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Metformin enhances the antitumor activity of oncolytic herpes simplex virus HF10 (canerpaturev) in a pancreatic cell cancer subcutaneous model

Mohamed Abdelmoneim Ahmed Ali Mohamed 名古屋大学

2023.12.01

概要

主論文の要旨

Metformin enhances the antitumor activity of oncolytic
herpes simplex virus HF10 (canerpaturev) in
a pancreatic cell cancer subcutaneous model
メトホルミンは、膵臓細胞癌皮下モデルにおける腫瘍溶解性単純
ヘルペスウイルス HF10 (canerpaturev) の抗腫瘍活性を増強します

名古屋大学大学院医学系研究科
病態外科学講座

総合医学専攻

消化器外科学分野

(指導:中山 吾郎

特命教授)

Mohamed Abdelmoneim Ahmed Ali Mohamed

【Introduction】
Pancreatic ductal adenocarcinoma (PDAC) is the most common form of pancreatic cancer
and it represents the fourth leading cause of cancer deaths in Japan, with forecasts indicating
a further escalation of mortality rates in the coming decades. Now, the current standard of care
for patients with PDAC focuses on chemotherapeutic regimens and pancreatic cancer surgery.
However, limited treatment options, advanced tumor stages due to late diagnosis, and the
aggressive behavior of PDAC contribute to the high mortality of the disease. Consequently,
there is an urgent need for an alternative approach to pancreatic cancer treatment.

Recently,

immunotherapy has been considered a promising approach to cancer treatment. Even though
advancements in cancer immunotherapy, it showed limited preclinical and clinical response
against pancreatic cancer. In addition to this, PDAC patients showed no response to a single
treatment by immune checkpoint inhibitors (ICIs). Additionally, combination ICIs with
chemotherapy have not either induced marked effects in patients. The limitations of treatments
are attributed to its cold tumor microenvironment (TME) with low MHC-I expression. These
are accompanied by high infiltration of suppressive immune cells , as well as the physical
limitations like the presence of fibrotic tissue and stellate cells. These factors impair cytotoxic
CD8 + T cells infiltration and lead to T cell exhaustion. Therefore, to improve the outcomes,
other approaches are critically needed to beat PDAC resistance.
One of the immune therapeutic targeted agents that has the potential against cold tumors is
Oncolytic viruses (OVs). OV therapy is a promising alternative for patients who does not
respond to ICIs due to their dual benefit in one therapy. OVs are attenuated viruses that cause
anticancer effects by directly killing cancer cells (oncolysis) because they preferentially
replicate in the tumor cells and can be engineered to express transgenes that enhance their
cytotoxic effect. Moreover, OVs can modulate the TME and promote antitumor immunity.
Canerpaturev (C-REV) is a promising OV, which was originally isolated from herpes simplex
virus-1 (HSV-1) strain HF as clone 10 (Previously known as HF10). C-REV showed potent
antitumor effects against various preclinical models, including pancreatic cancer. C-REV
combined with anti-PD-L1 showed a greater antitumor effect with high infiltration of CD8 +
PD-1 - tumor-infiltrating lymphocyte cells (TILs) in SCC-VII model. C-REV combined with
chemotherapeutic S-1 also enhanced antitumor efficacy in a murine triple-negative breast
cancer model. It also demonstrated its safety and efficacy in phases I, and II clinical trials
targeting melanoma, pancreatic, breast, head, and neck cancer. C-REV combined with
gemcitabine and nab-paclitaxel in phase I clinical trial against unresectable stage III or IV
pancreatic cancer, and showed a favorable benefit/risk profile with antitumor activity.
Furthermore, C-REV combined with cetuximab and bevacizumab synergistically inhibited the
growth of human colorectal cancer as well as human breast carcinoma xenograft, respectively.
Concluding with those results that the combination approach is promising and highlighting the
need of new combination therapy to overcome cold tumors.

-1-

Metformin is an FDA-approved, commonly prescribed systemic antidiabetic medication for
type II diabetes patients. Recently, metformin demonstrated its cancer antitumor effectiveness.
Several epidemiological studies showed that metformin reduces cancer incidence in type II
diabetes patients and improves their prognosis. Metformin improved the survival of diabetic
patients with pancreatic cancer. Metformin affects the growth of cancer cells, and it showed a
potent immune modulator effect. Metformin mainly modulates immune suppressive cells,
which could be ideal for combining with OVs against cold tumors such as pancreatic cancer.
【Hypothesis】
we hypothesized that the combination of C-REV as an oncolytic virus plus metformin might
be a good option for pancreatic cancer treatment.
【Material and Methods】
We used a low immunogenic Pan02 murine PDAC model due to its high morbidity and
mortality. A bilateral tumor model of Pan02 was used to evaluate antitumor effects. Tumors
were cut into cubes (2 mm 3 ). Pan02 tumors were inoculated into mice; one tumor cube was
inoculated into each flank (right and left). When the average tumor size reached 100 mm 3 ,
treatments were then started on day 0. Mice were randomly divided into four groups (n= 4
mice/group) with an equal average tumor volume among the groups. C-REV was injected three
times (1X10 6 PFU/100 ul PBS) with three days intervals (D0, D3, and D6) on only one side
(injected side). Metformin was continuously supplied in the drinking water (5 mg/ml) when
C-REV treatment started.
【Results】
In vitro, metformin does not enhance the C-REV cell cytotoxic effect and it had no effect
on C-REV replication in Pan02 cell line. However, in in vivo model, intratumoral
administration of C-REV with the systemic administration of metformin led to synergistic
antitumor effect on both sides of tumor and prolonged survival. Interestingly, combination
therapy showed synergism from the calculation of the synergistic effect on both the injected
and contralateral sides . Combination therapy enhanced the infiltration and IFN-γ production
from CD8 + CD3 + TILs. Moreover, the combination therapy increased the effector CD44 + CD8 +
PD1 - and CD69 + CD8 + PD1 - subsets as well as decreased the proportion of terminallydifferentiated CD103 + KLRG-1 + T-regulatory cells on both sides of tumor. In addition,
Combination treatment significantly increased tumor-infiltrating DCs (CD11c + MHC-II + ) on
both the injected and contralateral sides. Interestingly, combination therapy efficiently
modulates conventional dendritic cells type-1 (cDC1) on tumors, and tumor-drained lymph
nodes. Combination therapy significantly enhanced XCR-1 expression on cDC1 on both the
injected and contralateral sides. Moreover, combination treatment significantly increased the

-2-

cDC1 population in the TDLNs, which is essential for CD8 + T cell activation that infiltrated
into the tumors after activation.
【Conclusion】
In summary, we observed that the combination of C-REV with metformin may be a novel
therapeutic combination. C-REV mainly enhances CD8 + TILs infiltration and function, which
could be upregulated by metformin. Metformin also increases cDC1 infiltration as well as
modulates suppressor terminally-differentiated tumor-infiltrating T regulatory cells. Thus, this
combination can enhance the antitumor effect. Currently, many OVs are undergoing clinical
trials including C-REV in addition metformin is a highly prescribed medicine and millions of
diabetic patients use this drug on a daily base. Our findings may provide new insights into the
role of combination treatment in the modulation of immune-suppressive tumors.

-3-

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Acknowledgements

We are thankful to Prof. Yukihiro Nishiyama for the isolation of C-REV in the Department of Virology, Nagoya

University Graduate School of Medicine. M.A is supported by a full scholarship from the Japanese government.

M.A.A is supported by a full scholarship from the Ministry of Higher Education of the Arab Republic of Egypt.

We also thank Emi Uematsu, Yumiko Samizo and Yukiko Kohmura for their technical assistance.

Author contributions

Conceptualization: Y.N., H.K.; investigation: M.A., I.R.E., M.A.A.; project administration: H.K.; supervision:

Y.N., M.T., Y.K., H.K.; writing-original draft: M.A., M.A.A.; writing-review & editing: S.M., P.A.S., I.B.V. All

authors reviewed the manuscript.

Funding

Takara Bio, Inc.; Japan Grants-in-Aid for Scientific Research, Grant/Award Numbers: 16K15611, 16H05413.

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Competing interests Maki Tanaka is an employee of Takara Bio, Inc. and Hideki Kasuya received research funding from Takara Bio,

Inc. The other authors declare no competing interests. Takara Bio, Inc. had no role in the conceptualization, or

design of the study, in the collection, analysis, or interpretation of data, in the writing of the article, or in the

decision to publish the article.

Additional information

Supplementary Information The online version contains supplementary material available at https://​doi.​org/​

10.​1038/​s41598-​022-​25065-w.

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