Physiological Mechanisms of Treatment Resistance

Significance of Specific Oxidoreductases in the Design of Hypoxia-Activated Prodrugs and Fluorescent Turn Off–On Probes for Hypoxia Imaging

Simple Summary

Hypoxia-activated prodrugs (HAPs), selectively reduced by specific oxidoreductases under hypoxic conditions, form cytotoxic agents damaging the local cancer cells. On the basis of the reported clinical data concerning several HAPs, one can draw conclusions regarding their preclinical attractiveness and, regrettably, the low efficacy of Phase III clinical trials. Clinical failure may be explained, inter alia, by the lack of screening of patients on the basis of tumor hypoxia and low availability of specific oxidoreductases involved in HAP activation. There is surprisingly little information on the quantification of these enzymes in cells or tissues, compared to the advanced research associated with the use of HAPs. Our knowledge about the expression and activity of these enzymes in various cancer cell lines under hypoxic conditions is inadequate. Only in a few cases were researchers able to demonstrate the differences in the expression or activity of selected oxidoreductases, depending on the oxygen concentration. Additionally, it was cell line dependent. More systematic studies are required. The optical probes, based on turning on the fluorescence emission upon irreversible reduction catalyzed by the overexpressed oxidoreductases, can be helpful in this type of research. Ultimately, such sensors can estimate both the oxidoreductase activity and the degree of oxygenation in one step. To achieve this goal, their response must be correlated with the expression or activity of enzymes potentially involved in turning on their emissions, as determined by biochemical methods. In conclusion, the incorporation of biomarkers to identify hypoxia is a prerequisite for successful HAP therapies. However, it is equally important to assess the level of specific oxidoreductases required for their activation.

Abstract

Hypoxia is one of the hallmarks of the tumor microenvironment and can be used in the design of targeted therapies. Cellular adaptation to hypoxic stress is regulated by hypoxia-inducible factor 1 (HIF-1). Hypoxia is responsible for the modification of cellular metabolism that can result in the development of more aggressive tumor phenotypes. Reduced oxygen concentration in hypoxic tumor cells leads to an increase in oxidoreductase activity that, in turn, leads to the activation of hypoxia-activated prodrugs (HAPs). The same conditions can convert a non-fluorescent compound into a fluorescent one (fluorescent turn off–on probes), and such probes can be designed to specifically image hypoxic cancer cells. This review focuses on the current knowledge about the expression and activity of oxidoreductases, which are relevant in the activation of HAPs and fluorescent imaging probes. The current clinical status of HAPs, their limitations, and ways to improve their efficacy are briefly discussed. The fluorescence probes triggered by reduction with specific oxidoreductase are briefly presented, with particular emphasis placed on those for which the correlation between the signal and enzyme expression determined with biochemical methods is achievable.

Correlation and colocalization of HIF-1α and pimonidazole staining for hypoxia in laryngeal squamous cell carcinomas: A digital, single-cell-based analysis

OBJECTIVE

Tumor hypoxia results in worse local control and patient survival. We performed a digital, single-cell-based analysis to compare two biomarkers for hypoxia (hypoxia-inducible factor 1-alpha [HIF-1α] and pimonidazole [PIMO]) and their effect on outcome in laryngeal cancer patients treated with accelerated radiotherapy with or without carbogen breathing and nicotinamide (AR versus ARCON).

MATERIALS AND METHODS

Immunohistochemical staining was performed for HIF-1α and PIMO in consecutive sections of 44 laryngeal cancer patients randomized between AR and ARCON. HIF-1α expression and PIMO-binding were correlated using digital image analysis in QuPath. High-density areas for each biomarker were automatically annotated and staining overlap was analyzed. Kaplan-Meier survival analyses for local control, regional control and disease-free survival were performed to predict a response benefit of ARCON over AR alone for each biomarker.

RESULTS

106 Tissue fragments of 44 patients were analyzed. A weak, significant positive correlation was observed between HIF-1α and PIMO positivity on fragment level, but not on patient level. A moderate strength correlation (r = 0.705, p < 0.001) was observed between the number of high-density staining areas for both biomarkers. Staining overlap was poor. HIF-1α expression, PIMO-binding or a combination could not predict a response benefit of ARCON over AR.

CONCLUSION

Digital image analysis to compare positive cell fractions and staining overlap between two hypoxia biomarkers using open-source software is feasible. Our results highlight that there are distinct differences between HIF-1α and PIMO as hypoxia biomarkers and therefore suggest co-existence of different forms of hypoxia within a single tumor.

Overexpression of bHLH domain of HIF-1 failed to inhibit the HIF-1 transcriptional activity in hypoxia

Background

Hypoxia inducible factor-1 (HIF-1) is considered as the most activated transcriptional factor in response to low oxygen level or hypoxia. HIF-1 binds the hypoxia response element (HRE) sequence in the promoter of different genes, mainly through the bHLH domain and activates the transcription of genes, especially those involved in angiogenesis and EMT. Considering the critical role of bHLH in binding HIF-1 to the HRE sequence, we hypothesized that bHLH could be a promising candidate to be targeted in hypoxia condition.

Methods

We inserted an inhibitory bHLH (ibHLH) domain in a pIRES2-EGFP vector and transfected HEK293T cells with either the control vector or the designed construct. The ibHLH domain consisted of bHLH domains of both HIF-1a and Arnt, capable of competing with HIF-1 in binding to HRE sequences. The transfected cells were then treated with 200 µM of cobalt chloride (CoCl₂) for 48 h to induce hypoxia. Real-time PCR and western blot were performed to evaluate the effect of ibHLH on the genes and proteins involved in angiogenesis and EMT.

Results

Hypoxia was successfully induced in the HEK293T cell line as the gene expression of VEGF, vimentin, and β-catenin were significantly increased after treatment of untransfected HEK293T cells with 200 µM CoCl₂. The gene expression of VEGF, vimentin, and β-catenin and protein level of β-catenin were significantly decreased in the cells transfected with either control or ibHLH vectors in hypoxia. However, ibHLH failed to be effective on these genes and the protein level of β-catenin, when compared to the control vector. We also observed that overexpression of ibHLH had more inhibitory effect on gene and protein expression of N-cadherin compared to the control vector. However, it was not statistically significant.

Conclusion

bHLH has been reported to be an important domain involved in the DNA binding activity of HIF. However, we found that targeting this domain is not sufficient to inhibit the endogenous HIF-1 transcriptional activity. Further studies about the function of critical domains of HIF-1 are necessary for developing a specific HIF-1 inhibitor.

Accomplices of the Hypoxic Tumor Microenvironment Compromising Antitumor Immunity: Adenosine, Lactate, Acidosis, Vascular Endothelial Growth Factor, Potassium Ions, and Phosphatidylserine

In this minireview, we aim to highlight key factors of the tumor microenvironment, including adenosine, lactate, acidosis, vascular endothelial growth factor, phosphatidylserine, high extracellular K⁺ levels, and tumor hypoxia with respect to antitumor immune functions. Most solid tumors have an immature chaotic microvasculature that results in tumor hypoxia. Hypoxia is a key determinant of tumor aggressiveness and therapy resistance and hypoxia-related gene products can thwart antitumor immune responses.

Blood flow and oxygenation status of prostate cancers

Hypoxia is a characteristic of many solid tumors, can lead to the development of an aggressive phenotype and acquired treatment resistance, and is an independent, adverse prognostic indicator. In this literature review, we show that hypoxia is also a typical feature in prostate cancer (PC), the most commonly diagnosed cancer among men in most western countries. Data on blood flow (a major determinant of oxygenation status in malignancies) and on the oxygenation status (as assessed by O(2)-sensitive electrodes) are presented. Where possible, data on prostate cancers are compared to normal prostate (NP) tissue and benign prostate hyperplasia (BPH). The average blood flow rate in NP is 0.21 vs. 0.28 mL/g/min in BPH. Blood flow in PC is approximately three times higher than in NP (mean flow: 0.64 mL/g/min) and shows pronounced intra- and inter-tumor variability. Despite relatively high flow rates in PC, the overall mean pO(2) in cancers is 6 mmHg compared to 26 mmHg in NP. As was the case with blood flow, tissue oxygenation was extremely heterogeneous with no clear dependency on a series of tumor (Gleason score, clinical size, androgen deprivation) and patient characteristics (serum PSA levels, age).

Intra- and intertumor heterogeneities in total, chronic, and acute hypoxia in xenografted squamous cell carcinomas. Detection and quantification using (immuno-)fluorescence techniques

BACKGROUND

Heterogeneously distributed hypoxia is a major characteristic of solid tumors. (Immuno-)fluorescence detection of hypoxia in experimental tumors is frequently assessed in a single central section; however, this may not necessarily be representative of the whole tumor. In order to determine whether analysis of one central section is exemplary of the whole tumor and whether different volumes have an impact on tumor oxygenation, we assessed the fractions of total (TH), chronic (CH), and acute hypoxia (AH) throughout different layers of tumors of varying volumes.

MATERIALS AND METHODS

Xenografted FaDu human squamous cell carcinomas of different volumes were investigated for intra- and intertumor heterogeneities. Tissue blocks located at the apical, central, and basal layer were sliced from individual tumors. Four serial cryosections were analyzed from each tissue block. Vital tumor tissue was explored for the distribution of Hoechst 33342 (perfusion), pimonidazole (hypoxia), and CD31 (endothelium) to assess TH, CH, and AH.

RESULTS

Fractions of TH, CH, and AH were consistently similar in the serial sections of individual tissue blocks. However, significant differences were found between the apical, central, and basal blocks that were even opposite depending on the tumor volume. Pooled data from all three tissue blocks revealed significantly higher fractions of hypoxia in the large tumors than in the small tumors.

CONCLUSION

FaDu tumors exhibit a heterogeneous and volume-dependent oxygenation status. Assessing the average fractions of TH, CH, and AH from central blocks corresponds best to the average of the entire tumor. However, information on intratumor heterogeneities is lost, especially when considering tumors of substantially different volumes.

Acute versus chronic hypoxia in tumors: Controversial data concerning time frames and biological consequences

BACKGROUND

Many tumors contain hypoxic regions. Hypoxia, in turn, is known to increase aggressiveness and to be associated with treatment resistance. The two most frequently described and investigated subtypes of tumor hypoxia are acute and chronic. These two subtypes can lead to completely different hypoxia-related responses within the tumor, which could have a direct effect on tumor development and response to treatment. In order to accurately assess the specific biological consequences, it is important to understand which time frames best define acute and chronic hypoxia.

MATERIALS AND METHODS

This article provides an overview of the kinetics of in vitro and in vivo acute and chronic tumor hypoxia. Special attention was paid to differentiate between methods to detect spontaneous in vivo hypoxia and to describe the biological effects of experimental in vitro and in vivo acute and chronic tumor hypoxia.

RESULTS AND CONCLUSIONS

There are large variations in reported spontaneous fluctuations in acute hypoxia that are dependent on the cell lines investigated and the detection method used. In addition to differing hypoxia levels, exposure times used to induce in vitro and in vivo experimental acute and chronic hypoxia range from 30 min to several weeks with no clear boundaries separating the two. Evaluation of the biological consequences of each hypoxia subtype revealed a general trend that acute hypoxia leads to a more aggressive phenotype. Importantly, more information on the occurrence of acute and chronic hypoxia in human tumors is needed to help our understanding of the clinical consequences.

Quantitative assessment of hypoxia subtypes in microcirculatory supply units of malignant tumors using (immuno-)fluorescence techniques

BACKGROUND AND PURPOSE

Hypoxia is a characteristic of tumors, is known to increase aggressiveness, and causes treatment resistance. Traditional classification suggests two types of hypoxia: chronic and acute. Acute hypoxia is mostly caused by transient disruptions in perfusion, while chronic hypoxia is caused by diffusion limitations. This classification may be insufficient in terms of pathogenetic and pathophysiological mechanisms. Therefore, we quantified hypoxia subtypes in tumors based on (immuno-)fluorescent marker distribution patterns in microcirculatory supply units (MCSUs).

MATERIAL AND METHODS

Cryosections from hSCC lines (SAS, FaDu, UT-SCC-5, UT-SCC-14, UT-SCC-15) were analyzed. Hypoxia was identified by pimonidazole, perfusion by Hoechst 33342, and endothelial cells by CD31. The following patterns were identified in vital tumor tissue: (1) normoxia: Hoechst 33342 fluorescence around microvessels, no pimonidazole, (2) chronic hypoxia: Hoechst 33342 fluorescence around microvessels, pimonidazole distant from microvessels, (3) acute hypoxia: no Hoechst 33342 fluorescence around microvessels, pimonidazole in immediate vicinity of microvessels, and (4) hypoxemic hypoxia: Hoechst 33342 fluorescence and pimonidazole directly around microvessels.

RESULTS

Quantitative assessment of MCSUs show predominance for normoxia in 4 out of 5 tumor lines (50.1-72.8%). Total hypoxia slightly prevails in UT-SCC-15 (56.9%). Chronic hypoxia is the dominant subtype (65.4-85.9% of total hypoxia). Acute hypoxia only accounts for 12.9-29.8% and hypoxemic hypoxia for 1.2-6.4% of total hypoxia. The fraction of perfused microvessels ranged from 82.5-96.6%.

CONCLUSION

Chronic hypoxia is the prevailing subtype in MCSUs. Acute hypoxia and hypoxemic hypoxia account for only a small fraction. This approach enables assessment and recognition of different hypoxia subtypes including hypoxemic hypoxia and may facilitate methods to (clinically) identify and eliminate hypoxia.

Oxygenation status of urogenital tumors

In malignant urogenital tumors, tissue oxygenation is compromised and very heterogeneous,with steep and fluctuating spatio-temporal oxygen gradients signaling a complex instability in tumor oxygenation (complex "4D-heterogeneity"). Tumor hypoxia is highly dynamic, and rapidly changing pO(2) gradients may be key factors driving hypoxia-dependent adaptive processes leading to malignant progression. The grand median oxygen tension in malignant urogenital tumors is 7-11 mmHg. In contrast, benign leiomyomas of the uterus are severely, but uniformly, hypoxic with only shallow oxygen gradients ("static hypoxia"). In these benign tumors, the median pO(2) is 1 mmHg and signs of hypoxia-driven processes are missing.

Quantitative assessment of hypoxia kinetic models by a cross-study of dynamic 18F-FAZA and 15O-H2O in patients with head and neck tumors

Several kinetic models have been proposed to assess the underlying oxygenation status behind hypoxia tracer uptake and have shown advantages, compared with static analysis, in discriminating hypoxic regions. However, the quantitative assessment of mathematic models that take into consideration clinical applications and their biologic nature is still challenging. We performed a feasibility study to assess hypoxia kinetic models using voxelwise cross-analysis between the uptake of the perfusion tracer (15)O-H(2)O and the hypoxia tracer (18)F-fluoroazomycin arabinoside ((18)F-FAZA).

METHODS

Five patients with advanced head and neck cancer were included. For each patient, dynamic sequences of (15)O-H(2)O for 5 min and (18)F-FAZA for 60 min were acquired consecutively after injections of approximately 1 GBq and 300 MBq of each tracer, respectively. The compartment model, Thorwarth model, Patlak plot, Logan plot, and Cho model were applied to model the process of tracer transport and accumulation under hypoxic conditions. The standard 1-tissue-compartment model was used to compute a perfusion map for each patient. The hypoxia kinetic models were based on the assumption of a positive correlation between tracer delivery and perfusion and a negative (inverse) correlation between tracer accumulation (hypoxia) and perfusion.

RESULTS

Positive correlations between tracer delivery and perfusion were observed for the Thorwarth and Cho models in all patients and for the reversible and irreversible 2-compartment models in 4 patients. Negative correlations between tracer accumulation and perfusion were observed for the reversible 2-compartment model in all patients and for the irreversible 2-compartment model and Cho model in 4 patients. When applied to normal skeletal muscle, the smallest correlation variance over all 5 patients was observed for the reversible 2-compartment model.

CONCLUSION

Hypoxia kinetic modeling delivers different information from static measurements. Different models generate different results for the same patient, and they even can lead to opposite physiologic interpretations. On the basis of our assessment of physiologic precision and robustness, the reversible 2-compartment model corresponds better to the expectations of our assumptions than the other investigated models.

Pathophysiological and vascular characteristics of tumours and their importance for hyperthermia: heterogeneity is the key issue

Tumour blood flow before and during clinically relevant mild hyperthermia exhibits pronounced heterogeneity. Flow changes upon heating are not predictable and are both spatially and temporally highly variable. Flow increases may result in improved heat dissipation to the extent that therapeutically relevant tissue temperatures may not be achieved. This holds especially true for tumours or tumour regions in which flow rates are substantially higher than in the surrounding normal tissues. Changes in tumour oxygenation tend to reflect alterations in blood flow upon hyperthermia. An initial improvement in the oxygenation status, followed by a return to baseline levels (or even a drop to below baseline at high thermal doses) has been reported for some tumours, whereas a predictable and universal occurrence of sustained increases in O(2) tensions upon mild hyperthermia is questionable and still needs to be verified in the clinical setting. Clarification of the pathogenetic mechanisms behind possible sustained increases is mandatory. High-dose hyperthermia leads to a decrease in the extracellular and intracellular pH and a deterioration of the energy status, both of which are known to be parameters capable of acting as direct sensitisers and thus pivotal factors in hyperthermia treatment. The role of the tumour microcirculatory function, hypoxia, acidosis and energy status is complex and is further complicated by a pronounced heterogeneity. These latter aspects require additional critical evaluation in clinically relevant tumour models in order for their impact on the response to heat to be clarified.