Lymphocytic infiltrate is associated with favorable biomarkers profile in HER2-overexpressing breast cancers and adverse biomarker profile in ER-positive breast cancers

Pathological complete response, histologic grade, and level of stromal tumor-infiltrating lymphocytes in ER + HER2- breast cancer

BACKGROUND

Recent trials have integrated immune checkpoint inhibitors (ICIs) into neoadjuvant chemotherapy (NAC) in patients with estrogen receptor (ER)-positive, human epidermal growth factor receptor 2 (HER2)-negative breast cancer of histologic grade (HG) III. We assessed the pathological complete response (pCR) rate according to the level of stromal tumor-infiltrating lymphocytes (sTIL) and HG in patients with ER + HER2- breast cancer undergoing NAC.

METHODS

Between January 2016 and December 2023, we retrospectively identified 376 patients with ER + HER2- breast cancer who underwent NAC followed by surgery. HG and sTIL levels were examined in the biopsied samples before NAC. Multiple sTIL cutoff values as 10%, 20%, and 30% were applied.

RESULTS

Twenty-seven patients (7.2%) had HG III tumors. The pCR rate in the HG III group was 22.2%, which was significantly higher than that in the HG I/II group (4.0%) (p < 0.001). The HG III group had a higher mean sTIL level than HG I/II group (38.7% vs. 12.9%; p < 0.001). According to the sTIL levels, the pCR rate in the high sTIL group was significantly higher than that in the low sTIL group: i) cutoff of 10%, 2.4% vs. 9.5%; cutoff of 20%, 2.8% vs. 13.7%; and cutoff of 30%, 3.2% vs. 18.3%. In the high sTIL (≥ 30%) group, the pCR rate for HG III was 33.3%, whereas that for HG I/II was 13.3%.

CONCLUSIONS

High tumor grade and sTIL levels were associated with higher rates of pCR in ER + HER2- breast cancer. Our findings support that the addition to ICIs to NAC increased pCR in high-risk, HG III, ER + HER2- breast cancer and suggest that sTIL levels could be utilized to identify patients with ER + HER2- breast cancer eligible for chemoimmunotherapy.

Spatial distributions of CD8 and Ki67 cells in the tumor microenvironment independently predict breast cancer-specific survival in patients with ER+HER2- and triple-negative breast carcinoma

INTRODUCTION

Breast cancer (BC) presents diverse malignancies with varying biological and clinical behaviors, driven by an interplay between cancer cells and tumor microenvironment. Deciphering these interactions is crucial for personalized diagnostics and treatment. This study explores the prognostic impact of tumor proliferation and immune response patterns, assessed by computational pathology indicators, on breast cancer-specific survival (BCSS) models in estrogen receptor-positive HER2-negative (ER+HER2-) and triple-negative BC (TNBC) patients.

MATERIALS AND METHODS

Whole-slide images of tumor surgical excision samples from 252 ER+HER2- patients and 63 TNBC patients stained for estrogen and progesterone receptors, Ki67, HER2, and CD8 were analyzed. Digital image analysis (DIA) was performed for tumor tissue segmentation and quantification of immunohistochemistry (IHC) markers; the DIA outputs were subsampled by hexagonal grids to assess the spatial distributions of Ki67-positive tumor cells and CD8-positive (CD8+) cell infiltrates, expressed as Ki67-entropy and CD8-immunogradient indicators, respectively. Prognostic models for BCSS were generated using multivariable Cox regression analysis, integrating clinicopathological and computational IHC indicators.

RESULTS

In the ER+HER2- BC, multivariable Cox regression revealed that high CD8+ density within the tumor interface zone (IZ) (HR: 0.26, p = 0.0056), low immunodrop indicator of CD8+ density (HR: 2.93, p = 0.0051), and low Ki67-entropy (HR: 5.95, p = 0.0.0061) were independent predictors of better BCSS, while lymph node involvement predicted worse BCSS (HR: 3.30, p = 0.0013). In TNBC, increased CD8+ density in the IZ stroma (HR: 0.19, p = 0.0119) and Ki67-entropy (HR: 3.31, p = 0.0250) were independent predictors of worse BCSS. Combining these independent indicators enhanced prognostic stratification in both BC subtypes.

CONCLUSIONS

Computational biomarkers, representing spatial properties of the tumor proliferation and immune cell infiltrates, provided independent prognostic information beyond conventional IHC markers in BC. Integrating Ki67-entropy and CD8-immunogradient indicators into prognostic models can improve patient stratification with regard to BCSS.

Magnetic Resonance Imaging Features Associated with a High and Low Expression of Tumor-Infiltrating Lymphocytes: A Stratified Analysis According to Molecular Subtypes

A total of 457 patients, including 241 HR+/HER2- patients, 134 HER2+ patients, and 82 TN patients, were studied. The percentage of TILs in the stroma adjacent to the tumor cells was assessed using a 10% cutoff. The low TIL percentages were 82% in the HR+ patients, 63% in the HER2+ patients, and 56% in the TN patients (p < 0.001). MRI features such as morphology as mass or non-mass enhancement (NME), shape, margin, internal enhancement, presence of peritumoral edema, and the DCE kinetic pattern were assessed. Tumor sizes were smaller in the HR+/HER2- group (p < 0.001); HER2+ was more likely to present as NME (p = 0.031); homogeneous enhancement was mostly seen in HR+ (p < 0.001); and the peritumoral edema was present in 45% HR+, 71% HER2+, and 80% TN (p < 0.001). In each subtype, the MR features between the high- vs. low-TIL groups were compared. In HR+/HER2-, peritumoral edema was more likely to be present in those with high TILs (70%) than in those with low TILs (40%, p < 0.001). In TN, those with high TILs were more likely to present a regular shape (33%) than those with low TILs (13%, p = 0.029) and more likely to present the circumscribed margin (19%) than those with low TILs (2%, p = 0.009).

Evaluation of tumour infiltrating lymphocytes in luminal breast cancer using artificial intelligence

BACKGROUND

Tumour infiltrating lymphocytes (TILs) are a prognostic parameter in triple-negative and human epidermal growth factor receptor 2 (HER2)-positive breast cancer (BC). However, their role in luminal (oestrogen receptor positive and HER2 negative (ER + /HER2-)) BC remains unclear. In this study, we used artificial intelligence (AI) to assess the prognostic significance of TILs in a large well-characterised cohort of luminal BC.

METHODS

Supervised deep learning model analysis of Haematoxylin and Eosin (H&E)-stained whole slide images (WSI) was applied to a cohort of 2231 luminal early-stage BC patients with long-term follow-up. Stromal TILs (sTILs) and intratumoural TILs (tTILs) were quantified and their spatial distribution within tumour tissue, as well as the proportion of stroma involved by sTILs were assessed. The association of TILs with clinicopathological parameters and patient outcome was determined.

RESULTS

A strong positive linear correlation was observed between sTILs and tTILs. High sTILs and tTILs counts, as well as their proximity to stromal and tumour cells (co-occurrence) were associated with poor clinical outcomes and unfavourable clinicopathological parameters including high tumour grade, lymph node metastasis, large tumour size, and young age. AI-based assessment of the proportion of stroma composed of sTILs (as assessed visually in routine practice) was not predictive of patient outcome. tTILs was an independent predictor of worse patient outcome in multivariate Cox Regression analysis.

CONCLUSION

AI-based detection of TILs counts, and their spatial distribution provides prognostic value in luminal early-stage BC patients. The utilisation of AI algorithms could provide a comprehensive assessment of TILs as a morphological variable in WSIs beyond eyeballing assessment.

The Peritumoral CD8 + /FOXP3 + Cell Ratio Has Prognostic Value in Triple-negative Breast Cancer

Compelling data has demonstrated the prognostic significance of tumor-infiltrating lymphocytes (TILs) in triple-negative breast cancer (TNBC), a subtype generally associated with a poor clinical outcome but highly heterogeneous in nature. There have been limited studies investigating the importance of subsets of T cells in TILs. Further, the significance of intratumoral versus peritumoral TILs remains controversial. We examined the prognostic value of tumor-associated CD8 + cytotoxic T cells and FOXP3 + regulatory T cells in 35 chemotherapy-naive TNBC cases with a tumor-host interface in the tissue sections. The CD8 + and FOXP3 + cell count was expressed by immunoreactive cells per high-power field in an average of 10 high-power fields. There was a wide range of CD8 + and FOXP3 + T cells within the peritumoral and intratumoral stroma. Both CD8 + and FOXP3 + TILs were significantly higher at the former location as compared with the latter ( P <0.0001 and 0.003, respectively). The numbers of CD8 + and FOXP3 + T cells, either within peritumoral or intratumoral stroma, were not significantly associated with distant relapse-free or disease-specific survival. However, the peritumoral CD8 + /FOXP3 + ratio of TILs was significantly associated with prolonged relapse-free survival ( P =0.04) and disease-specific survival ( P =0.02). This association was not observed with the CD8 + /FOXP3 + ratio of intratumoral TILs. These observations suggest that the immunologic balance in the tumor microenvironment might determine antitumor immunity. Further, the peritumoral TILs appear to play a more important role in the progression of TNBC when compared with the intratumoral TILs, thus reaffirming the necessity of revisiting the method for the assessment of TILs.

The effect of neoadjuvant chemotherapy on tumor-infiltrating lymphocytes in patients with breast cancer

Aim: This study investigated the effect of neoadjuvant chemotherapy (NAC) on stromal tumor-infiltrating lymphocytes (sTILs) and their treatment response. Materials & methods: One hundred fifteen patients with pre-NAC core biopsies and post-NAC surgical resection specimens were reviewed. Results: There was no significant change between pre- and post-treatment sTILs. Both pre- and post-NAC sTILs were significantly lower in patients with luminal A subtype. An increase in sTILs was observed in 21 (25.9%) patients after NAC, a decrease in 29 (35.8%) and no change in 31 (38.3%; p = 0.07). Pretreatment sTIL density was independent predictor of pathological complete response in multivariate analyses (odds ratio: 1.025, 95% CI: 1.003-1.047; p = 0.023). Conclusion: High sTIL density in core biopsies was independently related to pathological complete response. In addition, ER appears to be the most crucial factor determining the rate of sTIL.

Research Progress on the Role of Regulatory T Cell in Tumor Microenvironment in the Treatment of Breast Cancer

The tumor microenvironment (TME) is a complex ecosystem comprised of cancer cells, stromal cells, and immune cells. Analysis of the composition of TME is essential to assess the prognosis of patients with breast cancer (BC) and the efficacy of different regimes. Treg plays a crucial role in the microenvironment of breast cancer subtypes, and its function contributes to the development and progression of BC by suppressing anti-tumor immunity directly or indirectly through multiple mechanisms. In addition, conventional treatments, such as anthracycline-based neoadjuvant chemotherapy, and neo-therapies, such as immune-checkpoint blockades, have a significant impact on the absence of Tregs in BC TME, thus gaining additional anti-tumor effect to some extent. Strikingly, Treg in BC TME revealed the predicted efficacy of some therapeutic strategies. All these results suggest that we can manipulate the abundance of Treg to achieve the ultimate effect of both conventional and novel treatments. In this review, we discuss new insights into the characteristics of Treg in BC TME, the impact of different regiments on Treg, and the possibilities of Treg as a predictive marker of efficacy for certain treatments.

The tale of TILs in breast cancer: A report from The International Immuno-Oncology Biomarker Working Group

The advent of immune-checkpoint inhibitors (ICI) in modern oncology has significantly improved survival in several cancer settings. A subgroup of women with breast cancer (BC) has immunogenic infiltration of lymphocytes with expression of programmed death-ligand 1 (PD-L1). These patients may potentially benefit from ICI targeting the programmed death 1 (PD-1)/PD-L1 signaling axis. The use of tumor-infiltrating lymphocytes (TILs) as predictive and prognostic biomarkers has been under intense examination. Emerging data suggest that TILs are associated with response to both cytotoxic treatments and immunotherapy, particularly for patients with triple-negative BC. In this review from The International Immuno-Oncology Biomarker Working Group, we discuss (a) the biological understanding of TILs, (b) their analytical and clinical validity and efforts toward the clinical utility in BC, and (c) the current status of PD-L1 and TIL testing across different continents, including experiences from low-to-middle-income countries, incorporating also the view of a patient advocate. This information will help set the stage for future approaches to optimize the understanding and clinical utilization of TIL analysis in patients with BC.

The Multifaceted Role of Regulatory T Cells in Breast Cancer

The microenvironment of breast cancer hosts a dynamic cross talk between diverse players of the immune system. While cytotoxic immune cells are equipped to control tumor growth and metastasis, tumor-corrupted immunosuppressive immune cells strive to impair effective immunity and promote tumor progression. Of these, regulatory T cells (T_regs), the gatekeepers of immune homeostasis, emerge as multifaceted players involved in breast cancer. Intriguingly, clinical observations suggest that blood and intratumoral T_regs can have strong prognostic value, dictated by breast cancer subtype. Accordingly, emerging preclinical evidence shows that T_regs occupy a central role in breast cancer initiation and progression and provide critical support to metastasis formation. Here, T_regs are not only important for immune escape but also promote tumor progression independent of their immune regulatory capacity. Combining insights into T_reg biology with advances made across the rapidly growing field of immuno-oncology is expected to set the stage for the design of more effective immunotherapy strategies.

Evaluation of Tumor infiltrating lymphocytes in breast carcinoma and their correlation with molecular subtypes, tumor grade and stage

BACKGROUND

Tumour infiltrating lymphocytes (TILs) exhibit the local immune response directed against tumor growth and metastasis. TILs have emerged as a tool to assess immune-reactivity in various malignancies including colon, ovary, lung, bladder, breast etc as well as independent marker of favourable prognosis in many tumors. TILs in breast cancer (BC) play a role in tumor response to therapy in the adjuvant and neoadjuvant settings, especially in triple-negative cancers.

MATERIAL & METHODS

This cross sectional study comprised of 101cases of invasive breast carcinoma. For each case, a representative 5 μm H&E stained section was selected and the clinicopathological details were recorded. To establish the molecular subtype of breast cancer, immunohistochemistry for ER, PR and Her2neu was done. Both stromal (sTIL) and intratumoral (iTIL) TILs were assessed based on the recommendations of the International TIL Working Group (ITILWG).

RESULTS

A statistically significant difference was observed in the mean sTIL as well as iTIL scores and tumor grade, size, molecular type and lymph node metastasis. A signification correlation was observed between stromal TIL and tumor grade, lymph node metastasis, molecular subtype and mitosis. Intratumoral TIL showed a significant correlation with tumor size, mitosis, tumor grade, distant metastasis, stage and lymph node metastasis. Moreover, stromal and intratumoral TIL showed a highly significant correlation with each other.

CONCLUSION

The ITILWG recommendations are reproducible and reliable for the evaluation of sTILs and iTILs. TILs, as evaluated on Hematoxylin and eosin (H&E) slides, has been shown in numerous studies now to be a reliable, reproducible, inexpensive and readily available marker of pre-existing antitumor immunity in breast cancer. We suggest that TILs should be evaluated for each case of breast carcinoma and should be part of histopathology report.

Emerging immune gene signatures as prognostic or predictive biomarkers in breast cancer

Several multigene assays have been developed to predict the risk of distant recurrence and response to adjuvant therapy in early breast cancer. However, the prognostic or predictive value of current proliferation gene signature-based assays are limited to hormone receptor-positive, human epidermal growth factor receptor 2-negative (HR+/HER2-) early breast cancer. Considerable discordance between the different assays in classifying patients into risk groups has also been reported, thus raising questions about the clinical utility of these assays for individual patients. Therefore, there still remains a need for better prognostic or predictive biomarkers for breast cancer. The role of immune cells comprising tumor microenvironment in tumor progression has been recognized. Accumulating evidences have shown that immune gene signatures and tumor-infiltrating lymphocytes (TILs) can be prognostic or predictive factors in breast cancer, particularly with regard to HER2+ and triple-negative breast cancer. In this review, I summarize current multigene assays for breast cancer and discuss recent progress in identifying novel breast cancer biomarkers, focusing on the emerging importance of immune gene signatures and TILs as prognostic or predictive biomarkers.

The composition of T cell infiltrates varies in primary invasive breast cancer of different molecular subtypes as well as according to tumor size and nodal status

T lymphocytes are the most numerous immune cells in tumor-associated infiltrates and include several subpopulations of either anticancer or pro-tumorigenic functions. However, the associations between levels of different T cell subsets and breast cancer molecular subtypes as well as other prognostic factors have not been fully established yet. We performed immunohistochemistry for CD8 (cytotoxic T cells (CTL)), FOXP3 (regulatory T cells (Tregs)), and GATA3 (Th2 cells) in 106 formalin-fixed paraffin-embedded invasive breast cancer tissue samples and analyzed both the numbers and percentages of investigated cells in tumor-associated infiltrates. We observed that triple-negative breast cancer (TNBC) and HER2+ non-luminal breast tumors were associated with more numerous CTLs and Tregs and a higher Treg/Th2 cell ratio as compared with luminal A subtype. A higher Treg percentage was related to a decreased hormone receptor expression, an increase in the Ki67 level, a greater tumor size of luminal tumors, and the presence of lymph node metastases. Moreover, differences in the composition of T cell infiltrates were associated with HER2 status and histologic grade and type, and a distinct immune pattern was observed in tumors of different phenotypes regarding pT stage and nodal status. The results of our work show the diversity of T cell infiltrates in primary invasive breast cancers of different phenotypes and suggest that progression of luminal or non-luminal tumors is related to distinct tumor-associated T cell composition.

Exploration of tumour-infiltrating lymphocytes as a predictive biomarker for adjuvant endocrine therapy in early breast cancer

PURPOSE

Tumour-infiltrating lymphocytes (TILs) have been shown to be prognostic for disease-free survival and predictive for the benefit of chemotherapy in patients with early breast cancer, but have not been studied for endocrine therapy.

EXPERIMENTAL DESIGN

The number of CD8-positive TILs was assessed in a subcohort of 236 patients in the Intergroup Exemestane Study. AQ After 2-3 years of adjuvant tamoxifen, AQpatients were randomized between the schemes of continuation for 5 years on tamoxifen and switching to exemestane. The numbers of CD8-positive TILs were analysed for correlations with disease-free survival (DFS) and overall survival (OS). A similar analysis was performed on 2596 patients in the TEAM trial who were randomized between the sequential scheme and the exemestane monotherapy.

RESULTS

In the first cohort, patients with low (below median) numbers of CD8-positive TILs had a univariate hazard ratio (HR) for DFS of 0.27 (95% CI 0.13-0.55) in favour of treatment with exemestane, whereas this benefit was not observed in patients with high numbers of CD8-positive TILs (HR 1.34, 95% CI 0.71-2.50, HR for interaction 5.02, p = 0.001). In the second cohort, patients with low numbers of CD8-positive TILs showed a benefit of exemestane treatment on recurrence-free survival (RFS HR 0.67, 95% CI 0.45-0.99), and not with above-median numbers of CD8-positive TILs (HR 0.86, 95% CI 0.59-1.26, HR for interaction 1.29, p = 0.36).

CONCLUSIONS

This study is the first to propose the number of CD8-positive TILs as potential predictive markers for endocrine therapy, with the low presence of CD8-positive TILs associated to benefit for exemestane-inclusive therapy. However, treatment-by-marker interactions were only significant in one cohort, indicating the need for further validation.

Comparison of tumor-infiltrating lymphocytes of breast cancer in core needle biopsies and resected specimens: a retrospective analysis

PURPOSE

Neoadjuvant chemotherapy (NAC) is being increasingly used to treat locally advanced breast cancer and to conserve the breast. In triple-negative breast cancer and HER2-positive breast cancer, a high density of tumor-infiltrating lymphocytes (TILs) is an important predictor of NAC response. Thus far, it remains unclear whether the TIL scores in core needle biopsies (CNBs) are closely representative of those in the whole tumor section in resected specimens. This study aimed to evaluate the concordance between the TIL scores of CNBs and resected specimens of breast cancer.

METHODS

A total of 220 matched pairs of CNBs and resected specimens of breast cancer were included. Stromal TILs were scored on slides stained with hematoxylin and eosin. Clinicopathologic parameters and the agreement of the TIL scores between CNBs and resected specimens were statistically analyzed.

RESULTS

The average TIL score was approximately 4.4% higher for the resected specimens than for the CNBs. When the tumors were divided into two groups according to a 60% TIL score cut-off (low and intermediate TIL vs. high TIL), 8.2% showed discordance between the CNB and resected specimen. The overall intraclass correlation coefficient (ICC) value of the TIL score was 0.895 (95% confidence interval, 0.864-0.920, P < 0.001), and all molecular subtypes showed ICC values over 0.8 (P < 0.001). The ICC values were > 0.9 when ≥ 5 cores were included in the CNBs. Tumors with discordant TILs were characterized by histologic grade III, ER negativity, high proliferative index, and HER2 and triple-negative subtypes. A high proliferative index was an independent risk factor for TIL discordance.

CONCLUSIONS

The TIL score in CNB specimens is a reliable value that reflects the TIL status of the entire tumor in resected specimens of breast cancer. More than five CNB cores may accurately predict the TIL score of the entire tumor.

The prognostic value of regulatory T cells infiltration in HER2-enriched breast cancer microenvironment

Breast cancer represents a complex and heterogeneous disease that comprises distinct disease conditions, histological features, and clinical outcome. Since many years, it has been demonstrated as an association between HER2 amplification and poor prognosis, because its overexpression is associated with an aggressive phenotype of breast tumor cells. A significant proportion of cases have developed resistance to the current therapies available. Consequently, new prognostic markers are urgently needed to identify patients who are at the highest risk for developing metastases. During the past decade, new insights provided valuable knowledge regarding mechanisms underlying the dynamic interplayed between immune cells and tumor progression. It has been shown that the presence of a lymphocytic infiltrate, particularly of regulatory T cells, in cancer tissue, is associated with clinical outcome promoting rather than inhibiting cancer development and progression. It has been also verified that the clinical value of lymphocytic infiltration in breast cancers could be subtype-dependent, including the HER2-enriched subtype. In this context, this work summarizes proposed to discuss the prognostic value of regulatory T cell infiltration in microenvironment of HER2-enriched breast cancer.

The CD4/CD8 ratio of tumor-infiltrating lymphocytes at the tumor-host interface has prognostic value in triple-negative breast cancer

Compelling evidence has demonstrated the prognostic value of tumor-infiltrating lymphocytes (TILs), especially in triple-negative breast cancer (TNBC). However, only a limited number of studies to investigate the importance of the subsets of T cells in TILs have been carried out, less so the significance of the location of these TILs. In this study, we explored in a cohort of 42 consecutive TNBC cases the prognostic significance of TIL subsets at the tumor-host interface (within 1 high-power field [0.5 mm] of the invasive front) and compared them with TILs within the intratumoral stroma. Given the reported importance of TILs in HER2-overexpressing breast cancer, a subset of such tumors was also included for comparison. The range was wide in both locations; nevertheless, the mean CD4⁺ and CD8⁺ T cell count was significantly higher at the tumor-host interface than that found within the intratumoral stroma (both P<.0001). The number of CD4⁺ or CD8⁺ T cells at either location was not significantly associated with distant relapse-free or overall survival. However, the CD4/CD8 ratio at the tumor-host interface was significantly associated with both relapse-free survival (hazard ratio 0.2, P=.002) and overall survival (hazard ratio 0.13, P=.002), whereas this association was not seen for the CD4/CD8 ratio within the intratumoral stroma. As expected, both tumor size and nodal status were significantly associated with survival outcomes. The findings further support the contention that TILs, as markers of regional immune escape, are of prognostic importance in TNBC progression and that the CD4/CD8 ratio of TILs at the tumor-host interface plays a distinctive role, thus appearing to be of clinical relevance.

Distinct Tertiary Lymphoid Structure Associations and Their Prognostic Relevance in HER2 Positive and Negative Breast Cancers

BACKGROUND

The presence of tumor infiltrating lymphocytes (TIL) is associated with favorable prognosis. Recent evidence suggested that not only their density, but also the spatial organization as tertiary lymphoid structures (TLS), play a key role in determining patient survival.

MATERIALS AND METHODS

In a cohort of 248 breast cancers, the clinicopathologic association and prognostic role of TLS was examined.

RESULTS

Tertiary lymphoid structures were associated with higher tumor grade, apocrine phenotype, necrosis, extensive in situ component, lymphovascular invasion (LVI), and high TIL. For biomarkers, TLS were associated with hormone receptors negativity, HER2 positivity, and c-kit expression. Tertiary lymphoid structures were significantly related to better disease-free survival (DFS) in HER2 positive (HER2+) breast cancers (log-rank = 4.054), which was not dependent on high TIL status. The combined TLS and TIL status was an independent favorable factor associated with DFS in those cases. Interestingly, tumor cell infiltration into the TLS was found in 41.9% of TLS positive cases. It was associated with LVI in HER2 negative (HER2-) TLS positive (particularly estrogen receptor positive [ER+] HER2-) cases. In the ER+ HER2- cases, tumor cell infiltration into TLS was also associated with increased pathologic nodal stage (pN) stage and nodal involvement.

CONCLUSION

Tertiary lymphoid structures showed a similar relationship with clinicopathologic features and biomarkers as TIL. The presence of TLS, irrespective of TIL level, could be an important favorable prognostic indicator in HER2+ breast cancer patients. Given the significance of TLS in promoting effective antitumor immunity, further understanding of its organization and induction may provide new opportunities to improve the current immunotherapy strategies.

IMPLICATIONS FOR PRACTICE

Despite recent interest on the clinical value of tumor infiltrating lymphocyte (TIL), little was known on the clinical significance on their spatial organization as tertiary lymphoid structures (TLS). Although TLS showed similar relationships with clinicopathologic features and biomarkers as TIL, the prognostic value of TLS, particularly in HER2 positive cancers, was independent of TIL. Moreover, tumor infiltration could be present in TLS which appears to be related to tumor invasion in HER2 negative cancers. Overall, the results demonstrated the additional value for TLS in HER2 cancer subtypes. Further investigations and its standardized evaluation will enhance its use as standard practice.

MMP11 and CD2 as novel prognostic factors in hormone receptor-negative, HER2-positive breast cancer

Purpose

More accurate prediction of patient outcome based on molecular subtype is required to identify patients who will benefit from specific treatments.

Methods

We selected novel 16 candidate prognostic genes, including 10 proliferation-related genes (p-genes) and 6 immune response-related genes (i-genes), from the gene list identified in our previous study. We then analyzed the association between their expression, measured by quantitative real-time reverse transcription-PCR in formalin-fixed, paraffin-embedded tissues, and clinical outcome in 819 breast cancer patients according to molecular subtype.

Results

The prognostic significance of clinical and gene variables varied according to the molecular subtype. Univariate analysis showed that positive lymph node status was significantly correlated with the increased risk of distant metastasis in all subtypes except the hormone receptor-negative, HER2-positive (HR−/HER2+) subtype. Most p-genes were significantly associated with poor prognosis in patients with the HR+/HER2− subtype, whereas i-genes correlated with a favorable outcome in patients with HR−/HER2+ breast cancer. In HR−/HER2+ breast cancer, four genes (three i-genes BTN3A2, CD2, and TRBC1 and the p-gene MMP11) were significantly associated with distant metastasis-free survival (DMFS). A new prognostic model for HR−/HER2+ breast cancer based on the expression of MMP11 and CD2 was developed and the DMFS for patients in the high-risk group according to our model was significantly lower than that for those in the low-risk group. Multivariate analyses revealed that our risk score is an independent prognostic factor for DMFS. Moreover, C-index showed that our risk score has a superior prognostic performance to traditional clinicopathological factors.

Conclusions

Our new prognostic model for HR−/HER2+ breast cancer provides more accurate information on the risk of distant metastasis than traditional clinical prognostic factors and may be used to identify patients with a good prognosis in this aggressive subtype of breast cancer.

Electronic supplementary material

The online version of this article (doi:10.1007/s10549-017-4234-4) contains supplementary material, which is available to authorized users.

Meroxest improves the prognosis of immunocompetent C57BL/6 mice with allografts of E0771 mouse breast tumor cells

INTRODUCTION

Recently, we have reported the antitumor properties of a new family of synthetic merosesquiterpenes, among which meroxest is highlighted, since it has high activity and specificity for ER⁺ breast cancer cells. In this paper, we characterize allografts of ER⁺ E0771 mouse breast tumor cells in immunocompetent C57BL/6 mice, and also analyze the effect of meroxest on the prognosis of the disease.

MATERIAL AND METHODS

Twenty female C57BL/6 mice were injected with 10⁶ E0771 cells. Once the tumors reached the appropriate size, the mice were divided into two groups, one control and another treated orally with 15 mg/kg of meroxest. After 20 days, tumor samples were taken for histopathological study and for determination of the expression of the prognostic markers Ki67 and vascular endothelial growth factor (VEGF) by immunofluorescence.

RESULTS

In sections stained with hematoxylin-eosin, we observed that tumors have a well-defined capsule enclosing E0771 tumor cells. The central area of tumors contains necrotic regions with leukocyte infiltration. Meroxest treatment significantly reduces tumor size (68%, p < 0.05), induces changes in its structure, decreases the degree of leukocyte infiltration, and significantly reduces the expression of Ki67 (33%, p < 0.05) and VEGF (82%, p < 0.05).

CONCLUSIONS

Meroxest improves the prognosis of mice since it reduces leukocyte infiltration, and decreases the expression of Ki67 and VEGF markers. Consequently, the merosesquiterpene could become a useful antiangiogenic drug in the treatment of breast cancer. These results encourage us to deepen the study of meroxest, in order to find more evidence that supports the convenience of its evaluation in a clinical study or trial.

CD8(+) tumor-infiltrating lymphocytes contribute to spontaneous "healing" in HER2-positive ductal carcinoma in situ

We evaluated the associations between tumor‐infiltrating lymphocytes (TIL) including CD8‐positive [+] lymphocytes in ductal carcinoma in situ (DCIS) and histopathologic factors, particularly spontaneous “healing” and immunohistochemical (IHC)‐based subtypes, to clarify the effects of host immune response to cancer cells proliferation during early carcinogenesis for the breast cancer. This cohort enrolled 82 DCIS patients. We examined the relationships between clinicopathologic factors including age, DCIS architecture, Van Nuys classification, grade, comedo necrosis, apocrine features, TIL, CD8⁺ lymphocytes, healing, estrogen receptor and HER2 positivity, and IHC‐based subtypes [luminal, luminal‐HER2, HER2‐positive, triple negative (TN)]. The results were analyzed by univariate and multivariate analyses. High numbers of TIL (high‐TIL) and healing were seen in 30.5% and 39.0% of the cohort, respectively. The distributions of luminal, luminal‐HER2, HER2 and TN subtypes were 73.2%, 9.8%, 13.4%, and 3.6%, respectively. High Van Nuys grading, high‐grade, comedo necrosis, apocrine features, high‐TIL, high CD8⁺ lymphocytes and healing were significantly associated with HER2‐positive (luminal‐HER2, HER2), and TN subtypes. High‐TIL was significantly associated with high‐grade, comedo necrosis, apocrine features, healing, high CD8⁺ lymphocytes and HER2 and TN subtypes. Healing was significantly correlated with high CD8⁺ lymphocytes, high‐grade, comedo necrosis, apocrine features, and HER2‐positive and TN subtypes. Logistic regression analysis revealed a strong association between healing and TIL (odds ratio: 11.72, P = 0.024). High CD8⁺ lymphocytes was also significantly associated with healing (odds ratio: 9.26, P = 0.009). The results of this study suggested that the spontaneous healing phenomenon might be induced by CD8⁺ high‐TIL associated with high‐grade, comedo necrosis, apocrine features and HER2‐positive DCIS.

Immunological Effects of Conventional Chemotherapy and Targeted Anticancer Agents

The tremendous clinical success of checkpoint blockers illustrates the potential of reestablishing latent immunosurveillance for cancer therapy. Although largely neglected in the clinical practice, accumulating evidence indicates that the efficacy of conventional and targeted anticancer agents does not only involve direct cytostatic/cytotoxic effects, but also relies on the (re)activation of tumor-targeting immune responses. Chemotherapy can promote such responses by increasing the immunogenicity of malignant cells, or by inhibiting immunosuppressive circuitries that are established by developing neoplasms. These immunological "side" effects of chemotherapy are desirable, and their in-depth comprehension will facilitate the design of novel combinatorial regimens with improved clinical efficacy.

Clinicopathological and prognostic significance of FOXP3+ tumor infiltrating lymphocytes in patients with breast cancer: a meta-analysis

Background

The prognostic significance of FOXP3+ tumor-infiltrating lymphocytes (TILs) in patients with breast cancer remains controversial. The aims of our meta-analysis are to evaluate its association with clinicopathological characteristics and prognostic significance in patients with breast cancer.

Methods

PubMed, Embase, Cochrane Database and the Ovid Database were systematically searched (up to April 2015). The meta-analysis was performed using hazard ratio (HR), odds ratio (OR) and 95 % confidence intervals (CI) as effect measures. Using the random-effects model, statistical analysis was performed using Stata software, version 12.0.

Results

Seventeen studies including 8277 patients with breast cancer were analyzed. The meta-analysis indicated that the incidence difference of FOXP3+ TILs was significant when comparing the lymph node positive group to negative group (OR = 1.305, 95 % CI [1.071, 1.590]), the histological grade III group to the I–II group (OR = 3.067, 95 % CI [2.288, 4.111]), the ER positive group to the negative group (OR = 0.435, 95 % CI [0.287, 0.660]), the PR positive group to the negative group (OR = 0.493, 95 % CI [0.296, 0.822]), the HER2 positive group to the negative group (OR = 1.896, 95 % CI [1.335, 2.692]), the TNBC group to the non TNBC group (OR = 2.456, 95 % CI [1.801, 3.348]). The detection of FOXP3+ TILs was significantly correlated with the recurrence-free survival (RFS) of patients (HR = 1.752, 95 % CI [1.188–2.584]) and the overall survival (OS) of patients (HR =1.447, 95 % CI [1.037–2.019]).

Conclusions

Our meta-analysis demonstrates that the presence of high levels of FOXP3+ TILs is associated with prognosis for breast cancer patients and predicts lymph node metastasis, hormone receptor and HER-2 status.

Effect of aromatase inhibition on functional gene modules in estrogen receptor-positive breast cancer and their relationship with antiproliferative response

PURPOSE

To investigate potential associations between gene modules representing key biologic processes and response to aromatase inhibitors (AI) in estrogen receptor-positive (ER(+)) breast cancer.

PATIENTS AND METHODS

Paired gene expression and Ki67 protein expression were available from 69 postmenopausal women with ER(+) early breast cancer, at baseline and 2 weeks post-anastrozole treatment, in the presurgical setting. Functional gene modules (n = 26) were retrieved from published studies and their module scores were computed before and after elimination of proliferation-associated genes (PAG). Ki67 and module scores were assessed at baseline and 2 weeks post-anastrozole. Unsupervised clustering was used to assess associations between modules and Ki67.

RESULTS

Proliferation-based modules were highly correlated with Ki67 expression both pretreatment and on-treatment. At baseline with and without PAGs, Ki67 expression was significantly inversely correlated with ERG, ESR1.2, SET, and PIK3CA modules. Modules measuring estrogen signaling strongly predicted antiproliferative response to therapy with and without PAGs. Baseline expression of insulin-like growth factor-1 (IGF-I) module predicted a poor change in Ki67-implicating genes within the module as involved in de novo resistance to AIs. High expression of Immune.2.STAT1 module pretreatment predicted poor antiproliferative response to therapy. A significant association between estrogen-regulated genes modules (ESR1, ESR1-2, SET, and ERG) was evident post AI.

CONCLUSIONS

Multiple processes and pathways are affected by AI treatment in ER(+) breast cancer. Modules closely associated with ESR1 expression were predictive of good antiproliferative response to AIs, but modules representing immune activity and IGF-I/MAPK were predictive of poor Ki67 response, supporting their therapeutic targeting in combination with AIs.