Immune checkpoint markers in gastroenteropancreatic neuroendocrine neoplasia

in Endocrine-Related Cancer
Correspondence should be addressed to T Knösel:
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Cancer immunotherapy has evolved major breakthroughs in the last years. The cell-surface receptor programmed death-1 (PD-1) and its ligand, programmed death ligand-1 (PD-L1), have been detected in various cancer types. However, the analysis on gastroenteropancreatic neoplasia (GEP-NENs) is limited. Therefore, the aim of this study was to characterize GEP-NENs with regard to PD-1/PD-L1 pathway and tumor-infiltrating lymphocytes (TILs). On protein level, we examined TILs, PD-1 and PD-L1 expression in tumor tissue of 244 GEP-NENs using immunohistochemistry. Expression levels were correlated with clinicopathological parameters including long-term survival in an observational study. In total, 244 patients could be included. Most of the patients had a NEN of the small intestine (52.5%) or the pancreas (29.5%). All tumors could be graded by their morphology and Ki67 index, with 57.8% G1, 34% G2 and 8.2% G3 tumors. High TILs (19.6%) and high PD-1 (16.1%) expression showed a significant correlation with shorter patient survival (P < 0.05) and with a higher grading. Furthermore, expression of PD-L1 (8.7%) showed a trend to shorter patient survival. High TILs and PD-1 expression are significantly associated with shorter patient survival and higher grading in GEP-NENs. PD-L1 expression showed a trend to shorter patient survival. Immunotherapy might be a promising therapeutic approach in GEP-NENs especially in tumors with high TILs.


      Society for Endocrinology

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  • View in gallery

    Examples of (A) well-differentiated neuroendocrine tumor (NET, G1), (B) poorly differentiated neuroendocrine carcinoma (NEC, G3) with high TILs and areas of necrosis (10× magnification), (C) high PD-1-positive lymphocytes in specimen with high TILs (40× magnification) and (D) high PD-L1 staining (score 3) in tumor cells within a specimen with high TILs.

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    Kaplan–Meier overall survival curves for patients divided into levels of tumor-infiltrating lymphocytes (TIL) (P < 0.05).

  • View in gallery

    Kaplan–Meier overall survival curves for patients with G1/2 (A) (P < 0.05) and G3 (B) tumors (P > 0.05) divided into levels of tumor-infiltrating lymphocytes (TIL).

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    Kaplan–Meier overall survival curves for patients divided into PD-1 expression (P < 0.05).

  • View in gallery

    Kaplan–Meier overall survival curves for patients divided into PD-L1 expression (P > 0.05).


AuernhammerCJSpitzwegCAngeleMKBoeckSGrossmanANoltingSIlhanHKnoselTMayerleJReinckeMet al. 2018 Advanced neuroendocrine tumours of the small intestine and pancreas: clinical developments, controversies, and future strategies. Lancet Diabetes and Endocrinology 6 404415. (

BeattyGLGladneyWL 2015 Immune escape mechanisms as a guide for cancer immunotherapy. Clinical Cancer Research 21 687692. (

CampesatoLFBarroso-SousaRJimenezLCorreaBRSabbagaJHoffPMReisLFGalantePACamargoAA 2015 Comprehensive cancer-gene panels can be used to estimate mutational load and predict clinical benefit to PD-1 blockade in clinical practice. Oncotarget 6 3422134227. (

CavalcantiEArmentanoRValentiniAMChieppaMCarusoML 2017 Role of PD-L1 expression as a biomarker for GEP neuroendocrine neoplasm grading. Cell Death and Disease 8 e3004. (

ChauhanAHornMMageeGHodgesKEversMArnoldSAnthonyL 2018 Immune checkpoint inhibitors in neuroendocrine tumors: a single institution experience with review of literature. Oncotarget 9 88018809. (

ClementeCGMihmMCJrBufalinoRZurridaSColliniPCascinelliN 1996 Prognostic value of tumor infiltrating lymphocytes in the vertical growth phase of primary cutaneous melanoma. Cancer 77 13031310. (<1303::AID-CNCR12>3.0.CO;2-5)

da SilvaAQianZZhangSMasugiYRodigSBraisLDuttonTChanJHodiSOginoSet al. 2016 Immune checkpoint markers and immune response in well differentiated neuroendocrine tumors (NET) of the small intestine and pancreas. In NANETS Symposium abstract B03. (available at:

DieciMVMathieuMCGuarneriVContePDelalogeSAndreFGoubarA 2015 Prognostic and predictive value of tumor-infiltrating lymphocytes in two phase III randomized adjuvant breast cancer trials. Annals of Oncology 26 16981704. (

FarkonaSDiamandisEPBlasutigIM 2016 Cancer immunotherapy: the beginning of the end of cancer? BMC Medicine 14 73. (

GiraldoNABechtEPagesFSklirisGVerkarreVVanoYMejeanASaint-AubertNLacroixLNatarioIet al. 2015 Orchestration and prognostic significance of immune checkpoints in the microenvironment of primary and metastatic renal cell cancer. Clinical Cancer Research 21 30313040. (

HanahanDWeinbergRA 2000 The hallmarks of cancer. Cell 100 5770. (

HanahanDWeinbergRA 2011 Hallmarks of cancer: the next generation. Cell 144 646674. (

IshigamiSNatsugoeSTokudaKNakajoAOkumuraHMatsumotoMMiyazonoFHokitaSAikouT 2003 Tumor-associated macrophage (TAM) infiltration in gastric cancer. Anticancer Research 23 40794083.

KampmannEAltendorf-HofmannAGibisSLindnerLHIsselsRKirchnerTKnoselT 2015 VEGFR2 predicts decreased patients survival in soft tissue sarcomas. Pathology – Research and Practice 211 726730. (

KatzSCDonkorCGlasgowKPillarisettyVGGonenMEspatNJKlimstraDSD’AngelicaMIAllenPJJarnaginWet al. 2010 T cell infiltrate and outcome following resection of intermediate-grade primary neuroendocrine tumours and liver metastases. HPB 12 674683. (

KimSTHaSYLeeSAhnSLeeJParkSHParkJOLimHYKangWKKimKMet al. 2016 The impact of PD-L1 expression in patients with metastatic GEP-NETs. Journal of Cancer 7 484489. (

KloppelGAnlaufM 2005 Epidemiology, tumour biology and histopathological classification of neuroendocrine tumours of the gastrointestinal tract. Best Practice and Research: Clinical Gastroenterology 19 507517. (

KlugerHMZitoCRTurcuGBaineMKZhangHAdeniranASznolMRimmDLKlugerYChenLet al. 2017 PD-L1 studies Across tumor types, its differential expression and predictive value in patients treated with immune checkpoint inhibitors. Clinical Cancer Research 23 42704279. (

KoideNNishioASatoTSugiyamaAMiyagawaS 2004 Significance of macrophage chemoattractant protein-1 expression and macrophage infiltration in squamous cell carcinoma of the esophagus. American Journal of Gastroenterology 99 16671674. (

KonishiJYamazakiKAzumaMKinoshitaIDosaka-AkitaHNishimuraM 2004 B7-H1 expression on non-small cell lung cancer cells and its relationship with tumor-infiltrating lymphocytes and their PD-1 expression. Clinical Cancer Research 10 50945100. (

KrpinaKBabarovicEJonjicN 2015 Correlation of tumor-infiltrating lymphocytes with bladder cancer recurrence in patients with solitary low-grade urothelial carcinoma. Virchows Archiv 467 443448. (

LamarcaANonakaDBreitwieserWAshtonGBarriusoJMcNamaraMGMoghadamSRoganJMansoorWHubnerRAet al. 2018 PD-L1 expression and presence of TILs in small intestinal neuroendocrine tumours. Oncotarget 9 1492214938. (

LatteyerSTiedjeVSchillingBFuhrerD 2016 Perspectives for immunotherapy in endocrine cancer. Endocrine-Related Cancer 23 R469R484. (

LawrenceBGustafssonBIChanASvejdaBKiddMModlinIM 2011 The epidemiology of gastroenteropancreatic neuroendocrine tumors. Endocrinology and Metabolism Clinics of North America 40 118 vii. (

MahoneyKMSunHLiaoXHuaPCalleaMGreenfieldEAHodiFSSharpeAHSignorettiSRodigSJet al. 2015 PD-L1 antibodies to its cytoplasmic domain most clearly delineate cell membranes in immunohistochemical staining of tumor cells. Cancer Immunology Research 3 13081315. (

MehnertJMRugoHSO’NeilBHSantoroASchellensJHMCohenRBDoiTOttPAPishvaianMJPuzanovIet al. 2017 Pembrolizumab for patients with PD-L1–positive advanced carcinoid or pancreatic neuroendocrine tumors: results from the KEYNOTE-028 study. Annals of Oncology 28 v142v157.

ModlinIMObergKChungDCJensenRTde HerderWWThakkerRVCaplinMDelle FaveGKaltsasGAKrenningEPet al. 2008 Gastroenteropancreatic neuroendocrine tumours. Lancet Oncology 9 6172. (

NakanoOSatoMNaitoYSuzukiKOrikasaSAizawaMSuzukiYShintakuINaguraHOhtaniH 2001 Proliferative activity of intratumoral CD8(+) T-lymphocytes as a prognostic factor in human renal cell carcinoma: clinicopathologic demonstration of antitumor immunity. Cancer Research 61 51325136.

PostowMACallahanMKWolchokJD 2015 Immune checkpoint blockade in cancer therapy. Journal of Clinical Oncology 33 19741982. (

PowlesTEderJPFineGDBraitehFSLoriotYCruzCBellmuntJBurrisHAPetrylakDPTengSLet al. 2014 MPDL3280A (anti-PD-L1) treatment leads to clinical activity in metastatic bladder cancer. Nature 515 558562. (

RemarkRAlifanoMCremerILupoADieu-NosjeanMCRiquetMCrozetLOuakrimHGocJCazesAet al. 2013 Characteristics and clinical impacts of the immune environments in colorectal and renal cell carcinoma lung metastases: influence of tumor origin. Clinical Cancer Research 19 40794091. (

RibasA 2012 Tumor immunotherapy directed at PD-1. New England Journal of Medicine 366 25172519. (

RindiGKloppelGCouvelardAKomminothPKornerMLopesJMMcNicolAMNilssonOPerrenAScarpaAet al. 2007 TNM staging of midgut and hindgut (neuro) endocrine tumors: a consensus proposal including a grading system. Virchows Archiv 451 757762. (

RobertsJAGonzalezRSDasSBerlinJShiC 2017 Expression of PD-1 and PD-L1 in poorly differentiated neuroendocrine carcinomas of the digestive system: a potential target for anti-PD-1/PD-L1 therapy. Human Pathology 70 4954. (

RyschichEAutschbachFEisoldSKlarEBuchlerMWSchmidtJ 2003 Expression of HLA class I/II antigens and T cell immune response in human neuroendocrine tumors of the pancreas. Tissue Antigens 62 4854. (

SaxenaAChuaTCSarkarAChuFLiauwWZhaoJMorrisDL 2011 Progression and survival results after radical hepatic metastasectomy of indolent advanced neuroendocrine neoplasms (NENs) supports an aggressive surgical approach. Surgery 149 209220. (

StraubMDrecollEPfarrNWeichertWLangerRHapfelmeierAGotzCWolffKDKolkASpechtK 2016 CD274/PD-L1 gene amplification and PD-L1 protein expression are common events in squamous cell carcinoma of the oral cavity. Oncotarget 7 1202412034. (

SullivanRJFlahertyKT 2015 Immunotherapy: anti-PD-1 therapies-a new first-line option in advanced melanoma. Nature Reviews Clinical Oncology 12 625626. (

TaubeJMKleinABrahmerJRXuHPanXKimJHChenLPardollDMTopalianSLAndersRA 2014 Association of PD-1, PD-1 ligands, and other features of the tumor immune microenvironment with response to anti-PD-1 therapy. Clinical Cancer Research 20 50645074. (

TeixidoCKarachaliouNGonzalez-CaoMMorales-EspinosaDRosellR 2015 Assays for predicting and monitoring responses to lung cancer immunotherapy. Cancer Biology and Medicine 12 8795. (

TsuruokaKHorinouchiHGotoYKandaSFujiwaraYNokiharaHYamamotoNAsakuraKNakagawaKSakuraiHet al. 2017 PD-L1 expression in neuroendocrine tumors of the lung. Lung Cancer 108 115120. (

VikmanSSommaggioRDe La TorreMObergKEssandMGiandomenicoVLoskogATottermanTH 2009 Midgut carcinoid patients display increased numbers of regulatory T cells in peripheral blood with infiltration into tumor tissue. Acta Oncologica 48 391400. (

WeberMMFottnerC 2018 Immune checkpoint inhibitors in the treatment of patients with neuroendocrine neoplasia. Oncology Research and Treatment 41 306312. (

WilliamsEDSandlerM 1963 The classification of carcinoid tum ours. Lancet 1 238239. (

WimberlyHBrownJRSchalperKHaackHSilverMRNixonCBossuytVPusztaiLLanninDRRimmDL 2015 PD-L1 expression correlates with tumor-infiltrating lymphocytes and response to neoadjuvant chemotherapy in breast cancer. Cancer Immunology Research 3 326332. (

YanXJiaoSCZhangGQGuanYWangJL 2017 Tumor-associated immune factors are associated with recurrence and metastasis in non-small cell lung cancer. Cancer Gene Therapy 24 5763. (

ZitvogelLKroemerG 2012 Targeting PD-1/PD-L1 interactions for cancer immunotherapy. Oncoimmunology 1 12231225. (


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