Radio therapy and immunotherapy
Radio therapy and immunotherapy
Radio therapy and immunotherapy
com/sigtrans
Radiotherapy (RT) is delivered for purposes of local control, but can also exert systemic effect on remote and non-irradiated tumor
deposits, which is called abscopal effect. The view of RT as a simple local treatment has dramatically changed in recent years, and it
is now widely accepted that RT can provoke a systemic immune response which gives a strong rationale for the combination of RT
and immunotherapy (iRT). Nevertheless, several points remain to be addressed such as the interaction of RT and immune system,
the identification of the best schedules for combination with immunotherapy (IO), the expansion of abscopal effect and the
mechanism to amplify iRT. To answer these crucial questions, we roundly summarize underlying rationale showing the whole
immune landscape in RT and clinical trials to attempt to identify the best schedules of iRT. In consideration of the rarity of abscopal
effect, we propose that the occurrence of abscopal effect induced by radiation can be promoted to 100% in view of molecular and
genetic level. Furthermore, the “radscopal effect” which refers to using low-dose radiation to reprogram the tumor
microenvironment may amplify the occurrence of abscopal effect and overcome the resistance of iRT. Taken together, RT could be
regarded as a trigger of systemic antitumor immune response, and with the help of IO can be used as a radical and systemic
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treatment and be added into current standard regimen of patients with metastatic cancer.
1
Department of Radiation Oncology, Shandong University Cancer Center, Yantai Road, No. 2999, Jinan, Shandong, China and 2Department of Radiation Oncology, Shandong
Cancer Hospital and Institute, Shandong First Medical University and Shandong Academy of Medical Sciences, Jiyan Road, No. 440, Jinan, Shandong, China
Correspondence: Dawei Chen ([email protected]) or Jinming Yu ([email protected])
These authors contributed equally: Zengfu Zhang, Xu Liu.
1893 1895 1953 2012 2015 2016 2017 2019 2020 2021 2022
in medicine have never slowed down. Tracing back the FLASH RT, proton RT, and carbon ion RT may benefit more
development history in RT, it can be summarized as two paths patients with reduced toxicities and improved survival outcomes.
(physical development and biological effect) and four major eras Cancer immunotherapy has a history of more than 100 year so
(discovery era, orthovoltage era, megavoltage era, and ion beams far. Although difficult to prove, the initiation of immunotherapy
era).52,53 During the era of discovery, which referred to the period can be traced back to 2400 years ago.61 Nowadays, William B.
from the discovery of X-ray to 1930, the roots of RT were Coley is widely accepted as the father of immunotherapy. The first
established. In addition to the salient discovery by Röntgen in clinical trial using IO (mixtures of Streptococcus pyogenes and
1895, Becquerel reported the phenomenon of radioactivity in Serratia marcescens) to treat tumors was designed by Coley in
1896 and in 1898 the Curies isolated radium, which lay the 1893. However, due to the lack of known mechanisms about the
foundation of RT. Indeed, a patient with breast cancer received the “Coley’s toxins” and immune system, IO has been in a slow
treatment of RT using X-ray in 1896.54 Although X-rays were used development stage and even raises doubts about tumor immunity
in the clinic, biological effects and mechanisms still remain and its treatment. In 1959, the first cancer vaccine study
unclear. Regaud and Coutard found the advantages of fractio- conducted by Ruth and John Graham achieved success and
nated therapy in the research of delivering the total radiation dose aroused interest in this area.62 With the establishment of existence
and their studies promoted the understanding of X-ray’s biological and the key role of T cell in adaptive immunity by Miller in 1967,63
characteristics.55 Another crucial discovery is a practical X-ray tube cancer IO was made in rapid-fire succession. In addition to the
which can promote the delivery of X-rays with higher-energy above-mentioned development, the discovery of dendritic cells
(180–200 kV) by Coolidge.56 The orthovoltage era is from 1930 to and natural killer cells, promoted the understanding of underlying
1950 which is a booming and transitional period of physical and mechanisms of immune system and aided in the process of cancer
machine developments. The cyclotron was developed by Widerøe IO. In the 1980’s, Taniguchi et al. cloned the IL-2 and it showed
in 1927 and invented in 1930 by Lawrence and Livingston.57 promising results in clinical trials.64,65 Furthermore, it was
Another major advance was the synchrotron, conceived by Veksler approved by the US FDA in 1991 for the patients who were
and McMillan during 1944–1945.58 The first synchrotron began suffering from metastatic kidney cancer. In 1987, Brunet et al. first
operation in 1952 at Brookhaven National Laboratory.59 The proved cytotoxic T-lymphocyte antigen 4 (CTLA-4) and its immune
megavoltage era refers to the period from about 1950 to 1985 and checkpoint function was proved by Jim Allison and his colleagues
it seems that this era is still in progress. Cobalt teletherapy and in 1995.66 Until 2010, ipilimumab as the revolutionary checkpoint
megavoltage linear electron accelerators were considered a inhibitor was approved by FDA for the treatment of stage IV
revolution in cancer treatment which produced radiation with melanoma after the definitive clinical study.67 Another checkpoint
high energy to treat deep tumors.60 In the 1960s and 1970s, inhibitor, nivolumab, was approved by FDA in 2014. Atezolizumab,
electron linacs have been widely used. With the development of another checkpoint inhibitor of the programmed death 1 ligand
computer and imaging technologies, computed tomography (PD-L1) protein, was approved by FDA in 2016.
scans and similar imaging technologies were applied to treatment With the deepening research on biological effect of RT, it seems
planning of RT for determining tumor volumes as well as that combining RT and IO become an inevitable strategy to
identifying normal organ anatomy. The appearance of intensity- improve the outcomes of cancer treatment. In 1975, Milas et al.
modulated radiation therapy (IMRT) improves the radiation beams first proposed that the antitumor effect of local irradiation could
adjusted to the three-dimensional shape of the target and reduces be improved by administration of Corynebacterium granulosum
the damage to surrounding normal tissues.2 In addition, image- or Corynebacterium parvum in C3Hf/Bu mice with a syngeneic
guided radiation therapy (IGRT), using frequent pretreatment fibrosarcoma.68 Besides immunosuppressive effect induced by RT,
imaging to increase certainty regarding tumor location, also investigators realized that RT also has a potential to activate
occurred with the technological progress. And due to the advent immune system of human body, which lay a solid foundation for
of these imaging technologies, stereotactic body radiotherapy iRT. In 2005, Demaria and his colleagues first proposed radio-
(SBRT) has been widely used recent years. In the near future, immunotherapy as a novel approach to treat cancer.69 Following
Radiation TGF-β
IL-10
TβRII TβRI
miR-10a P
JAK
P
JAK T3
3 S TA
T smad7
P
S TA P P
smad3
F-қB
smad2
N
P P
STAT3 STAT3
smad4
Nucleus
P P
smad3
smad2
P P smad4
STAT3 STAT3
CNS1
Foxp3
Expansion ↑
Differentiation ↑ Expansion ↑
T cell suppression ↑ Differentiation ↑
CTLA-4 expression ↑ Treg cell Development ↑
Fig. 2 Immunomodulatory effect of radiation on Treg cells. Radiation promotes the conversion from CD4+ T cells to Treg cells and enhances
Treg function through IL-10R-mediated STAT3 signaling pathway. Radiation also increases the secretion of IL-10 which can bind to IL-10
receptors. This binding activates JAKs and activated JAKs, such as JAK1 and JAK2, phosphorylate STAT3 at Tyr705, resulting in translocation of
activated STAT3 dimers to the nucleus. STAT3, as a cotranscription factor with FOXP3, promotes expansion, differentiation, and T cell
suppression and increases CTLA-4 expression of Treg cells. In addition, miR-10a induced by radiation can enhance the expression level of
FOXP3 and promote the differentiation of Treg from naive CD4+ T cell. Radiation increases the level of TGF-β in the TME greatly and TGF-β
recognizes and binds TGFβRII, which then phosphorylates TGFβRI. TGF-β activates Smad2 and Smad3 and promotes the formation of a
heterotrimer with Smad4. Smads are recruited to the CNS1 region which has been identified at the Foxp3 gene locus. The CNS1 promotes
generation, expansion, differentiation, and development of Treg cells. Parts of this figure were drawn with aid of Servier Medical Art (http://
www.servier.com), licensed under a Creative Commons Attribution 3.0 Unported License. Parts of this figure were drawn with aid of Servier
Medical Art (http://www.servier.com), licensed under a Creative Commons Attribution 3.0 Unported License
expression, which rendered them more resistant to RT-induced According to functional differences, tumor-associated neutro-
apoptosis.171,172 In addition to the increasing count of Treg cells, IR phils (TANs) can be divided into two subtypes: antitumorigenic or
can modulate the phenotype and function of human Treg cells. protumorigenic neutrophils, termed N1 and N2, respec-
Beauford and colleagues found that IR can attenuate the function of tively.173–177 TANs can be a component of tumor-promoting
Treg to suppress the proliferation of CD8+ T cells through inflammation by promoting angiogenesis, immunosuppression,
downregulating Foxp3 expression and modulating the expression remodeling of the extracellular matrix, and metastasis. The
of Treg signature molecules, for example, increasing the expression interaction between neutrophil polarization and tumor micro-
of lymphocyte activation gene 3 (LAG-3) and decreasing the environment has been well summarized but there are few studies
expression of CD25 and CTLA-4.142 Kumagai et al.147 found Treg focusing on the relationship between TANs polarization and
cells has indicative significance for the prediction of PD-1 therapeutic IR.178–184 Generally, TGF-β, an immunosuppressive cytokine over-
effect. They confirmed that the frequency of PD-1+CD8+ T cells has a expressed by tumor cells, polarizes neutrophils to a protumori-
close relation to that of PD-1+ Treg cells in the tumor microenviron- genic phenotype (N2) and inhibits N1 phenotypic polarization. On
ment and this ratio may be a better predictor for PD-1 therapeutic the contrary, IFN-β polarizes neutrophils to an antitumorigenic
effect. The signaling pathways of immunomodulatory effect on Treg phenotype (N1) while inhibits N2 polarization.185 The function of
cells are summarized in Fig. 2. N1 involves in promoting tumor cell cytotoxicity/apoptosis,
Cytotoxicity Genetic
instablity
ROS
IFN-β Radiation
ROS
Type 1 TGF-β
interferon
receptor TGFβR1
Cancer cell
CTL-mediated lysis proliferation
Neutrophil
N1 TAN N2 TAN
Type-1 IFN
Treg cell
M1 φ M2 φ
CD8+ T cell
CD8+ T cell
Immunostimulation Immunosuppression
NK cell
Fig. 3 Immunomodulatory effect of radiation on TANs. Radiation shows complexity regarding the immunomodulatory effect on TANs. On the
one hand, radiation may induce TANs to exhibit the antitumor characteristic (N1) by IFN-β. N1 phenotype induces tumor cells cytotoxicity/
apoptosis through ROS and activates CD8+ T cells and M1 macrophage. On the other hand, radiation may induce TANs to exhibit the pro-
tumor characteristic through TGF-β. N2 phenotype promotes genetic instability by ROS, cancer proliferation, and immunosuppression effect
by inhibiting CD8+ T cells and NK cells and enhancing Treg cells. Parts of this figure were drawn with aid of Servier Medical Art (http://
www.servier.com), licensed under a Creative Commons Attribution 3.0 Unported License
strengthening the antibody-dependent cellular cytotoxicity polarization.179 Once more, the contradictory roles of neutrophils
(ADCC), and activating T cells.186–189 N2 phenotype shows the in RT responses may reflect differences in tumor phenotypes
protumorigenic characteristics including promoting the tumor (Fig. 3).
growth, stemness, angiogenesis, invasion, and suppressing Similar to TANs, tumor-associated macrophages (TAMs) can be
immunity.190,191 However, to date our knowledge on the role of classified into two categories, a tumor-cell-killing phenotype of
N1 and N2 in RT responses remains limited and contradictory. macrophage called M1, and the other being a tumor-promoting
Similar to DCs, IR activates neutrophils through toll-like receptors phenotype called M2,201–208 although in reality there is a
(TLR)-dependent mechanisms.192 Neutrophils recognize DAMPs spectrum-like level of activation that cannot be simply classified
which are TLRs agonists after RT and the ligation of TLRs enhances as M1 and M2.209 Brown et al.210 reviewed a series of evidence
the immune responses directed against tumor-associated anti- that had explored the significance of the increasing TAMs in the
gens (TAAs). On the one hand, RT may induce TANs to exhibit the tumor microenvironment after IR in preclinical studies and clinical
pro-tumor characteristic, since neutrophils may promote resis- trials of newly diagnosed glioblastoma patients. Akkari et al.211
tance to RT.193–195 Wisdom and his colleagues found that elevated reported the dynamic changes in glioma macrophage populations
neutrophil levels have a close relation to poor outcome of patients after RT and altered expression of several genes and proteins in
with cervical cancer after chemoradiation. Similarly, others have recurrent human glioblastoma. The mechanisms for radiation-
found that genetic depletion of neutrophils improves RT response induced alteration of TAMs are unclear. Generally, IR elicits a high
in a genetically engineered mouse model of sarcoma. Notably, recruitment of TAMs through chemokine (C-C Motif) ligand 2
evidence has verified that anti-Ly6G antibody-mediated neutro- (CCL2) and colony-stimulating factor 1 (CSF1) pathways, and IR
phil depletion may lead to an improvement of the RT can also cause oxygen deprivation and upregulate hypoxia-
efficacy.196,197 These data suggest that neutrophils play a crucial inducible factor (HIF) which recruits TAMs to infiltrate tumor sites,
role in the tumor microenvironment following RT which may especially hypoxia sites through stromal cell-derived factor 1 (SDF-
promotes the conversion of N1 to N2. Thus, targeting neutrophils 1)/C-X-C chemokine receptor type 4 (CXCR4)-dependent signaling
and their immunosuppressive effector molecules, TGFβ and pathways (Fig. 4).212–214 These recruited macrophages adopted an
nicotinamide phosphoribosyltransferase (NAMPT) might be crucial M2-like pro-tumoral phenotype with enhanced pro-survival and
to reversing immunosuppression.198 Besides the pro-tumor pro-angiogenic activities, often leading to tumor recurrence and
characteristics, TANs also exhibit antitumor characteristics by treatment failure.215 In addition to the slight changes of IR to the
inhibiting the growth of tumor cells, and interacting with other viability of macrophages, it is reported that IR can also modify the
immune cells which is induced by RT. Takeshima et al.199 observed macrophage phenotype. Genard et al.216 systematically summar-
that RT may lead to sterile inflammation by infiltrating CD11b+Gr- ized the dose-dependent effects of IR to polarize macrophages.
1high+ neutrophils into the tumors rapidly and transiently and Generally, numerous studies have implicated that TAMs may
sterile inflammation eventually activated tumor-specific cytotoxic polarize to M2 phenotype in the context of low-dose IR while
T cells which may result in tumor regression. Liu et al.200 proved high-dose IR may promote the polarization to M1 in vitro.217,218
that RT can promote the recruitment of neutrophils and that the Thus, IR promotes not only M1 activation of TAMs but also
radiosensitivity can be improved by neutrophils which inhibit the facilitates M2 activation. Although Meng et al.219 have investi-
process of epithelial-mesenchymal transition via the ROS- gated that a large single dose (20 Gy) or at 2 Gy in 10 fractions
mediated PI3K/Akt/Snail signaling pathway. As we discussed (10 × 2 Gy) promotes the conversion of immunosuppressive TAMs,
above, TGF-β polarizes neutrophils to a protumorigenic pheno- but some studies revealed a contrary effect of short-course or low-
type (N2) and inhibits N1 phenotype. However, RT has dose RT on TAMs. A study shows low-dose radiation programs
also been demonstrated as an inhibitor of the TGF-β pathway, macrophage differentiation to an inducible nitric oxide synthase
thereby stimulating the antitumor-N1 neutrophil phenotype (iNOS)+/M1 phenotype and these iNOS+/M1 macrophages can
M0 φ
CD4+ T cell
IκBα IκBα Radiation
NF-қB
p65 p50 p50
p50
ROS
TNFR
IFNγR CSF-1R
CCR2
M2 φ
M1 φ
CXCR4
CXCL12
SIRPα LILRB1 Radiation
IL-10
MHC
CD47
IL-12
TGF-β
IL-1β CCL22
Tumor cell
Treg cell
Dendritic cell
Fig. 4 Immunomodulatory effect of radiation on TAMs. Under the effect of p50–p50 NFκB homodimer induced by radiation, M2 macrophages
acquired their phenotype. Meanwhile, increased ROS caused by radiation also promotes the polarization to M2 macrophage. The activation of
p50–p50 dimer promotes the conversion towards M2 phenotype, leading to the secretion of IL-10 and TGF-β which inhibit DCs. And CCL22 secreted
by M2 macrophage also recruits Treg cells to exert immunosuppressive function. Radiation elicits a high recruitment of TAMs through CCL2/CCR2
and CSF1/CSF1R pathways. And it can also recruit TAMs to infiltrate tumor sites, especially hypoxia sites through SDF-1/CXCR4-dependent signaling
pathways. Moreover, M1 macrophage ban be activated by CD4+ cells through TNF and IFN-γ and then kill tumor cells via phagocytosis which plays
a crucial role in abscopal effect. Parts of this figure were drawn with aid of Servier Medical Art (http://www.servier.com), licensed under a Creative
Commons Attribution 3.0 Unported License
orchestrate effective T cell recruitment and kill tumor cells through reducing M1-surface markers expression in the context of RT. And
iNOS.220 Moreover, total body low-dose radiation also promotes tumor-vasculature development via endothelial-to-mesenchymal
the polarization of TAMs towards an iNOS+/M1 phenotype.221 transition after RT may play a crucial role in macrophage
Another study shows short-course neoadjuvant RT reprograms polarization.228
macrophages towards an M1 phenotype in rectal cancer MDSCs are the “queen bee” of the tumor microenvironment
patients.222 These conflicting results may reflect the complexity that protect the tumors and contribute to tumor progres-
and plasticity of TAMs and more investigations into how RT affects sion.229–235 In normal conditions, bone marrow-derived myeloid
macrophage polarization are needed. The mechanisms about the cells can differentiate into cells of the innate immune system
effects of radiation dose on the polarization of TAMs remain including macrophages, dendritic cells, and granulocytes. But in a
unclear but there are several possible interpretations including pathological condition, myeloid cell precursors may be prolifer-
ROS, NF-κB signaling, and MAPK phosphorylation (Fig. 5). One of ated and differentiated into MDSCs that migrate to the tumor
the most critical mechanisms is the NF-κB balance. It is reported microenvironment and develop into TAMs which are induced by
that p50–p50 NF-κB homodimer may promote the polarization inflammatory cytokines, for instance, soluble tumor necrosis factor
towards M2 macrophages while p50–p65 NF-κB heterodimer (sTNF). MDSCs have a close relation with TAMs and TANs in the
favors the polarization towards M1 macrophages.223 Crittenden tumor microenvironment. Polymorphonuclear (PMN)-MDSCs seem
et al. demonstrated that M2 phenotype emerged in the context of to develop into N2 TANs while monocytic (M)-MDSCs seem to
high-dose irradiation (60 Gy) which activated p50–p50 dimer and proliferate and develop into TAMs under chemotaxis of several
promoted the secretion of IL-10.224 Of note, ROS is known as a factors, such as CCL2, CXCLs, and S100A8/A9, etc.236 And signals
secondary messenger which leads to secretion of a series of underlying the development, differentiation, and recruitment of
proinflammatory cytokines. However, it has been proved for the MDSCs are complex and involve granulocyte-macrophage colony-
M2 activation.225 Tabraue et al.226 demonstrated the role of liver X stimulating factor (GM-CSF), granulocyte (G)-CSF, macrophage
receptor (LXR) nuclear receptors on radiation-induced polarization (M)-CSF and vascular endothelial growth factor (VEGF); cytokines
of macrophages in LXR double knock-out mice models. Moreover, such as IL-4, IL-6, IL-10, IL-1β, interferon IFN-γ, TGF-β, and
the regulatory function of CAFs on macrophages after RT has been prostaglandin E2 (PGE2); chemokines such as CCL2, CXCL5, and
proved.227 The interaction between CAFs and M1-macrophages CXCL12. MDSCs can exert the immunosuppressive effect through
showed that CAFs can inhibit the function of M1-macrophages by releasing TGFβ, and IL-10, and inducing Treg cells.35,237–243 In
Radiation
CXCL12
Gβ Gγ Gβ Gγ
PI3K
JAK
RAS
Akt
P P
RAF STAT3 STAT3
MEK ERK
NF-κB
Chemotaxis
Migration
Proliferation
Cytokines expression
M2 φ
Fig. 5 Signaling pathways of radiation on TAMs. Radiation increases the level of CXCL12 which then binds to CXCR4, a kind of G-protein-
coupled receptor (GPCR). Similarly, CCL2 and its receptor, CCR2 are also activated by radiation. Next, the receptor undergoes a second
conformational change that activates the intracellular trimeric G protein by the dissociation of Gα subunit from the Gβ/Gγ dimer. Then, the
phosphatidylinositide 3-kinases (PI3Ks) can be activated by both Gβ/γ and Gα subunits. PI3Ks regulate gene transcription, migration, and
adhesion of TAMs by the phosphorylation of AKT and of several focal adhesion components. In addition, Gα subunit also activates the Ras and
Rac/Rho pathways, leading to the phosphorylation of ERK. Activated ERK can phosphorylate and regulate other cellular proteins, as well as
translocate into the nucleus and phosphorylate and regulate transcription factors, leading to migration, proliferation, and cytokines
expression of TAMs. Gβ/Gγ dimer also activates JAK/STAT signaling pathway to promote changes in cell morphology leading to chemotactic
responses. Of note, CSF-1/CSF-1R activates all the three signaling pathways we discussed above. Parts of this figure were drawn with aid of
Servier Medical Art (http://www.servier.com), licensed under a Creative Commons Attribution 3.0 Unported License
almost all patients with tumors, MDSCs seem to be the major may enhance the transcription of CSF1 gene which lead to the
factor to protect the tumors and contribute to tumor progression. significant release of CSF1 in prostate post-RT. And Liang et al.
Zeng et al. found that caspase-1 from human MDSCs may lead to found a mechanism by which extrinsic resistance develops after
T cell-independent tumor proliferation through inactivating T cells local ablative radiation that relies on the immunosuppressive
and NK cells.244 Moreover, MDSCs also have the function to action of STING of MDSCs.249 The STING/type I interferon pathway
facilitate the expansion and activation of Treg cells. A study enhances suppressive inflammation in tumors by recruiting
showed that monocytic MDSCs which is isolated from transplant myeloid cells in part via the CCR2 pathway (Fig. 6). Intriguingly,
patients can suppress the proliferation of CD4+ T cells and it is reported that activation of STING pathway can reprogram
promote the expansion of Treg cells.245,246 It is reported that a MDSCs into immunostimulatory cells.250 However, majority of
significant increase of MDSCs in some organs or tissues of the studies showed that STING signaling pathway in the tumor
human body such as spleen, lung, lymph nodes, and peripheral microenvironment can inhibit the recruitment, differentiation, and
blood was observed when primary tumor sites received RT.247 function of MDSCs.100 Cheng et al. observed that the activation of
However, other groups reported that there was a dramatical STING signaling pathway by cGAMP may enhance the secretion of
decrease of MDSCs 7–14 days after the murine colon tumors IFN-γ but decrease the number of MDSCs in vivo.251 Therefore,
received a single high dose of RT.196,248 These contrary data might these studies suggest the suppression function of IR on MDSCs. In
be related to the various tumor models and difference of radiation summary, cGAS/STING signaling is vital in the context of RT and its
doses, fractionation, irradiated sites as well as the timings of the complex effect on MDSCs need to be exploited. In pancreatic
analyses. CSF1/CSF1R signaling pathway plays a key role in the cancer, the potential mechanism of intensive immunosuppression
infiltration of MDSCs into tumors in the context of RT. The of MDSCs after RT is by increasing lactate secretion induced by
blockade of this signaling pathway can improve tumor recurrence Warburg effect.252 And the essential factor to mediate lactate-
post local RT. Xu and colleagues proved the importance of CSF1/ regulated activation of MDSCs is HIF-1α which activates HIF-1α/
CSF1R signaling in the recruitment of MDSCs which can limit the STAT3 pathway. Another study showed that silencing information
efficacy of RT.247 The further studies revealed that the accumula- regulator 2 related enzyme 1 (SIRT1) can deregulate function and
tion and translocation of the DNA damage-induced kinase ABL1 differentiation of MDSCs through orchestrating HIF-1α-dependent
Radiation
DNA damage
CSF-1
CCL2
CSF-1R CCR2
Gα Gβ Gγ
Gβ Gγ
cGAS
GTP PI3K
JAK
ATP STING
cGAMP
P P Akt
STAT3 STAT3
TBK1 IKK
IRF3
IFNβ P
IFN-β1 NF-κB
Chemotaxis
Recruitment
Migration
myeloid cells
Proliferation
MDSC
Fig. 6 Immunomodulatory effect of radiation on MDSCs. DNA damage resulted from radiation may activate two signaling pathways in
MDSCs: cGAS-STING and JAK/STAT signaling pathways. Similar to signaling pathways in TAMs, JAK/STAT signaling and PI3K/AKT signaling
pathway are activated in MDSCs caused by CSF-1/CSF-1R and CCL2/CCR2. Upon DNA damage, all of these damaged DNA including
cytoplasmic DNA and mtDNA induced by IR can be recognized by cGAS, which then oligomerizes with DNA in the form of a 2:2
complex.114–116 After binding to DNA, cGAS then exerts a catalytic role to promote the synthesis of the second messenger 2′3′-cyclic
GMP–AMP (cGAMP). Binding of 2′3′-cGAMP stimulates STING and promotes the translocation to the Golgi which acivates TANK-binding kinase
1 (TBK1). TBK1 phosphorylates STING and promote the interferon regulatory factor 3 (IRF3) to translocate to the nucleus which triggers the
expression of IFN-β gene. Parts of this figure were drawn with aid of Servier Medical Art (http://www.servier.com), licensed under a Creative
Commons Attribution 3.0 Unported License
glycolysis.253 Of note, IR generally induces the recruitment and addition, IR can strengthen tumor cross-presentation of DCs which
infiltration of MDSCs to yield immunosuppressive effect on the may promote the activation and proliferation of T cells.267,268 The
immune system (as discussed above). release of DAMPs and TAAs promotes DCs to migrate towards
Dendritic cells are the most potent antigen-presenting cells for lymph nodes and further results in the emergence of systemic
their specialized dendritic morphology, as the essential compo- antitumor immune responses. On the other hand, inflammatory
nent to link innate and adaptive immunity.254–260 The most cytokines modified by RT may augment the function of DCs and
common contributors to activate DCs are pathogen-associated potentially exert an immunostimulatory response to radiation.34
molecular pattern molecules (“danger signals”) through the Moreover, new mechanisms have been proved by researchers
respective receptors. But in the case of RT, DCs are mainly (Fig. 7). Yu and colleagues found that in vitro when DCs are
activated by DAMPs including HMGB1 and calreticulin. Gupta and exposed to 0.2 Gy radiation, there is an increase of migration
colleagues observed that after tumor RT, there is an upregulation mediated by CCR7 and IL-12 production induced by the ATM/NF-
of two co-stimulatory molecules, CD70 and CD86 on DCs.85 On the κB pathway.269 For high dose of radiation, Zhou found that it may
one hand, the initial factors are increased by IR and the promote DCs homing and T cells priming through facilitating the
mechanisms that IR can upregulate the expression of class I ROS-induced cytoskeletal reorganization.86 In addition to the
MHC have been well established.84,261–263 And immunogenic cell positive immune effect of radiation to DCs, DCs may also play a
death caused by radiation may release large amounts of antigens crucial role in radiation-induced immunosuppression. Liu et al.
and DAMPs including HMGB1, ATP, calreticulin, heat shock observed a decrease of CD8+ DC both in patients and mice after IR
proteins, etc.264 These molecules can further activate DCs through which causes shift from Th1 to Th2 immunity and this process
binding to the receptors which comprise TLRs, retinoic acid- might be mediated by Fms-like tyrosine kinase 3 ligand (FLT3
inducible gene 1 (RIG1)-like receptors, and nucleotide-binding and ligand), a CD8+DC-inducing cytokine.270
oligomerization domain (NOD)-like receptors. For instance, calre- Generally speaking, B cells and T cells are sensitive to IR, so IR
ticulin increased by RT acts as a pro-phagocytosis eat-me signal in damage to these lymphocytes which may lead to adverse events
opposition to CD47.265 Release of HMGB1 from tumor cells, via of RT. Within the lymphocyte population, B cells are the most
TLR4 activation, promotes antigen presentation by DCs.266 In sensitive to IR. Compared with B cells, T cell subsets show different
Radiation
CCL19/CCL21
IL-10
CCR7
DAMPs CD28
B7
Tumor cell TCR
TLR4 CD4+ T cell
MHC
Dendritic cell
TAAs
NK cell
CCL5/CXCL1
Fig. 7 Immunomodulatory effect of radiation on DCs. Radiation on DCs significantly increases the expression of chemokines CCL19 and
CCL21 which then bind to CCR7 and mediate migration of DCs. In addition, immunogenic cell death caused by radiation may release large
amounts of antigens and DAMPs including HMGB1, ATP, calreticulin, heat shock proteins, and other cellular factors which bind specific
pattern-recognition receptors on the dendritic cell, including Toll-like receptors, RIG1-like receptors, and NOD-like receptors. And radiation
also results in the release of TAAs which promotes DCs activation, migration, and proliferation of T cells. Parts of this figure were drawn with
aid of Servier Medical Art (http://www.servier.com), licensed under a Creative Commons Attribution 3.0 Unported License
sensitivity to IR. Thus, the sensitivity to IR for T cells has been patients who receive SBRT combined with IO, which better
explored in a large body of studies but there are a large of facilitates the abscopal effect and increases the occurrence rate in
conflicting results.271 Arina et al.272 found that RT can reprogram a patients with metastatic disease in iRT.280 Moreover, RT induces
huge proportion of T cells which show increased motility and the production and release of cytokines. The most important
increased secretion of IFN-γ. In addition, T cells within the tumor mechanism is to activate the cGAS-STING and NF-κB signaling
may be more resistant to IR compared with naive and circulating leading to an increase of cytokines.128,281,282 Some investigations
T cells. Generally, CD4+ T cells are considered more radioresistant show that IR promotes the secretion of CXCL16 in tumor cells
than CD8+ T cells, with Treg cells even more resistant to which can be combined with Th1 cells and CXCR6 on activated
RT.271,273,274 Except the direct damage to T cells of IR, it also CD8+ T cells to increase the infiltration of local immune cells.283,284
activates T cell through increasing major histocompatibility class I On the other hand, IR may promote the migration of T cells
(MHC-I), DAMPs, and TAAs and enhances T-cell infiltration. towards irradiated tumor sites resulting in a positive immunolo-
Moreover, these molecules as well as increased proinflammatory gical outcome. In this process, the intercellular adhesion of
cytokines augment the prime of T cells to exert an antitumor molecule-1 (ICAM-1) may promote leukocytes migration to the
response with the migration of DCs towards adjacent lymph endothelial cells, and reprogram an inflammatory tumor micro-
nodes95. It has been proven that IL-1β, TGF-β, fibroblast growth environment. This is enhanced by IR and this leads to more T-cell
factor (FGF), and TNF, as well as NACHT, LRR, and PYD domains- infiltration into tumor tissues.285–287 It is reported that the density
containing protein 3 (NALP3)-inflammasome activation and of CD3+ and CD8+ lymphocytes in tumor site is associated with
signaling are key components to mediate the response to disease-free and overall survival in patients treated with chemor-
IR.275–278 Recently, Lin and colleagues found that radiation- adiotherapy for rectal cancer.87 More recently, Dovedi et al.288
induced small extracellular vesicles may play a role as efficient found that low-dose RT combined with PD-1 blockade can
carriers containing TAAs and DAMPs in promoting tumor antigen promote the migration of T-cells to primary treated sites and
release and triggering antitumor immunity.83 Moreover, a study augment tumor regression. Thus, RT enhances the secretion of
has proved that radiation can promote tumor cells to release more cytokines which may promote T-cell infiltration and augmenting
MHC-I molecules in murine tumor models, which facilitates cross- T-cell priming.
presentation and T-cell priming.279 In fact, the high release of TAAs NK cells are cytotoxic lymphocytes in the innate immune
and MHC-I has been already reported in human carcinoma cell system to kill cancerous cells. The two most well-characterized
lines when researchers use sublethal irradiation on human tumor subsets of NK cells are the CD56brightCD16− and CD56dimCD16+
cells.89 This result just accords with the role of low-dose RT in populations.289–292 In the subsets of NK cells, the CD56dim NK cell
TGF-β
Radiation
Granzyme B
Perforin
TGF-βR
CD112 CD112R
NKG2D NKG2DL
NK cell Tumor cell
Dendritic cell
CD155 TIGIT
KIR PD-1 FASL FAS
PD-L1
IL-12
MHC
TNF-α
Tumor cell
IFN-γ
Fig. 8 Immunomodulatory effect of radiation on NK cells. On the one hand, radiation inhibits NK cells through increasing TGF-β. Moreover,
the exposure of MHC-I molecules on the surface of tumor cells caused by radiation also inactivates NK cells through KIR. In addition, radiation
induces the upregulation of activating receptors NKG2D and NKG2D ligands (NKG2DLs) to enhance the function of NK cells via granzyme B
and perforin, FAS and FAS ligand and ADCC. Parts of this figure were drawn with aid of Servier Medical Art (http://www.servier.com), licensed
under a Creative Commons Attribution 3.0 Unported License
population is the major contributor to kill infected and malignant signaling pathways especially cGAS-STING signaling, secretion of
cells. The main mechanisms are granzyme B and perforin, FAS and chemokines and cytokines (Table 1), formation of hypoxia
FAS ligand and ADCC. For the direct effect on tumor cells and condition, and activation of the classical and alternative comple-
cellular cross-talk, NK cell-based immunotherapies have been ment system play a crucial role in reprogramming tumor
explored well.293–300 The activation of NK cells depends on the microenvironment induced by IR.308–312 The process of repro-
balance between activation and suppression signals.301 The gramming the tumor microenvironment is suffused with complex
activating receptors of NK cells such as NKG2D can promote the and profound changes, which is not only limited to a change in
secretion of cytokines and enhance the cytotoxicity and an quantity and form, but also full of various interactions and
increasing expression of NKG2D ligands was observed by modulations. We have discussed this process in the above article.
investigators in several human cancer cell lines after IR.301,302 Besides, many reviews have given an unambiguous and detailed
The increasing expression of NKG2D ligands (NKG2DLs) induced interpret of reprogrammed tumor microenvironment and have
by radiation may further activate the NK pathway and NKG2D- shown potential benefit of reprogrammed tumor microenviron-
based CAR T cells combined with RT can exert synergistic efficacy ment induced by RT to combine with IO.123,146,313–318
in glioblastoma (Fig. 8).303 Meanwhile, inhibitory signaling path-
ways including PD-1, NKG2A and killer immunoglobulin-like iRT enhcances abscopal effect
receptors (KIRs) play a key role in function of NK cells so ICIs Traditionally, abscopal effect refers to an interesting phenomenon
can attenuate suppression of NK cell through binding to these that local radiation may exert a systemic antitumor immune
inhibitory signaling pathways.304 Furthermore, other molecules response and lead to the regression of non-irradiated distant
such as MHC-I induced by RT may also inhibit the function of NK tumors. Unfortunately, it is so rare for the occurrence rate of
cells. In addition to increasing NKG2D ligands, IR enhances NK cell abscopal effect that it has no broad application value seemingly.
homing and cytotoxicity in canine models of sarcoma.305 Whereas, with the advent of immunotherapy, it seems that using
Researchers observed significantly increased NK cells homing to radiotherapy combined with immunotherapy to enhance absco-
tumors in vivo and increased activation of circulating NK cells after pal effect is available. A large number of studies about abscopal
RT which yield tumor regression and abscopal responses. This has effect induced by iRT has come out.21,48,319–326 Nowadays, the
also been shown in a human triple-negative breast cancer criterion for determining whether abscopal effect has occurred is
xenograft model.306 whether the tumor regression at distant non-irradiated sites can
be observed. In view of the combination of RT with IO, the
IR reprograms the tumor microenvironment immune state of the whole human body and have already
IR not only reprograms the tumor microenvironment from “cold” changed before tumor regression at distant non-irradiated sites
to “hot”, but also exerts immunoinhibitory effects in the tumor (macroscopic abscopal effect). This force is not powerful enough
microenvironment.307 In the above, the authors have discussed to decrease tumor volume although molecules and gene
and summarized the effects of IR on cancer cells, stromal cells, and expression of tumor cells or normal tissue cells nearby really do
immune cells which lay a basis for reprogramming the tumor change. Thus, we propose a broad concept of abscopal effect from
microenvironment. Along with this process, activation of intrinsic three aspects: macro level, molecular and genetic levels. From this
RT
Fig. 9 Macro, molecular, and genetic abscopal effect. Abscopal effect in the traditional sense refers to the tumor regression at distant non-
irradiated sites which can be observed in clinic. However, when the primary tumor is irradiated, cytokines and immune cells at distant non-
irradiated sites also changes due to the systemic immune response caused by IR. In addition, there are alterations of gene expression at
distant non-irradiated sites. Parts of this figure were drawn with aid of Servier Medical Art (http://www.servier.com), licensed under a Creative
Commons Attribution 3.0 Unported License
levels of TNF and TGFβ1 increased indicating a systemic about potential mechanisms of low-dose RT. In summary, both
inflammatory response and there was a decrease in Ccl2, Mdm2, high-dose and low-dose radiation can mediate molecular altera-
and Trp53 gene expression.335 Similarly, Aravindan et al. found a tion at abscopal tumor site and exert systemic antitumor response.
robust increase in p65 and cMyc expression in distant heart after However, mechanisms about how molecular changes of abscopal
the radiation of lower abdomen.336 These results indicate that the sites remains largely unclear and what happened at abscopal sites
status of abscopal sites has possibly started to change before the in the condition of high-dose radiation is unknown. We expect
observed tumor regression. Hence, the alteration of non-irradiated there is much direct and powerful evidence to explore the
sites in molecule and gene level may reflect the sensitivity of abscopal effect at the molecular level and we hold the view that
patients to RT and become predictors of abscopal effect and this will increase occurrence rate of abscopal effect and provide
response to the treatment. For instance, recent studies indicated new approach to overcome the resistance of immunotherapy.
that tumor-derived exosomes may become a biomarker in
gastrointestinal cancer.337 The contents of exosomes also had a Immunomodulatory effect of low-dose radiation and radscopal
strong association with survival.338 However, the clinical meanings effect
of molecular and genetic changes of abscopal sites induced by RT With a view to immune effect of conventional dose RT, low-dose
remains unclear for the lack of clinical data. We expect more RT may play a distinct role in antitumor immune response
investigations to explore the molecular and genetic changes of combined with IO. Many studies have affirmed the immunomo-
abscopal sites to benefit more patients. dulatory effect of low-dose RT,220,339–341 sometimes termed the
Fortunately, the authors observed the effect of low-dose RT on “radscopal effect”. Radscopal effect refers to the systemic
non-irradiated tumor stroma and discussed possible mechanisms antitumor effects which are strengthened by low-dose RT on the
and values.280 Combined with SBRT and immunotherapy, low- basis of stereotactic RT. This radiation strategy with high-dose
dose RT (doses below the threshold thought to physically damage stereotactic RT and low-dose RT was proposed by James Welsh
DNA or kill cancer cells directly) stimulated abscopal tumor stroma and this strategy was named as “RadScopal” technique.342 Unlike
throughout the body and facilitated abscopal tumor regression. tumoricidal-dose RT, low-dose RT can reprogram the tumor
This provides circumstantial evidence for the existence of microenvironment and reactivate the immune microenvironment,
molecular abscopal effect and thereout it triggers new thoughts thus reversing the resistance of patients to IO. Herrera et al. also
that based on pre-existing abscopal effect in molecule level, low- reviewed that innate and adaptive immunity can be mobilized
dose radiation and immunotherapy offer a force more powerful when all lesions are treated with low-dose RT combined with
method to activate abscopal antitumor immune response causing IO.343 Generally, conventional RT may produce potent immuno-
macroscopic tumor regression. Moreover, Yin et al.321 discussed suppressive factors but low-dose radiation may be a strong
NCT02474186 Phase 1 Various Concurrent 35 Gy in 10 fractions GM-CSF Abscopal responses in NYU July 2015
Phase 2 27.6% of patients Langone Health
NCT02125461 Phase 3 NSCLC RT, IO 54 to 66 Gy Durvalumab Durable PFS and AstraZeneca December
sustained OS benefit 30, 2022
with durvalumab after
chemoradiotherapy
NCT02608385 Phase 1 Solid tumors SBRT, IO SBRT dosing varied by Pembrolizumab Well tolerated with University of July 2022
site and ranged from acceptable toxicity Chicago
30 to 50 Gy in three to
five fractions
NCT02221739 Phase 1 NSCLC Concurrent 6 Gy x5, later changed Ipilimumab Objective responses NYU October 27, 2015
Phase 2 to 9.5 Gy x3 were observed in 18%, Langone Health
and 31% had disease
control
NCT02434081 Phase 2 NSCLC Concurrent 66 Gy in 33 fractions Nivolumab The addition of European Thoracic March 31, 2020
nivolumab to Oncology Platform
concurrent CRT is safe
and tolerable
NCT02492568 Phase 2 NSCLC RT, IO SBRT 3 doses of 8 Gy Pembrolizumab Well tolerated and a The Netherlands June 2018
Zhang et al.
Radiotherapy combined with immunotherapy: the dawn of cancer treatment
NCT03383302 Phase 1 NSCLC Stage II and Stage I RT, IO SBRT Nivolumab Recruiting Royal Marsden NHS January 2022
Phase 2 Foundation Trust
NCT03825510 Not Metastatic NSCLC RT, IO SBRT Nivolumab/ Recruiting Crozer-Keystone August 28, 2021
Applicable pembrolizumab Health System
NCT04577638 Phase 2 NSCLC Stage III Concurrent Intensity Modulated Nivolumab Recruiting Center Eugene February 1, 2024
Radiotherapy Marquis
NCT03168464 Phase 1 NSCLC Metastatic Concurrent 6 Gy x 5 fractions Ipilimumab/ Recruiting Weill Medical December
Phase 2 nivolumab College of Cornell 30, 2022
University
NCT03867175 Phase 3 Stage IV NSCLC Concurrent SBRT Pembrolizumab Recruiting Wake Forest December
University Health 31, 2027
Sciences
NCT05229614 Phase 2 NSCLC, Head and Neck IO, RT Carbon ion therapy Pembrolizumab Not yet recruiting CNAO National August 2026
Squamous Cell Carcinoma, Center of
Melanoma, Urothelial Oncological
Carcinoma Hadrontherapy
NCT03705806 Stage IV NSCLC IO, RT 30 Gy in 10 fractions PD-1 inhibitor Recruiting University Health September
Network, Toronto 15, 2022
NCT03224871 Early Metastatic NSCLC Concurrent Hypo-fractionated Intralesional IL-2, Completed University of January 10, 2020
Phase 1 Radiotherapy nivolumab, California, Davis
pembrolizumab
NCT05265650 Phase 1 Metastatic NSCLC Concurrent SBRT Nivolumab Not yet recruiting Clinica Universidad June 2024
Phase 2 de Navarra,
Universidad de
Navarra
NCT04513301 Phase 2 Recurrent or IV NSCLC after Concurrent 50-60 Gy/25-30 f Sintilimab Recruiting Shanghai Cancer December 1, 2022
failure of platinum-based Hospital, China
chemotherapy
NCT05222087 Phase 1 Metastatic NSCLC RT, IO SBRT Pembrolizumab Not yet recruiting Peter MacCallum April 2024
Cancer Centre,
Australia
NCT02444741 Phase 1 Stage IV NSCLC Concurrent SBRT Pembrolizumab Active, not recruiting M.D. Anderson September
Phase 2 Cancer Center 17, 2022
Radiotherapy combined with immunotherapy: the dawn of cancer treatment
17
18
Table 2. continued
ClinicalTrials.gov Trial Phase Condition or disease Sequence RT IO Results Sponsors Estimated/actual
identifier study
completion date
NCT03217071 Phase 2 Stage I-IIIA NSCLC IO, RT SBRT Pembrolizumab Active, not recruiting Sue Yom February 28, 2022
NCT02492568 Phase 2 Advanced NSCLC RT, IO SBRT 3 doses of 8 Gy Pembrolizumab Completed The Netherlands June 2018
Cancer Institute
NCT04892849 Not HNSCC, NSCLC, Esophageal IO, RT RT PD-1/PD-L1 inhibitor Recruiting University of December
Applicable Cancer, Urothelial Erlangen-Nürnberg 31, 2027
Carcinoma, Renal Cell Medical School
Carcinoma, Squamous Cell
Carcinoma of the Skin, Small
Cell Bronchial Carcinomas
NCT03223155 Phase 1 Stage IV NSCLC Concurrent or SBRT Ipilimumab/ Recruiting University of December 2024
sequential nivolumab Chicago
NCT04013542 Phase 1 Stage II–III NSCLC Concurrent RT Ipilimumab and Recruiting M.D. Anderson February 1, 2022
nivolumab Cancer Center
NCT04902040 Phase 1 Advanced Bladder RT, IO RT Atezolizumab, Recruiting M.D. Anderson June 1, 2025
Phase 2 Carcinoma, Advanced avelumab, Cancer Center
NSCLC, Advanced Malignant durvalumab,
Solid Neoplasm, Advanced nivolumab and
Melanoma, Advanced Merkel pembrolizumab
Cell Carcinoma, Advanced
Zhang et al.
Radiotherapy combined with immunotherapy: the dawn of cancer treatment
NCT05111197 Phase 3 Locally advanced or IO, RT SBRT Anti-PD-1 or anti-PD- Not yet recruiting Institut December 2024
metastatic NSCLC L1 immunotherapy Cancerologie de
l’Ouest
NCT04765709 Phase 2 Large volume stage III NSCLC Concurrent RT Durvalumab Not yet recruiting Mario Negri June 2026
Institute for
Pharmacological
Research
NCT04549428 Phase 2 NSCLC Stage IV Concurrent a single fraction of Atezolizumab Recruiting Oncology Institute July 31, 2022
8 Gy of Southern
Switzerland
NCT04245514 Phase 2 NSCLC Concurrent 20 × 2 Gy (weekdaily, Durvalumab Recruiting Swiss Group for March 2025
4 weeks) Clinical Cancer
5 × 5 Gy (weekdaily, Research
19
20
Table 2. continued
ClinicalTrials.gov Trial Phase Condition or disease Sequence RT IO Results Sponsors Estimated/actual
identifier study
completion date
NCT03446547 Phase 2 Stage I NSCLC RT, IO SBRT Durvalumab Recruiting Vastra July 2023
Gotaland Region
NCT05034055 Phase 2 Metastatic NSCLC RT, IO SBRT Atezolizumab/ Not yet recruiting Yonsei University December 2023
tiragolumab
NCT05157542 Phase 1 Stage III NSCLC Concurrent Low dose radiation Durvalumab Recruiting Juan LI, MD June 10, 2023
therapy
NCT03391869 Phase 3 Stage IV NSCLC IO, RT Local consolidation Nivolumab and Recruiting M.D. Anderson December
therapy ipilimumab Cancer Center 31, 2022
NCT03818776 Early Unresectable NSCLC Concurrent Proton beam Durvalumab Recruiting Case November 1, 2023
Phase 1 therapy RT Comprehensive
Cancer Center
NCT03801902 Phase 1 Locally advanced NSCLC IO, RT Hypofractionated Durvalumab Active, not recruiting National Cancer January 5, 2023
Radiation Therapy/ Institute (NCI)
Fractionated
Stereotactic Radiation
Therapy
NCT02463994 Early Metastatic NSCLC RT, IO Hypo-fractionated PD-L1 antibody Completed University of November 7, 2018
Phase 1 Image-guided Michigan Rogel
Radiotherapy Cancer Center
Zhang et al.
Radiotherapy combined with immunotherapy: the dawn of cancer treatment
NCT02888743 Phase 2 Metastatic Colorectal IO, RT high dose radiation Tremelimumab and Active, not recruiting National Cancer December
or NSCLC therapy/low dose durvalumab Institute (NCI) 31, 2022
radiation therapy
NCT04944173 Phase 2 Stage I NSCLC Concurrent SBRT Durvalumab Not yet recruiting University of British December 2024
Columbia
NCT04310020 Phase 2 Stage II or III NSCLC IO, RT Hypo-fractionated Atezolizumab Recruiting National Cancer March 15, 2022
Radiation Therapy Institute (NCI)
NCT04081688 Phase 1 Refractory NSCLC Stage IV SBRT Atezolizumab/ Recruiting Rutgers, The State June 30, 2023
varlilumab University of
New Jersey
NCT04889066 Phase 2 Brain metastases NSCLC Concurrent Personalized ultra- Durvalumab Not yet recruiting University of Texas January 2025
fractionated Southwestern
stereotactic adaptive Medical Center
radiotherapy or
Fractionated
Stereotactic
Radiotherapy
NCT04892849 Not HNSCC, NSCLC, Esophageal IO, RT RT PD-1/PD-L1 inhibitor Recruiting University of December
Applicable Cancer, Urothelial Erlangen-Nürnberg 31, 2027
Carcinoma, Renal Cell Medical School
Carcinoma, Squamous Cell
21
22
Table 2. continued
ClinicalTrials.gov Trial Phase Condition or disease Sequence RT IO Results Sponsors Estimated/actual
identifier study
completion date
CTLA-4
NCT03168464 Phase 1 NSCLC Metastatic Concurrent 6 Gy x 5 fractions Ipilimumab/ Recruiting Weill Medical December
Phase 2 Nivolumab College of Cornell 30, 2022
University
NCT04929041 Phase 2 Stage IV NSCLC Concurrent SBRT Ipilimumab/ Recruiting National Cancer December
Phase 3 Nivolumab/ Institute (NCI) 31, 2027
Pembrolizumab
NCT03275597 Phase 1 NSCLC Stage IV IO, RT SBRT Durvalumab and Active, not recruiting University of July 2025
tremelimumab Wisconsin, Madison
NCT03391869 Phase 3 Stage IV NSCLC IO, RT Local consolidation Nivolumab and Recruiting M.D. Anderson December
therapy ipilimumab Cancer Center 31, 2022
NCT02888743 Phase 2 Metastatic Colorectal IO, RT high dose radiation Tremelimumab and Active, not recruiting National Cancer December
or NSCLC therapy/low dose durvalumab Institute (NCI) 31, 2022
radiation therapy
NCT03223155 Phase 1 Stage IV NSCLC Concurrent or SBRT Ipilimumab/ Recruiting University of December 2024
sequential Nivolumab Chicago
NCT03237377 Phase 2 Stage III Resectable NSCLC Concurrent Thoracic radiation: Durvalumab or Active, not recruiting Sidney Kimmel September 2022
45 Gy in 25 fractions durvalumab plus Comprehensive
Zhang et al.
Radiotherapy combined with immunotherapy: the dawn of cancer treatment
monoclonal antibody
3H1 anti-idiotype
vaccine
NCT00828009 Phase 2 Unresectable Stage IIIA and RT, IO RT Tecemotide Completed ECOG-ACRIN May 22, 2019
IIIB Non-Squamous NSCLC Cancer
Research Group
Others
NCT05269485 Phase 1 Stage III NSCLC High-dose fractionated IT Recruiting Anhui Provincial June 1, 2023
Phase 2 radiotherapy: Hospital
60–68 Gy/15-17f; low-
dose fractionated
radiotherapy: 48 Gy/
15-12f
NCT00879866 Phase 1 NSCLC Stage IIIb With RT, IO 5 ×4 Gy Selectikine (EMD Completed Merck KGaA, September 2012
Malignant Pleural Effusion or 521873) Darmstadt,
Stage IV With Disease Germany
Control
NCT04081688 Phase 1 Refractory NSCLC Stage IV SBRT Atezolizumab/ Recruiting Rutgers, The State June 30, 2023
varlilumab University of
New Jersey
Radiotherapy combined with immunotherapy: the dawn of cancer treatment
23
Radiotherapy combined with immunotherapy: the dawn of cancer treatment
Zhang et al.
24
oligometastatic NSCLC have shown that the use of RT to all sites of delayed administration of checkpoint inhibitors after RT so that
disease is associated with a significant improvement in OS and newly recruited T cells can destroy tumor cells, both at the primary
PFS.393,394 Data from a phase III trial aiming to determine the site and systemically after being presented with novel tumor
efficacy of iRT in metastatic prostate cancer showed that results antigens. The PACIFIC trial has proved that durvalumab after
are negative when RT was delivered to a single bony lesion.395 chemoradiotherapy improved PFS significantly and the new
Subgroup analyses of this trial and other clinical trials also support results reported that estimated 4-year OS rates were 49.6% versus
IO may achieve better efficacy when patients with lower disease 36.3% for durvalumab versus placebo, and 4-year PFS rates were
burden and a reduction in tumor burden by comprehensive (but 35.3% versus 19.5% respectively.42,45 The PACIFIC trial has laid a
not single-site) RT may potentiate IO. Furthermore, a phase 2 trial framework of adjuvant administration of durvalumab after
of pembrolizumab therapy after locally ablative therapy (surgery chemoradiotherapy for patients who are suffering from NSCLC
or SBRT) for patients with oligometastatic NSCLC which treated all in stage III. Similarly, other clinical trials also confirmed the safety
metastatic sites demonstrated that FPS increased by 12 months and efficacy of pembrolizumab and nivolumab after chemora-
compared with the historical median of 6.6 months.396 Thus, diotherapy.398,406 However, the HOPE-005/CRIMSON, a multi-
multiple target RT might be required to optimize responses to iRT. center, retrospective, real-world cohort study of 275 patients
Of note, a phase I study estimated multi-site SBRT followed by receiving concurrent chemoradiotherapy in advanced NSCLC, 204
pembrolizumab for metastatic solid tumors, including NSCLC.367 of whom received durvalumab consolidation therapy showed that
This trial enrolled 79 patients receiving SBRT to 2 to 4 metastases 81.8% of patients who received durvalumab after concurrent
and metastases >65 mL were partially irradiated. After completion chemoradiotherapy had pneumonitis and 59.5% were asympto-
of SBRT, patients started to administer pembrolizumab within matic pneumonitis.407 Another real-world study of durvalumab
7 days and it lasted at least one cycle. The RECIST-based overall consolidation after chemoradiotherapy in stage III NSCLC sug-
ORR was 13.2% and the mOS and mPFS were 9.6 months (95% CI, gested that the incidence of grade 3 radiation pneumonitis was
6.5 months to undetermined) and 3.1 months (95% CI, 2.9 to 14.3 % in the durvalumab group versus 2.5 % in the observation
3.4 months), respectively. Their results are similar to data from group.408 These data remind that the adverse effect cannot be
KEYNOTE-028 (9–33% response rate), which evaluated the safety ignored and it needs to be further improved for PACIFIC mode.
and efficacy of pembrolizumab alone in patients with PD-L1- Analysis of PACIFIC study and a retrospective analysis of clinical
positive advanced solid tumors.397 Nevertheless, investigators data suggest that patient outcome seems to be better if IO is
should consider these data carefully because the tumor areas given concurrently or begun soon after RT, as compared with
excluded from the SBRT program are exposed to low doses of RT starting IO later after the RT.42,409 The update data from PACIFIC
and there is a lack of PD-L1 status for patients with various study show that there is a significant improvement of OS and FPS
cancers. both within 14 days and after RT, but the advantage is more
obvious within 14 days when combined IO with RT.45 However, a
Selection of immunotherapy modality retrospective study proved that patients who received
Although hypofractionated RT has shown advances for inducing IO ≥ 21 days after the onset of SBRT had a longer OS than those
antitumor immunity, it is not known which immune checkpoint who received IO within 21 days after the onset of SBRT.410 But the
inhibitor to use in combination with RT. There are an increasing data from this study should be considered carefully because it
number of studies which have already confirmed the efficacy of RT included many confounding factors. Thus, the optimal timing of
combined with ICIs including pembrolizumab, nivolumab, durva- iRT still needs to be explored through large randomized clinical
lumab, and atezolizumab.42,398–401 Considering that the most trials.
widely used ICI is PD-1 and CTLA-4 blockades, a retrospective Sequential administration of IO followed by RT have been
analysis of two single-institution prospective trials reported that affirmed, many studies started to investigate whether we could
the FPS of anti-PD1 combined with SBRT for metastatic NSCLC was use concurrent administration to achieve immunotherapy for-
significantly better than anti-CTLA4 combined with SBRT, although ward. Researchers hypothesized that adding IO concurrently with
there was no statistically significant difference in efficacy.365 The concurrent chemoradiotherapy may improve the efficacy without
PFS was 76% for anti-CTLA4 vs 94% anti-PD1 at 3 months, 52% vs additive toxicity so they designed a phase II trial of concurrent
87% at 6 months, 31% vs 80% at 12 months, and 23% vs 63% at administration.411 This phase II study was conducted in two parts.
18 months (p = 0.02). This tentative exploration requires further Part 1 involved administration of conventionally fractionated
data, and this conclusion is restricted to metastatic NSCLC. There chemoradiotherapy followed by consolidation chemotherapy
are few of studies to support and more clinical trials are needed (atezolizumab [two cycles] and maintenance atezolizumab up to
for other form of tumors. Notably, in the view of multi-site RT, we 1 year). Part 2 involved administration of concurrent chemor-
should consider whether we can use one or multiple ICIs. A adiotherapy with atezolizumab followed by the same consolida-
randomized, multicenter, phase II clinical study assessing the tion and maintenance therapies as in part 1. The results showed
primary safety of two kinds of ICIs as consolidation therapy after that immune-related adverse events of grade 3 or higher had an
concurrent chemoradiotherapy for patients with stage III, unre- incidence rate of 20% to 30%, and pneumonitis of grade 2 or
sectable NSCLC. This trial enrolled 105 patients with unresectable higher had an incidence rate of 10% to 16%. The median FPS of
stage IIIA/ IIIB NSCLC and they were divided equally into to group part 1/2 was 18.6 months and 13.2 months, respectively. There-
(nivolumab group and nivolumab + ipilimumab group) after fore, safety and efficacy of combining IO with chemoradiotherapy
concurrent chemoradiotherapy. Safety analysis of the first 50 concurrently have been confirmed. Since the PACIFIC trial
patients showed that after concurrent chemoradiotherapy, the indicated that there was a trend of PFS being longer in the
incidence of grade 3 adverse events is higher in nivolumab + 14 days group, investigators designed a phase 2, nonrandomized
ipilimumab treatment, leading to higher drug withdrawal rate KEYNOTE-799 clinical trial aiming for improve outcomes and
than that in nivolumab monotherapy group. Therefore, this area safety of pembrolizumab with concurrent chemoradiotherapy.46
requires further exploration from additional clinical trials. Patients corresponding to the inclusion criteria were selected by
investigators to enter the following cohort: in cohort A, patients
The optimal timing for iRT with squamous cell cancer/non-squamous cell cancer received
In addition to the selection of RT and immunotherapy molality, paclitaxel 200 mg/m2 combined with carboplatin (AUC = 6), and
one of the most important matters is the optimal timing for after one cycle were switched to paclitaxel 45 mg/m2 combined
combination “concurrent” or “sequential”.402–405 Generally, the with carboplatin (AUC = 2), lasting for 6 weeks. Two cycles of
data available to date seem to justify either simultaneous or pembrolizumab therapy (once every three weeks) and standard