Citation: Cell Death and Disease (2013) 4, e532; doi:10.1038/cddis.2013.

60
& 2013 Macmillan Publishers Limited All rights reserved 2041-4889/13
www.nature.com/cddis

Review

Targeting cellular metabolism to improve cancer

therapeutics
Y Zhao1,4, EB Butler2,4 and M Tan*,2,3

The metabolic properties of cancer cells diverge significantly from those of normal cells. Energy production in cancer cells is
abnormally dependent on aerobic glycolysis. In addition to the dependency on glycolysis, cancer cells have other atypical
metabolic characteristics such as increased fatty acid synthesis and increased rates of glutamine metabolism. Emerging
evidence shows that many features characteristic to cancer cells, such as dysregulated Warburg-like glucose metabolism, fatty
acid synthesis and glutaminolysis are linked to therapeutic resistance in cancer treatment. Therefore, targeting cellular
metabolism may improve the response to cancer therapeutics and the combination of chemotherapeutic drugs with cellular
metabolism inhibitors may represent a promising strategy to overcome drug resistance in cancer therapy. Recently, several
review articles have summarized the anticancer targets in the metabolic pathways and metabolic inhibitor-induced cell death
pathways, however, the dysregulated metabolism in therapeutic resistance, which is a highly clinical relevant area in cancer
metabolism research, has not been specifically addressed. From this unique angle, this review article will discuss the
relationship between dysregulated cellular metabolism and cancer drug resistance and how targeting of metabolic enzymes,
such as glucose transporters, hexokinase, pyruvate kinase M2, lactate dehydrogenase A, pyruvate dehydrogenase kinase, fatty
acid synthase and glutaminase can enhance the efficacy of common therapeutic agents or overcome resistance to
chemotherapy or radiotherapy.
Cell Death and Disease (2013) 4, e532; doi:10.1038/cddis.2013.60; published online 7 March 2013
Subject Category: Cancer Metabolism

Facts  Is targeting dysregulated metabolism a selective approach

to inhibit cancer cells?
 The metabolic properties of cancer cells are remarkably  What are the mechanisms by which targeting metabolic
different from those of normal cells. enzymes improves the efficacy of cancer therapy or
 Dysregulated cellular metabolism is linked to drug resis- overcomes chemoresistance?
tance in cancer therapy.
 Targeting metabolic enzymes improves the efficacy of The metabolic properties of cancer cells are different from
cancer therapy. those of normal cells. Cancer cells are more dependent on
 Targeting metabolic enzymes may overcome therapeutic aerobic glycolysis, fatty acid synthesis and glutaminolysis for
resistance. proliferation.1 This difference suggests that targeting meta-
bolic dependence could be a selective approach to treat
Open Questions cancer patients. In 1956, Warburg observed that the rate of
glycolysis was abnormally high in cancer cells, yet a smaller
 Whether the dysregulated cellular metabolism contributes fraction of this glucose is broken down by oxidative
to therapeutic resistance? phosphorylation. This ‘Warburg effect’ indicates that cancer
 Is inhibition of metabolic enzymes a promising strategy to cells prefer glycolytic breakdown of glucose for energy, rather
improve the efficacy of cancer therapy or overcome than mitochondrial oxidative phosphorylation.1–9 Although the
therapeutic resistance? molecular mechanisms that define the Warburg effect are not

1
Department of Biochemistry and Molecular Biology, West China School of Preclinical and Forensic Medicine, Sichuan University, Chengdu, Sichuan, China; 2Center for
Cell Death and Metabolism Research, Mitchell Cancer Institute, University of South Alabama, Mobile, AL, USA and 3Department of Cell Biology and Neuroscience,
University of South Alabama, Mobile, AL, USA
*Corresponding author: M Tan, Mitchell Cancer Institute, University of South Alabama, 1660 Spring Hill Avenue, Mobile, AL 36604, USA. Tel: þ 1 251 460 6993;
Fax: þ 1 251 460 6994; E-mail: mtan@usouthal.edu
4
These authors contributed equally to this work.
Keywords: cancer metabolism; drug resistance; glycolysis; fatty acid synthesis; glutaminolysis
Abbreviations: ABC, ATP-binding cassette; AFPGC, AFP-producing gastric cancer; ALL, acute lymphoblastic leukemia; BPTES, bis-2-[5-phenylacetamido- 1,2,4-
thiadiazol-2-yl] ethyl sulfide; 3-BrPA, 3-bromopyruvate; DCA, dichloroacetate; 2-DG, 2-deoxyglucose; ER, endoplasmic reticulum; FASN, fatty acid synthase; 5-FU, 5-
fluorouracil; GDH, glutamate dehydrogenase; GLS, glutaminase; GLUTs, glucose transporters; HK, hexokinase; HSF1, heat shock factor 1; a-KG, a-ketoglutarate;
LDHA, lactate dehydrogenase A; LND, lonidamine; MM, multiple myeloma; mTORC1, mammalian target of rapamycin complex 1; PDH, pyruvate dehydrogenase; PDK,
pyruvate dehydrogenase kinase; PKM2, pyruvate kinase M2
Received 27.6.12; revised 21.1.13; accepted 23.1.13; Edited by C Munoz-Pinedo
 Targeting metabolic enzymes to improve cancer therapy
Y Zhao et al
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yet fully understood, the increased glycolysis observed in Dysregulated Metabolism has been Linked to Drug
cancer cells is well accepted to be important for the support of Resistance
malignant phenotypes (Box 1).8
The ability to reduce chemoresistance would be a significant
In addition to the dependency on glycolysis, cancer cells
boon for cancer patients, demonstrating the importance of
exhibit other metabolic characteristics such as increased fatty
research into the mechanisms underlying how chemoresis-
acid synthesis and glutamine metabolism. Enhanced fatty
tance arises (Box 2). Mounting evidence supports the idea that
acid synthesis provides rapidly proliferating tumor cells lipids
dysregulated cellular metabolism is linked to drug resistance in
for membrane biogenesis, conferring both a growth and
cancer therapy.22–25 In the glycolytic pathway, lactate dehy-
survival advantage.10 Similarly, cancer cells are extremely
drogenase A (LDHA) contributes to paclitaxel/trastuzumab
sensitive to glutamine deprivation and cannot proliferate in
resistance in breast cancer and pyruvate dehydrogenase
culture without it. ‘Glutamine addiction’ results in enhanced
production of byproducts necessary for rapidly proliferating
cells, such as amino-acid precursors.11,12
Recently many review articles on cancer and metabo- Box 2 Anticancer agents that can be potentiated by
lism13–21 have been published. However, dysregulated metabolic inhibitors.
metabolism in therapeutic resistance, a highly clinical relevant In general, anticancer agents work by interrupting critical
area in cancer research, has not been specifically addressed. events within the cellular lifecycle resulting in either
Here we will discuss the relationship between cellular meta- irreversible damage to the cell or induction of apoptotic
bolism and drug resistance in cancer cells and how to improve pathways. DNA replication is directly or indirectly a feature
cancer therapeutics and to overcome drug resistance by targeted by a wide variety of compounds. Both the cisplatin
targeting dysregulated metabolic enzymes and pathways. and temozolomide families of compounds modify the DNA,
either by forming bulky adducts or by alkylating the bases,
preying on the limited or compromised DNA repair ability
that is common within many cancers. Similarly, nucleoside
mimics such as gemcitabine and 5-FU disrupt replication
by inhibiting the synthesis of deoxynucleotides – through
Box 1 The Warburg effect and cancer. the inhibition of ribonucleotide reductase or thymidylate
The Warburg effect is defined by an increased utilization of synthase, respectively. More indirect methods of disrupt-
glucose via glycolysis as a cellular resource, and is a ing DNA replication target the topoisomerases, using
common phenotype of cancerous cells. The characteristic families of compounds such as adriamycin and doxorubi-
enhanced glucose uptake observed in cancer cells has cin. These intercalating drugs stop DNA replication by
been used to detect and image cancers via PET detection stabilizing topoisomerase II, which prevents progression of
of 2-18F-2-deoxyglucose, which preferentially concen- the replication fork and ultimately leads to cellular death.
trates within tumors as a result of their rapid uptake of Similarly, taxol class drugs indirectly target replication by
glucose. Although normal cells require growth factor stabilizing tubulin. This blocks progression of the cellular
signaling to utilize available resources for anything more cycle, as metaphase chromosomes can no longer achieve
than preservation, cancer cells often display dysregulated the correct configuration, ultimately resulting in cell
metabolism and freely take advantage of the abundant checkpoint activation and/or stalling of the cell cycle.
resources available within the body. Breaking these Although DNA replication is a common target for current
resources down via glycolysis and glutaminolysis is more clinical anticancer drugs, it is not the only clinically effective
to feed and protect the cell as it grows than provide energy target. Other classes of drugs affect the signaling path-
to maintain cellular functions. Intermediates produced ways that have gone awry within cancer. The unchecked
through glycolysis and glutaminolysis are diverted to activation of these signaling networks often results in
biosynthetic pathways that are necessary to produce the increased angiogenesis and unregulated growth. Selective
basic building blocks of cellular growth. Carbon and estrogen receptor modulators, such as tamoxifen and
nitrogen from glucose and glutamine fuel nucleoside and raloxifen, modulate signaling through the estrogen recep-
amino-acid synthesis, whereas pyruvate feeds the citric tor-mediated pathways and have been particularly effec-
acid cycle supporting continued fatty acid synthesis by tive for patients with certain types of breast cancer.
supplying acetyl- and malonyl-CoA. The metabolic Similarly, the EGFR family has been effectively targeted
changes, such as the Warburg effect, observed in cancer using drugs such as lapatinib (tyrosine kinase inhibitor
allow readily available resources to be converted into active against EGFR and HER2) and trastuzumab (a
biomass in an efficient manner. This metabolic shift humanized antibody targeting the HER2 receptor). The
releases cells from the typical restraints on growth, and EGFR family, and specifically HER2, are aberrantly active
provides a potential way to distinguish them from healthy in many types of cancers and initiate signaling pathways
cells – allowing for treatments that may be selective for that lead the cells to grow aggressively and often results in
cancerous cells. In addition, there are many links between a less positive outcome than seen in non-HER2 expressing
cancer metabolism and drug resistance and compounds tumors. We anticipate that as the molecular mechanisms
that influence dysregulated cellular metabolism often have defining differing subsets of cancer are better understood
the ability to increase the effect or reduce resistance to new drug families exploiting those characteristics will be
current anticancer treatments. successfully developed for clinical use.

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 Targeting metabolic enzymes to improve cancer therapy
Y Zhao et al
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kinase 3 (PDK3) contributes to hypoxia-induced drug resis- membrane. The GLUT family of proteins is responsible for
tance in cervical and colon cancer. Fatty acid synthase this, and are often found dysregulated or overexpressed in
(FASN), a key complex catalyzing fatty acid synthesis, is malignant cells.26 The human GLUT family consists of 14
linked to acquired docetaxel/trastuzumab/adriamycin resis- members (GLUT1-14 or SLC2A1-14).26–28 Here we will focus
tance in breast cancer or intrinsic gemcitabine and radiation on targeting GLUT1, GLUT3 and GLUT4 for improving
resistance in pancreatic cancer. Finally, glutaminolysis is cancer therapy.
linked to cisplatin resistance via the activation of mammalian WZB117 is an inhibitor of GLUT1 that decreases glucose
target of rapamycin complex 1 (mTORC1) signaling in gastric uptake, intracellular ATP levels and glycolytic enzymes
cancer (Table 1). In this review, we will discuss the role of leading to a lowered rate of glycolysis and cellular growth.
these enzymes or processes in drug resistance in detail below. Exogenous ATP rescues growth of WZB117-treated cancer
cells, suggesting that reduction of ATP is an important
Targeting Cellular Metabolism to Improve Cancer mechanism of WZB117’s anticancer effect. WZB117
Therapeutics also induces endoplasmic reticulum (ER) stress leading to
cell-cycle arrest. The combination of WZB117 and cisplatin or
Targeting glycolytic enzymes. As a central energetic paclitaxel displayed synergistic anticancer effects
resource for the cell, glucose metabolism is quite complex. (Table 1).29,30 Under hypoxia, the GLUT1 inhibitor phloretin
Many enzymes contribute to the series of reactions significantly enhances daunorubicin’s anticancer effects
necessary for the glycolytic breakdown of glucose. Below (Table 1) and overcomes hypoxia-conferred drug resistance.
we will discuss glycolytic inhibition as an anticancer strategy Inhibition of glucose uptake by phloretin sensitizes P-glyco-
in the context of selected components of the glycolytic protein overexpressed doxorubicin-resistant cells to daunor-
pathway, such as glucose transporters (GLUTs), hexokinase ubicin via enhancing daunorubicin-induced apoptosis only
(HK), pyruvate kinase M2 (PKM2) and LDHA. under hypoxia.27
Multiple myeloma (MM) cells are dependent on GLUT4
Glucose transporters. The first rate-limiting step of glucose activity for basal glucose consumption, maintenance of Mcl-1
metabolism is the transport of glucose across the plasma protein levels, growth and viability. Ritonavir displays

Table 1 Targeting cellular metabolism improves cancer therapeutics

Targeted Targeted Metabolic Cancer therapeutics/ Cancer types (in vitro and/or in vivo) Refs
metabolism metabolic inhibitors other inhibitors
enzymes
27
Glycolysis GLUT1 Phloretin Daunorubicin Colon cancer (in vitro), leukemia (in vitro)
29
WZB117 Cisplatin/paclitaxel Lung cancer (in vitro), breast cancer (in vitro)
28
GLUT4 Ritonavir Doxorubicin Multiple myeloma (in vitro)
38–40
HK 2-DG ABT-737/ABT-263 Leukemia (in vitro), cervical cancer (in vitro), hepatocarcinoma
(in vitro), breast cancer (in vitro), small lung cancer (in vitro),
lymphoma (in vitro), prostate cancer (in vitro and in vivo)
23
Trastuzumab Breast cancer (in vitro and in vivo)
54
Prednisolone Leukemia (in vitro)
52
3-BrPA Daunorubicin Leukemia (in vitro)
52
Doxorubicin Multiple myeloma (in vitro and in vivo)
53
Oxaliplatin/5-FU Colon cancer (in vitro)
54
Prednisolone Leukemia (in vitro)
39
LND ABT-737 Leukemia (in vitro), lymphoma (in vitro)
54
Prednisolone Leukemia (in vitro)
62
PKM2 shRNA Cisplatin Lung cancer (in vivo)
63
Docetaxel Lung cancer (in vitro and in vivo)
66
LDHA FX11 FK866 Lymphoma (in vivo)
24
Oxamate Paclitaxel Breast cancer (in vitro)
23
Trastuzumab Breast cancer (in vitro and in vivo)
71
Citric acid PDK3 siRNA Paclitaxel Cervical cancer (in vitro)
cycle
72
Cisplatin/paclitaxel/ Colon cancer (in vitro)
oxaliplatin
79
PDK DCA Omeprazole Fibrosarcoma (in vitro and in vivo) colon cancer (in vitro)
80
Omeprazole þ tamoxifen Fibrosarcoma (in vitro)
81
5-FU Colon cancer (in vitro)
82
Sulindac Lung cancer (in vitro), squamous cell carcinoma (in vitro)
75
Irradiation Prostate cancer (in vitro)
84
Fatty acid FASN Cerulenin Docetaxel Breast cancer (in vitro)
synthesis
92
Trastuzumab Breast cancer (in vitro)
93
5-FU Breast cancer (in vitro)
85
C75 Trastuzumab Breast cancer (in vitro)
22
Orlistat Adriamycin/ Breast cancer (in vitro)
mitoxantrone
86
Gemcitabine Pancreatic cancer (in vitro)

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off-target inhibitory effects on GLUT4 and inhibits glucose cancer patients, yet acquired trastuzumab resistance occurs
consumption and proliferation by reducing Mcl-1 expression in most patients.42–48 Our previous studies showed that
to induce apoptosis. Ritonavir also inhibits viability of primary overexpression of ErbB2 promotes glycolysis and increases
myeloma cells and increases the sensitivity to doxorubicin their sensitivity to glycolytic inhibition.49 Trastuzumab-resis-
(Table 1).28 Temozolomide is used with radiation and tant human cells also have increased glucose uptake and
chemotherapy to treat glioblastoma, yet nearly all glioblas- lactate production, indicative of increased glycolysis. Trastu-
toma patients develop resistance. Long-term treatment of zumab also inhibits glycolysis via downregulation of HSF1 and
glioblastoma cells with temozolomide in vitro induces partial LDHA in breast cancer (Figure 1).23 We found 2-DG/
resistance in vivo through upregulation of GLUT3, suggesting trastuzumab combination therapy synergistically inhibits
involvement in temozolomide resistance and that selective growth of both trastuzumab-sensitive and trastuzumab-
targeting of GLUT3 could delay the acquisition of such resistant human breast cancers in vitro and in vivo
resistance in glioblastoma cells.31 Inhibiting glucose uptake (Table 1), because of more efficient glycolysis inhibition.23
may potentiate cancer therapeutics or overcome hypoxia/ These results suggest that 2-DG can effectively enhance
drug-induced resistance. efficacy of trastuzumab in treating ErbB2-positive human
breast cancer cells and overcome trastuzumab resistance.
Hexokinase. HK has important roles in both glycolysis and 3-BrPA is a glycolysis inhibitor that targets HKII and
apoptosis and inhibitors of HK, such as 2-deoxyglucose (2- depletes cellular ATP reserves, a key determinant of
DG), 3-bromopyruvate (3-BrPA) and lonidamine (LND) are in chemoresistance in certain cancer types.50,51 In leukemia
pre-clinical and early phase clinical trials. The effects of 2- and MM cells increased glycolysis raises ATP levels, which
DG, 3-BrPA and LND on cell death in combination with activates ATP-binding cassette (ABC) transporters and
chemotherapy or radiotherapy have been reviewed in confers drug resistance via enhanced drug efflux activity
detail.17 We will discuss the impact of these inhibitors on (Figure 1). 3-BrPA causes ATP depletion, decreasing ABC
cell death and their use to combat drug resistance. transporter activity and drug efflux, therefore enhancing drug
2-DG is a glucose analog that is phosphorylated by HK to 2- retention in cells producing preferential cell death in malignant
DG-phosphate, which cannot be further metabolized. Accu- cells. Glycolysis inhibition by 3-BrPA not only enhances the
mulation of 2-DG inhibits glycolysis causing ATP depletion, cytotoxic effects of daunorubicin and doxorubicin, but also
cell cycle inhibition and cell death.32,33 Under normoxic markedly suppresses tumor growth when used with doxor-
conditions, 2-DG can interfere with N-linked glycosylation ubicin to treat MM-bearing mice (Table 1).52 In addition to
and induce an unfolded protein response, leading to activating ABC transporters, increased ATP levels from
subsequent induction of some proapoptotic BH3-only pro- elevated glycolysis upregulate HIF-1a and enhance HIF-1a-
teins.17,34 There are no ongoing clinical trials using 2-DG as a mediated signaling, which can confer chemoresistance
single agent as in some systems it does not have a significant (Figure 1). ATP depletion by 3-BrPA partially reversed the
effect on tumor growth in vivo.35 However, combining 2-DG resistant phenotype and resensitized cells to chemothera-
with radiation or chemotherapeutic treatments potentiates the peutic agents such as oxaliplatin and 5-fluorouracil (5-FU;
tumor-destroying effects and enhances the clinical efficacy.36 Table 1).53 These findings demonstrate that glycolysis
Bcl-2 family proteins have an important role in the regulation inhibition by 3-BrPA causes ATP depletion, which can
of apoptosis, tumorigenesis and cellular response to cancer improve cancer therapeutics or overcome chemoresistance.
therapeutics. Bcl-2 family proteins are divided into three Most treatment failure in childhood acute lymphoblastic
groups: anti-apoptotic members (Bcl-2, Bcl-XL, Bcl-w, Mcl-1 leukemia (ALL) is ascribed to glucocorticoid (e.g., predniso-
and A1); pro-apoptotic members (Bax and Bak); and those lone) resistance. Increased glycolysis is directly associated to
with only a BH3 domain that promote apoptosis by binding glucocorticoid resistance and inhibition of glycolysis by 2-DG,
anti-apoptotic proteins (Bad, Bid, Bim, Noxa and Puma).37 3-BrPA or LND increases prednisolone-induced toxicity in
BH3-mimetics, such as ABT-737 and ABT-263, are small- leukemia cells (Table 1).54 Importantly, 2-DG can reverse
molecule inhibitors of Bcl-2, Bcl-XL, Bcl-w, but not Mcl-1. glucocorticoid resistance in primary leukemia cells isolated
Several recent studies have demonstrated that 2-DG or LND from pediatric ALL patients.54
enhances ABT-263/737-induced apoptosis both in vitro and
in vivo (Table 1).38–40 There are two proposed mechanisms Pyruvate kinase M2. Pyruvate kinase (PK) is the last rate-
explaining the effect of 2-DG on ABT-263/737-induced limiting enzyme in the glycolytic pathway and catalyzes the
apoptosis. In the first 2-DG decreases Mcl-1 levels indirectly conversion of phosphoenolpyruvate and ADP into pyruvate
by inhibiting glycolysis and depleting ATP levels, leading to and ATP. There are four isoforms of PK in mammals (M1,
activation of AMP-activated protein kinase and inhibition of M2, L and R), which are expressed in different cell types.14,55
Mcl-1 translation.38,39,41 In the second mechanism, 2-DG PKM2 is expressed predominantly in tumor cells56 and is
weakens the interaction between Bak and Mcl-1, which important for cancer metabolism and tumor growth.57
increases the ability of ABT-263/737 to release Bak from the Several studies showed a negative correlation between
Mcl-1/Bcl-XL/Bak heterotrimer, thus inducing apoptosis.40 PKM2 expression and drug resistance.58–60 Decreased
Both 2-DG and ABT-737 are well tolerated by patients and in PKM2 protein and activity is linked to cisplatin resistance
clinical trials, suggesting 2-DG-ABT-737 co-treatment has the while suppression of PKM2 expression by siRNA increased
potential to be developed in treating ABT-737 resistance. cisplatin resistance.60 Both PKM2 mRNA and protein levels
Trastuzumab is a humanized monoclonal antibody against are downregulated in oxaliplatin-resistant cells and PKM2
ErbB2 and has shown efficacy treating ErbB2-positive breast mRNA levels are inversely correlated with oxaliplatin

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Y Zhao et al
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Figure 1 Dysregulated metabolism affects chemoresistance via multiple cellular pathways. Glycolytic intermediates generated by dysregulated cancer metabolism fuel
expanded cellular growth and contribute to clinical resistance. ATP generated by the glycolytic breakdown of glucose fuels the active export of chemotherapeutic agents by the
ABC transporters and induces HIF-1a expression. Export of the glycolytic end product, lactate and expression of carbonic anhydrases shift the pH ratio of the interior and
exterior of the cell resulting in decreased passive transport of basic drugs. Signaling pathways activated by dysregulated metabolism also contribute to resistance, either via
repressing pro-apoptotic signaling or activating compensatory pathways to circumvent drug-induced signal inhibition

resistance in a panel of eight colorectal cancer cell lines. Low maintenance. Knockdown of LDHA in tumor cells produces
PKM2 mRNA levels in patients are associated with high p53 increased mitochondrial respiration, decreased cellular ability
protein levels and predict poor response to oxaliplatin.59 In to proliferate under hypoxic conditions, and suppressed
contrast, PKM2 levels are significantly upregulated in tumorigenicity.64 LDHA knockdown in the fumarate hydra-
secreted proteins of the 5-FU-resistant colon cancer cell tase knockdown background results in increased apoptosis
line. Moreover, increased PKM2 is also observed in sera and via ROS production, resulting in a reduction in tumor growth
tissues from colorectal cancer patients with poor response to and indicating that LDHA might be a promising therapeutic
5-FU. These findings suggested that upregulation of PKM2 is target.65 Inhibition of LDHA by siRNA or FX11 treatment
linked to 5-FU resistance in colon cancer.61 reduces ATP levels and induces significant oxidative stress
Changes in PKM2 expression are associated with drug resulting in cell death.66 Importantly, combining FX11 with
resistance in different tumor. This indicates that PKM2 is a FK866, an NAD þ synthesis inhibitor, induces lymphoma
potential target for adjuvant cancer therapy. For example, regression in a xenograft model (Table 1).66
shRNA targeting PKM2 improves the therapeutic efficacy of Paclitaxel (taxol) is a widely used chemotherapeutic agent
cisplatin by increasing apoptosis and inhibiting proliferation in the treatment of a variety of human cancers (Table 1).
(Table 1).62 Silencing of PKM2 enhances the efficacy of LDHA expression and activity is higher in taxol-resistant
docetaxel because of increased inhibition of proliferation and breast cancer cells than in taxol-sensitive cells, and down-
apoptosis-inducing activity both in vitro and in vivo (Table 1).63 regulation of LDHA resensitizes taxol-resistant cells to taxol.
A possible mechanism for the sensitization of lung cancer Taxol-resistant cells are more sensitive to oxamate, a
cells to docetaxel is that shPKM2 decreases ATP levels pyruvate analog that inhibits glycolysis by inhibiting the
leading to intracellular accumulation of docetaxel.63 These conversion of pyruvate to lactate. These results indicate that
results indicated that targeting PKM2 can effectively improve LDHA and lactate metabolism have an important role in the
the efficacy of chemotherapeutic drugs. resistance to paclitaxel. Moreover, combination of paclitaxel
with oxamate shows synergistic inhibitory effect on taxol-
Lactate dehydrogenase A. LDHA catalyzes the final step in resistant cells (Table 1) by promoting cellular apoptosis.24
the glycolytic pathway, the conversion of pyruvate and NADH Heat shock factor 1 (HSF1) is the master regulator of the
to lactate and NAD þ , and has a critical role in tumor heat shock response in eukaryotes. HSF1 functions primarily

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to coordinate the response to heat shock, but recent studies patient and successfully blocked the disease progression for 3
demonstrate HSF1 exhibiting non-heat shock functions months.80 Owing to its low price, low toxicity, oral administra-
important for cancer development.67–69 Dai et al70 reported tion, long history of clinical use and ability to overcome cancer
that HSF1 increases glucose uptake, lactate production and cells apoptosis resistance DCA serves as a potential
LDH activity. Our previous study showed that ErbB2 promotes metabolic-targeting molecule for sensitizing cancer cells to
glycolysis partially through upregulation of HSF1 and LDHA chemotherapy or radiotherapy.76 DCA potentiates the antic-
(Figure 1), whereas downregulation of HSF1 leads to ancer effects of 5-FU (Table 1) via inducing more mitochon-
decreased glycolysis.49 Our recent studies showed that drial-mediated apoptosis.81 Sulindac, a FDA-approved non-
trastuzumab-resistant cells have significantly higher HSF1 steroidal anti-inflammatory drug, has anticancer activity. The
protein levels than trastuzumab-sensitive cells. Moreover, we combination of DCA and sulindac enhances killing of lung and
found that inhibition of HSF1 sensitizes cells to trastuzumab squamous cell carcinoma cells (Table 1), but not normal cells.
and overexpression of HSF1 increased trastuzumab resis- The selective killing mechanism involves ROS production,
tance, demonstrating that HSF1 can have an important role in loss of mitochondrial membrane potential, JNK-mediated
resistance to trastuzumab.23 signaling and apoptotic death.82 DCA can also increase the
We reported that increased glycolysis via HSF1 and LDHA sensitivity to radiotherapy.75 Cao et al75 reported that DCA
contributes to trastuzumab resistance. Importantly, we found sensitizes both wild-type and Bcl-2-overexpressing cancer
that combination of trastuzumab and oxamate synergistically cells to radiation (Table 1) by potentiating the apoptotic
inhibits growth of both trastuzumab-sensitive and trastuzu- machinery via interaction with Bcl-2. In summary, targeting
mab-resistant cancer both in vitro and in vivo (Table 1), PDK can sensitize cancer cells to chemotherapy, radio-
because of more efficient glycolysis inhibition.23 Overall, high- therapy or overcome drug resistance.
rate glycolysis confers chemoresistance and HSF1 and LDHA
may potentially act as excellent targets for overcoming this Targeting FASN. The fatty acid biosynthesis pathway
resistance in cancer patients. catalyzes lipid synthesis from basic metabolites like acetyl-
and malonyl-CoA. The FASN complex facilitates lipogenesis
Targeting PDK. Pyruvate dehydrogenase (PDH) is respon- by synthesizing palmitate from its base components. FASN
sible for the rate-limiting conversion of pyruvate to acetyl- expression in normal adult tissues is generally very low or
CoA, which enters the tricarboxylic acid (TCA) cycle to undetectable, and it is significantly upregulated and correlates
generate ATP. PDK phosphorylates PDH and inhibits its with poor prognosis in many types of cancer. The metabolic
enzymatic activity. Four isotypes of PDK (PDK1–4) have products of the FASN complex are rapidly consumed by
been identified with PDK3 demonstrating the highest activity actively dividing cells and recent data demonstrates that
coupled with a lack of inhibition in response to high FASN expression is important for tumor growth and survival,
concentrations of pyruvate.71 Hypoxia induces PDK3 expres- suggesting that FASN is a metabolic oncogene.83
sion via upregulation of HIF-1a, which binds to the promoter of FASN has an active role in ErbB2-induced breast cancer
PDK3, resulting in a switch from mitochondrial respiration to chemoresistance to docetaxel,84 while trastuzumab-resistant
glycolysis for energy production. Hypoxia-mediated PDK3 breast cancer cells gain high sensitivity to FASN inhibition
induction or forced PDK3 overexpression significantly inhibits indicating that FASN is also important in ErbB2-induced
cell apoptosis and increases resistance to cisplatin or resistance in breast cancers.85 FASN is overexpressed and
paclitaxel (Figure 1). Knockdown of PDK3 inhibited hypoxia- its activity is increased in the multidrug-resistant breast cancer
induced glycolysis and increases susceptibility of cancer cells cell line MCF7/AdVp3000.22 Increased palmitic acid produc-
to anticancer drugs such as cisplatin, paclitaxel or oxaliplatin tion from ectopic FASN overexpression is also shown to
(Table 1).71,72 Moreover, PDK3 levels are elevated and decrease adriamycin and mitoxantrone-induced apoptosis.22
correlated with the HIF-1a level in patient colon cancer tissues In pancreatic cancer, there is also a positive correlation
and strongly correlates with the severity of the cancer while between FASN expression and resistance to chemo- or
predicting poor disease-free survival outcomes.72 These radiotherapy. FASN expression is significantly upregulated in
findings indicate that PDK3 contributes to hypoxia-induced pancreatic cancer and inhibition of FASN by siRNA or the FAS
drug resistance and is potentially a novel target for improving inhibitor orlistat reduces gemcitabine resistance, whereas
chemotherapy or overcoming drug resistance. ectopic overexpression of FASN contributes to intrinsic
Dichloroacetate (DCA) inactivates PDK leading to reactiva- resistance to gemcitabine and radiation. FASN-induced
tion of PDH and a metabolic switch from glycolysis to radiation resistance may result from decrease in radiation-
mitochondrial respiration.55,73 The preclinical trials on DCA mediated ceramide production, leading to reduced caspase 8-
have shown its effectiveness in a variety of tumors via induced apoptosis. However, the mechanism of FASN-
induction of apoptosis.74–78 However, its effect as a solitary induced gemcitabine resistance remains to be elucidated.86
agent is limited in the ongoing clinical trials.79,80 Combina- To date, several FASN inhibitors have shown antitumor
tional therapy has displayed more effectiveness; cotreatment activity including cerulenin, C75, orlistat, C93, GSK 837149A
with DCA and omeprazole exhibits synergistic antitumor and natural plant-derived polyphenols. Both cerulenin and
activity (Table 1).79 Cotreatment of DCA, omeprazole and C75 are early small-molecule FASN inhibitors. Cerulenin is a
tamoxifen completely blocks the proliferation of fibrosarcoma natural compound isolating from Cephalosporium caerulens
cells (Table 1), whereas the same combination does not affect and contains an epoxy group that reacts with FASN to inhibit
the proliferation of human normal fibroblast cells. Moreover, its activity. C75 is derived from cerulenin and interacts with
these three drugs were prescribed to a cholangiocarcinoma FASN to inhibit its activity.83 Both cerulenin and C75 induce

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cancer cell apoptosis by similar mechanism including mal- generated by the TCA cycle to feed other biosynthetic
onyl-CoA accumulation,87 p53 accumulation,88 induction of pathways as precursors.98 Therefore, cancer cells are
ER stress89 and suppression of DNA replication.90 FASN dependent on glutamine to maintain the TCA cycle.
blockade by cerulenin synergistically enhances the efficacy of Glutaminolysis co-induced by glutamine and leucine acti-
docetaxel against ErbB2-overexpressing and docetaxel- vates mTORC1 signaling, which triggers cell growth and
resistant SKBR3 cells (Table 1) in part via decreasing ErbB2 inhibits autophagy.97 The mTOR pathway is involved in
expression.84 Inhibition of FASN activity with cerulenin/C75 or cisplatin resistance in highly malignant AFP-producing
by siRNA upregulates the expression of PEA3, a transcrip- gastric cancer (AFPGC).100 This indicates that elevated
tional repressor of ErbB2, leading to downregulation of ErbB2 glutaminolysis is linked to drug resistance.
in ErbB2-overexpressing breast and ovarian cancer cells.84 A Bis-2-[5-phenylacetamido-1,2,4-thiadiazol-2-yl] ethyl sulfide
combination of the FASN inhibitor cerulenin and trastuzumab (BPTES), an inhibitor of GLS, caused decreased aerobic cell
synergistically downregulates ErbB2 expression, leading to proliferation and hypoxic cell death.101 Inhibition of GLS by
more effective tumor growth inhibition (Table 1). Furthermore, siRNA or BPTES slows the growth of glioblastoma cells with an
inhibition of FASN activity synergistically enhances trastuzu- isocitrate dehydrogenase 1 (IDH1) mutation. BPTES treatment
mab-induced apoptosis in ErbB2-overexpressing breast inhibits GLS activity, lowers glutamate and a-KG levels and
cancer cells.91 The model proposed by Menendez et al91 increases glycolytic intermediates, suggesting that simulta-
describes crosstalk between FASN and ErbB2 and suggests neous inhibition of GLS and glycolysis may be a more efficient
that FASN has a role in regulation of proliferation and cell strategy to treat mutant IDH1 patients.102 An inhibitor of Rho
survival by assisting in the maintenance of the cancerous GTPase-dependent cellular transformation, named 968, was
phenotype. FASN inhibition affects the phospholipid partition- found to block the growth of human breast cancer and B
ing and the formation of lipid rafts, which may result in the lymphoma cells without affecting normal cells. 968 Targets GLS
internalization and degradation of ErbB2 rather than success- C, a specific carboxy-terminal splice variant form of GLS1.
fully migration to the cell surface. This depletion of cell Elevated levels of basal GLS activity has been shown to be
surface-associated ErbB2 could enhance the antitumor dependent on Rho GTPases and NF-kB activity in transformed
effects of trastuzumab (Table 1).92 In addition to enhancing fibroblasts and breast cancer cells, which is blocked by 968.25
the efficacy of docetaxel and trastuzumab, cerulenin This demonstrates that oncogenic transformation can be
increases 5-FU-induced growth inhibition (Table 1).93 Simi- inhibited by targeting GLS activity, a potential therapeutic
larly, C75 and trastuzumab synergistically decrease ErbB2 strategy against human malignancies.11,16,25
expression and enhance apoptotic cell death (Table 1).85 Rapamycin, a mTORC1 inhibitor, enhances the antitumor
Orlistat is a b-lactone compound and an irreversible effect of cisplatin in AFPGC both in intro and in vivo.100
inhibitor of FASN. Orlistat induces cell cycle G1/S arrest by Inhibition of mTORC1 by NVP-BEZ235, a dual PI3K/mTOR
downregulating Skp2, a component of the E3 ubiquitin ligase inhibitor, synergizes with chemotherapeutic agents such as
that controls the turnover of p27Kip1, leading to activation of cyclophosphamide, cytarabine and dexamethasone in T-cell
the retinoblastoma protein pathway.94 Orlistat inhibits ALL cell lines. Moreover, NVP-BEZ235 can sensitize vincris-
endothelial cell proliferation and angiogenesis.95 In addition tine-resistant Jurkat cells, indicating that inhibition of
to cytostatic effects, orlistat also has cytotoxic effects through mTORC1 activity may revert chemoresistance.103 Glutami-
activation of caspase-8-mediated apoptosis because of nolysis activates mTORC1 signaling and inhibition of gluta-
negative regulation of the mTOR pathway by upregulation of minolysis via GLS inhibitors (DON and BPTES) or siRNA-
DNA damage-inducible transcript 4.96 FASN inhibition with targeting GLS or GDH, prevents mTORC1 activation.97 It is
orlistat increases sensitivity to adriamycin and mitoxantrone in reasonable to predict that targeting glutaminolysis or GLS
FASN-overexpressing breast cancer cells (Table 1) but not in may sensitize cancer cells to common chemotherapeutic
the normal mammary epithelial cell line.22 Orlistat treatment of agents by reducing mTORC1 activity.
pancreatic cancer cells increases the response to gemcita-
bine (Table 1).86 In summary, FASN is a promising anticancer
Conclusions
target that may result in chemosensitization or enhanced
efficacy when FASN function is disrupted as part of a Cancer cells reprogram their metabolism in order to satisfy
combinatorial treatment regimen. their bioenergetic and biosynthetic requirements. Increased
aerobic glycolysis, fatty acid synthesis and glutamine meta-
Targeting glutaminolysis. Glutamine has an important role bolism has been linked to therapeutic resistance in cancer.
in cell growth and energy metabolism. Glutaminolysis, We speculate that deregulated cancer metabolism promotes
consists of two steps: the first is catalyzed by glutaminase cell proliferation because of increased energy production and
(GLS) and converts glutamine to glutamate, whereas the metabolite synthesis, which decreases drug-induced apopto-
second is catalyzed by glutamate dehydrogenase (GDH) and sis, conferring therapeutic resistance. Molecular mechanisms
converts glutamate to a-ketoglutarate (a-KG).97 There are of drug resistance are complex and include increased drug
two types of GLS in mammalian cells, kidney-type GLS efflux, drug inactivation, enhanced DNA damage repair and
(GLS1) and liver-type GLS (GLS2).98 Metabolic flux experi- activation of pro-survival signaling (Figure 1). Increased
ments tracking 13C show that cancer cells exhibiting glycolysis produces higher ATP and NADPH levels. Che-
Warburg-like metabolism do not stop utilizing the TCA cycle motherapeutic drugs display antitumor effects in part by
– instead these cells come to rely on glutamine as the carbon inducing oxidative damage. NADPH is a critical antioxidant
source for the TCA cycle.99 This allows the intermediates and high levels maintained through increased glycolysis in

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 Targeting metabolic enzymes to improve cancer therapy
Y Zhao et al
8

cancer cells may contribute to chemoresistance. ATP exerts inhibitors promotes intracellular drug accumulation, leading to
two effects on drug resistance: elevated ATP levels can increased drug sensitization. However, the molecular
activate ABC transporters leading to increased drug efflux and mechanisms by which targeting metabolism could impair
upregulate HIF-1a signaling inducing hypoxia-associated chemoresistance is not fully understood and deserves further
drug resistance. Both increased drug efflux and upregulation investigation. Combining chemotherapeutic agents with tar-
of HIF-1a signaling result in therapeutic resistance. geted disruption of dysregulated cellular metabolism repre-
HIF-1a-mediated resistance occurs through a variety of sents a promising strategy to overcome drug resistance and
mechanisms. Upregulation of the enzymes necessary for improve the efficacy of current chemotherapeutic agents in
glycolysis facilitates a metabolic shift that enhances non- cancer patients. Although therapeutic resistance can arise by
mitochondrial mechanisms of ATP production.104 Reduced multiple mechanisms, the examples listed above demonstrate
reliance on mitochondria results in less reactive oxygen that targeting a common feature across multiple types of
species, which prevents the DNA damage that would cancer – dysregulated metabolism – can result in reduction of
activate both DNA repair and stress response pathways, chemoresistance in a wide array of cancer types. Further
steps that help set the stage for the induction of apoptotic investigation into the workings of cancer metabolism and
pathways.105,106 resistance will help us to design more selective metabolic
The increase in glycolytic metabolism also results in the inhibitors allowing for a wide array of options and a more
production of lactate, whose export results in the acidification individually tailored response to chemoresistance.
of the extracellular environment. The resulting extracellular
acidification coupled with HIF-1a-induced expression of Conflict of Interest
carbonic anhydrases causes a significant change in the pH The authors declare no conflict of interest.
ratio between the intracellular and extracellular environ-
ments.107–109 This pH shift decreases the passive absorption
of many drugs that would otherwise accumulate at a greater Acknowledgements. We are grateful to the support from the Vincent F
Kilborn, Jr Cancer Research Foundation (M Tan), NIH Grant RO1-CA149646 (M
concentration within the cell. Active drug efflux is also fueled
Tan), Radiumhospitalets Legater Award Project 334003 (M Tan) and NFSC Project
by glycolytic ATP production and HIF-1a-induced transporter 81272907 (Y Zhao).
overexpression resulting in a significant decrease in the
cytoplasmic retention of many anticancer agents.110,111
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