Distinct immune responses to proton and photon radiotherapy: implications for anti-PD-L1 combination therapy in colorectal cancer

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BACKGROUND: Ionizing radiation can influence the antitumor immune response, either activating or suppressing the immune system depending on the tumor type and radiotherapy modality. While photon radiation (RT) combined with immunotherapy (IT) is widely studied in clinical trials, proton radiation (PT) combined with IT has not been thoroughly investigated in clinical or preclinical studies despite its radiobiological advantages. This study aims to explore the immune effects of a hypofractionated PT scheme compared to RT and its efficacy with anti-PD-L1 immunotherapy. METHODS: Balb/c mice bearing subcutaneous CT26 colon tumors were treated with RT or PT, delivered with 3 × 8 Gy. Seven days post-treatment, transcriptomic analysis and immune response assessments to characterize lymphoid cells, myeloid cells, and PD-L1 expression were performed. Tumor growth was monitored to evaluate the efficacy of combining RT or PT with anti-PD-L1 IT. RESULTS: The RNA sequencing analysis demonstrated an overexpression of genes involved in the interferon type I pathway after both RT and PT. Tumor microenvironment analysis showed enhanced immune cell infiltration in tumors after both treatments. Immunoactivating cells infiltration was observed, with LT CD8 + cells infiltration after both RT and PT, more significantly after RT. NK and TAM1 cells infiltrated only after RT. Immunosuppressive cell populations were induced by PT, including MDSCs, while Tregs infiltrated both RT and PT treated tumors. PD-L1 expression was significantly induced only by RT. The combination of anti-PD-L1 with RT or PT resulted in tumor growth delay compared to RT or PT alone, with a significant survival benefit observed only after the combination of RT and IT. CONCLUSIONS: This study demonstrates that hypofractionated RT and PT induced both similar and significantly distinct immune responses. PT triggers a stronger immunosuppressive response than RT. Optimizing the combination of PT with IT, including dose, fractionation, and sequencing is crucial for improving treatment efficacy.

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