REVIEW SERIES: HYPOXIA AND INFLAMMATION The Journal of Clinical Investigation Series Editor: M. Celeste Simon The impact of hypoxia on tumor-associated macrophages Anne-Theres Henze1,2 and Massimiliano Mazzone1,2 1Laboratory of Tumor Inflammation and Angiogenesis, Vesalius Research Center, VIB, Leuven, Belgium. 2Laboratory of Tumor Inflammation and Angiogenesis, Department of Oncology, KU Leuven, Leuven, Belgium. The role of tumor-associated macrophages (TAMs) in cancer is often correlated with poor prognosis, even though this statement should be interpreted with care, as the effects of macrophages primarily depend on their localization within the tumor. This versatile cell type orchestrates a broad spectrum of biological functions and exerts very complex and even opposing functions on cell death, immune stimulation or suppression, and angiogenesis, resulting in an overall pro- or antitumoral effect. We are only beginning to understand the environmental cues that contribute to transient retention of macrophages in a specific phenotype. It has become clear that hypoxia shapes and induces specific macrophage phenotypes that serve tumor malignancy, as hypoxia promotes immune evasion, angiogenesis, tumor cell survival, and metastatic dissemination. Additionally, TAMs in the hypoxic niches within the tumor are known to mediate resistance to several anticancer treatments and to promote cancer relapse. Thus, a careful characterization and understanding of this macrophage differentiation state is needed in order to efficiently tailor cancer therapy. Macrophages and the tumor microenvironment marrow–derived macrophages can give rise to self-renewing tis- Tumor tissue comprises a highly complex network of diverse cell sue-resident macrophages (in this case, Kupffer cells) during the types. In a simplified view, the tumor microenvironment can be first weeks of life or during tissue injury in adulthood when the subdivided into the cancer cell and the stromal cell compart- niche becomes available. These bone marrow–derived macro- ments, the latter of which harbors many different cell types. A con- phages and their embryonic counterparts were further shown to siderable number of innate immune cells reside within the tumor exhibit a significant phenotypic and transcriptional overlap (8). microenvironment, including macrophages, which are the most Macrophages are equipped to execute a broad repertoire of prevalent cell type in a variety of tumors. Macrophages are primar- functions that range from their involvement in tissue homeostasis ily considered essential mediators in immune defense and it has and wound healing to their role as immune effectors. In a simpli- been assumed that they might contribute to an antitumor immune fied view, there are two main activation states that represent a para- response to combat tumor growth; however, mounting evidence digm for understanding the opposing functions that these cells can indicates that macrophages foster malignancy and tumor progres- carry out: the classical M1 and the alternative M2 macrophage phe- sion. The discrepancy between these contrasting observations notypes, a classification that mirrors the Th1/Th2 polarization of T might stem from the fact that, in general, macrophages are excep- cells (9). Macrophage responses, which are shaped by these activa- tionally plastic cells that respond and adapt to the microenviron- tion modes, are characterized by two contrasting actions: killing ment in which they are embedded (1, 2). Moreover, the functional and repairing. Proinflammatory cytokines such as TNF-α or IFN-γ, properties of tissue-resident macrophages greatly vary between as well as microbial cell wall components, serve as cues that trigger different organs, not only due to their environmental skewing a proinflammatory, antibacterial, and antiangiogenic (M1-like) pro- (3), but also with respect to their specific origin, further compli- gram, thereby arming macrophages with important effector mol- cating a simplified classification of macrophages. For example, ecules that allow pathogen recognition and killing as well as recruit- brain macrophages arise from the yolk sac (4), Kupffer cells are ment of other immune cells to the site of infection. Generation of believed to arise from a mixed lineage that includes the yolk sac ROS and NO, expression of high amounts of IL-12, and low levels and embryonic hematopoietic stem cells (5), and macrophages in of IL-10 are typically associated with an M1 macrophage response. the intestine are derived entirely from adult hematopoietic stem In contrast, cytokines such as IL-4, IL-13, and IL-10 induce macro- cells (6). During adulthood each organ determines to what extent phages to acquire the ability to execute antiinflammatory, protu- tissue-circulating blood monocytes replace tissue-resident mac- morigenic, and proangiogenic (M2-like) functions (10, 11). Under rophages. However, it still remains an open question as to what physiological conditions, M2-like macrophages facilitate wound extent cell lineage determines macrophage behavior and pheno- healing by promoting angiogenesis, cell proliferation, and clearing type (7). A recent study demonstrated for the first time that bone of cellular debris (12, 13). However, as we will discuss in more detail, these capacities are coopted within the tumor microenvironment to fuel tumor growth. In reality, the distinction between these acti- Conflict of interest: The authors have declared that no conflict of interest exists. vation states becomes rather blurry, as macrophages might exhibit Reference information: J Clin Invest. 2016;126(10):3672–3679. doi:10.1172/JCI84427. phenotypes anywhere in between these two extremes. Recent pub- 3672 jci.org Volume 126 Number 10 October 2016 The Journal of Clinical Investigation REVIEW SERIES: HYPOXIA AND INFLAMMATION lications dealing with this issue shed new light on the complexity of Tumor hypoxia occurs when uncontrolled cell proliferation macrophage activation states (and ontogeny), proposing new guide- prevails such that blood vessel growth and the supply of oxygen lines for nomenclature and experimental standards to describe and nutrition become limiting. The hypoxic response initiates a macrophage heterogeneity (14, 15). program to restore oxygen availability. On the cellular level this is Within the cancerous tissue, macrophages are designated as reflected by angiogenesis induction, metabolic reprogramming, tumor-associated macrophages (TAMs). It is clear that M1-like proliferation, self-renewal, and autophagy, which are among mul- macrophages can contribute to an antitumor response; however, tiple mechanisms to counteract oxygen shortage; however, these experimental evidence suggests that during tumor initiation, per- are also detrimental processes that are exploited to foster tumor sistent, proinflammatory (M1-like) macrophage functions might progression and metastatic dissemination (31). Therefore, the promote malignant transformation (16), supporting the hypoth- consequences of oxygen shortage are multifaceted, but exhibit esis that inflammation promotes cancer, which was established a commonality in that they contribute to a hostile microenviron- by Rudolf Virchow in the 19th century (17). An overwhelming and ment that selects for a more aggressive cancer phenotype (32). long-lasting release of inflammation-promoting factors, such as The hypoxic response is mediated by, among others, the cytokines, chemokines, or free radicals, has been shown to culmi- hypoxia-inducible transcription factors HIF1α and HIF2α, making it nate in cell proliferation, mutagenesis, and oncogene activation, apparent how perturbations in oxygen availability can alter cellular all of which are determinants of cell transformation (16). Thus, responses. M1 and M2 macrophages differentially express HIF1α chronic inflammatory conditions are characterized by a greater and HIF2α as well as inducible nitric oxide synthase (iNOS) and argi- risk of tumor incidence. In an established tumor, macrophages are nase 1 (ARG1) (33). Myeloid-specific loss of HIF1α reduced tumor educated to a proangiogenic tumor-promoting (M2-like) pheno- growth and retarded tumor progression in the murine MMTV-PyMT type. Tumor hypoxia is thought to play a pivotal role in the pheno- model (34). Loss of HIF2α in macrophages had a favorable outcome typic control of TAMs, as hypoxic TAMs release factors that assist in hepatocellular and colitis-associated colon carcinomas (35). in tumor growth, cancer immunosuppression, and angiogenesis Under oxygen deprivation the angiogenic process is induced (18, 19). It is therefore easy to conceive that phenotypic switches in to ensure oxygen availability; however, the excessive release of TAMs occur in a spatiotemporal fashion, as they are dependent on angiogenic factors within the tumor microenvironment under microenvironmental cues such as hypoxia in conjunction with cyto- hypoxic conditions culminates in a rather tortuous vascular net- kine availability. It should be noted that it is the concerted action of work that does not effectively restore the blood supply. This hypoxia and cytokines that ultimately shapes macrophage respons- aberrant vascular structure further contributes to spatiotempo- es, as hypoxia alone is a common feature in many pathophysiologi- ral changes in oxygen delivery, thereby aggravating the hypoxic cal settings (20–22) in which the respective macrophage phenotype phenotype of tumors. Additionally, hypoxic cells are subjected to might differ strongly. LPS