1The efficacy of aminolevulinic acid (5-ALA)-based photodynamic diagnosis (5-ALA-PDD) and 2 photodynamic therapy (5-ALA-PDT) is dependent on the 5-ALA-induced cancer-specific 3 accumulation of protoporphyrin IX (PpIX). We previously reported that inhibition of oncogenic 4 Ras/MEK increases PpIX accumulation in cancer cells by reducing PpIX efflux through ATP-binding 5 cassette sub-family B member 1 (ABCB1) as well as PpIX conversion to heme by ferrochelatase 6 (FECH). Here, we sought to identify the downstream pathways of Ras/MEK involved in the 7 regulation of PpIX accumulation via ABCB1 and FECH. First, we demonstrated that Ras/MEK 8 activation reduced PpIX accumulation in RasV12-transformed NIH3T3 cells and HRAS transgenic 9 mice. Knockdown of p90 ribosomal S6 kinases (RSK) 2, 3, or 4 increased PpIX accumulation in the 10 RasV12-transformed NIH3T3 cells. Further, treatment with an RSK inhibitor reduced ABCB1 11 expression and increased PpIX accumulation. Moreover, HIF-1α expression was reduced when the 12 RasV12-transformed NIH3T3 cells were treated with a MEK inhibitor, demonstrating that HIF-1α is a 13 downstream element of MEK. HIF-1α inhibition decreased the activity of FECH and increased PpIX 14 accumulation. Finally, we demonstrated the involvement of RSKs and HIF-1α in the regulation of 15 PpIX accumulation in human cancer cell lines (DLD-1, SNB-75, Hs 578T, and MDA MB 231). These 16 results demonstrate that the RSK-ABCB1 and HIF-1α-FECH axes are the downstream pathways of 17 Ras/MEK involved in the regulation of PpIX accumulation. 18 19