The Di Bella Method (DBM) in the treatment of prostate cancer: a preliminary
retrospective study of 16 patients and a review of the literature
Giuseppe DI BELLA 1, Fabrizio MASCIA 1, Biagio COLORI 2
1 Di Bella Foundation, Via Guglielmo Marconi, 51 40122 Bologna, Italy
2 Rizzoli Scientific Research and Care Institute, Via Giulio Cesare Pupill, 40136 Bologna, Italy Correspondence to:
Dr. Giuseppe Di Bella
Di Bella Foundation, Via Marconi 51, Post code 40122, Bologna, Italy.
tel: +39 051 239662; fax: +39 051 2961238; e-mail: [email protected]
To evaluate the objective clinical response and the safety of the combined administration of
somatostatin, melatonin, retinoids, vitamin D3, dopamine subtype 2 receptor (D2R) agonists and low
doses of cyclophosphamide, associated with androgen ablation, in patients with a histological
diagnosis of prostate adenocarcinoma (Pac).
Materials and Methods:
The clinical data of 30 patients with non-invasive and metastatic prostate
cancer, who attended our institution over a period of more than 5 years, were retrospectively
16 patients satisfied the evaluation criteria. Median age: 64 years. Disease stages: 8 patients
(50%) were in Stage II. For advanced stages (Stage IV), secondary lesions were located in the bones
and lymph nodes. Taken together, an overall objective response (OR) [Complete response (CR) +
Partial Response (PR)] was achieved in 69 % of the patients, with 88 % of objective clinical benefit
[CR+PR+SD]. For local Prostate Cancer group,
an OR was achieved in 87,5% of patients (7 cases;
53-98; 95% CI), with CR in 62,5 % (5 cases, 31–86; 95% CI). In metastatic disease, the OR was 50%
(4 cases; 21–78; 95% CI), with a 20% of CR (2 cases; 7-59; 95% CI) and 75% of clinical benefit.
This preliminary study shows that patients with early and advanced forms of prostate
cancer, not previously treated by surgery and/or chemo-radiotherapy, can achieve a more than
positive clinical benefit with the protocol foreseen by the Di Bella Method
. Further clinical
investigations are strongly recommended.
: Prostate Cancer, somatostatin/octreotide; melatonin; retinoids; vitamins E, D3, C;
Bromocriptine; Cabergoline, androgen deprivation
The main therapeutic strategies currently employed for the treatment of Pac are surgery (laparoscopy
), chemotherapy and radiation therapy (external beam radiation and/or LDR
and HDR brachytherapy, IMRT
), often associated with hormone therapy (LH-RH agonists, anti-
androgens). Although these treatments have achieved modest results in terms of survival, the
anticancer efficacy is usually limited to remission while cases of actual stable cure are considerably
limited. This is mainly due either to the tumor clonal heterogeneity, which makes them less responsive
to such treatments, and to the complexity of their cellular pathways; even after several new molecules
were provided during the last decade (Bostwick et al.
2005). In fact, the removal of just one causal
factor (like androgen)/ single target by using the latest generation of monoclonal antibodies obviously
cannot eradicate a complex multifactor disease like cancer. A series of concepts forming the basis of
the Di Bella (DBM) have recently been assessed and applied, including the combined use of "multiple
molecular target" agents; and experimental investigations confirming the biochemical basis and the
clinical responses of these therapeutic concepts are continually increasing in number (Sluka et al.
2006). Especially as regards basic research, these investigations are clearly
demonstrating the crucial oncogenic, ubiquitary and interactive role of growth hormone (GH) and
Prolactin (PRL) in every type of tumor. These pituitary hormones thus also strongly affect both the
development and differentiation of Pac. Finally, translational and clinical studies confirm the use of
the respective neoplastic growth inhibitors, reporting considerable benefits in terms of clinical
response and safety/tolerability (Xu et al.
2004; Schally et al.
2000). In the present
study, we report the preliminary results achieved from the administration of biological molecules (Di
Bella Method, DBM) in 30 patients affected by local and metastatic prostate cancer.
MATERIALS AND METHODS
Patient selection criteria.
Only patients with a diagnosis of prostate cancer and with the measurable
disease characteristics according to RECIST (Vergote et al.
2000) were evaluated. All patients gave
informed consent, agreeing to the administration of the biological approach as first line therapy.
This patient collection was divided into two main groups:
Group A: patients with local/non-invasive prostate cancer (Stage II: pT2, N0, M0)
Group B: patients with metastatic prostate cancer (Stage IV: any pT, any N, M1)
. All patients received a daily dose of Somatostatin (SST), Melatonin (ML), Retinoids
solubilized in Alfa Tocopheryl Acetate, D2R dopamine agonists, androgen inhibitors and minimal
doses of cyclophosphamide. In detail, these were administered as follows: solution of all-trans-
retinoic acid (ATRA, 46662 IU), axeroftole palmitate (25452 UI), beta-carotene (93352 IU) in alfa
tocopheryl acetate (38,08 IU), at the stochiometric ratio of 1:1:4:2; gradual dosage;
dihydrotachysterol (cholecalciferol-Vit.D3, ATITEN; 15200 IU). Somatostatin tapered
administration: 1 mg the first week, increasing by 1 mg a week up to 3 mg at treatment day 21;
Tetracosactide (Synachten® - synthetic ACTH) with frequent blood pressure and blood sugar
monitoring: 0.25 mg twice a week intramuscularly; slow-release octreotide 20 mg every month
intramuscularly; melatonin 5 mg per os:
10 mg in the morning, at midday, and in the evening at
mealtimes plus 40 mg before bedtime (overall daily dose = 70 mg); Cabergoline (Parlodel®) 0.25 mg
at midday (half a 0.5 mg tablet) twice a week along with Bromocriptine (Dostinex®) 2.5 mg
1 tablet morning and evening; Cyclophosphamide (ENDOXAN® 50 mg) per os,
starting with 1 tablet a day, after one week 1 tablet in the morning and 1 in the evening;
Ascorbic Acid (Vit C) per os
, gradual dosage (2g = 40000 IU) in a glass of water at midday and in
the evening during meals, with 500 mg of calcium in the same glass; Taurine (500 mg) one tablet in
the morning and in the evening; Chondroitin sulphate (500 mg) one tablet in the morning, at midday
and in the evening during meals; Intrafer® 20 drops with the main meal; Calcium levofolinate 22 mg
one tablet a day. More details regarding methods of administration, concentrations and respective
doses are provided in Table 5.
Evaluation of the response to treatment of the target lesions (Efficacy):
Statistical and Analytical
Methods: the criteria for evaluation of the objective response refer to the guidelines adopted by the
World Health Organization (WHO handbook
) and the Response Evaluation Criteria in Solid Tumors
(Patrick T et al.
2000). These are divided into Overall Response (OR); Complete Response
(PR); Progressive Disease
(PD); Stable Disease
(SD), expressed as absolute
frequency (n), relative frequency (%) plus 95% Confidence Interval (95% CI).
Safety and Toxicity Evaluation
. To evaluate toxicity, only the adverse events that could potentially
be correlated with the treatment were considered (degrees of correlation: possible, probable or
expressed as absolute frequency (n), relative frequency (%), and 95% Confidence Interval
This study was carried out in accordance with the directives established by the Declaration of
. All patients therefore gave their informed consent for the collection and supervision of their
own clinical data.
The biological therapy - DBM was administered as first line treatment to a total of 30 patients who
attended our institution over a period of more than 5 years. The patients were monitored from 2009
to 2012 (median follow-up
16 months, min 5, max 37). Sixteen (16) of these patients fulfilled the
inclusion criteria and their clinical records were therefore retrospectively assessed. As regards the
excluded cases (14), 8 did not have any hystological diagnosis while 6 patients did not followed the
regimen continuously (see flow-chart). Table 1 shows the baseline characteristics of the patients at
the time of their first visit: median age 64 years (range 40-74 years), disease stage = grade 6 and 7
(Gleason Score) in 37,5 % and 62,5 % of the patients respectively. The histotype of the primary
lesions was Prostate adenocarcinoma
(Pca), while bones and lymph nodes represented the main
metastatic sites. Taken together, an overall response (OR) [Complete response (CR) + Partial
response (PR)] was observed in 69 % of the patients (11 Cases, 44-86 95% CI), with a Complete
Response equal to 44% (7 cases; 23–67; 95% CI). In addition, 87.5% (14 cases; 57-93; 95% CI) of
the patients achieved an objective clinical benefit [CR+PR+SD] (Table 3). Group A (Local/Non
Invasive Prostate Cancer,
Stage II, pT2, NA= 8):
an OR (CR+PR) was observed in 87,5% of the
patients (7 cases; 41-93; 95% CI), with a CR in 83% of the cases (n=5, 22–79; 95% CI). The mean
time to the first objective clinical response was 6 months: furthermore, all the patients obtained a
clinical benefit [CR+PR+SD]. For patients with metastatic disease (Group B, Metastatic,
pT2, any N, M1, NB=8)
, the OR (CR + PR) was 50% (4 cases; 22–79; 95% CI), with a CR in 25% of
the cases (2 patients; 7-59; 95% CI). Six cases (75%) achieved a clinical benefit [CR+PR+SD] (Fig.
Evaluation of the safety
The most frequent transitory signs of toxicity (grade II) were as follows: haematological (mild
leukopenia 61.5 %), gastrointestinal (Nausea, 30 %), and tiredness (8%). Reduction, suspension or
discontinuation of the treatment due to toxicity was necessary in patients with leukopenia (suspension
of cyclophosphamide until normal blood count values were restored), and in cases of gastrointestinal
Rationale of the treatmen and review of the literature
A greater understanding of the biological and physiological basis of cancer ethiopathology has
gradually led to the identification of new molecular cues involved in these complex cellular pathways
and to propose new evermore specific strategies for the treatment of hormone-dependent tumors (e.g.
breast cancer and Pca). It is well known that cellular growth mechanisms of prostate cancer are mainly
based on the androgenic action and on the concomitant neuroendocrine action, with special reference
to the role of other growth factors (GFs) released both by the hypothalamic-pituitary axis (Growth
Hormone Release Hormone
, GHRH; GH and PRL) and systemically (Takanara et al.
2011). Agonists and antagonists molecules of the luteinizing
hormone release hormone (LHRH), antagonists of gastrin and mammal bombesin homologues,
growth hormone release hormones (GHRH), somatostatin analogues and dopaminergic agonists were
in fact evaluated (Xu et al.
2012; Schally at al, 2000). Although their use in clinical practice has been
limited to neuroendocrine tumors (NET), there is increasing significantly important evidence in the
literature both of their gene expression and receptorial immunohistochemical localization/co-
localization in several non-NET: similar data were also obtained for Vasoactive Intestinal Peptide
(VIP) and somatostatin (SSTR), whose expression has been detected both in various forms Pca, in its
precursor (HGPIN) and normal epithelium (Nep) (Mazzucchelli et al.
2012). Similarly, significant
results have been observed for all types of non-NET, providing further evidence of the rationale of
the DBM with somatostatin analogues combined with cytostatic and differentiating molecules used
as a "receptorial target biological therapy" against the tumor phenotype (Di Bella G, 2010). This
strategy extends its action to the different stations of the hypothalamic-pituitary-hepatic axis and is
not limited to the simple direct activation of the antiproliferative pathway et. al, 2009). In
fact, the other fundamental, indirect anticancer mechanism is achieved by reducing the bioavailability
of GH, hepatic somatomedines (IGF-I) and all the GH-dependent GFs, released in the tumor
microenvironment responsible for tumor progression phenomena, such as cancer cell motility,
methastasis and clonal heterogenecity (Russel et al.
1998). Reduced GH bioavailability therefore
inhibits neoplastic angiogenesis, negatively regulating the growth factor's releasing, and so the
angiogenesis-promoting molecules of the systemic microenvironment of the tumor with a
strong/significant antiblastic efficacy al.
2009; Erten et al.
2009). It has also been
observed that this biological approaches restores the responsiveness of tissues towards antiandrogens,
thereby obtaining objective clinical responses. At the same time, the crucial role of the D2R receptors
has been confirmed, both in the direct control of cell growth and in the antiproliferative interaction
with somatostatin: their proliferation pathway is in fact significantly inhibited when this particular
subclass of receptors synergically cross-talk in association with the SST5 receptorial subclass
(SSTR5) et al.
2010). This type of androgen deprivation allows an up-regulation of the SSTR
receptors, thus increasing the probability of a positive response (Mazzucchelli et al.
2011). It has also
be shown that tochopherole, another component belonging to the DBM, increases such receptorial
expression of somatostatin, with evident increase of the antiproliferative effects. The cytostatic-
antiproliferative properties of SST in prostate cancer are mediated in their pathway by the citosolic
phosphotyrosine phosphatase (SHP-1). Finally, these data suggest a dynamic receptorial interaction
induced by the ligands SST and Bromocripine/Cabergoline, whose interplay might be fundamental
for a marked anticancer action (Zapata et al.
2004). This increase in antiproliferative responsiveness
is further obtained by the primary contribute of Melatonin (ML), retinoids and Vitamin D3; whose
antitumoral properties are well known: ML exerts many antiproliferative properties by promoting cell
differentiation towards the neuroendocrine phenotype (epigenetic-control), the latter being
characterised by androgen-dependent type growth et al.
2010). The cell differentiation
promoted by ML is not exclusively mediated by the protein kinase A (PKA) activation (although this
temporarily increases the intracellular levels of cyclic adenosine mono-phosphate, cAMP).ML also
markedly affects the proliferative condition of the prostate cancer cells by acting through their
membrane and nuclear cellular/nuclear receptorial pathways. Together with the above data, our
results indicate the antiproliferative synergism between melatonin and androgen deprivation in
androgen-sensitive tumors. This dual action of such antiproliferative signal suggests a specific
mediation of the MT1 receptorial pathway towards the down-regulation of the AR-dependent signal
and and an up-regulation of the p27 gene expression. The phenotype changes caused by the chronic
treatment of this indolamine thus make the cells more responsive to the action of cytokines (TNF-
alfa and TRAIL), SST, androgenic antagonists and some chemotherapy components, if administered
at low doses (metronomic chemotherapy). (Rodriguez-Garcia et al.
2012et al. et
2009, Siu et al. et al.
1995). Another important contribute is provided by
cholecalciferol, acting through its nuclear receptor VDR (Leyssens et al.
2013). Actually, It has be
well known that this type of lyposoluble pro-hormone exerts several oncosuppressive activities, also
by interacting with the other components of the multitherapy in inhibiting cancer cell proliferation
and in triggering the apoptosis cascade, differentiation, reduction of cell invasion, angiogenesis, and
migration/invasion (extracellular inhibition/gene downregulation of Matrix Metalloproteinases MMP
and the expression of the cell membrane adhesion molecules and promotion of cell adhesion through
an increase in the expression of E-caderine, regulation of the chemotaxis of adhesion cells towards
the blood circulation, with an antimetastatic effect) both in vitro
and in vivo
(Yin Y et al 2009). In
addition, the synthesis of the prostaglandins and the Wnt/b-catenine signal are also influenced by
vitamin D3 and analogues al.
2011). Finally, retinoid
are a family of organic compounds that are used for the treatment of various diseases, also including
many forms of tumors of the blood. This class of molecules are fundamental for the normal
development of the prostate and negatively regulate the growth of various prostate cancer cell lines
and their progression in vivo
. Among the retinoid, all-trans-retinoic acid (ATRA) has been widely
studied, showing a marked differentiating activity. One of the mechanisms of action consists of the
reduction of methylation processes (epigenetic modulation) at the level of the HOX genes (HOXB3)
and the regulation of the formation of gap junctions in androgen-responsive prostate cancer cells (Liu
2012; Kelsey et al.
2012). Overall, numerous in vivo
and in vitro
studies have shown that ATRA
slows down tumor cell proliferation, inducing apoptosis (surviving down-regulation). One of the
anticancer mechanisms is represented by the selective regulation (p21 and p27) with which ATRA is
able to inhibit the typical proliferative processes of prostate cancer. Since the retinoid act by inducing
cell differentiation and maturation, it is clear that they are probably of use in reversing neoplastic
pathogenesis (Benelli Et al.
2010). Other recent molecular targets include retinoid receptors (RAR
and RXR), glucocorticoid receptors (GR), oestrogen receptors (ER) and the receptors activated by
Although our preliminary results are based on a relatively small number of subjects, they suggest that
patients affected by local and/or metastatic prostate cancer, can achieve encouraging results with the
combination of the above mentioned biological approach. A further support is given by the several
pre-clinical and clinical investigation that are gradually suggesting the potential antitumoral role of
the biological compound belonging to the DBM. Since the results regarding surgical – radiotherapy
standard treatments are contradictory and because it has been recently shown that chemotherapy
improves prostate cancer resistance and progression (Sun et al.
2012), we suggest further clinical
studies in order to investigate the first line use of this multimodal treatment and its putative application
in medical oncology.
1. Gatto F, Ruscica M et al
Somatostatin and dopamine receptor interaction
in prostate and lung cancer cell linesDec;207(3):309-17.
2. Monteghirfo S, Venè R et al.
(2010). The chemopreventive retinoid 4HPR impairs
prostate cancer cell migration and invasion by interfering with FAK/AKT/GSK3beta pathway
and beta-catenin stabilit Jun 10;9:142. doi: 10.1186/1476-4598-9-142.
3. Bostwick et al.
(2005) eds. American Cancer Society's Complete Guide to Prostate Cancer
Atlanta, Ga: American Cancer Society.
5. Di Bella G. (2010). The Di Bella Method. Neuro Endocrinol Lett;31 Suppl 1:1-42. Review
6. Karaca B, Kucukzeybek Y et al.
(2009). Regulation of growth factors in hormone
and drug resistant prostate cancer cells by synergistic combination of docetaxel and octreotide.
7. Weinberg VK, Small EJ et al.
(2012). Effect of the somatostatin analog
octreotide acetate on circulating insulin-like growth factor-1 and related peptides in patients
with non-metastatic castration-resistant prostate cancer: results of a phase II study.
8. Hoang DT, Bogorad RL, Nevalainen MT. (2011). Prolactin regulation of the
prostate gland: a female player in a male gamOct 4;8(11):597-607
9. et al.
(2011). Suppression of prostate cancer cell rolling
and adhesion to endothelium by 1α,25-dihydroxyvitamin Feb;178(2):872-
10. Katoch P, Johnson KE et al.
(2013). Retinoids regulate the formation and
degradation of gap junctions in androgen-responsive human prostate cancer c
2013 Mar 22;20(2):R31-47. doi: 10.1530/ERC-12-0381. Print 2013 Apr.
11. et al.
(2006). Combination therapy using
LHRH and somatostatin analogues plus dexamethasone in androgen ablation refractory
prostate cancer patients with bone involvement: a bench to bedside app
12. (2004). Effective treatment of
experimental androgen sensitive and androgen independent intraosseous prostate cancer
with targeted cytotoxic somatostatin analogue AN-Feb;171(2 Pt 1):911-5.)
13. Leyssens C, Verlinden L, Verstuyf M. (2013). Antineoplastic effects of 1, 25(OH)2D3 and its
analogs in breast, prostate and colorectal cancer. Mar 22;20(2):R31-
14. Dondi D, Marelli MM et al.
15. (2009). Somatostatin and somatostatin receptors:
implications for neoplastic growth and cancer biology.
16. Morichetti D, Santinelli A et al.
(2011). Immunohistochemical expression
and localization of somatostatin receptor subtypes in androgen ablated prostate cancer. Cell
Oncol (Dordr). Jun;34(3):235-43
17. Scarpelli M, Lopez-Beltran A et al.
expression and localization of somatostatin receptors in normal prostate, high grade prostatic
intraepithelial neoplasia and prostate cancer and its many
18. , (2013). Differential effects of
exogenous and autocrine growth hormone on LNCaP prostate cancer cell proliferation and
19. Delansorne R, Wakimoto N, et al.
(2012). Inecalcitol, an analog of
1α,25(OH)(2) D(3), induces growth arrest of androgen-dependent prostate cancer cells.
20. Hwang MS, Suh SI, Baek WK (2009). Melatonin down-regulates HIF-1 alpha
expression through inhibition of protein translation in prostate cancer cel
21. Mayo JC, Hevia D et al.
(2012). Phenotypic changes caused by
melatonin increased sensitivity of prostate cancer cells to cytokine-induced apoptosis.
May 31. doi: 10.1111/j.1600-079X.2012.01017.x. [Epub ahead of print]
22. (1998). Growth factor involvement in progression of
23. Comaru-Schally AM, Plonowski A et al. (2000). Peptide analogs in the
therapy of prostate cancer.Oct 1;45(2):158-66.
24. Leung WY, Tam CW et al.
(2012). Melatonin MT(1) receptor-induced
transcriptional up-regulation of p27(Kip1) in prostate cancer antiproliferation is mediated via
inhibition of constitutively active nuclear factor kappa B (NF-κB): potential implications on
prostate cancer chemoprevention and therJun 20. doi: 10.1111/j.1600-
079X.2012.01026.x. [Epub ahead of print]
25. Lau KW, Tam PC,et al.
(2002). Melatonin and prostate cancer cell
proliferation: interplay with castration, epidermal growth factor, and androgen sensitivity.
26. (2013). Cell mates: paracrine and stromal targets for prostate cancer
27. , Martinesi M, Simoni A et al.
(2011). The novel vitamin D analog ZK191784 inhibits
prostate cancer cell Dec;31(12):4091-8.
28. Sun Y, Campisi, J, Higano C et al
. (2012). Treatment-induced damage to the tumor
microenvironment promotes prostate cancer. Therapy resistance through WNT16B. Nat. Med
29. Chan KW, Liu VW et al.
(2008). Melatonin as a negative mitogenic hormonal
regulator of human prostate epithelial cell growth: potential mechanisms and clinical
30. et al.
(2013). The influence of growth hormone/insulin-like
growth factor deficiency on prostatic dysplasia in pbARR2-Cre, PTEN knockout mice.
31. Vergote I. et al.
(2000). New Guidelines to Evaluate the Response to Treatment in Solid
Tumors. J Natl Cancer Inst
. Sep 20;92(18):1534-5
32. (2012). New agonist and antagonist-based treatment approaches for
advanced prostate cance4):1217-26.
33. Colas B, López-Ruiz P et al.
(2004). Phosphotyrosine phosphatase SHP-1,
somatostatin and prostate cancer. [Article in Spanish]Apr;28(4):269-85.
TABLES & FIGURES
patient enrolment criteria.
Rel. Freq (%)
( Min – Max )
Site of the
: Summary of Clinical Data at baseline visit
Global effectiveness with DBM in Prostate Cancer (Groups A+B). Response Rates (N=16). CR: Complete
remission; SD: Stable disease, PR: Progression. * Dead patients
Group A (Local/non-invasive prostate adenocarcinoma, NA= 8). Overall objective responses.
Group B (Metastatic prostate adenocarcinoma, NB= 8). Overall objective responses. * Dead patients
14 aa peptide
(nightly, 12 hours of
Octreotide Acetate 8 aa
Melatonin 12 %
Adenosine 51 % Glycine 37 %
Alfa Tocopheryl Acetate
+ Calcium carbonate
DBM Therapeutical Regimen. * These molecules are mixed in solution form, a formulation which allows
maximum bioavailability. The daily dose is calculated on the basis of body weight decimals; **** Can be used together
with or instead of Bromocriptine.
Safety Data Sheet according to Regulation (EC) No1907/2006 SDS No. : 76601 TEROSON SB 2444 known as TEROKAL 2444 TB 175GR Revision: 17.09.2014 printing date: 21.11.2014 SECTION 1: Identification of the substance/mixture and of the company/undertaking 1.1. Product identifier TEROSON SB 2444 known as TEROKAL 2444 TB 175GR
1.0 INTRODUCTION TO THE STUDY Forum Syd, a Swedish Non Governmental Organization (NGO) working together with The Livelihoods Foundation (LEO), a Kenyan NGO to support the Empowerment of Rural Population in Nyatoto Community in Central Division of Homa Bay County in Kenya, Africa. Forum Syd has solicited support from SIDA, Sweden to fulfill this objective. LEO