CP0204

Anatomopatologia de los linfocitos

infiltrantes del tumor (TILs)

Blanca González Farré

Anatomia Patológica, Hospital Clínic de Barcelona
 Outline and Objective

• Review the concept of TILs

• Tils in invasive BC

• Discuss the role of the pathologist in driving the field of cancer

inmunology and inmunotherapy
TILs in cancer
Medullary carcinoma

Sistrunk WE et al Ann Surg 1922 Jan; 75(1): 61–69

Aaltomaa S et al Eur J Cancer 1992;28A(4-5):459-64
Ridolfi RL et al Cancer 1977 Oct;40(4):1365-85
The immune contexture

Favorable immune
response Immunosupressive
• CD8+ cytotoxic T cells • T reg cells (FOXP3+)

• Th1 lymphocytes • Th2 lymphocytes

• NK cells • B lymphocytes

• B lymphocytes • Plasma cells

• Plasma cells • M2 macropahages

• M1 macropahages • DC2 dendrític cells

• DC1 dendrític cells

Salgado R et al Ann Oncol. 2015 Feb;26(2):259-71

Tumor infiltrating lymphocytes (TILs)

Yeong J et al Front Immunol 2018 May 30;9:1209

TILs: current approach
Tumor infiltrating lymphocytes (TILs)

• Stromal TILs (sTIL)

v Mononuclear immune cells in the tumoral stroma

v Percentage of the stromal area occupied by mononuclear inflammatory cells over the
total stromal area within the tumor (not the % of stromal cells that are lymphocytes)

• Intratumoral TIL (iTIL)

v Lymphocytes inside the tumor nests which are in contact with the tumor cells
without stroma in between
What do we know about TILs and
breast carcinoma?
TILs in BC according subtype

20-28% of patients had a

lymphocytic-predominant BC
Loi S et al. SABCS 2013
phenotype Stanton SE, et al. JAMA Oncol. 2016
Savas P, et al. Nat Rev Clin Oncol. 2016
TILs as prognostic biomarker
HER2+ TN

For LBPC TNBCs (10.5% of

TNBCs), the 5-year DFS
• 75% of early stage TNBC and HER2+ have TILs and 20% of them with was 89% vs 62% (HR, 0.29;
high TILs 95% CI, 0.11–0.81;
P=0.018)
• ER+ BC less TILs
• High TILs is associated with better DFS and OS in TNBC and HER2+
Loi S et al J Clin Oncol 2013 Mar 1;31(7):860-7
Yang X et al Target Oncol. 2018; 13(6): 757–767
TILs as prognostic biomarker (TNBC)

• sTILs add important prognostic information in

systemically untreated early-stage TNBC patients.

• sTILs can identify a subset of stage I TNBC patients with

an excellent prognosis without adjuvant chemotherapy

De Jong VMT et al J Clin Oncol. 2022 Mar 30

Park JH et al Ann Oncol 2019 Dec 1;30(12):1941-1949
TILs: level IB evidence as prognostic
biomarker in TNBC

Loi S et al J Clin Oncol. 2019 Mar 1;37(7):559-569

TILs as prognostic biomarker

• TILs are found to strongly up and downstage traditional pathological-staging in the Pathological and Clinical
Prognostic Stage Groups from the AJJC 8th edition Cancer Staging System.

Loi S et al J NPJ Breast Cancer. 2022 Jan 11;8(1):3

 In a post-hoc univariable logistic regression analysis,
TILs in neoadjuvant setting TIL concentrations predicted pathological complete
response in most clinicopathological subgroups of
TNBC, HER2-positive breast cancer, and luminal–HER2-
negative breast cancer, suggesting that the association
between immunological infiltrates and chemotherapy
response is similar across subtypes and clinicopatho-
logical subgroups (appendix p 3).
We assessed TILs as a prognostic marker for disease-
free survival and overall survival in 2570 patients from
five clinical trial cohorts.6–9,11 The median follow-up for
overall survival was 62·8 months (IQR 37·6–73·2) and
the median follow-up for disease-free survival was
63·3 months (IQR 38·0–73·5). When TIL concentration
was assessed as a continuous variable, patients with
increased TIL concentrations and TNBC had significantly
longer disease-free survival and overall survival than did
patients with TNBC and lower TIL concentrations;
A A total of 632 patients with TNBC, 986 patients with
60 Low (0–10%)
Intermediate (11–59%)
High (≥60%)
50
40
pCR (%)
30
20
10
0 HER2-negative tumours, patients with a pathological
All patients Luminal–HER2-negative HER2-positive
Breast cancer subtype
B Denkert C et al, SABCS 2016
n/N OR (95% CI)
increased TIL concentrations in patients with HER2-
positive breast cancer had a significantly longer disease-
free survival than did patients with HER2-positive breast
cancer with lower TIL concentrations but there was no
association for overall survival (figure 4A, D). By contrast,
in the luminal–HER2-negative patients, TIL conc-
entration was not significantly associated with disease-
free survival, and a low TIL concentration was
significantly associated with longer overall survival than
was a high TIL concentration (figure 4A, D). The
association between TIL concentration and survival was
similar between univariable analysis and multivariable
analysis including baseline parameters (figure 4B, E) for
all subtypes. However, when pathological complete
response was included as a parameter in the
multivariable analysis, TILs were no longer significantly
associated with disease-free survival in patients with
TNBC or with overall survival in patients with TNBC or
HER2-positive breast cancer (figure 4C, F).
HER2-positive breast cancer, and 832 patients with
luminal–HER2-negative breast cancer were included in
the Kaplan-Meier survival analysis. By use of the three
predefined TIL subgroups, the analysis showed that high
TILs were a positive prognostic factor for disease-free
survival in TNBC (figure 5A) and HER2-positive breast
cancer (figure 5C). By contrast, in the luminal–HER2-
negative group, low TILs were a positive prognostic
factor for disease-free survival (figure 5E). Results for
overall survival were similar to those for disease-free
survival in all subtypes (figure 5B, D, F). When the overall
survival analysis was stratified for pathological complete
response within the subtypes of TNBC and luminal–
TNBC complete response had a good prognosis regardless of
TILs (appendix p 4). Patients with TNBC without a
pathological complete response had a similar prognosis Denkert C et al Lancet Oncol 2018:19:40-50
p value across all three TIL groups; by contrast, in patients with
 TILs and RCB in residual disease in TNBC

• The lower TILs levels the more residual tumor • Higher TILs in residual disease are associated with
postNAT and the more advanced lymph node better RFS (HR:0,86) and better OS (HR: 0,87)
stage

• No differences regarding RCB

Luen S.J et al Annals of Oncology 30: 236–242, 2019

Potencial role for the use of TILs in early-stage
TNBC?

Brown L C et al, Cancer J. 2021 Jan-Feb 01;27(1):25-31

 TILs and Expert committee
• TILs assessment is gaining importance as a prognostic marker

• High number of TILs are associated with better outcome and better response to neadjuvant
therapy in TNBC and HER2+ BC (level 1B evidence)

• TILs have a strong prognostic value in improving estimates of distant RFS, DFS, and OS in
early-stage tretated with standard adjuvant/neoadjuvant CT (level 1B evidence)

• This finding is based on an evaluation by pathologists using H&E-stained glass slides at the
time of diagnosis (before tretament) and in the residual disease after neodyuvant CT

• The presence and extent of TILs in IBC vary greatly from tumor to tumor

• Clinical utility (for treatment allocation) is under investigation

• TILs should be considered as a stratification factor in clinical trials and should be included
in studies involving or evaluating prognosis

• It is recommended to follow the international consensus scoring recommendations for

quantifying TILs
Burstein HJ et al Ann Oncol. 2019 Oct 1;30(10):1541-1557
Cardoso F et al Ann Oncol. 2019 30(8):1194-1220
Board, I.A.f.R.O.c.l., Breast tumours, WHO classification of tumours, 5th edition. 2019.2
How do we evaluateTILs in breast
carcinoma?
Consensus guidelines
Consensus guidelines
3 groups based on low magnification
o Report the average of the stromal area, do not focus on hot spots
o TILs as a continuos parameter
o For intermediate group evaluate diferent areas at higher magnification
Estimate average TIL from the different microscopic fields
(200-400x magnification)
TILs in neoadyuvant setting
 TILs in residual disease
Residual tumour bed

Concentrinc shrinkage
TILs in in situ carcinoma
Interobserver variability and digital imaging

• Two key factors improve consistency of sTIL

results:
ü Scoring multiple areas in heterogeneous
tumors and averaging results
ü Use of reference images

Denkert C et al, Mod Pathol. 2016 Oct;29(10):1155-64

Schisher SK et al, Ann Surg Oncol. 2016 Jul;23(7):2242-8
Kos Z et al, NPJ Breast Cancer. 2020; 6: 17
 Pitfalls
• Heterogeneity

ü Increased sTILs at the leading edge compared to central tumor

ü Marked hterogeneity in sTIL density within the tumor

ü Variably spaced apart clusters of cancer cells with a dense tight

ü Lymphocytic infiltrate separated by collagenous stroma with sparse infiltrate

• Scoring wrong area or cells

ü Defining tumor boundary and scoring outside of tumor (Fig. 6a)

ü Including lymphocytes surrounding DCIS

ü Including lymphocytes surrounding benign glands

ü Including intratumoral TILs

ü Misinterpreting apoptotic cells as lymphocytes

• Limited stroma within tumor for evaluation

Kos Z et al , NPJ Breast Cancer. 2020; 6: 17

Molecular histology

Multiplex Stack EC et al, Methods. 2014 Nov;70(1):46-58

Cesano, A Abstract 1371, Proceedings of the 107th AACR Annual Meeting
Yan Liang et al, Nanostring technologies
Longuespée et al ROMICS. 2014 Sep;18(9):539-52
Why should pathologist score TILs in their
daily practice?

Laenkholm A-V et al, Virchows Arch. 2022 Jan;480(1):147-162

Take home messages
• TILs as surrogate to evaluate patient’s immune response and tumor immmunogenecity

• Most BC show some degree of TILS

• High levels of TILs associated wit better DFS and OS in TNBC and HER2+ BC

• TILs may predict benefit from NACT

• Published consensus guidelines to homogeniously evaluate TILs

• Future tecnologies should be incorporated in the pathology labs to improve the value of

the immune background

https://www.tilsinbreastcancer.org/