IDH (isocitrate dehydrogenase) mutation, hypoxia, and neo-angiogenesis, three hallmarks of diffuse gliomas, modulate the expression of small non-coding RNAs (miRNA). In this paper, we tested whether pro-angiogenic and/or pro-hypoxic miRNAs could be used to monitor patients with glioma. The miRNAs were extracted from tumoral surgical specimens embedded in the paraffin of 97 patients with diffuse gliomas and, for 7 patients, from a blood sample too. The expression of 10 pro-angiogenic and/or pro-hypoxic miRNAs was assayed by qRT-PCR and normalized to the miRNA expression of non-tumoral brain tissues. We confirmed in vitro that IDH in hypoxia (1% O2, 24 h) alters pro-angiogenic and/or pro-hypoxic miRNA expression in HBT-14 (U-87 MG) cells. Then, we reported that the expression of these miRNAs is (i) strongly affected in patients with glioma compared to that in a non-tumoral brain; (ii) correlated with the histology/grade of glioma according to the 2016 WHO classification; and (iii) predicts the overall and/or progression-free survival of patients with glioma in univariate but not in a multivariate analysis after adjusting for sex, age at diagnosis, and WHO classification. Finally, the expression of miRNAs was found to be the same between the plasma and glial tumor of the same patient. This study highlights a panel of seven pro-angiogenic and/or pro-hypoxic miRNAs as a potential tool for monitoring patients with glioma.

Tumor hypoxia is known to limit the efficacy of ionizing radiations, a concept called oxygen enhancement ratio (OER). OER depends on physical factors such as pO2 and linear energy transfer (LET). Biological pathways, such as the hypoxia-inducible transcription factors (HIF), might also modulate the influence of LET on OER. Glioblastoma (GB) is resistant to low-LET radiation (X-rays), due in part to the hypoxic environment in this brain tumor. Here, we aim to evaluate in vitro whether high-LET particles, especially carbon ion radiotherapy (CIRT), can overcome the contribution of hypoxia to radioresistance, and whether HIF-dependent genes, such as erythropoietin (EPO), influence GB sensitivity to CIRT. Hypoxia-induced radioresistance was studied in two human GB cells (U251, GL15) exposed to X-rays or to carbon ion beams with various LET (28, 50, 100 keV/µm), and in genetically-modified GB cells with downregulated EPO signaling. Cell survival, radiobiological parameters, cell cycle, and ERK activation were assessed under those conditions. The results demonstrate that, although CIRT is more efficient than X-rays in GB cells, hypoxia can limit CIRT efficacy in a cell-type manner that may involve differences in ERK activation. Using high-LET carbon beams, or targeting hypoxia-dependent genes such as EPO might reduce the effects of hypoxia.

(1) We wanted to assess the impact of Ang2 in RCT-induced changes in the environment of glioblastoma. (2) The effect of Ang2 overexpression in tumor cells was studied in the GL261 syngeneic immunocompetent model of GB in response to fractionated RCT. (3) We showed that RCT combined with Ang2 led to tumor clearance for the GL261-Ang2 group by acting on the tumor cells as well as on both vascular and immune compartments. (4) In vitro, Ang2 overexpression in GL261 cells exposed to RCT promoted senescence and induced robust genomic instability, leading to mitotic death. (5) Coculture experiments of GL261-Ang2 cells with RAW 264.7 cells resulted in a significant increase in macrophage migration, which was abrogated by the addition of soluble Tie2 receptor. (6) Together, these preclinical results showed that, combined with RCT, Ang2 acted in an autocrine manner by increasing GB cell senescence and in a paracrine manner by acting on the innate immune system while modulating the vascular tumor compartment. On this preclinical model, we found that an ectopic expression of Ang2 combined with RCT impedes tumor recurrence.

Approaches able to counteract, at least temporarily, hypoxia, a well-known factor of resistance to treatment in solid tumors are highly desirable. Herein, we report the use of nanosized zeolite crystals as hyperoxic/hypercapnic gas carriers for glioblastoma. First, the non-toxic profile of nanosized zeolite crystals in living animals (mice, rats and non-human primates) and in various cell types is presented. Second, the ability of the nanosized zeolites to act as a vasoactive agent for a targeted re-oxygenation of the tumor after intravenous injection is shown. As attested by an MRI protocol, the zeolites were able to increase oxygenation and blood volume specifically within the brain tumor whilst no changes in the healthy-non tumoral brain-were observed. The first proof of concept for the use of metal-containing nanosized zeolites as a tool for vectorization of hyperoxic/hypercapnic gases in glioblastoma is revealed.

The resistance of cancer cells to radiotherapy is a major issue in the curative treatment of cancer patients. This resistance can be intrinsic or acquired after irradiation and has various definitions, depending on the endpoint that is chosen in assessing the response to radiation. This phenomenon might be strengthened by the radiosensitivity of surrounding healthy tissues. Sensitive organs near the tumor that is to be treated can be affected by direct irradiation or experience nontargeted reactions, leading to early or late effects that disrupt the quality of life of patients. For several decades, new modalities of irradiation that involve accelerated particles have been available, such as proton therapy and carbon therapy, raising the possibility of specifically targeting the tumor volume. The goal of this review is to examine the up-to-date radiobiological and clinical aspects of hadrontherapy, a discipline that is maturing, with promising applications. We first describe the physical and biological advantages of particles and their application in cancer treatment. The contribution of the microenvironment and surrounding healthy tissues to tumor radioresistance is then discussed, in relation to imaging and accurate visualization of potentially resistant hypoxic areas using dedicated markers, to identify patients and tumors that could benefit from hadrontherapy over conventional irradiation. Finally, we consider combined treatment strategies to improve the particle therapy of radioresistant cancers.

Background Glioblastoma (GB), a highly hypoxic brain tumor (Bekaert et al. 2017), is characterized by a massive macrophage (MΦ) infiltration (Lapa et al. 2015). Hypoxia triggers a shift to a pro-tumoral M2 phenotype in GB (Leblond et al. 2016). Thus, strategies aiming to reduce hypoxia could promote an anti-tumoral M1 phenotype. Among these reoxygenation strategies, we recently developed a new approach with zeolites nanoparticles. These zeolites are able to carry hyperoxic/hypercapnic gases and release them according to a hypoxic gradient. We have demonstrated that the charge balancing cation changes affinity to the gases but also the ability to track zeolite with MRI. Our objective is to study the reoxygenation efficacy of zeolites specifically in the GB and to evaluate their impact on tumor associated MΦ with in vitro and in vivo studies. Methods Faujasite zeolites (FAU, ∼20nm of diameter) were used and modified by ion exchange with various cations (Fe, Gd, Cu, Ag). GB model was obtained by orthotopic glioblastoma cells implantation (U251) in nude rats (ONCOModels/Unicaen). 7T MRI (Bruker/Cyceron) was used to follow zeolites after intravenous injection and for oxygen measurement. Murine bone marrow derived MΦ were prepared and polarized to M1 and M2 using LPS/IFNg or IL4 as previously described (Leblond et al. 2016). Zeolites were added in MΦ medium and their impact on MΦ were evaluated by crystal violet dye assay, flow cytometry (Plateau ICORE/Unicaen) and polarization assays. Results Our results show that zeolites are able to accumulate and release the carried gases specifically in the brain tumor leading to tumor reoxygenation. Regarding the effect on MΦ, our preliminary results show, in vitro, the safety of as-prepared zeolites or Fe, Gd or Cu dopped zeolites on M0, M1 and M2 MΦ cultures. Similarly, no alteration of the cell cycle was observed. As a positive control of cell death, the presence of Ag-dopped zeolites dramatically decreased M0 and M1 MΦ viability. Conclusions Zeolites can deliver oxygen to the brain tumor and may improve the effectiveness of conventional treatments. Zeolites do not exhibit toxicity on primary cultures of MΦ. Additional studies are underway to evaluate the effect of zeolites on the polarization of MΦ, both in vitro and in vivo. Legal entity responsible for the study The authors. Funding Region Normandie, CNRS, Universite de Caen Normandie, Ministere de l’Enseignement Superieur et de la Recherche, European Union-Fonds Europeen de Developpement Regional (FEDER), HABIONOR European project, co-funded by the Normandy County Council, the French State in the framework of the interregional development Contract “Vallee de la Seine” 2015-2020, ARCHADE, Federation pour la Recherche sur le Cerveau (FRC) et INCa (INCA-11699). Disclosure All authors have declared no conflicts of interest.

Background Glioblastoma (GB) are brain tumors with a poor prognosis despite multimodal treatment combining resection, chemotherapy (CT) and radiotherapy (RT). The rich vascularization of these tumors led to the introduction of anti-angiogenic therapy with most efforts focused on the vascular endothelial growth factor (VEGF). However, the angiopoietins (Ang) have emerged as alternative regulators of angiogenesis. In particular, in GB, Ang2 is up-regulated and stimulates tumor angiogenesis in concert with VEGF but also activates pro-angiogenic functions of macrophages. However, Ang2 functions are context-dependent. Therefore, we sought to elucidate the involvement of Ang2 in the interaction of glioma response to CT and RT, both therapeutic modalities known to alter tumor angiogenesis and inflammation. Methods To recapitulate high levels of Ang2 in GB patients, Ang2 was overexpressed in murine glioma cells (GL261-Ang2). Effects of Ang2 were studied on an orthotopic syngenic model of GB (GL261 cells) in response to combined CT/RT. C57bl/6 mice were co-treated with temozolomide (TMZ 10 mg/kg; i.p.) and brain tumors were irradiated with X-rays (4 Gy) at 7, 9 and 11 days post-cell injection. The tumor growth and its microenvironment were followed by MRI and immunohistology analyses. Results We showed that, in this model, the chronic overexpression of Ang2 does not modify tumor progression, but leads to a decrease in vessel density (-39±10%, p 3 months) compared with treated GL261 tumors (18±3 days). In vitro, no difference in the chemo-radiosensitivity of GL261 and GL261-Ang2 cells was noticed, suggesting a paracrine effect of Ang2 on the tumor microenvironment. Accordingly, we showed that Ang2 sensitizes the tumor vasculature to CT/RT and sustains inflammatory cells in the tumor microenvironment until 3 months post-treatment. Conclusions These results suggest that Ang2 might influence the therapeutic response of GB by acting on angiogenesis and inflammation. Legal entity responsible for the study E. Petit. Funding This study was funded by the Region Normandie, the Centre National de la Recherche Scientifique (CNRS), the Universite de Caen Normandie (UNICAEN), the European Union-Fonds Europeen de Developpement Regional (FEDER), ARCHADE, HABIONOR European project, la Federation pour la Recherche sur le Cerveau par l’operation Rotary «Espoir en tete » (FRC), EdNBise 497 - Normandie Universite. Disclosure All authors have declared no conflicts of interest.

Introduction Glioblastoma (GB) are known to be highly hypoxic and both hypoxia inducible factors, HIF-1 and HIF-2, have been implicated in their growth and resistance to treatments. Recently, it was proposed that a severe chronic hypoxia would enhance HIF-2 expression at the expense of HIF-1 through HAF (hypoxia-associated factor). HAF is expressed in many cancers including high and low grade glioma. However, its implication in GB growth and its treatments is poorly documented (Koh et al., 2011). In this context, we conducted in vivo and in vitro studies to identify whether HAF expressed by glioma cells modulates tumour growth and efficacy of GB conventional treatments, i.e. chemotherapy (temozolomide, TMZ) and radiotherapy (X-rays). Material and methods Stable inhibition of HAF expression was established in human glioblastoma cells by RNA interference (U251shHAF). Orthotopic GB models were developed in mice (8/group) for U251shHAF and U251Sc cells (scrambled-shRNA infected cells) as control. Tumour development was assessed with 7T MRI (T2w sequence). At the end of the experiments, an immunohistology study was performed to characterise the vascularisation (PECAM), glial (GFAP) and inflammatory (CD68) reactions. In vitro, the radio- and chemosensitivity of U251shHAF were studied by clonogenic assay and cell cycle analysis following X-rays irradiation (X-RAD 225Cx) or TMZ exposition. Annexin-V binding and propidium iodure uptake followed by flow cytometry was used to quantify apoptotic and necrotic cells. Results and discussions The stable inhibition of HAF expression in U251 cells leads to around 70% of its extinction in either normoxia or hypoxia (1% O2). Accordingly, the expression of VEGFA and CAIX, both known as HIF-1 and HIF-2 dependent genes, was decreased in U251shHAF cultured in hypoxia (1% O2) compared to U251Sc cells. Loss of function of HAF leads to a significant growth delay of U251shHAF tumours of 3 weeks compared to U251Sc tumours, although both tumours display similar vascularisation, glial and inflammation reactions. In other hand, HAF silencing in glioma cells does not modified their sensitivity to X-rays or TMZ as suggested by the similar results obtained for both U251shHAF and U251Sc cells, through clonogenic assay, cell cycle and apoptosis analyses. Conclusion Our results suggest that HAF might be of poor prognosis for GB since its inhibition in glioma cells reduces tumour growth without alleviating glioma cell chemo- and radioresistance.

The alleviation of hypoxia in glioblastoma with carbogen to improve treatment has met with limited success. Our hypothesis is that the eventual benefits of carbogen depend on the capacity for vasodilation. We examined, with MRI, changes in fractional cerebral blood volume, blood oxygen saturation, and blood oxygenation level dependent signals in response to carbogen. The analyses were performed in two xenograft models of glioma (U87 and U251) recognized to have different vascular patterns. Carbogen increased fractional cerebral blood volume, blood oxygen saturation, and blood oxygenation level dependent signals in contralateral tissues. In the tumor core and peritumoral regions, changes were dependent on the capacity to vasodilate rather than on resting fractional cerebral blood volume. In the highly vascularised U87 tumor, carbogen induced a greater increase in fractional cerebral blood volume and blood oxygen saturation in comparison to the less vascularized U251 tumor. The blood oxygenation level dependent signal revealed a delayed response in U251 tumors relative to the contralateral tissue. Additionally, we highlight the considerable heterogeneity of fractional cerebral blood volume, blood oxygen saturation, and blood oxygenation level dependent within U251 tumor in which multiple compartments co-exist (tumor core, rim and peritumoral regions). Finally, our study underlines the complexity of the flow/metabolism interactions in different models of glioblastoma. These irregularities should be taken into account in order to palliate intratumoral hypoxia in clinical trials.

Hypoxia in gliomas is associated with tumor resistance to radio- and chemotherapy. However, positron emission tomography (PET) imaging of hypoxia remains challenging, and the validation of biological markers is, therefore, of great importance. We investigated the relationship between uptake of the PET hypoxia tracer [18F]-FMISO and other markers of hypoxia and angiogenesis and with patient survival.

Quantitative imaging modalities for the analysis of hypoxia in brain tumors are lacking. The objective of this study was to generate absolute maps of tissue p t O 2 from [ 18 F]-FMISO images in glioblastoma and less aggressive glioma patients in order to quantitatively assess tumor hypoxia. An ancillary objective was to compare estimated p t O 2 values to other biomarkers: perfusion weighted imaging (PWI) and tumor metabolism obtained from 1 H-MR mono-voxel spectroscopy (MRS). Ten patients with glioblastoma (GBM) and three patients with less aggressive glioma (nGBM) were enrolled. All patients had [ 18 F]-FMISO and multiparametric MRI (anatomic, PWI, MRS) scans. A non-linear regression was performed to generate p t O 2 maps based on normal appearing gray (NAGM) and white matter (NAWM) for each patient. As expected, a marked [ 18 F]-FMISO uptake was observed in GBM patients. The p t O 2 based on patient specific calculations was notably low in this group (4.8 ± 1.9 mmHg, p < 0.001) compared to all other groups (nGBM, NAGM and NAWM). The rCBV was increased in GBM (1.4 ± 0.2 when compared to nGBM tumors 0.8 ± 0.4). Lactate (and lipid) concentration increased in GBM (27.8 ± 13.8%) relative to nGBM (p < 0.01). Linear, nonlinear and ROC curve analyses between p t O 2 maps, PWI-derived rCBV maps and MRS-derived lipid and lactate concentration strengthens the robustness of our approaches.

In some highly inflammatory tumors, such as glioblastoma (GB), macrophages (MΦ) represent the most abundant population of reactive cells. MΦ, initially denoted as M0 MΦ, can be polarized into two further phenotypes: the antitumor M1 MΦ, and the protumor M2 MΦ. The three phenotypes can reside simultaneously in the tumor mass and various external factors may influence MΦ polarization. Radiotherapy is a common modality of cancer treatment aiming to target tumor cells. However, the specific effects of X-ray radiation on the inflammatory cells are, so far, controversial and not fully understood. In the present investigation, we have first analyzed, in vivo, the effect of X-ray radiation on MΦ present in GB tumors. We have observed a decrease in MΦ number paralleled by an increase in the proportion of M2 MΦ. To understand this phenomenon, we then evaluated, in vitro, the effects of X-rays on the MΦ phenotypes and survival. We have found that X-ray radiation failed to modify the phenotype of the different MΦ. However, M1 MΦ were more sensitive to ionizing radiation than M2 MΦ, both in normoxia and in hypoxia, which could explain the in vivo observations. To conclude, M2 MΦ are more radioresistant than M0 and M1 MΦ and the present study allows us to propose that X-ray radiotherapy could contribute, along with other phenomena, to the increased density in the protumor M2 MΦ in GB.