CUSP9 / ROS Cancer Research Results

CUSP9, CUSP9: Click to Expand ⟱
Features:
CUSP9 coordinated undermining of survival paths with nine repurposed drugs
-includes aprepitant, artesunate, auranofin, captopril, celecoxib, disulfiram, itraconazole, sertraline, ritonavir

CUSP9 — CUSP9 is a coordinated multi-drug repurposing regimen for glioblastoma built around the concept of Coordinated Undermining of Survival Paths. It is a polypharmacologic adjunct oncology protocol rather than a single molecular entity, formally classified as a multi-agent drug-repurposing regimen used with low-dose metronomic temozolomide in the clinically tested CUSP9v3 version. Standard abbreviations include CUSP9, CUSP9*, and CUSP9v3. The regimen originated from the International Initiative for Accelerated Improvement of Glioblastoma Care and subsequent Ulm University clinical development.

Primary mechanisms (ranked):

  1. Multi-pathway blockade of glioblastoma survival, invasion, inflammation, redox adaptation, efflux, and compensatory resistance networks.
  2. Redox stress amplification through thioredoxin reductase inhibition, ALDH inhibition, ROS generation, and impaired detoxification capacity.
  3. Temozolomide augmentation through resistance-pathway suppression, metronomic alkylator pressure, and reduced adaptive escape rather than a single direct chemosensitizing target.
  4. Invasion and microenvironment suppression through angiotensin, MMP, COX-2, microglial, cytokine, and inflammatory axes.
  5. Drug transport and exposure modulation through P-gp, BCRP, CYP, and BBB-relevant pharmacology, with both therapeutic and toxicity implications.
  6. Apoptosis and mitochondrial stress, particularly in CUSP9v3 combinations and in vitro TTFields plus CUSP9v3 experiments.

Bioavailability / PK relevance: CUSP9 is orally administered and highly PK-constrained because it combines multiple approved drugs with different half-lives, CNS penetration, protein binding, hepatic metabolism, and CYP or transporter effects. CUSP9v3 specifically requires careful dose escalation and monitoring because ritonavir, itraconazole, aprepitant, celecoxib, sertraline, and other components create clinically meaningful interaction potential. BBB exposure is component-specific and may not scale linearly with plasma exposure.

In-vitro vs systemic exposure relevance: CUSP9 is concentration-driven, but the clinically relevant question is not the exposure of one drug alone; it is whether simultaneous low-to-moderate exposure across multiple repurposed agents can suppress glioblastoma escape pathways. Some in-vitro work used clinically oriented fixed concentrations, but sensitivity is model-dependent, and lower-order subsets may match or exceed the full nine-drug cocktail in some patient-derived cultures. Translation should therefore treat in-vitro efficacy as supportive, not definitive.

Clinical evidence status: Preclinical rationale is extensive and includes multiple in-vitro glioblastoma and glioma stem-like cell studies. Human evidence is small but real: compassionate-use experience and a phase Ib/IIa recurrent glioblastoma trial support feasibility and tolerability under careful monitoring. Efficacy remains unproven because randomized outcome data are not yet available. CUSP9/CUSP9v3 is not an approved oncology regimen; its components are approved for other indications.

CUSP9 cancer mechanism table

Rank Pathway / Axis Cancer Cells Normal Cells TSF Primary Effect Notes / Interpretation
1 Multi-pathway survival network blockade Parallel GBM survival routes ↓; compensatory escape ↓; heterogeneity buffering ↓ Broad off-target burden possible; toxicity depends on cumulative dose and interactions G Resistance-network suppression Core identity of CUSP9; strongest conceptual rationale is simultaneous weak-to-moderate pressure across many GBM survival axes rather than a dominant single target.
2 Redox detoxification and thioredoxin axis Thioredoxin reductase ↓; ALDH ↓; ROS ↑; apoptotic susceptibility ↑ Redox reserve may be stressed; hepatic and hematologic monitoring relevant R/G Pro-oxidant tumor stress Auranofin and disulfiram are central contributors. This is one of the clearest mechanistic pressure points in CUSP9v3.
3 Temozolomide resistance and chemosensitization Adaptive survival pathways ↓; TMZ escape capacity ↓; alkylator pressure maintained Myelosuppression and cumulative tolerability remain limiting G Adjunct chemosensitization CUSP9v3 was clinically tested with continuous low-dose metronomic temozolomide. Some in-vitro data found limited added benefit from TMZ under specific conditions, so this row is clinically important but mechanistically model-dependent.
4 Invasion and extracellular matrix remodeling MMP-2 ↓; MMP-9 ↓; migration ↓; invasion ↓ Normal inflammatory and wound-remodeling processes may also be affected G Anti-invasive activity Captopril and minocycline in CUSP9v3 are most relevant; original and variant CUSP9 compositions differ, so component-specific interpretation is required.
5 Inflammatory COX and prostaglandin signaling COX-2 ↓; PGE2-linked proliferation and inflammatory support ↓ GI, renal, cardiovascular, and blood pressure risks are clinically relevant G Inflammatory support suppression Celecoxib contributes anti-inflammatory and possible carbonic anhydrase-linked effects, but clinical leverage depends on tolerability and patient risk profile.
6 NK-1 substance P signaling NK-1 signaling ↓; proliferation and pro-survival signaling ↓ Generally tolerable, but CYP interaction context matters G Growth signal suppression Aprepitant is included for NK-1 receptor inhibition and supportive antiemetic pharmacology; its oncology role remains adjunctive and not independently validated as a GBM therapy.
7 Drug efflux and BBB exposure P-gp/BCRP-linked efflux ↓ or altered; intracellular drug exposure may ↑ Systemic drug exposure and interaction risk may ↑ R/G Exposure modulation Itraconazole, ritonavir, and sertraline can alter transporter or CYP-linked exposure. This can be therapeutically useful but is also a major safety constraint.
8 PI3K AKT mTOR and TCTP signaling AKT/mTOR survival tone ↓; TCTP-linked survival signaling ↓ Context-dependent effects on metabolism, mood, and systemic signaling G Growth and survival suppression Sertraline and ritonavir are relevant contributors. This is a secondary but mechanistically meaningful survival-axis target.
9 Hedgehog autophagy and sterol-linked signaling Hedgehog/autophagy programs ↓; adaptive survival ↓ Hepatic toxicity and CYP3A4 interactions are important G Adaptive pathway suppression Itraconazole is a key component, but this axis is limited by drug interaction and hepatic monitoring requirements.
10 Mitochondrial apoptosis and oxidative phosphorylation MOMP ↓; caspase-3 cleavage ↑; Bcl-2/Mcl-1 ↓; OXPHOS ↓ Potential mitochondrial stress is context-dependent R/G Apoptosis promotion Especially supported by recent TTFields plus CUSP9v3 in-vitro work, where combined treatment enhanced apoptosis and reduced respiratory chain activity.
11 Glioma stem-like phenotype and tumor sphere formation Sphere formation ↓; stem-like viability ↓; migration ↓ Normal neural progenitor relevance uncertain G Stem-like compartment suppression Reported in preclinical glioblastoma stem-like models, with heterogeneous response across cultures and possible subtype dependence.
12 Clinical Translation Constraint Potential benefit depends on simultaneous pathway pressure, tumor subtype, and achievable exposure Dose limitation, hepatic enzymes, GI effects, neurologic symptoms, CYP interactions, BBB variability, and adherence burden are major constraints G Feasibility and safety limitation Human evidence supports careful monitored administration, not routine efficacy. The regimen is complex and should be treated as investigational.

TSF legend: P: 0–30 min; R: 30 min–3 hr; G: >3 hr
ROS, Reactive Oxygen Species: Click to Expand ⟱
Source: HalifaxProj (inhibit)
Type:
Reactive oxygen species (ROS) are highly reactive molecules that contain oxygen and can lead to oxidative stress in cells. They play a dual role in cancer biology, acting as both promoters and suppressors of cancer.
ROS can cause oxidative damage to DNA, leading to mutations that may contribute to cancer initiation and progression. So normally you want to inhibit ROS to prevent cell mutations.
However excessive ROS can induce apoptosis (programmed cell death) in cancer cells, potentially limiting tumor growth. Chemotherapy typically raises ROS.
-mitochondria is the main source of reactive oxygen species (ROS) (and the ETC is heavily related)

"Reactive oxygen species (ROS) are two electron reduction products of oxygen, including superoxide anion, hydrogen peroxide, hydroxyl radical, lipid peroxides, protein peroxides and peroxides formed in nucleic acids 1. They are maintained in a dynamic balance by a series of reduction-oxidation (redox) reactions in biological systems and act as signaling molecules to drive cellular regulatory pathways."
"During different stages of cancer formation, abnormal ROS levels play paradoxical roles in cell growth and death 8. A physiological concentration of ROS that maintained in equilibrium is necessary for normal cell survival. Ectopic ROS accumulation promotes cell proliferation and consequently induces malignant transformation of normal cells by initiating pathological conversion of physiological signaling networks. Excessive ROS levels lead to cell death by damaging cellular components, including proteins, lipid bilayers, and chromosomes. Therefore, both scavenging abnormally elevated ROS to prevent early neoplasia and facilitating ROS production to specifically kill cancer cells are promising anticancer therapeutic strategies, in spite of their contradictoriness and complexity."
"ROS are the collection of derivatives of molecular oxygen that occur in biology, which can be categorized into two types, free radicals and non-radical species. The non-radical species are hydrogen peroxide (H 2O 2 ), organic hydroperoxides (ROOH), singlet molecular oxygen ( 1 O 2 ), electronically excited carbonyl, ozone (O3 ), hypochlorous acid (HOCl, and hypobromous acid HOBr). Free radical species are super-oxide anion radical (O 2•−), hydroxyl radical (•OH), peroxyl radical (ROO•) and alkoxyl radical (RO•) [130]. Any imbalance of ROS can lead to adverse effects. H2 O 2 and O 2 •− are the main redox signalling agents. The cellular concentration of H2 O 2 is about 10−8 M, which is almost a thousand times more than that of O2 •−".
"Radicals are molecules with an odd number of electrons in the outer shell [393,394]. A pair of radicals can be formed by breaking a chemical bond or electron transfer between two molecules."

Recent investigations have documented that polyphenols with good antioxidant activity may exhibit pro-oxidant activity in the presence of copper ions, which can induce apoptosis in various cancer cell lines but not in normal cells. "We have shown that such cell growth inhibition by polyphenols in cancer cells is reversed by copper-specific sequestering agent neocuproine to a significant extent whereas iron and zinc chelators are relatively ineffective, thus confirming the role of endogenous copper in the cytotoxic action of polyphenols against cancer cells. Therefore, this mechanism of mobilization of endogenous copper." > Ions could be one of the important mechanisms for the cytotoxic action of plant polyphenols against cancer cells and is possibly a common mechanism for all plant polyphenols. In fact, similar results obtained with four different polyphenolic compounds in this study, namely apigenin, luteolin, EGCG, and resveratrol, strengthen this idea.
Interestingly, the normal breast epithelial MCF10A cells have earlier been shown to possess no detectable copper as opposed to breast cancer cells [24], which may explain their resistance to polyphenols apigenin- and luteolin-induced growth inhibition as observed here (Fig. 1). We have earlier proposed [25] that this preferential cytotoxicity of plant polyphenols toward cancer cells is explained by the observation made several years earlier, which showed that copper levels in cancer cells are significantly elevated in various malignancies. Thus, because of higher intracellular copper levels in cancer cells, it may be predicted that the cytotoxic concentrations of polyphenols required would be lower in these cells as compared to normal cells."

Majority of ROS are produced as a by-product of oxidative phosphorylation, high levels of ROS are detected in almost all cancers.
-It is well established that during ER stress, cytosolic calcium released from the ER is taken up by the mitochondrion to stimulate ROS overgeneration and the release of cytochrome c, both of which lead to apoptosis.

Note: Products that may raise ROS can be found using this database, by:
Filtering on the target of ROS, and selecting the Effect Direction of ↑

Targets to raise ROS (to kill cancer cells):
• NADPH oxidases (NOX): NOX enzymes are involved in the production of ROS.
    -Targeting NOX enzymes can increase ROS levels and induce cancer cell death.
    -eNOX2 inhibition leads to a high NADH/NAD⁺ ratio which can lead to increased ROS
• Mitochondrial complex I: Inhibiting can increase ROS production
• P53: Activating p53 can increase ROS levels(by inducing the expression of pro-oxidant genes)
• Nrf2 inhibition: regulates the expression of antioxidant genes. Inhibiting Nrf2 can increase ROS levels
• Glutathione (GSH): an antioxidant. Depleting GSH can increase ROS levels
• Catalase: Catalase converts H2O2 into H2O+O. Inhibiting catalase can increase ROS levels
• SOD1: converts superoxide into hydrogen peroxide. Inhibiting SOD1 can increase ROS levels
• PI3K/AKT pathway: regulates cell survival and metabolism. Inhibiting can increase ROS levels
• HIF-1α inhibition: regulates genes involved in metabolism and angiogenesis. Inhibiting HIF-1α can increase ROS
• Glycolysis: Inhibiting glycolysis can increase ROS levels • Fatty acid oxidation: Cancer cells often rely on fatty acid oxidation for energy production.
-Inhibiting fatty acid oxidation can increase ROS levels
• ER stress: Endoplasmic reticulum (ER) stress can increase ROS levels
• Autophagy: process by which cells recycle damaged organelles and proteins.
-Inhibiting autophagy can increase ROS levels and induce cancer cell death.
• KEAP1/Nrf2 pathway: regulates the expression of antioxidant genes.
    -Inhibiting KEAP1 or activating Nrf2 can increase ROS levels and induce cancer cell death.
• DJ-1: regulates the expression of antioxidant genes. Inhibiting DJ-1 can increase ROS levels
• PARK2: regulates the expression of antioxidant genes. Inhibiting PARK2 can increase ROS levels
• SIRT1 inhibition:regulates the expression of antioxidant genes. Inhibiting SIRT1 can increase ROS levels
• AMPK activation: regulates energy metabolism and can increase ROS levels when activated.
• mTOR inhibition: regulates cell growth and metabolism. Inhibiting mTOR can increase ROS levels
• HSP90 inhibition: regulates protein folding and can increase ROS levels when inhibited.
• Proteasome: degrades damaged proteins. Inhibiting the proteasome can increase ROS levels
• Lipid peroxidation: a process by which lipids are oxidized, leading to the production of ROS.
    -Increasing lipid peroxidation can increase ROS levels
• Ferroptosis: form of cell death that is regulated by iron and lipid peroxidation.
    -Increasing ferroptosis can increase ROS levels
• Mitochondrial permeability transition pore (mPTP): regulates mitochondrial permeability.
    -Opening the mPTP can increase ROS levels
• BCL-2 family proteins: regulate apoptosis and can increase ROS levels when inhibited.
• Caspase-independent cell death: a form of cell death that is regulated by ROS.
    -Increasing caspase-independent cell death can increase ROS levels
• DNA damage response: regulates the repair of DNA damage. Increasing DNA damage can increase ROS
• Epigenetic regulation: process by which gene expression is regulated.
    -Increasing epigenetic regulation can increase ROS levels

-PKM2, but not PKM1, can be inhibited by direct oxidation of cysteine 358 as an adaptive response to increased intracellular reactive oxygen species (ROS)

ProOxidant Strategy:(inhibit the Mevalonate Pathway (likely will also inhibit GPx)
-HydroxyCitrate (HCA) found as supplement online and typically used in a dose of about 1.5g/day or more
-Atorvastatin typically 40-80mg/day, -Dipyridamole typically 200mg 2x/day Combined effect research
-Lycopene typically 100mg/day range (note debatable as it mainly lowers NRF2)

Dual Role of Reactive Oxygen Species and their Application in Cancer Therapy 
ROS-Inducing Interventions in Cancer — Canonical + Mechanistic Reference
-generated from AI and Cancer database
ROS rating:  +++ strong | ++ moderate | + weak | ± mixed | 0 none
NRF2:        ↓ suppressed | ↑ activated | ± mixed | 0 none
Conditions:  [D] dose  [Fe] metal  [M] metabolic  [O₂] oxygen
             [L] light [F] formulation [T] tumor-type [C] combination




Item ROS↑ NRF2 Condition Mechanism Class Remarks 



ROS">Piperlongumine
+++ ↓ [D][T] ROS-dominant






ROS">Shikonin
+++↓/±[D][T]ROS-dominant






ROS">Vitamin K3 (menadione)
+++↓[D]ROS-dominant






ROS">Copper (ionic / nano)
+++↓[Fe][F]ROS-dominant






ROS">Sodium Selenite
+++↓[D]ROS-dominant






ROS">Juglone
+++↓[D]ROS-dominant






ROS">Auranofin
+++↓[D]ROS-dominant






ROS">Photodynamic Therapy (PDT)
+++0[L][O₂]ROS-dominant






ROS">Radiotherapy / Radiation
+++0[O₂]ROS-dominant






ROS">Doxorubicin
+++↓[D]ROS-dominant






ROS">Cisplatin
++↓[D][T]ROS-dominant






ROS">Salinomycin
++↓[D][T]ROS-dominant






ROS">Artemisinin / DHA
++↓[Fe][T]ROS-dominant






ROS">Sulfasalazine
++↓[C][T]ROS-dominant






ROS">FMD / fasting
++↓[M][C][O₂]ROS-dominant






ROS">Vitamin C (pharmacologic)
++↓[Fe][D]ROS-dominant






ROS">Silver nanoparticles
++±[F][D]ROS-dominant






ROS">Gambogic acid
++↓[D][T]ROS-dominant






ROS">Parthenolide
++↓[D][T]ROS-dominant






ROS">Plumbagin
++↓[D]ROS-dominant






ROS">Allicin
++↓[D]ROS-dominant






ROS">Ashwagandha (Withaferin A)
++↓[D][T]ROS-dominant






ROS">Berberine
++↓[D][M]ROS-dominant






ROS">PEITC
++↓[D][C]ROS-dominant






ROS">Methionine restriction
+↓[M][C][T]ROS-secondary






ROS">DCA
+±[M][T]ROS-secondary






ROS">Capsaicin
+±[D][T]ROS-secondary






ROS">Galloflavin
+0[D]ROS-secondary






ROS">Piperine
+±[D][F]ROS-secondary






ROS">Propyl gallate
+↓[D]ROS-secondary






ROS">Scoulerine
+?[D][T]ROS-secondary






ROS">Thymoquinone
±±[D][T]Dual redox






ROS">Emodin
±±[D][T]Dual redox






ROS">Alpha-lipoic acid (ALA)
±↑[D][M]NRF2-dominant






ROS">Curcumin
±↑/↓[D][F]NRF2-dominant






ROS">EGCG
±↑/↓[D][O₂]NRF2-dominant






ROS">Quercetin
±↑/↓[D][Fe]NRF2-dominant






ROS">Resveratrol
±↑[D][M]NRF2-dominant






ROS">Sulforaphane
±↑↑[D]NRF2-dominant






ROS">Lycopene
0↑—Antioxidant






ROS">Rosmarinic acid
0↑—Antioxidant






ROS">Citrate
00—Neutral


Scientific Papers found: Click to Expand⟱
6237- CUSP9,    CUSP9* treatment protocol for recurrent glioblastoma: aprepitant, artesunate, auranofin, captopril, celecoxib, disulfiram, itraconazole, ritonavir, sertraline augmenting continuous low dose temozolomide
- NA, GBM, NA
PI3K↓, Akt↓, ROS↑, NF-kB↓, TNF-α↓, TLR2↓, other↓, TrxR↓, STAT3↓, MMPs↓, COX1↓, COX2↓, CA↓, ALDH↓, P-gp↓, HH↓, 5LO↓, mTOR↓, CycD3↓, Proteasome↓, other↓, MMP2↓, MMP9↓, ALDH↓, Copper↓,
6238- CUSP9,    A phase Ib/IIa trial of 9 repurposed drugs combined with temozolomide for the treatment of recurrent glioblastoma: CUSP9v3
- Trial, GBM, NA
toxicity↓, TrxR↓, ROS↓, TumCI↓, TumCMig↓, TumCA↓, MMP2↓, MMP9↓, COX2↓, ALDH↓, TumAuto↑, P-gp↓, eff↑,

Showing Research Papers: 1 to 2 of 2

* indicates research on normal cells as opposed to diseased cells
Total Research Paper Matches: 2

Pathway results for Effect on Cancer / Diseased Cells:


Redox & Oxidative Stress ⓘ

Copper↓, 1,   ROS↓, 1,   ROS↑, 1,   TrxR↓, 2,  

Cell Death ⓘ

Akt↓, 1,   Proteasome↓, 1,  

Transcription & Epigenetics ⓘ

other↓, 2,  

Autophagy & Lysosomes ⓘ

TumAuto↑, 1,  

Cell Cycle & Senescence ⓘ

CycD3↓, 1,  

Proliferation, Differentiation & Cell State ⓘ

ALDH↓, 3,   HH↓, 1,   mTOR↓, 1,   PI3K↓, 1,   STAT3↓, 1,  

Migration ⓘ

5LO↓, 1,   CA↓, 1,   MMP2↓, 2,   MMP9↓, 2,   MMPs↓, 1,   TumCA↓, 1,   TumCI↓, 1,   TumCMig↓, 1,  

Barriers & Transport ⓘ

P-gp↓, 2,  

Immune & Inflammatory Signaling ⓘ

COX1↓, 1,   COX2↓, 2,   NF-kB↓, 1,   TLR2↓, 1,   TNF-α↓, 1,  

Drug Metabolism & Resistance ⓘ

eff↑, 1,  

Functional Outcomes ⓘ

toxicity↓, 1,  
Total Targets: 30

Pathway results for Effect on Normal Cells:


Total Targets: 0

Scientific Paper Hit Count for: ROS, Reactive Oxygen Species
Query results interpretion may depend on "conditions" listed in the research papers.
Such Conditions may include : 
  -low or high Dose
  -format for product, such as nano of lipid formations
  -different cell line effects
  -synergies with other products 
  -if effect was for normal or cancerous cells

Filter Conditions: Pro/AntiFlg:%  IllCat:%  CanType:%  Cells:%  prod#:296  Target#:275  State#:%  Dir#:%
  wNotes=0  sortOrder:rid,rpid

 

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