Abstract LB-200: Integrating dynamic 18F-FDG PET-CT, tumor metabolomics and functional genomics to understand metformin's pharmacodynamic effects in breast cancer: results of a phase 0 clinical trial
Authors: Lord Simon , Liu Daniel , Haider Syed , Gaude Edoardo , Teoh Eugene , Neel Patel , Zhang Qifeng , Gleeson Fergus , Wakelam Michael , Frezza Christian , Buffa Francesca , John Fenwick , Harris Adrian 
Published: July 2016

Abstract
There is growing interest in the anticancer effect of the diabetes drug, metformin, and over 100 clinical trials are underway worldwide. However it is still not determined as to whether metformin has significant direct effects on cancer cells or solely indirect effects via modulation of host metabolism.
We recruited 41 non-diabetic patients with primary breast cancer to a neoadjuvant window trial. Patients received an escalating dose of metformin (500mg up to 1500mg) for 2 weeks with pre- and post-metformin pharmacodynamic assessments including, dynamic 18F-FDG PET-CT scans, serum metabolic markers, and tumour biopsies for whole transcriptome RNASeq, tumour metabolomics and immunohistochemistry.
Assessment of tumour FDG kinetics using a classic 2-tissue compartment model with three rate constants showed a 1.3 fold change (FC) post-metformin in the composite 18F-FDG flux constant, Kflux (p = 0.041, on paired t-test). There was a non-statistically significant 1.1 fold increase in the variable, metabolic rate of glucose utilization (MRglu) (p = 0.141). Mass spectrometry analysis revealed a decrease in intra-tumoral levels of the short-chain acyl-carnitines, propionylcarnitine (FC -0.50, p = 0.039) and acetylycarnitine (FC -0.40, p = 0.046) consistent with inhibition of fatty acid oxidation (wilcoxon rank test). This effect on fatty acid oxidation was validated in pre-clinical in vitro and in vivo breast cancer cell line models. There was a statistically significant positive correlation between the actual difference in Kflux and intratumoral levels of acetylcarnitine (p = 0.012, Spearman's rank test). Small but consistent falls in the levels of serum glucose (p = 0.032), c-peptide (p = 0.001), insulin (p = 0.005), IGF1 (p = 0.048) and IGF2 (p = 0.040) were observed following metformin treatment (paired t-test) but there was no correlation with change in Kflux or short chain acyl-carnitine levels. Pathway annotation analysis using GeneCodis revealed several pathways associated with mitochondrial and fatty acid metabolism that were upregulated. Immunohistochemical intratumoral nuclear expression of pAMPK increased 1.5 fold (p = 0.037, paired t-test) but this did not correlate with change in Kflux or levels of short-chain acyl-carnitines. Peak serum metformin levels correlated with intratumoral metformin levels (p = 0.012, Spearman's rank test) but did not correlate with change in Kflux or short-chain acyl-carnitine levels.
Our data shows that metformin treatment alters FDG kinetics, inhibits fatty acid oxidation and leads to altered gene expression in the mitochondrial (nuclear encoded) transcriptome but that these effects do not correlate with changes in host metabolism. This data provides strong evidence that metformin has a direct effect on breast cancer metabolism at clinical doses.
Citation Format: Simon Lord, Daniel Liu, Syed Haider, Edoardo Gaude, Eugene Teoh, Patel Neel, Qifeng Zhang, Fergus Gleeson, Michael Wakelam, Christian Frezza, Francesca Buffa, Fenwick John, Adrian Harris. Integrating dynamic 18F-FDG PET-CT, tumor metabolomics and functional genomics to understand metformin's pharmacodynamic effects in breast cancer: results of a phase 0 clinical trial. [abstract]. In: Proceedings of the 107th Annual Meeting of the American Association for Cancer Research; 2016 Apr 16-20; New Orleans, LA. Philadelphia (PA): AACR; Cancer Res 2016;76(14 Suppl):Abstract nr LB-200.