 Okay great. What I'd like to do this morning is give you an overview of some aspects of cancer in general and then more specifically brain cancer and show how we are able to manipulate energy metabolism in the body and in the brain to target cancers. As I said we can work on any kind of a tumor but I'll specifically be speaking about brain tumors today. First I put here a provocative question. For those of you who are in the cancer field you will know that the National Cancer Institute on their website has put 24 provocative questions. These questions are thought to direct cancer research for the remain for the throughout the century and stimulate various kinds of approaches and new insights into the disease. However you will not see this provocative question on the 24 question list mainly because most people in the cancer field have already determined that cancer is a genetic disease. The question is that true or not. Now what I have done is reviewed over 50 years of research from a variety of perspectives on the nature of the role of the nucleus and the mitochondria in the progression of an origin of this disease. Now these studies I put this very simple diagram to distill down quite a number of articles that go back to the 1940s all the way up to present day investigations and basically I don't know if you can see this this might I know we had oh maybe here's another one here let's see if this oh there it is okay so what I've done here is I've shown here's a normal cell in green a tumor cell in red what I've shown is a normal nucleus and Christi in the mitochondria and we know normal cells beget normal cells and when we look at the cancer cell in red we have a dysmorphic nucleus and we have mitochondria that have absent Christi to signal to indicate that we have defects in both the nucleus and and mitochondria in the cancer cell and cancer cells beget cancer cells there have been a number of studies where nuclei have been transferred these are an animal and human tumors nuclei can be transferred from one cell to another and when the nucleus of the cancer cell is transferred to the cytoplasm of either an oocyte or a very early stem cell what you get are our normal cells sometimes normal tissues and sometimes complete organisms from the nucleus of a cancer cell now what happens depending on the number of mutations will determine how foreign development that organism goes before it aborts so the mutations that are associated with cancer don't cause cancer they abort development now if you take the nucleus from the normal cell and put it into the cytoplasm of the cancer cell you either get dead cells or tumor cells you don't get normal cells what what these findings indicate is that is that it's the mitochondria can suppress tumor agenesis and that and that mutations whatever they happen to be or how they're related are not the drivers of this disease regardless of what you might read now if cancer is not a genetic disease what kind of a disease is it and out of Warburg many years ago he did the most of the work we've heard some preliminary speakers about this all cancer arises from damage to cellular respiration glucose fermentation gradually compensates compensates for inefficient respiration uh respiratory damage eventually becomes irreversible and cancer cells continue to ferment uh and he was primarily talking about glucose we have expanded this now to include glutamine fermentation tumor cells can ferment not only carbohydrates but they can also ferment some amino acids in particular glutamine so this is another i'm not going to have chance to talk about that but if we don't target glutamine we won't get a complete management of the disease although targeting glucose will certainly be very effective now we know that metabolism most of the energy coming from the cells will be coming through oxidative phosphorylation we get small amounts of energy through glucose fermentation and we can also get energy through the Krebs cycle cancer cells have damaged oxidative phosphorylation thereby having to need compensatory energy source through fermentation glucose fermentation goes way up in many cancers and also glutamine fermentation can go up so these two sources of energy can compensate for the loss of oxfoss so when we look at mitochondria of tumor cells this is a normal electron micrograph you can see the kristae loaded the kristae contain the proteins of the electron transport chain which are which generate most of the energy in our bodies but you can see here this is a mitochondria of a glioblastoma multiformia brain tumor you can see it's crystallizes there's many examples i've gone through in my book many many we never find completely normal mitochondria in any tumor cell and there's no way that these tumor cells are going to be able to produce energy through oxfoss if they don't have the structures needed to do this now what i've done here is just summarize the entire cancer field in this simple diagram that my students and i uh we we worked on this for about five years you can get the students will so they can help us build this whole thing uh cancer is a metabolic mitochondrial disease caused by multiple different things in the environment damaging respiration this then leads to a retrograde signaling system the mitochondria is signal to the nucleus we are we don't have enough energy the nucleus then turns on oncogenes the oncogenes are compensatory they're transcription factors that drive fermentations both glucose and glutamine fermentations but if the cells continue to ferment the nucleus becomes unstable so you get genomic instability as a secondary downstream epiphenomena of damage to respiration so oxfoss is gradually replaced by substrate level phosphorylation unfortunately i won't have a chance to talk about advanced cancers which are basically a macrophage disease macrophage is used tremendous amounts of glutamine and glucose so you really have to target to manage metastatic advanced cancer you have to target both metabolites anyway you can get the entire spectrum of the hand-to-hand Weinberg characteristics following this i like to talk now a little bit about brain cancer and specifically a highly these are highly invasive and vascularized tumors generally poor prognosis incidents may be increasing through cell phone use but this is only for those individuals that might be susceptible to this unfortunately most therapies for brain cancer are ineffective in managing the disease two major categories we have the primary and the secondary brain tumors glial blastoma is a primary brain tumor one of the worst very low very poor survival after five years this is a childhood cerebellar tumor medulla blastoma about 22 and a half percent 22.5 percent of all cancer deaths come from metastasis that is the movement of cancer cells from some other organ to the brain now we have used calorie restriction restricted ketogenic diets and these kinds of approaches as a metabolic approach to cancer management now calorie restriction involves a total dietary restriction it differs from starvation in that calorie restriction can maintain adequate levels of minerals and nutrients calorie restriction if it done the right way and in the and looking at the correct biomarkers will enhance mitochondrial biogenesis and increase efficiency of oxidative phosphorylation it's important to recognize the calorie restriction in the mouse mimics therapeutic water only fasting in humans so everything you see about all the stuff that i'll talk about calorie restriction how do humans do that you have to stop eating do therapeutic fast so this is because the basal metabolic rate of the mouse is seven times that of the human so the biomarkers for calorie restriction are reduced blood glucose and elevated ketone bodies let me get this one let's hit one so we know the brain uses glucose exclusively however do an evolutionary conserved adaptation to low glucose we mobilize fats this is again related to hormone changes insulin and glucagon and things like this and the three major ketone bodies are beta hydroxybutyrate acetoacetate acetone is a non-nesemitic degradation product of acetoacetate so the brain will then transition gradually over to ketone use as an alternative to glucose to subserve energy needs for that organ other organs will use ketones as well in fatty acids when we look at the energy problems in brain cancer in fact most cancers for that matter what we have well in the brain specifically glucose is the primary fuel it enters through transporters goes into the it's goes through the emden meyerhoff pathway to pyruvate pyruvate in normal cells will be fully oxidized in the tca cycle because all the mitochondrial problems and brain tumors and other tumors pyruvate then is fermented to lactate lactate goes back into the circulation goes to the liver be converted back to glucose through the core recycle it comes back this is this vicious cycle we just heard about and some other components of that calorie restriction will lower blood glucose levels naturally you can bring those blood sugars down carbohydrate ketone bodies will then enter into the brain and then the problem is is the cancer cells we and others have shown that the tumor cells cannot metabolize the ketone bodies for energy so what happens then is they be their main source of fuel glucose not only that the normal cells up regulate glucose transporters putting additional metabolic pressure on these cancer cells they can't use the fuel that the normal cells are using they become metabolically marginalized now to show you we've done a lot of work in mice on on calorie restriction this shows ad libitum ale is an unrestricted mouse fed ad libitum this is a 40% calorie restriction over about 12 days starting three days after tumor implantation you can clearly see we can get reductions anywhere from 65 to 90% reduction depending upon how we do this the important thing is what are the what are the what's going on inside the tumor cells what we've shown that this is powerfully anti angiogenic blood vessels are significantly reduced in these tumors you know you hear about all the antigenic therapies there's nothing more powerful than calorie restriction or reducing the vascularization of the tumor it's also pro apoptotic it kills the tumor cells through program cell death mechanisms and we've shown we've shown that so you can see the tunnel positive these are the dead cells in ad libitum fed cancer you don't see as many as you do in the calorie restricted tumors we've done linear regression analysis to ask you know what is the what are the drivers for this whole thing and glucose as glucose levels go down each one of these is it out as a mouse under a different dietary condition ketones go up this is an evolutionary conserved adaptation as glucose down to go goes down tumor weight goes down the size of the tumors shrink for the reasons that I've said we've also seen a correlation between glucose and igf one insulin like growth factor one which is a driver of tumor angiogenesis as glucose goes down igf one goes down and the corresponding signaling cascades associated with that hormone go down we've just recently shown how calorie restriction can target the most problematic aspect of cancer's inflammation which is nf kappa b calorie restriction knocks down phosphorylated nf kappa b through cox mechanisms it shuts down the entire inflammatory system that's going on that's driving and contributing to the progression of the disease so can calories and now the other thing is as well in cancer especially brain cancer these terribly invasive tumor cells they don't just grow as a lump in the brain they actually spread through the brain we've developed a natural mouse model for human glioblastoma multiforme and we're able to test a number of therapies on this new mouse model that we developed it's one of the only mice models mouse models that reflect the entire spectrum of what you see in the human disease and this shows you here this is the tumor growing in an ad libitum fed mouse here's the hippocampus these tumor cells will will invade right through the entire brain they'll move from one hemisphere to the other hemisphere and you can quantitate that using bio bioluminescent imaging as we've done but you can see in the calorie restricted guys that the borders of the tumor become much sharper they they don't invade as much and we've shown how you can they reduce invasion significantly the calorie restricted diet which is linked to low glucose and elevated ketones another question is does can we get therapeutic synergy when we combine a glycolysis inhibitor uh together with a restricted ketogenic diet we've heard already about ketogenic diets um the diets it doesn't in this case we're looking at a standard mouse chow diet which is actually like a standard american diet high in carbs low in fat and you've seen the whole thing here uh any kind of a ketogenic diet will work we've looked at various this is a keto count but we've looked at lard base we've looked at other base diets this is a low carbohydrate high fat moderate protein produces a fat to protein carb ratio of four to one as opposed to less than one for the high carb diet uh two deoxy glucose is a non-metabolizable analog of glucose so what what happens is a substitution here for a hydrogen for a hydroxyl group this molecule enters in the cells in fact it's like fluorideoxy glucose it can go into the cells but it can not be used for metabolism through glycogen to make glycogen or through glycolysis so it kind of uh inhibits the the energy metabolism so we've done a preliminary study in mice um showing now this is a standard diet high carb diet unrestricted a body weight control and then we gave the animals 2 deoxy glucose at a dosage that had no therapeutic benefit i wanted to use a dose that you could say well he's they've got 2 deoxy glucose but it's not having any effect and the body weights were the same now we we give the ketogenic diet in restricted amounts because we've shown if you don't restrict the ketogenic diet it has no therapeutic benefit so we calorie restrict the ketogenic diet to lower blood sugars and elevate ketones even further and then we added the 2 deoxy glucose and now we got powerful synergy between a diet and and and the drug and and basically what happens here is under the fed state you have a lot of glucose molecules going around glucose is the sole fuel for the for the tumor cells which will drive their progression also normal cells will use the glucose however when you go into the restricted diet glucose levels go down and ketones go up the normal cells now uh uh take in the ketones which the tumor cells can't use the ketones not only that receptors for glucose actually go up in the normal cells putting additional metabolic pressure on the tumor cells you throw in a little 2 deoxy glucose which now will more specifically target the tumor cells to give you a synergistic interaction between the ketogenic diet restricted and drugs this is an emerging field we've just started this there are many other metabolites out there that we can use together with these diets to kill off these tumor cells and and also hit targeting their glutamine metabolism which i want to have time to talk about so the clinical question can the ketogenic diet be used to manage brain cancer in humans you can do all i'm finished doing the mouse stuff forget it we just we you know there's a hundred studies out there on mice and cancer forget it we got to go to the patients now we have proved this is works in the mouse and it will work in humans and and we already heard from the first study linden ebbling study back case western reserve uh with a with a diet that lowered glucose and elevated ketone she was able to get um uh longer term management for two children with uh inoperable brain tumor we published the second paper uh on a patient uh from italy uh using uh therapeutic fasting ketogenic diets together unfortunately with the standard of care you can't get away from it it's a terrible thing it's responsible for the demise of most the can't brain cancer patients are dying from the standard of care now this patient had classic histological evidence for glioblastoma high cell density palisading cells um the radio this is the radiographic image before any treatment uh you can see multicentric this is an MRI image uh glioblastoma we confirm that histologically the patient did receive the standard of care following the standard of care the patient then uh was on a therapeutic fast for three days uh then on a calorie restricted ketogenic diet for several months now we had radiological resolution which very rarely happens when using just radiation and chemo temozolomide so we had a really quite remarkable response we had two more MRIs both look clean the patient then gets off the ketogenic diet about two months later uh tumor recurrence rather than going back on the diet the patient chose to go on a vaston uh which we now know enhances the invasive properties of the tumor cells terrible drug never never recommended anyway it selects for the most invasive cells and unfortunately the patient expired the the issue here of course is that will this therapy work and the answer is uh this proves the cons yes we can we can we can greatly improve this as long as we can get glucose elevations and ketones ketone elevation you can get uh put the tumor in a defensive state and then once it's in this defensive state we then go after the tumor with specific drugs to put additional pressure on the um on the cells so we have preclinical and case report studies indicate that this restricted ketogenic diet can be an effective metabolic therapy for managing malignant brain cancer in children and adults and the therapeutic effects of the diet against brain cancer can be enhanced when we combine it with specific non-toxic drugs that work together with the diet to target the surviving tumor cells now uh i put all this out in a recent book it just came out from Wiley Press discusses this and many other therapeutic non-toxic therapeutic options for managing cancer not just brain cancer and i thank my collaborators that have worked with me on this and many of my students in my cancer class have that have been very helpful on this thank you for your attention because uh uh because i'm running this i'm i'm gonna ask the only question uh are you currently taking patients so uh what i've done is i i collaborate with physicians and we're trying to get a pilot trial going at the university of pittsburgh our biggest problem is uh irb institutional review review board uh they they just put so many pressures i mean this is not a toxic therapy yet they they treated us oh my god all these patients are gonna get sick we're trying to get a pilot study there's another pilot study at michigan state university i wrote the protocols for both of these of the both of these uh approaches it's just very hard to get through irbs the institutional review board once that happens i think there'll be a lot more a lot more use for this well all right we'll take you um this is more of a clarification but um we talked about standard of care being the main cause for demands of cancer patients can you just say what that is that includes yes um standard of care for brain cancer involves radiation and tinnazolamide okay as soon as you irradiate the brain you you damage you release a lot of inflammatory cytokines you allow glutamate to go into the micro environment the glutamate is then taken up by glial cells and converted to glutamine because the neurons have been killed the glutamine now goes into the tumor cells and is fermented along with the tumor cells to reduce the inflammation they give steroids steroids make your blood sugar go up to the level of a diabetic so what you have now is you have powerful glucose and you have powerful glutamine and together they will fuel the tumor this is the demise of the cancer patient the reason why we have so few people surviving is because of the standard of care it has to be changed if it's not changed there will be no major problems thank you period