Clinical impact of T cells, B cells and the PD-1/PD-L1 pathway in muscle invasive bladder cancer: a comparative study of transurethral resection and cystectomy specimens

Sara Wahlin, Björn Nodin, Karin Leandersson, Karolina Boman, Karin Jirström, Sara Wahlin, Björn Nodin, Karin Leandersson, Karolina Boman, Karin Jirström

Abstract

In patients with muscle invasive bladder cancer (MIBC), neoadjuvant chemotherapy (NAC) prior to radical cystectomy has improved survival but there is an urgent unmet need to identify prognostic and predictive biomarkers to stratify patients who will benefit from treatment. This study aimed to examine the composition of tumor-infiltrating immune cells in MIBC, with particular reference to the clinical outcome and the potential modifying effect of NAC. To this end, the expression of CD8+ and FoxP3+ T cells, CD20+ B cells, PD-1+ and PD-L1+ immune cells and PD-L1+ tumor cells was evaluated by immunohistochemistry on tissue microarrays with paired transurethral resection (TURB) specimens, cystectomy specimens and lymph node metastases from 145 patients, 65 of whom had received NAC. Kaplan-Meier and Cox regression analyses were applied to assess the impact of investigated cell subsets on time to recurrence (TTR). In cystectomy specimens, high infiltration of the investigated immune cell populations, but not PD-L1+ tumor cells, were independently associated with a prolonged TTR, whereas in TURB specimens, this association was only seen for CD8+ lymphocytes. An additive beneficial prognostic effect of NAC was seen for the majority of the cell subsets but there was no significant interaction between any immune marker and NAC in relation to TTR. Furthermore, no differences in cell densities prior to NAC treatment were observed between complete and non-complete responders, or pre- and posttreatment in non-complete responders. In conclusion, immune cell infiltration provides important prognostic information in both pre- and postsurgical samples of MIBC, independently of NAC.

Keywords: Bladder cancer; immunotherapy; neoadjuvant chemotherapy; prognosis; tumor microenvironment.

© 2019 The Author(s). Published with license by Taylor & Francis Group, LLC.

Figures

Figure 1.
Figure 1.
Immunohistochemical staining of CD8, FoxP3, CD20, PD-1 and PD-L1 in muscle invasive bladder cancer. Sample images (10x magnification with 40x insertion) of studied cell subsets in TURB specimens, cystectomy specimens and lymph node metastases (LN). The estimated percentage of stained cells was annotated. Arrow-heads illustrating a lymphoid aggregate of CD20+ B cells. Scale bar = 50 μm (10x) and 20 μm (40x).
Figure 2.
Figure 2.
Distribution of immune marker expression in different types of specimens. Bar charts illustrating the distribution of different immune cell subsets and PD-L1TC in A) TURB specimens, B) cystectomy specimens and C) lymph node metastases.
Figure 3.
Figure 3.
Distribution of immune cell density and PD-L1TC in strata according to neoadjuvant chemotherapy and histopathological response to treatment. A) Densities of different immune cell subsets in tissue specimens from NAC untreated (n = 80) and treated (n = 65) patients. B) Densities of different immune cell subsets prior to NAC treatment in complete (i.e. T-stage 0 or Ta/CIS) and non-complete (i.e. T-stage ≥1) responders. Whiskers represent 5% and 95%.
Figure 4.
Figure 4.
Clinicopathological correlates of different immune cell subsets and PD-L1TC. Box plots visualizing the associations between clinicopathological characteristics and immune marker density in A) TURB specimens and B) cystectomy specimens. Whiskers represent 5% to 95%. P-values are from non-parametric tests, only significant associations (p < .05) are denoted in the panels.
Figure 5.
Figure 5.
Time to recurrence (TTR) according to the density of tumor-infiltrating immune cells and neoadjuvant chemotherapy. Kaplan-Meier estimates of TTR in combined strata according to high and low expression of CD8, FoxP3 and CD20 and neoadjuvant chemotherapy in A) TURB specimens and B) cystectomy specimens. Dichotomization into high and low expression was based on median values. Number at risk demonstrates the number of patients at risk of recurrence of muscle invasive bladder cancer at given time intervals during follow-up.
Figure 6.
Figure 6.
Time to recurrence (TTR) according to PD-1 and PD-L1 expression and neoadjuvant chemotherapy. Kaplan-Meier estimates of TTR in combined strata according to high and low expression of PD-1, PD-L1IC and PD-L1TC and neoadjuvant chemotherapy in A) TURB specimens and B) cystectomy specimens. Dichotomization into high and low expression was based on median values. Number at risk demonstrates the number of patients at risk of recurrence of muscle invasive bladder cancer at given time intervals during follow-up.

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