PPARα Activation Can Help Prevent and Treat Non–Small Cell Lung Cancer

Non–small cell lung cancer (NSCLC) accounts for approximately 85% of all lung cancer cases and has a 5-year survival rate of only 15% (1). Early-stage NSCLC is potentially curable by surgery, but its long-term survival after resection is limited by local or distal recurrences. The best therapy available for inoperable and/or late-stage NSCLC is radiation with or without chemotherapy (2, 3). In addition, antiangiogenic therapy targeting VEGF prolongs survival in patients with lung cancer (4). However, the outcomes of targeting VEGF are dependent on cancer type and stage, and often result in the development of resistance (5), hypertension and proteinuria (6, 7), and death associated with primary or metastatic disease. Thus, there is the need for new, more effective, and safer antitumorigenic and/or antiangiogenic therapies.

The cytochrome P450 arachidonic acid epoxygenases (CYP2C) oxidize arachidonic acid to epoxyeicosatrienoic acids (EET). EETs stimulate hormonal signaling (8–10) and have antihypertensive and vasodilatory actions (11, 12). In addition, we and others characterized the EETs as proangiogenic lipids both in vitro and in vivo (13–15) and identified the murine Cyp2c44 as a proangiogenic epoxygenase (16). Disruption of the Cyp2c44 gene, or downregulation of its expression via activation of the PPARα, reduces endothelial cell function in vitro and primary tumor growth in vivo (17).

Like Cyp2c44, its functional homolog human CYP2C9 is expressed in endothelial cells and its downregulation reduces EET biosynthesis and endothelial cell function (17). Interestingly, CYP2C9 is upregulated in the vasculature of human NSCLC (17), making this epoxygenase an attractive target for antiangiogenic therapy.

PPARs regulate the transcription of genes involved in lipid and glucose homeostasis (18). Upon ligand binding, the three PPAR isotypes PPARα, -β/δ, and -γ form heterodimers with the retinoic acid receptor and, in the presence of specific coactivators, bind to response elements in the promoter region of their target genes. The PPARα ligands derivatives of fibric acid are used for the treatment of hyperlipidemia and their safety, tolerance, and minimal side effects are well documented (19, 20). In addition, the PPARα ligands bezafibrate and Wyeth-14,643 decrease in vivo hepatic Cyp2c expression and hepatic and plasma EET levels (16). Wyeth-14,643 decreases Cyp2c44 and CYP2C9 expression and EET biosynthesis in mouse and human endothelial cells (16, 17). PPARα ligands also exhibit pro- and antitumorigenic effects. In rodents, extended exposure to fibrates causes PPARα-mediated hepatocarcinoma (21–23), which is not observed in humans even after extended exposure to PPARα ligands (24). In contrast, PPARα ligands decrease intestinal polyp formation in ApcMin/+ mice, inhibit vascular smooth muscle hyperplasia, induce apoptosis, and prevent tumor cell invasion (25–27). We showed that Wyeth-14,643 inhibits primary growth of human NSCLC cells, its effects require a functional host PPARα gene, and are associated with PPARα-mediated reduction in endothelial Cyp2c expression and EET levels (16). Thus, PPARα acts as an antiangiogenic and antitumorigenic receptor.

A limitation of the primary model of human NSCLC cells showing beneficial effects of PPARα activation is that the tumors do not metastasize and do not recapitulate the steps of tumor progression in human NSCLC (16). In this study, we used the KRasLA2 mouse model of spontaneous NSCLC to analyze tumor initiation and growth (28), and a human orthotopic model of NSCLC to analyze tumor progression and metastasis (29). We show that treatment with selective PPARα ligands inhibits NSCLC primary and metastatic growth and that their beneficial effects are associated with downregulation of Cyp2c expression in tumor-associated vasculature and EET biosynthesis. This study, together with the fact that PPARα ligands are in clinical use as hypolipidemic drugs, suggests that they should be also safe and well-tolerated drugs for the prevention and treatment of NSCLC.

The EET analogs 2-(13-(3-pentylureido)tridec-8(Z)-enamido)succinic acid (EET analog 1) and N-isopropyl-N-(5-((2-pivalamidobenzo[d]thiazol-4-yl)oxy)pentyl)heptanamide (EET analog 2) were generated based on 14,15-EET. The labile epoxide characteristic of EETs was replaced by urea and amide bioisosteres, respectively (30). The carboxylate was replaced by bioisosteres and most of the olefins were removed to minimize auto-oxidation. EET analogs with these types of modifications have been described (31). These two EET analogs can ameliorate cisplatin nephrotoxicity and hypertension-mediated kidney injury in vivo (32, 33).

Pulmonary microvascular endothelial cells were freshly isolated from wild type (WT) and Cyp2c44-null (Cyp2c44KO) mice and cultured as described (17). The large T antigen/ras/Myc–transformed mouse fibroblast p60.5 cells, lung tumor cells from KrasLA2 mice, and the human NSCLC A549 cells transfected with pEGFP-N1 (GFP-A549) were previously generated (16, 28, 29). Cells were authenticated before use by CD31-positive staining, ability to form tumors in vivo, or GFP intensity. Cells were cultured for one month from freshly isolated organs or low-passage frozen stocks. For proliferation, cells were plated (5 × 10³/well; 96-well plate) in serum-free media with or without EETs (1 μmol/L), or the EET analogs 1 and 2 (0.125–1 μmol/L; ref. 34). In some experiments, cells were cultured in 2.5% fetal calf serum with or without different concentrations of Wyeth-14,643. Two days after, the medium was replaced with medium containing [³H]thymidine (1 μCi/well), the cells incubated for 48 hours, and proliferation was determined as described (16, 17). Two to three independent experiments were performed in quadruplicate.

Animal protocols were approved by the Vanderbilt University Institutional Animal Care and Use Committee. 129SvJ male (12 weeks old; n = 9) WT and Cyp2c44KO mice (generated as described in 17) were given two dorsal subcutaneous injections of syngeneic p60.5 cells (2 × 10⁵ in 200 μL PBS; ref. 17). Cyp2c44KO mice were left untreated or administered the EET analog 1 or 2 (10 mg/kg in drinking water) four days before tumor injection and throughout the duration of the experiment. The animals were sacrificed 2 weeks after cell injection and tumor volume and weight were evaluated. Tumor volumes were calculated using the formula: tumor volume (mm³) = [length (mm) × width (mm)²]/2 (35). The dose of EET analogs selected was chosen as it did not significantly enhance tumor volume in p60.5 tumor-bearing WT mice after 18 days of treatment.

Age- and gender-matched 129SvJ KrasLA2 heterozygotes (described in 36 and here referred to as KrasLA2) mice were divided into water-treated [and sacrificed at 1 month (group 1), 3 months (group 2), and 5 months (group 4) of age)] or Wyeth-14,643–treated (0.02% in drinking water; refs. 16, 17). Among the Wyeth-14,643–treated mice, one group received treatment from 1 to 3 months of age and then immediately sacrificed (group 3, early treatment). Another group received treatment from 3 to 5 months of age and then immediately sacrificed (group 5, late treatment), whereas a third group received treatment from 1 to 3 months of age and sacrificed at 5 months of age (group 6, treatment withdrawal). At sacrifice, the number of tumors visible on the lung surface was counted. Tumors were divided into three groups: 0 to 2 mm, 2 to 5 mm, and >5 mm tumor diameter. Lungs containing tumors were fixed in 4% paraformaldehyde or frozen in ornithine optimum cutting temperature and processed for histology or immunofluorescence. Livers and plasma were collected at sacrifice for evaluation of liver/body weight ratio and analysis of circulating levels of EETs.

Human GFP-A549 cells (1 × 10⁶ in 20 μL PBS containing 20 μL Matrigel; BD Pharmingen) were injected into the left lung parenchyma of 12 weeks old athymic nude mice as described (29). Mice were then divided into groups of water-treated and sacrificed 5 weeks after injection (group a) or Wyeth-14,643–treated (0.02% in the drinking water) or bezafibrate (0.3% in drinking water). Treated mice were divided into 3 groups. One group was treated immediately after cell injection for 5 weeks and then sacrificed (group b, prevention group). Another group was treated immediately after cell injection for 2 weeks and then sacrificed 3 weeks later (group c, treatment withdraw). A third group received treatment for 3 weeks starting 2 weeks after injection and then immediately sacrificed (group d, late treatment). Two weeks after tumor cell injection was chosen as at this time point GFP-A549 cells form only visible primary (left lung) but not metastatic (right lung and liver) tumors. All mice were sacrificed 5 weeks after tumor cell injection as at this time point GFP-A549 cells generate both primary and metastatic tumors (29).

At sacrifice, organs (left and right lungs, liver) were removed, placed under a fluorescence microscope, and the number of tumors on the surface and within the organs was counted. Images of GFP-positive tumors were recorded and processed with the Scion Image software as described (29). Tumor area was expressed as a percentage of the area occupied by GFP-positive structures per microscopic field. Organs containing tumors were fixed in 4% paraformaldehyde and processed for histology or immunohistochemistry. Liver and plasma were collected for evaluation of liver/body weight ratio and analysis of circulating levels of EETs.

Mouse plasma was obtained from blood collected in EDTA. Plasma EETs and dihydroxyeicosatrienoic acids (DHET) were extracted in the presence of equimolar mixtures of ²H₃-labeled EETs and ²H₈-labeled DHETs (5 ng each). After saponification and purification (37), EETs and DHETS were quantified by ultra high pressure liquid chromatography/tandem mass spectrometry and the isotope ratio method (38).

Microsomal fractions from livers or A549 cells were isolated by differential centrifugation as described (39). Microsomal proteins (20 μg/well) were resolved by SDS-PAGE and transferred to Immobilon-P membranes (Millipore), and the membranes were incubated with anti-Cyp2c44 (17) or rabbit anti-human CYP2C9 (Abcam) antibodies. Proteins were visualized using peroxidase-conjugated anti-rabbit antibodies and an ECL kit (Pierce). Membranes were stained with Ponceau S Stain to verify equal loading.

Frozen sections (5 μm) of lungs from KrasLA mice, or tumors grown in WT and Cyp2c44KO mice, were stained with anti-mouse CD31 antibodies (1:400, BD Pharmingen) with or without anti-mouse Cyp2c44 antibodies (1:1,000) followed by the appropriate fluorescence-labeled secondary antibodies (1:200; Jackson ImmunoResearch). Vascularization, expressed as percentage of area occupied by CD31-positive structures/microscopic field, was evaluated using the Scion Imaging Software (16), using 5 to 6 images per tumor and 5 tumors per genotype.

Total RNAs were isolated from GFP-A549 cells or human liver with the TRIzol Reagent (Invitrogen) and 2 μg of RNA were reverse-transcribed using SuperScript III (Invitrogen) and Oligo (dT)₂₀. RNA incubated without reverse transcriptase (RT)-PCR SuperScript III was used as negative control. RT-PCR was performed using primers for human β-actin (5′-CAGGATGCAGAAGGAGATCAC-3′, 5′-TGTCAAGAAAGGGTGTAACGC-3′), PPARα (5′-TGGTAGCGTATGGAAATGGG-3′, 5′-GTGGAGTCTGAGCACATGTAC-3′), and CYP2C9 (5′-TTGCTTCTCCTTTCACTCTGG-3′, 5′-TCCTTCACTGCTTCATATCCATG-3′) using the following program: 94°C/3 minutes; 40 cycles of 94°C/1 minute, 57°C/30 seconds, 72°C/1 minute; 72°C/10 minutes.

The Student t test was used for comparisons between two groups (unpaired, 2-tailed), and analysis of variance using Sigma-Stat software was used to analyze statistical differences between multiple groups. P ≤ 0.05 was considered statistically significant.

Disruption of Cyp2c44, the gene that codes for the murine Cyp2c44 and the major EET generating epoxygenase, leads to decreased endothelial EET biosynthesis and primary tumor growth and vascularization (17). To determine whether the decreased tumorigenesis in the Cyp2c44KO mice was mainly due to reduced production and levels of EETs, we tested two synthetic EET functional analogs, namely EET analogs 1 and 2 (see Methods for details). Cyp2c44KO mice received water or one of the two EET analogs. Four days later, mice were subcutaneously injected with p60.5 cells and the EET analog treatment continued for 2 weeks. Mice were then sacrificed and tumor number, weight, and volume were evaluated. As reported (17), tumors in Cyp2c44KO mice were smaller and paler compared with those in untreated WT mice (Fig. 1A–C). In contrast, EET analog–treated Cyp2c44KO mice grew bigger and more vascularized tumors when compared with untreated Cyp2c44KO mice, and their size and weight were similar to those in untreated WT mice (Fig. 1A–C). In contrast to treated Cyp2c44KO mice, EET analog–treated WT mice did not grow significantly bigger p60.5-derived tumors when compared with untreated WT mice (not shown).

As Cyp2c44KO mice show decreased tumor vascularization (17), tumor sections were stained with anti-CD31 antibody. Tumors in Cyp2c44KO mice were significantly less vascularized than those in WT mice, whereas tumors from EET analog–treated Cyp2c44KO mice showed similar levels of vascularization as tumors from untreated WT mice (Fig. 1D and E).

We next determined whether the increased tumorigenesis and angiogenesis in EET analog–treated mice was because the analogs stimulated proliferation of endothelial and/or p60.5 cells. At baseline, Cyp2c44KO endothelial cells grew significantly less than WT cells, and their growth was significantly stimulated by the two EET analogs in a dose-dependent manner (Fig. 1F). In contrast, both EET analogs failed to promote p60.5 cell proliferation (Supplementary Fig. S1A).

Thus, EET analogs 1 and 2, at a dose that does not significantly affect tumor growth in WT mice, potentiate primary tumor growth in Cyp2c44KO mice by stimulating endothelial cell proliferation in vitro and angiogenesis in vivo.

The PPARα ligand Wyeth-14,643 downregulates endothelial Cyp2c44 expression and EET biosynthesis in a mouse model of subcutaneously injected NSCLC A549 tumor cells, which leads to reduced primary tumor growth and vascularization (16). As this mouse model is based on the subcutaneous injection of tumor cells, it fails to recapitulate the steps of NSCLC development seen in humans. To define the role of EETs and the effects of PPARα ligands to NSCLC initiation and growth, we used the KRasLA2 mouse model of spontaneous primary NSCLC (36). As described in Fig. 2A, three groups of mice received vehicle (water) and were sacrificed at 1 month (group 1), 3 months (group 2), and 5 months (group 4) of age. Three other groups received Wyeth-14,643. Group 3 (early treatment) received treatment from 1 to 3 months of age and then sacrificed; group 5 (late treatment) received treatment from 3 to 5 months of age and then sacrificed; and group 6 (treatment withdrawal) received treatment from 1 to 3 months of age and sacrificed at 5 months of age.

As PPARα activation leads to liver hypertrophy in rodents (16), we analyzed liver weight of untreated and Wyeth-14,643–treated mice. Significant liver hypertrophy was observed in mice in groups 3 and 5. Interestingly, mice in group 6 (treatment withdrawal) showed a liver/body weight ratio comparable with that of mice receiving water (Fig. 2B). As Wyeth-16,463 reduces hepatic Cyp2c44 expression and plasma EETs (16), we analyzed these parameters in KrasLA2 mice. Both early and late Wyeth-14,643 administration (groups 3 and 5) resulted in marked reductions in plasma EET levels and hepatic Cyp2c44 expression (Fig. 2C and D). Interestingly, mice in the Wyeth-14,643 withdrawal protocol (group 6) showed similar levels of plasma EETs and hepatic Cyp2c44 to those of untreated mice (Fig. 2C and D). Thus, the effects of Wyeth-14,643 on liver hypertrophy, hepatic Cyp2c44 expression, and plasma EET levels are reversible.

We next analyzed whether early Wyeth-14,643 treatment reduced the number and size of lung tumors. One-month-old untreated mice (group 1) presented with a few small tumors on their lung surface (Fig. 3A–D). The number and size of lung tumors increased significantly when mice reached 3 months of age (group 2) (Fig. 3A–D). By contrast, 3-month-old mice treated with Wyeth-14,643 for 2 months starting at 1 month of age (group 3) showed lung tumor lesions and numbers comparable with those of group 1 (Fig. 3A–C). Wyeth-14,643 treatment also decreased tumor size in this group (Fig. 3D).

We next evaluated the beneficial effects of late treatment and/or the long-lasting effects of Wyeth-14,643. Five-month-old untreated mice (group 4) were presented with the highest number and biggest tumors on their lung surface (Fig. 3A–D). Tumors in groups 5 and 6 were significantly fewer and smaller when compared with those of group 4 (Fig. 3A–D). Thus, Wyeth-14,643 reduces the number and size of primary lung tumors, and its beneficial antitumorigenic effects are long lasting and independent of treatment time.

Activation of PPARα decreases endothelial cell function by downregulating Cyp2c expression and EET biosynthesis (16). Therefore, we evaluated vascularization in lung tumors from the various groups of KrasLA2 mice. A significant decrease in vascularization was evident in tumors of KrasLA2-treated mice compared with untreated mice and this effect was independent of the length of treatment (Fig. 4A and B). Double immunostaining with anti-CD31 and anti-Cyp2c44 antibodies revealed that in the untreated mice, Cyp2c44 was expressed in the endothelium and tumor tissue, whereas in the tumors grown in Wyeth-14,643–treated mice, Cyp2c44 expression was restricted mostly to tumor cells (Fig. 4C and D). Because Wyeth-14,643 does not affect the in vitro proliferation of lung tumor cells from KrasLA2 mice (Supplementary Fig. S1B), we concluded that Wyeth-14,643 only affects endothelial Cyp2c44 expression with no measurable effects on the proliferation of KrasLA2 lung tumor cells.

Tumors in the KRasLA2 mice rarely metastasize, thus making the analysis of interventional therapy in lung cancer progression impossible to perform. To determine whether activation of PPARα is beneficial in cancer progression, we used a lung orthotopic model in which human NSCLC A549 cells are injected directly into the lung parenchyma of immunodeficient mice (29). Upon injection into the primary site (left lung), primary tumors form and metastasize to secondary sites (right lung and liver; ref. 29). We used NSCLC A549 transfected with GFP (GFP-A549 cells) because (i) they metastasize within 5 weeks of injection (29); (ii) they express PPARα, but lack CYP2C9, the functional homolog of Cyp2c44 (Supplementary Fig. S2A and S2B); (iii) they do not produce EETs (Supplementary Fig. S2C); and (iv) their growth is not affected by Wyeth-14,643 (Supplementary Fig. S2D). Thus, in contrast to endothelial cells, PPARα ligands do not affect A549 cell growth.

As described in Fig. 5A, injected mice were divided into one control group (water) and sacrificed 5 weeks after tumor cell injection (group a), or three Wyeth-14,643–treated groups. Group b (prevention group) was treated for 5 weeks immediately after tumor cell injection and then sacrificed; group c (treatment withdraw) was treated for 2 weeks immediately after tumor cell injection and sacrificed after 5 weeks; and group d (late treatment) was treated for 3 weeks starting 2 weeks after tumor cell injection and then sacrificed.

Analysis of liver hypertrophy revealed that although Wyeth-14,643 increased liver/body weight ratio in groups b and d, its effects were no longer evident when the ligand was withdrawn after 2 weeks treatment (group c; Fig. 5B). In contrast, plasma EET levels in Wyeth-14,643–treated mice remained significantly lower compared with untreated mice regardless of the length and time of treatment (Fig. 5C). The number and size of primary (left lung) and metastatic (right lung and liver) GFP-A549–derived tumors were significantly reduced in Wyeth-14,643–treated mice and these effects were independent of the time of treatment initiation or its duration (Figs. 6 and 7). Thus, activation of the host PPARα with Wyeth-14,643 reduces both primary and metastatic growth of human tumor cells.

To explore the generality and potential clinical relevance of the above results, we performed orthotopic models of NSCLC using bezafibrate, a PPARα ligand used clinically as a hypolipidemic drug with limited toxicity and excellent tolerance (40). Early and late treatment with bezafibrate decreased the numbers of primary and metastatic GFP-A549-derived lung tumors and, as with Wyeth-14,643, these effects were accompanied by liver hypertrophy and decreased plasma EET levels (Supplementary Fig. S3A–S3F). Thus, bezafibrate inhibits lung tumor progression irrespective of whether it is administered at early and/or late stages of cancer progression.

The goal of this study was to determine whether activation of PPARα plays a beneficial role in NSCLC progression, based on the findings that PPARα ligands reduce primary growth of subcutaneously injected human NSCLC (16) and are safely used clinically for the treatment of dyslipidemia (40). We show using two models of NSCLC that PPARα ligands inhibit both primary and metastatic lung cancer growth, and these effects are independent of the time of treatment (before or after onset of primary lesions) or whether the drug is withdrawn. We further show that the antitumorigenic and antiangiogenic activity of PPARα ligands reside in their ability to downregulate endothelial cell Cyp2c expression and EET biosynthesis. Taken together, these results suggest the PPARα/Cyp2c axis is an attractive target for treating NSCLC.

PPARs regulate different cellular functions including proliferation, thus making PPAR agonists promising drugs for the treatment of cancer (41). Published data suggest a beneficial role for PPARγ ligands in lung cancer (42). PPARγ is upregulated in human lung cancer (43) and activation of PPARγ by troglitazone inhibits lung cancer cell growth (44). Thiazolidinediones, a group of PPARγ activating drugs, are associated with a lower risk of developing lung cancer (45), prevent smoke-induced lung cancer in mice, and together with glucocorticoids prevent carcinogen-induced lung cancer in rodents (46, 47). In contrast to these findings, expression of PPARγ in multidrug-resistant NSCLC cells protects them from cytokine-mediated mitoinhibition (48) and the PPARγ ligand pioglitazone increases the rate of lung cancer metastasis by promoting recruitment of anti-inflammatory macrophages in mice (49). Finally, the observation that some of the effects of PPARγ ligands do not require the expression of this nuclear receptor (50) makes PPARγ an ambiguous target for the treatment of NSCLC.

Unlike PPARγ, the significance of PPARα ligands to lung cancer development and progression has received less attention. Fenofibrate and Wyeth-14,643 inhibit A549 cell proliferation in vitro, suggesting that PPARα has antitumorigenic activity (51). However, these effects were evident only when the ligands were used at high concentration questioning PPARα-dependent versus cytotoxic effects. The in vivo antitumorigenic properties of Wyeth-14,643 and fenofibrate have been reported (16, 52), and we showed that they are PPARα dependent and are the result of reduced endothelial cell proliferation and tumor vascularization (16). The beneficial effects of PPARα ligands seem to reside in their ability to promote the generation of antiangiogenic factors (52), or to decrease endothelial Cyp2c44 expression and EET biosynthesis (16). The finding that Cyp2c44KO mice show decreased tumor growth and vascularization, which are no further reduced by Wyeth-14,643 treatment (17), points to the Cyp2c44 as a protumorigenic gene and suggests that reduction in Cyp2c44 expression is a major mechanism responsible for the beneficial antitumorigenic effects of PPARα ligands. Finally, the present finding that when used at concentrations known to inhibit endothelial cell growth, Wyeth-14,643 failed to alter the growth of human and mouse tumor cells, indicates that its antitumorigenic properties are primarily endothelial and not tumor cell mediated.

The finding that synthetic EET functional analogs promote tumor growth in Cyp2c44KO mice and stimulate tumor angiogenesis and growth to levels comparable with WT mice supports a central role for epoxygenases and their EET metabolites in tumorigenesis and angiogenesis. Several mechanisms have been proposed for the proangiogenic action of EETs (53), including potentiation of the VEGF-activated signal transduction cascade. In this context, EETs induce VEGF synthesis (54); VEGF promotes CYP2C expression and EET biosynthesis (55); and disruption of the Cyp2c44 gene (17) and/or chemical inhibition of epoxygenase activity (56) prevent VEGF-mediated endothelial cell function.

Tumor metastasis is a serious clinical challenge due to limited treatment strategies, severe treatment-associated side effects, and negative outcomes. The two models of NSCLC used in this study show that PPARα-mediated downregulation of endothelial Cyp2c epoxygenase expression and EET biosynthesis might be viewed as a beneficial and safe strategy for the prevention and treatment of NSCLC. Consistent with a role for the endothelial Cyp2c/EET axis in tumor growth and metastasis, mice expressing the human CYP2C8 in the endothelium develop faster and bigger primary and metastatic tumors compared with WT mice (57). Moreover, EET administration promotes exit from tumor dormancy and stimulates metastasis by enhancing tumor-associated angiogenesis (57).

Our finding that Wyeth-14,643 reduces primary and metastatic NSCLC growth whether administered before or after the onset of primary growth, and its antimetastatic effects persisted for at least three weeks after cessation of treatment clearly identifies new avenues for cancer treatment and management. The potential clinical usefulness of these results is further highlighted by the demonstration that bezafibrate, a safe and well-tolerated drug for the treatment of dyslipidemia (40), inhibits primary and metastatic NSCLC tumor growth whether it is administered at early and/or late stages of lung cancer development. In addition to PPARα, bezafibrate can also target PPARβ/δ and PPARγ. Interestingly, activation of PPARβ/δ and PPARγ in lung cancer cells inhibits their proliferation (44, 58). Thus, bezafibrate may be beneficial for the treatment of lung cancer because it can target both tumor and endothelial cells and it does not have the severe side effects often associated with classic antitumorigenic and/or antiangiogenic therapies (5–7).

In conclusion, in this study we identified two different, yet interlinked participants to the biology of lung tumor progression, namely Cyp2c epoxygenases and PPARα. We propose that, in addition to its well-documented role in the metabolism of carcinogens and anticancer drugs (59), cytochrome P450 is a key participant in the development and progression of lung cancer and a potentially valuable target for anticancer drug development. Furthermore, as PPARα ligands are used clinically as effective and safe hypolipidemic drugs (19, 20), our study could set the basis for future studies designed to validate in patients the usefulness of PPARα ligands as new, safer, and well-tolerated antiangiogenic and antitumorigenic agents. Targeting PPARα, endothelial Cyp2c epoxygenase, and EETs with new drugs, designed to interact with these targets either individually or in combination, could provide new, potent, and effective tools for the treatment of cancer, including lung cancer.

No potential conflicts of interest were disclosed.

Conception and design: N. Skrypnyk, R. Zent, J.H. Capdevila, A. Pozzi

Development of methodology: X. Chen, S. Wei, R. Zent, J.H. Capdevila

Acquisition of data (provided animals, acquired and managed patients, provided facilities, etc.): N. Skrypnyk, X. Chen, W. Hu, Y. Su, S. Mont, S. Yang, M. Gangadhariah, S. Wei, J.H. Capdevila

Analysis and interpretation of data (e.g., statistical analysis, biostatistics, computational analysis): N. Skrypnyk, X. Chen, S. Mont, S. Yang, M. Gangadhariah, J.H. Capdevila, A. Pozzi

Writing, review, and/or revision of the manuscript: N. Skrypnyk, X. Chen, J.R. Falck, R. Zent, J.H. Capdevila, A. Pozzi

Administrative, technical, or material support (i.e., reporting or organizing data, constructing databases): N. Skrypnyk, X. Chen, J.L. Jat, A. Pozzi

Study supervision: A. Pozzi

This work was supported by the VA Merit Review 1I01BX002025 (A. Pozzi) and 1I01BX002196 (to R. Zent); the NIH grants R01-CA162433, R01-DK095761 (A. Pozzi), RO1-DK083187, RO1-DK075594, R01-DK383069221 (R. Zent); P01-DK38226 (A. Pozzi, J.R. Falck, and J.H. Capdevila) and NCI SPORE in Lung Cancer 5P50 CA-090949 (Lung Cancer Pilot Project to A. Pozzi); and the Vanderbilt University Mass Spectrometry Center, supported in part by Cancer Center Grant CA-68485.

The costs of publication of this article were defrayed in part by the payment of page charges. This article must therefore be hereby marked advertisement in accordance with 18 U.S.C. Section 1734 solely to indicate this fact.