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Comparison of Immunological Characteristics Between Paired Liu et al. J Transl Med (2018) 16:195 https://doi.org/10.1186/s12967-018-1570-z Journal of Translational Medicine RESEARCH Open Access Comparison of immunological characteristics between paired mismatch repair‑profcient and ‑defcient colorectal cancer patients Shou‑Sheng Liu1,2†, Yuan‑Zhong Yang1,3†, Chang Jiang1,2, Qi Quan1,2, Qian‑Kun Xie1,2, Xiao‑Pai Wang4, Wen‑Zhuo He1,2, Yu‑Ming Rong1,2, Ping Chen1,2, Qiong Yang5, Lin Yang1,2, Bei Zhang1,2, Xiao‑Jun Xia1, Peng‑Fei Kong1,2* and Liang‑Ping Xia1,2* Abstract Background: Currently, mismatch repair-defcient (dMMR) status is a promising candidate for targeted immune checkpoint inhibition therapy in colorectal cancer (CRC) patients, however, the potential immunological mechanism has not yet been well clarifed and some other predictors need to be excavated as well. Methods: We collected 330 CRC patients by the match of mismatch repair-profcient (167) and dMMR (163), explored the relationship between MMR status and some important immune molecules including MHC class I, CD3, CD4, CD8, CD56, programmed death-1 and programmed death ligand-1, and investigated the risk factors for dMMR status as well as low MHC class I expression. The Pearson Chi square test was used for analyzing the associations between clinicopathological and immune characteristics and MMR status, and two categories logistic regression model was used for univariate and multivariate analysis to predict the odds ratio of risk factors for dMMR status and low MHC class I expression. Results: Multivariate logistic regression analysis showed that low MHC class I and CD4 expression and high CD8 expression were signifcant risk factors for dMMR status [odds ratio (OR) 24.66, 2.94 and 2.97, respectively; all p < 0.05] and dMMR status was the only risk factor for low MHC class I expression= (OR 15.34; p < 0.001). = Conclusions: High CD8 and low MHC class I expression suggests the contradiction and complexity of immune microenvironment in dMMR CRC patients. Some other immunocytes such as ­CD56+ cells might also participate in the process of immune checkpoint inhibition, whereas needs further investigations. Keywords: Colorectal cancer, Mismatch repair-defcient, Mismatch repair-profcient, MHC class I molecules, Programmed death-1 *Correspondence: [email protected]; [email protected] †Shou-Sheng Liu and Yuan-Zhong Yang contributed equally to this work 1 State Key Laboratory of Oncology in South China, Collaborative Innovation Centre for Cancer Medicine, Sun Yat-sen University Cancer Center, No. 651 Dongfeng East Road, Guangzhou 510060, People’s Republic of China Full list of author information is available at the end of the article © The Author(s) 2018. This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creat​iveco​mmons​.org/licen​ses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver (http://creat​iveco​mmons​.org/ publi​cdoma​in/zero/1.0/) applies to the data made available in this article, unless otherwise stated. Liu et al. J Transl Med (2018) 16:195 Page 2 of 9 Background Yat-Sen University Cancer Center in Guangzhou, China. In the past few years, immune checkpoint inhibi- Clinicopathological characteristics are summarized in tors including anti-programmed death-1 (PD-1), pro- Table 1. Te obtained surgical specimens were fxed in grammed death ligand-1 (PD-L1) and CTL-associated 10% formalin and embedded in parafn for further use. antigen-4 (CTLA-4) have yielded positive efect in a series of malignancies such as melanoma, non-small cell Immunohistochemistry lung cancer, renal cell carcinoma, bladder cancer, and To detect MMR proteins, mouse anti-MLH1, MSH2, Hodgkin’s lymphoma [1–3]. Nevertheless, anti-PD-1 MSH6 and PMS2 monoclonal antibodies (DAKO, Den- therapy has not shown encouraging outcomes in colo- mark) were used. Mouse monoclonal antibodies against rectal cancer (CRC) until 2015, when a phase II study pan MHC class I molecule (EMR8-5, Hokudo, Japan), showed that 40% of mismatch repair-defcient (dMMR) CD3, CD4, CD8 and CD56 (DAKO, Denmark) as well CRC patients achieved an objective response, while none as rabbit monoclonal antibodies against PD-1 (Abcam, of the patients with mismatch repair-profcient (pMMR) UK) and PD-L1 (Cell Signaling Technology, USA) were status responded to anti-PD-1 therapy [4]. used to test the expression of corresponding proteins. Currently, dMMR CRC patients are suggested to be Tissue sections of 4 μm thickness were deparafnized in promising candidates for targeted immune checkpoint xylene, washed and dehydrated with graded ethanol, and inhibition therapy. Te most mentioned explanation for then dipped in methanol with 0.3% hydrogen peroxide the enhanced activity of anti-PD-1 therapy in dMMR for more than 15 min followed by antigen retrieval. Te patients is the generation of neo-antigens, which then slides were then incubated with the primary antibody activate T cell response to tumor cells [4, 5]. Previous at 4 °C overnight. After been washed three times with studies have also presented some other possible mecha- phosphate-bufered saline (PBS), the slides were subse- nisms such as changes in signaling pathways that lead to quently co-incubated with the biotin-linked secondary more cytokine and chemokine expression [6–8]. How- antibodies according to the manufacturer’s instructions. ever, which immune cells and how they participate in Slides were then counter-stained with haematoxylin for the process remains unclear. Since approximately only color reaction, washed and dehydrated in graded etha- 10–20% of all colorectal tumors (about 20% in stage II, nol, ultimately mounted under a cover slip. Each slide 12% in stage III and 4% in stage IV) have microsatellite was examined by three pathologists to obtain coincident instability (MSI) or to say dMMR [9–12], it is not easy immunohistochemical (IHC) results. to obtain enough dMMR cases to investigate the con- crete mechanisms. Besides, as only less than half dMMR Scoring of immunohistochemistry CRC patients beneft from anti-PD-1 therapy, MMR Both intratumoral and interstitial areas were included status might not be the only positive predictor for anti- for analyzing the presence of CD3, CD4+, CD8+ and PD-1 therapy, some other predictive indexes should be CD56+ cells using a modifed semi-quantitative scoring explored to combine with MMR status in order to better method: 0 = “none” (no stained cells), 1 = “focal” (< 10% predict the curative efect. stained cells), 2 “moderate” (10–40% stained cells), and In this study, we enrolled 330 CRC patients by the = 3 = “severe” (> 40% stained cells) [13, 14]. Cases of scores match of pMMR (167) and dMMR (163) and explored 1 were divided into low-expression group and scores the relationship between MMR status and other clinico- ≤ ≥ 2 were considered to be high-expression group. Te pathologic characteristics, especially some important expression of MHC class I on tumor cells was graded anti-tumor immune molecules such as MHC class I, as previously described: score 1 (< 20% positive cells), CD3, CD4, CD8, CD56, PD-1 and PD-L1 to explain the score 2 (20–80% positive cells), and score 3 (> 80% posi- better efect of anti-PD-1 therapy in dMMR group and tive cells). Populations of scores 1 and 2 were classifed explore some other possible efcacy predictors besides into low-expression group and score 3 was regarded as MMR status. high-expression group [15, 16]. PD-1 expression on lym- phocytes was evaluated using a semi-quantitative scoring system (0 none, 1 < 5% of lymphocytes, 2 5–50% Methods = = = of lymphocytes, 3 50% of lymphocytes). Scores 0 and Patients and specimens ≥ 1 were graded as low and scores 2 and 3 were graded as We collected surgical specimens from 330 patients who high [13, 17]. PD-L1 expression on the surface of tumor underwent primary surgery and diagnosed with stage I cells and tumor-infltrating immune cells was divided into to IV CRC according to the seventh edition of the TNM two groups: specimens with < 5% membranous expres- Classifcation from March 2009 to December 2013 at Sun sion indicated “negative”, while ≥ 5% was considered Liu et al. J Transl Med (2018) 16:195 Page 3 of 9 Table 1 Clinicopathological and immune characteristics Table 1 (continued) of CRC patients based on MMR status Characteristics pMMR dMMR r p value Characteristics pMMR dMMR r p value CD56 expression 0.228 < 0.001 Number of cases (n, %) Low 41 (24.7) 75 (47.2) Age at diagnosis (years) 0.194 < 0.001 High 125 (75.3) 84 (52.8) < 60 80 (47.9) 110 (67.5) CD4 expression 0.2 < 0.001 60 87 (52.1) 53 (32.5) Low 49 (30.1) 78 (50.0) ≥ Gender 0.24 High 114 (69.9) 78 (50.0) Male 96 (57.5) 104 (63.8) PD‑1 expression 0.043 0.483 Female 71 (42.5) 59 (36.2) Low 62 (46.3) 55 (42.0) Primary tumor site 0.264 < 0.001 High 72 (53.7) 76 (58.0) Left colon 81 (48.5) 41 (25.2) PD‑L1 expression 0.133 0.015 Right colon 47 (28.1) 86 (52.8) Negative 77 (46.1) 97 (59.5) Rectum 39 (23.4) 36 (22.1) Positive 90 (53.9) 66 (40.5) Stage (7th AJCC) 0.965 r: contingency coefcient I 27 (16.2) 26 (16.0) II 89 (53.3) 85 (52.1) III 42 (25.1) 41 (25.2) “positive” [1]. Tumors lacking any one of MLH1, MSH2, IV 9 (5.4) 11 (6.7) PMS2, or MSH6 expression were identifed as dMMR, Tumor stage 0.193 0.012 only if tumors that express of all of the four markers were T1 8 (4.8) 5 (3.1) considered pMMR.
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