Cracking Cancer Toolkit Slides June 19 Jeffrey Dach Mitch Ghen 2021 AA2
Cracking Cancer Toolkit Slides June 19 Jeffrey Dach Mitch Ghen 2021 AA2
Jeffrey Dach MD
7450 Griffin Road
Suite 190
Davie, FL 33021
954-792-4663
Pecqueur, Claire, et al. “Targeting metabolism to induce cell death in cancer cells and cancer
stem cells.” International journal of cell biology (2013).
Can Chemotherapy
Kill Cancer Stem Cells ?
• “Generally, conventional chemotherapy
can only inhibit tumor growth and lead
to drug resistance, but cannot kill
Cancer Stem Cells”. (Du, Fang-Yu, 2019)
Du, Fang-Yu, et al. “Targeting cancer stem cells in drug discovery: Current state and future
perspectives.” World journal of stem cells 11.7 (2019): 398.
New Technologies
Driving the New Paradigm
Restore
Host
Immune
Surveillance
© Copyright 2021 Jeffrey Dach MD
Fifth Pillar
Upregulation
Inflammatory
Pathways
NF-kB, IL-6
cytokines
© Copyright 2021 Jeffrey Dach MD
The Cancer Stem Cell
• Exists in Dormant State
• Negative on PET Scan
• Cancer Relapse after
Chemotherapy
• Exists in Energetic State –
CTC Circulating Tumor Cells
Cancer Stem Cell Pathways
•Wnt/Beta Catenin
•Hedgehog
•Notch
Targeting these pathways
eliminates cancer stem cells
© Copyright 2021 Jeffrey Dach MD
Cancer Stem Cell Pathway
Wnt Signaling
• “Our results suggest that the inability of
conventional chemotherapy to kill MCL-
ICS (Lymphoma Cancer Stem Cells) can
be overcome by adding inhibitors of
Wnt signaling” (Mathur, Rohit, et al, 2015)
Mathur, Rohit, et al. “Targeting Wnt pathway in mantle cell lymphoma-initiating cells.”
Journal of hematology & oncology 8.1 (2015): 63
Pyrvinium
Ivermectin
Wnt Cancer Stem Cell Pathway
Wnt OFF: In the absence of
Wnt OFF Wnt signals, a cellular
complex degrades β-catenin,
so there is no entry of the
β-catenin protein into the
nucleus, the gene TCF/LEF is
suppressed, and no nuclear
transcription of Cyclin D1 or
other growth signals takes
place.
Han, Jae-Ik, and Ki-Jeong Na. "Wnt/β-Catenin signaling pathway in melanoma."
Melanoma in the Clinic-Diagnosis, Management of Malignancy. IntechOpen, 2011.
Repurposed Drugs Targeting Wnt Signaling
• Metformin (Anti-Diabetic Drug, OXPHOS inhibitor)
• Ivermectin (Specific WNT-TCF Blocker at low
micromolar concentrations.)
• Niclosamide (Hookworm, OXPHOS Uncoupler)
• Pyrvinium (hookworm,pinworm)
• Mefloquine/Chloroquine (Antimalarial,
Autophagy Inhibitors)
• Doxycycline/ Clarithromycin/Azithromycin
• Sulfasalazine (Rheumatology, Xct inhibitor )
• VIT A, Fenretinde, ATRA, (Pro Myleo Leukemia)
Melotti, Alice, et al. “The river blindness drug Ivermectin and related macrocyclic lactones
inhibit WNT‐TCF pathway responses in human cancer.” EMBO molecular medicine (2014):
e201404084.
Metformin Oxphos Inhibitor
• First Line Diabetic Drug (French Lilac plant)
• Targets Cancer Stem Cells.
• Docks in the HK II binding site, blocks function,
separates HK II from VDAC on the outer
mitochondrial membrane.
• Accumulates in Mito, Inhibits Complex I ETC.
• Activates AMPk, Inhibits mTOR, induces
“Protective Autophagy”, Synergy wth chloroquine
Salani, Barbara, et al. “Metformin impairs glucose consumption and survival in Calu-1 cells by
direct inhibition of hexokinase-II.” Scientific reports 3 (2013).
Rattan, Ramandeep et al. "Metformin: an emerging new therapeutic option for targeting
cancer stem cells." Journal of oncology 2012 (2012).
© Copyright 2021 Jeffrey Dach MD
Ivermectin Top Candidate, Blocks TCF Gene
Alice Melotti et al. used a transcriptional reporter assay for
TCF activity driven by ß-catenin to test a collection of
1,040 drugs. Only one agent, ivermectin, perfectly
tracked the profile induced by blocking the TCF gene,
blocks the Wnt pathway, and kills cancer stem cells…!!!!
(2014)
Sharmeen et al. at the University of Toronto screened a
library of 100 drugs for activity against a leukemic cell line.
They reported ivermectin as the top candidate for
inducing leukemic cell death at low micromolar
concentrations. (2010)
Melotti, Alice, et al. “The river blindness drug Ivermectin inhibit WNT‐TCF pathway responses
in human cancer.” EMBO molecular medicine (2014): e201404084.
Sharmeen, et al. “Antiparasitic ivermectin induces hyperpolarization and cell death in
leukemia cells.” Blood 116.18 (2010): 3593-3603 © Copyright 2021 Jeffrey Dach MD
Niclosamide
• Antiparasitic for Hookworm
• Inhibits OXPHOS-Mitochondrial Uncoupler.
• Targets CSC, Wnt and Notch inhibitor
• Downregulates NF-Kb
• Effective for Ovarian CA w/wo chemo
• Effective for P53 deficient/mutated cell types
• Reverses EMT Epithelial to Mesenchymal Trans
• Blocks Late Stage Autophagy
• Inhibits antegrade lysosomal trafficking
Pan, Jing-Xuan, Ke Ding, and Cheng-Yan Wang. “Niclosamide, an old antihelminthic agent,
demonstrates antitumor activity by blocking multiple signaling pathways of cancer stem
cells.” Chinese journal of cancer 31.4 (2012): 178.
Niclosamide for MM
• “At clinically achievable nontoxic concentrations,
[Niclosamide] killed Multiple Myeloma cell lines
as efficiently or better than chemotherapy and
anti-myeloma drugs with little impact on normal
cells. More importantly there was rapid reduction
in light chain production [the clonal antibodies
which cause amyloid deposits and renal
impairment].” (Khanim, 2011)
Thorne, Curtis A., et al. “Small-molecule inhibition of Wnt signaling through activation of
casein kinase 1α.” Nature chemical biology 6.11 (2010): 829.
1) Hanahan, Douglas, and Robert A. Weinberg. “The hallmarks of cancer.” cell 100.1 (2000):
57-70.
2) Hanahan, Douglas, and Robert A. Weinberg. “Hallmarks of cancer: the next generation.”
cell 144.5 (2011): 646-674.
All Hallmarks Are Downstream of
Metabolic Disturbance
• “All recognized hallmarks of cancer are considered
downstream epiphenomena of the initial
disturbance of cellular energy metabolism. The
disturbances in tumor cell energy metabolism can
be linked to abnormalities in the structure and
function of the mitochondria.” (Thomas Seyfried
2013).
1) Seyfried, Thomas N., et al. “Cancer as a metabolic disease: implications for novel
therapeutics.” Carcinogenesis 35.3 (2013): 515-527.
© Copyright 2021 Jeffrey Dach MD
Reprogramming Energy Metabolism
• The Warburg Effect/Fermentation.
• Carbon Shunted Away from OXPHOS
towards GLYCOLYSIS (PDK upregulated,
Inhibiting PDC)
• High Lactate Generation/Accumulation.
• HKII - Translocated to the VDAC
• Provides ATP for Glycolysis Pathway
• Prevents Mitochondrial Apoptosis.
Phan, Liem Minh, "Cancer metabolic reprogramming: importance, main features, and
potentials for precise targeted anti-cancer therapies." Cancer biology & med 11.1 (2014): 1.
Ward, Patrick S., and Craig B. Thompson. "Metabolic reprogramming: a cancer hallmark
even warburg did not anticipate." Cancer cell 21.3 (2012): 297-308.
Reprogramming Energy
Metabolism
Hexokinase-II
Translocated
to the VDAC
© Copyright 2021 Jeffrey Dach MD
HKII-VDAC
VDAC • Hexokinase II
attached to VDAC
on mitochondrial
membrane,
utilizing ATP to
convert glucose
to G6-P
• Mathupala, Ko, and P. L.
Pedersen. “Hexokinase
II: cancer’s double-
edged sword when
bound to mitochondria.”
Oncogene 25.34 (2006):
4777.
HKII-VDAC
• Release of
HKII from
Bcl2 VDAC
Bcl2 HKII induces
Apoptosis
HKII • BCL2 goes
with it.
• Fig 3 Mathupala, Ko,
and P. L. Pedersen.
“Hexokinase II:
VDAC cancer’s double-edged
sword when bound to
VDAC mitochondria.”
Oncogene 25.34
Repurposed Drugs
Detach HKII from VDAC
Itraconazole
Fenofibrate
Aspirin
Metformin
Head, Sarah A., et al. “Antifungal drug itraconazole targets VDAC1 to modulate the
AMPK/mTOR signaling axis in endothelial cells.” Proceedings of the National
Jan, Chia-Ing, et al. “Fenofibrate suppresses oral tumorigenesis via reprogramming
metabolic processes: drug repurposing for cancer.” Int J Bio Sci 12.7 (2016): 786.
Academy of Sciences 112.52 (2015): E7276-E7285.
Tewari, Debanjan, et al. “Aspirin induces cell death by directly modulating mitochondrial
voltage-dependent anion channel (VDAC).” Scientific reports 7.1 (2017): 1-9.
© Copyright 2021 Jeffrey Dach MD
Itraconazole (Sporonox) Antifungal
Itraconazole Binds to VDAC and Disrupts HK2
(Hexokinase 2) from mitochondria.
Inhibits Wnt and Hedgehog (Hh) Pathways.
Inhibits Akt/mTOR, induces“Protective
Autophagy”
Inhibits 5-LOX and VEGF
Tsubamoto, Hiroshi, et al. "Repurposing itraconazole as an anticancer agent."
Oncology letters 14.2 (2017): 1240-1246.
Head, Sarah A., et al. “itraconazole targets VDAC1 to modulate the
AMPK/mTOR signalin.” Proc Nat Acadof Sci 112.52 (2015): E7276-E7285.
Head, Sarah A., et al. “Simultaneous Targeting of NPC1 and VDAC1 by
Itraconazole Leads to Synergistic Inhibition of mTOR Signaling and
Angiogenesis.” ACS chemical biology 12.1 (2016): 174-182.
© Copyright 2021 Jeffrey Dach MD
Fenofibrate Lipid Drug
Accumulates in mitochondria, inhibits Complex
One of the ETC.
Interrupts the Warburg Effect
Disrupts HK-2 from the VDAC,
Destroys BCL-2, and restores apoptosis.
Blocks FASN (Fatty Acid Synthetase),
Activates PPAR-alpha
Potentiated by vitamin A derivatives.
Dual GLYCOLYSIS and OXPHOS inhibitor
Lian, Xin, et al. "Anticancer properties of fenofibrate: a repurposing use." Journal of
Cancer 9.9 (2018): 1527.
Aspirin - Glycolysis Inhibitor
Targets VDAC, Detaches HK2 from the VDAC.
Glycolysis Inhibitor, Reduces Glycolytic CSC.
Aspirin/Metformin Combination Striking synergy.
Combined with EGFR-TKIs shows considerable synergy,
overcomes TKI drug resistance.
Combined with chemotherapy reduces inflammation,
NF-kB, reducing numbers of cancer stem cells.
Inhibit platelets and modifies the genetic expression of
the cancer cell.
Yue, Wen, et al. “Metformin combined with aspirin significantly inhibit pancreatic cancer
in vitro and in vivo by suppressing anti-apoptotic proteins Bcl-2.” Oncotarget 6.25 (2015
Abdelmonsif, Doaa Ali, et al. “Targeting AMPK, mTOR and β-catenin by combined
metformin and aspirin therapy in HCC.” Molecular diag & ther 22.1 (2018): 115-127.
Natural Substances
Bind to and Detaches HKII from VDAC
• Methyl Jasmonate
• Chinese Skullcap (Baicalin, Oroxylin A)
• Curcumin
• CBD (Cannabidiol)
Goldin, N., et al. “Methyl jasmonate binds to and detaches mitochondria-bound hexokinase.”
Oncogene 27.34 (2008): 4636-4643
Wei, L., et al. “Oroxylin A induces dissociation of hexokinase II from the mitochondria and
inhibits in breast carcinoma.” Cell death & disease 4.4 (2013): e601.
Tewari, Debanjan, et al. “Modulation of the mitochondrial voltage dependent anion channel
(VDAC) by curcumin.” Biochimica et Biophysica Acta (BBA)- Biomembranes 1848.1 (2015):
151-158.
Rimmerman, N., et al. “Direct modulation of the outer mitochondrial membrane channel,
voltage-dependent anion channel 1 (VDAC1) by cannabidiol: a novel mechanism for
cannabinoid-induced cell death.” Cell death & disease 4.12 (2013): e949-e949.
Three Pillars of Cancer Cell Metabolism
GLYCOLYSIS
Warburg Effect
© Copyright 2021 Jeffrey Dach MD
Metabolic Reprogramming in Cancer Cells
“Inhibition of PDC activity by pyruvate
dehydrogenase kinase [PDK]–mediated
phosphorylation has been associated with the
pathobiology of …cancer. Consequently, the
PDC/PDK axis has long been a therapeutic
target.” (Stacpoole, Peter 2017)
Inhibition of PDC Reprograms from
Mitochondrial OXPHOS to Glycolysis in
Cytoplasm.
Stacpoole, Peter W. “Therapeutic targeting of the pyruvate dehydrogenase
complex/pyruvate dehydrogenase kinase (PDC/PDK) axis in cancer.” JNCI: Journal
of the National Cancer Institute 109.11 (2017).
© Copyright 2021 Jeffrey Dach MD
PDH/PDC PDH Cycle
Thiamine
PDC- The
Pyruvate
Dehydrogenase
Complex in
Cancer. Paul M.
Bingham and
Zuzana Zachar in
Biochemistry,
Genetics and
Molecular
Biology edited by
Rosa Angela
Pyruvate Canuto,
Dehydrogenase Published:
Complex November 14,
2012. (15)
DCA Dichloroacetic Acid
DCA (Dichloroacetate) - Pyruvate Analog, Not
Metabolized.
Strongly Inhibits PDK Function, and Activates PDH
(Pyruvate Dehydrogenase), which Activates
Mitochondrial OXPHOS, and Inhibits Glycolysis in
Cytoplasm (Warburg Effect)
Thiamine and R-Alpha Lipoic Acid (Poly MVA) -
Co-factors needed to prevent DCA INDUCED
Neuropathy.
Tataranni, Tiziana, and Claudia Piccoli. "Dichloroacetate (DCA) and cancer: an overview
towards clinical applications." Oxidative medicine and cellular longevity 2019 (2019).
Tataranni, Tiziana, and Claudia Piccoli. "Dichloroacetate (DCA) and cancer: an overview
towards clinical applications." Oxidative medicine and cellular longevity 2019 (2019).
DCA Dichloroacetic Acid
Tataranni, Tiziana, and Claudia Piccoli. "Dichloroacetate (DCA) and cancer: an overview
towards clinical applications." Oxidative medicine and cellular longevity 2019 (2019).
“Truly Big Advance”
DCA - Glycolysis Inhibitor
“The combined use of DCA and Poly-MVA
has been one of the Truly Big Advances in
integrative cancer therapies in the past 20
years. (Paul Anderson, 2018)”
Poly-MVA is Alpha Lipoic Acid, Thiamine
and Palladium, Liquid Polymer.
Stengler, Mark and Anderson Paul. Outside the Box Cancer Therapies: Alternative
Therapies that Treat and Prevent Cancer. Hay House, Inc, 2018.
© Copyright 2021 Jeffrey Dach MD
DCA (GLYCOLYSIS Inhibitor) Synergy with
OXPHOS and Autophagy Inhibitors
DCA Plus Metformin (OXPHOS Inhibitor)
Villalba, Martin, et al. “Chemical metabolic inhibitors for the treatment of blood-borne
cancers.” Anti-Cancer Agents in Medicinal Chemistry 4.2 (2014): 223-232.
Propranolol Beta Blocker
“Most Striking Discovery to Date.”
Inhibits OXPHOS (ATP Reduces Tumor
synthase). Proliferation.
Activates GLYCOLYSIS Anti-Angiogenic
Reduces HK2 protein effects.
levels. Restores Anti-tumor
Inhibits Autophagy Immune Function.
(chloroquine-like) Decreases mortality,
metastases, recurrence.
OXPHOS
© Copyright 2021 Jeffrey Dach MD
OXPHOS -The Mitochondrion
VDAC
Metformin – OXPHOS Inhibitor
Diabetic Drug from French Lilac Plant
Metfromin Users - 30–50 % Reduction in cancer.
Metformin Inhibits Complex I of ETC.
Activates AMP-kinase (AMPK)
Inhibits mTOR signaling.
OXPHOS Inhibitor- Shifts to Glycolytic Phenotype
Synergy with Glycolysis Inhibitors (DCA)
Metformin docks in the HKII binding site,
blocking its function, separates HKII from VDAC
membrane.
Yu, Hong, et al. "The potential effect of metformin on cancer: an umbrella review."
Frontiers in endocrinology 10 (2019): 617.
Metformin – OXPHOS/Wnt Inhibitor
“Perturbation of mitochondrial function
using a number of inhibitors can cause
decreased Wnt activity both in vitro and in
vivo.” (Costa, Roberto, 2019)
All Mitochondrial OXPHOS inhibitors are
also Anti-CSC agents.
Costa, Roberto, et al. “Impaired mitochondrial ATP production downregulates
Wnt signaling via ER stress induction.” Cell reports 28.8 (2019): 1949-1960.
Zhang, Xiaonan, et al. “Targeting mitochondrial function to treat quiescent
tumor cells in solid tumors.” International journal of molecular sciences 16.11
(2015): 27313-27326.
Metformin – Detaches HKII from VDAC
“HK2 inhibition by metformin causes
release of this enzyme [HK2] from the
outer membrane of mitochondria, thus
leading to the activation of apoptotic
signals [cell death].” (Salani, Barbara 2013)
Autophagy
© Copyright 2021 Jeffrey Dach MD
Autophagy
Pro-survival mechanism in
cancer cells under
Trafficking (opposite
TQ, Mefloquine
HCQ, ChloroQ, Niclos
Racoma, Ira O., et al. "Thymoquinone inhibits autophagy and induces
cathepsin-mediated, caspase-independent cell death in glioblastoma cells."
PLoS One 8.9 (2013): e72882.
“Protective Autophagy”
Many Anti-Cancer Drugs induce “Protective
Autophagy”.
Survival Mechanism. (Hibernation)
Activation AMPK/mTOR Inhibition induces
“Protective Autophagy”.
Perinuclear Clustering of Lysosomes (Dormant)
Antegrade Lysosome Trafficking (Aggressive)
Deng, Shuo, et al. "Targeting autophagy using natural compounds for cancer
prevention and therapy." Cancer 125.8 (2019): 1228-1246.
Kocaturk, Nur Mehpare, et al. "Autophagy as a molecular target for cancer
treatment." European Journal of Pharmaceutical Sciences 134 (2019): 116-
137.
Peri-Nuclear Clustering
Top Row: Untreated
Breast Cancer Cells
showing lysosomes (dark
stained particles)
dispersed throughout
cells.
Apoptotic Threshold
Cell Death
Tompkins, K,"Focus: Death: Regulation of apoptosis by autophagy to enhance
cancer therapy." Yale journal of biology and medicine 92.4 (2019): 707.
© Copyright 2021 Jeffrey Dach MD
Providing the Extra “Apoptotic Push”
Tompkins, Kenneth D., and Andrew Thorburn. "Focus: Death: Regulation of apoptosis by
autophagy to enhance cancer therapy." The Yale journal of biology and medicine 92.4
(2019): 707.
© Copyright 2021 Jeffrey Dach MD
Autophagy Inhibitors
Mefloquine, Chloroquine, Hydroxy CHQ
Azithromycin/Clarithromycin (Doxy ?)
PPI’s
Loratidine (Claritin)
Thymoquinone (Black Seed Oil)
Propranolol (Dual OXPHOS/Autophagy)
Niclosamide (OXPHOS/Glycolysis/Autophagy)
Levy, Jean M. Mulcahy, Christina G. Towers, and Andrew Thorburn. "Targeting autophagy
in cancer." Nature Reviews Cancer 17.9 (2017): 528-542.
Deng, Shuo, et al. "Targeting autophagy using natural compounds for cancer prevention
and therapy." Cancer 125.8 (2019): 1228-1246.
Amaravadi, Ravi K., Alec C. Kimmelman, and Jayanta Debnath. "Targeting autophagy in
cancer: recent advances and future directions." Cancer discovery 9.9 (2019): 1167-1181.
Fourth Pillar
Restoring
Host
Immune
Surveillance
Inhibit
NF-kB, IL-6
cytokines
Gao, Yunfei, et al. "Active hexose correlated compound enhances tumor surveillance through
regulating both innate and adaptive immune responses." Cancer Immunology,
Immunotherapy 55.10 (2006): 1258-1266.
Kroemer, Guido, and Laurence Zitvogel. “Cancer immunotherapy in 2017: The breakthrough
of the microbiota.” Nature Reviews Immunology 18.2 (2018): 87.
Mebendazole
• Old Antiparasitic Drug.
• Microtubule inhibitor, prevents spindle formation
needed for cell replication.
• Immunomodulatory Effects – upregulates anti-
cancer host immune function.
• Link to PIBF ? Replacement for Mifepristone ?
• Induces Apoptosis by inactivating BCL-2
• Induces “Protective Autophagy”, Synergy with
Autophagy Inhibitors.
• Inhibits Hedgehog CSC pathway
Pantziarka, Pan, et al. "Repurposing Drugs in Oncology (ReDO)—mebendazole as an anti-
cancer agent." ecancermedicalscience 8 (2014).
Fifth Pillar Inflammation
Inhibit
NF-kB, IL-6
cytokines
Stacpoole,
CBD Cannabidiol
Detaches HKII from VDAC.
“Using microscale thermophoresis, we showed a
direct interaction between purified fluorescently
labeled VDAC1 and CBD.” (Rimmerman, 2013)
Potent Anti-inflammatory Effect
Immune Modulator
Rimmerman, N., et al. “Direct modulation of the outer mitochondrial membrane channel,
voltage-dependent anion channel 1 (VDAC1) by cannabidiol: a novel mechanism for
cannabinoid-induced cell death.” Cell death & disease 4.12 (2013): e949-e949.
Stacpoole,
Dipyridamole Anti-Platelet Agents
Sol
Stacpoole,
Financial Dislosure
None to Disclose
Cancer Prevention
• Selenium
• Iodine
• Vitamin D3
• Di-Indole Methane (DIM)
Haider,
LDN Low Dose Naltrexone
Opiate Receptor Blocker
Inhibits Tumor Growth
Stacpoole
Case Report Targeting Cancer Stem Cells
Aggressivbe Aamous Cell CA 90 year old.
Fenofibrate
Itraconazole
Mebendazole
Exemestane
Doxycycline
Stacpoole,
Alpha Lipoic Acid
Cofactor which Increases PDC Activity.
Shunts From Glycolysis to OXPHOS.
Restores Apoptosis.
Co-Factors are Thiamine, and Carnitine.
Synergy with Melatonin (Glycolysis
Inhibitor- Reverses Warburg Effect)
Bingham, Paul M. "Lipoic acid and lipoic acid analogs in cancer metabolism and
chemotherapy." Expert review of clin pharmacology 7.6 (2014): 837-846.
Berkson, Burton M. "Revisiting the ALA/N (α-Lipoic Acid/Low-Dose Naltrexone) protocol
for people with metastatic and nonmetastatic pancreatic cancer: a report of 3 new
cases." Integrative cancer ther 8.4 (2009): 416-422.
Melatonin - Glycolysis Inhibitor
Sleep Hormone from Pineal Gland.
Reverses Warburg Effect via PDK inhibition.
Bacteria and Mitochondria Make Melatonin Acetyl-CoA.
Enters Cells via Glucose Transporters.
Accumulates in Cancer Cells.
Cancer Cell Mitochondria Lose ability to make Melatonin
Melatonin has a Decoupling Effect on OXPHOS.
Increases Electron Flow through ETC with Decoupling
Effect Causes Excess Damaging ROS… apoptosis in
cancer cells.