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Annals of Surgery:
doi: 10.1097/SLA.0b013e318295c160
Original Articles

Hypoxia After Liver Surgery Imposes an Aggressive Cancer Stem Cell Phenotype on Residual Tumor Cells

Govaert, Klaas M. MD; Emmink, Benjamin L. MD; Nijkamp, Maarten W. MD, PhD; Cheung, Zing J. MD; Steller, Ernst J. A. MD, PhD; Fatrai, Szabolcs PhD; de Bruijn, Menno T. MD, PhD; Kranenburg, Onno PhD; Borel Rinkes, Inne H. M. MD, PhD

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Objective: To assess the contribution of hypoxia and bone marrow–derived cells to aggressive outgrowth of micrometastases after liver surgery.

Background: Liver surgery generates a microenvironment that fosters aggressive tumor recurrence. These areas are characterized by chronic hypoxia and influx of bone marrow–derived cells.

Methods: The contribution of hematopoietic cell types was studied in mice lacking specific components of the immune system and in irradiated mice lacking all bone marrow–derived cells. Tumor cells were derived from colorectal cancer patients and from a metastatic tumor cell line. Hypoxia-induced changes in stem cell and differentiation marker expression, clone-forming potential, and metastatic capacity were assessed. The effect of vascular clamping on cancer stem cell (CSC) characteristics was performed in mice bearing patient-derived liver metastases.

Results: Immune cells and bone marrow–derived cells were not required for aggressive outgrowth of micrometastases in livers treated with surgery. Rather, hypoxia was sufficient to promote invasion and accelerate metastatic outgrowth. This was associated with a rapid loss of differentiation markers and increased expression of CSC markers and clone-forming capacity. Likewise, metastases residing in ischemia-reperfusion-injured liver lobes acquired CSC characteristics. Despite their renowned general resistance to chemotherapy, clone-forming CSCs were readily killed by the hypoxia-activated prodrug tirapazamine.

Conclusions: Surgery-generated hypoxia in the liver causes rapid dedifferentiation of tumor cells into immature CSCs with high clone- and metastasis-forming capacity. The results help explain the phenomenon of aggressive local tumor recurrence after liver surgery and offer a potential strategy to kill aggressive CSCs by hypoxia-activated prodrugs.

© 2014 by Lippincott Williams & Wilkins.


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