Dissecting the Role of Autophagy-Related Proteins in Cancer Metabolism and Plasticity

Modulation of autophagy as an anticancer strategy has been widely studied and evaluated in several cell models. However, little attention has been paid to the metabolic changes that occur in a cancer cell when autophagy is inhibited or induced. In this review, we describe how the expression and regulation of various autophagy-related (ATGs) genes and proteins are associated with cancer progression and cancer plasticity. We present a comprehensive review of how deregulation of ATGs affects cancer cell metabolism, where inhibition of autophagy is mainly reflected in the enhancement of the Warburg effect. The importance of metabolic changes, which largely depend on the cancer type and form part of a cancer cell’s escape strategy after autophagy modulation, is emphasized. Consequently, pharmacological strategies based on a dual inhibition of metabolic and autophagy pathways emerged and are reviewed critically here.

Autophagy is known to be involved in the pathophysiology of many human diseases, including neurodegenerative [8], cardiovascular [9,10] and autoimmune [11,12] diseases and cancer [13].To understand the mechanisms of its regulation in mammalian cells, various modulators of autophagy, both activators and inhibitors, were developed and used [14].Some of these modulators have been proposed for use in anticancer chemotherapy [13].
It should be mentioned here that, in cancer, autophagy plays a controversial role, sometimes acting as a suppressor or as a promoter of tumorigenesis [4,7,[15][16][17].Whether autophagy will be protective or, on the contrary, associated with the death of cancer cells largely depends on the type of cancer as well as the tumor microenvironment, disease stage and external stimuli [1,17].For each specific situation, the level of autophagy optimal for the survival of tumor cells can be determined.Accordingly, new strategies are being developed for cancer therapy through genetic and pharmacological modulation of autophagy, including either its inhibition [4,6,[17][18][19] or induction [6].Some drugs such as chloroquine (CQ) or hydroxychloroquine (HCQ) alone [13] or in combination with other drugs [4] that inhibit autophagy are in different phases of clinical trials.Likewise, other ATG inhibitors have demonstrated effectiveness in pre-clinical trials [13].
Intra-and extracellular triggers of autophagy are diverse and include nutrient deficiency or deprivation, growth factor depletion, energy starvation, organelle/DNA damage, infection and hypoxia.As a basis for self-recycling and cell survival in adverse environments, autophagy must be well regulated and controlled [21,28] and goes through a series of steps to ensure correct processing.Although autophagy is mostly a cytoprotective mechanism, excessive self-degradation can lead to type 2 cell death (autophagic cell death) [29,30].
The main feature that distinguishes autophagy from CMA and micro-autophagy is the formation of autophagosomes, spherical double-membrane structures in which the cytoplasmic content (cargo) is encapsulated.The means of encapsulation and the cargo content largely determine whether autophagy is selective or non-selective [31,32].In nonselective autophagy, the cytoplasmic material is randomly sequestrated in response cytoplasmic content (cargo) is encapsulated.The means of encapsulation and the cargo content largely determine whether autophagy is selective or non-selective [31,32].In nonselective autophagy, the cytoplasmic material is randomly sequestrated in response to starvation, while in selective autophagy, the cargo can be mitochondria, endoplasmic reticulum, protein aggregates or lysosomes, giving the specific name to this autophagosome-mediated recycling process [31][32][33].
The general mechanism by which the autophagic process develops is divided into different steps, as shown in Figure 1 (top panel).For each step in the sequence, a complex and highly regulated machinery is required, which is briefly described below.→ (blue bold arrow), modulation; Ⱶ (red), inhibition; ↓, process down-regulated; ↑, process up-regulated.
Under normal conditions, the interaction between the ULK1 complex and mTORC1 keeps ULK1 [34,35] and ATG13 [34] phosphorylated and inactive, whereas under metabolic stress, mTORC1 dissociates from the ULK1 complex, leaving it to interact with the class III PI3K complex.Under low energy conditions, AMPK directly phosphorylates and inhibits mTORC1 [36], activates the class III PI3K complex by phosphorylating hVPS34 and BECN1 [37] and phosphorylates ULK1 [35,38,39], thus connecting energy sensing to mitophagy [38].All these pathways result in autophagy induction.cytoplasmic content (cargo) is encapsulated.The means of encapsulation and the cargo content largely determine whether autophagy is selective or non-selective [31,32].In nonselective autophagy, the cytoplasmic material is randomly sequestrated in response to starvation, while in selective autophagy, the cargo can be mitochondria, endoplasmic reticulum, protein aggregates or lysosomes, giving the specific name to this autophagosome-mediated recycling process [31][32][33].
The general mechanism by which the autophagic process develops is divided into different steps, as shown in Figure 1 (top panel).For each step in the sequence, a complex and highly regulated machinery is required, which is briefly described below.

Phagophore Elongation
This step occurs with ATG9 in collaboration with microtubule-associated protein 1 light chain 3 (LC3) in its lipidated form (LC3-II) and the ATG12-ATG5-ATG16L complex.The measurement of LC3-II expression is one of the most frequently used assays to monitor autophagy [44].The LC3 conversion is dependent on ATG3, ATG7, the ATG12-ATG5-ATG16L complex and ATG4; the last one is regulated by ULK1 [45].The ATG12-ATG5-ATG16L complex formation is orchestrated by ATG7 and ATG10.The correct assembly of this complex as well as the formation of LC3-II is essential for autophagosome biogenesis, elongation and maturation [46,47], and for LC3-II, the following steps of the autophagic process are essential [47].

Cargo Sequestration
Cytosolic material, designated for degradation, must be engulfed in the phagophore membrane to be sealed later, giving rise to the formation of the phagosome, with its cargo ready for lysosome degradation.For this, several autophagy receptors such as p62/SQSTM1 (sequestosome 1), NIX (BNIP3L) or neighbor of BRCA1 gene 1 (NBR1) are necessary to recruit cytosolic cargo in the collaboration with LC3-II acting as a bridge [48][49][50][51].Participating receptors will depend on the nature of the cargo [49,50], especially for selective autophagy.

Fusion with Lysosome
The newly formed autophagosome can fuse with a lysosome (autophagolysosome) for cargo degradation.For this process, the outer and inner autophagosome membranes must be degraded so that the cargo is delivered to the lysosome, and they can be degraded by lysosomal hydrolases.The formation of the autophagolysosome is highly regulated by several proteins, including the SNARE (soluble NSF attachment protein receptor) complex and mTORC1 [52,53].

ATG Status in Different Types of Cancer Cells May Vary
BECN1 is one of the most important ATGs in the initial stages of autophagy, being a part of the class III PI3K complex.Although BECN1 mutations have been identified in gastric and colorectal cancers [54], their occurrence in the general cancer landscape is extremely rare [55].However, BECN1 was considered a haploinsufficient tumor suppressor gene because its monoallelic deletion is frequently seen in breast, ovarian and prostate cancers [56][57][58].Recent review of the published data on the status of BECN1 in various tumors suggests that its reduced expression often occurs in tumors as compared to normal tissues and that lower BECN1 levels generally correlate with a poorer prognosis [59].In particular, down-regulation of BECN1 has been reported in lymphoma, melanoma, osteosarcoma and brain and lung cancers [60][61][62][63][64].
Lower expression of key ATGs (BECN1, ATG3, ATG5, ATG4, ATG14) was shown in a large panel of primary acute myeloblastic leukemia (AML) patients as compared to normal granulocytes [65].Similarly, p62/SQSTM1 mRNA levels are down-regulated in the immature myeloid phenotype (AML cell lines, primary CD34 + progenitors cells and primary blasts from AML patients) compared with mature granulocytes from healthy donors [66].
Bone marrow (BM) aspirates from AML patients show decreased NIX (BNIP3L) mRNA expression in comparison to BM aspirates from healthy controls [67].Also, in BM samples from AML patients, low mRNA levels of BECN1 and p62 indicate worse overall survival.
In addition, down-regulation of the ATGs BECN1, LC3 and NBR1 is shown in AML patients compared to patients with hematological diseases (anemia, thrombocytosis) [68].Similarly, LC3, ATG5 and ATG10 are down-regulated in whole-blood samples from complete remission patients compared to newly diagnosed AML patients [69].Therefore, ATG levels can be used as biomarkers to differentiate more aggressive or resistant phenotypes in leukemias.
However, up-regulation of BECN1 has also been reported in hematologic malignances.Higher levels of BECN1 and ATG5 compared to healthy patients were reported in samples derived from patients with chronic lymphoblastic leukemia (CLL) and AML.However, they were associated with favorable prognosis in CLL, in contrast to AML [70,71].In CD34+ hematopoietic stem cells from chronic myeloblastic leukemia (CML), BECN1 and ATG5 are also overexpressed, along with ATG4 [72].ATG12 was up-regulated in samples of glucocorticoid-resistant pediatric pre-B acute lymphoblastic leukemia (preB-ALL) in comparison to sensitive ones [73].High ATG7 levels in leukemic blasts were associated with shorter remission duration in AML patients [74].ATG7 silencing enhanced the sensitivity of AML cells to the chemotherapeutic agents cytarabine and idarubicin in in vitro assays as well as in a mouse model of human AML [74].Therefore, the role of autophagy and ATGs is apparently different in chronic and acute leukemias of different lineages, which differ by proliferation rates and metabolic profiles.
A higher BECN1 level was detected in colorectal and gastric carcinomas as compared to normal mucosal cells, irrespective of invasion, metastasis and stage [75].On the other hand, ATG12 was identified as possible biomarker since it is up-regulated in oral squamous cell carcinoma tissues without correlation of the mRNA levels with clinical parameters [76].Finally, ULK1, BECN1, ATG3, ATG5, ATG7, ATG9, ATG10, ATG12, LC3B and p62/SQSTM1 are expressed in gastric cancer tissues, where differences in expression correlate with clinicopathological characteristics such as histological types and lymph node metastasis, positioning these genes as potential biomarkers in gastric cancer [77].
In this sense, the dysregulation of these ATGs represents an attractive strategy to stop the progression of cancer.

ATG Regulation Is Related to Cell Metabolism
BECN1 is regulated by the anti-apoptotic protein Bcl-2 (B-cell lymphoma 2), forming the BECN1-Bcl-2 complex under normal nutrient conditions.This association prevents BECN1 from participating in autophagy induction, while in nutrient deprivation, Bcl-2 phosphorylation dissociates Bcl-2 from BECN1, leaving BECN1 free to bind to the class III PI3K complex [78].
As mentioned above, many cancer cells meet their energy needs through aerobic glycolysis.Glucose starvation has been shown to induce autophagy through a mechanism involving hexokinase 2 (HK2) binding to mTOR and its subsequent inhibition [79].It is noteworthy that some autophagic steps are regulated by glycolytic enzymes (Figure 2), which can be related to cancer cell pathophysiology.
BECN1 can be regulated by the glycolytic enzymes pyruvate kinase (PKM2), phosphoglycerate kinase 1 (PGK1) and lactate dehydrogenase A (LDHA).PKM2, a key mediator for the Warburg effect [80], increases the phosphorylation of BECN1 and contributes to cell survival via autophagic activation in a nucleophosmin-mutated AML cell line, where PKM2 knockdown reduces the phosphorylation of BECN1 at T119 [81].Similarly, PGK1 directly phosphorylates BECN1 at S30, which in human glioblastoma samples correlate with more aggressive tumors and lower median survival [82].On the other hand, LDHA-BECN1 colocalization suggests the possible involvement of LDHA in the initiation of cytoprotective autophagy [83].Finally, in a model of doxorubicin-resistant gallbladder cancer cells, PGK1 knockdown reduces ATG5 and ATG12 protein levels [84].BECN1 can be regulated by the glycolytic enzymes pyruvate kinase (PKM2), phosphoglycerate kinase 1 (PGK1) and lactate dehydrogenase A (LDHA).PKM2, a key mediator for the Warburg effect [80], increases the phosphorylation of BECN1 and contributes to cell survival via autophagic activation in a nucleophosmin-mutated AML cell line, where PKM2 knockdown reduces the phosphorylation of BECN1 at T119 [81].Similarly, cytoplasmic content (cargo) is encapsulated.The means of encapsulation and the cargo content largely determine whether autophagy is selective or non-selective [31,32].In nonselective autophagy, the cytoplasmic material is randomly sequestrated in response to starvation, while in selective autophagy, the cargo can be mitochondria, endoplasmic reticulum, protein aggregates or lysosomes, giving the specific name to this autophagosome-mediated recycling process [31][32][33].
The general mechanism by which the autophagic process develops is divided into different steps, as shown in Figure 1 (top panel).For each step in the sequence, a complex and highly regulated machinery is required, which is briefly described below.
The involvement of BECN1 in the induction of autophagy seems to also be related to lipid metabolism through fatty acid β-oxidation (FAO) and subsequent entry into the TCA cycle in myeloid leukemia [85] and colon [86] and gastric [87] cancer.

ATG Status in Cancer Microenvironment
Tumors represent a specific type of pathologic tissue, and they establish functional interactions with non-transformed cells of the tumor microenvironment (TME) or niche.With tumor progression, cancer cells can affect the TME to adopt them for their needs.Autophagy in the TME is an important element of non-cancer cells' fitness and their ability to support tumor growth [90].
Interestingly, cancer cells seem to stimulate autophagy in TME cells [90,91].In turn, autophagy-dependent metabolite secretion by the TME is pivotal to maintain the metabolism and growth of tumor cells.In this regard, a high level of basal autophagy was reported in cancer-associated fibroblasts (CAFs) from patients with head and neck squamous carcinoma (HNSC) in comparison to normal fibroblasts from the same anatomical area, evidenced by the presence of high number of autophagosomes and increased level of LC3 [92].Conditioned media from CAFs with mitigated autophagy (BECN1 knockdown or CQ treatment), in contrast to conditional media from non-manipulated CAF, were not able to maintain growth of HNSC cells in vitro, indicating the importance of CAF autophagydependent secretion for HNSC progression [92].Autophagy-dependent alanine secretion from stromal cells was demonstrated to be essential for the metabolism and growth of pancreatic ductal adenocarcinoma [93].
In hematologic malignances, special attention should be given to the metabolic features of leukemic cells, which allow them to adapt to the niches of the bone marrow (BM) [94].There is evidence that microenvironmental autophagy may play an important role in AML chemoresistance [74,95].As was mentioned above, ATG7 knockdown in AML cells increases their chemosensitivity, and this effect is enhanced by concomitant knockdown of ATG7 in both AML and stromal cells [74].The levels of autophagy and ATG5 expression are increased in mesenchymal stem cells (MSCs) derived from the BM of AML patients (AML-MSCs) as compared to healthy donors [95].When autophagy is inhibited by 3-Methyladenine (3-MA) or ATG5 silencing in AML-MSCs, their cell cycle is arrested in G1, and the expression of CXCL12, which is responsible for the interaction of leukemic and stromal cells in the BM, is significantly reduced.When leukemic cells are cocultured with these "autophagy-modulated" AML-MSCs, they are more sensitive to the genotoxic agents daunorubicin and doxorubicin in comparison to leukemic cells cocultured with unmanipulated AML-MSCs.
Overexpression of stromal ATG16L [96] and ATG10 correlates with lymphovascular invasion and lymph node metastasis in human oral squamous cell carcinoma and colorectal cancer, respectively [97].
In AML, leukemic stem cells (LSCs), which are largely responsible for chemotherapy resistance and disease relapse [98], exhibit an oxidative phenotype (are OXPHOS-dependent), while normal hematopoietic stem cells (HSCs) display a glycolytic phenotype [99,100].It has been shown that the metabolism of AML blasts is mainly based on OXPHOS rather than on oxidative glycolysis [89], but blasts, unlike LSCs, can up-regulate glycolysis to compensate for the loss of OXPHOS [99,100].Additionally, AML blasts can generate hypoxic conditions in the BM, which drives the transfer of functional mitochondria from stromal cells to leukemic blasts via tunneling nanotubes [101].A healthy microenvironment is then paramount for the survival of both AML blasts and LSCs.

Metabolic Changes Caused by Modulation of Autophagy in Cancer Cells
Several studies that have manipulated ATGs and autophagy followed by an assessment of cell metabolism have been reported and will be discussed in this section.The reported data are summarized in Table 1 and illustrated in Figure 1 (lower panel).

Metabolic Changes Caused by Autophagy Induction
When autophagy is induced by treatment of AML cell lines with the mTORC1 inhibitor rapamycin, glucose uptake is reduced as expected [102].Similarly, glycolytic activity is reduced in the Panc-1 pancreatic cancer cell line treated with the rapamycin analogue everolimus [103].

Metabolic Changes Caused by Knockdown or Inhibition of ATGs
ATG silencing or pharmacologic inhibition of the respective proteins are common experimental approaches to study the role of ATG proteins in cancer cell metabolism.The following are compounds frequently used in experimental models to modulate autophagy at various stages.
3-MA blocks autophagosome formation via the inhibition of the class III PI3K complex [107].
Here, we provide details regarding the metabolic changes induced by the pharmacological blockade of several ATGs at different stages of autophagy in experimental models in vitro (Table 1, Figure 1).
The prevention of phagophore nucleation through the deletion of BECN1 or pharmacologic inhibition of the class III PI3K complex by 3-MA attenuates lipid degradation, reduces FAO and decreases the basal and ATP-linked oxygen consumption rate (OCR, indicator of mitochondrial respiration) in the acute myeloblastic leukemia (AML) cell line MOLM14 [85].In cell lines derived from solid tumors (colon and gastric cancers), BECN1 ablation drastically decreases OXPHOS and lipid degradation and shifts cellular metabolism towards aerobic glycolysis, with increases in glucose uptake and lactate production [86,87].Strengthening the idea of the shift from OXPHOS to aerobic glycolysis, BECN1 inhibition by Spautin-1 reduces OCR and suppresses mitochondrial complex I activity in a human fibrosarcoma cell line [108].3-MA causes down-regulation of genes involved in FAO and fatty acid transportation in a human hepatocellular carcinoma cell line [109].
Remarkably, deletion of ATG3, which is necessary for LC3 lipidation, or ATG12, which, in complex with ATG5, is required for the elongation of phagophores, also causes FAO reduction but increases glucose uptake and consumption in AML cell lines [85,110].
When a hepatocellular carcinoma cell line was transfected with inactive ATG4 (ATG4B C74A ), compromising the first step of LC2 conjugation, it conserved a diminished FAO and lipid catabolism [109].Similarly, deletion of ATG5 and ATG7 favors the maintenance of an increased level of glycolysis and glycolytic capacity in human cancer cell lines.In particular, the glycolytic enzyme HK2 level increases after the deletion of ATG5 in liver cancer [111], while ATG7 knockdown increases PKM2 phosphorylation [80].Notably, tyrosine phosphorylation decreases PKM2 enzymatic activity [112].
In pancreatic adenocarcinoma cells, ATG7 silencing increases glutamine consumption and decreases TCA cycle intermediate levels under normal conditions.However, with glutamine deprivation, this deletion further decreases intracellular glutamine levels, demonstrating that autophagy is necessary for the maintenance of intracellular glutamine levels and provides glutamine to support anaplerosis of the TCA cycle [113].Furthermore, whereas ATG7 deletion leads to impaired autophagy and favors glycolysis with lactate production (Warburg effect) [80,111], ATG7 overexpression inhibits the Warburg effect in the HeLa cell line by suppressing PKM2 phosphorylation [80].
Although several aforementioned studies evidence that ATG impairment causes metabolic shift toward glycolysis, contrasting data have also been reported.For example, spautin-1 reduces glucose uptake and the activity of HK2 in the human lung cancer A549 cell line [114].There are also reports that ATG7 deletion causes decreased LDH activity and glycolytic capacity in the MDA-MB-231 cell line [115] and decreases glucose uptake and lactate production in the human CML cell line K562 [116].Deletion of FIP200 (from the ULK complex) in mammary tumor cells derived from female C57BL/6 mice decreases glucose uptake and intracellular lactate production [117].
Similar findings have been described in the TAM-resistant MCF7 cell line, where AMPKα1 knockout impairs estrogen receptor-induced FAO [118].

The Blockade of the Autophagic Flux Alters the Metabolism of Human Cancer Cells
The autophagic process implies the need for the autophagosome to remain completely formed, enclosing the content to be degraded by the lysosome.Autophagosome-lysosome fusion can be prevented pharmacologically by using the lysosomotropic agent CQ [119] or Bafilomycin A1 (Baf A1), which disrupts autophagic flux by inhibiting both V-ATPasedependent lysosome acidification and Ca-P60A/SERCA-dependent autophagosome-lysosome fusion [44,120].When autophagic flux is blocked (autophagosome-lysosome fusion arrest), a large number of autophagosomes can accumulate, which causes the cancer cell to embark on the path of cell death, especially if autophagy was enhanced to survive in adverse environmental conditions.
An interesting link between HK2 levels and autophagic flux has been reported in liver cancer cell lines: cells with low autophagic flux exhibited high expression of HK2 and a high glycolysis phenotype, while cells with high autophagic flux acquired a low-glycolysis phenotype because HK2 is degraded by p62/SQSTM1-mediated autophagy [111] and CMA [121].
In human cholangiocarcinoma and colon and pancreatic cancer, CQ attenuates lipid degradation [86] with decreased levels of TCA cycle intermediates and increased glutamine consumption [113].Additionally, CQ decreases the activity of glucose-6-phosphate dehydrogenase (G6PDH) [122], an enzyme that catalyzes the first step in the pentose phosphate pathway (a metabolic pathway parallel to glycolysis); in turn, a decrease in G6PDH activity favors the use of glucose-6-phosphate (G6P) in glycolysis.
Taken together, the data presented in Sections 4.1-4.3indicate that the silencing of the different ATGs as well as the pharmacological blockade of different phases of autophagy drastically alter the metabolism of cancer cells.In many types of tumors, a switch to the glycolytic phenotype and decrease in the use of fatty acids was observed (Table 1, Figure 1).Since contrasting data are also reported, a more detailed systemic analysis of the complex relationship between metabolism and autophagy in different cancer types at different stages of disease progression is needed.

How Cross-Talk between Autophagy and Cell Metabolism Affects the Drug Sensitivity of Tumor Cells
Most anticancer strategies based on autophagy modulation (mostly inhibition) are limited to monitoring cell viability.In our opinion, monitoring the concomitant metabolic changes is important, so respective data are listed in Table 1.
A dual strategy to improve the drug sensitivity of cancer cells is to simultaneously target metabolic pathways and autophagy (Table 2).Below, we present some outcomes of this strategy.Inhibition of glycolysis with 2-Deoxy-D-glucose (2-DG), a glucose analog that inhibits the function of HK2 and G6P isomerase [125], in combination with the autophagy inducer rapamycin prevents the induction of cell death caused by 2-DG in pancreatic and breast cancer [126], as well as neuroblastoma and colon carcinoma [127] cell lines.Controversially, HK2 inhibition with 3-Bromopyruvate (3-BrPA) and autophagy induction with rapamycin decrease cell proliferation with apoptosis induction in neuroblastoma cell lines [128].
Similarly, the glycolysis inhibitors 3-BrPA, 2-DG, lonidamine and DCA demonstrate greater cytotoxicity in ATG7 [126,129,130] or ATG5 [111] knockdown cancer cell lines than in the corresponding wild-type cell lines, as was evidenced by decreased viability and proliferation and increased cell death.
Consistent with this additive or synergistic effect of the pharmacological inhibition of glycolysis and inhibition of the initial steps of autophagy, blocking the autophagic flux with CQ in combination with the glucose transporter (GLUT) inhibitor silibinin enhances apoptosis induction in glioblastoma cell lines [134] and, likewise, 3-BrPA or 2-DG in breast cancer [129] and glioblastoma [135] cell lines, respectively.
On the other hand, the use of metformin, a drug that inhibits HK2 and mitochondrial complex I [136,137], in co-treatment with autophagy inhibitors rescues cells from metformin-mediated cytotoxicity: AMPK inhibitor compound C or AMPK knockdown decreases growth inhibition and cell cycle arrest in B-lymphoma and T-lymphoma cell lines [138].3-MA reduces apoptosis and growth/viability inhibition of B-lymphoma and T-lymphoma [138] and gastric cancer [139] cell lines.Spautin-1 enhances the inhibition of colony formation of BRCA1-deficient mammary tumor cells [140].In contrast, inhibition of autophagy with 3-MA, CQ or BECN1 knockdown reduces metformin-mediated cytotoxicity (viability and apoptosis) in the Ishikawa cell line (endometrial adenocarcinoma) [141].
Autophagy induction with rapamycin decreases the apoptosis and necrosis caused by the mitochondrial complex I inhibitors rotenone [142] or paraquat [143] in neuroblastoma cell lines.In contrast to this, 1-methyl-4-phenylpyridinium (MPP + , mitochondrial complex I inhibitor) [143] or doxycycline (inhibitor of mitochondrial biogenesis) [144,145] in combination with rapamycin increases cell death and decreases the cell proliferation of neuroblastoma [143] and glioblastoma [145] cell lines.
Additionally, depending on the cellular model and strategy used, the inhibition of autophagy in combination with drugs that alter OXPHOS by inhibiting mitochondrial complex I demonstrates different effects.Inhibition of ATG5-dependent autophagy through overexpression of a dominant negative form of ATG5 (dnATG5) in a neuroblastoma cell line increases cell death induced by paraquat or MPP + [143].CQ reduces necrosis induced by mito-lonidamine (which also inhibits mitochondrial complex I) in a lung adenocarcinoma that metastasized to the brain cell line [146].
Finally, inhibition of fatty acid synthase (FAS) with orlistat in combination with 3-MA shows a cytotoxic effect in a pancreatic cancer cell line [150], while in epithelial ovarian cancer cell lines, 3-MA reduces the loss of cell viability induced by orlistat [151].A similar effect is caused by another FAS inhibitor, emodin [152], where blocking autophagy with CQ reverses the decrease in cell migration and invasion caused by emodin [153].In addition, the carnitine palmitoyltransferase (CPT1) inhibitor etomoxir (FAO inhibition) individually and in combination with CQ produces a disruption of spheroid structure and cell death in primary ovarian tumor tissue [154].Although the ultimate consequence of alteration (mainly inhibition) of various metabolic pathways in combination with inhibition of autophagy at different stages largely depends on the cell model evaluated and the drugs used, most of the data presented here point to the fact that simultaneous inhibition of autophagy and cellular metabolism is a promising strategy against cancer cells.

Combination of Drugs Targeting Autophagy and Metabolic Pathways as a Strategy That Can Improve Chemotherapeutic Protocols
Therapeutic compounds, targeting either metabolic enzymes or autophagy, show efficacy in multiple cancers at various stages of clinical trials, but chemoresistance still represents the major challenge in cancer treatment [6].In this regard, currently available data indicate that the plasticity and chemoresistance of tumor cells is based on the cross-talk of autophagy and metabolic processes (glycolysis, FAO, glutaminolysis and OXPHOS).Thus, a combined therapy that simultaneously targets autophagy and metabolic pathways may represent a viable strategy to overcome chemoresistance.
Inhibition of glycolysis in various types of cancer can induce autophagy, which prevents cells from dying: glucose deprivation causes metabolic reprogramming towards mitochondrial OXPHOS in an autophagy-dependent manner, which allows the survival of multiple types of tumor cells, including pancreatic cancer (PANC-1), cervical cancer (HeLa) and lung adenocarcinoma (A549) [155].In human glioblastoma, glycolysis inhibition leads to the induction of autophagy, senescence and escape from apoptosis [133].
Glucocorticoid resistance in acute lymphoblastic leukemia from T lineage (T-ALL) cell lines was shown to be related to the induction of a moderate level of protective autophagy (mitophagy), increased consumption of fatty acids and FAO after treatment with dexamethasone (Dex).Then, combined treatment of T-ALL with Dex and autophagy inhibitor CQ increased Dex cytotoxicity and made the Dex-resistant T-ALL Dex-sensitive [156].
Most tumors rely on aerobic glycolysis for ATP production (Warburg effect).As was mentioned above, some glycolytic enzymes are involved in the regulation of autophagy and maintenance of FAO and OXPHOS (Section 3).Not surprisingly, autophagy suppression results in up-regulation of glycolysis in many cancer types (Section 4).Thus, suppression of glycolysis may represent a valid strategy to improve the therapeutic response of cancer patients to autophagy inhibitors.The possible effectiveness of such a strategy was demonstrated in in vitro experiments, where inhibition of HK2 decreased the viability of autophagy-impaired liver cancer cells [111].
As mentioned above, the glycolytic enzymes PKM2 and PGK1 can activate BECN1 via phosphorylation, while LDHA can do so via complex formation (Figure 2).It is noteworthy that deficiency of PKM2 compromises progenitor and AML cells, while LDHA deletion inhibits the function of HSCs, progenitor and AML blasts [157].Association of BECN1 with LDHA induces pro-survival autophagy in a model of tamoxifen-resistant breast cancer [83], while overexpression of PKM2 has been linked to increased proliferation and metastasis [158] and its phosphorylation promotes tumor growth and the Warburg effect [111], regulated by ATG7 [80].These effects could be explained by the fact that enzymes such as HK2 and LDHA are direct targets of oncogenic transcription factors [6].In addition, LDHA has been associated with drug resistance in AML [131].
It has recently been demonstrated that FAO favored the increased biogenesis of mitochondrial membrane phospholipids, mediated by STAT3-acetylation, which in turn increased mitochondrial membrane potential and caused resistance to paclitaxel in breast cancer cells [159].Generally, the transcription factor STAT3 (signal transducer and activator of transcription 3) can regulate autophagy in various ways, depending on its subcellular localization: (1) nuclear STAT3 regulates the transcription of various ATGs, including BECN1; (2) cytoplasmic STAT3 interacts with autophagy-related signaling molecules and inhibits autophagy; (3) mitochondrial STAT3 suppresses ROS-induced mitophagy [160].This correlates with the overcoming of chemoresistance to paclitaxel in a model of lung adenocarcinoma through the inhibition of lipolysis by mercaptoacetate or etomoxir [161].
p62/SQSTM1 and LC3 expression is associated with tumor recurrence in oral squamous cell carcinoma [162], whereas p62/SQSTM1-LC3 interaction increases invasiveness in lung cancer and correlates with poor prognosis [163].Similarly, LC3-II expression in colorectal cancer tissues is higher than in normal tissue [164].In this sense, inhibition of p62/SQSTM1 causes autophagic cell death in adenocarcinomas and squamous cell carcinomas [165].
In a model of lung cancer, knockdown of ATG5, BECN1, ATG7 and p62/SQSTM1 decreases A549 cell invasiveness in the presence of cancer-associated fibroblasts (CAFs).In this model, even in the absence of CAFs, lung cancer cells exhibit an elevated autophagic flux that favors invasive ability, while blocking autophagic flux (CQ) completely inhibits this invasion [163].
Furthermore, ATG9 has been reported as a target in hypoxia-induced autophagy, so the inhibition of autophagy decreases cell proliferation and glioblastoma tumor growth in vivo [166], whereas in a model of B-cell leukemia, the knockdown of hVPS34 reduces cell proliferation and survival [167].

Conclusions
Under stressful conditions, cancer cells resort to autophagy as a strategy that allows the elimination of damaged organelles and recycling of metabolic blocks for survival and proliferation.This fact has provided the basis for the widely accepted view that inhibition of autophagy is an effective approach for anticancer therapy.This view, however, is not always correct.In this review, we provided experimental evidence that the suppression of ATGs in many types of tumors can lead to activation of the Warburg effect, characteristic for aggressive tumors.In particular, the overexpression of glycolytic enzymes such as HK2, LDHA and PKM2, which promote glycolysis and survival, was observed.Considering this adaptation mechanism, the use of different autophagy inhibition strategies should be carefully evaluated for each cancer type.To prevent chemoresistance, the possibility of a combination of autophagy inhibitors with the inhibitors of cellular metabolism, in particular inhibitors of glycolysis, should be considered.

Figure 1 .
Figure 1.Metabolic alterations caused by modulation of autophagy in cancer cells.The stages of autophagy are indicated.The ATGs subjected to modulation are shown in gray.Silencing genes are labeled with a prohibition sign.Inhibitors are enclosed in yellowish ovals.Symbols are as follows: → (blue bold arrow), modulation; Ⱶ (red), inhibition; ↓, process down-regulated; ↑, process up-regulated.

Figure 1 .
Figure 1.Metabolic alterations caused by modulation of autophagy in cancer cells.The stages of autophagy are indicated.The ATGs subjected to modulation are shown in gray.Silencing genes are labeled with a prohibition sign.Inhibitors are enclosed in yellowish ovals.Symbols are as follows: → (blue bold arrow), modulation;

Figure 1 .
Figure 1.Metabolic alterations caused by modulation of autophagy in cancer cells.The stages of autophagy are indicated.The ATGs subjected to modulation are shown in gray.Silencing genes are labeled with a prohibition sign.Inhibitors are enclosed in yellowish ovals.Symbols are as follows: → (blue bold arrow), modulation; Ⱶ (red), inhibition; ↓, process down-regulated; ↑, process up-regulated.

Figure 2 .
Figure 2. Glycolytic enzymes that favor autophagy in cancer cells.The stages of autophagy are indicated.Glycolytic enzymes are enclosed in red ovals.Symbols: → (blue bold arrow), modulation; Ⱶ (red), inhibition.

Figure 2 .
Figure 2. Glycolytic enzymes that favor autophagy in cancer cells.The stages of autophagy are indicated.Glycolytic enzymes are enclosed in red ovals.Symbols: → (blue bold arrow), modulation;

Figure 1 .
Figure 1.Metabolic alterations caused by modulation of autophagy in cancer cells.The stages of autophagy are indicated.The ATGs subjected to modulation are shown in gray.Silencing genes are labeled with a prohibition sign.Inhibitors are enclosed in yellowish ovals.Symbols are as follows: → (blue bold arrow), modulation; Ⱶ (red), inhibition; ↓, process down-regulated; ↑, process up-regulated.

Table 1 .
Modulation of autophagy and metabolic changes in cancer cells.

Table 2 .
Cross-talk between autophagy and cancer cell metabolism.