FLASH radiotherapy spares lymphocytes in tumor-draining lymph nodes and increases infiltration of immune cells in tumors.

Radiotherapy (RT) delivered at conventional dose rates (CONV) can both stimulate antitumor immune responses and inhibit these immune responses by depleting circulating lymphocytes. Given the observed normal tissue sparing associated with ultra-high dose rate (FLASH) RT, we hypothesized that FLASH RT may protect lymphocytes while increasing the immunogenicity of cancer cells. We irradiated cancer cell lines in vitro with FLASH RT or CONV RT and assessed immunogenic mRNA and protein expression. Both HPV-positive cell lines MEER and TC-1 showed upregulation of Calr, Hmgb1, and cGAS-STING family members after FLASH RT but not after CONV RT in vitro. To assess changes in lymphocyte populations, we irradiated murine mEER tumors in syngeneic C57BL/6 mice with 27 Gy in 3 fractions of FLASH RT or CONV RT. In mice bearing FLASH irradiated tumors, tumor-draining lymph nodes contained greater numbers of CD8+ T cells (FLASH 1.7×104 vs 0.8×104 CONV; P<0.001) and CD4+ T cells (FLASH 2.3×104 vs CONV 1.2×104; P<0.001) after irradiation. FLASH RT was associated with increased numbers of activated CD44+CD62LloCD8+ and CD4+ lymphocytes. In irradiated tumors, FLASH RT was associated with increased CD8+ tumor-infiltrating lymphocytes, increased PD1 expression on these lymphocytes and increased PDL1 expression on macrophages. Compared with CONV RT, FLASH RT spared activated T cells in tumor-draining lymph nodes and in tumors but increased checkpoint inhibitor expression in tumors. These results suggest that FLASH RT may enhance antitumor immune responses by maintaining the immunogenic effects of RT while preserving lymphocyte numbers, which may be augmented with immune checkpoint blockade.