Assessment of the tumor immune microenvironment can be used as a prognostic tool for improved survival and as a predictive biomarker for treatment benefit, particularly from immune modulating treatments including cytotoxic chemotherapy. Using Digital Spatial Profiling (DSP), we studied the tumor immune microenvironment of 522 breast cancer cases by quantifying 35 immune biomarkers on tissue microarrays from the MA.5 phase III clinical trial. In this trial, node-positive breast cancer patients were randomized to receive either a non-anthracycline chemotherapy (CMF) or anthracycline-containing cytotoxic chemotherapy (CEF). Donor block hematoxylin and eosin (H&E)-stained sections were scored for the level of stromal tumor infiltrating lymphocytes (sTILs), according to the international guidelines. We hypothesized that patients with higher levels of tumor immune infiltration, assessed by either DSP or H&E staining, would benefit from CEF (relative to CMF) more than patients with lower immune infiltration. Unsupervised hierarchical clustering of digitally scored biomarkers revealed two patient clusters: immune infiltrated vs. ignored. Following a pre-specified statistical plan crafted to meet ReMARK guidelines, we found that the DSP-derived Immune Cluster assignment did not predict an improved 10-year relapse-free survival for patients receiving CEF compared to CMF. However, a secondary hypothesis revealed a significant predictive value for H&E-sTILs assessed on full-faced sections for CEF benefit over CMF in the entire cohort and the HER2-enriched subset. As exploratory analyses, supervised clustering of DSP scored biomarkers suggested that low levels of TIM-3 and high levels of HLA-DR and PD-L1 are associated with sensitivity to CEF. Although novel high-plex techniques provide a detailed insight into the tumor microenvironment, conventional H&E staining remains a powerful tool that can be applied onto full-faced sections to assess the value of immune microenvironment, particularly sTILs, in predicting benefits from immunogenic chemotherapies.
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