Reengineering the tumor microenvironment to alleviate hypoxia and overcome cancer heterogeneity

Solid tumors consist of cancer cells and stromal cells, including resident and transiting immune cells—all ensconced in an extracellular matrix (ECM)—nourished by blood vessels and drained by lymphatic vessels. The microenvironment constituents are abnormal and heterogeneous in morphology, phenotype, and physiology. Such irregularities include an inefficient tumor vascular network comprised of leaky and compressed vessels, which impair blood flowand oxygen delivery. Low oxygenation in certain tumor regions—or focal hypoxia—is a mediator of cancer progression, metastasis, immunosuppression, and treatment resistance. Thus, repairing an abnormal and heterogeneous microenvironment—and hypoxia in particular—can significantly improve treatments of solid tumors. Here, we summarize two strategies to reengineer the tumor microenvironment (TME)—vessel normalization and decompression—that can alleviate hypoxia. In addition, we discuss how these two strategies alone and in combination with each other—or other therapeutic strategies—may overcome the challenges posed by cancer heterogeneity.