Hypoxia/Reoxygenation-Induced Mitochondrial Reverse Electron Transfer: A Targetable Mechanism to Enhance Radiosensitivity in Non-Small Cell Lung Cancer

Hypoxia-induced radioresistance remains a major obstacle in non-small cell lung cancer (NSCLC) radiotherapy. This study investigates whether artificially activating mitochondrial reverse electron transfer (RET) can enhance radiosensitivity in NSCLC by triggering oxidative stress. An in vitro hypoxia/reoxygenation (H/R) model was established in A549 cells to assess reactive oxygen species (ROS) levels, mitochondrial function, and metabolic alterations using fluorescence probes, flow cytometry, confocal microscopy, and targeted metabolomics. Mitochondrial complex inhibitors and dimethyl succinate (DM-S) were employed to validate the RET mechanism, and radiosensitivity was evaluated through clonogenic survival, apoptosis assays, and γ-H2AX staining. In vivo, A549 tumor-bearing mice received high oxygen (95% O2) combined with DM-S and localized irradiation (4 Gy); tumor growth, histopathology, and immunohistochemistry were examined. H/R triggered substantial mitochondrial ROS production via complex I-mediated RET, dependent on a high mitochondrial membrane potential and electron transport chain imbalance, with succinate accumulation serving as a key metabolic switch. Exogenous DM-S exacerbated H/R-induced oxidative damage, DNA fragmentation (8-OHdG elevation, mtDNA integrity loss), and mitochondrial network disruption. H/R combined with DM-S significantly enhanced in vitro radiosensitivity, reducing clonogenic survival and increasing apoptosis to 53.4% ± 1.9% versus 10.3% ± 1.2% with irradiation alone. In vivo, the combination therapy markedly suppressed tumor growth, induced apoptosis and oxidative lipid damage (4-HNE), alleviated hypoxia (reduced HIF-1α), and showed no overt toxicity. These findings demonstrate that activating mitochondrial RET effectively enhances radiosensitivity in NSCLC. Succinate metabolism is a critical therapeutic target, and combining high oxygen with a succinate analog represents a promising radiosensitization strategy for hypoxic tumors.