Addition of chemotherapy to radiotherapy promotes progenitor-exhausted CD8⁺ T-cell clonal dominance in head and neck cancer

Concomitant chemoradiotherapy (CRT) is a standard-of-care for unresectable locally-advanced head and neck squamous cell carcinoma (LA-SCCHN), but its immune effects, particularly compared to radiotherapy (RT) alone, remain unclear. Using syngeneic murine models, we integrated Nr4a3-Tocky reporter analysis with single-cell transcriptomics and T-cell receptor clonotyping comprehensively to profile intratumoural CD8 T-cells following RT/CRT. We show that CRT uniquely drives robust antigen-specific clonal expansion and biases differentiation toward progenitor (or precursor) exhausted (TPEX) phenotypes, while RT favours terminal exhaustion (TEX). Single-cell analyses reveal CRT-induced clonal dominance within TPEX subsets, suggesting the potential for enhanced immune reinvigoration. In peripheral blood mononuclear cells (PBMCs) from patients treated with CRT, high levels of TEX cells were found early and at 3 months post-treatment, with delayed peripheral TPEX expansion at 3 months, indicating phased progenitor recovery. These findings demonstrate distinct immunological remodelling by CRT versus RT and underscore the critical importance of treatment timing for optimising combination immunotherapy strategies in LA-SCCHN.