Understanding the functions of tumor stroma in resistance to ionizing radiation: Emerging targets for pharmacological modulation

Maintenance of both normal epithelial tissues and their malignant counterparts is supported by the host tissue stroma. The tumor stroma mainly consists of the basement membrane, fibroblasts, extracellular matrix, immune cells, and vasculature. Although most host cells in the stroma possess certain tumor-suppressing abilities, the stroma will change during malignancy and eventually promote growth, invasion, and metastasis. There is growing evidence that the stroma influences importantly the response to radiation therapy (RT). On the one hand, irradiation releases numerous inflammatory cytokines within the extracellular matrix and activates tumor specific antigens presentation, triggering an immune reaction that contributes to the antitumor effect seen after RT. On the other hand, the stroma significantly contributes to radioresistance but also increases the metastatic risk. Indeed, fibroblasts, which are major actors of the impact of stroma on tumor response, are involved in activation of autocrine and paracrine molecular signaling pathways regulating tumor cell proliferation, cell death, response to hypoxia, DNA repair systems and mesenchymal-epithelial transition. They are also actors of the peritumoral desmoplastic reaction, which decreases tumor radiosensitivity. The irradiated stroma can also contribute to tumor relapse after RT through recruitment of bone marrow-derived progenitors that contribute to local tumor relapse through neovascularization. It is therefore time to question preclinical models that would not take into account this impact of stroma. The increasing knowledge of the relationship between stroma and response to IR could help developing innovative strategies for potentially improve antitumor effect of RT.