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Glioblastoma is a severe cancer with extremely poor survival. Its treatment typically involves a combination of surgery, chemotherapy, and radiation therapy. However, glioma stem-like cells (GSCs)-a subpopulation of tumor-propagating glioblastoma cells—cause post-treatment recurrence and are a major factor in the poor prognosis of the disease. GSCs have higher proliferation than non-GSCs and are more resistant to invasive chemotherapy and radiotherapy. In this study, we subjected GSCs to nutrient starvation (deprived of glucose, glutamine, and calcium) to determine whether cell death can be triggered as a potential strategy to improve treatment outcomes. Flow cytometry revealed that 35.1%, 96.1%, and 99.9% of starved GSCs underwent apoptosis on days 1, 3, and 5, respectively, along with nearly 100% autophagy on all three days. Western blots detected cleaved caspase-3 (an apoptosis marker) and phospho-beclin 1, LC 3B-I, LC 3B-II (autophagy markers) in C6 GSCs after nutrient starvation for 1, 3, 4, and 5 days. Transmission electron microscopic observation of GSC ultrastructure after starvation treatment revealed that compared with control GSCs, starved cells had more pyknotic nuclei, membrane bleb, swollen endoplasmic reticulum, degenerative mitochondria, lipid droplets, and microvilli loss. Thus, nutrient starvation stresses cells by increasing free radicals. Cell stress opens more channels between mitochondria and endoplasmic reticulum. This study demonstrated that nutrient starvation decreases proliferation by approximately 81%, while increasing apoptosis (99.9%) and autophagy (94.6%) in C6 GSCs by the fifth day. Nutrient starvation of GSCs may, therefore, be an effective therapeutic strategy that can trigger apoptotic and autophagic metabolic reprogramming in cancer cells., C6 glioma stem cells, Nutrient starvation, Apoptosis, Autophagy.

Glioblastoma (GBM) is the most commonly diagnosed type of brain cancer and the leading cause of brain cancer-related death. GBM contains a subpopulation of tumor-propagating glioblastoma stem-like cells that are thought to drive cancer progression and recurrence. Although several clinical trials are ongoing to explore new chemotherapeutic agents to treat GBM, the use of metformin (Met), a first-line drug for type 2 diabetes mellitus, in cancer remains controversial. Here, we show that combining Met with 9-cis retinoic acid (9-cis RA) reduced the proliferation rate of C6-GSCs (glioblastoma stem-like cells) in vitro. The results of flow cytometric analysis showed that treatment with 9-cis RA for 24 h induced 4.5% early and 38.0% late apoptosis in C6-GSCs. Twenty-four hours of Met treatment induced 23.6% early and 33.5% late apoptosis in C6-GSCs. Combination of Met and 9-cis RA treatment significantly increased both early and late apoptosis to 30.4% and 55.4%, respectively. The present findings suggest that not only 9-cis RA but also Met has the potential to induce early and late apoptotic GSCs death by affecting the functional cytoplasmic and nuclear organelles. At the protein level, there was increased cleaved caspase-3 but decreased procaspase-3 expression in Met-, 9-cis RA- and Met+9-cis RA-treated C6 GSCs, as detected by western blotting. The ratio of cleaved caspase-3/procaspase-3 was 1.6 times higher in Met+9-cis RA-treated groups compared to control. Ultimately, a combination of Met and 9-cis RA might be a possible therapeutic target for the treatment of GBM.