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Mol Biol Rep

DOI 10.1007/s11033-015-3857-y


Introduction to the molecular basis of cancer metabolism

and the Warburg effect
Darleen C. Ngo • Katherine Ververis •
Stephanie M. Tortorella • Tom C. Karagiannis

Ó Springer Science+Business Media Dordrecht 2015

Abstract In differentiated normal cells, the conventional emerging molecular aspects of cancer metabolism and the
route of glucose metabolism involves glycolysis, followed Warburg effect. Aspects of the Warburg effect are analyzed
by the citric acid cycle and electron transport chain to in the context of the established hallmarks of cancer in-
generate usable energy in the form of adenosine triphos- cluding the role of oncogenes and tumor suppressor genes.
phate (ATP). This occurs in the presence of oxygen. In
hypoxic conditions, normal cells undergo anaerobic gly- Keywords Warburg effect  Cancer metabolism 
colysis to yield significantly less energy producing lactate Glucose metabolism  Glycolysis  Oncogene
as a product. As first highlighted in the 1920s by Otto
Warburg, the metabolism exhibited by tumor cells involves
an increased rate of aerobic glycolysis, known as the Physiological metabolic pathways
Warburg effect. In aerobic glycolysis, pyruvate molecules
yielded from glycolysis are converted into fewer molecules In normal differentiated cells, the metabolism of glucose
of ATP even in the presence of oxygen. Evidence indicates begins with glycolysis [1] (Fig. 1). After entering a cell via
that the reasons as to why tumor cells undergo aerobic glucose transporters on the plasma membrane, glucose is
glycolysis include: (1) the shift in priority to accumulate converted to various intermediates mediated via a multi-
biomass rather than energy production, (2) the evasion of enzyme process in the cytosol to ultimately yield two
apoptosis as fewer reactive oxygen species are released by molecules of pyruvate, two molecules of adenosine
the mitochondria and (3) the production of lactate to further triphosphate (ATP) and two molecules of reduced nicoti-
fuel growth of tumors. In this mini-review we discuss namide adenine dinucleotide (NADH) [2]. The two mole-
cules of pyruvate are subsequently converted to acetyl CoA
mediated by pyruvate dehydrogenase [2]. The mitochon-
D. C. Ngo  K. Ververis  T. C. Karagiannis (&)
Epigenomic Medicine, The Alfred Medical Research and drial phase begins when acetyl CoA combines with ox-
Education Precinct, Baker IDI Heart and Diabetes Institute, 75 aloacetate entering the citric acid cycle, in which three
Commercial Road, Melbourne, VIC, Australia molecules of NADH, one molecule of guanosine triphos-
phate (GTP) and one molecule of reduced flavin adenine
D. C. Ngo  K. Ververis  T. C. Karagiannis dinucleotide (FADH2) are created by a series of enzymatic
Department of Pathology, The University of Melbourne, processes in preparation for oxidative phosphorylation [3].
Parkville, VIC, Australia High-energy molecules NADH and FADH2 are reduced by
the inner mitochondrial membrane complexes to create a
S. M. Tortorella
Melbourne School of Land and Environment, Department of proton gradient in the intermembrane space of the mito-
Agriculture and Food Systems, The University of Melbourne, chondria [4, 5]. As protons are continuously pumped out in
Parkville, VIC, Australia the intermembrane space, the last step occurs as oxygen is
the final acceptor of electrons driving ATP synthase to be
S. M. Tortorella
Department of Chemical and Biomolecular Engineering, The activated. This forces protons back into the mitochondrial
University of Melbourne, Parkville, VIC, Australia matrix against a concentration gradient creating energy in

Mol Biol Rep

Fig. 1 The glycolytic pathway, citric acid cycle, and electron and a high proton concentration accumulates in the inner membrane
transport chain. Glycolysis is a ten step multi-enzymatic pathway in space of the mitochondria. Direction of electron flow is highlighted
which glucose is converted to pyruvate. Enzymes are shown in italics, through the mitochondrial complexes. Aerobic Glycolysis in Tumour
and boxes indicate Hypoxia Inducible Factor targets. Conversion of Cells. Aerobic glycolysis in tumour cells occurs in the presence of
pyruvate into acetyl coA allows the entry into the Citric Acid Cycle to oxygen. The conversion of pyruvate to ATP and lactate is facilitated
generate NADH and FADH2. This process is followed by the by lactate dehydrogenase
Electron Transport Chain in which NADH and FADH2 are oxidised

the form of ATP [4, 5]. Typically, 30–34 molecules of ATP (Fig. 1) [1, 7, 9]. Known as the Warburg effect, cancer
are produced from one molecule of glucose and this pro- metabolism by aerobic glycolysis has emerged as a topic of
cess occurs in the presence of oxygen [2, 6]. When oxygen intense research interest [10]. In short, the paradigm sug-
levels are low or absent, cells utilize anaerobic respiration gests that even in the presence of oxygen, cancer cells me-
to metabolize glucose [6, 7]. Following glycolysis, the two tabolize glucose into pyruvate via glycolysis, which is
molecules of pyruvate are converted to lactate and four followed by the conversion of pyruvate to lactate and four
molecules of ATP via lactate dehydrogenase [7, 8]. molecules of ATP [2, 7, 11]. It was noted that the proportion
of pyruvate converted into acetyl CoA prior to entering the
citric acid cycle, was significantly reduced and therefore
The Warburg Effect and cancer metabolism entry of acetyl CoA into citric acid cycle was decreased [2].
As a result, high-energy molecules NADH and FADH2 are
As first indicated by Otto Warburg, cancer cells follow a yielded in low concentrations from the citric acid cycle
different metabolic path known as aerobic glycolysis consequently decreasing the proportion of ATP produced

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during oxidative phosphorylation [2]. A number of hy- include: phosphatases, G-protein inhibitors, ubiquitin li-
potheses have been suggested to answer the question: Why gase, dehydrogenases as well as genes encoding DNA repair
do cancer cells metabolize glucose via aerobic glycolysis? and cell cycle checkpoint proteins [15]. A classical example
An important aspect is the generation of biomass to sustain of an effective tumor suppressor gene is p53 [18]. This
the proliferative capacity of the rapidly dividing cells [12]. transcription factor is responsible for arresting the cell cycle
There is also evidence suggesting that due to the Warburg to allow for the DNA repair machinery to perform its
effect and the production of lactate cancer cells possess a function to curtail the accumulation of mutations that could
selective advantage over normal cells in their microenvi- potentially lead to tumorigenesis [19]. Failure to repair
ronment [2]. It has also been shown that lactate is a key cellular damage may result in the initiation of apoptosis
driver of angiogenesis and is critical for the development mediated by p53 [20]. Inactivation or reduced p53 activity is
and growth of cancer cells [13]. Studies have shown that observed in the majority of cancers [21]. In general, p53
oncogenes and tumor suppressor genes play important roles inactivation allows cancer cells, even those with accumu-
in the switch to aerobic glycolysis in cancer cells and lated damage, to continue to proliferate, increasing the
molecular aspects are discussed below [13]. likelihood of carcinogenic accumulation of mutations.
Another tumor suppressor, the retinoblastoma protein (RB)
has an important role in the cell cycle, regulating prolif-
The role of oncogenes and tumor suppressor genes eration [22]. RB controls the entry into the S phase of the
in the Warburg effect cell cycle by binding and interacting with the transcription
factor, E2F [23, 24]. In the presence of growth stimuli in the
The dysregulation of oncogenes and tumor suppressor genes form of a mitogen or growth factor, RB is phosphorylated
are key components of carcinogenesis [13]. Activation of and therefore inactivated, releasing E2F – triggering the
oncogenes, typically as a result of mutation can ultimately entry into S phase of the cell cycle [25]. Hence, uncontrolled
lead to uncontrolled proliferation of cells leading to carcino- regulation of mitogen release in cancer will ultimately prime
genesis [2, 12]. Similarly, the inactivation of tumor suppressor cells to constitutively enter S phase causing increased pro-
genes can result in uncontrolled cell growth [12, 14]. liferation [26]. This defiance of cancer cells in response to
Oncogenes include growth factors (for example, insulin- growth and anti-growth signals are among the fundamental
like growth factor, IGF-1; epidermal growth factor, EGF; features that form part of the hallmarks of cancer [27, 28].
Her-2), receptor tyrosine kinases such as epidermal growth In this context, the complex relationship between the
factor receptor (EGFR), cytoplasmic tyrosine kinases Warburg effect and formation of reactive oxygen species
(proto-oncogene c-Src (Src), spleen tyrosine kinase (Syk), (ROS) is interesting. ROS is produced in various sites within
Abelson murine leukemia viral oncogene (Abl)), hydrolyse a cell, including the mitochondria via the electron transport
guanosine triphosphate enzymes (GTPases, Ras) and tran- chain, the endoplasmic reticulum through the Ero1-DPI
scription factors such as c-Myc (Myc) [13, 15]. As an ex- oxidative folding system and cell membrane bound nicoti-
ample, a well established event in carcinogenesis is aberrant namide adenine dinucleotide phosphate oxidases (NOX)
activation of Ras which results in continuous activity of complexes [29]. According to Li et al., ROS are considered
signal transduction pathways that ultimately control the cell to be versatile signaling molecules, which have the ability to
cycle, survival and migration in tumor cells [15]. Further, regulate cellular activities, ultimately influencing whether a
the interaction between the catalytic domain of phos- cell survives or undergoes programmed cell death [30].
phatidylinositol-3 kinase (PI3K) and Ras has been shown to Numerous studies have shown that the accumulation of ROS
activate protein kinase B (Akt), a serine/threonine kinase, to has the potential to cause mutations via various cellular
promote cell proliferation, avoid apoptosis as well as to pathways including: ATG4–ATG8/LC3, Beclin-1, phos-
promote aerobic glycolysis and glucose dependence [15, phatase and tensin homolog (PTEN), p53, phosphotidyl
16]. Myc, also over-expressed in a number of malignancies, inositol 3 kinase (PI3K–Akt–mTOR) and MAPK signaling
combined with hypoxia-inducible factor 1 (HIF-1) has the [31]. Moreover, emerging research into the role of the tu-
potential to upregulate glucose transporters, glycolytic en- mour microenvironment, which involves the release of
zymes, lactate dehydrogenase and pyruvate dehydrogenase ROS, appears to also influence the Warburg effect [32].
lipoamide kinase isozyme 1 (PDK1) to enhance aerobic
glycolysis in cancer cells [10, 17].
Similarly, the down-regulation or inactivation of tumor The tumor microenvironment and its role in cancer
suppressor genes has been shown to be important in cancer metabolism
metabolism and the Warburg effect. Under normal physio-
logical conditions, tumor suppressor genes act to regulate The tumour microenvironment consists of various com-
metabolic pathways. Classes of tumor suppressor genes ponents including: cancer associated fibroblasts (CAFs),

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inflammatory cells, signalling molecules, endothelial cells, to various signalling molecules under the control oncoge-
blood vessels, stroma and the extracellular (ECM) matrix all nes and tumour suppressor genes is important in the de-
of which have been implicated in aberrant cancer metabo- velopment of potential drug therapies. The observations of
lism [33, 34]. For example, fibroblasts are particularly im- Otto Warburg and the renaissance of the field have created
portant, facilitating the structural and functional properties new opportunities for drug development; interventions
of the extracellular matrix [35]. Activated cytokines and which may modulate the activity of key enzymes in cel-
chemokines recruit fibroblasts to the site of injury and fa- lular metabolism or modify the tumour microenvironment
cilitate wound healing in particular, tissue remodelling and are expected to emerge. To date, therapeutic agents tar-
differentiation into myofibroblasts [35, 36]. Myofibroblasts geting metabolism, in particular the Warburg effect in
differ from their quiescent fibroblast form such that myofi- cancer, have been limited, predominantly due to lack of
broblasts express a-smooth muscle actin (a-SMA), which is specificity. In looking forward, perhaps combinations of
needed to generate force in order to complete ECM and metabolic regulators and conventional chemotherapeutic
wound contraction [37]. Once the wound healing process agents to target different aspects in malignancy may prove
has completed, myofibroblasts undergo nemosis, a spe- to be beneficial.
cialised programmed cell-death followed by degradation by
granulation tissue [38]. Fibrosis on the other hand deviates Acknowledgments TCK is supported by an Australian Research
Council Future Fellowship and the Epigenomic Medicine Laboratory
from this response by prolonging fibrous tissue deposition is supported by McCord Research. Supported in part by the Victorian
leading to mass accumulation of ECM. These concepts are Government’s Operational Infrastructure Support Program.
related to the hypothesis that tumors are essentially wounds
that do not heal [39].This leads to the idea that CAFs share
similar properties to myofibroblasts, where both express a-
SMA in its activated form. However unlike myofibroblasts,
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