In vitro hypoxic cytotoxicity of nitroimidazoles: uptake and cell cycle phase specificity

Therapeutic Modification of Hypoxia

Regions of reduced oxygenation (hypoxia) are a characteristic feature of virtually all animal and human solid tumours. Numerous preclinical studies, both in vitro and in vivo, have shown that decreasing oxygen concentration induces resistance to radiation. Importantly, hypoxia in human tumours is a negative indicator of radiotherapy outcome. Hypoxia also contributes to resistance to other cancer therapeutics, including immunotherapy, and increases malignant progression as well as cancer cell dissemination. Consequently, substantial effort has been made to detect hypoxia in human tumours and identify realistic approaches to overcome hypoxia and improve cancer therapy outcomes. Hypoxia-targeting strategies include improving oxygen availability, sensitising hypoxic cells to radiation, preferentially killing these cells, locating the hypoxic regions in tumours and increasing the radiation dose to those areas, or applying high energy transfer radiation, which is less affected by hypoxia. Despite numerous clinical studies with each of these hypoxia-modifying approaches, many of which improved both local tumour control and overall survival, hypoxic modification has not been established in routine clinical practice. Here we review the background and significance of hypoxia, how it can be imaged clinically and focus on the various hypoxia-modifying techniques that have undergone, or are currently in, clinical evaluation.

The impact of hypoxia and its modification of the outcome of radiotherapy

Since the initial observations made at the beginning of the last century, it has been established that solid tumors contain regions of low oxygenation (hypoxia). Tumor cells can survive in these hypoxic conditions and are a major factor in tumor radioresistance. This significance has resulted in hypoxia becoming the most cited biological topic in translational radiation oncology. Identifying hypoxic cells in human tumors has become paramount, and the ability to do this has been improved by the help of new imaging techniques and the use of predictive gene profiles. Substantial data confirm the presence of hypoxia in many types of human tumors, although with considerable heterogeneity among individual tumors. Various approaches have been investigated for eliminating the hypoxic population. These include increasing oxygen availability, directly radiosensitizing or killing the hypoxic cells, indirectly affecting them by targeting the tumor vascular supply, increasing the radiation dose to this resistant population, or by using radiation with a high linear energy transfer, for which hypoxia is believed to be less of an issue. Many of these approaches have undergone controlled clinical trials during the last 50 years, and the results have shown that hypoxic radiation resistance can indeed be overcome. Thus, ample data exists to support a high level of evidence for the benefit of hypoxic modification. However, such hypoxic modification still has no impact on general clinical practice. In this review we summarize the biological rationale, and the current activities and trials, related to identifying and overcoming hypoxia in modern radiotherapy.

Modulation of the tumor vasculature and oxygenation to improve therapy

The tumor microenvironment is increasingly recognized as a major factor influencing the success of therapeutic treatments and has become a key focus for cancer research. The progressive growth of a tumor results in an inability of normal tissue blood vessels to oxygenate and provide sufficient nutritional support to tumor cells. As a consequence the expanding neoplastic cell population initiates its own vascular network which is both structurally and functionally abnormal. This aberrant vasculature impacts all aspects of the tumor microenvironment including the cells, extracellular matrix, and extracellular molecules which together are essential for the initiation, progression and spread of tumor cells. The physical conditions that arise are imposing and manifold, and include elevated interstitial pressure, localized extracellular acidity, and regions of oxygen and nutrient deprivation. No less important are the functional consequences experienced by the tumor cells residing in such environments: adaptation to hypoxia, cell quiescence, modulation of transporters and critical signaling molecules, immune escape, and enhanced metastatic potential. Together these factors lead to therapeutic barriers that create a significant hindrance to the control of cancers by conventional anticancer therapies. However, the aberrant nature of the tumor microenvironments also offers unique therapeutic opportunities. Particularly interventions that seek to improve tumor physiology and alleviate tumor hypoxia will selectively impair the neoplastic cell populations residing in these environments. Ultimately, by combining such therapeutic strategies with conventional anticancer treatments it may be possible to bring cancer growth, invasion, and metastasis to a halt.

Bioreductive drugs: from concept to clinic

One of the key issues for radiobiologists is the importance of hypoxia to the radiotherapy response. This review addresses the reasons for this and primarily focuses on one aspect, the development of bioreductive drugs that are specifically designed to target hypoxic tumour cells. Four classes of compound have been developed since this concept was first proposed: quinones, nitroaromatics, aliphatic and heteroaromatic N-oxides. All share two characteristics: (1) they require hypoxia for activation and (2) this activation is dependent on the presence of specific reductases. The most effective compounds have shown the ability to enhance the anti-tumour efficacy of agents that kill better-oxygenated cells, i.e. radiation and standard cytotoxic chemotherapy agents such as cisplatin and cyclophosphamide. Tirapazamine (TPZ) is the most widely studied of the lead compounds. After successful pre-clinical in vivo combination studies it entered clinical trial; over 20 trials have now been reported. Although TPZ has enhanced some standard regimens, the results are variable and in some combinations toxicity was enhanced. Banoxantrone (AQ4N) is another agent that is showing promise in early phase I/II clinical trials; the drug is well tolerated, is known to locate in the tumour and can be given in high doses without major toxicities. Mitomycin C (MMC), which shows some bioreductive activation in vitro, has been tested in combination trials. However, it is difficult to assign the enhancement of its effects to targeting of the hypoxic cells because of the significant level of its hypoxia-independent toxicity. More specific analogues of MMC, e.g. porfiromycin and apaziquone (EO9), have had variable success in the clinic. Other new drugs that have good pre-clinical profiles are PR 104 and NLCQ-1; data on their clinical safety/efficacy are not yet available. This paper reviews the pre-clinical data and discusses the clinical studies that have been reported.

Hypoxia facilitates tumour cell detachment by reducing expression of surface adhesion molecules and adhesion to extracellular matrices without loss of cell viability

The effects of acute hypoxia on integrin expression and adhesion to extracellular matrix proteins were investigated in two human melanoma cell lines, HMB-2 and DX3, and a human adenocarcinoma cell line, HT29. Exposure to hypoxia caused a significant down-regulation of cell surface integrins and an associated decrease in cell adhesion. Loss of cell adhesion and integrin expression were transient and levels returned to normal within 24 h of reoxygenation. Other cell adhesion molecules, such as CD44 and N-CAM, were also down-regulated after exposure of cells to hypoxia. Acute exposure to hypoxia of cells at confluence caused rapid cell detachment. Cell detachment preceded loss of viability. Detached HMB-2 and DX3 cells completely recovered upon reoxygenation, and floating cells re-attached and continued to grow irrespective of whether they were left in the original glass dishes or transferred to new culture vessels, while detached HT29 cells partly recovered upon reoxygenation. Cell detachment after decreased adhesion appears to be a stress response, which may be a factor enabling malignant cells to escape hypoxia in vivo, with the potential to form new foci of tumour growth.

Apoptosis and 1-methyl-2-nitroimidazole toxicity in CHO cells

The time course and characteristics of the selective hypoxic cytotoxicity of the 2-nitroimidazole model compound 1-methyl-2-nitroimidazole (INO2) were analysed during prolonged time periods (up to 5 days post treatment). When control populations were seeded at the same cell density as drug-treated cells, they entered confluency at day 3 and underwent apoptosis at day 5, which appeared to be mediated by an autocrine mechanism. In subsequent studies of drug-treated cells, the seeding density of treated cells was adjusted to avoid this cell confluency effect. Treatment with a low INO2 concentration (2.5 mM) resulted in apoptotic DNA fragmentation (ladders), which was observed 4-5 days after an acute 6-h hypoxic drug exposure. In contrast, at a high INO2 concentration (40 mM) for 2 h, which was equitoxic to the low concentration, no characteristic DNA ladders were observed. Fluorescence microscopy revealed apoptotic bodies and pyknotic nuclei 5 days following hypoxic 2.5 mM INO2 exposure, whereas 40 mM INO2 hypoxic treatment produced cellular ghosts devoid of DNA 5 days after exposure, consistent with the DNA ladder results. However, characteristic apoptotic morphology was previously observed immediately after the acute hypoxic exposure of 40 mM INO2. Cell cycle analysis and DNA fragmentation as measured by the TdT assay suggested that dose-dependent differences in the apoptotic response occur post exposure after an equitoxic acute hypoxic exposure to either the low or the high INO2 concentration. This dose-dependent differential in response may be attributed to the degree of initial DNA damage as measured by the comet assay.

Hypoxia-induced drug resistance: comparison to P-glycoprotein-associated drug resistance

In this report, we investigate several examples of hypoxia-induced drug resistance and compare them with P-glycoprotein associated multidrug resistance (MDR). EMT6/Ro cells exposed to drugs in air immediately after hypoxic treatment developed resistance to adriamycin, 5-fluorouracil, and actinomycin D. However, these cells did not develop resistance to colchicine, vincristine or cisplatin. When the cells were returned to a normal oxygen environment, they lost resistance. There was no correlation between the content of adriamycin and the development of adriamycin resistance induced by hypoxia. There was no difference between the efflux of adriamycin from aerobic cells and that from hypoxia-treated cells. The mRNA for P-glycoprotein was not detected in the hypoxia-treated cells. These results suggest that hypoxia-induced drug resistance is different from P-glycoprotein associated multidrug resistance.

Oxygen regulated 80 kDa protein and glucose regulated 78kDa protein are identical

Ischemic stress of cells within solid tumors arises from inadequate perfusion of regions of the tumor and results in microenvironments which are hypoxic and deficient in nutrient delivery and waste product removal. Stressed cells within these microenvironments show growth inhibition and synthesize unique sets of proteins referred to as glucose and oxygen regulated proteins (GRPs and ORPs respectively). The commonality of proteins induced by glucose-starvation and hypoxia has not been proven. To this end, ORPs were induced in Chinese hamster ovary cells in the presence of high glucose concentration in the media and ORP 80 isolated from two dimension gels. Eleven tryptic peptides of the 80 kDa ORP were sequenced and found to be identical to GRP 78 sequences. The data demonstrate that GRP 78 and ORP 80 have the same primary amino acid sequence and suggest that glucose-starvation and hypoxia can induce the same cellular responses.

Enhanced synthesis of stress proteins caused by hypoxia and relation to altered cell growth and metabolism

Cultured cells maintained in very low oxygen levels alter their structure, metabolism and genetic expression. Culture conditions for cells were modified to minimise variation of nutrients and to allow normal survival levels after 24 h of hypoxic exposure. Under these hypoxic conditions, glucose consumption and lactate production rates were similar to aerobic rates until about 12 h after which the hypoxic rates increased. DNA and protein synthesis rates are continuously inhibited to about 48% or 55% of the respective aerobic rates. During this period of decreased protein synthesis, a set of proteins termed oxygen regulated proteins (ORPs), exhibits enhanced relative synthesis. The molecular weights of the five major ORPs are approximately 260, 150, 100, 80 and 33 kDa. While increased relative synthesis of oxygen regulated proteins is partly due to increased levels of mRNA which encode these proteins, the mechanism of enhanced synthesis of ORPs may be more complex.

Changes in growth characteristics and macromolecular synthesis on recovery from severe hypoxia

Chinese hamster ovary cells subjected to severe hypoxia stop growing. When oxygen was reintroduced growth resumed, but at a slower rate. The longer the hypoxic stress, the slower the recovery growth rate. Six hours of hypoxia caused very little decrease in growth rate while a 24 h period almost halved the rate. Short hypoxic periods resulted in almost no growth lag, while longer periods caused significant lag. Clonogenic survival was 60% after 12 h of hypoxia and rose slowly during recovery, reaching control levels after 60 h. Following 24 h of hypoxia, survival remained around 60% throughout recovery. The cell cycle distribution after hypoxia was similar to that of aerobic cultures. After 4-6 h of recovery, a subpopulation of cells entered S phase, and reached G2 by 12 h. During this time few G2-M cells divided. With longer recovery, cells much larger than aerobic cells emerged, containing greater than 4C DNA content and enhanced amounts of RNA. When these cells were isolated, they exhibited slightly slower growth kinetics, greatly lengthened lag time and decreased survival when compared to aerobic cells or the smaller cells. Most of the extra DNA and RNA was lost within one cell cycle.

Cytotoxic effect of misonidazole and cyclophosphamide on aerobic and hypoxic cells in a C3H mammary carcinoma in vivo

The chemosensitising effect of the nitroaromatic radiosensitiser misonidazole (MISO) on the alkylating agent cyclophosphamide (CTX) has been investigated in a C3H mammary carcinoma in CDF1 mice. The selective cytotoxicity against aerobic and hypoxic cells was measured indirectly, using a local tumour control (TCD50) assay. The hypoxic fraction was calculated from the dose difference between the TCD50S for tumours irradiated either in air or under clamped conditions. The relative survival of tumour cells after drug therapy was expressed as a surviving fraction (SF). CTX (100 mg kg-1) was found to be considerably more toxic towards hypoxic than aerobic cells (SF 4% versus 52%). MISO (1000 mg kg-1) was almost exclusively toxic to hypoxic cells (SF 22%). When MISO and CTX were administered simultaneously a decrease in the surviving fraction was observed. The effect on aerated cells was found to be 10-fold more than expected from addition of toxicities, suggesting a chemosensitising effect on these cells by MISO when used in combination with CTX. No synergistic effect was found on radiobiologically hypoxic cells. The exact role of hypoxia for the development of chemosensitisation seems to be complex and requires additional research in the future.

Chemosensitization at reduced nitroimidazole concentrations by mixed-function compounds combining 2-nitroimidazole and chloroethylnitrosourea

A mixed-function compound (I-278) combining 2-nitroimidazole and chloroethylnitrosourea has been shown to be greater than 2-fold more toxic to hypoxic HeLa-MR cells than to cells similarly exposed under aerobic conditions, consistent with chemosensitization of nitrosourea toxicity by the 2-nitroimidazole Misonidazole (MISO). However, in the case of I-278, the enhancement resulted from micromolar concentrations of 2-nitroimidazole as opposed to the millimolar quantities required for a similar enhancement by MISO. These experiments provide evidence (1) that the enhanced hypoxic toxicity of I-278 is not attributable to additional, independent hypoxic cell killing by the nitroimidazole group and (2) that the interaction between the two functions under hypoxic conditions results in increased crosslink formation typical of chemosensitization. The data strongly suggest that the chemosensitizing efficiency of nitroimidazoles can be dramatically improved by covalent linkage to a chloroethylating species.

Tumor hypoxia: its impact on cancer therapy

The presence of radiation resistant cells in solid human tumors is believed to be a major reason why radiotherapy fails to eradicate some such neoplasms. The presence of unperfused regions containing hypoxic cells may also contribute to resistance to some chemotherapeutic agents. This paper reviews the evidence that radiation resistant hypoxic cells exist in solid tumors, the assumptions and results of the methods used to detect hypoxic cells, and the causes and nature of tumor hypoxia. Evidence that radiation resistant hypoxic cells exist in the vast majority of transplanted rodent tumors and xenografted human tumors is direct and convincing, but problems with the current methodology make quantitative statements about the magnitude of the hypoxic fractions problematic. Evidence that radiation resistant hypoxic cells exist in human tumors is considerably more indirect than the evidence for their existence in transplanted tumors, but it is convincing. However, evidence that hypoxic cells are a significant cause of local failure after optimal clinical radiotherapy or chemotherapy regimens is limited and less definitive. The nature and causes of tumor hypoxia are not definitively known. In particular, it is not certain whether hypoxia is a chronic or a transient state, whether hypoxic cells are proliferating or quiescent, or whether hypoxic cells have the same repair capacity as aerobic cells. A number of new methods for assessing hypoxia are reviewed. While there are still problems with all of the new techniques, some of them have the potential of allowing the assessment of hypoxia in individual human tumors.

Induction characteristics of oxygen regulated proteins

Extreme hypoxia induces many changes in the biology of cells, including the enhanced synthesis of oxygen regulated proteins (ORPs). We investigated the conditions required for the induction of ORPs and by modifying culture conditions, eliminated variables other than oxygen concentration. Several exponentially growing rodent and human cell lines were examined before, during, and after various periods of extreme hypoxia. The following responses were analyzed: cell growth, clonogenic survival, glucose consumption, lactate production, media pH, total protein synthesis, and specific protein synthesis. EMT6/Ro cells did not increase in cell number or progress through the cell cycle after initiation of extreme hypoxia. Cell morphology and cell survival were nearly normal for up to 12 hr of hypoxia. During this period, media pH remained constant, with the concentrations of glucose and lactate being virtually indistinguishable from aerobic cultures or initial values. Associated with these conditions, a marked inhibition of total protein synthesis was observed for EMT6/Ro cells, such that the hypoxic protein synthesis rate was about 60% of the aerobic rate. However, enhanced synthesis of a set of proteins, designated as ORPs, was preferentially induced in less than 6 hr. The molecular weights of the five major ORPs are 260, 150, 100, 80 and 33 kD. Under these conditions, the primary inducing agent was a low concentration of oxygen. This set of ORPs was distinctly different from the set of heat induced (heat-shock) proteins, but included the major 100 kD and 80 kD glucose regulated proteins. Although the functions of ORPs are unknown, their induction under conditions that are known to modify the sensitivity of cancer cells to therapeutic agents suggests that the presence of ORPs should be further investigated to determine their possible value in diagnosis and predicting treatment response.

Decreased hypoxic toxicity and binding of misonidazole by low glucose concentration

The modulation of the hypoxic toxicity and binding of Misonidazole (MISO) by glucose and lactate was studied by exposing exponential EMT6/Ro cells to 5 mM MISO under hypoxic conditions. The concentrations of glucose used were 0.015 mM and 5 mM, and the concentrations of lactate were 0, 3 and 10 mM. There was no significant hypoxic toxicity due to MISO in the absence of glucose. However, with 5 mM glucose, after a latent period of 0.5 hours, there was a rapid decrease in cell survival to less than 0.1% at 2.5 hours incubation in 5 mM MISO. The binding of MISO was also increased by glucose. The amount of MISO bound to cells in 0.015 mM glucose leveled off at 2 nmoles MISO/7 X 10(5) cells at 1 hour, whereas the binding in 5 mM glucose continued to increase to more than 5 nmoles MISO/7 X 10(5) cells after 3 hours incubation. There was no detectable effect of lactate on the binding of MISO to the cells either in 0.015 mM or 5 mM glucose. The high affinity of this binding was indicated by the lack of exchange of radioactive MISO with non-radioactive MISO even after 2 hours of incubation. These data showed that glucose concentrations could modify the toxicity and binding of MISO to hypoxic cells.

Survival in subpopulations of cells derived from solid KHT sarcomas by centrifugal elutriation following treatment with CCNU and MISO

Misonidazole (MISO) has been shown to enhance the cytotoxicity of 1-(2-chloroethyl)-3-cyclohexyl-1-nitrosourea (CCNU) in a number of different animal tumor systems. We have investigated the response to therapy of the various subpopulations of cells comprising the KHT sarcoma, to determine whether chemopotentiation occurred as a preferential enhancement of killing in one subpopulation of cells. Twenty-four hr after drug treatment, cells dissociated from solid tumors were separated into homogeneous populations based on cell size by the technique of centrifugal elutriation. By this method the majority of the non-neoplastic cells could be removed and the tumor cells separated into fractions containing 90 to 95% G1 cells, 70 to 75% S cells and 70 to 80% G2M cells. Clonogenic cell survival was measured for each elutriated fraction. In vivo treatment with 0.5 mg/g MISO produced no measurable cell-kill across the cell cycle. Those cells in late G1 and S phase 24 hr after treatment were most sensitive to CCNU alone. The enhancement of CCNU cytotoxicity by MISO occurred primarily in the early G1 and S fractions. These data suggest that chemopotentiation does not occur equally in all tumor cell subpopulations and that some specificity of enhanced cell killing exists.

In vitro inhibition of misonidazole toxicity and melphalan chemopotentiation by metyrapone

Overnight exposure of Chinese hamster cells, V-79-753B, to 10(-3)M metyrapone protected them against the hypoxiamediated toxicity of 10(-2)M misonidazole. This protection was accompanied by an increase in radiation resistance. There was no appreciable change in the oxygen-enhancement ratio, nor in the amount of sensitisation produced by 10(-3)M misonidazole. Treatment of cells with metyrapone (10(-3)M) or dexamethasone (1 microgram ml-1 [approximately 2 X 10(-6)M]) prior to exposure first to 5 X 10(-3)M misonidazole in hypoxia and then to melphalan in air, substantially decreased the amount of chemopotentiation produced by the sensitiser, although the toxicity of melphalan alone was not affected in cells treated with either compound. Cells pretreated with either metyrapone or dexamethasone had 2-3 times more glutathione than control cells. This increase in GSH could not explain the change in radiation response, since cells pretreated with 5 X 10(-5)M flurbiprofen, a non-steroidal anti-inflammatory agent, had similarly high GSH levels, but their radiation response is similar to that of untreated cells (Millar et al, 1981). Neither dexamethasone nor flurbiprofen affected cell growth, whilst metyrapone markedly decreased the growth of cells. The results are discussed in terms of possible mechanism(s).