Dual activation of PPARα/γ by bezafibrate triggers PINK1/Parkin-Mediated mitophagy to enhance lenvatinib sensitivity in hepatocellular carcinoma

Lenvatinib resistance, driven by metabolic adaptation and angiogenic escape, poses a major challenge in hepatocellular carcinoma (HCC) therapy. This study explores bezafibrate, a clinically approved Peroxisome Proliferator-Activated Receptor Alpha or Gamma (PPARα/γ) dual agonist, to enhance lenvatinib sensitivity by inducing PTEN-Induced Putative Kinase 1(PINK1)/ Parkin-mediated mitophagy. Using SNU-739/HepG2 cells, we investigated bezafibrate’s anti-tumor efficacy alone and in combination with lenvatinib. The results demonstrated that bezafibrate alone exhibits anti-tumor efficacy in HCC and enhances the anti-HCC efficacy of lenvatinib. It was observed that bezafibrate activated PPARα, increasing fatty acid oxidation (FAO) via Carnitine Palmitoyltransferase IA (CPT1A)/ Acyl-CoA Oxidase 1(ACOX1) upregulation, leading to elevated ROS and reduced mitochondrial membrane potential (ΔΨm). It also activated PPARγ, which bound to PINK1 with high affinity (ΔG = −64.6 kcal/mol). Dual PPARα/γ activation by bezafibrate enhanced Parkin recruitment and promoted mitophagic cell death, characterized by reduced p62 and Translocase of Outer Mitochondrial Membrane 20 (TOM20), increased LC3-II, decreased ATP, and elevated Annexin V-positive cells. This approach demonstrated efficacy, inducing PINK1/Parklin-mediated mitophagy and reducing VEGF-A/C and EGFR in vitro, and decreasing tumor volume and weight in a syngeneic H22 mouse model compared to lenvatinib alone, without significant toxicity. In conclusion, bezafibrate, through PPARα/γ-mediated PINK1/Parkin activation and angiogenic suppression, complements lenvatinib’s therapeutic effects in HCC, providing a rationale for clinical evaluation to address treatment resistance.