Ketogenic Diet Promotes Epithelial Ovarian Cancer Progression and Alters Tumor Gene Expression in-vivo (104)

Objectives: The ketogenic diet (KD) is hypothesized to impact tumor progression indirectly through altering the immune system as well as directly at the cellular level. Our studies were designed to assess changes in tumor resident immune cells and tumor gene expression in relation to epithelial ovarian cancer (EOC) progression in KD-fed mice. Methods: ID8 EOC cells, syngeneic with C57Bl/6J mouse strain, transfected with luciferase (ID8-Luc), were injected and monitored for tumor development via imaging with an in vivo Imaging System (IVIS) intraperitoneal D-luciferin. Tumor-bearing mice were fed a KD (10% protein, 0% carbohydrates, 90% fat), high fat diet (HFD) (10% protein, 15% carbohydrates, 75% fat), or control diet (CD) (10% protein, 77% carbohydrates, and 13% fat) (n=10 mice per group). EOC tumor growth was monitored weekly, and tumor burden was determined based on total flux recorded in photons/second measured. At the endpoint, tumors were collected and processed for flow cytometry and RNAseq analysis. Single-cell dissociated tumors (Papain System) were stained with an immune targeted antibody panel and analyzed on the BD Cytek Aurora. RNA was isolated (Qiagen), and sequencing was performed. Statistical tests included analysis of variance (ANOVA), permutational multivariate analysis (PERMANOVA), linear regression, and Wilcoxon test; a p-value of <0.05 was considered statistically significant. Results: Throughout the study, KD-fed mice exhibited a statistically significant increase in tumor progression. We observed a 9.1-fold increase in tumor volume from baseline in the KD-fed group compared to HFD and CD-fed groups (9.1 vs 2.0 vs 3.1-fold, respectively, p<0.001). At the endpoint, tumor-associated macrophages (TAM) were significantly enriched and activated lymphoid cells (NK cells) were significantly diminished in the KD group (p<0.001). There was a trend toward increased M2:M1 polarization in KD-fed mice. However, there was no significant difference in Treg cells or activated CD8+ cells among diet groups. EOC tumors in KD-fed mice exhibited a significant decrease in differential gene expression on RNA seq compared to CD- and HFD-fed tumors, with no significant difference between CD- and HFD-fed groups at the gene expression level. Gene set enrichment analysis (GSEA) demonstrated that EOC tumors from KD-fed mice had enhanced angiogenesis, inflammatory response, and epithelial to mesenchymal transition (EMT) phenotype, as well as altered lipid metabolism. Specifically, an increase in lipid catalytic activity and catabolism and decrease in lipid synthesis were noted among KD-fed mice versus HFD-fed mice. Conclusions: KD induced tumor progression in our murine EOC model compared to HFD and CD. KD was associated with an increase in TAM and a decrease in activated NK cells consistent with a protumorigenic immune environment. KD-fed mice exhibited markedly increased alterations in angiogenesis, inflammation, and EMT pathways with enhanced lipid catabolic activity. Further testing of KD in human EOC cells is needed to clarify the in-vivo effect of KD on EOC growth.Fig. 1