Lymphocytes infiltrant la tumeur (TIL) sur micro-biopsies et pièces opératoires Quel impact clinique? Quels moyens de mise en évidence? Comment restituer les résultats? TILs - Clinical impact / Evaluation / Reporting and reproducibility Gábor CSERNI 1. Bács-Kiskun County Teaching Hospital, Kecskemét 2. University of Szeged, Szeged
Introduction Medullary carcinoma
Medullary carcinoma 1. A carcinoma (anywhere in the body, in the breast too) which is soft on palpation due to predominance of tumor parenchyma as opposed to scirrhous carcinomas, which is hard on palpation because of excess desmoplasia. 2. A medullary carcinoma (of the breast but later colon too) with lymphoid stroma (Geschickter CF 1945; Moore OS & Foote FW 1949 - cit Fisher ER et al, Cancer 1975)
Medullary carcinoma (Ridolfi) Predominantly syncytial growth pattern (>75%) Microscopically completely circumscribed No intraductal component Moderate to marked diffuse mononuclear stromal infiltrate (TILs) Nuclear grade: high or intermediate Absence of microglandular features (i.e. tubule / gland formation) + Squamous, cartilagenous, spindle cell metaplasia, papillary areas were acceptable Ridolfi R. et al. Cancer 1977
Atypical medullary carcinoma Predominantly syncytial growth pattern (>75%) +1 or 2 of the following: Areas of tumor margins show focal or prominent infiltration OR Intraductal carcinoma present or prominent OR Mild or negligible mononuclear infiltrate at margins only OR Nuclear grade: low OR Presence of microglandular features Ridolfi R. et al. Cancer 1977
10-y-survival (OS) Medullary 84% Atypical medullary 74% IDC 63% Treatment: radical mastectomy (99%) or mastectomy variants (1%); + radiotherapy (16%); NO adjuvant systemic therapy. Ridolfi R. et al. Cancer 1977
Medullary carcinoma (MC) (WHO 3rd edition criteria 2002) At least 75% of the cells syncytial Diffuse lymphoid (lymphoplasmocytic) stroma marked to moderate Complete circumscription No tubule or gland formation Marked nuclear pleomorphism (No DCIS original Ridolfi et al criteria also included this)
Medullary like carcinoma Carcinoma with medullary features AMC is not associated with the same favorable outcome than MC; MC is rare and should be diagnosed with caution. Reproducibility of MC is less than optimal: Medullary like carcinoma has been introduced in the UK guidelines for MC/AMC. Pathology reporting of breast disease. NHSBSP Publications No 58, January 2005 WHO has introduced the term carcinoma with medullary features for the same group. WHO 4th ed, 2012
Mononuclear infiltrate and survival Patients Type Pts Mononuclears 10-y-survival p MEDULLARY 21 2+ 71% 36 3+, 4+ 91% <0,03 * ATYPICAL MEDULLARY 42 1+, 2+ 66% 37 3+, 4+ 82% <0,07 (NS) NON-MEDULLARY 42 1+, 2+ 56% 14 3+, 4+ 86% <0,1 (NS) Assessed in a 4-tiered system (1+ to 4+), it was found to be associated with better prognosis. Ridolfi R. et al. Cancer 1977
TIL - definition Tumor Infiltrating Lymphocytes (TILs): Lymphocytes infiltarting the tumor independent of phenotype (WG recommends the inclusion of plasma cells too) Can be intratumoral (tumor parenchyma), stromal, peritumoral; most studies favour STROMAL lymphocytes. WG: International TILs Working Group
Intratumoral (It-TILs) Stromal (Str-TILs) Peritumoral
TILs (leukocytes vs lymphocytes) are responsible for the host vs tumor immunologic/inflammatory reactions Tumor infiltrating leukocytes in cancer Modified from Ann Oncol 2015; 26:261 Immunoediting theory: Elimination Equilibrium Escape
IMPORTANCE I. - Prognostic e.g. Ridolfi R et al. Cancer 1977. Medullary carcinoma without systemic treatment e.g. Loi S et al. JCO 2013;31:860-7.TNBC with similar (anthracyclin based) systemic treatment e.g. Adams S, et al. J Clin Oncol. 2014;2(27): 2959 66. In TNBC from two phase III randomized adjuvant breast cancer trials: ECOG 2197 and ECOG 1199. Wang K et al. Oncotarget 2016;7(28):44288-98. Meta-analysis
TILs are associated With other prognostic markers: ER status (negativity) Grade (3 & 2 vs 1) Wang K et al. Oncotarget 2016;7(28):44288-98. Medullary (like) histological type
IMPORTANCE II Predictive e.g. Denkert C, et al. J Clin Oncol. 2010; 28(1):105 13. Predictive of effectiveness of NACT in two neoadjuvant trials in all BC subtypes. (pcr also correlated with CD3+ or CD20+ or CXCR3+ cells.) e.g. Denkert C, et al. J Clin Oncol. 2015; 33(9): Predictive of effectiveness of NACT in HER2+ and TNBC e.g. Ali R, et al BCR 2016;18:21. Median lymphocyte density predictive pcr after NACT Wang K et al. Oncotarget 2016;7(28):44288-98. Meta-analysis
IMPORTANCE III post NACT E.g. Dieci MV, et al (incl F. Andre). Ann Oncol 2014;25:611-8. High TILs (>60%) in post- NACT TNBCs reflects better prognosis (27/278 pts) 91% 5-y-OS 55% 5-y-OS for low TILs E.g. Ali R, et al BCR 2016;18:21. Increase in TILs post-nact (in about 25% of the cases): predictors of less response to CT (less pcr) and worse outcome
pre-nact TILs vs post-nact TILs (Fig. 3) Dieci MV, et al. Ann Oncol 2014; 25:611-8. In all but one case, post NACT TILs were more abondant, suggesting that the increase was due to chemotherapy, partially acting through a TIL mediated immune response.
Kaplan-Meier curves (Fig. 2) post-nact TILs MetFS OS Dieci MV, et al. Ann Oncol 2014;25:611-8.
Decreased Ly-density associated with higher pcr rates Ali R, et al BCR 2016;18:21.
Evaluation: heterogeneous Semiquantitative: absent/mild/moderate vs severe in the NSABP-B4 trial Fisher ER et al. Cancer 1975 1+ to 4+ Ridolfi et al. Cancer 1977 International TILs WG: continuous variable (1%, 5% and steps of 10%) (stromal) Salgado R et al. Ann Oncol 2015 Computational: Ali R, et al. BCR 2016;18:21.
Digitized slides (Neo-tAnGo trial; n=765) Fig 1. Ali R, et al BCR 2016;18:21 3 cell types: - Cancer cells - Stromal cells - Lymphocytes 5 parameter each: - Absolute number - Relative number (fraction) - Density (min) - Density (max) - Density (median) highly associated with pcr Overall 98/614 (16%) pcr rate; 1st decile of TIL density 3/61 (4,9%) pcr and last decile 22/62 (35,5%)
TIL WG recommendations 1 Assess STROMAL lymphocytes (+plasma cells;), i.e.: TILs as an average proportion of the stromal area occupied by them within the invasive tumor (not hot spots). Exclude TILs (also tertiary lymphoid structures) outside the tumor borders (invasive edge included), around CIS, normal breast parenchyma, crush artifacts, necrosis, hyaline regression and core biopsy site. Salgado R et al. Ann Oncol 2015
TIL WG recommendations 2 One HE section (full section preferable to CNB) per tumour seems enough no IHC Estimate 1% and the rest with 5-10% precision as continuous variable Lymphocyte predominant breast cancer - more TILs than tumor cells ; but defined with at least 50% or 60% stromal TILs No obvious recommendations for post treatment TIL counting Salgado R et al. Ann Oncol 2015
TIL WG recommendations, but with <10%, 10-50%, >50% (LPBC) categories adjuvant Hida AI, et al BCRT 2016
Reproducibility Swan or Elephant?
Lymphoid infiltrate grading Absent/slight/moderate vs severe: large areas of infiltrate as in medullary carcinoma 90% intraobserver agreement 85% interobserver agreement (n=2) 1 HE slide / 75 CNB, 4 pathologists, 3 categories for stats (<10%, 10-50%, >50%) ICC: 0,62 acceptable agreement; kappa: 0,57 moderate agreement Swisher SK, et al. Ann Surg Oncol 2016 Fisher ER, et al. Cancer 1975
Interobserver agreement 1 HE digital slide / 60 CNB, 32 pathologists, ICC: 0,70 kappa (>50% vs 50%): 0,51 1 HE digital slide / 60 CNB, 28 pathologists, minimum 3x1 mm2 area evaluated + software with visual feedback ICC: 0,89 kappa (>50% vs 50%): 0,72 Denkert C, et al. Mod Pathol 2016; Jul 1 E-pub
Practical advice (publication evidence) Intratumoral TILs correlate with stromal TILs (stils). IHC identified subsets (CD3+, CD20+, CD4+, CD8+, FOXP3+) [meta-anal: only CD8+ subset] correlate with pcr, therefore with HE evaluation stil should be ennumerated according to the TIL WG recommendations: as a continous (steps of 10%) or categorical (low:<10%; LPBC:>50%) variable TIL enumeration is not part of the standard pathology report suggested use: as biomarker in clinical trials and research LPBC (a descriptive term) could be used in reports
Fig. 4. Salgado R et al. Ann Oncol 2015
Pas de liens d intérêts Angel Ferrant: Majesty 1951 Reina Sofia (Madrid)
FIG2 12 mrna markers (both immune activating and suppressing) correlated with each other 3 immune groups with different TIL and pcr rates Denkert C et al. JCO 2015 GeparSixto study