PD-1/PD-L1 Immune Checkpoint Inhibition with Radiation in Bladder Cancer: In Situ and Abscopal Effects

The combination of radiation with immune checkpoint inhibitors was reported in some cancers to have synergic effects both locally and distally. Our aim was to assess this combined therapy on both radiated and nonradiated bladder tumors and to characterize the immune landscape within the tumor microenvironment. Murine bladder cancer cells (MB49) were injected subcutaneously in both flanks of C57BL/6 mice. Mice were randomly assigned to the following treatments: placebo, anti-PD-L1 (four intraperitoneal injections over 2 weeks), radiation to right flank (10 Gy in two fractions), or radiation+anti-PD-L1. Tumor digestion, flow cytometry, and qPCR were performed. Log-rank analysis was used for statistical significance. Radiation+anti-PD-L1 group demonstrated statistically significant slower tumor growth rate both in the radiated and non-irradiated tumors (P < 0.001). Survival curves demonstrated superior survival in the combination group compared with each treatment alone (P = 0.02). Flow cytometry showed increased infiltration of immunosuppressive cells as well as CTL in the radiation and combination groups (P = 0.04). Ratio of immunosuppressive cells to CTL shifted in favor of cytotoxic activity in the combination arm (P < 0.001). The qPCR analysis revealed down-regulation of immunosuppressive genes (CCL22, IL22, and IL13), as well as upregulation of markers of CTL activation (CXCL9, GZMA, and GZMB) within both the radiated and distant tumors within the combination group. Combining radiation with immune checkpoint inhibitor provided better response in the radiated tumors and also the distant tumors along with a shift within the tumor microenvironment favoring cytotoxic activity. These findings demonstrate a possible abscopal effect in urothelial carcinoma with combination therapy.