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Karancsi Z, Gregus B, Krenács T, Cserni G, Nagy Á, Szőcs-Trinfa KF, Kulka J, Tőkés AM. Digital Whole Slide Image Analysis of Elevated Stromal Content and Extracellular Matrix Protein Expression Predicts Adverse Prognosis in Triple-Negative Breast Cancer. Int J Mol Sci 2024; 25:9445. [PMID: 39273393 PMCID: PMC11394775 DOI: 10.3390/ijms25179445] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2024] [Revised: 08/27/2024] [Accepted: 08/28/2024] [Indexed: 09/15/2024] Open
Abstract
Triple-negative breast cancer (TNBC) is a subtype of breast cancer with a poor prognosis and limited treatment options. This study evaluates the prognostic value of stromal markers in TNBC, focusing on the tumor-stroma ratio (TSR) and overall stroma ratio (OSR) in whole slide images (WSI), as well as the expression of type-I collagen, type-III collagen, and fibrillin-1 on tissue microarrays (TMAs), using both visual assessment and digital image analysis (DIA). A total of 101 female TNBC patients, primarily treated with surgery between 2005 and 2016, were included. We found that high visual OSR correlates with worse overall survival (OS), advanced pN categories, lower stromal tumor-infiltrating lymphocyte count (sTIL), lower mitotic index, and patient age (p < 0.05). TSR showed significant connections to the pN category and mitotic index (p < 0.01). High expression levels of type-I collagen (>45%), type-III collagen (>30%), and fibrillin-1 (>20%) were linked to significantly worse OS (p = 0.004, p = 0.013, and p = 0.005, respectively) and progression-free survival (PFS) (p = 0.028, p = 0.025, and p = 0.002, respectively), validated at the mRNA level. Our results highlight the importance of stromal characteristics in promoting tumor progression and metastasis and that targeting extracellular matrix (ECM) components may offer novel therapeutic strategies. Furthermore, DIA can be more accurate and objective in evaluating TSR, OSR, and immunodetected stromal markers than traditional visual examination.
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Affiliation(s)
- Zsófia Karancsi
- Department of Pathology Forensic and Insurance Medicine, Semmelweis University, 1091 Budapest, Hungary
| | - Barbara Gregus
- Department of Pathology Forensic and Insurance Medicine, Semmelweis University, 1091 Budapest, Hungary
| | - Tibor Krenács
- Department of Pathology and Experimental Cancer Research, Semmelweis University, 1085 Budapest, Hungary
| | - Gábor Cserni
- Department of Pathology, Albert Szent-Györgyi Faculty of Medicine, University of Szeged, 6725 Szeged, Hungary
- Department of Pathology, Bács-Kiskun County Teaching Hospital, 6000 Kecskemét, Hungary
| | - Ágnes Nagy
- Department of Pathology and Experimental Cancer Research, Semmelweis University, 1085 Budapest, Hungary
| | | | - Janina Kulka
- Department of Pathology Forensic and Insurance Medicine, Semmelweis University, 1091 Budapest, Hungary
| | - Anna Mária Tőkés
- Department of Pathology Forensic and Insurance Medicine, Semmelweis University, 1091 Budapest, Hungary
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Madabhushi A, Azarianpour-Esfahani S, Khalighi S, Aggarwal A, Viswanathan V, Fu P, Avril S. Computational Image and Molecular Analysis Reveal Unique Prognostic Features of Immune Architecture in African Versus European American Women with Endometrial Cancer. RESEARCH SQUARE 2023:rs.3.rs-3622429. [PMID: 38234757 PMCID: PMC10793492 DOI: 10.21203/rs.3.rs-3622429/v1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/19/2024]
Abstract
Endometrial cancer (EC) disproportionately affects African American (AA) women in terms of progression and death. In our study, we sought to employ computerized image and bioinformatic analysis to tease out morphologic and molecular differences in EC between AA and European-American (EA) populations. We identified the differences in immune cell spatial patterns between AA and EA populations with markers of tumor biology, including histologic and molecular subtypes. The models performed best when they were trained and validated using data from the same population. Unsupervised clustering revealed a distinct association between immune cell features and known molecular subtypes of endometrial cancer that varied between AA and EA populations. Our genomic analysis revealed two distinct and novel gene sets with mutations associated with improved prognosis in AA and EA patients. Our study findings suggest the need for population-specific risk prediction models for women with endometrial cancer.
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Larre A, Fernandes RC, Gerbasi GJ, Carvalho FM. Tumor-Infiltrating Lymphocytes and Tumor-Stroma Ratio on Early-Stage Cervix Carcinoma: Prognostic Value of Two Distinct Morphological Patterns of Microenvironment. Cureus 2023; 15:e45148. [PMID: 37842421 PMCID: PMC10571070 DOI: 10.7759/cureus.45148] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/12/2023] [Indexed: 10/17/2023] Open
Abstract
Background Tumor progression is influenced by the complex network of different cellular elements that make up its microenvironment. Tumor-infiltrating lymphocytes (TILs) and stroma characteristics reflect two faces of the intricate mechanisms involved in the tumor-host interaction and can be easily evaluated by routine histological examination. Their prognostic value could be demonstrated in different tumor tumor types, but they are poorly explored in cervical cancer. Methodology In this retrospective study, we analyzed the association of TILs, tumor-stroma ratio (TSR), and pattern of stromal fibroblasts with prognosis and classical clinicopathological variables. We studied 61 patients with early-stage cervical cancer. We reviewed histological type, tumor grade, Silva pattern of invasion for adenocarcinomas, tumor thickness, depth of stromal invasion, lymph vascular space invasion, and lymph node status. The median follow-up was 37.77 months (range 4.77 to 112.37 months). Results The TSR did not correlate with any clinicopathological features or disease-free and overall survival. On the other hand, the reactive pattern of stroma composed of larger fibroblasts and less collagenization was associated with the FIGO IB2 stage (p=0.04), larger tumor (p=0.03), and deeper infiltration (p=0.005). There were more recurrences in the group of reactive stroma (33.13% vs. 11.5%), although the difference did not reach statistical significance. Reactive stroma was associated with lower survival free of recurrence (p=0.05) and overall survival (p=0.009). High TILs were associated with squamous cell type (p=0.003), higher tumor grade (p=0.02), and more LVSI (p=0.02). Tumors with higher TILs presented higher free recurrence interval (p=0.06) and overall survival (p=0.03). No association was observed between stroma characteristics and TILs. Conclusions Our study suggested that although immune activation and stromal changes are important features of microenvironment remodeling during tumoral progression, they are independent, following distinct carcinogenetic pathways. Pathological assessment of stroma characteristics and TILs adds significant prognostic information and demonstrates how a simple routine laboratory assessment can generate a better understanding of biological phenomena.
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Affiliation(s)
- Ailma Larre
- Pathology, Faculdade de Medicina da Universidade de Sao Paulo, Hospital Beneficiencia Portuguesa, Sao Paulo, BRA
| | | | - Giovana J Gerbasi
- Obstetrics and Gynecology, Instituto Brasileiro de Controle do Cancer, Hospital Israelita Albert Einstein, Sao Paulo, BRA
| | - Filomena M Carvalho
- Pathology, Faculdade de Medicina da Universidade de Sao Paulo, Sao Paulo, BRA
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Pyo JS, Kim NY, Min KW, Kang DW. Significance of Tumor-Stroma Ratio (TSR) in Predicting Outcomes of Malignant Tumors. MEDICINA (KAUNAS, LITHUANIA) 2023; 59:1258. [PMID: 37512068 PMCID: PMC10384099 DOI: 10.3390/medicina59071258] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/04/2023] [Revised: 06/17/2023] [Accepted: 06/27/2023] [Indexed: 07/30/2023]
Abstract
Background and Objectives: The present study aimed to elucidate the distribution and the prognostic implications of tumor-stroma ratio (TSR) in various malignant tumors through a meta-analysis. Materials and Methods: This meta-analysis included 51 eligible studies with information for overall survival (OS) or disease-free survival (DFS), according to TSR. In addition, subgroup analysis was performed based on criteria for high TSR. Results: The estimated rate of high TSR was 0.605 (95% confidence interval (CI) 0.565-0.644) in overall malignant tumors. The rates of high TSR ranged from 0.276 to 0.865. The highest rate of high TSR was found in endometrial cancer (0.865, 95% CI 0.827-0.895). The estimated high TSR rates of colorectal, esophageal, and stomach cancers were 0.622, 0.529, and 0.448, respectively. In overall cases, patients with high TSR had better OS and DFS than those with low TSR (hazard ratio (HR) 0.631, 95% CI 0.542-0.734, and HR 0.564, 95% CI 0.0.476-0.669, respectively). Significant correlations with OS were found in the breast, cervical, colorectal, esophagus, head and neck, ovary, stomach, and urinary tract cancers. In addition, there were significant correlations of DFS in breast, cervical, colorectal, esophageal, larynx, lung, and stomach cancers. In endometrial cancers, high TSR was significantly correlated with worse OS and DFS. Conclusions: The rate of high TSR was different in various malignant tumors. TSR can be useful for predicting prognosis through a routine microscopic examination of malignant tumors.
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Affiliation(s)
- Jung-Soo Pyo
- Department of Pathology, Uijeongbu Eulji University Hospital, Eulji University School of Medicine, Uijeongbu-si 11759, Republic of Korea
| | - Nae Yu Kim
- Department of Internal Medicine, Uijeongbu Eulji Medical Center, Eulji University School of Medicine, Uijeongbu-si 11759, Republic of Korea
| | - Kyueng-Whan Min
- Department of Pathology, Uijeongbu Eulji University Hospital, Eulji University School of Medicine, Uijeongbu-si 11759, Republic of Korea
| | - Dong-Wook Kang
- Department of Pathology, Chungnam National University Sejong Hospital, 20 Bodeum 7-ro, Sejong 30099, Republic of Korea
- Department of Pathology, Chungnam National University School of Medicine, 266 Munhwa Street, Daejeon 35015, Republic of Korea
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Karancsi Z, Hagenaars SC, Németh K, Mesker WE, Tőkés AM, Kulka J. Tumour-stroma ratio (TSR) in breast cancer: comparison of scoring core biopsies versus resection specimens. Virchows Arch 2023:10.1007/s00428-023-03555-0. [PMID: 37198327 DOI: 10.1007/s00428-023-03555-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2022] [Revised: 03/29/2023] [Accepted: 04/27/2023] [Indexed: 05/19/2023]
Abstract
PURPOSE Tumour-stroma ratio (TSR) is an important prognostic and predictive factor in several tumour types. The aim of this study is to determine whether TSR evaluated in breast cancer core biopsies is representative of the whole tumour. METHOD Different TSR scoring methods, their reproducibility, and the association of TSR with clinicopathological characteristics were investigated in 178 breast carcinoma core biopsies and corresponding resection specimens. TSR was assessed by two trained scientists on the most representative H&E-stained digitised slides. Patients were treated primarily with surgery between 2010 and 2021 at Semmelweis University, Budapest. RESULTS Ninety-one percent of the tumours were hormone receptor (HR)-positive (luminal-like). Interobserver agreement was highest using 100 × magnification (κcore = 0.906, κresection specimen = 0.882). The agreement between TSR of core biopsies and resection specimens of the same patients was moderate (κ = 0.514). Differences between the two types of samples were most frequent in cases with TSR scores close to the 50% cut-off point. TSR was strongly correlated with age at diagnosis, pT category, histological type, histological grade, and surrogate molecular subtype. A tendency was identified for more recurrences among stroma-high (SH) tumours (p = 0.07). Significant correlation was detected between the TSR and tumour recurrence in grade 1 HR-positive breast cancer cases (p = 0.03). CONCLUSIONS TSR is easy to determine and reproducible on both core biopsies and in resection specimens and is associated with several clinicopathological characteristics of breast cancer. TSR scored on core biopsies is moderately representative for the whole tumour.
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Affiliation(s)
- Zsófia Karancsi
- Department of Pathology, Forensic and Insurance Medicine, Semmelweis University, Üllői út 93, 1091, Budapest, Hungary.
| | - Sophie C Hagenaars
- Department of Surgery, Leiden University Medical Centre, Albinusdreef 2, 2333 ZA, Leiden, The Netherlands
| | - Kristóf Németh
- Department of Pathology, Forensic and Insurance Medicine, Semmelweis University, Üllői út 93, 1091, Budapest, Hungary
| | - Wilma E Mesker
- Department of Surgery, Leiden University Medical Centre, Albinusdreef 2, 2333 ZA, Leiden, The Netherlands
| | - Anna Mária Tőkés
- Department of Pathology, Forensic and Insurance Medicine, Semmelweis University, Üllői út 93, 1091, Budapest, Hungary
| | - Janina Kulka
- Department of Pathology, Forensic and Insurance Medicine, Semmelweis University, Üllői út 93, 1091, Budapest, Hungary
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Xu L, Zhong W, Li C, Hong P, Xia K, Lin R, Cheng S, Wang B, Yang M, Chen J, Ma L, Li X, Zhou L, Huang J, Lin T. The tumour-associated stroma correlates with poor clinical outcomes and immunoevasive contexture in patients with upper tract urothelial carcinoma: results from a multicenter real-world study (TSU-01 Study). Br J Cancer 2023; 128:310-320. [PMID: 36396819 PMCID: PMC9902452 DOI: 10.1038/s41416-022-02049-1] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2022] [Revised: 09/23/2022] [Accepted: 10/27/2022] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND In this real-world study, we aimed to elucidate the predictive value of tumour-associated stroma for clinical prognostic and therapeutic response in upper tract urothelial carcinoma (UTUC) by reviewing the clinicopathologic characteristics of 1015 UTUC patients through a nationwide multicenter analysis. METHODS The tumour-stroma ratio (TSR) was assessed based on tissue sections stained for hematoxylin and eosin (H&E), and patients were further stratified into stroma-high (>50% stroma) and stroma-low group (≤50% stroma). Kaplan-Meier curve and Cox regression hazard analysis were conducted to assess the survival outcomes of UTUC patients. Bioinformatics analysis and immunostaining analysis were applied to portray the tumour microenvironment (TME). RESULTS Stroma-high UTUC was significantly associated with poorer survival outcomes and inferior chemotherapeutic responsiveness. Our established nomogram achieved a high prognostic accuracy in predicting overall survival and cancer-specific survival in both of the discovery cohort (area under the curve [AUC] 0.663 and 0.712) and the validation cohort (AUC 0.741 and 0.747). Moreover, stroma-high UTUC was correlated with immunoevasive TME accompanied by increased cancer-associated fibroblasts, tumour-associated macrophages and, conspicuously a cluster of highly exhausted CD8+ T cells. CONCLUSION Our results showed stroma-high UTUC was associated with an inferior prognosis and an immunoevasive TME with exhausted CD8+ T cells in UTUC patients. Our TSR-based nomogram could be used to refine prognosis and inform treatment decisions of patients with UTUC.
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Affiliation(s)
- Longhao Xu
- Department of Urology, Sun Yat-sen Memorial Hospital; Guangdong Provincial Key Laboratory of Malignant Tumor Epigenetics and Gene Regulation; Guangdong Provincial Clinical Research Center for Urological Diseases, Sun Yat-sen (Zhongshan) University, Guangzhou, P. R. China
| | - Wenlong Zhong
- Department of Urology, Sun Yat-sen Memorial Hospital; Guangdong Provincial Key Laboratory of Malignant Tumor Epigenetics and Gene Regulation; Guangdong Provincial Clinical Research Center for Urological Diseases, Sun Yat-sen (Zhongshan) University, Guangzhou, P. R. China
| | - Chenchen Li
- Department of Medical Oncology, The Sixth Affiliated Hospital, Sun Yat-sen University, Guangzhou, P. R. China
| | - Peng Hong
- Department of Urology, Peking University Third Hospital, Beijing, P. R. China
| | - Kun Xia
- Department of Urology, Sun Yat-sen Memorial Hospital; Guangdong Provincial Key Laboratory of Malignant Tumor Epigenetics and Gene Regulation; Guangdong Provincial Clinical Research Center for Urological Diseases, Sun Yat-sen (Zhongshan) University, Guangzhou, P. R. China
- Department of Urology, Jiangxi provincial People's Hospital Affiliated to Nanchang University, Nanchang, P. R. China
| | - Rongcheng Lin
- Department of Urology, Fujian Provincial Hospital, Fuzhou, P. R. China
| | - Sida Cheng
- Department of Urology, Peking University First Hospital, Beijing, P. R. China
| | - Bo Wang
- Department of Urology, Sun Yat-sen Memorial Hospital; Guangdong Provincial Key Laboratory of Malignant Tumor Epigenetics and Gene Regulation; Guangdong Provincial Clinical Research Center for Urological Diseases, Sun Yat-sen (Zhongshan) University, Guangzhou, P. R. China
| | - Meng Yang
- Department of Urology, Yan'an Hospital Affiliated with Kunming Medical University, Kunming, P. R. China
| | - Junyu Chen
- Department of Urology, Sun Yat-sen Memorial Hospital; Guangdong Provincial Key Laboratory of Malignant Tumor Epigenetics and Gene Regulation; Guangdong Provincial Clinical Research Center for Urological Diseases, Sun Yat-sen (Zhongshan) University, Guangzhou, P. R. China
| | - Lulin Ma
- Department of Urology, Peking University Third Hospital, Beijing, P. R. China
| | - Xuesong Li
- Department of Urology, Peking University First Hospital, Beijing, P. R. China.
| | - Liqun Zhou
- Department of Urology, Peking University First Hospital, Beijing, P. R. China.
| | - Jian Huang
- Department of Urology, Sun Yat-sen Memorial Hospital; Guangdong Provincial Key Laboratory of Malignant Tumor Epigenetics and Gene Regulation; Guangdong Provincial Clinical Research Center for Urological Diseases, Sun Yat-sen (Zhongshan) University, Guangzhou, P. R. China.
| | - Tianxin Lin
- Department of Urology, Sun Yat-sen Memorial Hospital; Guangdong Provincial Key Laboratory of Malignant Tumor Epigenetics and Gene Regulation; Guangdong Provincial Clinical Research Center for Urological Diseases, Sun Yat-sen (Zhongshan) University, Guangzhou, P. R. China.
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Diederiks N, Ravensbergen CJ, Treep M, van Wezel M, Kuruc M, Renee Ruhaak L, Tollenaar RA, Cobbaert CM, van der Burgt YE, Mesker WE. Development of Tier 2 LC-MRM-MS protein quantification methods for liquid biopsies. J Mass Spectrom Adv Clin Lab 2022; 27:49-55. [PMID: 36619217 PMCID: PMC9811211 DOI: 10.1016/j.jmsacl.2022.12.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2022] [Revised: 12/13/2022] [Accepted: 12/15/2022] [Indexed: 12/24/2022] Open
Abstract
In the pursuit of personalized diagnostics and tailored treatments, quantitative protein tests contribute to a more precise definition of health and disease. The development of new quantitative protein tests should be driven by an unmet clinical need and performed in a collaborative effort that involves all stakeholders. With regard to the analytical part, mass spectrometry (MS)-based platforms are an excellent tool for quantification of specific proteins in body fluids, for example focused on cancer. The obtained readouts have great potential in determining tumor aggressiveness to facilitate treatment decisions, and can furthermore be used to monitor patient response. Internationally standardized TNM classifications of malignant tumors are beneficial for diagnosis, however treatment outcome and survival of cancer patients is poorly predicted. To this end, the importance of the tumor microenvironment has endorsed the introduction of the tumor-stroma ratio as a prognostic parameter in solid primary tumor types. Currently, the stromal content of tumor tissues is determined via routine diagnostic pathology slides. With the development of liquid chromatography (LC)-MS methods we aim at quantification of tumor-stroma specific proteins in body fluids. In this mini-review the analytical aspect of this developmental trajectory is further detailed.
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Affiliation(s)
- Nina Diederiks
- Department of Clinical Chemistry and Laboratory Medicine, Leiden University Medical Center, Albinusdreef 2, 2333 ZA Leiden, the Netherlands
| | - Cor J. Ravensbergen
- Department of Surgery, Leiden University Medical Center, Albinusdreef 2, 2333 ZA Leiden, the Netherlands
| | - Maxim Treep
- Department of Clinical Chemistry and Laboratory Medicine, Leiden University Medical Center, Albinusdreef 2, 2333 ZA Leiden, the Netherlands
| | - Madelein van Wezel
- Department of Clinical Chemistry and Laboratory Medicine, Leiden University Medical Center, Albinusdreef 2, 2333 ZA Leiden, the Netherlands
| | - Matt Kuruc
- Biotech Support Group LLC, 1 Deer Park Drive, Suite M, Monmouth Junction, NJ 08852, USA
| | - L. Renee Ruhaak
- Department of Clinical Chemistry and Laboratory Medicine, Leiden University Medical Center, Albinusdreef 2, 2333 ZA Leiden, the Netherlands
| | - Rob A.E.M. Tollenaar
- Department of Surgery, Leiden University Medical Center, Albinusdreef 2, 2333 ZA Leiden, the Netherlands
| | - Christa M. Cobbaert
- Department of Clinical Chemistry and Laboratory Medicine, Leiden University Medical Center, Albinusdreef 2, 2333 ZA Leiden, the Netherlands
| | - Yuri E.M. van der Burgt
- Department of Clinical Chemistry and Laboratory Medicine, Leiden University Medical Center, Albinusdreef 2, 2333 ZA Leiden, the Netherlands,Corresponding author.
| | - Wilma E. Mesker
- Department of Surgery, Leiden University Medical Center, Albinusdreef 2, 2333 ZA Leiden, the Netherlands
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Feng Y, Ma F, Wu E, Cheng Z, Wang Z, Yang L, Zhang J. Ginsenosides: Allies of gastrointestinal tumor immunotherapy. Front Pharmacol 2022; 13:922029. [PMID: 36386161 PMCID: PMC9659574 DOI: 10.3389/fphar.2022.922029] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2022] [Accepted: 09/26/2022] [Indexed: 09/25/2023] Open
Abstract
In the past decade, immunotherapy has been the most promising treatment for gastrointestinal tumors. But the low response rate and drug resistance remain major concerns. It is therefore imperative to develop adjuvant therapies to increase the effectiveness of immunotherapy and prevent drug resistance. Ginseng has been used in Traditional Chinese medicine as a natural immune booster for thousands of years. The active components of ginseng, ginsenosides, have played an essential role in tumor treatment for decades and are candidates for anti-tumor adjuvant therapy. They are hypothesized to cooperate with immunotherapy drugs to improve the curative effect and reduce tumor resistance and adverse reactions. This review summarizes the research into the use of ginsenosides in immunotherapy of gastrointestinal tumors and discusses potential future applications.
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Affiliation(s)
| | | | | | | | | | | | - Jiwei Zhang
- Shanghai Key Laboratory of Compound Chinese Medicines, The MOE Key Laboratory for Standardization of Chinese Medicines, Institute of Chinese Materia Medica, Shanghai University of Traditional Chinese Medicine, Shanghai, China
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The PDGF Family Is Associated with Activated Tumor Stroma and Poor Prognosis in Ovarian Cancer. DISEASE MARKERS 2022; 2022:5940049. [PMID: 36199822 PMCID: PMC9529473 DOI: 10.1155/2022/5940049] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/31/2022] [Accepted: 08/01/2022] [Indexed: 12/04/2022]
Abstract
The initiation and progression of cancer depend on the genetic alterations inherent in cancer cells, coupled with the mutual interplay of cancer cells with the surrounding tumor stroma. The platelet-derived growth factor (PDGF) family, as a mesenchymal growth factor, was involved in tumor progression by affecting the surrounding tumor stroma in some cancer types. However, the association of the PDGF family with the ovarian cancer stroma remains elusive. In our study, we first explored the expression pattern of the PDGF family using RNA expression profiles from public databases. We found that the PDGF family was highly expressed in tumor stroma compared with the corresponding epithelial components of ovarian cancer. In particular, PDGF receptors were weakly expressed in ovarian cancer tissues compared with the respective normal tissues; even in tumor mass, PDGF receptors were predominantly expressed by tumor stroma rather than ovarian cancer cells. Importantly, functional enrichment analyses and correlation analyses revealed that the PDGF family was strongly associated with activated stromal scores in ovarian cancer, including higher stromal scores, enriched pathways related to the extracellular matrix (ECM) organization and remodeling, elevated cancer-associated fibroblasts (CAFs) infiltration, and increased tumor-associated macrophages (TAMs) infiltration, especially macrophage M2. Besides, the positive correlations of the PDGF family with CAFs infiltration and macrophage M2 infiltration were observed in other various cancer types. Of note, the PDGF family was also involved in tumor progression-related pathways, such as transforming growth factor β (TGF-β) signaling, epithelial-mesenchymal transition (EMT), angiogenesis, and phosphatidylinositol 3-kinase-Akt (PI3K-Akt) signaling. Higher expressions of PDGF receptors were also observed in ovarian cancer patients with venous or lymphatic invasion. Furthermore, we uncovered the prognostic prediction of the PDGF family in ovarian cancer and constructed a PDGF family-based risk prognosis model with a hazard ratio of 1.932 (95%confidence interval (CI) = 1.27–2.95) and P value < 0.01 (AUC = 0.782, 0.752 for 1 year and 2 years, respectively). Taken together, we demonstrated that ovarian cancers with high PDGF family expression biologically exhibit malignant progression behaviors as well as poor clinical survival, which is attributed to the activated tumor stroma in ovarian cancer.
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Chen C, Cao Y, Li W, Liu Z, Liu P, Tian X, Sun C, Wang W, Gao H, Kang S, Wang S, Jiang J, Chen C, Tian J. The pathological risk score: A new deep learning-based signature for predicting survival in cervical cancer. Cancer Med 2022; 12:1051-1063. [PMID: 35762423 PMCID: PMC9883425 DOI: 10.1002/cam4.4953] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2021] [Revised: 05/26/2022] [Accepted: 06/06/2022] [Indexed: 02/06/2023] Open
Abstract
PURPOSE To develop and validate a deep learning-based pathological risk score (RS) with an aim of predicting patients' prognosis to investigate the potential association between the information within the whole slide image (WSI) and cervical cancer prognosis. METHODS A total of 251 patients with the International Federation of Gynecology and Obstetrics (FIGO) Stage IA1-IIA2 cervical cancer who underwent surgery without any preoperative treatment were enrolled in this study. Both the clinical characteristics and WSI of each patient were collected. To construct a prognosis-associate RS, high-dimensional pathological features were extracted using a convolutional neural network with an autoencoder. With the score threshold selected by X-tile, Kaplan-Meier survival analysis was applied to verify the prediction performance of RS in overall survival (OS) and disease-free survival (DFS) in both the training and testing datasets, as well as different clinical subgroups. RESULTS For the OS and DFS prediction in the testing cohort, RS showed a Harrell's concordance index of higher than 0.700, while the areas under the curve (AUC) achieved up to 0.800 in the same cohort. Furthermore, Kaplan-Meier survival analysis demonstrated that RS was a potential prognostic factor, even in different datasets or subgroups. It could further distinguish the survival differences after clinicopathological risk stratification. CONCLUSION In the present study, we developed an effective signature in cervical cancer for prognosis prediction and patients' stratification in OS and DFS.
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Affiliation(s)
- Chi Chen
- Beijing Advanced Innovation Center for Big Data‐Based Precision Medicine, School of Medicine and EngineeringBeihang UniversityBeijingChina,CAS Key Laboratory of Molecular Imaging, Beijing Key Laboratory of Molecular Imaging, the State Key Laboratory of Management and Control for Complex SystemsInstitute of Automation, Chinese Academy of SciencesBeijingChina
| | - Yuye Cao
- Department of Obstetrics and GynecologyNanfang Hospital, Southern Medical UniversityGuangzhouChina
| | - Weili Li
- Department of Obstetrics and GynecologyNanfang Hospital, Southern Medical UniversityGuangzhouChina
| | - Zhenyu Liu
- CAS Key Laboratory of Molecular Imaging, Beijing Key Laboratory of Molecular Imaging, the State Key Laboratory of Management and Control for Complex SystemsInstitute of Automation, Chinese Academy of SciencesBeijingChina,School of Artificial IntelligenceUniversity of Chinese Academy of SciencesBeijingChina
| | - Ping Liu
- Department of Obstetrics and GynecologyNanfang Hospital, Southern Medical UniversityGuangzhouChina
| | - Xin Tian
- Department of Obstetrics and GynecologyNanfang Hospital, Southern Medical UniversityGuangzhouChina
| | - Caixia Sun
- Beijing Advanced Innovation Center for Big Data‐Based Precision Medicine, School of Medicine and EngineeringBeihang UniversityBeijingChina,CAS Key Laboratory of Molecular Imaging, Beijing Key Laboratory of Molecular Imaging, the State Key Laboratory of Management and Control for Complex SystemsInstitute of Automation, Chinese Academy of SciencesBeijingChina
| | - Wuliang Wang
- Department of Obstetrics and GynecologyThe Second Affiliated Hospital of He' nan Medical UniversityZhengzhouChina
| | - Han Gao
- Beijing Advanced Innovation Center for Big Data‐Based Precision Medicine, School of Medicine and EngineeringBeihang UniversityBeijingChina,CAS Key Laboratory of Molecular Imaging, Beijing Key Laboratory of Molecular Imaging, the State Key Laboratory of Management and Control for Complex SystemsInstitute of Automation, Chinese Academy of SciencesBeijingChina
| | - Shan Kang
- Department of GynecologyFourth Hospital Hebei Medical UniversityShijiazhuangChina
| | - Shaoguang Wang
- Department of GynecologyYantai Yuhuangding HospitalYantaiChina
| | - Jingying Jiang
- Beijing Advanced Innovation Center for Big Data‐Based Precision Medicine, School of Medicine and EngineeringBeihang UniversityBeijingChina,Key Laboratory of Big Data‐Based Precision Medicine (Beihang University)Ministry of Industry and Information TechnologyBeijingChina
| | - Chunlin Chen
- Department of Obstetrics and GynecologyNanfang Hospital, Southern Medical UniversityGuangzhouChina
| | - Jie Tian
- Beijing Advanced Innovation Center for Big Data‐Based Precision Medicine, School of Medicine and EngineeringBeihang UniversityBeijingChina,CAS Key Laboratory of Molecular Imaging, Beijing Key Laboratory of Molecular Imaging, the State Key Laboratory of Management and Control for Complex SystemsInstitute of Automation, Chinese Academy of SciencesBeijingChina
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11
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Ma M, Sun J, Liu Z, Ouyang S, Zhang Z, Zeng Z, Li J, Kang W. The Immune Microenvironment in Gastric Cancer: Prognostic Prediction. Front Oncol 2022; 12:836389. [PMID: 35574386 PMCID: PMC9096124 DOI: 10.3389/fonc.2022.836389] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2021] [Accepted: 03/25/2022] [Indexed: 11/13/2022] Open
Abstract
Although therapeutic methods have been developed, gastric cancer (GC) still leads to high rates of mortality and morbidity and is the fourth leading cause of cancer-associated death and the fifth most common cancer worldwide. To understand the factors associated with the prognostic prediction of GC and to discover efficient therapeutic targets, previous studies on tumour pathogenesis have mainly focused on the cancer cells themselves; in recent years, a large number of studies have shown that cancer invasion and metastasis are the results of coevolution between cancer cells and the microenvironment. It seems that studies on the tumour microenvironment could help in prognostic prediction and identify potential targets for treating GC. In this review, we mainly introduce the research progress for prognostic prediction and the immune microenvironment in GC in recent years, focusing on cancer-associated fibroblasts (CAFs), tumour-associated macrophages (TAMs), and tumour-infiltrating lymphocytes (TILs) in GC, and discuss the possibility of new therapeutic targets for GC.
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Affiliation(s)
- Mingwei Ma
- Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China.,Department of General Surgery, Peking Union Medical College Hospital, Beijing, China
| | - Juan Sun
- Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China.,Department of General Surgery, Peking Union Medical College Hospital, Beijing, China
| | - Zhen Liu
- Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China.,Department of General Surgery, Peking Union Medical College Hospital, Beijing, China
| | - Siwen Ouyang
- Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China.,Department of General Surgery, Peking Union Medical College Hospital, Beijing, China
| | - Zimu Zhang
- Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China.,Department of General Surgery, Peking Union Medical College Hospital, Beijing, China
| | - Ziyang Zeng
- Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China.,Department of General Surgery, Peking Union Medical College Hospital, Beijing, China
| | - Jie Li
- Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China.,Department of General Surgery, Peking Union Medical College Hospital, Beijing, China
| | - Weiming Kang
- Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China.,Department of General Surgery, Peking Union Medical College Hospital, Beijing, China
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12
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Standardization of the tumor-stroma ratio scoring method for breast cancer research. Breast Cancer Res Treat 2022; 193:545-553. [PMID: 35429321 PMCID: PMC9114083 DOI: 10.1007/s10549-022-06587-3] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2022] [Accepted: 03/27/2022] [Indexed: 11/28/2022]
Abstract
Purpose The tumor-stroma ratio (TSR) has repeatedly proven to be correlated with patient outcomes in breast cancer using large retrospective cohorts. However, studies validating the TSR often show variability in methodology, thereby hampering comparisons and uniform outcomes. Method This paper provides a detailed description of a simple and uniform TSR scoring method using Hematoxylin and Eosin (H&E)-stained core biopsies and resection tissue, specifically focused on breast cancer. Possible histological challenges that can be encountered during scoring including suggestions to overcome them are reported. Moreover, the procedure for TSR estimation in lymph nodes, scoring on digital images and the automatic assessment of the TSR using artificial intelligence are described. Conclusion Digitized scoring of tumor biopsies and resection material offers interesting future perspectives to determine patient prognosis and response to therapy. The fact that the TSR method is relatively easy, quick, and cheap, offers great potential for its implementation in routine diagnostics, but this requires high quality validation studies.
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13
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Stromal scoring in advanced colon and rectal cancer: Stroma-rich tumors and their association with aggressive phenotypes. ARCHIVE OF ONCOLOGY 2022. [DOI: 10.2298/aoo210403003s] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
Background: Our aim was to explore relevance of the proportion between neoplastic cell component and tumor-associated stroma in order to assess its association with confirmed aggressive phenotypes of right/left colon and rectum cancers in a large series of patients. Methods: The quantification of stroma component was performed in patients diagnosed with colorectal adenocarcinoma who underwent surgical resection. The analyzed variables were age, gender, anatomical/pathological features, and tumor-stroma proportion. Tumor-stroma proportion was estimated based on slides used in routine pathology for determination of T status and was described as low, with a stromal percentage ?50% or high, with a stromal percentage >50%. The tumor-stroma proportion was estimated by two observers, and the inter-observer agreement was assessed. Results: The sample included 390 colorectal adenocarcinoma patients. Stroma-rich tumors were observed in 53.3% of cases. Well-differentiated tumors had the lowest stromal proportions (p = 0.028). Stroma-poor tumors showed less depth of invasion (p<0.001). High stromal content was observed in association with tumor budding, perineural, angiolymphatic, and lymph node involvement, and distant metastasis (p?0.001). Colorectal adenocarcinoma without lymph node or distant metastasis involvement had lower stromal proportion, while metastatic ones exhibited high stromal content (p <0.001). The inter-rater reliability (concordance) between the estimations of pathologists for tumor-stroma proportions was high (?=0.746). Conclusion: The tumorstroma proportion in colorectal adenocarcinoma was associated with adverse prognostic factors, reflecting the stage of the disease. Stroma-rich tumors showed a significant correlation with advancement of the disease and its aggressiveness. Due to its availability tumor-stroma proportion evaluation has high application potential and can complement current staging system for colorectal adenocarcinoma.
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14
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Goyal S, Banga P, Meena N, Chauhan G, Sakhuja P, Agarwal AK. Prognostic significance of tumour budding, tumour-stroma ratio and desmoplastic stromal reaction in gall bladder carcinoma. J Clin Pathol 2021; 76:308-314. [PMID: 34853164 DOI: 10.1136/jclinpath-2021-207957] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2021] [Accepted: 11/03/2021] [Indexed: 11/04/2022]
Abstract
AIMS AND METHODS The prognostic role of tumour budding (TBd) and its interaction with the stromal microenvironment has gained a lot of attention recently, but remains unexplored in gall bladder cancer (GBC). We aimed to study the interrelationship of TBd by International Tumour Budding Consensus Conference scoring system, tumour-stroma ratio (TSR) and desmoplastic stromal reaction (DSR) with the conventional clinicopathological prognostic factors, mortality and overall survival (OS) in 96 patients of operated GBC. RESULTS Higher age, high TNM stage, lymphovascular and perineural invasion, positive resection margins, higher TBd score, low TSR and immature DSR were significantly associated with worse OS. However, on multivariate analysis, only metastases, positive resection margins and TSR <50% proved to be independent prognostic factors. The TBd score of stroma-rich tumour group (6.40±4.69) was significantly higher than that of stroma-poor group (2.77±3.79, p≤0.001). The TBd score of immature and intermediate DSR groups was significantly higher than that of mature group (p≤0.001 and p=0.002, respectively). There was a strong interobserver agreement for TBd score, TSR and type of DSR (Cohen's Kappa=0.726 to 0.864, p≤0.001). Stroma-rich tumours were significantly associated with immature DSR and fibrotic DSR with high TSR (p≤0.001). CONCLUSION A high TBd, low TSR and immature DSR were significantly associated with several high-risk clinicopathological parameters and poor OS in GBC. These novel, simple, reproducible and cost-effective parameters may be included in the routine reporting checklist for GBC as additional prognostic parameters that can substratify the high-risk patients.
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Affiliation(s)
- Surbhi Goyal
- Pathology, Govind Ballabh Pant Institute of Postgraduate Medical Education and Research, New Delhi, Delhi, India
| | - Priyanka Banga
- Pathology, Govind Ballabh Pant Institute of Postgraduate Medical Education and Research, New Delhi, Delhi, India
| | - Nisha Meena
- Pathology, Govind Ballabh Pant Institute of Postgraduate Medical Education and Research, New Delhi, Delhi, India
| | - Geeta Chauhan
- Pathology, Govind Ballabh Pant Institute of Postgraduate Medical Education and Research, New Delhi, Delhi, India
| | - Puja Sakhuja
- Pathology, Govind Ballabh Pant Institute of Postgraduate Medical Education and Research, New Delhi, Delhi, India
| | - Anil Kumar Agarwal
- Gastrointestinal Surgery, Govind Ballabh Pant Institute of Postgraduate Medical Education and Research, New Delhi, Delhi, India
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15
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Nastały P, Smentoch J, Popęda M, Martini E, Maiuri P, Żaczek AJ, Sowa M, Matuszewski M, Szade J, Kalinowski L, Niemira M, Brandt B, Eltze E, Semjonow A, Bednarz-Knoll N. Low Tumor-to-Stroma Ratio Reflects Protective Role of Stroma against Prostate Cancer Progression. J Pers Med 2021; 11:1088. [PMID: 34834440 PMCID: PMC8622253 DOI: 10.3390/jpm11111088] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2021] [Revised: 10/21/2021] [Accepted: 10/23/2021] [Indexed: 12/09/2022] Open
Abstract
Tumor-to-stroma ratio (TSR) is a prognostic factor that expresses the relative amounts of tumor and intratumoral stroma. In this study, its clinical and molecular relevance was evaluated in prostate cancer (PCa). The feasibility of automated quantification was tested in digital scans of tissue microarrays containing 128 primary tumors from 72 PCa patients stained immunohistochemically for epithelial cell adhesion molecule (EpCAM), followed by validation in a cohort of 310 primary tumors from 209 PCa patients. In order to investigate the gene expression differences between tumors with low and high TSR, we applied multigene expression analysis (nCounter® PanCancer Progression Panel, NanoString) of 42 tissue samples. TSR scores were categorized into low (<1 TSR) and high (≥1 TSR). In the pilot cohort, 31 patients (43.1%) were categorized as low and 41 (56.9%) as high TSR score, whereas 48 (23.0%) patients from the validation cohort were classified as low TSR and 161 (77.0%) as high. In both cohorts, high TSR appeared to indicate the shorter time to biochemical recurrence in PCa patients (Log-rank test, p = 0.04 and p = 0.01 for the pilot and validation cohort, respectively). Additionally, in the multivariate analysis of the validation cohort, TSR predicted BR independent of other factors, i.e., pT, pN, and age (p = 0.04, HR 2.75, 95%CI 1.07-7.03). Our data revealed that tumors categorized into low and high TSR score show differential expression of various genes; the genes upregulated in tumors with low TSR score were mostly associated with extracellular matrix and cell adhesion regulation. Taken together, this study shows that high stroma content can play a protective role in PCa. Automatic EpCAM-based quantification of TSR might improve prognostication in personalized medicine for PCa.
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Affiliation(s)
- Paulina Nastały
- Laboratory of Translational Oncology, Medical University of Gdańsk, 80-210 Gdańsk, Poland; (P.N.); (J.S.); (M.P.); (A.J.Ż.)
- FIRC (Italian Foundation for Cancer Research), Institute of Molecular Oncology (IFOM), 20139 Milan, Italy; (E.M.); (P.M.)
| | - Julia Smentoch
- Laboratory of Translational Oncology, Medical University of Gdańsk, 80-210 Gdańsk, Poland; (P.N.); (J.S.); (M.P.); (A.J.Ż.)
| | - Marta Popęda
- Laboratory of Translational Oncology, Medical University of Gdańsk, 80-210 Gdańsk, Poland; (P.N.); (J.S.); (M.P.); (A.J.Ż.)
| | - Emanuele Martini
- FIRC (Italian Foundation for Cancer Research), Institute of Molecular Oncology (IFOM), 20139 Milan, Italy; (E.M.); (P.M.)
| | - Paolo Maiuri
- FIRC (Italian Foundation for Cancer Research), Institute of Molecular Oncology (IFOM), 20139 Milan, Italy; (E.M.); (P.M.)
| | - Anna J. Żaczek
- Laboratory of Translational Oncology, Medical University of Gdańsk, 80-210 Gdańsk, Poland; (P.N.); (J.S.); (M.P.); (A.J.Ż.)
| | - Marek Sowa
- Department of Urology, Medical University of Gdańsk, 80-214 Gdańsk, Poland; (M.S.); (M.M.)
| | - Marcin Matuszewski
- Department of Urology, Medical University of Gdańsk, 80-214 Gdańsk, Poland; (M.S.); (M.M.)
| | - Jolanta Szade
- Department of Pathomorphology, Medical University of Gdańsk, 80-214 Gdańsk, Poland;
| | - Leszek Kalinowski
- Department of Medical Laboratory Diagnostics-Biobank, Medical University of Gdańsk, 80-210 Gdańsk, Poland;
- Biobanking and Biomolecular Resources Research Infrastructure (BBMRI.pl), 80-214 Gdańsk, Poland
| | - Magdalena Niemira
- Clinical Research Centre, Medical University of Bialystok, 15-276 Bialystok, Poland;
| | - Burkhard Brandt
- Institute of Clinical Chemistry, University Medical Centre Schleswig-Holstein, 24105 Kiel, Germany;
| | - Elke Eltze
- Institute of Pathology Saarbruecken-Rastpfuhl, 66113 Saarbruecken, Germany;
| | - Axel Semjonow
- Department of Urology, Prostate Center, University Clinic Münster, 48149 Münster, Germany;
| | - Natalia Bednarz-Knoll
- Laboratory of Translational Oncology, Medical University of Gdańsk, 80-210 Gdańsk, Poland; (P.N.); (J.S.); (M.P.); (A.J.Ż.)
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16
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Miller S, Bauer S, Schrempf M, Schenkirsch G, Probst A, Märkl B, Martin B. Semiautomatic analysis of tumor proportion in colon cancer: Lessons from a validation study. Pathol Res Pract 2021; 227:153634. [PMID: 34628263 DOI: 10.1016/j.prp.2021.153634] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/09/2021] [Revised: 09/23/2021] [Accepted: 09/24/2021] [Indexed: 11/15/2022]
Abstract
The tumor stroma ratio (TSR) is a promising histopathologic prognostic biomarker, which could allow for more accurate risk stratification and improved patient management in colorectal cancer. The purpose of our research was to validate the results of a previous study, which had suggested that not only a low but also a high tumor proportion (TP) might be an independent risk factor for occurrence of distant metastasis and worse overall survival using a semiautomatic image analysis approach with the open-source software ImageJ. We investigated 253 pT3 and pT4 adenocarcinomas of no special type. The previously established thresholds (PES-cut-offs) used to classify the patients (previous 3-tiered-classification) according to the tumor proportion (TP) in a highTP (TP ≥ 54%), a mediumTP (TP < 54% ∩ TP >15%) and a lowTP (TP ≤ 15%) group did not show a significant risk stratification. Even the adjustment of these threshold revealed no significant results. Therefore, a receiver-operating characteristic (ROC) analysis was performed to establish the cut-off with the most significant predictive power and a "new 2-tiered-classification" using this cut-off (40% at MinTP) showed a significantly shorter absence of metastasis for patients with a low TP (p = 0.007). These results confirm that a low TP is associated with an adverse prognosis. This study did not confirm the previous assumption that a high TP might also be a risk factor for occurrence of metastasis. Furthermore, it demonstrates that this semiautomatic technique is not superior to the established method, so that approaches to enhance prognostic techniques should continue.
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Affiliation(s)
- Silvia Miller
- General Pathology and Molecular Diagnostics, Medical Faculty Augsburg, University Augsburg, Germany
| | - Svenja Bauer
- General Pathology and Molecular Diagnostics, Medical Faculty Augsburg, University Augsburg, Germany
| | - Matthias Schrempf
- Department of Visceral Surgery, University Hospital Augsburg, Augsburg, Germany
| | | | - Andreas Probst
- Medicine III - Gastroenterology, Medical Faculty Augsburg, University Augsburg, Germany
| | - Bruno Märkl
- General Pathology and Molecular Diagnostics, Medical Faculty Augsburg, University Augsburg, Germany.
| | - Benedikt Martin
- General Pathology and Molecular Diagnostics, Medical Faculty Augsburg, University Augsburg, Germany
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17
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Hong Y, Heo YJ, Kim B, Lee D, Ahn S, Ha SY, Sohn I, Kim KM. Deep learning-based virtual cytokeratin staining of gastric carcinomas to measure tumor-stroma ratio. Sci Rep 2021; 11:19255. [PMID: 34584193 PMCID: PMC8478925 DOI: 10.1038/s41598-021-98857-1] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2021] [Accepted: 09/01/2021] [Indexed: 12/27/2022] Open
Abstract
The tumor-stroma ratio (TSR) determined by pathologists is subject to intra- and inter-observer variability. We aimed to develop a computational quantification method of TSR using deep learning-based virtual cytokeratin staining algorithms. Patients with 373 advanced (stage III [n = 171] and IV [n = 202]) gastric cancers were analyzed for TSR. Moderate agreement was observed, with a kappa value of 0.623, between deep learning metrics (dTSR) and visual measurement by pathologists (vTSR) and the area under the curve of receiver operating characteristic of 0.907. Moreover, dTSR was significantly associated with the overall survival of the patients (P = 0.0024). In conclusion, we developed a virtual cytokeratin staining and deep learning-based TSR measurement, which may aid in the diagnosis of TSR in gastric cancer.
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Affiliation(s)
- Yiyu Hong
- Department of R&D Center, Arontier Co., Ltd, Seoul, Republic of Korea
| | - You Jeong Heo
- The Samsung Advanced Institute for Health Sciences & Technology (SAIHST), Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Binnari Kim
- Department of Pathology and Translational Genomics, Samsung Medical Center, Sungkyunkwan University School of Medicine, #81, Irwon-ro, Gangnam-Gu, Seoul, 06351, Korea
- Center of Companion Diagnostics, Samsung Medical Center, Seoul, Republic of Korea
- Department of Pathology, Ulsan University Hospital, University of Ulsan College of Medicine, Ulsan, Republic of Korea
| | - Donghwan Lee
- Department of R&D Center, Arontier Co., Ltd, Seoul, Republic of Korea
| | - Soomin Ahn
- Department of Pathology and Translational Genomics, Samsung Medical Center, Sungkyunkwan University School of Medicine, #81, Irwon-ro, Gangnam-Gu, Seoul, 06351, Korea
| | - Sang Yun Ha
- Department of Pathology and Translational Genomics, Samsung Medical Center, Sungkyunkwan University School of Medicine, #81, Irwon-ro, Gangnam-Gu, Seoul, 06351, Korea
| | - Insuk Sohn
- Department of R&D Center, Arontier Co., Ltd, Seoul, Republic of Korea
| | - Kyoung-Mee Kim
- The Samsung Advanced Institute for Health Sciences & Technology (SAIHST), Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea.
- Department of Pathology and Translational Genomics, Samsung Medical Center, Sungkyunkwan University School of Medicine, #81, Irwon-ro, Gangnam-Gu, Seoul, 06351, Korea.
- Center of Companion Diagnostics, Samsung Medical Center, Seoul, Republic of Korea.
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18
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19
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The prognostic impact of the tumour stroma fraction: A machine learning-based analysis in 16 human solid tumour types. EBioMedicine 2021; 65:103269. [PMID: 33706249 PMCID: PMC7960932 DOI: 10.1016/j.ebiom.2021.103269] [Citation(s) in RCA: 31] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2020] [Revised: 02/04/2021] [Accepted: 02/18/2021] [Indexed: 02/08/2023] Open
Abstract
Background The development of a reactive tumour stroma is a hallmark of tumour progression and pronounced tumour stroma is generally considered to be associated with clinical aggressiveness. The variability between tumour types regarding stroma fraction, and its prognosis associations, have not been systematically analysed. Methods Using an objective machine-learning method we quantified the tumour stroma in 16 solid cancer types from 2732 patients, representing retrospective tissue collections of surgically resected primary tumours. Image analysis performed tissue segmentation into stromal and epithelial compartment based on pan-cytokeratin staining and autofluorescence patterns. Findings The stroma fraction was highly variable within and across the tumour types, with kidney cancer showing the lowest and pancreato-biliary type periampullary cancer showing the highest stroma proportion (median 19% and 73% respectively). Adjusted Cox regression models revealed both positive (pancreato-biliary type periampullary cancer and oestrogen negative breast cancer, HR(95%CI)=0.56(0.34-0.92) and HR(95%CI)=0.41(0.17-0.98) respectively) and negative (intestinal type periampullary cancer, HR(95%CI)=3.59(1.49-8.62)) associations of the tumour stroma fraction with survival. Interpretation Our study provides an objective quantification of the tumour stroma fraction across major types of solid cancer. Findings strongly argue against the commonly promoted view of a general associations between high stroma abundance and poor prognosis. The results also suggest that full exploitation of the prognostic potential of tumour stroma requires analyses that go beyond determination of stroma abundance. Funding The Swedish Cancer Society, The Lions Cancer Foundation Uppsala, The Swedish Government Grant for Clinical Research, The Mrs Berta Kamprad Foundation, Sweden, Sellanders foundation, P.O.Zetterling Foundation, and The Sjöberg Foundation, Sweden.
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20
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Souza da Silva RM, Queiroga EM, Paz AR, Neves FFP, Cunha KS, Dias EP. Standardized Assessment of the Tumor-Stroma Ratio in Colorectal Cancer: Interobserver Validation and Reproducibility of a Potential Prognostic Factor. CLINICAL PATHOLOGY (THOUSAND OAKS, VENTURA COUNTY, CALIF.) 2021; 14:2632010X21989686. [PMID: 33634262 PMCID: PMC7887673 DOI: 10.1177/2632010x21989686] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/13/2020] [Accepted: 12/29/2020] [Indexed: 12/24/2022]
Abstract
The tumor stroma plays a relevant role in the initiation and evolution of solid tumors. Tumor-stroma ratio (TSR) is a histological feature that expresses the proportion of the stromal component that surrounds cancer cells. In different studies, the TSR represents a potential prognostic factor: a rich stroma in tumor tissue can promote invasion and aggressiveness. The aim of this study was to evaluate the reproducibility and determine the interobserver agreement in the TSR score. The stromal estimate was evaluated in patients diagnosed with colorectal adenocarcinoma (CRA), who underwent surgical resection. We also evaluated age, gender, and other anatomopathological features. Tumor-stroma ratio was calculated based on the slide used in routine diagnostic pathology to determine the T-status. Stromal percentages were separated into 2 categories: ⩽50%-low stroma and >50%-high stroma. The interobserver agreement in the TSR scoring was evaluated among 4 pathologists at different stages of professional experience, using 2 different ways to learn the scoring system. In total, 98 patients were included in this study; 54.1% were male, with a mean age of 61.9 years. Localized disease was diagnosed in 60.2% of patients. Stromal-poor CRA was predominant. The concordance between the TSR percentages of the 4 pathologists was substantial (Kappa > 0.6). There was greater agreement among pathologists for stromal-poor tumors. Substantial agreement and high reproducibility were observed in the determination of TSR score. The TSR score is feasible, suggesting that the presented methodology can be used to facilitate the determination of the stromal proportion of potential prognostic factor.
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Affiliation(s)
- Ricella M Souza da Silva
- Postgraduation Program in Pathology, School of Medicine, Fluminense Federal University, Niterói, Rio de Janeiro,Brazil
- Pathological Anatomy Service, Lauro Wanderley University Hospital of Federal University of Paraíba, João Pessoa, Paraíba, Brazil
| | - Eduardo M Queiroga
- Laboratory of Pathological Anatomy, Alcides Carneiro University Hospital of the Federal University of Campina Grande, Campina Grande, Paraíba, Brazil
| | - Alexandre R Paz
- Pathological Anatomy Service, Lauro Wanderley University Hospital of Federal University of Paraíba, João Pessoa, Paraíba, Brazil
| | - Fabiana F P Neves
- Anatomopathological Diagnosis Center, Pathology Laboratory, João Pessoa, Paraíba, Brazil
| | - Karin S Cunha
- Postgraduation Program in Pathology, School of Medicine, Fluminense Federal University, Niterói, Rio de Janeiro,Brazil
| | - Eliane P Dias
- Postgraduation Program in Pathology, School of Medicine, Fluminense Federal University, Niterói, Rio de Janeiro,Brazil
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21
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Huang J, Yang B, Tan J, Zhou S, Chen Z, Zhong G, Gao H, Zhu J, Zeng J, Zhong L, Liu X, Han F. Gastric cancer nodal tumour-stroma ratios influence prognosis. THE BRITISH JOURNAL OF SURGERY 2020; 107:1713-1718. [PMID: 33090456 PMCID: PMC7702113 DOI: 10.1002/bjs.12054] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/23/2020] [Revised: 07/06/2020] [Accepted: 08/18/2020] [Indexed: 11/05/2022]
Abstract
This study showed that nodal tumour-stroma ratio (NTSR) is an independent prognostic factor for overall and disease-free survival of patients with gastric cancer. Both relative stroma-rich primary tumour-stroma ratio (PTSR) and NTSR were independent negative prognostic factors for overall survival in gastric cancer. This study supports assessment of tumour-stroma ratio in the routine pathological diagnosis of gastric cancer. validated in node-positive disease.
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Affiliation(s)
- J Huang
- Department of Gastrointestinal Surgery, Sun Yat-sen Memorial Hospital, Sun Yat-sen University, Guangzhou, China
| | - B Yang
- Department of Gastrointestinal Surgery, Sun Yat-sen Memorial Hospital, Sun Yat-sen University, Guangzhou, China
| | - J Tan
- Department of Gastrointestinal Surgery, Sun Yat-sen Memorial Hospital, Sun Yat-sen University, Guangzhou, China
| | - S Zhou
- Department of Gastrointestinal Surgery, Sun Yat-sen Memorial Hospital, Sun Yat-sen University, Guangzhou, China
| | - Z Chen
- Department of Gastrointestinal Surgery, Sun Yat-sen Memorial Hospital, Sun Yat-sen University, Guangzhou, China
| | - G Zhong
- Department of Gastrointestinal Surgery, Sun Yat-sen Memorial Hospital, Sun Yat-sen University, Guangzhou, China
| | - H Gao
- Department of Gastrointestinal Surgery, Sun Yat-sen Memorial Hospital, Sun Yat-sen University, Guangzhou, China
| | - J Zhu
- Department of Gastrointestinal Surgery, Sun Yat-sen Memorial Hospital, Sun Yat-sen University, Guangzhou, China
| | - J Zeng
- Department of Gastrointestinal Surgery, Sun Yat-sen Memorial Hospital, Sun Yat-sen University, Guangzhou, China
| | - L Zhong
- Department of Gastrointestinal Surgery, Sun Yat-sen Memorial Hospital, Sun Yat-sen University, Guangzhou, China
| | - X Liu
- Zhu Jiang Hospital of Southern Medical University, Southern Medical University, Guangzhou, China
| | - F Han
- Department of Gastrointestinal Surgery, Sun Yat-sen Memorial Hospital, Sun Yat-sen University, Guangzhou, China
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22
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Rani P, Gupta AJ, Mehrol C, Singh M, Khurana N, Passey JC. Clinicopathological correlation of tumor-stroma ratio and inflammatory cell infiltrate with tumor grade and lymph node metastasis in squamous cell carcinoma of buccal mucosa and tongue in 41 cases with review of literature. J Cancer Res Ther 2020; 16:445-451. [PMID: 32719249 DOI: 10.4103/0973-1482.193113] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
Introduction Several studies regarding tumor-stroma ratio (TSR) in colorectal, esophageal, breast, endometrial, and cervical carcinomas have been done in the past with significant results. Objectives The objectives of this study were to (1) study and grade TSR in buccal mucosa and tongue squamous cell carcinoma (SCC), (2) grade inflammatory cell infiltrate surrounding the tumor, and (3) correlate the above two parameters with tumor grade, lymph node metastasis, lymphovascular invasion (LVI), and perineural invasion (PNI). Materials and Methods Totally, 25 patients of buccal SCC and 16 cases of tongue SCC were included in the study. TSR was assessed visually on the hematoxylin and eosin-stained tissue sections by two independent observers. Cases were categorized into two groups: One with high TSR >50% (stroma poor) and the other with low TSR <50% as the stroma-rich group. TSR was correlated with tumor size, lymph node metastasis, inflammatory cell infiltrate, LVI, and PNI. Data were analyzed by the Statistical Package for the Social Sciences version 16.0 (Chicago, IL, USA) for Windows. The Chi-square and Fischer's exact tests were applied in the analysis of categorical variable. Results and Conclusion SCC of buccal mucosa showed a significant correlation between TSR and size of the tumor (P = 0.001). We found that smaller the tumor size ≤2 cm (Stage T1), lesser the TSR, and size >2 cm was found to be associated with higher TSR. Hence, higher TSR (stroma poor) was associated with an adverse pathological characteristic, i.e., advanced T significantly. There was no significant correlation between TSR and inflammatory infiltrate with grade of the tumor, lymph node metastasis, LVI, and PNI. In 16 cases of SCC of the tongue; no correlation was observed between TSR and inflammatory infiltrate with tumor size, grade of the tumor, lymph node metastasis, LVI, and PNI. TSR has been studied in various malignancies (mostly adenocarcinomas) including laryngeal SCCs; however, it has never been studied on oral SCCs.
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Affiliation(s)
- Poonam Rani
- Department of Pathology, Maulana Azad Medical College, New Delhi, India
| | - Amita Jain Gupta
- Department of Pathology, Maulana Azad Medical College, New Delhi, India
| | - Chetna Mehrol
- Department of Pathology, Maulana Azad Medical College, New Delhi, India
| | - Meeta Singh
- Department of Pathology, Maulana Azad Medical College, New Delhi, India
| | - Nita Khurana
- Department of Pathology, Maulana Azad Medical College, New Delhi, India
| | - J C Passey
- Department of ENT, Maulana Azad Medical College, New Delhi, India
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Jones B, Thomas G, Westreich J, Nofech-Mozes S, Vitkin A, Khorasani M. Novel quantitative signature of tumor stromal architecture: polarized light imaging differentiates between myxoid and sclerotic human breast cancer stroma. BIOMEDICAL OPTICS EXPRESS 2020; 11:3246-3262. [PMID: 32637252 PMCID: PMC7316019 DOI: 10.1364/boe.392722] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/16/2020] [Revised: 05/12/2020] [Accepted: 05/14/2020] [Indexed: 05/02/2023]
Abstract
As a leading cause of death in women, breast cancer is a global health concern for which personalized therapy remains largely unrealized, resulting in over- or under-treatment. Recently, tumor stroma has been shown to carry important prognostic information, both in its relative abundance and morphology, but its current assessment methods are few and suboptimal. Herein, we present a novel stromal architecture signature (SAS) methodology based on polarized light imaging that quantifies patterns of tumor connective tissue. We demonstrate its ability to differentiate between myxoid and sclerotic stroma, two pathology-derived categories associated with significantly different patient outcomes. The results demonstrate a 97% sensitivity and 88% specificity for myxoid stroma identification in a pilot study of 102 regions of interest from human invasive ductal carcinoma breast cancer surgical specimens (20 patients). Additionally, the SAS numerical score is indicative of the wide range of stromal characteristics within these binary classes and highlights ambiguous mixed-morphology regions prone to misclassification. The enabling polarized light microscopy technique is inexpensive, fast, fully automatable, applicable to fresh or embedded tissue without the need for staining and thus potentially translatable into research and/or clinical settings. The SAS metric yields quantifiable and objective stromal characterization with promise for prognosis in many types of cancers beyond breast carcinoma, enabling researchers and clinicians to further investigate the emerging and important role of stromal architectural patterns in solid tumors.
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Affiliation(s)
- Blake Jones
- Department of Medical Biophysics, University of Toronto, 101 College St, Toronto, ON M5G 1L7, Canada
- Authors contributed equally
| | - Georgia Thomas
- Department of Medical Biophysics, University of Toronto, 101 College St, Toronto, ON M5G 1L7, Canada
- Authors contributed equally
| | - Jared Westreich
- Department of Medical Biophysics, University of Toronto, 101 College St, Toronto, ON M5G 1L7, Canada
| | - Sharon Nofech-Mozes
- Department of Laboratory Medicine and Pathobiology, University of Toronto, 1 King's College Cir, Toronto, ON M5S 1A8, Canada
| | - Alex Vitkin
- Department of Medical Biophysics, University of Toronto, 101 College St, Toronto, ON M5G 1L7, Canada
- Division of Biophysics and Bioimaging, Princess Margaret Cancer Center, University Health Network, 610 University Ave, Toronto, ON M5G 2C1, Canada
- Department of Radiation Oncology, University of Toronto, Stewart building, 149 College St Suite 504, Toronto, ON M5 T 1P5, Canada
- Co-senior authors
| | - Mohammadali Khorasani
- Department of Surgical Oncology, University of Toronto, Princess Margaret Cancer Center, OPG Wing, 6th floor, 610 University Avenue Toronto, ON M5G 2M9, Canada
- Co-senior authors
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24
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Kairaluoma V, Kemi N, Pohjanen VM, Saarnio J, Helminen O. Tumour budding and tumour-stroma ratio in hepatocellular carcinoma. Br J Cancer 2020; 123:38-45. [PMID: 32362654 PMCID: PMC7341881 DOI: 10.1038/s41416-020-0847-1] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2019] [Revised: 03/16/2020] [Accepted: 04/01/2020] [Indexed: 11/09/2022] Open
Abstract
BACKGROUND Tumour budding and low tumour-stroma ratio (TSR) are associated with poor prognosis in some cancers, but their value in Western hepatocellular carcinoma is unclear. The prognostic value of tumour budding and TSR in hepatocellular carcinoma was examined. METHODS Some 259 hepatocellular carcinoma patients treated in Oulu University Hospital 1983-2018 were included in this retrospective cohort study. Tumour budding and TSR were analysed from the haematoxylin- and eosin-stained original diagnostic slides, by dividing patients into bud-negative (0 bud) or bud-positive (≥1 bud) groups, and into high TSR (<50%) and low TSR (≥50%) groups. Surgically treated patients (n = 47) and other treatments (n = 212) were analysed separately. Primary outcomes were overall, and disease-specific 5-year mortality was adjusted for confounding factors. RESULTS Surgically treated patients with positive tumour budding had increased 5-year overall (adjusted HR 3.87, 95% CI 1.10-13.61) and disease-specific (adjusted HR 6.17, 95% CI 1.19-31.90) mortality compared with bud-negative patients. In surgically treated patients, TSR had no effect on 5-year overall (adjusted HR 2.03, 95% CI 0.57-7.21) or disease-specific (adjusted HR 3.23, 95% CI 0.78-13.37) mortality. No difference in survival related to tumour budding and TSR in non-surgically treated patients was observed. CONCLUSIONS Tumour budding is a prognostic factor in surgically treated hepatocellular carcinoma.
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Affiliation(s)
- Valtteri Kairaluoma
- Cancer and Translational Medicine Research Unit, Medical Research Center Oulu, University of Oulu and Oulu University Hospital, Oulu, Finland.
| | - Niko Kemi
- Cancer and Translational Medicine Research Unit, Medical Research Center Oulu, University of Oulu and Oulu University Hospital, Oulu, Finland
| | - Vesa-Matti Pohjanen
- Cancer and Translational Medicine Research Unit, Medical Research Center Oulu, University of Oulu and Oulu University Hospital, Oulu, Finland
| | - Juha Saarnio
- Cancer and Translational Medicine Research Unit, Medical Research Center Oulu, University of Oulu and Oulu University Hospital, Oulu, Finland
| | - Olli Helminen
- Cancer and Translational Medicine Research Unit, Medical Research Center Oulu, University of Oulu and Oulu University Hospital, Oulu, Finland.,Department of Surgery, Central Finland Central Hospital, Jyväskylä, Finland
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25
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Immunohistochemical staining of podoplanin is helpful in determining the microinvasion of cervical squamous cell carcinoma. Ann Diagn Pathol 2020; 46:151493. [PMID: 32179442 DOI: 10.1016/j.anndiagpath.2020.151493] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2019] [Revised: 02/01/2020] [Accepted: 02/25/2020] [Indexed: 12/24/2022]
Abstract
Cervical squamous cell carcinoma develops through a series of stages, including low-grade squamous intraepithelial lesions (LSIL), high-grade squamous intraepithelial lesions (HSIL), microinvasive squamous cell carcinoma (MISCC), and invasive squamous cell carcinoma (ISCC). The difference between HSIL and MISCC is the appearance of microinvasion, which determines the treatment for patients. However, sometimes it is difficult to differentiate HSIL from MISCC in morphology, and no effective markers are available to help determine microinvasion. Here, we evaluated the expression patterns of podoplanin in cervical tissues by immunohistochemistry staining. Results showed that podoplanin was specifically expressed in a continuous or discontinuous linear pattern within the basal layer of cells from normal cervical squamous epithelium (NS) (100%, 96/96) and HSIL (81%, 57/70). However, its expression was completely absent in microinvasive lesions (0%, 72/72), and the location of podoplanin expression loss was consistent with that of microinvasive lesions. Thus, for HSIL with positive podoplanin expression, the sudden loss of podoplanin represents the occurrence of early invasion. Furthermore, podoplanin was expressed in 3.4% (4/118) of ISCC, and its expression was not correlated with the age of the patient, tumor size, differentiation, FIGO stage, depth of invasion, lymph node, or distant metastasis. The prognosis of patients with positive podoplanin was slightly better than those without it (p > 0.05). Therefore, we found that podoplanin, as a new specific marker for the basal layer cells of cervical squamous epithelium, could assist the diagnosis of microinvasion in cervical squamous cell carcinoma. The specific staining pattern of podoplanin provides the possibility of clinical application in the future.
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26
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Martin B, Banner BM, Schäfer EM, Mayr P, Anthuber M, Schenkirsch G, Märkl B. Tumor proportion in colon cancer: results from a semiautomatic image analysis approach. Virchows Arch 2020; 477:185-193. [PMID: 32076815 PMCID: PMC7985049 DOI: 10.1007/s00428-020-02764-1] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2019] [Revised: 01/13/2020] [Accepted: 01/27/2020] [Indexed: 02/06/2023]
Abstract
The tumor stroma ratio (TSR) is a promising prognostic biomarker in colon cancer, which could provide additional risk stratification for therapy adaption. The objective of our study was the investigation of the prognostic significance of TSR at different tumor sites in a simple semiautomatic approach with the open-source program ImageJ. We investigated 206 pT3 and pT4 adenocarcinomas of no special type. According to our established thresholds, 31 tumors (15%) were classified as low tumor proportion (TP) (≤ 15% TP), 42 tumors (20%) were classified as high TP (≥ 54% TP), and 133 tumors (65%) were classified as medium TP. High and low TP were associated with an adverse overall survival in comparison to medium TP (p = 0.001 and p = 0.03). Furthermore, the TP was an independent risk factor of occurrence of distant metastasis next to T status, microsatellite status, and tumor budding. The 5-year survival rate was 49% in patients with high TP, 48% in patients with low TP, and 68% in patients with medium TP (p = 0.042, n = 160). Patients with a high TP had less often tumor budding (p = 0.012), lymphovascular invasion (p = 0.049), and less harvested lymph nodes (p = 0.042) in comparison to low TP tumors. The results provide first evidence that a high tumor proportion/low stroma proportion is also associated with an adverse prognosis and that this subgroup might be difficult to identify with other classical histopathologic characteristics that are linked to an adverse prognosis.
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Affiliation(s)
- Benedikt Martin
- Institute of Pathology and Molecular Diagnostics, University Hospital Augsburg, Augsburg, Germany.
| | - Bettina Monika Banner
- Institute of Pathology and Molecular Diagnostics, University Hospital Augsburg, Augsburg, Germany
| | - Eva-Maria Schäfer
- Institute of Pathology and Molecular Diagnostics, University Hospital Augsburg, Augsburg, Germany
| | - Patrick Mayr
- Institute of Pathology and Molecular Diagnostics, University Hospital Augsburg, Augsburg, Germany.,Department of Radiooncology, University Hospital Augsburg, Augsburg, Germany
| | - Matthias Anthuber
- Department of Visceral Surgery, University Hospital Augsburg, Augsburg, Germany
| | | | - Bruno Märkl
- Institute of Pathology and Molecular Diagnostics, University Hospital Augsburg, Augsburg, Germany
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27
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Bidirectional tumor/stroma crosstalk promotes metastasis in mesenchymal colorectal cancer. Oncogene 2020; 39:2453-2466. [PMID: 31974473 DOI: 10.1038/s41388-020-1157-z] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2019] [Revised: 12/13/2019] [Accepted: 01/10/2020] [Indexed: 12/23/2022]
Abstract
Patients with the mesenchymal subtype colorectal cancer (CRC) have a poor prognosis, in particular patients with stroma-rich tumors and aberrant SMAD4 expression. We hypothesized that interactions between SMAD4-deficient CRC cells and cancer-associated fibroblasts provide a biological explanation. In transwell invasion assays, fibroblasts increased the invasive capacity of SMAD4-deficient HT29 CRC cells, but not isogenic SMAD4-proficient HT29 cells. A TGF-β/BMP-specific array showed BMP2 upregulation by fibroblasts upon stimulation with conditioned medium from SMAD4-deficient CRC cells, while also stimulating their invasion. In a mouse model for experimental liver metastasis, the co-injection of fibroblasts increased metastasis formation of SMAD4-deficient CRC cells (p = 0.02) but not that of SMAD4-proficient CRC cells. Significantly less metastases were seen in mice co-injected with BMP2 knocked-down fibroblasts. Fibroblast BMP2 expression seemed to be regulated by TRAIL, a factor overexpressed in SMAD4-deficient CRC cells. In a cohort of 146 stage III CRC patients, we showed that patients with a combination of high stromal BMP2 expression and the loss of tumor SMAD4 expression had a significantly poorer overall survival (HR 2.88, p = 0.04). Our results suggest the existence of a reciprocal loop in which TRAIL from SMAD4-deficient CRC cells induces BMP2 in fibroblasts, which enhances CRC invasiveness and metastasis.
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28
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Vangangelt KMH, Green AR, Heemskerk IMF, Cohen D, van Pelt GW, Sobral-Leite M, Schmidt MK, Putter H, Rakha EA, Tollenaar RAEM, Mesker WE. The prognostic value of the tumor-stroma ratio is most discriminative in patients with grade III or triple-negative breast cancer. Int J Cancer 2020; 146:2296-2304. [PMID: 31901133 PMCID: PMC7065011 DOI: 10.1002/ijc.32857] [Citation(s) in RCA: 44] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2019] [Revised: 11/11/2019] [Accepted: 11/27/2019] [Indexed: 12/12/2022]
Abstract
The tumor-stroma ratio (TSR) was evaluated as a promising parameter for breast cancer prognostication in clinically relevant subgroups of patients. The TSR was assessed on hematoxylin and eosin-stained tissue slides of 1,794 breast cancer patients from the Nottingham City Hospital. An independent second cohort of 737 patients from the Netherlands Cancer Institute to Antoni van Leeuwenhoek was used for evaluation. In the Nottingham Breast Cancer series, the TSR was an independent prognostic parameter for recurrence-free survival (RFS; HR 1.35, 95% CI 1.10-1.66, p = 0.004). The interaction term was statistically significant for grade and triple-negative status. Multivariate Cox regression analysis showed a more pronounced effect of the TSR for RFS in grade III tumors (HR 1.89, 95% CI 1.43-2.51, p < 0.001) and triple-negative tumors (HR 1.86, 95% CI 1.10-3.14, p = 0.020). Comparable hazard ratios and confidence intervals were observed for grade and triple-negative status in the ONCOPOOL study. The prognostic value of TSR was not modified by age, tumor size, histology, estrogen receptor status, progesterone receptor status, human epidermal growth factor receptor 2 status or lymph node status. In conclusion, patients with a stroma-high tumor had a worse prognosis compared to patients with a stroma-low tumor. The prognostic value of the TSR is most discriminative in grade III tumors and triple-negative tumors. The TSR was not modified by other clinically relevant parameters making it a potential factor to be included for improved risk stratification.
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Affiliation(s)
- Kiki M H Vangangelt
- Department of Surgery, Leiden University Medical Center, Leiden, The Netherlands
| | - Andrew R Green
- Nottingham Breast Cancer Research Center, Division of Cancer and Stem Cells, School of Medicine, The University of Nottingham, Nottingham City Hospital, Nottingham, United Kingdom
| | | | - Danielle Cohen
- Department of Pathology, Leiden University Medical Center, Leiden, The Netherlands
| | - Gabi W van Pelt
- Department of Surgery, Leiden University Medical Center, Leiden, The Netherlands
| | - Marcelo Sobral-Leite
- Division of Molecular Pathology, Netherlands Cancer Institute, Amsterdam, The Netherlands
| | - Marjanka K Schmidt
- Division of Molecular Pathology, Netherlands Cancer Institute, Amsterdam, The Netherlands
| | - Hein Putter
- Department of Biomedical Data Sciences, Leiden University Medical Center, Leiden, The Netherlands
| | - Emad A Rakha
- Nottingham Breast Cancer Research Center, Division of Cancer and Stem Cells, School of Medicine, The University of Nottingham, Nottingham City Hospital, Nottingham, United Kingdom
| | - Rob A E M Tollenaar
- Department of Surgery, Leiden University Medical Center, Leiden, The Netherlands
| | - Wilma E Mesker
- Department of Surgery, Leiden University Medical Center, Leiden, The Netherlands
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Nunes SC. Tumor Microenvironment - Selective Pressures Boosting Cancer Progression. ADVANCES IN EXPERIMENTAL MEDICINE AND BIOLOGY 2020; 1219:35-49. [PMID: 32130692 DOI: 10.1007/978-3-030-34025-4_2] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
In 2018, 9.6 million deaths from cancer were estimated, being this disease the second leading cause of death worldwide. Notwithstanding all the efforts developed in prevention, diagnosis and new treatment approaches, chemoresistance seems to be inevitable, leading to cancer progression, recurrence and affecting the outcome of the disease. As more and more evidence support that cancer is an evolutionary and ecological process, this concept is rarely applied in the clinical context. In fact, cancer cells emerge and progress within an ecological niche - the tumor microenvironment - that is shared with several other cell types and that is continuously changing. Therefore, the tumor microenvironment imposes several selective pressures on cancer cells such as acidosis, hypoxia, competition for space and resources, immune predation and anti-cancer therapies, that cancer cells must be able to adapt to or will face extinction.In here, the role of the tumor microenvironment selective pressures on cancer progression will be discussed, as well as the targeting of its features/components as strategies to fight cancer.
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Affiliation(s)
- Sofia C Nunes
- CEDOC, Chronic Diseases Research Centre, NOVA Medical School | Faculdade de Ciências Médicas, Universidade NOVA de Lisboa, Lisbon, Portugal
- Instituto Português de Oncologia de Lisboa Francisco Gentil (IPOLFG), Lisbon, Portugal
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30
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Zong L, Zhang Q, Kong Y, Yang F, Zhou Y, Yu S, Wu M, Chen J, Zhang Y, Xiang Y. The tumor-stroma ratio is an independent predictor of survival in patients with 2018 FIGO stage IIIC squamous cell carcinoma of the cervix following primary radical surgery. Gynecol Oncol 2019; 156:676-681. [PMID: 31882242 DOI: 10.1016/j.ygyno.2019.12.022] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2019] [Revised: 12/15/2019] [Accepted: 12/17/2019] [Indexed: 12/20/2022]
Abstract
OBJECTIVE To determine the value of the tumor-stroma ratio (TSR) while identifying prognostic factors in patients with 2018 International Federation of Gynecology and Obstetrics (FIGO) stage IIIC squamous cell carcinoma of the cervix following primary radical surgery. METHODS Three hundred eighty-four patients with node-positive squamous cell carcinoma of the cervix (2018 FIGO stage IIIC) who underwent radical surgery between January 2005 and December 2016 were included in this retrospective study. The TSRs were assessed on hematoxylin and eosin-stained tumor slides and classified as stroma-low (<50% stroma) or stroma-high (≥50% stroma). RESULTS Sixty-seven patients were categorized as stroma-high; they had shorter disease-free survival (DFS) and overall survival (OS) periods than did their stroma-low counterparts. On multivariate analysis, a tumor size ≥4 cm, ≥3 metastatic lymph nodes, and stroma-high status were independent predictors of shorter DFS and OS. These factors were incorporated into a prognostic scoring system in which patients were categorized into low- (score 0), intermediate- (score 1), and high-risk (scores 2-3) groups. The scoring system differentiated DFS and OS well (C-index = 0.65, 95% confidence interval, 0.59-0.72; and C-index = 0.65, 95% confidence interval, 0.59-0.72, respectively). CONCLUSIONS The TSR is an independent prognostic factor, and our prognostic scoring system that incorporates this parameter exhibits good discriminative ability for both recurrence and survival in patients with 2018 FIGO stage IIIC cervical cancer after radical surgery. The TSR is a potentially novel clinicopathological variable for predicting the prognoses of these patients contingent on the validation of our findings.
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Affiliation(s)
- Liju Zong
- Department of Obstetrics and Gynecology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, China; Department of Pathology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, China
| | - Qianqian Zhang
- Department of Obstetrics and Gynecology, Qilu Hospital, Shandong University, China; Department of Obstetrics and Gynecology, The Second Affiliated Hospital of Shandong First Medical University, China
| | - Yujia Kong
- Department of Obstetrics and Gynecology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, China
| | - Fan Yang
- Department of Pathology, The Second Affiliated Hospital of Shandong First Medical University, China
| | - Yuncan Zhou
- Department of Obstetrics and Gynecology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, China
| | - Shuangni Yu
- Department of Pathology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, China
| | - Ming Wu
- Department of Obstetrics and Gynecology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, China
| | - Jie Chen
- Department of Pathology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, China.
| | - Youzhong Zhang
- Department of Obstetrics and Gynecology, Qilu Hospital, Shandong University, China.
| | - Yang Xiang
- Department of Obstetrics and Gynecology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, China.
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Zengin M. Tumour Budding and Tumour Stroma Ratio are Reliable Predictors for Death and Recurrence in Elderly Stage I Colon Cancer Patients. Pathol Res Pract 2019; 215:152635. [PMID: 31564570 DOI: 10.1016/j.prp.2019.152635] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/16/2019] [Revised: 08/26/2019] [Accepted: 09/14/2019] [Indexed: 12/14/2022]
Abstract
AIM Tumour budding (BD) and Tumour stroma ratio (TSR) are considered valuable survival parameters for colon cancer (CC), but it is still unclear whether these parameters predict a poor prognosis. This study aimed to determine the survival effect of TB and TSR in elderly stage I CC patients. METHODS We evaluated these parameters in eighty-eight stage I CC patients who underwent surgical treatment alone between 1998 and 2015. The relationship between these parameters and age was investigated. Model A was used for methodology. RESULTS In elderly patients (≥68), these parameters obtained more successful results for following analysis: relationship between prognostic factors [lymphatic invasion (BD, p = 0.003; TSR, p = 0.003), perineural invasion (BD, p = 0.016; TSR, p = 0.004), tumour deposites (BD, p = 0.005; TSR, p = 0.033), MSI (BD, p=0.031; TSR, p=0.012), etc.], correlation of estimates (BD, r=0.724; TSR, r=0.703), and reproducibility of study (BD [Kappa (ĸ)]=0.53-0.75; TSR (ĸ) =0.56-0.71). Also, the cut-off values were useful for BD (area of under ROC (AUC)=0.816 [0.707-0.925]) and TSR (AUC=0.810 [0.697-0.924]). In univariate analysis, in elderly patients, these parameters had a poor 5-year survival for RFS (p<0.001[BD], p=0.001[TSR]), OS (p<0.001[BD], p=0.005[TSR]), and LR (p=0.008[BD], p=0.034[TSR]). Multivariate analysis confirmed that these parameters are independent worse predictors for RFS (BD: 1.42[HR], p=0.002; TSR: 1.50[HR], p=0.001), OS (BD: 1.38[HR], p=0.014; TSR: 1.42[HR], p=0.005), and LR (BD: 1.61[HR], p=0.034) in elderly patients. CONCLUSIONS Our results confirm that BD and TSR are reliable indexes for poor survival in elderly stage I CC patients. We recommend using model A for successful results and standardization.
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Affiliation(s)
- Mehmet Zengin
- Kırıkkale University, Faculty of Medicine, Pathology Department, Kırıkkale 71000, Turkey.
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Wang Y, Lu S, Xiong J, Singh K, Hui Y, Zhao C, Brodsky AS, Yang D, Jolly G, Ouseph M, Schorl C, DeLellis RA, Resnick MB. ColXα1 is a stromal component that colocalizes with elastin in the breast tumor extracellular matrix. J Pathol Clin Res 2019; 5:40-52. [PMID: 30207088 PMCID: PMC6317058 DOI: 10.1002/cjp2.115] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2018] [Revised: 09/05/2018] [Accepted: 09/07/2018] [Indexed: 12/21/2022]
Abstract
The tumor microenvironment regulates tissue development and homeostasis, and its dysregulation contributes to neoplastic progression. Increased expression of type X collagen α-1 (ColXα1) in tumor-associated stroma correlates with poor pathologic response to neoadjuvant chemotherapy in estrogen receptor (ER) and human epidermal growth factor receptor 2 (HER2)-positive breast cancers. Evaluation of ColXα1 expression patterns suggests a potential connection with elastin fibers. To investigate the possible interaction between ColXα1 and elastin, we evaluated the expression of ColXα1 in relation to elastin fibers in normal breast tissue, ductal carcinoma in situ, and invasive breast carcinomas at cellular and subcellular levels. Our findings demonstrate that ColXα1 colocalizes with elastin in invasive breast cancer-associated stroma by immunohistochemistry, immunofluorescence, and electron microscopy. In 212 invasive breast carcinomas, this complex was aberrantly and selectively expressed in tumor extracellular matrix in 79% of ER+/HER2-, 80% of ER+/HER2+, 76% of ER-/HER2+, and 58% of triple negative breast cancers. In contrast, ColXα1 was generally absent, while elastin was present perivascularly in normal breast tissue. ColXα1 and elastin were coexpressed in 58% of ductal carcinoma in situ (DCIS) in periductal areas. In mass-forming DCIS with desmoplastic stroma, the complex was intensely expressed in periductal areas as well as within the tumor-associated stroma in all cases. Our data suggest that the breast carcinoma neoplastic process may involve aberrant expression of ColXα1 and elastin in the tumor microenvironment emerging early at the DCIS stage. Enrichment of these complexes in tumor-associated stroma may represent a stromal signature indicative of intrinsic differences between breast cancers. These findings shed light on investigation into the role of aberrant collagen complex expression in tumorigenesis and tumor progression which may be leveraged in therapeutic and theranostic applications.
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Affiliation(s)
- Yihong Wang
- Department of Pathology and Laboratory MedicineRhode Island Hospital and Lifespan Medical Center, Warren Alpert Medical School of Brown UniversityProvidenceRIUSA
| | - Shaolei Lu
- Department of Pathology and Laboratory MedicineRhode Island Hospital and Lifespan Medical Center, Warren Alpert Medical School of Brown UniversityProvidenceRIUSA
| | - Jinjun Xiong
- Department of PathologyWomen and Infants Hospital, Warren Alpert Medical School of Brown UniversityProvidenceRIUSA
| | - Kamaljeet Singh
- Department of PathologyWomen and Infants Hospital, Warren Alpert Medical School of Brown UniversityProvidenceRIUSA
| | - Yiang Hui
- Department of Pathology and Laboratory MedicineRhode Island Hospital and Lifespan Medical Center, Warren Alpert Medical School of Brown UniversityProvidenceRIUSA
| | - Chaohui Zhao
- Department of Pathology and Laboratory MedicineRhode Island Hospital and Lifespan Medical Center, Warren Alpert Medical School of Brown UniversityProvidenceRIUSA
| | - Alexander S Brodsky
- Department of Pathology and Laboratory MedicineRhode Island Hospital and Lifespan Medical Center, Warren Alpert Medical School of Brown UniversityProvidenceRIUSA
| | - Dongfang Yang
- Department of Pathology and Laboratory MedicineRhode Island Hospital and Lifespan Medical Center, Warren Alpert Medical School of Brown UniversityProvidenceRIUSA
| | - Grant Jolly
- Department of Pathology and Laboratory MedicineRhode Island Hospital and Lifespan Medical Center, Warren Alpert Medical School of Brown UniversityProvidenceRIUSA
| | - Madhu Ouseph
- Department of Pathology and Laboratory MedicineRhode Island Hospital and Lifespan Medical Center, Warren Alpert Medical School of Brown UniversityProvidenceRIUSA
| | - Christoph Schorl
- Molecular Biology, Cell Biology, and BiochemistryBrown UniversityProvidenceRIUSA
| | - Ronald A DeLellis
- Department of Pathology and Laboratory MedicineRhode Island Hospital and Lifespan Medical Center, Warren Alpert Medical School of Brown UniversityProvidenceRIUSA
| | - Murray B Resnick
- Department of Pathology and Laboratory MedicineRhode Island Hospital and Lifespan Medical Center, Warren Alpert Medical School of Brown UniversityProvidenceRIUSA
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Du Y, Zhang R, Zargari A, Thai TC, Gunderson CC, Moxley KM, Liu H, Zheng B, Qiu Y. Classification of Tumor Epithelium and Stroma by Exploiting Image Features Learned by Deep Convolutional Neural Networks. Ann Biomed Eng 2018; 46:1988-1999. [PMID: 30051247 PMCID: PMC6286645 DOI: 10.1007/s10439-018-2095-6] [Citation(s) in RCA: 42] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2018] [Accepted: 07/13/2018] [Indexed: 01/17/2023]
Abstract
The tumor-stroma ratio (TSR) reflected on hematoxylin and eosin (H&E)-stained histological images is a potential prognostic factor for survival. Automatic image processing techniques that allow for high-throughput and precise discrimination of tumor epithelium and stroma are required to elevate the prognostic significance of the TSR. As a variant of deep learning techniques, transfer learning leverages nature-images features learned by deep convolutional neural networks (CNNs) to relieve the requirement of deep CNNs for immense sample size when handling biomedical classification problems. Herein we studied different transfer learning strategies for accurately distinguishing epithelial and stromal regions of H&E-stained histological images acquired from either breast or ovarian cancer tissue. We compared the performance of important deep CNNs as either a feature extractor or as an architecture for fine-tuning with target images. Moreover, we addressed the current contradictory issue about whether the higher-level features would generalize worse than lower-level ones because they are more specific to the source-image domain. Under our experimental setting, the transfer learning approach achieved an accuracy of 90.2 (vs. 91.1 for fine tuning) with GoogLeNet, suggesting the feasibility of using it in assisting pathology-based binary classification problems. Our results also show that the superiority of the lower-level or the higher-level features over the other ones was determined by the architecture of deep CNNs.
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Affiliation(s)
- Yue Du
- School of Electrical and Computer Engineering, University of Oklahoma, Norman, OK, 73019, USA
| | - Roy Zhang
- Department of Pathology, University of Oklahoma Health Sciences Center, Oklahoma City, OK, 73104, USA
| | - Abolfazl Zargari
- School of Electrical and Computer Engineering, University of Oklahoma, Norman, OK, 73019, USA
| | - Theresa C Thai
- Department of Radiology, University of Oklahoma Health Sciences Center, Oklahoma City, OK, 73104, USA
| | - Camille C Gunderson
- Department of Obstetrics and Gynecology, University of Oklahoma Health Sciences Center, Oklahoma City, OK, 73104, USA
| | - Katherine M Moxley
- Department of Obstetrics and Gynecology, University of Oklahoma Health Sciences Center, Oklahoma City, OK, 73104, USA
| | - Hong Liu
- School of Electrical and Computer Engineering, University of Oklahoma, Norman, OK, 73019, USA
| | - Bin Zheng
- School of Electrical and Computer Engineering, University of Oklahoma, Norman, OK, 73019, USA
| | - Yuchen Qiu
- School of Electrical and Computer Engineering, University of Oklahoma, Norman, OK, 73019, USA.
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The prognostic value of tumour-stroma ratio in primary breast cancer with special attention to triple-negative tumours: a review. Breast Cancer Res Treat 2018; 173:55-64. [PMID: 30302588 PMCID: PMC6394568 DOI: 10.1007/s10549-018-4987-4] [Citation(s) in RCA: 60] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2018] [Accepted: 09/28/2018] [Indexed: 01/09/2023]
Abstract
Purpose There is a strong need to improve the prognostication of breast cancer patients in order to prevent over- and undertreatment, especially when considering adjuvant chemotherapy. Tumour stroma characteristics might be valuable in predicting disease progression. Methods Studies regarding the prognostic value of tumour–stroma ratio (TSR) in breast cancer are evaluated. Results A high stromal content is related to a relatively poor prognosis. The most pronounced prognostic effect of this parameter seems to be observed in the triple-negative breast cancer (TNBC) subtype. Conclusions TSR assessment might represent a simple, fast and reproducible prognostic factor at no extra costs, and could possibly be incorporated into routine pathological diagnostics. Despite these advantages, a robust clinical validation of this parameter has yet to be established in prospective studies. Electronic supplementary material The online version of this article (10.1007/s10549-018-4987-4) contains supplementary material, which is available to authorized users.
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Scoring the tumor-stroma ratio in colon cancer: procedure and recommendations. Virchows Arch 2018; 473:405-412. [PMID: 30030621 PMCID: PMC6182321 DOI: 10.1007/s00428-018-2408-z] [Citation(s) in RCA: 109] [Impact Index Per Article: 18.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2017] [Revised: 07/03/2018] [Accepted: 07/08/2018] [Indexed: 12/28/2022]
Abstract
The tumor-stroma ratio (TSR) has been reported as a strong, independent prognostic parameter in colon cancer as well as in other epithelial cancer types, and may be implemented to routine pathology diagnostics. The TSR is an easy technique, based on routine hematoxylin and eosin stained histological sections, estimating the amount of stroma present in the primary tumor. It links tumors with high stromal content to poor prognosis. The analysis time is less than 2 min with a low inter-observer variation. Scoring of the TSR has been validated in a number of independent international studies. In this manuscript, we provide a detailed technical description of estimating the TSR in colon cancer, including examples, pitfalls, and recommendations.
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van Pelt GW, Sandberg TP, Morreau H, Gelderblom H, van Krieken JHJM, Tollenaar RAEM, Mesker WE. The tumour-stroma ratio in colon cancer: the biological role and its prognostic impact. Histopathology 2018; 73:197-206. [PMID: 29457843 DOI: 10.1111/his.13489] [Citation(s) in RCA: 81] [Impact Index Per Article: 13.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
The tumour microenvironment consists of a complex mixture of non-neoplastic cells, including fibroblasts, immune cells and endothelial cells embedded in the proteins of the extracellular matrix. The tumour microenvironment plays an active role in tumour behaviour. By interacting with cancer cells, it influences disease progression and the metastatic capacity of the tumour. Tumours with a high amount of stroma correspond to poor patient prognosis. The tumour-stroma ratio (TSR) is a strong independent prognostic tool in colon cancer and provides additional value to the current clinically used tumour-node-metastasis classification. The TSR is assessed on conventional haematoxylin and eosin-stained paraffin sections at the invasive front of the tumour. Here we review studies demonstrating the prognostic significance of the TSR in solid epithelial tumours with a focus on colon cancer. Moreover, the biological role of the tumour microenvironment during tumour progression and invasion will be discussed, as well as the attempts to target the tumour stroma for therapeutic purposes. We suggest that the TSR can be implemented with little effort and without additional costs in current routine pathology diagnostics owing to its simplicity and reliability.
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Affiliation(s)
- Gabi W van Pelt
- Department of Surgery, Leiden University Medical Centre, Leiden, the Netherlands
| | - Tessa P Sandberg
- Department of Surgery, Leiden University Medical Centre, Leiden, the Netherlands
| | - Hans Morreau
- Department of Pathology, Leiden University Medical Centre, Leiden, the Netherlands
| | - Hans Gelderblom
- Department of Clinical Oncology, Leiden University Medical Centre, Leiden, the Netherlands
| | - J Han J M van Krieken
- Department of Pathology, Radboud University Medical Centre, Nijmegen, the Netherlands
| | - Rob A E M Tollenaar
- Department of Surgery, Leiden University Medical Centre, Leiden, the Netherlands
| | - Wilma E Mesker
- Department of Surgery, Leiden University Medical Centre, Leiden, the Netherlands
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Wu J, Liang C, Chen M, Su W. Association between tumor-stroma ratio and prognosis in solid tumor patients: a systematic review and meta-analysis. Oncotarget 2018; 7:68954-68965. [PMID: 27661111 PMCID: PMC5356603 DOI: 10.18632/oncotarget.12135] [Citation(s) in RCA: 139] [Impact Index Per Article: 23.2] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2016] [Accepted: 09/05/2016] [Indexed: 12/21/2022] Open
Abstract
Tumor-related stroma plays an active role in tumor invasion and metastasis. The tumor–stroma ratio (TSR) in the pathologic specimen has drawn increasing attention from the field of predicting tumor prognosis. However, the prognostic value of TSR in solid tumors necessitates further elucidation. We conducted a meta-analysis on 14 studies with 4238 patients through a comprehensive electronic search on databases updated on May 2016 to explore the relationship between TSR and prognosis of solid tumors. The overall hazard ratio showed that rich stroma in tumor tissue was associated with poor overall survival (OS) (14 studies, 4238 patients) and disease-free survival (DFS) (9 studies, 2235 patients) of patients with solid tumors. The effect of low TSR on poor OS was observed among various cancer types, but not in the early stage of cervical caner. A significant relationship between low TSR and poor OS was also observed in the subgroup analyses based on study region, blinding status, and Newcastle–Ottawa Scale (NOS) score. Subgroup analyses indicated that cancer type, clinical stage, study region, blinding status, and NOS score did not affect the prognostic value of TSR for DFS. Moreover, low TSR was significantly correlated with the serious clinical stage, advanced depth of invasion, and positive lymph node metastasis. These findings indicate that a high proportion of stroma in cancer tissue is associated with poor clinical outcomes in cancer patients, and TSR may serve as an independent prognostic factor for solid tumors.
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Affiliation(s)
- Jiayuan Wu
- Nutritional Department, the Affiliated Hospital of Guangdong Medical University, Zhanjiang 524001, China
| | - Caixia Liang
- Department of Oncology, the Affiliated Hospital of Guangdong Medical University, Zhanjiang 524001, China
| | - Manyu Chen
- Department of Oncology, the Affiliated Hospital of Guangdong Medical University, Zhanjiang 524001, China
| | - Wenmei Su
- Department of Oncology, the Affiliated Hospital of Guangdong Medical University, Zhanjiang 524001, China
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38
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The tumor-stromal ratio as a strong prognosticator for advanced gastric cancer patients: proposal of a new TSNM staging system. J Gastroenterol 2018; 53:606-617. [PMID: 28815347 PMCID: PMC5910462 DOI: 10.1007/s00535-017-1379-1] [Citation(s) in RCA: 37] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/11/2017] [Accepted: 08/03/2017] [Indexed: 02/06/2023]
Abstract
BACKGROUND Insufficient attention is paid to the underlying tumor microenvironment (TME) evolution, that resulting in tumor heterogeneity and driving differences in cancer aggressiveness and treatment outcomes. The morphological evaluation of the proportion of the stroma at the most invasive part of primary tumor (tumor-stromal ratio, TSR) in cancer is gaining momentum as evidence strengthens for the clinical relevance. METHODS Tissue samples from the most invasive part of the primary gastric cancer (GC) of 494 patients were analyzed for their TSR, and a new TSNM (tumor-stromal node metastasis) staging system based on patho-biological behaviors was established and assessed. RESULTS TSR is a new and strong independent prognostic factor for GC patients. The likelihood of tumor invasion is increased significantly for patients in the stromal-high subgroup compared to those in the stromal-low subgroup (P = 0.011). The discrimination ability of TSR was not less than the TNM staging system and was better in patients with stages I and II GC. We integrated the TSR parameter into the TNM staging system and proposed a new TSNM staging system creatively. There were three new subgroups (IC, IIC, IIID). There were four major groups and 10 subgroups in the TSNM system. The difference in overall survival (OS) was statistically significant among all TSNM system (P < 0.005 for all). Deep analyses revealed well predictive performance of the TSNM (P < 0.001). CONCLUSIONS This study confirms the TSR as a TME prognostic factor for GC. TSR is a candidate TME parameter that could easily be implemented in routine pathology diagnostics, and the TSNM staging system has been established to optimize risk stratification for GC. The value of the TSNM staging system should be validated in further prospective study.
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Li X, Wang P, Li D, Zhu H, Meng L, Song Y, Xie L, Zhu J, Yu T. Intravoxel incoherent motion MR imaging of early cervical carcinoma: correlation between imaging parameters and tumor-stroma ratio. Eur Radiol 2017; 28:1875-1883. [DOI: 10.1007/s00330-017-5183-3] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2017] [Revised: 11/01/2017] [Accepted: 11/07/2017] [Indexed: 12/11/2022]
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40
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Zheng D, Mou HP, Diao P, Li XM, Zhang CL, Jiang J, Chen JL, Wang LS, Wang Q, Zhou GY, Chen J, Lin C, Yuan ZP. Chemoradiotherapy in combination with radical surgery is associated with better outcome in cervical cancer patients. Oncotarget 2017; 9:2866-2875. [PMID: 29416819 PMCID: PMC5788687 DOI: 10.18632/oncotarget.23165] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2017] [Accepted: 11/16/2017] [Indexed: 02/05/2023] Open
Abstract
Objectives To retrospectively assess the influence of radical surgery following concurrent chemoradiotherapy (CCRT) on outcomes in cervical cancer (CC) patients. Methods Patients diagnosed with cervical squamous cell carcinoma or adenocarcinoma (FIGO stages IB2 to IIB) at the Yinbin Second People's Hospital between September 2008 and September 2013, were included in this study. Patients were classified into 2 groups based on the treatment received: surgery group (CCRT plus radical surgery) and non-surgery groups (CCRT only). In addition to clinical information, inter-group differences with respect to local control rate (LCR), local recurrence rate (LRR), metastasis rate, overall survival (OS), progress free survival(PFS) and complications were assessed. Results A total of 314 patients were included in the analysis. Parametrial invasion, pelvic lymph node metastasis, tumor diameter > 4 cm and presence of residual disease were risk factors for recurrence in the non-surgery group. In patients with risk factors, radical surgery significantly improved their clinical outcome. The 3-year/5-year LCR in the surgery and non-surgery groups was 88.3%/87.4% and 82.3%/77.5%, respectively (P = 0.04). The 3-year/5-year OS rate in the two groups was 87.1%/81.7% and 72.8%/67.3%, respectively (P = 0.001). The 3-year/5-year LRR in the two groups were 11.7%/12.6% and 17.7%/22.5%, respectively (P = 0.04). The metastasis rates in the two groups were 19.9% and 24.8%, respectively (P = 0.09). Conclusions Surgery following CCRT could improve overall survival and progressfree survival. Radical surgery following CCRT appears to confer significant benefits including an increase in LCRs and decrease in LRR in CC patients with risk factors.
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Affiliation(s)
- Dan Zheng
- Department of Head and Neck and Mammary Gland Oncology, and Medical Oncology, Cancer Center, West China Hospital, Sichuan University, Chengdu, Sichuan, 610041, P.R. China.,State Key Laboratory of Biotherapy/Collaborative Innovation Center of Biotherapy, West China Hospital, Sichuan University, The Cancer Center, Chengdu, Sichuan, 610041, P.R. China
| | - Hua-Ping Mou
- Department of Gynecology, The Second People's Hospital of Sichuan Province, Yibin City, Yibin, Sichuan, 644000, P.R. China
| | - Peng Diao
- Sichuan Cancer Hospital and Institute, Sichuan Cancer Center, School of Medicine, 3 University of Electronic Science and Technology of China, Chengdu, Sichuan, 610041, P.R. China
| | - Xiao-Ming Li
- Department of Hematology, The First Affiliated Hospital of Southwest Medical University, Luzhou, Sichuan, 646000, P.R. China
| | - Chuan-Li Zhang
- Department of Gynecology, The Second People's Hospital of Sichuan Province, Yibin City, Yibin, Sichuan, 644000, P.R. China
| | - Jing Jiang
- Department of Gynecology, The Second People's Hospital of Sichuan Province, Yibin City, Yibin, Sichuan, 644000, P.R. China
| | - Jia-Lian Chen
- Department of Gynecology, The Second People's Hospital of Sichuan Province, Yibin City, Yibin, Sichuan, 644000, P.R. China
| | - Li-Shuai Wang
- Department of Oncology, The Second People's Hospital of Sichuan Province, Yibin City, Yibin, Sichuan, 644000, P.R. China
| | - Qiu Wang
- Department of Oncology, The Second People's Hospital of Sichuan Province, Yibin City, Yibin, Sichuan, 644000, P.R. China
| | - Guang-Yuan Zhou
- Department of Oncology, The Second People's Hospital of Sichuan Province, Yibin City, Yibin, Sichuan, 644000, P.R. China
| | - Jie Chen
- Department of Oncology, The Second People's Hospital of Sichuan Province, Yibin City, Yibin, Sichuan, 644000, P.R. China
| | - Chuan Lin
- Department of Oncology, The Second People's Hospital of Sichuan Province, Yibin City, Yibin, Sichuan, 644000, P.R. China
| | - Zhi-Ping Yuan
- Department of Hematology, The First Affiliated Hospital of Southwest Medical University, Luzhou, Sichuan, 646000, P.R. China.,Department of Oncology, The Second People's Hospital of Sichuan Province, Yibin City, Yibin, Sichuan, 644000, P.R. China
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Xi KX, Wen YS, Zhu CM, Yu XY, Qin RQ, Zhang XW, Lin YB, Rong TH, Wang WD, Chen YQ, Zhang LJ. Tumor-stroma ratio (TSR) in non-small cell lung cancer (NSCLC) patients after lung resection is a prognostic factor for survival. J Thorac Dis 2017; 9:4017-4026. [PMID: 29268412 DOI: 10.21037/jtd.2017.09.29] [Citation(s) in RCA: 48] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Background In recent years, the tumor-stroma ratio (TSR) has been considered to a new and independent predictive variable for the prognosis of some kinds of neoplasms. The objective of this study was to assess the prognostic significance of the TSR in non-small cell lung cancer (NSCLC). Methods A cohort of 261 NSCLC patients who underwent radical surgery of lung cancer were included in the present study. Two independent observers visually estimated the TSR on hematoxylin-eosin (H&E) stained tissue pathological slices. According to the proportion of stroma ≥50% or <50%, We separate the patients into two groups: those with stroma-poor and those with stroma-rich tumors. Results Both univariate and multivariate analyses disclosed that the TSR was associated with overall survival (OS) [hazard ratio (HR), 1.741; 95% confidence intervals (CI), 1.040-2.913 and HR, 1.904; 95% CI, 1.132-3.202, respectively]. The HR values for disease-free survival (DFS) were 1.795 (95% CI, 1.073-3.005) and 2.034 (95% CI, 1.210-3.420). The OS and DFS of patients with stroma-poor tumors were better than those with stroma-rich tumors. Conclusions These results demonstrated that the TSR is a new prognostic factor for NSCLC. Stroma-poor tumors were associated with longer disease-free period and better prognosis than were stroma-rich tumors in NSCLC patients. The TSR may contribute to the development of individualized treatment for NSCLC in the future.
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Affiliation(s)
- Ke-Xing Xi
- Department of Thoracic Surgery, Sun Yat-sen University Cancer Center, Guangzhou 510060, China.,State Key Laboratory of Oncology in South China, Collaborative Innovation Center for Cancer Medicine, Guangzhou 510060, China
| | - Ying-Sheng Wen
- Department of Thoracic Surgery, Sun Yat-sen University Cancer Center, Guangzhou 510060, China.,State Key Laboratory of Oncology in South China, Collaborative Innovation Center for Cancer Medicine, Guangzhou 510060, China
| | - Chong-Mei Zhu
- State Key Laboratory of Oncology in South China, Collaborative Innovation Center for Cancer Medicine, Guangzhou 510060, China.,Department of Pathology, Sun Yat-sen University Cancer Center, Guangzhou 510060, China
| | - Xiang-Yang Yu
- Department of Thoracic Surgery, Sun Yat-sen University Cancer Center, Guangzhou 510060, China.,State Key Laboratory of Oncology in South China, Collaborative Innovation Center for Cancer Medicine, Guangzhou 510060, China
| | - Rong-Qing Qin
- Department of Medical Oncology, The Affiliated Hospital Of Hangzhou Normal University, Hangzhou 310015, China
| | - Xue-Wen Zhang
- State Key Laboratory of Oncology in South China, Collaborative Innovation Center for Cancer Medicine, Guangzhou 510060, China.,Department of Medical Oncology, Sun Yat-sen University Cancer Center, Guangzhou 510060, China
| | - Yong-Bin Lin
- Department of Thoracic Surgery, Sun Yat-sen University Cancer Center, Guangzhou 510060, China.,State Key Laboratory of Oncology in South China, Collaborative Innovation Center for Cancer Medicine, Guangzhou 510060, China
| | - Tie-Hua Rong
- Department of Thoracic Surgery, Sun Yat-sen University Cancer Center, Guangzhou 510060, China.,State Key Laboratory of Oncology in South China, Collaborative Innovation Center for Cancer Medicine, Guangzhou 510060, China
| | - Wei-Dong Wang
- Department of Thoracic Surgery, Sun Yat-sen University Cancer Center, Guangzhou 510060, China.,State Key Laboratory of Oncology in South China, Collaborative Innovation Center for Cancer Medicine, Guangzhou 510060, China
| | - Yong-Qiang Chen
- Department of Thoracic Surgery, Sun Yat-sen University Cancer Center, Guangzhou 510060, China.,State Key Laboratory of Oncology in South China, Collaborative Innovation Center for Cancer Medicine, Guangzhou 510060, China
| | - Lan-Jun Zhang
- Department of Thoracic Surgery, Sun Yat-sen University Cancer Center, Guangzhou 510060, China.,State Key Laboratory of Oncology in South China, Collaborative Innovation Center for Cancer Medicine, Guangzhou 510060, China
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Dou YN, Chaudary N, Chang MC, Dunne M, Huang H, Jaffray DA, Milosevic M, Allen C. Tumor microenvironment determines response to a heat-activated thermosensitive liposome formulation of cisplatin in cervical carcinoma. J Control Release 2017; 262:182-191. [PMID: 28760449 DOI: 10.1016/j.jconrel.2017.07.039] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2017] [Revised: 07/25/2017] [Accepted: 07/28/2017] [Indexed: 01/02/2023]
Abstract
Significant heterogeneity in the tumor microenvironment of human cervical cancer patients is known to challenge treatment outcomes in this population. The current standard of care for cervical cancer patients is radiation therapy and concurrent cisplatin (CDDP) chemotherapy. Yet this treatment strategy fails to control loco-regional disease in 10-30% of patients. In order to improve the loco-regional control rate, a thermosensitive liposome formulation of CDDP (HTLC) was developed to increase local concentrations of drug in response to mild hyperthermia (HT). The HTLC formulation in combination with local HT demonstrated a significant therapeutic advantage in comparison to free drug and Lipoplatin™ in ME-180 and SiHa xenograft models of human cervical cancer, as well as in four distinct cervical patient-derived xenograft models. Differential response to HTLC+HT treatment was observed between the ME-180 and SiHa tumor models. Tumor doubling time, in vitro cell sensitivity, and tumor drug accumulation were found to be non-predictive of treatment efficacy. Rather, tumor microenvironment parameters, in particular elevated levels of both tumor hypoxia and associated stromal content, were found to serve as the overriding factors that limit drug efficacy. The prognostic value of these markers may enable stratification of cervical cancer patients for implementation of personalized medicine in the clinical setting.
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Affiliation(s)
- Yannan N Dou
- Leslie Dan Faculty of Pharmacy, University of Toronto, Toronto, ON M5S 3M2, Canada
| | - Naz Chaudary
- Ontario Cancer Institute, Princess Margaret Cancer Center and The Campbell Family Institute for Cancer Research, Toronto, ON M5G 0A3, Canada
| | - Martin C Chang
- Department of Pathology and Laboratory Medicine, Mount Sinai Hospital, Toronto, ON M5G 1X5, Canada; Department of Laboratory Medicine and Pathobiology, University of Toronto, Toronto, ON M5S 1A8, Canada
| | - Michael Dunne
- Leslie Dan Faculty of Pharmacy, University of Toronto, Toronto, ON M5S 3M2, Canada
| | - Huang Huang
- Dalla Lana School of Public Health, University of Toronto, Toronto, ON M5T 3M7, Canada
| | - David A Jaffray
- Techna Institute, University Health Network, Toronto, ON M5G 1L5, Canada; Department of Radiation Oncology, University of Toronto, ON M5S 3E2, Canada
| | - Michael Milosevic
- Department of Radiation Oncology, University of Toronto, ON M5S 3E2, Canada; Radiation Medicine Program, Princess Margaret Cancer Center, University Health Network, Toronto, ON M5G 2M9, Canada
| | - Christine Allen
- Leslie Dan Faculty of Pharmacy, University of Toronto, Toronto, ON M5S 3M2, Canada.
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Aurello P, Berardi G, Giulitti D, Palumbo A, Tierno SM, Nigri G, D'Angelo F, Pilozzi E, Ramacciato G. Tumor-Stroma Ratio is an independent predictor for overall survival and disease free survival in gastric cancer patients. Surgeon 2017. [PMID: 28629870 DOI: 10.1016/j.surge.2017.05.007] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
BACKGROUND Despite different prognostic factors have been already studied, patients undergoing potentially curative resection for gastric cancer, still have a poor outcome. There is therefore the need to identify novel prognostic factors. Recently, Tumor-Stroma Ratio (TSR) was proven to be associated with prognosis in different types of cancers. Aim of this study was to evaluate the prognostic value of TSR in gastric cancer patients. METHODS 106 patients underwent gastrectomy between January 2004 and December 2015. Demographics and histopathological characteristics were collected. We considered a 50% TSR cutoff value to divide patients in Stroma-Rich (≥50%) and Stroma-Poor (<50%) groups. RESULTS Forty-one (38.7%) patients were classified as Stroma-Poor while 65 (61.3%) as Stroma-Rich (61.3%). The Stroma-Rich patients had a higher number of positive lymph-nodes, lymph node ratio (LNR), a higher percentage of T3/T4 local invasion and N2/N3, and a more advanced TNM. Moreover, these patients showed a higher percentage of lymphovascular and perineural invasion. With a median FU of 38 months Stroma-Rich patients had a significantly worse 5-years actuarial overall survival (OS) and disease free survival (DFS) compared to Stroma-Poor patients. Moreover, the multivariate analysis showed that Stroma-Rich was the only independent factor associated with OS and DFS together with TNM-Stage. CONCLUSIONS TSR is an independent marker of poor prognosis in patients with gastric cancer that should be readily incorporated into routine clinical pathology reporting. Identification of sensitive markers for patients who had undergone curative gastrectomy and who are at high risk of recurrence could provide useful information for planning follow-up after surgery or intensive and or/targeting adjuvant chemotherapy.
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Affiliation(s)
- Paolo Aurello
- Department of General Surgery, University of Rome, "La Sapienza", Sant'Andrea Hospital, Via di Grottarossa, 1035-1039, 00189, Rome, Italy
| | - Giammauro Berardi
- Department of General Surgery, University of Rome, "La Sapienza", Sant'Andrea Hospital, Via di Grottarossa, 1035-1039, 00189, Rome, Italy.
| | - Diego Giulitti
- Department of General Surgery, University of Rome, "La Sapienza", Sant'Andrea Hospital, Via di Grottarossa, 1035-1039, 00189, Rome, Italy
| | - Antonio Palumbo
- Department of Pathology, University of Rome, "La Sapienza", Sant'Andrea Hospital, Via di Grottarossa, 1035-1039, 00189, Rome, Italy
| | - Simone Maria Tierno
- Department of General Surgery, University of Rome, "La Sapienza", Sant'Andrea Hospital, Via di Grottarossa, 1035-1039, 00189, Rome, Italy
| | - Giuseppe Nigri
- Department of General Surgery, University of Rome, "La Sapienza", Sant'Andrea Hospital, Via di Grottarossa, 1035-1039, 00189, Rome, Italy
| | - Francesco D'Angelo
- Department of General Surgery, University of Rome, "La Sapienza", Sant'Andrea Hospital, Via di Grottarossa, 1035-1039, 00189, Rome, Italy
| | - Emanuela Pilozzi
- Department of Pathology, University of Rome, "La Sapienza", Sant'Andrea Hospital, Via di Grottarossa, 1035-1039, 00189, Rome, Italy
| | - Giovanni Ramacciato
- Department of General Surgery, University of Rome, "La Sapienza", Sant'Andrea Hospital, Via di Grottarossa, 1035-1039, 00189, Rome, Italy
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Are disseminated tumor cells in bone marrow and tumor-stroma ratio clinically applicable for patients undergoing surgical resection of primary colorectal cancer? The Leiden MRD study. Cell Oncol (Dordr) 2016; 39:537-544. [PMID: 27613548 PMCID: PMC5121180 DOI: 10.1007/s13402-016-0296-2] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/26/2016] [Indexed: 02/07/2023] Open
Abstract
Purpose Current TNM staging does not appropriately identify high-risk colorectal cancer (CRC) patients. The aim of this study was to evaluate whether the presence of disseminated tumor cells (DTCs) in the bone marrow (BM) and the presence of stroma in the primary tumor, i.e., the tumor-stroma ratio (TSR), in patients undergoing surgical resection of primary CRC provides information relevant for disease outcome. Methods Patients with primary CRC (n = 125), consecutively admitted for curative resection between 2001 and 2007, were included in the study. All patients underwent BM aspiration before surgery. Detection of tumor cells was performed using immunocytochemical staining for cytokeratin (CK-ICC). The TSR was determined on diagnostic H&E stained sections of primary tumors. Results DTCs were detected in the BM of 23/125 patients (18 %). No association was found between BM status and overall survival (HR 0.97 (95 % CI 0.45–2.09), p = 0.93). Also, no significant difference was found in their 5-year survival rate (resp. 72 % and 68 % for BM-positive versus BM-negative patients). The TSR was found to be associated with a worse overall survival (HR 2.16, 95 % CI 1.02–4.57, p = 0.04) with 5-year survival rates of 84 % versus 62 % for stroma-low and stroma-high patients, respectively. No relation was found between the presence of DTCs and TSR. Conclusions Our data indicate that the presence of DTCs in the BM of CRC patients is not associated with disease outcome. The TSR was, however, found to be associated with a worse overall survival, which indicates that for CRC the tumor microenvironment plays an important role in its behavior and prognosis.
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Kather JN, Weis CA, Bianconi F, Melchers SM, Schad LR, Gaiser T, Marx A, Zöllner FG. Multi-class texture analysis in colorectal cancer histology. Sci Rep 2016; 6:27988. [PMID: 27306927 PMCID: PMC4910082 DOI: 10.1038/srep27988] [Citation(s) in RCA: 148] [Impact Index Per Article: 18.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2016] [Accepted: 05/25/2016] [Indexed: 02/08/2023] Open
Abstract
Automatic recognition of different tissue types in histological images is an essential part in the digital pathology toolbox. Texture analysis is commonly used to address this problem; mainly in the context of estimating the tumour/stroma ratio on histological samples. However, although histological images typically contain more than two tissue types, only few studies have addressed the multi-class problem. For colorectal cancer, one of the most prevalent tumour types, there are in fact no published results on multiclass texture separation. In this paper we present a new dataset of 5,000 histological images of human colorectal cancer including eight different types of tissue. We used this set to assess the classification performance of a wide range of texture descriptors and classifiers. As a result, we found an optimal classification strategy that markedly outperformed traditional methods, improving the state of the art for tumour-stroma separation from 96.9% to 98.6% accuracy and setting a new standard for multiclass tissue separation (87.4% accuracy for eight classes). We make our dataset of histological images publicly available under a Creative Commons license and encourage other researchers to use it as a benchmark for their studies.
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Affiliation(s)
- Jakob Nikolas Kather
- Institute of Pathology, University Medical Center Mannheim, Heidelberg University, Mannheim, Germany
- Institute of Computer Assisted Clinical Medicine, Medical Faculty Mannheim, Heidelberg University, Mannheim, Germany
| | - Cleo-Aron Weis
- Institute of Pathology, University Medical Center Mannheim, Heidelberg University, Mannheim, Germany
| | | | - Susanne M. Melchers
- Department of Dermatology, Venereology and Allergology, University Medical Center Mannheim, Heidelberg University, Mannheim, Germany
| | - Lothar R. Schad
- Institute of Computer Assisted Clinical Medicine, Medical Faculty Mannheim, Heidelberg University, Mannheim, Germany
| | - Timo Gaiser
- Institute of Pathology, University Medical Center Mannheim, Heidelberg University, Mannheim, Germany
| | - Alexander Marx
- Institute of Pathology, University Medical Center Mannheim, Heidelberg University, Mannheim, Germany
| | - Frank Gerrit Zöllner
- Institute of Computer Assisted Clinical Medicine, Medical Faculty Mannheim, Heidelberg University, Mannheim, Germany
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Roh JW, Lee DO, Suh DH, Lim MC, Seo SS, Chung J, Lee S, Park SY. Efficacy and oncologic safety of nerve-sparing radical hysterectomy for cervical cancer: a randomized controlled trial. J Gynecol Oncol 2016; 26:90-9. [PMID: 25872890 PMCID: PMC4397238 DOI: 10.3802/jgo.2015.26.2.90] [Citation(s) in RCA: 42] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2015] [Revised: 03/10/2015] [Accepted: 03/10/2015] [Indexed: 11/30/2022] Open
Abstract
OBJECTIVE A prospective, randomized controlled trial was conducted to evaluate the efficacy of nerve-sparing radical hysterectomy (NSRH) in preserving bladder function and its oncologic safety in the treatment of cervical cancer. METHODS From March 2003 to November 2005, 92 patients with cervical cancer stage IA2 to IIA were randomly assigned for surgical treatment with conventional radical hysterectomy (CRH) or NSRH, and 86 patients finally included in the analysis. Adequacy of nerve sparing, radicality, bladder function, and oncologic safety were assessed by quantifying the nerve fibers in the paracervix, measuring the extent of paracervix and harvested lymph nodes (LNs), urodynamic study (UDS) with International Prostate Symptom Score (IPSS), and 10-year disease-free survival (DFS), respectively. RESULTS There were no differences in clinicopathologic characteristics between two groups. The median number of nerve fiber was 12 (range, 6 to 21) and 30 (range, 17 to 45) in the NSRH and CRH, respectively (p<0.001). The extent of resected paracervix and number of LNs were not different between the two groups. Volume of residual urine and bladder compliance were significantly deteriorated at 12 months after CRH. On the contrary, all parameters of UDS were recovered no later than 3 months after NSRH. Evaluation of the IPSS showed that the frequency of long-term urinary symptom was higher in CRH than in the NSRH group. The median duration before the postvoid residual urine volume became less than 50 mL was 11 days (range, 7 to 26 days) in NSRH group and was 18 days (range, 10 to 85 days) in CRH group (p<0.001). No significant difference was observed in the 10-year DFS between two groups. CONCLUSION NSRH appears to be effective in preserving bladder function without sacrificing oncologic safety.
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Affiliation(s)
- Ju Won Roh
- Department of Obstetrics and Gynecology, Dongguk University Ilsan Hospital, Dongguk University College of Medicine, Goyang, Korea
| | - Dong Ock Lee
- Center for Uterine Cancer, Research Institute and Hospital, National Cancer Center, Goyang, Korea
| | - Dong Hoon Suh
- Department of Obstetrics and Gynecology, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam, Korea
| | - Myong Cheol Lim
- Center for Uterine Cancer, Research Institute and Hospital, National Cancer Center, Goyang, Korea
| | - Sang Soo Seo
- Center for Uterine Cancer, Research Institute and Hospital, National Cancer Center, Goyang, Korea
| | - Jinsoo Chung
- Department of Urology, Center for Prostate Cancer, National Cancer Center, Goyang, Korea
| | - Sun Lee
- Department of Pathology, Kyung Hee University School of Medicine, Seoul, Korea
| | - Sang Yoon Park
- Center for Uterine Cancer, Research Institute and Hospital, National Cancer Center, Goyang, Korea.
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Panayiotou H, Orsi NM, Thygesen HH, Wright AI, Winder M, Hutson R, Cummings M. The prognostic significance of tumour-stroma ratio in endometrial carcinoma. BMC Cancer 2015; 15:955. [PMID: 26674153 PMCID: PMC4682261 DOI: 10.1186/s12885-015-1981-7] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2015] [Accepted: 12/05/2015] [Indexed: 11/28/2022] Open
Abstract
Background High tumour stromal content has been found to predict adverse clinical outcome in a range of epithelial tumours. The aim of this study was to assess the prognostic significance of tumour-stroma ratio (TSR) in endometrial adenocarcinomas and investigate its relationship with other clinicopathological parameters. Methods Clinicopathological and 5-year follow-up data were obtained for a retrospective series of endometrial adenocarcinoma patients (n = 400). TSR was measured using a morphometric approach (point counting) on digitised histologic hysterectomy specimens. Inter-observer agreement was determined using Cohen’s Kappa statistic. TSR cut-offs were optimised using log-rank functions and prognostic significance of TSR on overall survival (OS) and disease-free survival (DFS) were determined using Cox Proportional Hazards regression analysis and Kaplan-Meier curves generated. Associations of TSR with other clinicopathological parameters were determined using non-parametric tests followed by Holm-Bonferroni correction for multiple comparisons. Results TSR as a continuous variable associated with worse OS (P = 0.034) in univariable Cox-regression analysis. Using the optimal cut-off TSR value of 1.3, TSR-high (i.e. low stroma) was associated with worse OS (HR = 2.51; 95 % CI = 1.22–5.12; P = 0.021) and DFS (HR = 2.19; 95 % CI = 1.15–4.17; P = 0.017) in univariable analysis. However, TSR did not have independent prognostic significance in multivariable analysis, when adjusted for known prognostic variables. A highly significant association was found between TSR and tumour grade (P < 0.001) and lymphovascular space invasion (P < 0.001), both of which had independent prognostic significance in this study population. Conclusions Low tumour stromal content associates with both poor outcome and with other adverse prognostic indicators in endometrial cancer, although it is not independently prognostic. These findings contrast with studies on many - although not all - cancers and suggest that the biology of tumour-stroma interactions may differ amongst cancer types.
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Affiliation(s)
- Hannah Panayiotou
- Section of Pathology and Tumour Biology, Leeds Institute of Cancer & Pathology, University of Leeds, St James's University Hospital, Leeds, LS9 7TF, UK.
| | - Nicolas M Orsi
- Section of Pathology and Tumour Biology, Leeds Institute of Cancer & Pathology, University of Leeds, St James's University Hospital, Leeds, LS9 7TF, UK.
| | - Helene H Thygesen
- Netherlands Cancer Institute, Plesmanlaan 121, 1066 CX, Amsterdam, Netherlands.
| | - Alexander I Wright
- Section of Pathology and Tumour Biology, Leeds Institute of Cancer & Pathology, University of Leeds, St James's University Hospital, Leeds, LS9 7TF, UK.
| | - Matthew Winder
- Section of Pathology and Tumour Biology, Leeds Institute of Cancer & Pathology, University of Leeds, St James's University Hospital, Leeds, LS9 7TF, UK.
| | - Richard Hutson
- Section of Pathology and Tumour Biology, Leeds Institute of Cancer & Pathology, University of Leeds, St James's University Hospital, Leeds, LS9 7TF, UK.
| | - Michele Cummings
- Section of Pathology and Tumour Biology, Leeds Institute of Cancer & Pathology, University of Leeds, St James's University Hospital, Leeds, LS9 7TF, UK.
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Prognostic Significance of the Tumor-Stroma Ratio in Epithelial Ovarian Cancer. BIOMED RESEARCH INTERNATIONAL 2015; 2015:589301. [PMID: 26609529 PMCID: PMC4644548 DOI: 10.1155/2015/589301] [Citation(s) in RCA: 37] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/06/2015] [Revised: 08/31/2015] [Accepted: 08/31/2015] [Indexed: 11/17/2022]
Abstract
Tumor-stroma ratio (TSR) has recently been identified as a promising prognostic parameter for several solid tumors. This study aimed to evaluate the prognostic role of TSR in epithelial ovarian cancer (EOC) and 838 EOC patients were enrolled in this study. TSR was estimated on hematoxylin-and-eosin-stained tissue sections from the most invasive part of the primary tumor. Patients were classified as stroma-rich or stroma-poor according to the proportion of stroma ≥50% or <50%. Chi-square test analysis revealed that TSR were significantly associated with FIGO stage, LN status, and recurrence or not (all of them P < 0.001). The higher stroma-rich proportions were found in EOC patients with advanced stage (36.13% versus 19.75%), LN metastasis (51.93% versus 27.25%), and recurrence (34.27% versus 6.82%). Stroma-rich EOC patients had obvious shorter median time of progression-free survival (29 versus 39 months) and overall survival (50 versus 58 months), respectively. TSR was an independent prognostic factor for the evaluation of PFS in EOC. Stroma-rich tumors had worse prognosis and higher risk of relapse compared with those in stroma-poor tumors in EOC patients. Considered easy to determine for routine pathological examination, TSR may serve as a new prognostic histological parameter in EOC.
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Drifka CR, Tod J, Loeffler AG, Liu Y, Thomas GJ, Eliceiri KW, Kao WJ. Periductal stromal collagen topology of pancreatic ductal adenocarcinoma differs from that of normal and chronic pancreatitis. Mod Pathol 2015; 28:1470-80. [PMID: 26336888 DOI: 10.1038/modpathol.2015.97] [Citation(s) in RCA: 96] [Impact Index Per Article: 10.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2015] [Accepted: 07/16/2015] [Indexed: 12/12/2022]
Abstract
Pancreatic ductal adenocarcinoma continues to be one of the most difficult diseases to manage with one of the highest cancer mortality rates. This is due to several factors including nonspecific symptomatology and subsequent diagnosis at an advanced stage, aggressive metastatic behavior that is incompletely understood, and limited response to current therapeutic regimens. As in other cancers, there is great interest in studying the role of the tumor microenvironment in pancreatic ductal adenocarcinoma and whether components of this environment could serve as research and therapeutic targets. In particular, attention has turned toward the desmoplastic collagen-rich pancreatic ductal adenocarcinoma stroma for both biological and clinical insight. In this study, we used quantitative second harmonic generation microscopy to investigate stromal collagen organization and structure in human pancreatic ductal adenocarcinoma pathology tissues compared with non-neoplastic tissues. Collagen topology was characterized in whole-tissue microarray cores and at specific pathology-annotated epithelial-stroma interfaces representing 241 and 117 patients, respectively. We quantitatively demonstrate that a unique collagen topology exists in the periductal pancreatic ductal adenocarcinoma stroma. Specifically, collagen around malignant ducts shows increased alignment, length, and width compared with normal ducts and benign ducts in a chronic pancreatitis background. These findings indicate that second harmonic generation imaging can provide quantitative information about fibrosis that complements traditional histopathologic insights and can serve as a rich field for investigation into pathogenic and clinical implications of reorganized collagen as a pancreatic ductal adenocarcinoma disease marker.
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Affiliation(s)
- Cole R Drifka
- Department of Biomedical Engineering, University of Wisconsin, Madison, WI, USA.,Laboratory for Optical and Computational Instrumentation, University of Wisconsin, Madison, WI, USA
| | - Jo Tod
- Cancer Sciences Unit, University of Southampton, Southampton, UK
| | - Agnes G Loeffler
- Department of Pathology, University of Wisconsin, Madison, WI, USA.,Paul P. Carbone Comprehensive Cancer Center, University of Wisconsin, Madison, WI, USA
| | - Yuming Liu
- Laboratory for Optical and Computational Instrumentation, University of Wisconsin, Madison, WI, USA
| | - Gareth J Thomas
- Cancer Sciences Unit, University of Southampton, Southampton, UK
| | - Kevin W Eliceiri
- Department of Biomedical Engineering, University of Wisconsin, Madison, WI, USA.,Laboratory for Optical and Computational Instrumentation, University of Wisconsin, Madison, WI, USA.,Paul P. Carbone Comprehensive Cancer Center, University of Wisconsin, Madison, WI, USA
| | - W John Kao
- Department of Biomedical Engineering, University of Wisconsin, Madison, WI, USA.,Laboratory for Optical and Computational Instrumentation, University of Wisconsin, Madison, WI, USA.,Paul P. Carbone Comprehensive Cancer Center, University of Wisconsin, Madison, WI, USA.,Department of Surgery, University of Wisconsin, Madison, WI, USA.,School of Pharmacy, University of Wisconsin, Madison, WI, USA
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50
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Lv Z, Cai X, Weng X, Xiao H, Du C, Cheng J, Zhou L, Xie H, Sun K, Wu J, Zheng S. Tumor-stroma ratio is a prognostic factor for survival in hepatocellular carcinoma patients after liver resection or transplantation. Surgery 2015; 158:142-50. [PMID: 25890776 DOI: 10.1016/j.surg.2015.02.013] [Citation(s) in RCA: 41] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2014] [Revised: 01/16/2015] [Accepted: 02/15/2015] [Indexed: 02/08/2023]
Abstract
BACKGROUND The stromal compartment in several organs seems to play an important role in the initiation, growth, and progression of certain neoplasms. The tumor-stroma ratio (TSR) has been found to be an independent factor for prognosis of several types of carcinomas, but the effect of the TSR on hepatocellular carcinoma (HCC) has not been explored yet. The objective of the study is to evaluate the prognostic importance of TSR in HCC patients after liver resection or transplantation. METHODS A total of 300 patients with HCC who underwent liver resection or transplantation were included in this study. TSR was assessed on hematoxylin and eosin-stained sections by 2 independent investigators. Patients were divided into 2 groups: a stroma-rich group (stroma ≥ 50%) and a stroma-poor group (stroma < 50%). Chi-square test, Kaplan-Meier method, and Cox univariable and multivariable regression were used in to analyze the data. RESULTS Among the post liver resection patients, the TSR was associated with overall survival (OS) in univariate and multivariate analyses (hazard ratio [HR], 4.35 [95% CI, 2.54-7.47] and HR, 2.55 [95% CI, 1.44-4.52], respectively). Among the post liver transplant patients, the TSR was also associated with OS in univariate and multivariate analyses (HR, 2.92 [95% CI, 1.63-5.23] and HR, 2.76 [95% CI, 1.47-4.85], respectively), and TSR with recurrence-free survival (RFS) in univariate and multivariate analyses (HR, 2.63 [95% CI, 1.42-4.86] and HR, 1.93 [95% CI, 1.03-3.62], respectively). Patients with stroma-poor tumor and who were within the Milan criteria or the UCSF criteria had a better in OS and RFS. CONCLUSION We show for the first time that TSR is an independent prognostic factor for HCC patients after liver resection or transplantation. TSR may enable better identification of patients at risk for recurrence in HCC patients after curative treatment and may aid in patient management and development of individualized medicine for treatment of HCC.
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Affiliation(s)
- Zhen Lv
- Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, First Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China; Collaborative Innovation Center of Diagnosis and Treatment of Infectious Diseases, Hangzhou, China
| | - Xianlei Cai
- Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, First Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China; Key Laboratory of Combined Multi-Organ Transplantation, Ministry of Public, Hangzhou, China
| | - Xiaoyu Weng
- Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, First Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China; Collaborative Innovation Center of Diagnosis and Treatment of Infectious Diseases, Hangzhou, China
| | - Heng Xiao
- Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, First Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China; Collaborative Innovation Center of Diagnosis and Treatment of Infectious Diseases, Hangzhou, China
| | - Chengli Du
- Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, First Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China; Collaborative Innovation Center of Diagnosis and Treatment of Infectious Diseases, Hangzhou, China
| | - Jun Cheng
- Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, First Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China; Collaborative Innovation Center of Diagnosis and Treatment of Infectious Diseases, Hangzhou, China
| | - Lin Zhou
- Collaborative Innovation Center of Diagnosis and Treatment of Infectious Diseases, Hangzhou, China
| | - Haiyang Xie
- Collaborative Innovation Center of Diagnosis and Treatment of Infectious Diseases, Hangzhou, China; Key Laboratory of Combined Multi-Organ Transplantation, Ministry of Public, Hangzhou, China
| | - Ke Sun
- Department of Pathology, First Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China
| | - Jian Wu
- Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, First Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China; Collaborative Innovation Center of Diagnosis and Treatment of Infectious Diseases, Hangzhou, China; Key Laboratory of Combined Multi-Organ Transplantation, Ministry of Public, Hangzhou, China.
| | - Shusen Zheng
- Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, First Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China; Collaborative Innovation Center of Diagnosis and Treatment of Infectious Diseases, Hangzhou, China; Key Laboratory of Combined Multi-Organ Transplantation, Ministry of Public, Hangzhou, China.
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