Immunologic impact of chemoradiation in cervical cancer and how immune cell infiltration could lead toward personalized treatment
Corresponding Author
Lien Lippens
Laboratory of Experimental Cancer Research, Department of Human Structure and Repair, Ghent University, Ghent, Belgium
Medical Oncology, Department of Internal Medicine and Pediatrics, Ghent University Hospital, Ghent, Belgium
Cancer Research Institute Ghent (CRIG), Ghent, Belgium
Correspondence to: Lien Lippens, E-mail: [email protected]Search for more papers by this authorMieke Van Bockstal
Laboratory of Experimental Cancer Research, Department of Human Structure and Repair, Ghent University, Ghent, Belgium
Pathology, Department of Diagnostic Sciences, Ghent University Hospital, Ghent, Belgium
Search for more papers by this authorEmiel A. De Jaeghere
Laboratory of Experimental Cancer Research, Department of Human Structure and Repair, Ghent University, Ghent, Belgium
Medical Oncology, Department of Internal Medicine and Pediatrics, Ghent University Hospital, Ghent, Belgium
Cancer Research Institute Ghent (CRIG), Ghent, Belgium
Search for more papers by this authorPhilippe Tummers
Cancer Research Institute Ghent (CRIG), Ghent, Belgium
Gynecology, Department of Human Structure and Repair, Gent University Hospital, Ghent, Belgium
Search for more papers by this authorAmin Makar
Gynecology, Department of Human Structure and Repair, Gent University Hospital, Ghent, Belgium
Search for more papers by this authorSofie De Geyter
Laboratory of Experimental Cancer Research, Department of Human Structure and Repair, Ghent University, Ghent, Belgium
Medical Oncology, Department of Internal Medicine and Pediatrics, Ghent University Hospital, Ghent, Belgium
Search for more papers by this authorKoen Van de Vijver
Pathology, Department of Diagnostic Sciences, Ghent University Hospital, Ghent, Belgium
Search for more papers by this authorAn Hendrix
Laboratory of Experimental Cancer Research, Department of Human Structure and Repair, Ghent University, Ghent, Belgium
Cancer Research Institute Ghent (CRIG), Ghent, Belgium
Search for more papers by this authorKatrien Vandecasteele
Cancer Research Institute Ghent (CRIG), Ghent, Belgium
Radiation Therapy, Department of Human Structure and Repair, Ghent University Hospital, Ghent, Belgium
Search for more papers by this authorHannelore Denys
Medical Oncology, Department of Internal Medicine and Pediatrics, Ghent University Hospital, Ghent, Belgium
Cancer Research Institute Ghent (CRIG), Ghent, Belgium
Search for more papers by this authorCorresponding Author
Lien Lippens
Laboratory of Experimental Cancer Research, Department of Human Structure and Repair, Ghent University, Ghent, Belgium
Medical Oncology, Department of Internal Medicine and Pediatrics, Ghent University Hospital, Ghent, Belgium
Cancer Research Institute Ghent (CRIG), Ghent, Belgium
Correspondence to: Lien Lippens, E-mail: [email protected]Search for more papers by this authorMieke Van Bockstal
Laboratory of Experimental Cancer Research, Department of Human Structure and Repair, Ghent University, Ghent, Belgium
Pathology, Department of Diagnostic Sciences, Ghent University Hospital, Ghent, Belgium
Search for more papers by this authorEmiel A. De Jaeghere
Laboratory of Experimental Cancer Research, Department of Human Structure and Repair, Ghent University, Ghent, Belgium
Medical Oncology, Department of Internal Medicine and Pediatrics, Ghent University Hospital, Ghent, Belgium
Cancer Research Institute Ghent (CRIG), Ghent, Belgium
Search for more papers by this authorPhilippe Tummers
Cancer Research Institute Ghent (CRIG), Ghent, Belgium
Gynecology, Department of Human Structure and Repair, Gent University Hospital, Ghent, Belgium
Search for more papers by this authorAmin Makar
Gynecology, Department of Human Structure and Repair, Gent University Hospital, Ghent, Belgium
Search for more papers by this authorSofie De Geyter
Laboratory of Experimental Cancer Research, Department of Human Structure and Repair, Ghent University, Ghent, Belgium
Medical Oncology, Department of Internal Medicine and Pediatrics, Ghent University Hospital, Ghent, Belgium
Search for more papers by this authorKoen Van de Vijver
Pathology, Department of Diagnostic Sciences, Ghent University Hospital, Ghent, Belgium
Search for more papers by this authorAn Hendrix
Laboratory of Experimental Cancer Research, Department of Human Structure and Repair, Ghent University, Ghent, Belgium
Cancer Research Institute Ghent (CRIG), Ghent, Belgium
Search for more papers by this authorKatrien Vandecasteele
Cancer Research Institute Ghent (CRIG), Ghent, Belgium
Radiation Therapy, Department of Human Structure and Repair, Ghent University Hospital, Ghent, Belgium
Search for more papers by this authorHannelore Denys
Medical Oncology, Department of Internal Medicine and Pediatrics, Ghent University Hospital, Ghent, Belgium
Cancer Research Institute Ghent (CRIG), Ghent, Belgium
Search for more papers by this authorAbstract
We investigated the potential of tumor-infiltrating immune cells (ICs) as predictive or prognostic biomarkers for cervical cancer patients. In total, 38 patients treated with (chemo)radiotherapy and subsequent surgery were included in the current study. This unique treatment schedule makes it possible to analyze IC markers in pretreatment and posttreatment tissue specimens and their changes during treatment. IC markers for T cells (CD3, CD4, CD8 and FoxP3), macrophages (CD68 and CD163) and B cells (CD20), as well as IL33 and PD-L1, were retrospectively analyzed via immunohistochemistry. Patients were grouped in the low score or high score group based on the amount of positive cells on immunohistochemistry. Correlations to pathological complete response (pCR), cause-specific survival (CSS) and metastasis development during follow-up were evaluated. In analysis of pretreatment biopsies, significantly more pCR was seen for patients with CD8 = CD3, CD8 ≥ CD4, positive IL33 tumor cell (TC) scores, IL33 IC < TC and PD-L1 TC ≥5%. Besides patients with high CD8 scores, also patients with CD8 ≥ CD4, CD163 ≥ CD68 or PD-L1 IC ≥5% had better CSS. In the analysis of posttreatment specimens, less pCR was observed for patients with high CD8 or CD163 scores. Patients with decreasing CD8 or CD163 scores between pretreatment and posttreatment samples showed more pCR, whereas those with increasing CD8 or decreasing IL33 IC scores showed a worse CSS. Meanwhile, patients with an increasing CD3 score or stable/increasing PD-L1 IC score showed more metastasis during follow-up. In this way, the intratumoral IC landscape is a promising tool for prediction of outcome and response to (chemo)radiotherapy.
Abstract
What's new?
This study explored the effects of (chemo)radiotherapy on the tumor immunome and the potential of tumor-infiltrating immune cells as predictive or prognostic biomarkers in a unique cervical cancer population treated with (chemo)radiotherapy and subsequent surgery. Analysis of pre- and post-treatment immune cell markers, and their changes during treatment showed correlations with pathological response, survival, and metastasis. The CD8/CD3 ratio, CD8/CD4 ratio, IL33-tumor cells, IL33-immune cell/tumor cell ratio, and PD-L1-tumor cells may predict pathological complete response and thus radiosensitivity in cervical cancer. Investigation of these markers in future trials may thus lead to more personalized care for cervical cancer patients.
Conflict of interest
E.A.D. received funding from Fonds Wetenschappelijk Onderzoek (FWO) and travel and congress support from Pfizer and PharmaMar. H.D. served as a consultant and/or speaker for Novartis, Amgen, Tesaro, Eli Lilly & Company, Roche, Pfizer, PharmaMar and Astra Zeneca. She received research grants from Roche and Stand up to Cancer (Kom op Tegen Kanker) and travel and congress support from Roche, Teva, Pfizer, PharmaMar and Astra Zeneca. K.V. received funding from Stichting tegen Kanker and travel and congress support from PharmaMar.
Supporting Information
| Filename | Description |
|---|---|
| ijc32893-sup-0001-supinfo.pdfPDF document, 909.2 KB | Table S1 Overview of the pCR, metastasis and survival data for each patient Table S2. Antibodies used Table S3. Overview of the scores given for the different markers for pretreatment and posttreatment samples. For every marker, the amount of patients scored with a specific score is given Table S4. Correlation between tumor grade and response to (chemo)radiotherapy as well as the different immune markers in pretreatment biopsy samples, posttreatment resection samples and the pre/post ratio showing statistically significant correlations with response to therapy. Also, the correlation between tumor size and immune markers in pretreatment biopsy samples, and the pre/post ratio for markers showing statistically significant correlations with CSS are shown. The p values are obtained via the Fisher's exact two-sided test Figure S1: Correlation between lymph node metastasis at diagnosis and the IL33 IC/TC ratio and the PD-L1 TC score (cut off: 1, 25 and 50%) in pretreatment biopsy samples. The p values are obtained via the Fisher's exact two-sided test. Figure S2: Correlation between the addition of concomitant chemotherapy (cCT) to the treatment schedule and the posttreatment score for CD3, CD4, CD8 and the CD4/CD20 ratio. The p values are obtained via the Fisher's exact two-sided test. Figure S3: Correlation between development of metastasis during follow-up and the ratio of pretreatment to posttreatment scores for CD3, CD8 and PD-L1 IC. The p-values are obtained via the Fisher's exact two-sided test. |
Please note: The publisher is not responsible for the content or functionality of any supporting information supplied by the authors. Any queries (other than missing content) should be directed to the corresponding author for the article.
References
- 1Stewart BW, Wild CP. World Cancer report 2014. Geneva, Switzerland: World Health Organization, International Agency for Research on Cancer, 2014. 630.
10.1201/b15152 Google Scholar
- 2Koh W-J, Abu-Rustum NR, Bean S, et al. Cervical Cancer, version 3.2019, NCCN clinical practice guidelines in oncology. J Natl Compr Canc Netw 2019; 17: 64–84.
- 3Koh W-J, Greer BE, Abu-rustum NR, et al. Cervical Cancer, version 2.2015, featured updates to the NCCN guidelines. J Natl Compr Canc Netw 2015; 13: 395–404.
- 4Pötter R, Haie-meder C, Van Limbergen E, et al. Recommendations from gynaecological (GYN) GEC ESTRO working group (II): concepts and terms in 3D image-based treatment planning in cervix cancer brachytherapy—3D dose volume parameters and aspects of 3D image-based anatomy, radiation physics, radiobiology. Radiother Oncol 2006; 78: 67–77.
- 5Tummers P, Makar A, Vandecasteele K, et al. Completion surgery after intensity-modulated arc therapy in the treatment of locally advanced cervical cancer: feasibility, surgical outcome, and oncologic results. Int J Gynecol Cancer 2013; 23: 877–83.
- 6Vandecasteele K, De Neve W, De Gersem W, et al. Intensity-modulated arc therapy with simultaneous integrated boost in the treatment of primary irresectable cervical cancer: treatment planning, quality control, and clinical implementation. Strahlenther Onkol 2009; 185: 799–807.
- 7Couvreur K, Naert E, De Jaeghere E, et al. Neo-adjuvant treatment of adenocarcinoma and squamous cell carcinoma of the cervix results in significantly different pathological complete response rates. BMC Cancer 2018; 18: 1101.
- 8Punt S, van Vliet ME, Spaans VM, et al. FoxP3(+) and IL-17(+) cells are correlated with improved prognosis in cervical adenocarcinoma. Cancer Immunol Immunother 2015; 64: 745–53.
- 9Punt S, Houwing-Duistermaat JJ, Schulkens IA, et al. Correlations between immune response and vascularization qRT-PCR gene expression clusters in squamous cervical cancer. Mol Cancer 2015; 14: 71.
- 10Nakano T, Oka K, Takahashi T, et al. Roles of langerhans' cells and T-lymphocytes infiltrating cancer tissues in patients treated by radiation therapy for cervical cancer. Cancer 1992; 70: 2839–44.
10.1002/1097-0142(19921215)70:12<2839::AID-CNCR2820701220>3.0.CO;2-7 CAS PubMed Web of Science® Google Scholar
- 11Carus A, Ladekarl M, Hager H, et al. Tumour-associated CD66b+ neutrophil count is an independent prognostic factor for recurrence in localised cervical cancer. Br J Cancer 2013; 108: 2116–22.
- 12Vadasz Z, Toubi E. FoxP3 expression in macrophages, Cancer, and B cells—is it real? Clin Rev Allergy Immunol 2017; 52: 364–72.
- 13Jordanova ES, Gorter A, Ayachi O, et al. Human leukocyte antigen class I, MHC class I chain-related molecule a, and CD8+/regulatory T-cell ratio: which variable determines survival of cervical cancer patients? Clin Cancer Res 2008; 14: 2028–35.
- 14Shah W, Yan X, Jing L, et al. A reversed CD4/CD8 ratio of tumor-infiltrating lymphocytes and a high percentage of CD4(+)FOXP3(+) regulatory T cells are significantly associated with clinical outcome in squamous cell carcinoma of the cervix. Cell Mol Immunol 2011; 8: 59–66.
- 15Ancuţa E, Ancuţa C, Zugun-Eloae F, et al. Predictive value of cellular immune response in cervical cancer. Rom J Morphol Embryol 2009; 50: 651–5.
- 16Fridman WH, Zitvogel L, Sautès–Fridman C, et al. The immune contexture in cancer prognosis and treatment. Nat Rev Clin Oncol 2017; 14: 717–34.
- 17de Vos van Steenwijk PJ, Ramwadhdoebe TH, Goedemans R, et al. Tumor-infiltrating CD14-positive myeloid cells and CD8-positive T-cells prolong survival in patients with cervical carcinoma. Int J Cancer 2013; 133: 2884–94.
- 18Maniecki MB, Møller HJ, Moestrup SK, et al. CD163 positive subsets of blood dendritic cells: the scavenging macrophage receptors CD163 and CD91 are coexpressed on human dendritic cells and monocytes. Immunobiology 2006; 211: 407–17.
- 19Liew FY, Girard JP, Turnquist HR. Interleukin-33 in health and disease. Nat Rev Immunol 2016; 16: 676–89.
- 20Gao X, Wang X, Yang Q, et al. Tumoral expression of IL-33 inhibits tumor growth and modifies the tumor microenvironment through CD8+ T and NK cells. J Immunol 2016; 194: 438–45.
- 21Tong X, Barbour M, Hou K, et al. Interleukin-33 predicts poor prognosis and promotes ovarian cancer cell growth and metastasis through regulating ERK and JNK signaling pathways. Mol Oncol 2016; 10: 113–25.
- 22Ishikawa K, Yagi-Nakanishi S, Nakanishi Y, et al. Expression of interleukin-33 is correlated with poor prognosis of patients with squamous cell carcinoma of the tongue. Auris Nasus Larynx 2014; 41: 552–7.
- 23Vandecasteele K, Makar A, Van Den Broecke R, et al. Intensity-modulated arc therapy with cisplatin as neo-adjuvant treatment for primary irresectable cervical cancer: toxicity, tumour response and outcome. Strahlenther Onkol 2012; 188: 576–81.
- 24Hamza A, Khan U, Khurram MS, et al. Prognostic utility of tumor-infiltrating lymphocytes in noncolorectal gastrointestinal malignancies. Int J Surg Pathol 2018; 27: 263–7.
- 25Rao UNM, Lee SJ, Luo W, et al. Presence of tumor-infiltrating lymphocytes and a dominant nodule within primary melanoma are prognostic factors for relapse-free survival of patients with thick (T4) primary melanoma pathologic analysis of the E1690 and E1694 intergroup trials. Am J Clin Pathol 2010; 133: 646–53.
- 26Weiss SA, Han SW, Lui K, et al. Immunologic heterogeneity of tumor infiltrating lymphocyte composition in primary melanoma. Hum Pathol 2016; 57: 116–25.
- 27Goode EL, Block MS, Kalli KR, et al. Dose-response association of CD8+ tumor-infiltrating lymphocytes and survival time in high-grade serous ovarian Cancer. JAMA Oncol 2017; 3: 1–9.
- 28Enwere EK, Kornaga EN, Dean M, et al. Expression of PD-L1 and presence of CD8-positive T cells in pre-treatment specimens of locally advanced cervical cancer. Mod Pathol 2017; 30: 577–86.
- 29Heeren AM, Punt S, Bleeker MC, et al. Prognostic effect of different PD-L1 expression patterns in squamous cell carcinoma and adenocarcinoma of the cervix. Mod Pathol 2016; 29: 753–63.
- 30Kim HS, Lee JY, Lim SH, et al. Association between PD-L1 and HPV status and the prognostic value of PD-L1 in oropharyngeal squamous cell carcinoma. Cancer Res Treat 2016; 48: 527–36.
- 31Ohri CM, Shikotra A, Green RH, et al. The tissue Microlocalisation and cellular expression of CD163, VEGF, HLA-DR, iNOS, and MRP 8/14 is correlated to clinical outcome in NSCLC. PLoS One 2011; 6: 1–9.
- 32Wang L, Li H, Liang F, et al. Examining IL-33 expression in the cervix of HPV-infected patients: a preliminary study comparing IL-33 levels in different stages of disease and analyzing its potential association with IFN-c. Med Oncol 2014; 31: 143.
- 33Mirchandani AS, Salmond RJ, Liew FY. Interleukin-33 and the function of innate lymphoid cells. Trends Immunol 2012; 33: 389–96.
- 34Specht E, Anne S, Polk D, et al. PD-L1 expression in breast cancer : expression in subtypes and prognostic significance : a systematic review. Breast Cancer Res Treat 2019; 174: 571–84.
- 35Karim R, Jordanova ES, Piersma SJ, et al. Tumor-expressed B7-H1 and B7-DC in relation to PD-1+ T-cell infiltration and survival of patients with cervical carcinoma. Clin Cancer Res 2009; 15: 6341–7.
- 36Gadiot J, Hooijkaas AI, Kaiser ADM, et al. Overall survival and PD-L1 expression in metastasized malignant melanoma. Cancer 2011; 117: 2192–201.
- 37Genard G, Lucas S, Michiels C. Reprogramming of tumor- associated macrophages with anticancer therapies: radiotherapy versus chemo- and immunotherapies. Front Immunol 2017; 8: 828.
- 38Talabot-ayer D, Calo N, Vigne S. The mouse interleukin (Il)33 gene is expressed in a cell type- and stimulus-dependent manner from two alternative promoters. J Leukoc Biol 2012; 91: 119–25.
- 39Goto W, Kashiwagi S, Asano Y, et al. Predictive value of improvement in the immune tumour microenvironment in patients with breast cancer treated with neoadjuvant chemotherapy. ESMO Open 2018; 3: 1–10.
- 40Chen TW, Chih K, Huang Y, et al. Prognostic relevance of programmed cell death-ligand 1 expression and CD8 + TILs in rectal cancer patients before and after neoadjuvant chemoradiotherapy. J Cancer Res Clin Oncol 2019; 145: 1043–53.
- 41Ladoire S, Arnould L, Apetoh L, et al. Pathologic complete response to Neoadjuvant chemotherapy of breast carcinoma is associated with the disappearance of T umor-infiltrating Foxp3 + regulatory T cells. Clin Cancer Res 2008; 3: 2413–21.
- 42Ladoire S, Coudert B, Martin F, et al. In situ immune response after neoadjuvant chemotherapy for breast cancer predicts survival. J Pathol 2011; 224: 389–400.
- 43Liang Y, Lü W, Zhang X, et al. Tumor-infiltrating CD8+ and FOXP3+ lymphocytes before and after neoadjuvant chemotherapy in cervical cancer. Diagn Pathol 2018; 13: 93.
- 44Qinfeng S, Depu W, Xiaofeng Y, et al. In situ observation of the effects of local irradiation on cytotoxic and regulatory T lymphocytes in cervical cancer tissue. Radiat Res 2013; 179: 584–9.
- 45Kroon P, Frijlink E, Iglesias-guimarais V, et al. Radiotherapy and cisplatin increase immunotherapy efficacy by enabling local and systemic intratumoral T-cell activity. Cancer Immunol Res 2019; 7: 670–82.
- 46Meng Y, Liang H, Hu J, et al. PD-L1 expression correlates with tumor infiltrating lymphocytes and response to Neoadjuvant chemotherapy in cervical Cancer. J Cancer 2018; 9: 2938–45.
- 47Babyak MA. What you see may not be what you get: a brief, nontechnical introduction to overfitting in regression-type models. Psychosom Med 2004; 66: 411–21.
- 48Nogueira Dias Genta ML, Martins TR, Mendoza Lopez RV, et al. Multiple HPV genotype infection impact on invasive cervical cancer presentation and survival. PLoS One 2017; 12: 1–10.
- 49Chen R, Gong Y, Zou D, et al. Correlation between subsets of tumor- infiltrating immune cells and risk stratification in patients with cervical cancer. PeerJ 2019; 7: 1–23.
- 50Näsman A, Romanitan M, Nordfors C, et al. Tumor infiltrating CD8 + and Foxp3 + lymphocytes correlate to clinical outcome and human papillomavirus (HPV) status in Tonsillar cancer. PLoS One 2012; 7: 1–8.
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