Antitumor Effect by Either FLASH or Conventional Dose Rate Irradiation Involves Equivalent Immune Responses

Abstract

Purpose: The capability of ultra-high dose rate FLASH radiotherapy (FLASH) to generate the FLASH effect has opened the possibility to enhance the therapeutic index of radiotherapy. The contribution of the immune response has frequently been hypothesized to account for a certain fraction of the anti-tumor efficacy and tumor kill of FLASH but has yet to be rigorously evaluated. Methods: To investigate the immune response as a potentially important mechanism of the anti-tumor effect of FLASH, various murine tumor models were grafted either subcutaneously or orthotopically into immunocompetent mice, or in moderately and severely immunocompromised mice. Mice were locally irradiated with single dose (20 Gy) or hypo-fractionated regimens (3 × 8 Gy; 2 × 6 Gy), using FLASH (≥ 2000 Gy/s) and Conventional dose rates (0.1 Gy/s, CONV), with/without anti-CTLA-4. Tumor growth was monitored over time, and immune profiling performed. Results: 20 Gy FLASH and CONV were isoeffective in delaying tumor growth in immunocompetent and moderately immunodeficient hosts, and increased tumor doubling time to >14 days vs. >7 days in control animals. Similar observations were obtained with hypo-fractionated scheme, regardless the microenvironment (subcutaneous flank vs. ortho lungs). Interestingly, in profoundly immunocompromised mice, 20 Gy FLASH retained anti-tumor activity and significantly increased tumor doubling time to >14 days vs. >8 days in control animals, suggesting a possible anti-tumor mechanism independent of the immune response. Analysis of the tumor microenvironment showed similar immune profiles after both irradiation modalities with significant decrease of lymphoid cells by ∼40 % and a corresponding increase of myeloid cells. In addition, FLASH and CONV did not increase TGF-β1 levels in tumors as compared to unirradiated control animals. Furthermore, when a complete and long-lasting anti-tumor response was obtained (> 140 days), both modalities of irradiation were able to generate a long-term immunological memory response. Conclusions: The present results clearly document that the tumor responses across multiple immunocompetent and immunodeficient mouse models are largely dose rate independent, and simultaneously contradict a major role of the immune response in the anti-tumor efficacy of FLASH. Therefore, our study indicates that FLASH is as potent as CONV in modulating anti-tumor immune response and can be used as an immunomodulatory agent.