Charged Particle and Conventional Radiotherapy: Current Implications as Partner for Immunotherapy

Abstract

Radiotherapy (RT) has been shown to interfere with inflammatory signals and to enhance tumor immunogenicity via, e.g., immunogenic cell death, thereby potentially augmenting the therapeutic efficacy of immunotherapy. Conventional RT consists predominantly of high energy photon beams. Hypofractionated RT regimens administered, e.g., by stereotactic body radiation therapy (SBRT), are increasingly investigated in combination with cancer immunotherapy within clinical trials. Despite intensive preclinical studies, the optimal dose per fraction and dose schemes for elaboration of RT induced immunogenic potential remain inconclusive. Compared to the scenario of combined immune checkpoint inhibition (ICI) and RT, multimodal therapies utilizing other immunotherapy principles such as adoptive transfer of immune cells, vaccination strategies, targeted immune-cytokines and agonists are underrepresented in both preclinical and clinical settings. Despite the clinical success of ICI and RT combination, e.g., prolonging overall survival in locally advanced lung cancer, curative outcomes are still not achieved for most cancer entities studied. Charged particle RT (PRT) has gained interest as it may enhance tumor immunogenicity compared to conventional RT due to its unique biological and physical properties. However, whether PRT in combination with immune therapy will elicit superior antitumor effects both locally and systemically needs to be further investigated. In this review, the immunological effects of RT in the tumor microenvironment are summarized to understand their implications for immunotherapy combinations. Attention will be given to the various immunotherapeutic interventions that have been co-administered with RT so far. Furthermore, the theoretical basis and first evidences supporting a favorable immunogenicity profile of PRT will be examined.

Keywords: carbon ion; charged particle radiation; clinical trials; immunogenicity; immunotherapy; proton; radiotherapy.

Figure 1

Combination of radiotherapy (RT) and different immunotherapeutic modalities. Each modality, such as dendritic cell vaccination, adoptive transfer of natural killer and T cells, agonist administration, conjugated antibodies or immune checkpoint inhibitors (ICIs), intervenes at different components of the immunological response chain. RT is able to synergize with all modalities. Created with BioRender.com.

Figure 2

Overview of immunogenic involvement of charged particle radiation. Created with BioRender.com.