul-Ehrlich-Straße 42-44, 60596, Frankfurt/Main, Germany.,Institute of Neuroradiology, University Hospital Frankfurt, Goethe University, Schleusenweg 2-16, 60528, Frankfurt/Main, Germany
| | - Joachim P Steinbach
- Dr. Senckenberg Institute of Neurooncology, University Hospital Frankfurt, Goethe University, Schleusenweg 2-16, 60528, Frankfurt/Main, Germany.,University Cancer Center Frankfurt (UCT), University Hospital Frankfurt, Goethe University, Theodor-Stern-Kai 7, 60590, Frankfurt/Main, Germany.,Partner Site Frankfurt/Mainz, German Cancer Research Center (DKFZ), German Cancer Consortium (DKTK), Stiftung Des Öffentlichen Rechts, Im Neuenheimer Feld 280, 69120, Heidelberg, Germany.,Frankfurt Cancer Institute (FCI), Georg-Speyer-Haus, Paul-Ehrlich-Straße 42-44, 60596, Frankfurt/Main, Germany
| | - Claus Rödel
- University Cancer Center Frankfurt (UCT), University Hospital Frankfurt, Goethe University, Theodor-Stern-Kai 7, 60590, Frankfurt/Main, Germany.,Partner Site Frankfurt/Mainz, German Cancer Research Center (DKFZ), German Cancer Consortium (DKTK), Stiftung Des Öffentlichen Rechts, Im Neuenheimer Feld 280, 69120, Heidelberg, Germany.,Frankfurt Cancer Institute (FCI), Georg-Speyer-Haus, Paul-Ehrlich-Straße 42-44, 60596, Frankfurt/Main, Germany.,Department of Radiotherapy and Oncology, University Hospital Frankfurt, Goethe University, Theodor-Stern-Kai 7, 60590, Frankfurt/Main, Germany
| | - Johannes Rieger
- Dr. Senckenberg Institute of Neurooncology, University Hospital Frankfurt, Goethe University, Schleusenweg 2-16, 60528, Frankfurt/Main, Germany.,Interdisciplinary Division of Neuro-Oncology, University Hospital Tübingen, Hoppe-Seyler-Straße 3, 72076, Tübingen, Germany
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20
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Montella L, Sarno F, Altucci L, Cioffi V, Sigona L, Di Colandrea S, De Simone S, Marinelli A, Facchini BA, De Vita F, Berretta M, de Falco R, Facchini G. A Root in Synapsis and the Other One in the Gut Microbiome-Brain Axis: Are the Two Poles of Ketogenic Diet Enough to Challenge Glioblastoma? Front Nutr 2021; 8:703392. [PMID: 34422883 PMCID: PMC8378133 DOI: 10.3389/fnut.2021.703392] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2021] [Accepted: 06/29/2021] [Indexed: 12/27/2022] Open
Abstract
Glioblastoma is the most frequent and aggressive brain cancer in adults. While precision medicine in oncology has produced remarkable progress in several malignancies, treatment of glioblastoma has still limited available options and a dismal prognosis. After first-line treatment with surgery followed by radiochemotherapy based on the 2005 STUPP trial, no significant therapeutic advancements have been registered. While waiting that genomic characterization moves from a prognostic/predictive value into therapeutic applications, practical and easy-to-use approaches are eagerly awaited. Medical reports on the role of the ketogenic diet in adult neurological disorders and in glioblastoma suggest that nutritional interventions may condition outcomes and be associated with standard therapies. The acceptable macronutrient distribution of daily calories in a regular diet are 45-65% of daily calories from carbohydrates, 20-35% from fats, and 10-35% from protein. Basically, the ketogenic diet follows an approach based on low carbohydrates/high fat intake. In carbohydrates starvation, body energy derives from fat storage which is used to produce ketones and act as glucose surrogates. The ketogenic diet has several effects: metabolic interference with glucose and insulin and IGF-1 pathways, influence on neurotransmission, reduction of oxidative stress and inflammation, direct effect on gene expression through epigenetic mechanisms. Apart from these central effects working at the synapsis level, recent evidence also suggests a role for microbiome and gut-brain axis induced by a ketogenic diet. This review focuses on rationales supporting the ketogenic diet and clinical studies will be reported, looking at future possible perspectives.
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Affiliation(s)
- Liliana Montella
- Medical Oncology Complex Unit, "Santa Maria delle Grazie" Hospital, ASL Napoli 2 Nord, Naples, Italy
| | - Federica Sarno
- Precision Medicine Department, "Luigi Vanvitelli" University of Campania, Naples, Italy
| | - Lucia Altucci
- Precision Medicine Department, "Luigi Vanvitelli" University of Campania, Naples, Italy
| | - Valentina Cioffi
- Neurosurgery Operative Complex Unit, "Santa Maria delle Grazie" Hospital, ASL Napoli 2 Nord, Naples, Italy
| | - Luigi Sigona
- Neurosurgery Operative Complex Unit, "Santa Maria delle Grazie" Hospital, ASL Napoli 2 Nord, Naples, Italy
| | - Salvatore Di Colandrea
- Department of Emergency and Critical Care, "Santa Maria delle Grazie" Hospital, ASL Napoli 2 Nord, Naples, Italy
| | - Stefano De Simone
- Medical Oncology Complex Unit, "Santa Maria delle Grazie" Hospital, ASL Napoli 2 Nord, Naples, Italy
| | - Alfredo Marinelli
- Operative Unit Neuroncology University Federico II, Naples, Italy.,Istituto di Ricerca e Cura a Carattere Scientifico (IRCCS) Neuromed Istituto Neurologico Mediterraneo (INM), Isernia, Italy
| | - Bianca Arianna Facchini
- Division of Medical Oncology, Precision Medicine Department, "Luigi Vanvitelli" University of Campania, Naples, Italy
| | - Ferdinando De Vita
- Division of Medical Oncology, Precision Medicine Department, "Luigi Vanvitelli" University of Campania, Naples, Italy
| | - Massimiliano Berretta
- Department of Clinical and Experimental Medicine, University of Messina, Messina, Italy
| | - Raffaele de Falco
- Neurosurgery Operative Complex Unit, "Santa Maria delle Grazie" Hospital, ASL Napoli 2 Nord, Naples, Italy
| | - Gaetano Facchini
- Medical Oncology Complex Unit, "Santa Maria delle Grazie" Hospital, ASL Napoli 2 Nord, Naples, Italy
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21
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Garcia JH, Jain S, Aghi MK. Metabolic Drivers of Invasion in Glioblastoma. Front Cell Dev Biol 2021; 9:683276. [PMID: 34277624 PMCID: PMC8281286 DOI: 10.3389/fcell.2021.683276] [Citation(s) in RCA: 34] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2021] [Accepted: 05/19/2021] [Indexed: 12/02/2022] Open
Abstract
Glioblastoma is a primary malignant brain tumor with a median survival under 2 years. The poor prognosis glioblastoma caries is largely due to cellular invasion, which enables escape from resection, and drives inevitable recurrence. While most studies to date have focused on pathways that enhance the invasiveness of tumor cells in the brain microenvironment as the primary driving forces behind GBM’s ability to invade adjacent tissues, more recent studies have identified a role for adaptations in cellular metabolism in GBM invasion. Metabolic reprogramming allows invasive cells to generate the energy necessary for colonizing surrounding brain tissue and adapt to new microenvironments with unique nutrient and oxygen availability. Historically, enhanced glycolysis, even in the presence of oxygen (the Warburg effect) has dominated glioblastoma research with respect to tumor metabolism. More recent global profiling experiments, however, have identified roles for lipid, amino acid, and nucleotide metabolism in tumor growth and invasion. A thorough understanding of the metabolic traits that define invasive GBM cells may provide novel therapeutic targets for this devastating disease. In this review, we focus on metabolic alterations that have been characterized in glioblastoma, the dynamic nature of tumor metabolism and how it is shaped by interaction with the brain microenvironment, and how metabolic reprogramming generates vulnerabilities that may be ripe for exploitation.
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Affiliation(s)
- Joseph H Garcia
- Department of Neurological Surgery, University of California, San Francisco, San Francisco, CA, United States
| | - Saket Jain
- Department of Neurological Surgery, University of California, San Francisco, San Francisco, CA, United States
| | - Manish K Aghi
- Department of Neurological Surgery, University of California, San Francisco, San Francisco, CA, United States
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22
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Seyfried TN, Shivane AG, Kalamian M, Maroon JC, Mukherjee P, Zuccoli G. Ketogenic Metabolic Therapy, Without Chemo or Radiation, for the Long-Term Management of IDH1-Mutant Glioblastoma: An 80-Month Follow-Up Case Report. Front Nutr 2021; 8:682243. [PMID: 34136522 PMCID: PMC8200410 DOI: 10.3389/fnut.2021.682243] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2021] [Accepted: 05/07/2021] [Indexed: 12/14/2022] Open
Abstract
Background: Successful treatment of glioblastoma (GBM) remains futile despite decades of intense research. GBM is similar to most other malignant cancers in requiring glucose and glutamine for growth, regardless of histological or genetic heterogeneity. Ketogenic metabolic therapy (KMT) is a non-toxic nutritional intervention for cancer management. We report the case of a 32-year-old man who presented in 2014 with seizures and a right frontal lobe tumor on MRI. The tumor cells were immunoreactive with antibodies to the IDH1 (R132H) mutation, P53 (patchy), MIB-1 index (4–6%), and absent ATRX protein expression. DNA analysis showed no evidence of methylation of the MGMT gene promoter. The presence of prominent microvascular proliferation and areas of necrosis were consistent with an IDH-mutant glioblastoma (WHO Grade 4). Methods: The patient refused standard of care (SOC) and steroid medication after initial diagnosis, but was knowledgeable and self-motivated enough to consume a low-carbohydrate ketogenic diet consisting mostly of saturated fats, minimal vegetables, and a variety of meats. The patient used the glucose ketone index calculator to maintain his Glucose Ketone Index (GKI) near 2.0 without body weight loss. Results: The tumor continued to grow slowly without expected vasogenic edema until 2017, when the patient opted for surgical debulking. The enhancing area, centered in the inferior frontal gyrus, was surgically excised. The pathology specimen confirmed IDH1-mutant GBM. Following surgery, the patient continued with a self-administered ketogenic diet to maintain low GKI values, indicative of therapeutic ketosis. At the time of this report (May 2021), the patient remains alive with a good quality of life, except for occasional seizures. MRI continues to show slow interval progression of the tumor. Conclusion: This is the first report of confirmed IDH1-mutant GBM treated with KMT and surgical debulking without chemo- or radiotherapy. The long-term survival of this patient, now at 80 months, could be due in part to a therapeutic metabolic synergy between KMT and the IDH1 mutation that simultaneously target the glycolysis and glutaminolysis pathways that are essential for GBM growth. Further studies are needed to determine if this non-toxic therapeutic strategy could be effective in providing long-term management for other GBM patients with or without IDH mutations.
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Affiliation(s)
- Thomas N Seyfried
- Biology Department, Boston College, Chestnut Hill, MA, United States
| | - Aditya G Shivane
- Department of Cellular and Anatomical Pathology, University Hospital Plymouth National Health Service (NHS) Trust, Plymouth, United Kingdom
| | | | - Joseph C Maroon
- Department of Neurosurgery, Medical Center, University of Pittsburgh, Pittsburgh, PA, United States
| | - Purna Mukherjee
- Biology Department, Boston College, Chestnut Hill, MA, United States
| | - Giulio Zuccoli
- Department of Radiology, St. Christopher Hospital for Children, Drexel University School of Medicine, Philadelphia, PA, United States
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23
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Abstract
Glioblastomas (GBMs) exhibit altered metabolism to support a variety of bioenergetic and biosynthetic demands for tumor growth, invasion, and drug resistance. Changes in glycolytic flux, oxidative phosphorylation, the pentose phosphate pathway, fatty acid biosynthesis and oxidation, and nucleic acid biosynthesis are observed in GBMs to help drive tumorigenesis. Both the genetic landscape of GBMs and the unique brain tumor microenvironment shape metabolism; therefore, an understanding of how both intrinsic and extrinsic factors modulate metabolism is becoming increasingly important for finding effect targets and therapeutics for GBM.
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Affiliation(s)
- Danielle Morrow
- Department of Molecular and Medical Pharmacology, University of California Los Angeles
| | - Jenna Minami
- Department of Molecular and Medical Pharmacology, University of California Los Angeles
| | - David A Nathanson
- Department of Molecular and Medical Pharmacology, University of California Los Angeles; David Geffen School of Medicine, University of California Los Angeles.
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