SFSPM Novembre Valeur prédictive et pronostique de l infiltrat immunitaire dans les cancers du sein traités par chimiothérapie néoadjuvante

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1 SFSPM Novembre 217 Valeur prédictive et pronostique de l infiltrat immunitaire dans les cancers du sein traités par chimiothérapie néoadjuvante Dr Fabien REYAL Service de Chirurgie INSERM U932 Immunity and Cancer Institut Curie

2 Tumor infiltration in the neoadjuvant setting Role of tumor-infiltrating lymphocytes (TILs) High levels of TILs at diagnosis : better response to NAC Better prognosis (triple negative breast cancers (TNBC) and HER2-positive BC) TILs following neoadjuvant chemotherapy (NAC)? Myashita Dieci Loi Hamy BC subtype TNBC TNBC TNBC HER2-pos Numbers n=131 n=278 n=111 n=175 Pairs pre & post n=78 n=19 n=39 n=175 Analysis in pcr patients No No No Yes 2

3 Tumor infiltration and response to treatment in breast cancer NEOREP cohort Institut Curie n=718 Microbiopsy BEFORE Neoadjuvant chemotherapy DURING Surgery AFTER TIL baseline TILs dynamics TIL residual Identify patterns of immune infiltration related to response to treatment and prognosis

4 Patients characteristics NEOREP cohort n=718 Mean age : 48 y.o TNBC 44% Luminal 31% HER2 24% Median tumor size: 45mm Anthra taxanes (8.4%) N=718 BMI class BMI<19 41 (5.7) BMI: 19 to (57.7) BMI: 25 to (23.2) BMI>3 96 (13.4) Tumor size 45. (2.5) Tumor size T1 47 (6.5) T2 482 (67.1) T3 189 (26.3) Clinical node status N 282 (39.3) N1-N2-N3 435 (6.7) BC subtype Luminal 223 (31.1) TNBC 32 (44.6) HER2 175 (24.4) Histology Ductal carcinoma NST 661 (92.6) Other 53 (7.4) Grade Grade I-II 211 (3.1) Grade III 491 (69.9) NAC regimen Anthracyclines based regimens 61 (8.5) Anthracyclines-taxanes regimens 577 (8.4) Others 8 (11.1)

5 Microbiopsy before NAC TIL=2% Microbiopsy before NAC TIL>6% 5

6 Surgical Specimen after NAC TIL=2% Surgical Specimen after NAC TIL>6%6

7 Lymphocyte PBC before neoadjuvant chemotherapy is a rare entity Lymphocyte predominant breast cancer Cut-off stromal TILs : 5 or 6% luminal TNBC HER BC subtype luminal TNBC HER Baseline TIL levels (%) Luminal 2% TN 18% HER2-positive 1%

8 Baseline TILs vary by BC subtype Baseline TILs are associated with agressive tumor characteristics A * B C * D * E * BC subtype 5 25 Clinical tumor size 5 25 Grade 5 25 Pre NAC mitotic index 5 25 Invasive tumor cellularity 5 25 luminal TNBC HER2 T1 T2 T3 Grade I II Grade III < >22 <=6% > 6%

9 Response to treatment

10 luminal TNBC HER2 luminal TNBC HER2 Baseline TIL levels* are associated with pcr Pre NAC str TILs (%) Pre NAC str TILs (%) c Post NAC str TILs (%) Pre NAC str TILs (%) d Post NAC str TILs (%) a b a b Pre NAC str TILs (%) ** pcr No pcr 6 6 pcr No pc Luminal and TNBC and NOT in HER2+ BC Significant interaction by BC subtype (p=.4) pcr No pcr

11 luminal TNBC HER2 luminal TNBC HER2 Baseline TIL levels* are associated with RCB a b c 6 6 a b Pre NAC str TILs (%) Pre NAC str TILs (%) Pre NAC str TILs (%) Pre NAC str TILs (%) pcr RCB I RCB II RCB III 4 4 c d In luminal and TNBC, NOT in HER2+ BC 6 11 pcr RCB I RCB II RCB III ) )

12 2 2nd tert 3rd tert % p 2 2 Baseline TILs levels are associated with pcr in luminal and TNBC not in HER2-positive BC luminal TNBC HER2 <6% =>6% % p luminal TNBC HER % =>5% B 1 t rt t t % pcr Str TILs (,1] (1,2] (2,3] (3,4] (4,5] (5,6] (6,7] (7,8] (8,9] luminal TNBC HER2 12

13 TILs dynamic

14 TILs levels decrease after neoadjuvant chemotherapy A Stromal TIL levels (%) Pre All Post B Luminal Pre Post C TNBC Pre Post D HER2 Pre Post

15 TILs dynamics is strongly correlated with baseline TILs levels TILs changes before and after NAC TILs changes before and after NAC, by baseline TILs (1% classes) 1 (,1] (1,2] (2,3] (3,4] (4,5] (5,6] (6,7] (7,8] (8,9] Baseline TIL levels (by 1% increment) 15

16 irrespective of response to treatment No pcr pcr TILs variation (abs. val.) 5 5 (,1] (1,2] (2,3] (3,4] (4,5] (5,6] (6,7] (7,8] (8,9] Baseline TILs 16

17 A high decrease in stromal TIL levels is associated with pcr 5 Change in str TIL levels (abs val) 5 pcr pcr No pcr

18 High baseline TILs and high decrease of lymphocytes after NAC are associated with pcr Median Ly density Change Ly density 1 75 cancer value stromal lymphocytes 18

19 Post-NAC stromal TILs

20 Lymphocyte-predominant breast Cancer is even rarer after NAC than before 1 luminal TNBC HER % cases 5 TILs levels (9,1] (8,9] (6,7] (5,6] (4,5] (3,4] (2,3] (1,2] (,1] TNBC luminal HER Post NAC TILs (%) Luminal 1% TN 4% HER2-positive 1%

21 Post-NAC TILs are higher in tumors with residual disease than in pcr specimens perc_stromal_lymphocyte2 Post NAC TILs (%) A perc_stromal_lymphocyte2 Post NAC TILs (%) luminal TNBC HER2 B pcr No pcr Post NAC TILs (%) C luminal TNBC HER2 pcr No pcr pcr No pcr pcr No pcr Post NAC TILs (%) D

22 luminal TNBC HER2 luminal TNBC HER2 Pre 2 Pre 2 Higher post-nac TIL levels are associated with increasing RCB only in HER2-positive BC pcr RCB I RCB II RCB III a b c c d Post NAC str TILs (%) Post NAC str TILs (%) luminal TNBC Post NAC str TILs (%) Post NAC str TILs (%) pcr RCB I RCB II RCB III NS HER2 4 2 (P interaction =.4) pcr RCB I RCB II RCB III

23 Impact on prognosis 23

24 E TNBC F E TNBC Luminal F E Luminal HER2 F. < 2% => 2% TILS (cut off: 2%) + < 2% + => 2% p = Time number at risk %) TILS + TILS (cut off: 3%) + < 3% < 2% p =.17 p = => => 3% 2% Time Time number at at risk risk < 3% < 2% => => 3% 2% %) TILS + (cut off: TILS (cut off: 3%) < 3% + < 2% p =.79p =.39 + => 3% + => 2% Time Time number number at risk at risk < 3% < 2% => 3% => 2% C TNBC D C TNBC Luminal D C Luminal HER2 D Disease free survival < 4% => 4% TILS (cut off: 4%) + < 4% + => 4% p = Time number at risk Disease free survival Disease free survival TILS TILS (cut off: 5%) 4%) + + < 5% < 4% + + => => 5% 4% p = 4e Time Time number at at risk risk p =.4 < 5% < 4% => => 5% 4% Disease free survival Disease free survival TILS (cut off: TILS (cut off: 5%) 4%) + < 5% + < 4% + => 5% + => 4% p =.23p = Time Time number number at risk at risk < 5% < 4% => 5% => 4%

25 Log relative Hazard < 2% Baseline stromal TIL levels are associated with DFS in TNBC => 2% number at risk < 3% => 3% n C TNBC D Disease free survival Disease free survival.5.25 TILS (cut off: 4%) + < 4% + => 4% p =.1.. Baseline str TILs Time number at risk n < 4% => 4% < 5% => 5%

26 HER2 luminal TNBC Log relative Hazard Baseline stromal TIL levels are associated with DFS in TNBC HER2 luminal B 1 Str TILs 1st quart 2nd quart 3rd quart 4th quart % pcr Baseline str TILs luminal TNBC 26

27 Post-NAC TILs are NOT associated with DFS, but this effect differs by BC subtype - Significant interaction with BC subtype - Effect of post-nac TILs on DFS different in TNBC / HER2-positive (P interaction =.4) - Effect linear : cut-off unknown? Adverse impact of high post-nac TILs in RD in HER2-positive BC, but trend to protective effect in TNBC 27

28 Take home messages Confirmation association pre-nac TILs pcr Dynamics : The highest baseline TILs are, the highest their level decrease High TILs decrease correlates with pcr Different prognostic value pre and post-nac = > Complex interactions BC subtype and TILs TILs subsetting is pivotal to understand mechanisms of resistance to treatment Assessment pre NAC & post NAC should become routine practice 28

29 U932 Immunity and Cancer Anne-sophie Hamy-Petit Hélène Bonsang Kitzis Department of tumour biology Marick Laé Lucian Topiu Diane Decroze 29

30 Univariate Multivariate name levels OR 95%CI pval OR 95%CI p Age <45 y.o y.o.97 [ ].877 >55 y.o 1.4 [ ].11 Menopausal status postmenopausal 1 premenopausal.8 [ ].193 BMI class BMI: 19 to 25 1 BMI<19.56 [ ].156 BMI: 25 to 3.76 [ ].186 BMI>3.9 [ ].69 Tumor size (2 cl) T1-T2 1 T3.8 [ ].245 Clinical nodal status N 1 N1-N2-N3.9 [ ].546 ER status ER negative 1 ER positive.2 [ ] <.1 PR status PR negative 1 PR positive.13 [ ] <.1 HER2 status HER2 negative 1 HER2 positive 1.94 [ ] <.1 BC subtype TNBC 1 1 luminal.8 [ ] <.1.9 [ ] <.1 HER2 1.2 [ ] [ ].958 Histology ductal 1 other.82 [ ].543 Grade Grade I-II 1 Grade III 2.71 [ ] <.1 ki67 ki67<2 1 ki67>= [ ].51 NAC regimen Anthracyclines based regimens 1 Anthracyclines-taxanes regimens.98 [ ].936 Others 1.32 [ ].456 Pre-NAC mitotic index 3 Mitotic index <= 1 1 Mitotic index [ ].187 Mitotic index > [ ].1 Pre-NAC tumor cellularity (inv.) <= Pre-NAC tumor cellularity 6% 1 Pre-NAC tumor cellularity (inv.) > 6%.94 [ ].733 IS component (pre NAC) No pre-nac in situ component 1 Pre-NAC in situ component.83 [ ].417 Str TIL levels (continuous) 1.3 [ ] < [ ] <.1 Multivariate analysis pcr Whole population Baseline TILs (continuous or cutoff 4%) BC subtype 3

31 TNBC Univariate Multiivariate TNBC Class HR CI p p HR CI p Pre-NAC parameters Age, years < [ ].93 >55.84 [ ].55 Menopause status Post 1.47 Pre 1.18 [ ].47 BMI class BMI < BMI>= [ ].26 Tumor size T1-T2 1 <.1 T [ ] <.1 Clinical node status N 1.15 N1-N2-N [ ].15 Histology Ductal carcinoma NST 1.44 Other 1.34 [ ].44 Grade Grade I-II 1.6 Grade III 1.19 [ ].6 Ki 67 <2% % 1.32 [ ].52 Pre-NAC mitotic index < [ ].27 > [ ].17 Pre-NAC inv. tumor cellularity 6% 1.19 > 6%.74 [ ].19 Pre-NAC str TILs (cut-off 4%) < 4% 1 < %.35 [ ] <.1.39 [ ].2 Post-NAC parameters pcr No pcr 1 <.1 pcr.22 [ ] <.1 RCB index pcr 1 <.1 RCB-I 1.39 [ ] RCB-II 3.52 [ ] < [ ].626 RCB-III [ ] < [ ].82 Post-NAC Str TILS (cut-off 25%) str TILs 25% str TILs > 25% Post-NAC Mitotic index 1 1 < [ ] [ ].27 Multivariate analysis DFS TNBC Baseline TILs RCB Post-NAC mitotic index > [ ] < [ ] <.1 Post-NAC inv. tumor cellularity 3% 1.7 > 3% 1.61 [ ].7 Post-NAC Str TILS (continuous).99 [ ].79

32 HER2 Univariate Multiivariate TNBC Class HR CI p p HR CI p Pre-NAC parameters Age, years < [ ].62 >55.42 [ ].27 Menopause status Post 1.38 Pre 1.58 [ ].38 BMI class BMI < 25 1 < BMI>= [ ] [ ].2 Tumor size T1-T T [ ].15 Clinical node status N 1.57 N1-N2-N [ ].57 ER status Negative 1.81 Positive 1.12 [ ].81 PR status Negative 1.74 Positive.84 [ ].74 Grade Grade I-II Grade III.32 [ ].2.18 [ ].2 Pre-NAC mitotic index < [ ].54 >22.56 [ ].36 Pre-NAC inv. tumor cellularity 6% 1.7 > 6%.83 [ ].7 Pre-NAC str TILs (continuous).61 Pre-NAC str TILs (cut-off 4%) < 4% 1.8 4% 1.14 [ ].8 Post-NAC parameters pcr No pcr 1 <.1 pcr.9 [.1 -.7].2 RCB index pcr 1 <.1 RCB-I 3.29 [ ].4 RCB-II 11.1 [ ].2 RCB-III [ ] <.1 Post-NAC Str TILS (cut-off 25%) str TILs 25% 1 < Multivariate analysis DFS HER2 Post-NAC TILs Grade BMI str TILs > 25% 5.5 [ ] < [ ].1 Post-NAC Mitotic index [ ].66 > [ ].1 Post-NAC inv. tumor cellularity 3% 1.13 > 3% 2.7 [ ].13 Post-NAC Str TILS (continuous) 1 <.1 32

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