Abstract 4762: Tumor treating fields (TTFields) increase cancer cell membrane permeability and improve sensitivity to doxorubicin in vitro and in vivo
Authors: Koltun Bella , Voloshin Tali , Kan Tal , David Cfir , Koren Lilach , Porat Yaara , Volodin Alexandra , Kaynan Noa , Klein-Goldberg Anat , Paz Rom , Brant Boris , Barsheshet Yiftah , Zemer-Tov Efrat , Haber Adi , Giladi Moshe , Weinberg Uri , Palti Yoram 
Published: March 2024

Abstract
Background: Tumor Treating Fields (TTFields) are electric fields that disrupt cellular processes critical for cancer cell viability and tumor progression. While the mechanism of action of TTFields has been associated with an antimitotic effect and impaired DNA damage repair mechanisms, the application of TTFields has also been shown to increase the membrane permeability of glioblastoma cells. The current study examined whether increased cell membrane permeability is relevant in other tumor types and may be leveraged to facilitate uptake of the anticancer agent doxorubicin (DOX).
Methods: Breast mammary carcinoma (4T1), breast adenocarcinoma (MCF-7), uterine sarcoma (MES-SA), lung fibroblasts (MRC-5), and brain endothelial (HBMVEC) cells were treated with TTFields using the inovitroTM system. Intracellular 7-aminoactinomycin D (7-AAD) accumulation and cell count were measured using flow cytometry to determine membrane permeability and cytotoxicity, respectively. TTFields (300 kHz) together with DOX were applied to 4T1 cells DOX-sensitive (4T1-S) and DOX-resistant (4T1-R, generated by repeated DOX exposure of the 4T1-S cells), followed by flow cytometry analysis of DOX accumulation (24 h treatment) and cell survival using cell count (72 h treatment). For proof of concept, mice were orthotopically inoculated with 4T1-S cells, followed by TTFields treatment for 72 h and injection of DOX (5 mg/kg) 24 h before ending TTFields treatment. DOX fluorescence was measured by flow cytometry in single-cell tumor suspension and whole tumor in vivo imaging system (IVIS). For the efficacy studies, mice were orthotopically inoculated with 4T1-S or 4T1-R cells. Tumors were allowed to grow, and then the mice were treated with TTFields (300 kHz) or sham-heat continuously for 8 days, with DOX (1 mg/kg for 4T1-S cells; 5 mg/kg for 4T1-R cells) or vehicle 2- and 6-days following treatment initiation. Tumor volumes were measured using caliper.
Results: TTFields increased 7-AAD accumulation in cancer but not normal cells. Maximal TTFields-induced cellular permeability was identified at 300 kHz for 4T1 cells, whereas TTFields-induced cytotoxicity was the highest at 150 kHz. The application of TTFields allowed DOX accumulation to the same extent in both DOX-resistant and DOX-sensitive cells and sensitized both cell types to DOX cytotoxicity. A 2- to 3-fold higher DOX accumulation was observed in tumors isolated from mice treated with TTFields relative to control mice. Significantly lower tumor volume was observed in mice treated with TTFields and DOX relative to control or mice treated with DOX alone.
Conclusions: TTFields increased cancer cell permeability, resulting in enhanced intracellular accumulation of DOX. Concomitant treatment with TTFields and DOX can improve treatment efficacy in DOX-resistant tumors and sensitize DOX-sensitive tumors to lower DOX concentrations.
Citation Format: Bella Koltun, Tali Voloshin, Tal Kan, Cfir David, Lilach Koren, Yaara Porat, Alexandra Volodin, Noa Kaynan, Anat Klein-Goldberg, Rom Paz, Boris Brant, Yiftah Barsheshet, Efrat Zemer-Tov, Adi Haber, Moshe Giladi, Uri Weinberg, Yoram Palti. Tumor treating fields (TTFields) increase cancer cell membrane permeability and improve sensitivity to doxorubicin in vitro and in vivo [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2024; Part 1 (Regular Abstracts); 2024 Apr 5-10; San Diego, CA. Philadelphia (PA): AACR; Cancer Res 2024;84(6_Suppl):Abstract nr 4762.