34Background. Glioblastoma (GBM) patients have an estimated survival of ~15 months with 35 treatment, and the standard of care only modestly enhances patient survival. Identifying 36 biomarkers representing vulnerabilities may allow for selection of efficacious chemotherapy 37 options to address personalized variations in GBM tumors. Irinotecan, currently in clinical trials 38 for GBM, targets topoisomerase I (TOP1) by forming a ternary DNA-TOP1 cleavage complex 39 (TOP1cc) inducing apoptosis. Tyrosyl-DNA phosphodiesterase 1 (TDP1) is a crucial repair 40 enzyme that may reduce the effectiveness of irinotecan. 41 42 3 Methods. We treated GBM cell lines with increasing concentrations of irinotecan and compared 43 the IC50 values. TOP1 and TDP1 protein levels from each cell type as well as GBM patient tumors 44 were determined by Western blot analysis, while activity levels were ascertained by specific 45 enzymatic assays. Cellular TDP1 was elevated by ectopic expression of wild-type or mutant TDP1. 46 47 Results. After comparing cellular susceptibility to TDP1 and TOP1 concentrations and activities, 48we found that the TDP1/TOP1 activity ratio had the strongest correlation (Pearson correlation 49 coefficient R = 0.92) with IC50 values following irinotecan treatment. Increasing the TDP1/TOP1 50 activity ratio by ectopic expression of wild-type TDP1 increased in irinotecan IC50, while 51 expression of the TDP1 catalytic-null mutant did not alter the susceptibility to irinotecan. 52 53 Conclusions. TDP1/TOP1 activity ratio may be a new predictive indicator for GBM vulnerability 54 to irinotecan, allowing for selection of individual patients for irinotecan treatment based on risk-55 benefit. Moreover, TDP1 inhibitors may be a novel combination treatment with irinotecan to 56 improve GBM patient responsiveness to genotoxic chemotherapies. 57 58 Keywords: glioblastoma, DNA repair, TOP1, TDP1, irinotecan 59 60 Key Points 61 1. TDP1/TOP1 activity ratio correlates with irinotecan sensitivity in GBM cell lines. 62