Tumor and Peripheral Immune Status in Soft Tissue Sarcoma: Implications for Immunotherapy

Molecular pathways and therapeutic strategies in dermatofibrosarcoma protuberans (DFSP): unravelling the tumor's genetic landscape

Dermatofibrosarcoma Protuberans (DFSP) is a rare soft tissue sarcoma distinguished by its infiltrative growth pattern and recurrence potential. Understanding the molecular characteristics of DFSP is essential for enhancing its diagnosis, prognosis, and treatment strategies. The paper provides an overview of DFSP, highlighting the significance of its molecular understanding. The gene expression profiling has uncovered unique molecular signatures in DFSP, highlighting its heterogeneity and potential therapeutic targets. The Platelet-Derived Growth Factor Receptors (PDGFRs) and Fibroblast Growth Factor Receptors (FGFRs) signaling pathways play essential roles in the progression and development of DFSP. The abnormal activation of these pathways presents opportunities for therapeutic interventions. Several emerging therapies, i.e., immunotherapies, immunomodulatory strategies, and immune checkpoint inhibitors, offer promising alternatives to surgical resection. In DFSP management, combination strategies, including rational combination therapies, aim to exploit the synergistic effects and overcome resistance. The article consisting future perspectives and challenges includes the discovery of prognostic and predictive biomarkers to improve risk stratification and treatment selection. Preclinical models, such as Patient-derived xenografts (PDX) and genetically engineered mouse models, help study the biology of DFSP and evaluate therapeutic interventions. The manuscript also covers small-molecule inhibitors, clinical trials, immune checkpoint inhibitors for DFSP treatment, combination therapies, rational therapies, and resistance mechanisms, which are unique and not broadly covered in recent pieces of literature. See also the graphical abstract(Fig. 1).

Immune Cells in the Tumor Microenvironment of Soft Tissue Sarcomas

Soft tissue sarcomas (STSs) are a rare heterogeneous group of malignant neoplasms characterized by their aggressive course and poor response to treatment. This determines the relevance of research aimed at studying the pathogenesis of STSs. By now, it is known that STSs is characterized by complex relationships between the tumor cells and immune cells of the microenvironment. Dynamic interactions between tumor cells and components of the microenvironment enhance adaptation to changing environmental conditions, which provides the high aggressive potential of STSs and resistance to antitumor therapy. Today, active research is being conducted to find effective antitumor drugs and to evaluate the possibility of using therapy with immune cells of STS. The difficulty in assessing the efficacy of new antitumor options is primarily due to the high heterogeneity of this group of malignant neoplasms. Studying the role of immune cells in the microenvironment in the progression STSs and resistance to antitumor therapies will provide the discovery of new biomarkers of the disease and the prediction of response to immunotherapy. In addition, it will help to initially divide patients into subgroups of good and poor response to immunotherapy, thus avoiding wasting precious time in selecting the appropriate antitumor agent.

Prognostic impact of the post-treatment T cell composition and spatial organization in soft tissue sarcoma patients treated with neoadjuvant hyperthermic radio(chemo)therapy

Soft tissue sarcomas (STS) form a heterogeneous group of tumors sharing a mesenchymal origin. Despite good local control of the disease, the occurrence of distant metastases often limits survival of STS patients with localized, high-risk tumors of the extremities. Accumulating evidence suggests a central role for the tumor immune microenvironment in determining the clinical outcome and response to therapy. Thus, it has been reported that STS patients with a high immune signature and especially presence of B cells and tertiary lymphoid structures display improved overall survival and response to checkpoint inhibitor treatment. Here, we explored the effect of curative multimodal therapy on the T cell landscape of STS using multiplex immunohistochemistry. We analyzed the phenotype, frequency, and spatial distribution of STS-infiltrating CD8⁺ T cells by staining for CD8, 4-1BB, Granzyme B, Ki67, PD-1, and LAG-3 as well as CD3⁺ T helper cells using a panel consisting of CD3, T-bet, GATA3, RORγT, FoxP3, and Ki67. All patients received neoadjuvant radiotherapy plus locoregional hyperthermia with or without chemotherapy. While the treatment-naïve biopsy sample allows an analysis of baseline T cell infiltration levels, both intra- and peritumoral areas of the matched resected tissue were analyzed to assess composition and spatial distribution of the T cell compartment and its therapeutic modulation. Generally, post-treatment tissues displayed lower frequencies of CD3⁺ and CD8⁺ T cells. Association with clinical data revealed that higher post-treatment frequencies of peritumoral and intratumoral CD3⁺ T cells and intratumoral PD-1⁺ CD8⁺ T cells were significantly associated with improved disease-free survival (DFS), while these densities had no prognostic significance in the biopsy. Upon spatial analysis, a high ratio of intratumoral to peritumoral CD8⁺ T cells emerged as an independent prognostic marker for longer DFS. These results indicate that the STS T cell landscape is altered by multimodal therapy and may influence the clinical outcome of patients. An enhanced understanding of the STS immune architecture and its modulation by neoadjuvant therapy may pave the way towards novel treatment modalities and improve the long-term clinical outcome of STS patients.

Macrophage Biomarkers sCD163 and sSIRPα in Serum Predict Mortality in Sarcoma Patients

Most soft tissue sarcoma (STS) patients do not respond to traditional checkpoint inhibitor treatment, which may be due to infiltrating immunosuppressive tumour-associated macrophages. This study investigated the prognostic value of four serum macrophage biomarkers. Methods: Blood samples were taken from 152 patients with STS at the time of diagnosis; clinical data were prospectively collected. The concentrations of four macrophage biomarkers (sCD163, sCD206, sSIRPα, sLILRB1) were measured in serum, dichotomised based on median concentration, and evaluated either individually or when combined with established prognostic markers. Results: All macrophage biomarkers were prognostic of overall survival (OS). However, only sCD163 and sSIRPα were prognostic for recurrent disease (sCD163: hazard ratio (HR): 1.97 (95% CI: 1.10-3.51) and sSIRPα: HR: 2.09 (95% CI: 1.16-3.77)). A prognostic profile was made based on sCD163 and sSIRPα; it also included c-reactive protein and tumour grade. Patients with intermediate- or high-risk prognostic profiles (adjusted for age and tumour size) had a higher risk of recurrent disease compared to low-risk patients (HR: 2.64 (95% CI: 0.97-7.19)) and (HR 4.3 (95% CI: 1.62-11.47)), respectively. Conclusion: This study demonstrated that serum biomarkers of immunosuppressive macrophages were prognostic for OS; when combined with well-established markers of recurrence they allowed for a clinically relevant categorising of patients.

The Landscape of Immunotherapy for Retroperitoneal Sarcoma

Significant multidisciplinary scientific effort has been undertaken to understand the heterogeneous family of neoplasms that comprise soft tissue sarcomas. Within this family of neoplasms, outcomes for retroperitoneal sarcomas (RPS) are currently limited given a lack of effective therapies. In this review, we focus on immunotherapy and its relationship with the common RPS histologic subtypes. Although initial outcomes for RPS patients with immune checkpoint inhibition alone have been somewhat disappointing, subsequent analyses on histologies, the tumor microenvironment, sarcoma immune class, tumor infiltrating lymphocytes and genetic analysis for tumor mutational burden have yielded insight into the interplay between sarcomas and immunotherapy. Such approaches have all provided critical insight into the environment and characterization of these tumors, with targets for potential immunotherapy in future clinical trials. With this insight, molecularly tailored combination treatments for improving response rates and oncologic outcomes for RPS are promising.

The efficacies and biomarker investigations of antiangiogenic agents and PD-1 inhibitors for metastatic soft tissue sarcoma: A multicenter retrospective study

Objective

To investigate the efficacy and safety of antiangiogenesis-immunotherapy in patients with advanced STS in China, and to explore the potential factors of prognosis.

Patients and Methods

This retrospective study was conducted at three hospitals in China, and the patients with metastatic STS who were ineligible for or declined anthracycline-based chemotherapy received antiangiogenic agents (anlotinib or apatinib) plus programmed death-1 (PD-1) inhibitors (camrelizumab or sintilimab) between June 2019 and May 2022. The primary endpoint was progression-free survival rate at 6 months (6-month PFSR), and the secondary endpoints were objective response rate (ORR), disease control rate (DCR), progression-free survival (PFS), and overall survival (OS) and toxicity. Biomarkers that might affect the prognosis were explored.

Results

Thirty-nine patients were included: five patients with alveolar soft tissue sarcoma (ASPS) and 34 with non-ASPS. With a median follow-up of 18.2 months, the 6-month PFSR was 51.3%, with the ORR of 20.5% and DCR of 76.9%. The median PFS and OS were 7.0 months and 17.2 months. The 6-month PFSR for patients with ASPS and non-ASPS was 80.0% and 47.1%, respectively. The most common adverse events were hypothyroidism (56.4%), followed by fatigue (46.2%), and hypertriglyceridemia (43.6%). No treatment-related deaths were observed. Patients with low baseline NLR (NLR < 4) had better 6-month PFSR than those with high NLR (NLR ≥ 4) (82.4% vs. 31.6%).

Conclusion

Antiangiogenic agents plus PD-1 inhibitors showed acceptable toxicity and promising efficacy in patients with advanced STS, especially patients with ASPS, and a low NLR might serve as a reliable biomarker for 6-month PFSR, PFS, and OS. It provides a reference for randomized controlled trials.

Identification of hub genes correlated with tumor-associated M1-like macrophage infiltration in soft tissue sarcomas

Soft tissue sarcomas (STS) are a heterogeneous series of tumors that might result in severe disability and death. Tumor-associated M1-like macrophage infiltration plays a critical role in tumor development and progression. This study aimed at identifying the hub genes associated with M1-like macrophage infiltration in STS cells. First, the expression profiles from The Cancer Genome Atlas (TCGA) and Gene Expression Omnibus (GEO) databases were imported to calculate the level of M1-like macrophage infiltration by CIBERSORTx. Afterward, the Kaplan-Meier survival analysis was performed to evaluate the correlation between macrophage infiltration and prognosis. Then, weighted gene co-expression network analysis (WGCNA) and protein-protein interaction analysis of GEO data were applied to identify the key gene related to M1-like macrophage infiltration, followed by the functional analysis using TCGA cohort to validate downstream signaling associated with the gene. Finally, pan-cancer analysis was conducted to investigate the gene function in other types of tumors. We found LCK expression positively related to the M1-like macrophage infiltration level, and it positively regulated the expression level of genes regulated to macrophage polarization, and chemotaxis, including interferon-γ (INF-γ), interleukin-12 (IL12), tumor necrosis factor (TNF), PI3K, NF-κB, and CXCL9, 10, and 11. In summary, an 'LCK-INF-γ/IL-12-TNF/PI3K-NF-κB' axis might exist in STS cells that regulate M1-like macrophage infiltration.

Genetic Heterogeneity, Tumor Microenvironment and Immunotherapy in Triple-Negative Breast Cancer

Heterogeneity of triple-negative breast cancer is well known at clinical, histopathological, and molecular levels. Genomic instability and greater mutation rates, which may result in the creation of neoantigens and enhanced immunogenicity, are additional characteristics of this breast cancer type. Clinical outcome is poor due to early age of onset, high metastatic potential, and increased likelihood of distant recurrence. Consequently, efforts to elucidate molecular mechanisms of breast cancer development, progression, and metastatic spread have been initiated to improve treatment options and improve outcomes for these patients. The extremely complex and heterogeneous tumor immune microenvironment is made up of several cell types and commonly possesses disorganized gene expression. Altered signaling pathways are mainly associated with mutated genes including p53, PIK3CA, and MAPK, and which are positively correlated with genes regulating immune response. Of note, particular immunity-associated genes could be used in prognostic indexes to assess the most effective management. Recent findings highlight the fact that long non-coding RNAs also play an important role in shaping tumor microenvironment formation, and can mediate tumor immune evasion. Identification of molecular signatures, through the use of multi-omics approaches, and effector pathways that drive early stages of the carcinogenic process are important steps in developing new strategies for targeted cancer treatment and prevention. Advances in immunotherapy by remodeling the host immune system to eradicate tumor cells have great promise to lead to novel therapeutic strategies. Current research is focused on combining immune checkpoint inhibition with chemotherapy, PARP inhibitors, cancer vaccines, or natural killer cell therapy. Targeted therapies may improve therapeutic response, eliminate therapeutic resistance, and improve overall patient survival. In the future, these evolving advancements should be implemented for personalized medicine and state-of-art management of cancer patients.

A Newly Established Cuproptosis-Associated Long Non-Coding RNA Signature for Predicting Prognosis and Indicating Immune Microenvironment Features in Soft Tissue Sarcoma

Cuproptosis, a new type of programmed cell death, is involved in the development and progression of malignancies. The study of cuproptosis-associated long non-coding RNAs (lncRNAs) in soft tissue sarcomas (STSs) is however limited. There is also uncertainty regarding the prognostic accuracy of cuproptosis-associated lncRNAs in STSs and their relationship to the tumor immune microenvironment. The aim of this study was to determine the prognostic significance of cuprotosis-associated lncRNAs in STSs and their relationship to the tumor immune microenvironment. Transcriptomic and clinical data from patients with STSs were obtained through The Cancer Genome Atlas (TCGA). Overall, 259 patients were randomly allocated to a training group or a testing group. In the training group, a cuproptosis-associated lncRNA signature was constructed, and the signature was verified in the testing group. On the basis of risk scores and clinical features, we later developed a hybrid nomogram. We also performed functional and tumor immune microenvironment analysis based on the cuproptosis-associated lncRNA signature. A signature of 5 cuproptosis-associated lncRNAs was created. Based on this signature, we categorized STS patients into high-risk and low-risk groups. The study showed that patients at high risk had a worse prognosis than those at low risk. A nomogram was then constructed combining clinical characteristics with the risk scores, and it was shown to have credible predictive power. Functional enrichment and tumor immune microenvironmental analyses showed that high-risk STSs tend to be immunologically sensitive tumors. In our study, we found a cuproptosis-associated lncRNAs signature, which serves as an independent prognostic indicator. Cuproptosis-associated lncRNAs may play a role in the tumor immune microenvironment, which might be a therapeutic target for patients with STSs.

Progress in Applicability of Scoring Systems Based on Nutritional and Inflammatory Parameters for Ovarian Cancer

Ovarian cancer is a malignancy that seriously endangers women’s health; its case fatality rate ranks first among the gynecological malignancies. The status of nutrition of ovarian cancer patients is related to their prognoses. Thus, it is important to evaluate, monitor, and improve the nutritional status of ovarian cancer patients during their treatment. Currently, there are several tools for examining malnutrition and nutritional assessment, including NRI (nutrition risk index), PG-SGA (patient-generated subjective global assessment), and NRS 2002 (nutritional risk screening 2002). In addition to malnutrition risk examination and related assessment tools, the evaluation of muscle mass, C-reactive protein, lymphocytes, and other inflammation status indicators, such as neutrophils to lymphocytes ratio, lymphocyte-to-monocyte ratio, and C-reactive protein-albumin ratio, is of great importance. The nutritional status of ovarian cancer patients undergoing surgery affects their postoperative complications and survival rates. Accurate evaluation of perioperative nutrition in ovarian cancer patients is crucial in clinical settings. An intelligent nutritional diagnosis can be developed based on the results of its systematic and comprehensive assessment, which would lay a foundation for the implementation of personalized and precise nutritional therapy.

A web-based calculator for predicting the prognosis of patients with sarcoma on the basis of antioxidant gene signatures

Background: Oxidative stress plays a critical role in tumorigenesis, tumor development, and resistance to therapy. A systematic analysis of the interactions between antioxidant gene expression and the prognosis of patients with sarcoma is lacking but urgently needed.

Methods: Gene expression and clinical data of patients with sarcoma were derived from The Cancer Genome Atlas Sarcoma (training cohort) and Gene Expression Omnibus (validation cohorts) databases. Least absolute shrinkage, selection operator regression, and Cox regression were used to develop prognostic signatures for overall survival (OS) and disease-free survival (DFS). Based on the signatures and clinical features, two nomograms for predicting 2-, 4-, and 6-year OS and DFS were established.

Results: On the basis of the training cohort, we identified five-gene (CHAC2, GPX5, GSTK1, PXDN, and S100A9) and six-gene (GGTLC2, GLO1, GPX7, GSTK1, GSTM5, and IPCEF1) signatures for predicting OS and DFS, respectively, in patients with sarcoma. Kaplan–Meier survival analysis of the training and validation cohorts revealed that patients in the high-risk group had a significantly poorer prognosis than those in the low-risk group. On the basis of the signatures and other independent risk factors, we established two models for predicting OS and DFS that showed excellent calibration and discrimination. For the convenience of clinical application, we built web-based calculators (OS: https://quankun.shinyapps.io/sarcOS/; DFS: https://quankun.shinyapps.io/sarcDFS/).

Conclusions: The antioxidant gene signature models established in this study can be novel prognostic predictors for sarcoma.

Landscape of Immune-Related Markers and Potential Therapeutic Targets in Soft Tissue Sarcoma

Simple Summary

Despite being a group of rare diseases of mesenchymal origin, soft tissue sarcomas are heterogenous and display varying clinical behavior, and depending on the subtype, intermediate- and high-grade sarcomas have significant metastatic potential, making it difficult to establish a standardized therapy. Our work, as well as studies by others, emphasizes the high potential of immunotherapy for the treatment of sarcoma. The aim of this study was to determine whether specific genomic alterations, as well as the expression of infiltrating cytotoxic and suppressive cell type markers identified by next-generation sequencing (NGS), warrant further consideration of immunotherapy agents for treating certain soft tissue sarcoma subtypes. Altogether, our data provide a better understanding of the immune composition of different sarcoma subtypes to better identify novel therapy targets.

Abstract

Soft tissue sarcomas, depending on the subtype and grade, frequently recur and become metastatic after localized treatment. There is now great interest in applying immunotherapy to sarcomas to immuno-profile the different subtypes and immune monitor for prognosis. Our group previously showed that key immunotherapy target genes are present in sarcomas. Here, we extend our findings by demonstrating that sarcomas with a relatively high mutational load are likely to be more sensitive to immunotherapy compared to sarcomas with a lower mutation load. We also show that sarcomas with a higher mutation load are associated with the expression of key immune-related genes. We found that CD8+ T cells are present in sarcoma subtypes and that PD-L2 is highly expressed. These findings further define potential mechanisms behind the immunotherapy response of specific sarcoma subtypes and can be used to develop more optimal treatments in the future.