Fatty acid oxidation is an adaptive survival pathway induced in prostate tumors by heat shock protein 90 inhibition.

HSP90 is a molecular chaperone required for stabilisation and activation of hundreds of client proteins, including many known oncoproteins. AUY922 (luminespib), a new generation HSP90 inhibitor, exhibits potent preclinical efficacy against several cancer types including prostate cancer (PCa). However, clinical use of HSP90 inhibitors for PCa has been limited by toxicity and treatment resistance. Here, we aimed to design an effective combinatorial therapeutic regimen that utilizes subtoxic doses of AUY922, by identifying potential survival pathways induced by AUY922 in clinical prostate tumors. We conducted a proteomic analysis of 30 patient-derived explants (PDEs) cultured in the absence and presence of AUY922, using quantitative mass spectrometry. AUY922 significantly increased the abundance of proteins involved in oxidative phosphorylation and fatty acid metabolism in the PDEs. Consistent with these findings, AUY922-treated PCa cell lines exhibited increased mitochondrial mass and activated fatty acid metabolism processes. We hypothesized that activation of fatty acid oxidation is a potential adaptive response to AUY922 treatment and that co-targeting this process will sensitize PCa cells to HSP90 inhibition. Combination treatment of AUY922 with a clinical inhibitor of fatty acid oxidation, perhexiline, synergistically decreased viability of several PCa cell lines, and had significant efficacy in PDEs. The novel drug combination treatment induced cell cycle arrest and apoptosis, and attenuated the heat shock response, a known mediator of HSP90 treatment resistance. This combination warrants further preclinical and clinical investigation as a novel strategy to overcome resistance to HSP90 inhibition. Implications: Metabolic pathways induced in tumor cells by therapeutic agents may be critical but targetable mediators of treatment resistance.