Localized FLASH Radiotherapy Reduces Long-Term Skin and Muscle Damage While Preserving Systemic Homeostasis

Abstract Radiotherapy (RT) is a cornerstone treatment for nearly 50% of cancer patients, but its curative potential and safe dosing are constrained by cumulative toxicity to surrounding healthy tissues. Delivering RT at ultra-high dose rates (FLASH-RT) represents a transformative strategy, as it appears to maintain tumor control, while sparing normal tissue. Melanoma is among the most radioresistant tumors, and skin and muscle are invariably exposed during RT, also in case of deep seated tumors. Here, we compared electron FLASH-RT and conventional RT (CONV-RT) in melanoma-bearing and naïve mice assessing tumor control, tissue integrity, and systemic homeostasis over the medium to long term. Both modalities achieved comparable tumor suppression. However, CONV-RT induced persistent skin damage, dermal fibrosis, muscle dysfunction and systemic inflammatory-metabolic alterations, while FLASH-RT largely spared normal tissue and systemic balance. Bulk RNA sequencing revealed striking differences: FLASH induced minimal transcriptional disruption in skin and muscle, whereas CONV-RT triggered thousands of differentially expressed genes, including massive activation of fibrosis, inflammation, cell death-related pathways in skin, and broad dysregulation of genes linked to muscle function, remodeling and the unfolded protein response. Histological and ultrastructural analyses corroborated the findings, showing reduced immune infiltration in the skin and preserved tissue architecture both in skin and muscle following FLASH. In conclusion our study not only confirms the protective nature of FLASH but also provides novel mechanistic insights into the cascade linking local injury to systemic dysfunction under CONV-RT, reinforcing the translational potential of FLASH to expand the therapeutic window of radiotherapy. One Sentence Summary Comparative analysis of FLASH and conventional radiotherapy in a murine model of melanoma and naïve mice - Therapeutical efficacy, local and systemic effects.