Concurrent Chemoradiotherapy Plus Immunotherapy Versus Concurrent Chemoradiotherapy in Locally Advanced Cervical Cancer: A Randomized, Single-Center, Phase II Trial of Early Tumor Regression and Pro-Inflammatory Tumor Microenvironment Remodeling

Abstract

Concurrent chemoradiotherapy (CCRT) followed by intrauterine brachytherapy is the standard treatment for locally advanced cervical cancer (LACC), yet its efficacy is frequently constrained by an immunosuppressive tumor microenvironment (TME). This randomized, single-center, Phase II trial (n = 18; 2:1 allocation; high-risk Stages III–IVA LACC) investigated whether adding immunotherapy to CCRT (CICRT) could enhance early tumor regression and overcome immune suppression. In this exploratory analysis, CICRT demonstrated a numerical advantage in tumor reduction over CCRT alone, although the difference did not reach conventional statistical significance (mean residual tumor volume: 3.0% vs. 7.4%, p = 0.080, 95% CI: −9.3%–0.6%, η² = 0.180). Single-cell RNA sequencing of paired biopsies (n = 12) revealed that CICRT was associated with pro-inflammatory remodeling, characterized by the upregulation of MHC-II and chemotaxis-related genes in malignant cells and cancer-associated fibroblasts. Notably, CICRT reduced regulatory T cell niches and exhausted CD8⁺ T cells, alongside a phenotypic shift in tumor-associated macrophages toward an inflammatory state. These findings demonstrate the potential of CICRT to enhance early tumor regression and mitigate TME suppression, providing an exploratory biological rationale for its therapeutic activity in LACC.

Keywords

cervical cancer / concurrent chemoradiotherapy / immunotherapy / single-cell RNA sequencing

References

[1] H. Sung, J. Ferlay, R. L. Siegel, et al., “Global Cancer Statistics 2020: GLOBOCAN Estimates of Incidence and Mortality Worldwide for 36 Cancers in 185 Countries,” CA: A Cancer Journal for Clinicians 71, no. 3 (2021): 209–249.

[2] D. Singh, J. Vignat, V. Lorenzoni, et al., “Global Estimates of Incidence and Mortality of Cervical Cancer in 2020: A Baseline Analysis of the WHO Global Cervical Cancer Elimination Initiative,” Lancet Global Health 11, no. 2 (2023): e197–e206.

[3] B. J. Monk, D. S. P. Tan, J. D. Hernández Chagüi, et al., “Proportions and Incidence of Locally Advanced Cervical Cancer: A Global Systematic Literature Review,” International Journal of Gynecological Cancer 32, no. 12 (2022): 1531–1539.

[4] “Cervical Cancer Survival Rates | Cancer 5-Year Survival Rates,” American Cancer Society, accessed April 22, 2025, https://www.cancer.org/cancer/types/cervical-cancer/detection-diagnosis-staging/survival.html.

[5] P. J. Eifel, K. Winter, M. Morris, et al., “Pelvic Irradiation With Concurrent Chemotherapy Versus Pelvic and Para-Aortic Irradiation for High-Risk Cervical Cancer: An Update of Radiation Therapy Oncology Group Trial (RTOG) 90-01,” Journal of Clinical Oncology 22, no. 5 (2004): 872–880.

[6] H. S. Bae, Y. J. Kim, M. C. Lim, et al., “Predictors of Radiation Field Failure After Definitive Chemoradiation in Patients With Locally Advanced Cervical Cancer,” International Journal of Gynecological Cancer 26, no. 4 (2016): 737–742.

[7] J. Oh, K. H. Seol, Y. S. Choi, J. W. Lee, and J. Y. Bae, “Clinical Significance of Lymph Node Size in Locally Advanced Cervical Cancer Treated With Concurrent Chemoradiotherapy,” Yeungnam University Journal of Medicine 36, no. 2 (2019): 115–123.

[8] C. Lin, N. Xiao, Q. Chen, et al., “Prognostic Implications of Tumor Volume Reduction During Radiotherapy in Locally Advanced Cervical Cancer: A Risk-Stratified Analysis,” Radiation Oncology 20, no. 1 (2025): 47.

[9] N. A. Mayr, V. A. Magnotta, J. C. Ehrhardt, et al., “Usefulness of Tumor Volumetry by Magnetic Resonance Imaging in Assessing Response to Radiation Therapy in Carcinoma of the Uterine Cervix,” International Journal of Radiation Oncology, Biology, Physics 35, no. 5 (1996): 915–924.

[10] Y. Watanabe, S. Nakamura, Y. Ichikawa, et al., “Early Alteration in Apparent Diffusion Coefficient and Tumor Volume in Cervical Cancer Treated With Chemoradiotherapy or Radiotherapy: Incremental Prognostic Value Over Pretreatment Assessments,” Radiotherapy and Oncology 155 (2021): 3–9.

[11] L. R. Mileshkin, K. N. Moore, E. H. Barnes, et al., “Adjuvant Chemotherapy Following Chemoradiotherapy as Primary Treatment for Locally Advanced Cervical Cancer Versus Chemoradiotherapy Alone (OUTBACK): An International, Open-Label, Randomised, Phase 3 Trial,” Lancet Oncology 24, no. 5 (2023): 468–482.

[12] J. Ye, B. N. Mills, T. Zhao, et al., “Assessing the Magnitude of Immunogenic Cell Death Following Chemotherapy and Irradiation Reveals a New Strategy to Treat Pancreatic Cancer,” Cancer Immunology Research 8, no. 1 (2020): 94–107.

[13] Y. Suzuki, K. Mimura, Y. Yoshimoto, et al., “Immunogenic Tumor Cell Death Induced by Chemoradiotherapy in Patients With Esophageal Squamous Cell Carcinoma,” Cancer Research 72, no. 16 (2012): 3967–3976.

[14] M. D. Vesely, M. H. Kershaw, R. D. Schreiber, and M. J. Smyth, “Natural Innate and Adaptive Immunity to Cancer,” Annual Review of Immunology 29 (2011): 235–271.

[15] G. Sriram, L. E. Milling, J. K. Chen, et al., “The Injury Response to DNA Damage in Live Tumor Cells Promotes Antitumor Immunity,” Science Signaling 14, no. 705 (2021): eabc4764.

[16] D. Lorusso, Y. Xiang, K. Hasegawa, et al., “Pembrolizumab or Placebo With Chemoradiotherapy Followed by Pembrolizumab or Placebo for Newly Diagnosed, High-Risk, Locally Advanced Cervical Cancer (ENGOT-cx11/GOG-3047/KEYNOTE-A18): A Randomised, Double-Blind, Phase 3 Clinical Trial,” Lancet 403, no. 10434 (2024): 1341–1350.

[17] F. Kouhen and M. Sqali Houssaini, “CALLA Trial: Immunotherapy in Locally Advanced Cervical Cancer,” Lancet Oncology 25, no. 3 (2024): e94.

[18] J. H. Yearley, C. Gibson, N. Yu, et al., “PD-L2 Expression in Human Tumors: Relevance to Anti-PD-1 Therapy in Cancer,” Clinical Cancer Research 23, no. 12 (2017): 3158–3167.

[19] Y. Wang, J. Du, Z. Gao, et al., “Evolving Landscape of PD-L2: Bring New Light to Checkpoint Immunotherapy,” British Journal of Cancer 128, no. 7 (2023): 1196–1207.

[20] C. Liu, X. Li, Q. Huang, et al., “Single-Cell RNA-Sequencing Reveals Radiochemotherapy-Induced Innate Immune Activation and MHC-II Upregulation in Cervical Cancer,” Signal Transduction and Targeted Therapy 8, no. 1 (2023): 44.

[21] L. Wang, J. Zhu, Z. Ding, et al., “Immune Predictors of Radiotherapy Outcomes in Cervical Cancer,” Advanced Science 13, no. 16 (2026): e09784.

[22] C. Liu, H. Yu, R. Huang, et al., “Radioimmunotherapy-Induced Intratumoral Changes in Cervical Squamous Cell Carcinoma at Single-Cell Resolution,” Cancer Communications 42, no. 12 (2022): 1407–1411.

[23] C. Lu, Y. Zhu, W. Kong, et al., “Study Protocol for a Prospective, Open-Label, Single-Arm, Phase II Study on the Combination of Tislelizumab, Nab-Paclitaxel, Gemcitabine, and Concurrent Radiotherapy as the Induction Therapy for Patients With Locally Advanced and Borderline Resectable Pancreatic Cancer,” Frontiers in Oncology 12 (2022): 879661.

[24] Z. Yang, J. Gao, J. Zheng, et al., “Efficacy and Safety of PD-1 Blockade Plus Long-Course Chemoradiotherapy in Locally Advanced Rectal Cancer (NECTAR): A Multi-Center Phase 2 Study,” Signal Transduction and Targeted Therapy 9, no. 1 (2024): 56.

[25] J. Yang, A. Huang, K. Yang, and K. Jiang, “Neoadjuvant Chemoradiotherapy Plus Tislelizumab Followed by Surgery for Esophageal Carcinoma (CRISEC Study): The Protocol of a Prospective, Single-Arm, Phase II Trial,” BMC Cancer 23, no. 1 (2023): 249.

[26] D. Dai, Y. Pei, B. Zhu, et al., “Chemoradiotherapy-Induced ACKR2+ Tumor Cells Drive CD8+ T Cell Senescence and Cervical Cancer Recurrence,” Cell Reports Medicine 5, no. 5 (2024): 101550.

[27] M. J. Gough and M. R. Crittenden, “The Paradox of Radiation and T Cells in Tumors,” Neoplasia 31 (2022): 100808.

[28] A. Subramanian, P. Tamayo, V. K. Mootha, et al., “Gene Set Enrichment Analysis: A Knowledge-Based Approach for Interpreting Genome-Wide Expression Profiles,” Proceedings National Academy of Science USA 102, no. 43 (2005): 15545–15550.

[29] P. J. de Vos van Steenwijk, T. H. Ramwadhdoebe, R. Goedemans, et al., “Tumor-Infiltrating CD14-Positive Myeloid Cells and CD8-Positive T-Cells Prolong Survival in Patients With Cervical Carcinoma,” International Journal of Cancer 133, no. 12 (2013): 2884–2894.

[30] X. J. Chen, L. F. Han, X. G. Wu, et al., “Clinical Significance of CD163+ and CD68+ Tumor-Associated Macrophages in High-Risk HPV-Related Cervical Cancer,” Journal of Cancer 8, no. 18 (2017): 3868–3875.

[31] L. Gorvel and D. Olive, “Tumor Associated Macrophage in HPV+ Tumors: Between Immunosuppression and Inflammation,” Seminars in Immunology 65 (2023): 101671.

[32] Y. Sheng, B. Zhang, B. Xing, et al., “Cancer-Associated Fibroblasts Exposed to High-Dose Ionizing Radiation Promote M2 Polarization of Macrophages, Which Induce Radiosensitivity in Cervical Cancer,” Cancers 15, no. 5 (2023): 1620.

[33] K. J. Hiam-Galvez, B. M. Allen, and M. H. Spitzer, “Systemic Immunity in Cancer,” Nature Reviews Cancer 21, no. 6 (2021): 345–359.

[34] V. Bergen, M. Lange, S. Peidli, F. A. Wolf, and F. J. Theis, “Generalizing RNA Velocity to Transient Cell States Through Dynamical Modeling,” Nature Biotechnology 38, no. 12 (2020): 1408–1414.

[35] X. Qiu, Y. Zhang, and J. D. Martin-Rufino, “Mapping Transcriptomic Vector Fields of Single Cells,” Cell 185, no. 4 (2022): 690–711.e45.

[36] R. Kalluri, “The Biology and Function of Fibroblasts in Cancer,” Nature Reviews Cancer 16, no. 9 (2016): 582–598.

[37] M. Schubert, B. Klinger, M. Klünemann, et al., “Perturbation-Response Genes Reveal Signaling Footprints in Cancer Gene Expression,” Nature Communications 9, no. 1 (2018): 20.

[38] P. G. Rose, B. N. Bundy, E. B. Watkins, et al., “Concurrent Cisplatin-Based Radiotherapy and Chemotherapy for Locally Advanced Cervical Cancer,” New England Journal of Medicine 340, no. 15 (1999): 1144–1153.

[39] M. R. Junttila and F. J. de Sauvage, “Influence of Tumour Micro-Environment Heterogeneity on Therapeutic Response,” Nature 501, no. 7467 (2013): 346–354.

[40] J. Fan, F. Lu, T. Qin, et al., “Multiomic Analysis of Cervical Squamous Cell Carcinoma Identifies Cellular Ecosystems With Biological and Clinical Relevance,” Nature Genetics 55, no. 12 (2023): 2175–2188.

[41] Z. Meng-Xi, F. Wen-Jie, Z. Ning, Z. Li-Yang, and W. Hong-Yan, “Concurrent Versus Sequential Immunotherapy With Chemoradiotherapy for Unresectable Stage III Non-Small-Cell Lung Cancer: A Retrospective Study,” Frontiers in Oncology 14 (2024): 1515382.

[42] S. J. Antonia, A. Villegas, D. Daniel, et al., “Durvalumab After Chemoradiotherapy in Stage III Non-Small-Cell Lung Cancer,” New England Journal of Medicine 377, no. 20 (2017): 1919–1929.

[43] J. Mayadev, D. Zamarin, W. Deng, et al., “Neoadjuvant or Concurrent Atezolizumab With Chemoradiation for Locally Advanced Cervical Cancer: A Randomized Phase I Trial,” Nature Communications 16, no. 1 (2025): 553.

[44] Y. Liu, Y. Dong, L. Kong, F. Shi, H. Zhu, and J. Yu, “Abscopal Effect of Radiotherapy Combined With Immune Checkpoint Inhibitors,” Journal of Hematology & Oncology 11, no. 1 (2018): 104.

[45] B. L. Rapoport and R. Anderson, “Realizing the Clinical Potential of Immunogenic Cell Death in Cancer Chemotherapy and Radiotherapy,” International Journal of Molecular Sciences 20, no. 4 (2019): 959.

[46] Y. Chen, M. Gao, Z. Huang, J. Yu, and X. Meng, “SBRT Combined With PD-1/PD-L1 Inhibitors in NSCLC Treatment: A Focus on the Mechanisms, Advances, and Future Challenges,” Journal of Hematology & Oncology 13, no. 1 (2020): 105.

[47] Y. Wang, W. Deng, N. Li, et al., “Combining Immunotherapy and Radiotherapy for Cancer Treatment: Current Challenges and Future Directions,” Frontiers in Pharmacology 9 (2018): 185.

[48] M. Jarosz-Biej, R. Smolarczyk, T. Cichoń, and N. Kułach, “Tumor Microenvironment as a “Game Changer” in Cancer Radiotherapy,” International Journal of Molecular Sciences 20, no. 13 (2019): 3212.

[49] B. J. Monk, T. Toita, X. Wu, et al., “Durvalumab Versus Placebo With Chemoradiotherapy for Locally Advanced Cervical Cancer (CALLA): A Randomised, Double-Blind, Phase 3 Trial,” Lancet Oncology 24, no. 12 (2023): 1334–1348.

[50] M. Rodrigues, G. Vanoni, P. Loap, et al., “Nivolumab Plus Chemoradiotherapy in Locally-Advanced Cervical Cancer: The NICOL Phase 1 Trial,” Nature Communications 14, no. 1 (2023): 3698.

[51] Y. Lin, Y. Wang, Q. Xue, et al., “GPRC5A is a Potential Prognostic Biomarker and Correlates With Immune Cell Infiltration in Non-Small Cell Lung Cancer,” Translational Lung Cancer Research 13, no. 5 (2024): 1010–1031.

[52] Y. Sawada, T. Kikugawa, H. Iio, et al., “GPRC5A Facilitates Cell Proliferation Through Cell Cycle Regulation and Correlates With Bone Metastasis in Prostate Cancer,” International Journal of Cancer 146, no. 5 (2020): 1369–1382.

[53] Y. Liu, Z. Bai, D. Chai, et al., “DNA Methyltransferase 1 Inhibits microRNA-497 and Elevates GPRC5A Expression to Promote Chemotherapy Resistance and Metastasis in Breast Cancer,” Cancer Cell International 22, no. 1 (2022): 112.

[54] J. Wang, N. Zhu, X. Su, Y. Gao, and R. Yang, “Novel Tumor-Associated Macrophage Populations and Subpopulations by Single Cell RNA Sequencing,” Frontiers in Immunology 14 (2023): 1264774.

[55] F. Zhong, L. Song, H. Li, et al., “Multi-Omics Evaluation of the Prognostic Value and Immune Signature of FCN1 in Pan-Cancer and Its Relationship With Proliferation and Apoptosis in Acute Myeloid Leukemia,” Frontiers in Genetics 15 (2024): 1425075.

[56] P. Balermpas, F. Rödel, R. Liberz, et al., “Head and Neck Cancer Relapse After Chemoradiotherapy Correlates With CD163+ Macrophages in Primary Tumour and CD11b+ Myeloid Cells in Recurrences,” British Journal of Cancer 111, no. 8 (2014): 1509–1518.

[57] Y. Zhang, J. Hu, K. Ji, et al., “CD39 Inhibition and VISTA Blockade May Overcome Radiotherapy Resistance by Targeting Exhausted CD8+ T Cells and Immunosuppressive Myeloid Cells,” Cell Reports Medicine 4, no. 8 (2023): 101151.

[58] B. C. Miller, D. R. Sen, and R. Al Abosy, “Subsets of Exhausted CD8+ T Cells Differentially Mediate Tumor Control and Respond to Checkpoint Blockade,” Nature Immunology 20, no. 3 (2019): 326–336.

[59] H. Zhang, X. Yue, Z. Chen, et al., “Define Cancer-Associated Fibroblasts (CAFs) in the Tumor Microenvironment: New Opportunities in Cancer Immunotherapy and Advances in Clinical Trials,” Molecular Cancer 22, no. 1 (2023): 159.

[60] J. Tommelein, E. De Vlieghere, L. Verset, et al., “Radiotherapy-Activated Cancer-Associated Fibroblasts Promote Tumor Progression Through Paracrine IGF1R Activation,” Cancer Research 78, no. 3 (2018): 659–670.

[61] Y. Zhang, N. Lv, M. Li, M. Liu, and C. Wu, “Cancer-Associated Fibroblasts: Tumor Defenders in Radiation Therapy,” Cell Death & Disease 14, no. 8 (2023): 541.

[62] Z. Zhang, X. Liu, D. Chen, and J. Yu, “Radiotherapy Combined With Immunotherapy: The Dawn of Cancer Treatment,” Signal Transduction and Targeted Therapy 7, no. 1 (2022): 258.

[63] M. M. Oken, R. H. Creech, D. C. Tormey, et al., “Toxicity and Response Criteria of the Eastern Cooperative Oncology Group,” American Journal of Clinical Oncology 5, no. 6 (1982): 649–655.

[64] E. Dann, N. C. Henderson, S. A. Teichmann, M. D. Morgan, and J. C. Marioni, “Differential Abundance Testing on Single-Cell Data Using k-Nearest Neighbor Graphs,” Nature Biotechnology 40, no. 2 (2022): 245–253.

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