Editorial: Tumor Hypoxia: Impact in Tumorigenesis, Diagnosis, Prognosis, and Therapeutics

Glioblastoma multiforme (GBM): An overview of current therapies and mechanisms of resistance

Glioblastoma multiforme (GBM) is a WHO grade IV glioma and the most common malignant, primary brain tumor with a 5-year survival of 7.2%. Its highly infiltrative nature, genetic heterogeneity, and protection by the blood brain barrier (BBB) have posed great treatment challenges. The standard treatment for GBMs is surgical resection followed by chemoradiotherapy. The robust DNA repair and self-renewing capabilities of glioblastoma cells and glioma initiating cells (GICs), respectively, promote resistance against all current treatment modalities. Thus, durable GBM management will require the invention of innovative treatment strategies. In this review, we will describe biological and molecular targets for GBM therapy, the current status of pharmacologic therapy, prominent mechanisms of resistance, and new treatment approaches. To date, medical imaging is primarily used to determine the location, size and macroscopic morphology of GBM before, during, and after therapy. In the future, molecular and cellular imaging approaches will more dynamically monitor the expression of molecular targets and/or immune responses in the tumor, thereby enabling more immediate adaptation of tumor-tailored, targeted therapies.

Pharmacological Regulation of Tumor Hypoxia in Model Murine Tumors and Spontaneous Canine Tumors

Simple Summary

Tumor hypoxia is a state of low oxygen tension typically occurring in most solid tumors because the oxygen supply does not meet the metabolic demand of the tissue. Hypoxia has been associated with increased resistance to anti-cancer therapy for decades. Reducing oxygen demand with therapeutic targeting of mitochondrial oxidative metabolism can mitigate tumor hypoxia. Here we show that pharmacological regulation of mitochondrial metabolism has a direct impact on the levels of tumor hypoxia in murine tumor models and spontaneous canine soft tissue sarcomas.

Abstract

Background: Hypoxia is found in many solid tumors and is associated with increased disease aggressiveness and resistance to therapy. Reducing oxygen demand by targeting mitochondrial oxidative metabolism is an emerging concept in translational cancer research aimed at reducing hypoxia. We have shown that the U.S. Food and Drug Administration (FDA)-approved drug papaverine and its novel derivative SMV-32 are potent mitochondrial complex I inhibitors. Methods: We used a dynamic in vivo luciferase reporter system, pODD-Luc, to evaluate the impact of pharmacological manipulation of mitochondrial metabolism on the levels of tumor hypoxia in transplanted mouse tumors. We also imaged canine patients with blood oxygen level-dependent (BOLD) MRI at baseline and one hour after a dose of 1 or 2 mg/kg papaverine. Results: We showed that the pharmacological suppression of mitochondrial oxygen consumption (OCR) in tumor-bearing mice increases tumor oxygenation, while the stimulation of mitochondrial OCR decreases tumor oxygenation. In parallel experiments in a small series of spontaneous canine sarcomas treated at The Ohio State University (OSU) Veterinary Medical Center, we observed a significant increase in BOLD signals indicative of an increase in tumor oxygenation of up to 10–50 mm HgO₂. Conclusion: In both transplanted murine tumors and spontaneous canine tumors we found that decreasing mitochondrial metabolism can decrease tumor hypoxia, potentially offering a therapeutic advantage.

Quantitative Visualization of Hypoxia and Proliferation Gradients Within Histological Tissue Sections

The formation of hypoxic microenvironments within solid tumors is known to contribute to radiation resistance, chemotherapy resistance, immune suppression, increased metastasis, and an overall poor prognosis. It is therefore crucial to understand the spatial and molecular mechanisms that contribute to tumor hypoxia formation to improve the efficacy of radiation treatment, develop hypoxia-directed therapies, and increase patient survival. The objective of this study is to present a number of complementary novel methods for quantifying tumor hypoxia and proliferation in multiplexed immunofluorescence images, especially in relation to the location of perfused blood vessels. A standard marker analysis strategy is to take a positive pixel count approach, in which a threshold for positive stain is used to compute a positive area fraction for hypoxia. This work is a reassessment of that approach, utilizing not only cell segmentation but also distance to nearest blood vessel in order to incorporate spatial information into the analysis. We describe a reproducible pipeline for the visualization and quantitative analysis of hypoxia using a vessel distance analysis approach. This methodological pipeline can serve to further elucidate the relationship between vessel distance and microenvironment-linked markers such as hypoxia and proliferation, can help to quantify parameters relating to oxygen consumption and hypoxic tolerance in tissues, as well as potentially serve as a hypothesis generating tool for future studies testing hypoxia-linked markers.

Vacuum-UV induced DNA strand breaks - influence of the radiosensitizers 5-bromouracil and 8-bromoadenine

Radiation therapy is a basic part of cancer treatment. To increase the DNA damage in carcinogenic cells and preserve healthy tissue at the same time, radiosensitizing molecules such as halogenated nucleobase analogs can be incorporated into the DNA during the cell reproduction cycle. In the present study 8.44 eV photon irradiation induced single strand breaks (SSB) in DNA sequences modified with the radiosensitizer 5-bromouracil (5BrU) and 8-bromoadenine (8BrA) are investigated. 5BrU was incorporated in the 13mer oligonucleotide flanked by different nucleobases. It was demonstrated that the highest SSB cross sections were reached, when cytosine and thymine were adjacent to 5BrU, whereas guanine as a neighboring nucleobase decreases the activity of 5BrU indicating that competing reaction mechanisms are active. This was further investigated with respect to the distance of guanine to 5BrU separated by an increasing number of adenine nucleotides. It was observed that the SSB cross sections were decreasing with an increasing number of adenine spacers between guanine and 5BrU until the SSB cross sections almost reached the level of a non-modified DNA sequence, which demonstrates the high sequence dependence of the sensitizing effect of 5BrU. 8BrA was incorporated in a 13mer oligonucleotide as well and the strand breaks were quantified upon 8.44 eV photon irradiation in direct comparison to a non-modified DNA sequence of the same composition. No clear enhancement of the SSB yield of the modified in comparison to the non-modified DNA sequence could be observed. Additionally, secondary electrons with a maximum energy of 3.6 eV were generated when using Si as a substrate giving rise to further DNA damage. A clear enhancement in the SSB yield can be ascertained, but to the same degree for both the non-modified DNA sequence and the DNA sequence modified with 8BrA.

Radiomics in Nuclear Medicine Applied to Radiation Therapy: Methods, Pitfalls, and Challenges

Radiomics is a recent area of research in precision medicine and is based on the extraction of a large variety of features from medical images. In the field of radiation oncology, comprehensive image analysis is crucial to personalization of treatments. A better characterization of local heterogeneity and the shape of the tumor, depicting individual cancer aggressiveness, could guide dose planning and suggest volumes in which a higher dose is needed for better tumor control. In addition, noninvasive imaging features that could predict treatment outcome from baseline scans could help the radiation oncologist to determine the best treatment strategies and to stratify patients as at low risk or high risk of recurrence. Nuclear medicine molecular imaging reflects information regarding biological processes in the tumor thanks to a wide range of radiotracers. Many studies involving ¹⁸F-fluorodeoxyglucose positron emission tomography suggest an added value of radiomics compared with the use of conventional PET metrics such as standardized uptake value for both tumor diagnosis and prediction of recurrence or treatment outcome. However, these promising results should not hide technical difficulties that still currently prevent the approach from being widely studied or clinically used. These difficulties mostly pertain to the variability of the imaging features as a function of the acquisition device and protocol, the robustness of the models with respect to that variability, and the interpretation of the radiomic models. Addressing the impact of the variability in acquisition and reconstruction protocols is needed, as is harmonizing the radiomic feature calculation methods, to ensure the reproducibility of studies in a multicenter context and their implementation in a clinical workflow. In this review, we explain the potential impact of positron emission tomography radiomics for radiation therapy and underline the various aspects that need to be carefully addressed to make the most of this promising approach.

Hematocrit and impact of transfusion in patients receiving extracorporeal life support

Introduction: Increasing the hematocrit is considered to increase oxygen delivery to the patient, especially when hypoxic conditions exist and the patient may become more stable. The aim of this study was to evaluate the relationship between hematocrit and hospital mortality via subgroup analyses of trauma and non-trauma patients. Methods: The hospital length of stay (LOS) and LOS in the intensive care unit (ICU) and hospital after extracorporeal life support (ECLS) treatment of 81 patients were analyzed and compared. In-hospital survival until extracorporeal membrane oxygen (ECMO) weaning and hospital discharge were defined as the clinical outcome. Results: Significantly increased mortality, with a relative risk of 1.73 with a 95% confidence interval of 1.134 to 2.639, was identified in the group with an hematocrit greater than 31%. However, no significant differences in relative risk (95% confidence interval) of death for each group were found among groups with an hematocrit less than or equal to 25%, 26-28% and 29-31%. Additionally, no significant relationship between survival and median hematocrit level was observed at a significance level of 0.413 and an Exp (B) of 1.089 at a 95% confidence interval of 0.878 to 1.373 in binary logistic regression analysis; a model was established with a -2 log likelihood of 40.687 for the entire group of patients. Moreover, a significant increase in mortality was observed as the average number of transfusions per day in the hospital increased (significance level 0.024, Exp (B) 4.378, 95% confidence interval for Exp (B) 1.212 to 15.810). Conclusion: Because a variety of factors influence therapy, the indication for transfusion should be re-evaluated and adapted repeatedly on a case-by-case basis. Further studies are needed to demonstrate whether an acceptable outcome from ECLS device therapy can also be achieved with a low hematocrit and a restrictive indication for transfusion.

NFIX as a Master Regulator for Lung Cancer Progression

About 40% of lung cancer cases globally are diagnosed at the advanced stage. Lung cancer has a high mortality and overall survival in stage I disease is only 70%. This study was aimed at finding a candidate of transcription regulator that initiates the mechanism for metastasis by integrating computational and functional studies. The genes involved in lung cancer were retrieved using in silico software. 10 kb promoter sequences upstream were scanned for the master regulator. Transient transfection of shRNA NFIXs were conducted against A549 and NCI-H1299 cell lines. qRT-PCR and functional assays for cell proliferation, migration and invasion were carried out to validate the involvement of NFIX in metastasis. Genome-wide gene expression microarray using a HumanHT-12v4.0 Expression BeadChip Kit was performed to identify differentially expressed genes and construct a new regulatory network. The in silico analysis identified NFIX as a master regulator and is strongly associated with 17 genes involved in the migration and invasion pathways including IL6ST, TIMP1 and ITGB1. Silencing of NFIX showed reduced expression of IL6ST, TIMP1 and ITGB1 as well as the cellular proliferation, migration and invasion processes. The data was integrated with the in silico analyses to find the differentially expressed genes. Microarray analysis showed that 18 genes were expressed differentially in both cell lines after statistical analyses integration between t-test, LIMMA and ANOVA with Benjamini-Hochberg adjustment at p-value < 0.05. A transcriptional regulatory network was created using all 18 genes, the existing regulated genes including the new genes PTCH1, NFAT5 and GGCX that were found highly associated with NFIX, the master regulator of metastasis. This study suggests that NFIX is a promising target for therapeutic intervention that is expected to inhibit metastatic recurrence and improve survival rate.