Hypoxia contributes to cytotoxic chemotherapy and radiation resistance and may play a role in the efficacy of antiangiogenesis cancer therapy. We have generated a series of cell lines derived from the colon adenocarcinoma models HT29 and HCT116 by exposing cells in vitro to repeated sublethal periods of profound hypoxia. These cell lines have altered sensitivity to hypoxia-induced apoptosis: those derived from HT29 are resistant, whereas those from HCT116 are more susceptible. We used cDNA selected subtractive hybridization to identify novel genes mediating sensitivity to hypoxia-induced apoptosis and isolated macrophage migration inhibitory factor (MIF) from the hypoxia-conditioned cell lines. MIF expression correlates with susceptibility of the cell lines to apoptosis. In hypoxia-resistant cells, the induction of apoptosis by hypoxia can be restored by the addition of exogenous recombinant MIF protein, suggesting that resistance may result in part from down-regulation of MIF production possibly through an autocrine loop. Inhibition of MIF using small interfering RNA in the susceptible lines conferred resistance to hypoxia-induced cell death. The relative expression of MIF in the hypoxia-conditioned cells implanted s.c. in severe combined immunodeficient mice in vivo was similar to that observed in vitro. In an analysis of 12 unrelated colon tumor cell lines, MIF expression and response to hypoxia varied widely. Cell lines in which MIF was inducible by hypoxia were more sensitive to oxaliplatin. In human colon tumor specimens analyzed by immunohistochemistry, MIF expression was similarly variable. There was no detectable expression of MIF in normal colon mucosa or adenoma but positive staining in all carcinomas tested. Taken together, these data indicate that MIF may be a determinant of hypoxia-induced apoptosis in vitro and that its variable expression in human colon cancers may indicate a functional role in vivo. We suggest that MIF expression in colorectal cancer may be a marker of susceptibility to therapies that may depend on induction of hypoxia, possibly including antiangiogenic therapy.Colon cancer is characterized by regions of variable hypoxia, known to be a consequence of disordered vasculature (1). Cells in these hypoxic regions are resistant to radiation and to cytotoxic drugs (2). We have shown previously that hypoxia induces increased expression of genes involved in the detoxification of cytotoxic drugs (3), an effect exerted in part by activation of transcription factors, including activator protein-1 and nuclear factor-nB (4, 5). Hurwitz et al. have shown recently that antiangiogenic therapy adds to the efficacy of chemotherapy in colorectal cancer (6), whereas Willett et al. showed that bevacizumab alone in rectal cancer markedly decreased blood flow to the tumor (7). These findings raise the possibility that apoptosis as a result of oxygen or nutrient withdrawal contributes to the therapeutic effect and prompted an investigation of the resistance of hypoxic cancer cells to apoptos...