Computational image analysis of T-cell infiltrates in resectable gastric cancer: association with survival and molecular subtypes

Background: Gastric and gastro-oesophageal junction cancers (GCs) frequently recur after resection but markers to predict recurrence risk are missing. T-cell infiltrates have been validated as prognostic markers in other cancer types, but not in GC due to methodological limitations of past studies. We aimed to define and validate the prognostic role of major Tcell subtypes in GC by objective computational quantification.

Methods: Surgically resected chemotherapy-naÔve GCs were split into discovery (n=327) and validation (n=147) cohorts. CD8 (cytotoxic), CD45RO (memory) and FOXP3 (regulatory) T-cell densities were measured through multicolour immunofluorescence and computational image analysis. Cancer specific survival (CSS) was assessed. All statistical tests were twosided.

Results: CD45RO-cell and FOXP3-cell densities statistically significantly predicted CSS in both cohorts. Stage, CD45RO-cell and FOXP3-cell densities were independent predictors of CSS in multivariable analysis; mismatch repair (MMR) and Epstein-Barr Virus (EBV) status were not statistically significant. Combining CD45RO-cell and FOXP3-cell densities into the Stomach Cancer Immune Score showed highly statistically significant (all pг0.002) CSS differences (0.9y median CSS to not reached). T-cell infiltrates were highest in EBV-positive GCs and similar in MMR-deficient and MMR-proficient GCs. Conclusion: The validation of CD45RO-cell and FOXP3-cell densities as prognostic markers in GC may guide personalized follow-up or (neo)adjuvant treatment strategies. Only those 20% of GCs with the highest T-cell infiltrates showed particularly good CSS, suggesting that a small subgroup of GCs is highly immunogenic. The potential for T-cell densities to predict immunotherapy responses should be assessed. The association of high FOXP3-cell densities with longer CSS warrants studies into the biology of regulatory T-cells in GC.