NEW THERAPEUTIC STRATEGIES AGAINST BLOOD CANCER

Abstract

The present invention relates to the combination of at least one agent and a reduced calorie intake for use in the treatment of a blood cancer. In particular the agent is a CD20 inhibitor Bruton's tyrosine kinase inhibitor, a phosphoinositide 3-kinase inhibitor, a class I and/class II histone deacetylase inhibitor, a non-taxane replication inhibitor or a proteasome inhibitor. The combination is advantageous in that it sensitize cancer cells to said agent while it protects normal cells from toxicity induced by said agent.

Claims

1. A method for the treatment of a blood cancer in a mammal, comprising administering to said mammal in need thereof an agent selected from the group consisting of: a CD20 inhibitor, a Bruton's tyrosine kinase inhibitor, a phosphoinositide 3-kinase inhibitor, a class I and/or class II histone deacetylase inhibitor, a non-taxane replication inhibitor and a proteasome inhibitor in combination with reduced caloric intake by said mammal, wherein the reduced caloric intake lasts for a period of 24 hours to 190 hours and wherein said reduced caloric intake is a daily caloric intake reduced by 10 to 100%.

2. The method of claim 1, wherein said CD20 inhibitor is selected from the group consisting of: Rituximab, Afutuzumab, Blontuvetmab, FBTA05, Ibritumomab tiuxetan, Obinutuzumab, Ocaratuzumab, Ocrelizumab, Ofatumumab, Samalizumab, Tositumomab and Veltusumab, said Bruton's tyrosine kinase inhibitor is selected from the group consisting of: Ibrutinib, Acalabrutini, ONO-4059 (Renamed GS-4059), Spebrutinib (AVL-292, CC-292) and BGB-3111, said phosphoinositide 3-kinase inhibitor is selected from the group consisting of: Idelalisib BEZ235 (NVP-BEZ235, Dactolisib), Pictilisib (GDC-0941), LY294002, CAL-101 (Idelalisib, GS-1101), BKM120 (NVP-BKM120, Buparlisib), PI-103, NU7441 (KU-57788), IC-87114, Wortmannin, XL147 analogue, ZSTK474, Alpelisib (BYL719), AS-605240, PIK-75, 3-Methyladenine (3-MA), A66, Voxtalisib (SAR245409, XL765), PIK-93, Omipalisib (GSK2126458, GSK458), PIK-90, PF-04691502 (T308), AZD6482, Apitolisib (GDC-0980, RG7422), GSK1059615, Duvelisib (IPI-145, INK1197), Gedatolisib (PF-05212384, PKI-587), TG100-115, AS-252424, BGT226 (NVP-BGT226), CUDC-907, PIK-294, AS-604850, BAY 80-6946 (Copanlisib), YM201636, CH5132799, PIK-293, PKI-402, TG100713, VS-5584 (SB2343), GDC-0032 CZC24832, Voxtalisib (XL765, SAR245409), AMG319, AZD8186, PF-4989216, Pilaralisib (XL147), PI-3065TOR, HS-173, Quercetin, GSK2636771, CAY10505 and Rapamycin, said class I and/or class II histone deacetylase inhibitor is selected from the group consisting of: Romidepsin, Vorinostat, Chidamide, Panobinostat, Belinostat (PXD101), Valproic acid (as Mg valproate), Mocetinostat (MGCD0103), Abexinostat (PCI-24781), Entinostat (MS-275), Resminostat (4SC-201), Givinostat (ITF2357), Quisinostat (JNJ-26481585), HBI-8000, (a benzamide HDI), Kevetrin and Givinostat (ITF2357), said non-taxane replication inhibitor is selected from the group consisting of: Vincristine, Eribulin, Vinblastine, Vinorelbine, Tenisopide, said proteasome inhibitor is selected from the group consisting of: Bortezomib, Lactacystin, Disulfiram, Marizomib (salinosporamide A), Oprozomib (ONX-0912), Delanzomib (CEP-18770), Epoxomicin, MG132, Beta-hydroxy beta-methylbutyrate, Carfilzomib, Ixazomib, Eponemycin, TMC-95, Fellutamide B, MLN9708 and MLN2238.

3. The method of claim 1 wherein the agent is selected from the group consisting of: Romidepsin, Belinostat, Bortezomib, Rituximab, Vincristine and Eribulin.

4. The method of claim 1, wherein said reduced caloric intake is a daily caloric intake reduced by 50 to 100%.

5. The method of claim 1, wherein said mammal is fed with a food having a content of monounsaturated and/or polyunsaturated fats from 20 to 60%, a content of proteins from 5 to 10% and a content of carbohydrates from 20 to 50%.

6. The method of claim 1, wherein said period of reduced caloric intake is of 48 to 168 hours, preferably 120 hours.

7. The method of claim 1, wherein radiotherapy or at least one further agent selected from the group consisting of: a Bruton's tyrosine kinase inhibitor, a phosphoinositide 3-kinase inhibitor, a class I histone deacetylase inhibitor, a class II histone deacetylase inhibitor, a CD20 inhibitor, a non-taxane replication inhibitor, a taxane replication inhibitor, an alkylating agent, a proteasome inhibitor, an anti-inflammatory agent and an alternative agent is administered.

8. The method of claim 7 wherein said alkylating agent is selected from the group consisting of: cyclophosphamide, gemcitabine, Mechlorethamine, Chlorambucil, Melphalan, Monofunctional Alkylators, Dacarbazine (DTIC), Nitrosoureas and Temozolomide, wherein said taxane replication inhibitor is selected from the group consisting of: Paclitaxel, Docetaxel, Abraxane and Taxotere, wherein said anti-inflammatory agent is selected from a non-steroidal anti-inflammatory agent, dexamethasone, prednisone and cortisone or a derivative thereof and wherein said an alternative agent is selected from curcumin, L-ascorbic acid, EGCG and polyphenone.

9. The method of claim 7 comprising administering to said mammal: at least one CD20 inhibitor and at least one proteasome inhibitor or, at least one CD20 inhibitor and at least one class I and/or class II histone deacetylase inhibitor or, at least one class I and/or class II histone deacetylase inhibitor and at least one proteasome inhibitor, at least one class I and/or class II histone deacetylase inhibitor and at least one alkylating agent.

10. The method of claim 9, wherein the CD20 inhibitor is Rituximab, the proteasome inhibitor is Bortezomib, the class I and/or class II histone deacetylase inhibitor is Belinostat or Romidepsin and the alkylating agent is cyclophosphamide.

11. The method of claim 7 comprising administering to said mammal a combination selected from the group consisting of: Romidepsin and Belinostat; Bortezomib and Romidepsin; Bortezomib and Belinostat; Bortezomib and Rituximab; Cyclophosphamide and Romidepsin; Cyclophosphamide and Bortezomib; Cyclophosphamide and Belinostat; Bortezomib, Romidepsin and Belinostat; Cyclophosphamide, Romidepsin and Belinostat; Cyclophosphamide, Bortezomib and Belinostat; and Cyclophosphamide, Bortezomib, Belinostat and Romidepsin.

12. The method of claim 1, wherein said blood cancer is selected from the group consisting of: leukemia, lymphoma and multiple myeloma.

13. The method of claim 12, wherein leukemia, is chronic lymphocytic leukemia (CLL).

14. An in vitro method of treating a blood cancer cell with an agent selected from the group consisting of: a CD20 inhibitor, a Bruton's tyrosine kinase inhibitor, a phosphoinositide 3-kinase inhibitor, a class I and/or class II histone deacetylase inhibitor, a non-taxane replication inhibitor and a proteasome inhibitor, comprising: cultivating the cancer cell in a medium with reduced serum or glucose concentration; and treating the cancer cell with the at least one agent; wherein the serum concentration in the medium is less than 10% or the glucose concentration in the medium is less than 1 g/l.

15. A method for sensitizing a blood cancer cell in a mammal to an agent selected from the group consisting of: a CD20 inhibitor, a Bruton's tyrosine kinase inhibitor, a phosphoinositide 3-kinase inhibitor, a class I histone deacetylase inhibitor, a class II histone deacetylase inhibitor, a non-taxane replication inhibitor or a proteasome inhibitor while minimizing agent toxicity on a non-cancer cell, comprising administering to said mammal said agent in combination with reduced caloric intake by said mammal, wherein the reduced caloric intake lasts for a period of 24-190 hours and wherein said reduced caloric intake is a daily caloric intake reduced by 10 to 100%.

16. The method of claim 4, wherein said reduced caloric intake is a daily caloric intake reduced by 85 to 100%.

17. The method of claim 16, wherein said reduced caloric intake is a daily caloric intake reduced by 10 to 85%.

Description

[0086] The present invention will be illustrated by means of non limiting examples in reference to the following figures.

[0087] FIG. 1Molecular pathways involved in fasting or FMD protection. Fasting or FMD lead to a significant reduction in circulating IGF-1 levels. GH/IGF-1 pathway signals through Tyrosine Kinase Receptors, via the AKT/mTOR and/or the RAS/MAPKs pathways. FoxO family of transcription factors are down-regulated targets of the pathway via AKT. DR=Dietary restriction.

[0088] FIG. 2Effect of FMD on MEC1, MEC2 and L1210 survival and mortality growth. Cells were cultured for 48 hours in physiological glucose concentrations (1.0 g/liter; white bars) and supplemented with 10% Fetal Calf Serum (FCS) or in FMD condition (0.5 g/liter of Glucose; 1% FCS; green bars). Cell viability was as measured by erythrosine exclusion. Results from 3 independent experiments. Data are expressed as percentage of viable/dead cellsSD. ***P<0.001.

[0089] FIG. 3Effect of FMD on MEC1 morphology. A-B: Immunofluorescent analysis of mitochondrial morphology using Tom20 antibody (green). C-D: Immunofluorescent analysis of autophagy process using LC3 Antibody (green). E-F: immunofluorescent analysis of apoptosis using caspase-3-cleaved antibody (green). Nuclei are stained with dapi (blue) while the cytoplasm was marked with phalloidin (red).

[0090] FIG. 4Schematic of in vitro experimental workflow. Cells were seeded on day 0 either in physiological (CTRL) or FMD medium. After 24 hours cells were treated with drugs for other 24 hours. At 48 hours from seeding cell death was measured by the Erythrosin B exclusion assay.

[0091] FIG. 5Effect of drug panel on L1210. The cells were cultured in physiological or FMD conditions and treated as described in the text. Black bars are the survival (A) or the mortality (B) rates for the samples only treated with the drug stripped bars show the combination of the drug with the FMD condition.

[0092] FIG. 6Effect of FMD on drug treatment of L1210. The Survival (A) and the Mortality (B) rates for the cells only treated with the drugs are here divided respectively by the Survival and the Mortality rates measured with the drugs conjugated with FMD. HDAC and Proteasome inhibitors show the highest effect.

[0093] FIG. 7Effect of FMD on drug treatment of MEC1. The survival and the mortality rates for cells cultured in CTRL and FMD in presence of HDACs, proteasome inhibitor and human anti-CD20 antibody (rituximab). CTRL, physiological condition; FMD, fasting-mimick diet: BTZ, bortezomib 10 nM; RMD, Romidepsin 10 M: BLN; Belisnostat, 50 nM; RTX, Rituximab 1 g/ml). Results from 3 independent experiments. Data are expressed as meanSD.

[0094] FIG. 8Effect of FMD on drug treatment of MEC2. The survival and the mortality rates for cells cultured in CTRL and FMD in presence of HDACs, proteasome inhibitor and human anti-CD20 antibody (rituximab). CTRL, physiological condition; FMD, fasting-mimick diet; BTZ, bortezomib 10 nM; RMD, Romidepsin 10 M: BLN; Belisnostat, 50 nM; RTX, Rituximab 1 g/ml). Results form 3 independent experiments. Data are expressed as meanSD.

[0095] FIG. 9Survival after drug exposure in L1210. Cells were cultured in physiological (diamonds) or FMD conditions (square) and exposed to different concentrations of Romidepsin (A), Bortezomib (B), Belinostat (C) and Cyclophosphamide (D) as described in the text.

[0096] FIG. 10Mortality after drug exposure in L1210. Cells were cultured in physiological (diamonds) or FMD conditions (square) and exposed at different concentration of Romidepsin (A). Bortezomib (B). Belinostat (C) and Cyclophosphamide (D) as described in the text.

[0097] FIG. 11Effect of drug cocktail exposure in MEC1 (A) and MEC2 (B). Cells were cultured in physiological (blue bar) or FMD conditions (red bar) and exposed to different drug cocktail as described in the text. Survival and mortality are shown. CTRL, physiological condition: FMD, fasting-mimick diet: BTZ, bortezomib 10 nM: RMD, Romidepsin 10M; BLN; Belisnostat, 50 nM; RTX, Rituximab 1 g/ml). Results form 3 independent experiments. Data are expressed as meanSD.

[0098] FIG. 12Effect of drug cocktail exposure in L1210. Cells were cultured in physiological (diamonds) or FMD conditions (square) and exposed to different drug cocktail as described in the text. Survival (A) and mortality (B) are shown. The drug cocktail consisting in a mixture of HDAC (Romodepsin and Belinostat) and proteasome inhibitors (Bortezomib) shows the highest cytotoxic effect, causing 0% living cells and 100% of death cells in cultured L1210. CTRL=physiological condition: FMD=fasting-mimicking diet.

[0099] FIG. 13Survival after drug exposure in primary MEF. Cells were cultured in physiological (CRTL, diamonds) or FMD conditions (square) and exposed at different concentration of Romidepsin (A), Bortezomib (B), Belinostat (C) and Cyclophosphamide (D) as described in the text.

[0100] FIG. 14Mortality after drug exposure in primary MEF. Cells were cultured in physiological (CTRL, diamonds) or FMD conditions (square) and exposed at different concentration of Romidepsin (A), Bortezomib (B), Belinostat (C) and Cyclophosphamide (D) as described in the text.

[0101] FIG. 15Survival and mortality in primary MEF cells upon FMD/Romidepsin treatment. Effect of fasting mimicking diet (FMD) on Differential Stress Resistance (DSR) in two different productions of mouse embryonic fibroblast (MEF-6664/5 and MEF-6664/8) after treatment with Romidepsin (10 M). The cells were cultured in physiological (CTRL) and fasting mimicking diet (FMD) condition as described in the text and analyzed using Erythrosin B exclusion assay exclusion.

[0102] FIG. 16Effect of FMD on Differential Stress Resistance in primary MEF. Two different mouse embryonic fibroblast cell productions (MEFI or MEF-6664/5 and MEFI or MEF-6664/8) were treated with Romidepsin (10 M). The cells were cultured in physiological (CTRL) and fasting mimicking diet (FMD) condition as described in the text. The relative cell death within the groups is measured as function of death cells observed in the control.

[0103] FIG. 17Effect of FMD on Differential Stress Resistance in normal human BJ and murine 3T3-NIH fibroblasts. Normal fibroblast cell lines, human BJ (A) and 3T3-NIH (B) were treated with Bortezomib (10 nM). Cell mortality was evaluated by AnnexinV/PI test. Results form 3 independent experiments. Data are expressed as meanSD. CTRL=physiological condition: FMD=fasting mimicking diet; BTZ=Bortezomib.

[0104] FIG. 18Cytotoxicity of drug cocktail exposure in primary MEF. Cells were obtained from mouse embryos at 11.5 days of prenatal development. Survival (A and B) and mortality (C and D) are represented. The drug cocktail consists in a mixture of HDAC (Romodepsin and Belinostat) and proteasome inhibitors (Bortezomib) as described in the text.

[0105] FIG. 19Schematic of periodical STS and Bortezomib in CLL in vivo modelRag2/ IL2/ female mice (8-12 weeks) were injected i.v. with 10*106 MEC-1 CELLS in 100 l of PBS. After 3 days from the injection the mice were divided in 6 experimental groups (5 mice each) according to following treatments: Ad lib=+vehicle; STS=Fasting+vehicle; BTZ=Ad lib+Bortezomib (Velcade millennium0.35 mg/kg once a week for 3 weeks (days 7, 14 21); STS+BTZ=Fasting+Bortezomib (0.35 mgg/kg) once a week for 3 weeks (days 7, 14 21): BTZ+RTX=Ad lib+Bortezomib (0.35 mg/kg once a week)+Rituximab (10 mg/kg once a week) for 3 weeks (days 7, 14 21); STS+BTZ+RTX=Fasting+Bortezomib (0.35 mg/kg once a week)+Rituximab (10 mg/k g once a week) for 3 week.

[0106] FIG. 20Body weight (gr). Rag2/IL2/ female mice (8-12 weeks) injected i.v. with 10*106 MEC-1 CELLS in 100 l of PBS and treated as described in the text were regularly weighted. In fasted mice the body weight underwent fluctuation according to STS regimen. Body weight was recovered rapidly 24 hours after the re-feeding.

[0107] FIG. 21Spleen weight (gr). Rag2/IL2/ female mice (8-12 weeks) were injected i.v. with 10*106 MEC-1 CELLS in 100 l of PBS and treated as described in the text. At the end of experimental procedures, spleens weight from mice of all groups was recorded. In fasted mice +/drug treatment, spleen weight is significantly low compared to the other groups. Ad lib=ad libitum; STS=Short-term starvation: BTZ=Bortezomib; RTX=Rituximab.

[0108] FIG. 22CD19 MEC1 positive cells in several organs of injected Rag2/mice. Cells collected from bone marrow (A), spleen (B), blood (C) and peritoneal cavity (D) were analyzed by cytometry after staining with mAb against human CD19 to identify leukemic B-cell population. CTRL=Ad lib+Vehicle: STS=Short term-starvation+vehicle; BTZ=Ad lib+Bortezomib (velcade millenium)1 mg/kg: STS+BTZ=Short term-starvation+Bortezomib (1 mg/kg): BTZ+RTX=Ad lib+Bortezomib+Rituximab: BTZ+RTX+STS=Bortezomib+Rituximab+short-term starvation.

[0109] FIG. 23CD20 MEC1 positive cells in several organs of injected Rag2/ mice. Cells collected from bone MEC1 cells injected intravenously localize in several organs of Rag2-!-mice. Cells collected from bone marrow (A), spleen (B), blood (C) and peritoneal cavity (D) were analyzed by cytometry after staining with mAb against human CD20 to identify leukemic B-cell population. CTRL=Ad lib+Vehicle; STS=Short term-starvation+vehicle; BTZ=Ad lib+Bortezomib (velcade millenium)1 mg/kg; STS+BTZ=Short term-starvation+Bortezomib (1 mg/kg); BTZ+RTX=Ad lib+Bortezomib+Rituximab; BTZ+RTX+STS=Bortezomib+Rituximab+short-term starvation.).

[0110] FIG. 24CD45 MEC1 positive cells in several organs of injected Rag2/ mice. Cells collected from bone MEC1 cells injected intravenously localize in several organs of Rag2/ mice. Cells collected from bone marrow (A), spleen (B), blood (C) and peritoneal cavity (D) were analyzed by cytometry after staining with mAb against human CD45 to identify leukemic B-cell population. CTRL=Ad lib+Vehicle; STS=Short term-starvation+vehicle; BTZ=Ad lib+Bortezomib (velcade millenium)1 mg/kg; STS+BTZ=Short term-starvation+Bortezomib (1 mg/kg); BTZ+RTX=Ad lib+Bortezomib+Rituximab; BTZ+RTX+STS=Bortezomib+Rituximab+short-term starvation.

[0111] FIG. 25Histopatological analysis of bone marrow. Histopatological analysis of bone marrow from Rag2/ female mice injected i.v. with MEC1 showed no tumoral lymphocytes infiltration (arrowhead) in BTZ+RTX and in STS+BTZ+RTX as compared with other experimental groups. H&E staining. Not injected=healthy mouse not injected with MEC cells. CTRL=Ad lib+Vehicle; STS=Short term-starvation+vehicle; BTZ=Ad lib+Bortezomib (velcade millenium)1 mg/kg; STS+BTZ=Short term-starvation+Bortezomib (1 mg/kg): BTZ+RTX=Ad lib+Bortezomib+Rituximab; BTZ+RTX+STS=Bortezomib+Rituximab+short-term starvation.

[0112] FIG. 26Histopatological analysis of spleen. Histopatological analysis of spleen from Rag2/ female mice injected i.v. with MEC1 showed no tumoral lymphocytes infiltration (arrowhead) in BTZ+RTX and in STS+BTZ+RTX as compared with other experimental groups. Insert, higher magnification. H&E staining. Not injected=healthy mouse not injected with MEC1 cells. CTRL=Ad lib+Vehicle; STS=Short term-starvation+vehicle; BTZ=Ad lib+Bortezomib (velcade millenium)1 mg/kg; STS+BTZ=Short term-starvation+Bortezomib (1 mg/kg): BTZ+RTX=Ad lib+Bortezomib+Rituximab; BTZ+RTX+STS=Bortezomib+Rituximab+short-term starvation.

[0113] FIG. 27Histopatological analysis of kidney. Histopatological analysis of kidney from Rag2/ female mice injected i.v. with MEC1 showed no tumoral lymphocytes infiltration (arrowhead, dark violet) in BTZ+RTX and inSTS+BTZ+RTX as compared with other experimental groups. Insert, higher magnification. H&E staining. Not injected=healthy mouse not injected with MEC1 cells. CTRL=Ad lib+Vehicle: STS=Short term-starvation+vehicle: BTZ=Ad lib+Bortezomib (velcade millenium)1 mg/kg; STS+BTZ=Short term-starvation+Bortezomib (1 mg/kg): BTZ+RTX=Ad lib+Bortezomib+Rituximab: BTZ+RTX+STS=Bortezomib+Rituximab+short-term starvation.

[0114] FIG. 28Histopatological analysis of liver. Histopatological analysis of liver from Rag2/ female mice injected i.v. with MEC1 showed no tumoral lymphocytes infiltration (arrowhead, dark violet) in BTZ+RTX and inSTS+BTZ+RTX as compared with other experimental groups. Insert, higher magnification. H&E staining. Not injected=healthy mouse not injected with MEC1 cells. CTRL=Ad lib+Vehicle; STS=Short term-starvation+vehicle; BTZ=Ad lib+Bortezomib (velcade millenium)1 mg/kg; STS+BTZ=Short term-starvation+Bortezomib (1 mg/kg): BTZ+RTX=Ad lib+Bortezomib+Rituximab; BTZ+RTX+STS=Bortezomib+Rituximab+short-term starvation.

[0115] FIG. 29White blood cells and absolute lymphocyte number in CLL patient. White blood cells (WBC) number and Absolute Lymphocyte (ABC Lymph) number were measured after two serial fasting mimicking diet (FMD) cycles. Pre-FMD=Before two cycles of FMD; Post=After two cycle of FMD.

DETAILED DESCRIPTION OF THE INVENTION

[0116] Material and Methods

[0117] Cell Culture

[0118] Human MEC1 and MEC2 CLL cell lines, murine L1210 CLL cell line, human BJ fibroblast cell line and murine 3T3-NIH cell line were purchased from American Type Culture Collection (ATCC). All cells were routinely maintained in Dulbecco's modified Eagle's medium (DMEM) and 10% FBS at 37 C. and 5% CO2.

[0119] In Vitro Treatment

[0120] Cells were seeded into 12-well microtiter plates at 110.sup.6 and treated as indicated in the text. All treatments were performed at 37 C. under 5% CO2. In vitro FMD was done by incubating cells in glucose-free DMEM (Invitrogen) supplemented with either low glucose (0.5 g/liter, Sigma) in 1% serum. Control group was done by incubating cells in DMEM/F12 supplemented with 10% serum and 1 g/liter of glucose. The schematic of the in vitro treatment is represented in FIG. 4. All drugs listed in Table 1 were used for in vitro and in vivo cytotoxic studies.

TABLE-US-00001 TABLE 1 Agent used in in vitro and/or in vivo studies Name Target Molecular Mechanisms Activity Company/Cat.# IBRUTINIB Bruton's It inhibits BTK, a signaling molecule of the B-cell antigen Tyrosine CAL-101 (Idelalisib, tyrosine kinase receptor and cytokine receptor pathways. As an irreversible kinases GS-1101), (BTK) covalent inhibition, ibrutinib continues to inhibit BTK even after inhibitors Selleckchem it is metabolized. IDELALISIB Phospho- Idelalisib (CAL-101) is an inhibitor of the delta isoform of the Ibrutinib (PCI-32765), inositide 3- 110 kDa catalytic subunit of class Ia phophoinositide-3 kinases Selleckchem kinase delta (PI3K) with potential immunomodulation and antineoplastic (PI3K) activities, PI3K-delta inhibitor CAL-101 inhibits the production of the second messanger phosphatidylinositol-3,4,5- trisphosphate (PIP3), preventing the activation of the PI3K signaling pathway and thus inhibiting tumor cell proliferation, motility and survival. ROMIDEPSIN Class I and II They act as a potent and selective inhibitor of classes I and II Deacetylase (FK228, histone histone dyacetilases. inhibitor depsipeptide), deacetylase Selleckchem BELINOSTAT PXD101, Selleckchem RITUXIMAB CD20 It binds specifically to the antigen CD20 (human B-lymphocyte- CD20 inhibitor RITUXAN restricted differentiation antigen, Bp35), a hydrophobic (rituximab), transmembrane protein of about 35 kDa located on pre-B and Genentech mature B lymphocytes. CD20 regulates an early step(s) in the activation process for cell cycle initiation and differentiation, and possibly functions as a calcium ion channel. DOCETAXEL Tubulin It binds to microtubules reversibily with high affinity. Replication TAXOTERE- inhibitors docetaxel. Sanofi PACLITAXEL It interferes with the normal function of microtubule growth by Paclitaxel (Paxene, hyper-stabilizes their structure. Anzatax, Taxol) VINCRISTINE It binds to tubulin dimers, by inhibiting their assembly and V8879, Sigma- arresting mitosis metaphase. Aldrich ERIBULIN It inhibits the growth phase of microtubules leading to G2/M cell HALAVEN cycle block, disrution of mitotic spindles and, ultimatelly, [Eribulina] apoptotic cell death. CYCLOPHOS- DNA It is an alkylating agent of nitrogen mustard type. It binds to Ciclofosfamide PHAMIDE DNA causing the cross-linking of strands of DNA and RNA and (Endoxan Baxter) the inhibition of protein synthesis GEMCITABINE Its inhibits thymidylate synthase, leading to inhibition of DNA Gemcitabina syntheis and cell death. It also inhibits ribonuclease reductase. (Gemzar) Finally, Gemcitabine competes with endogenous deoxynucleoside triphospahtes for incorporation into DNA. OXALIPLATIN DNA It is an alkylating agent containing platinum complexed to Oxaliplatino oxalate and diaminocyclohexane complex. Platinum complexes (Eloxatin) inhibit DNA synthesis through covalent bindings of DNA to form intrastrand and interstrand DNA crosslinks. DOXORUBICIN Topisomerase II It interacts with DNA by intercalation and inhibition of Doxorubicin macromolecular biosynthesis. (Adriamycin, Rubex) BORTEZOMIB 26S Proteasome It specifically binds the catalitic site of the 26S proteasome Proteasome Veicade, Millennium causing the inhibition of proteasome. inhibitor PREDNISONE P-Glycoprotein It binds the glucocorticoid receptor (GCR) the formation of Anti- P6254 Sigma-Aldrich Prednisone/GCR complex. Inside the nucleus, the complex inflammatory binds to specific DNA binding-sites resulting leading the synthesis of anti-inflammatory and the block the transcription of inflammatory genes. POLYPHENONE EGFR They inhibit vascular endotelial growth factor and hepatocyte Alternative ()Epigallocatechin AND EGCG growth factor, both of which promote cell migration and compounds Gallate (3668) Sigma- invasion. Aldrich CURCUMIN Cyclooxigenase Curcumin suppresses the activation of NF-B via inhibition of Sigma-Aldrich offers and Glutadione IKB activity, leading to suppression of TNF, COX-2, cyclin D1, Sigma-C1386 S-Transferase c-myc, MMP-9 and interleukins. Curcumin is involved in cell cycle control and stimulation of apoptosis via upregulation of p16 and p53. In addition, it is a modulator of autophagy and has inhibitory effects VEGF, COX-2, IVINIPs and ICAMs. L-ASCORSIC Catalase It acts as a pro-drug to deliver hydrogen peroxide to tissues. Sigma-Aldrich- ACID A92902, L-Ascorbic acid

[0121] After 24 hours of in vitro FMD treatment, cells were incubated with different drugs for 24 hours in physiologic or FMD medium (FIG. 4). Survival and mortality were determined by either Erythrosin B exclusion assay or by Annexin V/PI assay. Briefly, at the end of 48 hours, 25 L of cell suspension for each group was stained with Erythrosin B solution (1:1) in a tube and mix gently. The cells were counted under the microscope at magnification of 40. Death cells (those whose plasma membrane was damaged) appeared as light red while viable cells remained unstained (dye exclusion). Cell viability was calculated as the number of unstained cells per group divided by the viable cells counted in the control and expressed as a percentage. For each group, the mortality was calculated as the number of stained cells divided by the total number of cells and expressed in percentage. FMD conditions caused a major reduction of both MEC1 and MEC2 cell numbers, respectively, an effect that correlates directly with the increased percentage of dead cells (FIG. 2A, 2B). For Annexin V/PI cells were gently harvest, washed and resuspended in annexing buffer containing annexin-APC antibody (1:50). Cells were incubated for 1 h at room temperature in the dark, washed once with annexin buffer and resuspended in 0.5 ml of annexin buffer, in presence of Iodium propidium (PI). The samples were analyzed with a FC500 flow cytometer (Beckman-Coulter).

[0122] Immunofluorescence staining and confocal microscopy Cells were harvested and seeded on polylysine coating coverslips for 10 min. After 10 min of fixation with formaldehyde at 4% cells were washed and incubated with 3% BSA for 20 min. Primary polyclonal rabbit antibodies were: Tom20 (AB-CAM), LC3B and Caspase 3-cleaved (Cell Signaling) (1 hour, room temperature). Cells were washed and incubated with secondary antibody (goat anti rabbit, Sigma) FITC and or TRITC conjugated. Nuclei were stained with DAPI (Sigma).

[0123] In Vitro FMD Regimen

[0124] Cellular FMD was done by glucose and/or serum restriction to achieve blood glucose levels typical of fasted and normally fed mice: the lower level approximated to 0.5 g/liter and the upper level to 2.0 g/liter. For human cell lines, normal glucose was considered to be 1.0 g/liter. Serum (FBS) was supplemented at 1% for starvation conditions. Cells were washed twice with PBS before changing to fasting medium.

[0125] Animal Ethic Statement

[0126] All animal work and care were performed under the guidelines and in accordance with the recommendations of the Guide for the Care and Use of Laboratory Animals and with the approval of the Committee on the Ethics of Animal Experiments (IACUC) and finally approved by the Italian Ministry of Health. Specific authorization for the mouse experiments performed in this work (injection of Human MEC1 CLL cells in Rag2/ c/) was obtained in the protocol #742/2015PR: Ruolo della restrizione calorica e del sistema immunitario nella sensibilizzazione della leucemia linfatica cronica a terapia antitumorale. The inventors Franca Raucci and Valter Longo are elected responsible for the experiments. All reasonable efforts were made to ameliorate animal suffering. To sacrifice the mice CO2 inhalation was used accordingly with the protocol proposed for this study and approved by the ethics committee (IACUC) and the Italian Ministry of Health.

[0127] In Vivo CLL Model

[0128] Eight-week-old Rag2/ c/ female mice were challenged intravenously (iv) via lateral tail veins with 1010.sup.6 MEC1 cells in 0.1 ml of saline through a 27-gauge needle, as previously described by Bertilaccio et al., (2010). Before injection, cells in log phase of growth were harvested and suspended in phosphate-buffered saline (PBS) at 10010.sup.6 cells/ml, and 100 l (1010.sup.6 cells per mouse) was injected iv. All mice were gently warmed before intravenous injections to dilate the veins. Body weights were determined daily, and tumor progression was determined by blood smear. Animals were monitored every day for weight and general health conditions and were sacrificed when they experienced clinical signs of illness following the criteria approved and described in the protocol #742/2015PR (see Animal Ethics Statement).

[0129] In Vivo Fasting Regimen and Drug Treatment

[0130] Animals were fasted for a total of 48 hours by complete deprivation of food but with free access to water. Mice were individually housed in a clean new cage to reduce cannibalism, coprophagy, and residual chow. Body weight was measured daily and immediately before and after fasting. For in vivo studies, BTZ (0.35 mg/kg body weight) and RTX (10 mg/kg body weight) were injected intraperitoneally (alone and/or in combination) after 24 hours of fasting regimen for a total of 3 cycle of treatment (FIG. 19) After the third cycles of treatment animal were sacrified according to the protocol #742/2015PR

[0131] Sample Collection

[0132] Peripheral blood, peritoneal fluid and tissues (spleen, femoral bone marrow, kidney, liver and lung) were collected and used either for flow cytometry (FACS) or morphological analysis. FACS analysis was performed on blood, peritoneal fluid, spleen and bone marrow. The single cell suspensions were depleted of red blood cells by incubation in an ammonium chloride solution (ACK) lysis buffer (NH4Cl 0.15 M, KHCO3 10 mM, Na2EDTA 0.1 mM, pH 7.2-7.4) and were then stained after blocking the fragment crystallizable (Fc) receptors. After blocking Fc receptors with Fc block (BD Biosciences Pharmingen) for 10 minutes at room temperature to avoid nonspecific binding of antibodies, cells from peripheral blood, bone marrow, peritoneal exudates and spleen were separately stained with anti human CD19, anti human CD20 and anti human CD45 antibodies, respectively to investigate the presence of MEC1 cells in the different compartments, and analyzed with a FC500 flow cytometer (Beckman-Coulter).

[0133] Morphological Analysis

[0134] Mice tissues (bone marrow, spleen, kidney, livera md lung) sections were de-paraffinized in xylene, rehydrated in ethanol, immersed in PBS and serially stained with Mayer-Hematoxylin and Eosin. After dehydration in ethanol and xylene, slides were permanently mounted in Eukitt (Bio-Optica).

[0135] Patient Study

[0136] One CLL male patient voluntarily underwent two FMD cycles (plant-based- and protein free diet). FMD consists in 4 days of low-calorie intake (50% of regular calorie intake on day 1, and 10% on days 2-4), with low protein and low sugar, plant-based formulation followed by a standard ad libitum diet for 10 days. Before and at the end of the FMD cycles (2 cycles) white blood cells (WBC) and absolute lymphocyte number (AbsLymph) were measured using standard technique.

[0137] Statistical Analysis

[0138] Comparisons between groups were done with Student's t test using Excel software. P values<0.05 were considered significant.

EXAMPLES

[0139] FMD Affects CLL Growth

[0140] The inventors have previously shown, that fasting or FMD treatment reduces pro-growth signaling pathways and increases the susceptibility of tumor cells to death when coupled with chemotherapeutic drugs but also in its absence.sup.26,38.

[0141] To test whether sensitization by FDM may also occur in CLL, the inventors cultured for 48 hours either human CLL cell lines. MEC1 and MEC2, or murine CLL cell line, L1210, in physiological glucose concentrations (1.0 g/liter), supplemented with 10% Fetal Calf Serum (FCS) and theY compared their growing capabilities, when cultured in FMD condition (0.5 g/liter of Glucose: 1% FCS).

[0142] Living and dead cells were determined by Erythrosin B exclusion assay, which is a vital dye commonly used to determine cell viability. Briefly, at the end of 48 hours, 25 L of cell suspension for each group was stained with Erythrosin B solution (1:1) in a tube and mix gently. The cells were counted under the microscope at magnification of 40. Death cells (those whose plasma membrane was damaged) appeared as light red while viable cells remained unstained (dye exclusion). Cell viability was calculated as the number of unstained cells per group divided by the viable cells counted in the control and expressed as a percentage. For each group, the mortality was calculated as the number of stained cells divided by the total number of cells and expressed in percentage. FMD conditions caused a major reduction of both MEC1 and MEC2 cell numbers, respectively, an effect that correlates directly with the increased percentage of dead cells (FIG. 2A, 2B).

[0143] Similarly to human CLL, the application of FMD medium to murine L1210 cell line reduced their survival and increased the mortality as shown in FIG. 2C.

[0144] In order to characterize the physiological status of CLL cell lines upon low glucose/FCS culturing conditions the inventors examined the presence of mitophagy (Tom20), autophagy (LC3B) and apoptosis (Casp3), respectively by IFL (FIG. 3). Briefly, cells cultured in physiological conditions and in FMD for 48 hr were fixed with 4% formaldehyde, permeabilized with 0.1% Triton-X, incubated with specific primary antibody (anti-rabbit) and co-stained with the nuclear fluorescent dye 4,6-diamidin-2-fenilindolo (DAPI) and the Alexa488 anti-rabbit secondary antibody conjugated with a fluorophore that emits at 518 nm wavelength (green). The cytoplasm was stained with phalloidin (red). Images were acquired with a confocal microscope Leika LSM700. In MEC1 cells cultured in FMD medium, mitochondria morphology was dramatically altered, displaying an overall fragmentation as indicated by the localization of Tom20, a specific mitochondrial marker (compare FIG. 3B vs 3A). Similar results were detected also in murine L1210 CLL cell line (data not shown). As the fragmentation of mitochondria is responsive to a variety of cellular stressors, such as nutrient depletion, the inventors also examined the evidence of autophagy in CLL cell lines under the inventors' culture condition using LC3B antibody. Upon FMD, MEC1 displayed a notably presence of distinct cytoplasmic foci reminiscent of autophagosomes localizing LC3B, indicating that MEC1 can accumulate at autophagosomes during autophagy induction (compare FIG. 3D vs 3C). In line with the inventors' morphometric results, FMD condition induced cancer cell dead as shown from the presence of MEC1 cells stained positively with an antibody that recognizes active caspase-3 (compare FIG. 3F vs 3E).

[0145] FMD Enhances Drugs Inhibitory-Effect on CLL Cell Growth/Survival

[0146] The inventors screened 18 different wide spectrum drugs commonly used in cancer treatment and in particular in CLL for effects in combination with an FMD. The different drugs were clustered according to their mechanism of action and their target specificity (Table 1).

[0147] FIG. 4 shows the diagrammatic representation of the experimental procedure to analyze the effects of FMD in vitro. Briefly, FMD medium was applied to cells for 24 hours before and 24 hours during drugs treatment. Control groups were cultured in glucose (1.0 g/liter) supplemented with 10% of FCS. FMD groups were cultured in glucose (0.5 g/liter) supplemented with 1% of FCS. Samples were assayed for cell survival and cell death as previously described. After 24 hours of in vitro incubations all tested drugs (Table 1) reduced significantly the survival rates of control (non-starved) groups. In particular Vincristine, Eribulin and Cyclophosphamide showed less than 50% of living cells compared to the untreated samples, not exposed to the compounds (FIG. 5A, black bars). The application of FMD conditions dramatically improved the growth inhibitory/cell death effect of all drug tested, although the clustered group of alternative compound (as defined in Table 1, i.e Polyphenone-E, EGCG, Curcumin, Vitamin C) together with the anti-inflammatory hormone, Prednisone, did not show a strong efficiency, reducing survival rates, both alone or in combination with low glucose/FCS culturing conditions (FIG. 5A, stripped bars).

[0148] The mortality rates even more clearly remarked the previous observations on survival rates (FIG. 5B). The alternative compounds distinguished from all the other drugs, inducing cell death only marginally, both in combination with FMD treatment or alone. In all the other cases moderate mortality rates below 20% were doubled by the sensitizing effect of FMD culturing conditions (FIG. 5B, stripped bars). In particular the HDAC inhibitors (Romidepsin 10 M and Belinostat 50 nM) together with the proteasome inhibitor (Bortezomib 100 nM, and Cyclophosphamide were very effective in killing tumor cells, an effect increased further by the FMD. The specific contribution of FMD to survival and death rates is even better presented in FIGS. 6 (A & B), where HDAC inhibitors (in particular Romidepsin) and Bortezomib show a great increase of their growth inhibitory/pro-death effects. It is apparent also in this analysis that the alternative compounds, together with the anti-inflammatory drug, Prednisone, have no or limited effect on L1210 growth independently of the application of the FMD. Similarly to murine CLL, the application of FMD medium to MEC1 and MEC2 remarkably improved the growth inhibitory effect of Bortezomib, Romidespin and Belinostat as occurred in murine L1210 (FIGS. 7, 8). Furthermore, for both human CLL cell lines the application of another drug, the anti-CD20 human antibody (Rituximab 10 g/ml) was very effective on MEC1 (FIG. 7) and MEC2 (FIG. 8) cell survival and death under the inventors' culture conditions.

[0149] Romidepsin, Belinostat, Bortezomib and Cyclophosphamide Exhibit Concentration-Dependent Toxicity Against L1210 Upon FMD

[0150] In the current study, by screening 18 different wide spectrum drugs commonly used in CLL treatment the inventors have discovered that the most effective drugs that exhibited not just a very high lethality against CLL cells, but also high synergic effect with FMD are HDAC inhibitors (Romidepsin and Belinostat), proteasome inhibitor (Bortezomib) and Cyclophosphamide.

[0151] To test whether sensitization by FMD may also depend by drug concentration, the inventors incubated L1210 with different concentrations of selected drugs, using the schematic experimental workflow described in FIG. 4.

[0152] Briefly, FMD medium was applied to cells for 24 hours before and 24 hours after drug treatments. Control groups were cultured in glucose (2.0 g/liter) supplemented with 10% of FCS. FMD groups were cultured in glucose (0.5 g/liter) supplemented with 1% of FCS. Romidepsin was added at concentrations from 10 M to 400 M; Belinostat, from 50 nM to 500 nM: Bortezomib, from 10 nM to 400 nM: and Cyclophosphamide, from 100 M to 750 M. Living and death cells were determined by Erythrosin B exclusion, as previously described. Cell viability was calculated as the number of unstained cells per group divided by the number of viable cells counted in the control, and expressed as percentage. For each group, the mortality was calculated as number of stained cells divided by the total number of cells and expressed in percentage. Each experiment was done in triplicated and repeated twice.

[0153] In all treated groups, the percentage of L1210 survival gradually increased as function of drug concentration, in both control and FMD medium. However, the application of FMD condition dramatically improved the growth inhibitory effect by reducing the survival rate as compared with L1210 cells cultured in control medium and treated with drugs (FIG. 9). Again the inventors observed a synergistic cytotoxic effect of the FMD in combination with drug treatments through a range of concentrations (FIG. 10).

[0154] Romidepsin, Belinostat, Bortezomib and Rituximab Synergistically Interact with FMD by Causing the Highest Mortality Rate of CLL Cell Lines

[0155] In order to identify the best drug mixture that together FMD caused the highest mortality in CLL cell lines, the inventors tested a range of several drug cocktails obtained by different combination of Romidepsin, Belinostat, Bortezomib and Rituximab. When used in cocktail, the concentration of single drug was given as standard dose (Romidepsin, 10 M; Belinostat, 50 nM; Bortezomib, 10 nM; Rituximab, 10 g/ml). As shown in FIG. 11, all tested drug cocktails worked synergistically with the FMD, to cause a dramatic decrease in cell survival and increase of cells mortality, as compared with the effect of the same drugs in combination with control medium. Interestingly, in presence of FMD all drug cocktails tested were very potent in killing CLL cells. However the most potent ones were those resulted from combination of (1) Romodespin+Belinostat+Bortezomib and (2) Bortezomib+Rituximab, respectively (FIG. 11). Drug cocktails toxicity was also tested in murine L1210 cell line, leading to similar results to those observed for the human CLL in vitro models. In fact, in presence of FMD the combination of Romodespin+Belinostat+Bortezomib, resulted in 0% of surviving of L1210 cells (100% cell death, FIG. 12).

[0156] FMD-Dependent Differential Stress Resistance Protects Normal Cells Against High Concentration of Chemotherapy Drugs

[0157] To test whether FMD could induce a protective effect in normal cell against the treatment with high concentrations of drugs selected in this study, primary embryonic mouse fibroblast (MEF I) obtained from mouse embryos at 11.5 days of pre-natal development were used. When the drugs were added to primary MEF cultured in control medium, the percentage of survival dramatically decreased, and the trend of viability exhibited a concentration dependent behavior (FIG. 13). Interestingly, the application of FMD condition greatly improved the cytotoxic effect caused by drug supplementation, keeping the survival rate profile of primary MEF independent from the increase to the drug dose-exposure (FIG. 13).

[0158] The mortality rates observed in primary MEF was in line with the observation that FMD exerted a protective effect against the cytotoxic action of drugs in primary MEF (FIG. 14).

[0159] In another set of experiment, two different primary embryonic mouse fibroblast cell lines (MEF-6664/5 and MEF-666/8) obtained from mouse embryo at 11.5 days of pre-natal development were used. FMD medium was applied according to the in vitro experimental workflow and the differential stress resistance against the cytotoxic effect of Romidepsin (10 M) was assessed by Erythrosin B exclusion. After 24 hours, FMD reduced survival rates by about 18% as compared with those of the control group (FIG. 15). In the groups treated with Romidepsin (10 M) in presence of physiological medium, the percentage of surviving cells dramatically decreased by about 50% in both MEFI 6664/5 and MEFI 6664/8, while the mortality rate reached the value of about 12%. The application of FMD in presence of Romidepsin greatly improved the resistance of primary MEF cells against drug cytotoxicity. In fact, in both MEF cell lines the survival rate was about 77%, resembling that of the FMD alone group, while the percentage of mortality was reduced at 4% as compared with MEF treated with Romidespin in presence of the standard nourishment.

[0160] The specific contribution of FMD to death rates is even better presented in FIGS. 15 and 16, which clearly show the inhibitory effect of Romidepsin on cell growth.

[0161] In order to confirm these data, drug cytotoxicity was also tested in other two normal cell lines the human BJ fibroblast and the murine 3T3-NIH fibroblast, classically used for drug toxicity screening. Cells were seeded according to the inventors' in vitro protocol and expose to Bortezomib (10 nM). The vitality of cells was evaluated by using AnnexinV/PI method. As shown in FIG. 17, the application of FMD condition in presence of Bortezomib resulted protective on both BJ (FIG. 17 A) and 3T3-NIH (FIG. 17 B), being the mortality rate of cells treating with BTZ+FMD similar to that observed in the control.

[0162] In order to test the cytotoxicity of effective drug cocktail on normal cells, primary MEF were exposed to a mixture of romidepsin, belinostat and bortezomib according to the inventors' in vitro experimental design. As showed in FIG. 18, after 24 hours, the FMD reduced cell number by about 20% as compared to the control, while the rate of death cells was comparable between the two groups (control vs FMD). When treated with the drug cocktail in presence of control medium, the cell viability dramatically decreased (FIGS. 18, A & B), while the mortality rate increased (FIG. 18 C) and reached the value of 50% (FIG. 18 D).

[0163] Interestingly, the application of the FMD together with the drug cocktail exerted a protective effect, by improving the resistance of primary MEF cells to cytotoxicity. In fact, in this group, both the survival rate and mortality resembled that of starved group, being respectively about 77 and 9%.

[0164] In Vivo Studies

[0165] In in vivo experiments the inventors tested the efficacy of some selected drug (alone) and/or cocktail in combination with fasting regimen (STS, starvation).

[0166] Eight-week-old Rag2/c/ female mice were challenged intravenously via lateral tail veins with 1010.sup.6 MEC1 cells in 0.1 mL of saline through a 27-gauge needle as previously described.sup.40. 3 days later, mice were either fasted (STS, in presence of water) or fed ad libitum before drug treatments with BTZ alone, and/or BTZ+RTX (FIG. 19).

[0167] Mice were monitored regularly for general health and body weight was recorded daily. As shown in FIG. 20, animals from fasted groups showed a body weight reduction (lesser than about 16% of total body weight) according to 48 hr of STS. These changes were reversed on 24 hours of re-feeding.

[0168] At the end of experimental procedure, peripheral blood (PB), peritoneal exudates and organs [spleen, kidneys, liver, lungs, and femoral bone marrow (BM)] were collected and analyzed either for FACS or morphological analyses. For all experimental group, spleen weight was measured (FIG. 21). Interestingly, the macroscopic analysis of spleen showed an enlargement of this organ in all groups in which the drug therapy was given under ad lib condition, while in fasted groups (STS alone. STS+BTZ and ST+RTX+BTZ) the spleen weight was significantly lower (FIG. 21).

[0169] To examine the in vivo anti-CLL effects of STS regimen in combination with single drug and/or drug cocktail, BM, spleen, PB and peritoneal exudates were analyzed for the presence of specific chronic leukemia markers, such human CD19, human CD20 and human C45.

[0170] For FACS analysis, after blocking fragment crystallizable receptors for 10 minutes at room temperature to avoid nonspecific binding of antibodies, cells from PB, BM, peritoneal exudates, and spleen were stained with PE-Vio770 anti-human CD19 antibody. FITC anti-human CD20 and TRITC anti-human CD45 anti-human, respectively (MACS Miltenyi Biotec) and analyzed with BD FACSCANTO II flow cytometer. Flow cytometric studies confirmed the presence of MEC1 cells in BM, spleen, PB and peritoneal exudates (FIGS. 22, 23 and 24) in ad lib, STS, BTZ and in STS+BTZ groups. Fasting regimen alone reduced the presence of CLL tumor cells in BM, spleen and peritoneum, but not in the blood as compared with mice receiving vehicle alone (ad lib). Particularly, the treatment of BTZ in combination with STS potentiated the cytotoxic effect of the proteasome inhibitor drug and significantly decreases the expression of human CD19 (FIG. 22), human CD20 (FIG. 23) and human CD45 (FIG. 24) in the majority of analyzed tissues. The treatment with the drug cocktail obtained by combining BTZ and RTX significantly reduced the expression of CLL specific markers in all tissues (FIGS. 22, 23 and 24) but to a greater extent fasting combined with BTZ and RTX, reduced the presence of leukemic B-cell population in BM, spleen, PB and peritoneal exudate compared the other experimental groups. In particular, upon the treatment with BTZ+RTX in combination of STS, the presence of leukemic cells was almost undetectable in BM and spleen and ranged around 1-4% in peripheral blood and peritoneal exudates, depending on human CD marker (FIGS. 22, 23 and 24; compare BTZ+RTX vs BTZ+RTX+STS).

[0171] For morphological analysis, organs (BM, spleen, kidney, liver and lung) were formalin-fixed, paraffin-embedded, cut at 3-m-thick sections, and stained with hematoxylin and eosin. Histologic sections were evaluated in a double-blinded fashion. Histopatological evaluation of BM, spleen, kidney and liver confirmed that tumor cells substantially localized in all the tissues in ad lib, STS. BTZ and BTZ+STS groups, respectively (FIGS. 25, 26, 27 and 28). The examination of tumors in each examined organs from ad lib mice showed either a diffuse pattern (FIG. 25, BM) and/or focal, discrete aggregates (FIG. 26, spleen; FIG. 27, kidney and FIG. 28, liver) composed of medium-to-large lymphocytes, with clumped chromatin, and round and evident nucleoli. Metastases and cluster of infiltration were lesser expanse in the majority of organs from STS, BTZ and BTZ+STS animals. According to FACS screening, the treatment with the drug cocktail BTZ+RTX in +/STS regimen was significantly effective in killing tumor cells, as metastases, infiltration and tumor foci were not apparently detectable in BM, spleen, kidney and liver (FIGS. 25, 26, 27 and 28). For these mice groups, the morphology of analyzed organ was similar to the control (not injected=mice injected i.v. with MEC1).

[0172] Patient Study

[0173] One CLL male patient voluntarily underwent two FMD cycles (plant-based- and protein free diet). FMD consists in 4 days of low-calorie intake (50% of regular calorie intake on day 1, and 10% on days 2-4), with low protein and low sugar, plant-based formulation followed by a standard ad libitum diet for 10 days.sup.3435. At the end of the FMD cycles white blood cells (WBC) and absolute lymphocyte number (Abs Lymph) were measured as measures of CLL progression. As shown in FIG. 29, 2 cycles of the FMD decreased the levels of markers of CLL progression in agreement with the results described above with mouse and human CLL cells.

[0174] Discussion

[0175] The present invention identified novel and more effective treatments for CLL, based on the large body of evidence that has established the effect of the FMD as a potent treatment against tumors. The inventors have characterized well known CLL tumor cell lines (MEC-1, MEC-2 and L1210) in order to test the efficacy of the FMD as a CLL treatment alone and/or in combination with a variety of drugs. The inventors' first analysis focused either on MEC1 and MEC2 (two human CLL cell lines) or on L1210 (a mouse CLL cell line). The FMD alone had a remarkable effect in reducing CLL growth but the FMD was particularly effective in combination with several well-studied and clinically tested drugs. The highest synergic effect with FMD were the HDAC inhibitors (Romidepsin and Belinostat); Proteasome inhibitor (Bortezomib); cyclophosphamide and a chimeric monoclonal antibody targeted against the pan-B-cell marker CD20 (Rituximab, only for human CLL cell lines). The sensitization due to FMD depended also on drug concentration, since the exposure of L1210 cells to a high dose of the drug dramatically improved the growth inhibition effect and reduced the survival of CLL cells. These data led the inventors to test such cocktails in vitro. Very interestingly and promising, in the presence of the FMD the most effective drug mixtures were obtained by differently combining HDAC (Romidepsin and Belinostat) plus Proteasome inhibitors (Bortezomib)+anti-human CD20 (Rituximab, only for Human MEC1 and MEC2)+FMD. Then the cytotoxic effects of such drugs in normal cells in vitro were evaluated. The inventors' experiments showed that the exposure to FMD condition protect mouse embryonic fibroblasts and both normal BJ and 3T3-NIH fibroblasts from the toxic effects of drugs.

[0176] Results with human MEC and MEC2 CLL cells as well as those from a CLL patient who underwent 2 cycles of the FMD are consistent with the effects described above.

[0177] In the inventors' in vivo studies the inventors started to test the efficiency of single drugs and/or drug cocktail that in combination with low protein and low glucose levels resulted very effective in killing CLL cells in vitro. Thus, the inventors explored the benefit of the new proteasome inhibitor Bortezomib (BTZ) alone and together with another established single agent Rituximab (RTX) in combination with fasting regimen (STS, starvation). Bortezomib is the first-in-class of proteasome inhibitor approved in the United States and the European Union for the treatment to treat human malignancies (multiple myeloma, B cell non-Hodgkin's lymphoma) for patients who have received at least on prior therapy. The antineoplastic effect of BTZ likely involves several different potential mechanisms, including inhibition of cell-cycle progression, cell growth and surviving pathway, induction of apoptosis, inhibition of expression genes that control cellular adhesion, migration, and angiogenesis. Notably, BTZ induced apoptosis in cells that over express BCL2.sup.41. Rituximab (Rituxan) is a chimeric antibody directed against the CD20 antigen present on human B cells. The antibody is able to kill tumoral lymphocytes due to antibody-dependent cytotoxicity, induction of apoptosis, and complement activation. In the pivotal trial, RTX produced an overall response rate in relapsed and refractory indolent lymphomas of 50% when used as single agent.sup.42. Interestingly BTZ increases CD20 expression in rituximab-resistant cell lines in vitro.sup.43, thus BTZ and RTX (alone or in combination with chemotherapy) have addictive activity in treating follicular lymphoma and MCL.sup.44. However, these therapies often do not provide enough cyto-reductive power and adequate rate of response in relapsed setting. Moreover, BTZ+RTX regimen has an unexpectedly high incidence toxicity that represents a potential limiting factor with this combination.sup.45. The toxicities of BTZ+RTX regimen include hematologic and non-hematologic toxicity. The major hematologic toxicity is myelosuppression, including neutropenia, anemia, and thrombocytopenia. The major non-hematologic toxicities are nausea, fatigue, diarrhea, and peripheral sensory neuropathy.sup.45.

[0178] The inventors' in vivo experiments showed that the combination of BTZ+RTX was significantly stronger than the single agents in the treatment of chronic leukemia B (BTZ, either alone or in combination with STS). Interestingly and promising, the effectiveness of this drug cocktail appeared particularly potentiated in combination with STS, causing a significant reduction of CLL cells not only in target organs (bone marrow and spleen) but also in blood and peritoneal fluid. In vitro toxicity tests carried out on primary MEF and normal fibroblasts (Human BJ and murine 3T3-NIH) show that FMD exerts its protective effect against the drug cytotoxicity by reducing the mortality of normal healthy cells.

[0179] The results here presented demonstrate that BTZ+RTX+STS regimen offers new opportunity of therapy that can be adopted alone or integrated with conventional treatment for blood cancer, in particular CLL and other malignancies such as non-Hodgkin's lymphoma and multiple myeloma. Other preferred combinations include the ones describes in FIGS. 11 and 12.

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