Pitfalls in assessing stromal tumor infiltrating lymphocytes (sTILs) in breast cancer

Zuzana Kos; Elvire Roblin; Rim S. Kim; Stefan Michiels; Brandon D. Gallas; Weijie Chen; Koen K. van de Vijver; Shom Goel; Sylvia Adams; Sandra Demaria; Giuseppe Viale; Torsten O. Nielsen; Sunil S. Badve; W. Fraser Symmans; Christos Sotiriou; David L. Rimm; Stephen Hewitt; Carsten Denkert; Sibylle Loibl; Stephen J. Luen; John M.S. Bartlett; Peter Savas; Giancarlo Pruneri; Deborah A. Dillon; Maggie Chon U. Cheang; Andrew Tutt; Jacqueline A. Hall; Marleen Kok; Hugo M. Horlings; Anant Madabhushi; Jeroen van der Laak; Francesco Ciompi; Anne Vibeke Laenkholm; Enrique Bellolio; Tina Gruosso; Stephen B. Fox; Juan Carlos Araya; Giuseppe Floris; Jan Hudecek; Leonie Voorwerk; Andrew H. Beck; Jen Kerner; Denis Larsimont; Sabine Declercq; Gert Van den Eynden; Lajos Pusztai; Anna Ehinger; Wentao Yang; Khalid AbdulJabbar; Yinyin Yuan; International Immuno-Oncology Biomarker Working Group; Loes Kooreman

doi:10.1038/s41523-020-0156-0

Pitfalls in assessing stromal tumor infiltrating lymphocytes (sTILs) in breast cancer

Zuzana Kos^*, Elvire Roblin, Rim S. Kim, Stefan Michiels, Brandon D. Gallas, Weijie Chen, Koen K. van de Vijver, Shom Goel, Sylvia Adams, Sandra Demaria, Giuseppe Viale, Torsten O. Nielsen, Sunil S. Badve, W. Fraser Symmans, Christos Sotiriou, David L. Rimm, Stephen Hewitt, Carsten Denkert, Sibylle Loibl, Stephen J. LuenJohn M.S. Bartlett, Peter Savas, Giancarlo Pruneri, Deborah A. Dillon, Maggie Chon U. Cheang, Andrew Tutt, Jacqueline A. Hall, Marleen Kok, Hugo M. Horlings, Anant Madabhushi, Jeroen van der Laak, Francesco Ciompi, Anne Vibeke Laenkholm, Enrique Bellolio, Tina Gruosso, Stephen B. Fox, Juan Carlos Araya, Giuseppe Floris, Jan Hudecek, Leonie Voorwerk, Andrew H. Beck, Jen Kerner, Denis Larsimont, Sabine Declercq, Gert Van den Eynden, Lajos Pusztai, Anna Ehinger, Wentao Yang, Khalid AbdulJabbar, Yinyin Yuan, International Immuno-Oncology Biomarker Working Group, Loes Kooreman

^*Corresponding author for this work

Research output: Contribution to journal › Article › Academic › peer-review

Abstract

Stromal tumor-infiltrating lymphocytes (sTILs) are important prognostic and predictive biomarkers in triple-negative (TNBC) and HER2-positive breast cancer. Incorporating sTILs into clinical practice necessitates reproducible assessment. Previously developed standardized scoring guidelines have been widely embraced by the clinical and research communities. We evaluated sources of variability in sTIL assessment by pathologists in three previous sTIL ring studies. We identify common challenges and evaluate impact of discrepancies on outcome estimates in early TNBC using a newly-developed prognostic tool. Discordant sTIL assessment is driven by heterogeneity in lymphocyte distribution. Additional factors include: technical slide-related issues; scoring outside the tumor boundary; tumors with minimal assessable stroma; including lymphocytes associated with other structures; and including other inflammatory cells. Small variations in sTIL assessment modestly alter risk estimation in early TNBC but have the potential to affect treatment selection if cutpoints are employed. Scoring and averaging multiple areas, as well as use of reference images, improve consistency of sTIL evaluation. Moreover, to assist in avoiding the pitfalls identified in this analysis, we developed an educational resource available at www.tilsinbreastcancer.org/pitfalls.

Original language	English
Article number	17
Number of pages	16
Journal	npj Breast Cancer
Volume	6
Issue number	1
DOIs	https://doi.org/10.1038/s41523-020-0156-0
Publication status	Published - 12 May 2020

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Kos, Z., Roblin, E., Kim, R. S., Michiels, S., Gallas, B. D., Chen, W., van de Vijver, K. K., Goel, S., Adams, S., Demaria, S., Viale, G., Nielsen, T. O., Badve, S. S., Symmans, W. F., Sotiriou, C., Rimm, D. L., Hewitt, S., Denkert, C., Loibl, S., ... Kooreman, L. (2020). Pitfalls in assessing stromal tumor infiltrating lymphocytes (sTILs) in breast cancer. npj Breast Cancer, 6(1), Article 17. https://doi.org/10.1038/s41523-020-0156-0

@article{3c700fc69c524c24b76f28a822c075e1,

title = "Pitfalls in assessing stromal tumor infiltrating lymphocytes (sTILs) in breast cancer",

abstract = "Stromal tumor-infiltrating lymphocytes (sTILs) are important prognostic and predictive biomarkers in triple-negative (TNBC) and HER2-positive breast cancer. Incorporating sTILs into clinical practice necessitates reproducible assessment. Previously developed standardized scoring guidelines have been widely embraced by the clinical and research communities. We evaluated sources of variability in sTIL assessment by pathologists in three previous sTIL ring studies. We identify common challenges and evaluate impact of discrepancies on outcome estimates in early TNBC using a newly-developed prognostic tool. Discordant sTIL assessment is driven by heterogeneity in lymphocyte distribution. Additional factors include: technical slide-related issues; scoring outside the tumor boundary; tumors with minimal assessable stroma; including lymphocytes associated with other structures; and including other inflammatory cells. Small variations in sTIL assessment modestly alter risk estimation in early TNBC but have the potential to affect treatment selection if cutpoints are employed. Scoring and averaging multiple areas, as well as use of reference images, improve consistency of sTIL evaluation. Moreover, to assist in avoiding the pitfalls identified in this analysis, we developed an educational resource available at www.tilsinbreastcancer.org/pitfalls.",

author = "Zuzana Kos and Elvire Roblin and Kim, {Rim S.} and Stefan Michiels and Gallas, {Brandon D.} and Weijie Chen and {van de Vijver}, {Koen K.} and Shom Goel and Sylvia Adams and Sandra Demaria and Giuseppe Viale and Nielsen, {Torsten O.} and Badve, {Sunil S.} and Symmans, {W. Fraser} and Christos Sotiriou and Rimm, {David L.} and Stephen Hewitt and Carsten Denkert and Sibylle Loibl and Luen, {Stephen J.} and Bartlett, {John M.S.} and Peter Savas and Giancarlo Pruneri and Dillon, {Deborah A.} and Cheang, {Maggie Chon U.} and Andrew Tutt and Hall, {Jacqueline A.} and Marleen Kok and Horlings, {Hugo M.} and Anant Madabhushi and {van der Laak}, Jeroen and Francesco Ciompi and Laenkholm, {Anne Vibeke} and Enrique Bellolio and Tina Gruosso and Fox, {Stephen B.} and Araya, {Juan Carlos} and Giuseppe Floris and Jan Hudecek and Leonie Voorwerk and Beck, {Andrew H.} and Jen Kerner and Denis Larsimont and Sabine Declercq and {Van den Eynden}, Gert and Lajos Pusztai and Anna Ehinger and Wentao Yang and Khalid AbdulJabbar and Yinyin Yuan and {International Immuno-Oncology Biomarker Working Group} and Loes Kooreman",

note = "Funding Information: R.S. is supported by a grant from the Breast Cancer Research Foundation (BCRF, grant No. 17-194). S.L. is supported by the National Breast Cancer Foundation of Australia Endowed Chair (NBCF-17-001) and the Breast Cancer Research Foundation, New York (BCRF-19-102). S.G. is supported by Susan G Komen Foundation (CCR18547966) and a Young investigator Grant from Breast Cancer Alliance. T.O.N. receives funding support from the Canadian Cancer Society. A.M. acknowledges research reported in this publication was supported by the National Cancer Institute of the National Institutes of Health under award numbers 1U24CA199374-01, R01CA202752-01A1, R01CA208236-01A1, R01 CA216579-01A1, R01 CA220581-01A1, 1U01 CA239055-01, National Center for Research Resources under award number 1 C06 RR12463-01, VA Merit Review Award IBX004121A from the United States Department of Veterans Affairs Biomedical Laboratory Research and Development Service, the DOD Prostate Cancer Idea Development Award (W81XWH-15-1-0558), the DOD Lung Cancer Investigator-Initiated Translational Research Award (W81XWH-18-1-0440), the DOD Peer Reviewed Cancer Research Program (W81XWH-16-1-0329), the Ohio Third Frontier Technology Validation Fund and the Wallace H. Coulter Foundation Program in the Department of Biomedical Engineering and the Clinical and Translational Science Award Program (CTSA) at Case Western Reserve University. J.S. received funding from NCI grants UG3CA225021 and U24CA215109. C.S. is a Royal Society Napier Research Professor; this work was supported by the Francis Crick Institute that receives its core funding from Cancer Research UK (FC001169, FC001202), the UK Medical Research Council (FC001169, FC001202), and the Wellcome Trust (FC001169, FC001202); C.S. is also funded by Cancer Research UK (TRACERx and CRUK Cancer Immunotherapy Catalyst Network), the CRUK Lung Cancer Centre of Excellence, Stand Up 2 Cancer (SU2C), the Rosetrees Trust, Butterfield and Stoneygate Trusts, NovoNordisk Foundation (ID16584), the Prostate Cancer Foundation, the Breast Cancer Research Foundation (BCRF); the research leading to these results has received funding from the European Research Council (ERC) under the European Union{\textquoteright}s Seventh Framework Programme (FP7/2007-2013) Consolidator Grant (FP7-THESEUS-617844), European Commission ITN (FP7-PloidyNet 607722), ERC Advanced Grant (PROTEUS) has received funding from the European Research Council under the European Union{\textquoteright}s Horizon 2020 research and innovation programme (grant agreement No. 835297), Chromavision—this project has received funding from the European{\textquoteright}s Union Horizon 2020 research and innovation programme (grant agreement No. 665233); support was also provided to C.S. by the National Institute for Health Research, the University College London Hospitals Biomedical Research Centre, and the Cancer Research UK University College London Experimental Cancer Medicine Centre. R.K. and K.P.-G. acknowledge research leading to or reported in this publication was supported by NCI U10CA180868, -180822, UG1-189867, and U24-196067 the Breast Cancer Research Foundation and Genentech. Funding Information: A.E. is on the Roche advisory board and has reported honoraria from Amgen, Novartis and Roche. A.J.L. is a consultant for BMS, Merck, AZ/Medimmune, and Genentech. R.S. reports research funding from Roche, Puma, Merck; advisory board and consultancy for BMS; travel funding from Roche, Merck, and Astra Zeneca. S.G. reports Lab research funding from Lilly, Clinical research funding from Eli Lilly and Novartis and is a Paid advisor to Eli Lilly, Novartis, and G1 Therapeutics. J.v.d.L. is member of the scientific advisory boards of Philips, the Netherlands and ContextVision, Sweden and receives research funding from Philips, the Netherlands and Sectra, Sweden. S.A. reports Research funding to institution from Merck, Genentech, BMS, Novartis, Celgene and Amgen and is an uncompensated consultant /steering committee member for Merck, Genentech and BMS. T.O.N. has consulted for Nanostring and received compensation and has intellectual property rights/ownership interests from Bioclassifier LLC [not related to the subject material under consideration]. S.L. receives research funding to institution from Novartis, Bristol Meyers Squibb, Merck, Roche-Genentech, Puma Biotechnology, Pfizer and Eli Lilly, has acted as consultant (not compensated) to Seattle Genetics, Pfizer, Novartis, BMS, Merck, AstraZeneca and Roche-Genentech and acted as consultant (paid to her institution) to Aduro Biotech. S.R.L. has received travel and educational funding from Roche/Ventana. A.M. is an equity holder in Elucid Bioimaging and in Inspirata Inc., a scientific advisory consultant for Inspirata Inc, has served as a scientific advisory board member for Inspirata Inc, Astrazeneca, Bristol Meyers-Squibb and Merck, has sponsored research agreements with Philips and Inspirata Inc, is involved in a NIH U24 grant with PathCore Inc, and 3 different R01 grants with Inspirata Inc. and his technology has been licensed to Elucid Bioimaging and Inspirata Inc. G.C. is on the advisory boards of Roche, BMS, Pfizer, Seattle Genetics and Ellipsis, and reports personal fees from Roche, BMS, Pfizer, Seattle Genetics, and Ellipsis, outside of the submitted work. J.H. is the director and owner of Vivactiv Ltd. J.H. is the director and owner of Slide Score B. V. F.P.L. reports funding from Astrazeneca, BMS, Roche, MSD, Pfizer, Novartis, Sanofi, Eli Lilly. J.B. reports consultancies from Insight Genetics, BioNTech AG, Biotheranos-tics, Pfizer, RNA Diagnostics and OncoXchange, research funding from Thermo Fisher Scientific, Genoptix, Agendia, NanoString Technologies, Stratifyer GmbH and Biotheranostics, applied for patents, including Jan 2017: Methods and Devices for Predicting Anthracycline Treatment Efficacy, US utility—15/325,472; EPO— 15822898.1; Canada—not yet assigned; Jan 2017: Systems, Devices and Methods for Constructing and Using a Biomarker, US utility—15/328,108; EPO—15824751.0; Canada—not yet assigned; Oct 2016: Histone gene module predicts anthracycline benefit, PCT/CA2016/000247; Dec 2016: 95-Gene Signature of Residual Risk Following Endocrine Treatment, PCT/CA2016/000304; Dec 2016: Immune Gene Signature Predicts Anthracycline Benefit, PCT/CA2016/000305. M.A.S. reports consulting work for Achilles Therapeutics. C.S. reports receipt of grants/research support from Pfizer, AstraZeneca, BMS and Ventana; receipt of honoraria, consultancy, or SAB Member fees from Pfizer, Novartis, GlaxoSmithKline, MSD, BMS, Celgene, AstraZeneca, Illumina, Sarah Canon Research Institute, Genentech, Roche-Ventana, GRAIL, Medicxi; Advisor for Dynamo Therapeutics; Stock shareholder in Apogen Biotechnologies, Epic Bioscience, GRAIL; Co-Founder & stock options in Achilles Therapeutics. A.H.B. is the co-founder and CEO of PathAI. J.K. is an employee of PathAI. D.D. is on the advisory board for Oncology Analytics, Inc, and a consultant for Novartis. D.L.R. is on the advisory board of Amgen, Astra Zeneca, Cell Signaling Technology, Cepheid, Daiichi Sankyo, GSK, Konica/Minolta, Merck, NanoString, Perkin Elmer, Ventana, Ultivue; receives research support from Astra Zeneca, Cepheid, Navigate BioPharma, NextCure, Lilly, Ultivue; instrument support from Ventana, Akoya/Perkin Elmer, NanoString; paid consultant for Biocept; received travel honoraria from BMS, founder and equity holder for PixelGear and received royalty from Rarecyte. A.T. reports benefits from ICR{\textquoteright}s Inventors Scheme associated with patents for one of PARP inhibitors in BRCA1/2 associated cancers, as well as honoraria from Pfizer, Vertex, Prime Oncology, Artios, honoraria and stock in InBioMotion, honoraria and financial support for research from AstraZeneca, Medivation, Myriad Genetics and Merck Serono. This work includes contributions from, and was reviewed by, individuals at the FDA. This work has been approved for publication by the agency, but it does not necessarily reflect official agency policy. Certain commercial materials and equipment are identified in order to adequately specify experimental procedures. In no case does such identification imply recommendation or endorsement by the FDA, nor does it imply that the items identified are necessarily the best available for the purpose. This work includes contributions from, and was reviewed by, individuals who received funding from the National Institutes of Health, the U.S. Department of Veterans Affairs and the Department of Defense. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health, the U.S. Department of Veterans Affairs, the Department of Defense, or the United States Government. Publisher Copyright: {\textcopyright} 2020, The Author(s).",

year = "2020",

month = may,

day = "12",

doi = "10.1038/s41523-020-0156-0",

language = "English",

volume = "6",

journal = "npj Breast Cancer",

issn = "2374-4677",

publisher = "Nature Publishing Group",

number = "1",

}

Kos, Z, Roblin, E, Kim, RS, Michiels, S, Gallas, BD, Chen, W, van de Vijver, KK, Goel, S, Adams, S, Demaria, S, Viale, G, Nielsen, TO, Badve, SS, Symmans, WF, Sotiriou, C, Rimm, DL, Hewitt, S, Denkert, C, Loibl, S, Luen, SJ, Bartlett, JMS, Savas, P, Pruneri, G, Dillon, DA, Cheang, MCU, Tutt, A, Hall, JA, Kok, M, Horlings, HM, Madabhushi, A, van der Laak, J, Ciompi, F, Laenkholm, AV, Bellolio, E, Gruosso, T, Fox, SB, Araya, JC, Floris, G, Hudecek, J, Voorwerk, L, Beck, AH, Kerner, J, Larsimont, D, Declercq, S, Van den Eynden, G, Pusztai, L, Ehinger, A, Yang, W, AbdulJabbar, K, Yuan, Y, International Immuno-Oncology Biomarker Working Group & Kooreman, L 2020, 'Pitfalls in assessing stromal tumor infiltrating lymphocytes (sTILs) in breast cancer', npj Breast Cancer, vol. 6, no. 1, 17. https://doi.org/10.1038/s41523-020-0156-0

TY - JOUR

T1 - Pitfalls in assessing stromal tumor infiltrating lymphocytes (sTILs) in breast cancer

AU - Kos, Zuzana

AU - Roblin, Elvire

AU - Kim, Rim S.

AU - Michiels, Stefan

AU - Gallas, Brandon D.

AU - Chen, Weijie

AU - van de Vijver, Koen K.

AU - Goel, Shom

AU - Adams, Sylvia

AU - Demaria, Sandra

AU - Viale, Giuseppe

AU - Nielsen, Torsten O.

AU - Badve, Sunil S.

AU - Symmans, W. Fraser

AU - Sotiriou, Christos

AU - Rimm, David L.

AU - Hewitt, Stephen

AU - Denkert, Carsten

AU - Loibl, Sibylle

AU - Luen, Stephen J.

AU - Bartlett, John M.S.

AU - Savas, Peter

AU - Pruneri, Giancarlo

AU - Dillon, Deborah A.

AU - Cheang, Maggie Chon U.

AU - Tutt, Andrew

AU - Hall, Jacqueline A.

AU - Kok, Marleen

AU - Horlings, Hugo M.

AU - Madabhushi, Anant

AU - van der Laak, Jeroen

AU - Ciompi, Francesco

AU - Laenkholm, Anne Vibeke

AU - Bellolio, Enrique

AU - Gruosso, Tina

AU - Fox, Stephen B.

AU - Araya, Juan Carlos

AU - Floris, Giuseppe

AU - Hudecek, Jan

AU - Voorwerk, Leonie

AU - Beck, Andrew H.

AU - Kerner, Jen

AU - Larsimont, Denis

AU - Declercq, Sabine

AU - Van den Eynden, Gert

AU - Pusztai, Lajos

AU - Ehinger, Anna

AU - Yang, Wentao

AU - AbdulJabbar, Khalid

AU - Yuan, Yinyin

AU - International Immuno-Oncology Biomarker Working Group

AU - Kooreman, Loes

N1 - Funding Information: R.S. is supported by a grant from the Breast Cancer Research Foundation (BCRF, grant No. 17-194). S.L. is supported by the National Breast Cancer Foundation of Australia Endowed Chair (NBCF-17-001) and the Breast Cancer Research Foundation, New York (BCRF-19-102). S.G. is supported by Susan G Komen Foundation (CCR18547966) and a Young investigator Grant from Breast Cancer Alliance. T.O.N. receives funding support from the Canadian Cancer Society. A.M. acknowledges research reported in this publication was supported by the National Cancer Institute of the National Institutes of Health under award numbers 1U24CA199374-01, R01CA202752-01A1, R01CA208236-01A1, R01 CA216579-01A1, R01 CA220581-01A1, 1U01 CA239055-01, National Center for Research Resources under award number 1 C06 RR12463-01, VA Merit Review Award IBX004121A from the United States Department of Veterans Affairs Biomedical Laboratory Research and Development Service, the DOD Prostate Cancer Idea Development Award (W81XWH-15-1-0558), the DOD Lung Cancer Investigator-Initiated Translational Research Award (W81XWH-18-1-0440), the DOD Peer Reviewed Cancer Research Program (W81XWH-16-1-0329), the Ohio Third Frontier Technology Validation Fund and the Wallace H. Coulter Foundation Program in the Department of Biomedical Engineering and the Clinical and Translational Science Award Program (CTSA) at Case Western Reserve University. J.S. received funding from NCI grants UG3CA225021 and U24CA215109. C.S. is a Royal Society Napier Research Professor; this work was supported by the Francis Crick Institute that receives its core funding from Cancer Research UK (FC001169, FC001202), the UK Medical Research Council (FC001169, FC001202), and the Wellcome Trust (FC001169, FC001202); C.S. is also funded by Cancer Research UK (TRACERx and CRUK Cancer Immunotherapy Catalyst Network), the CRUK Lung Cancer Centre of Excellence, Stand Up 2 Cancer (SU2C), the Rosetrees Trust, Butterfield and Stoneygate Trusts, NovoNordisk Foundation (ID16584), the Prostate Cancer Foundation, the Breast Cancer Research Foundation (BCRF); the research leading to these results has received funding from the European Research Council (ERC) under the European Union’s Seventh Framework Programme (FP7/2007-2013) Consolidator Grant (FP7-THESEUS-617844), European Commission ITN (FP7-PloidyNet 607722), ERC Advanced Grant (PROTEUS) has received funding from the European Research Council under the European Union’s Horizon 2020 research and innovation programme (grant agreement No. 835297), Chromavision—this project has received funding from the European’s Union Horizon 2020 research and innovation programme (grant agreement No. 665233); support was also provided to C.S. by the National Institute for Health Research, the University College London Hospitals Biomedical Research Centre, and the Cancer Research UK University College London Experimental Cancer Medicine Centre. R.K. and K.P.-G. acknowledge research leading to or reported in this publication was supported by NCI U10CA180868, -180822, UG1-189867, and U24-196067 the Breast Cancer Research Foundation and Genentech. Funding Information: A.E. is on the Roche advisory board and has reported honoraria from Amgen, Novartis and Roche. A.J.L. is a consultant for BMS, Merck, AZ/Medimmune, and Genentech. R.S. reports research funding from Roche, Puma, Merck; advisory board and consultancy for BMS; travel funding from Roche, Merck, and Astra Zeneca. S.G. reports Lab research funding from Lilly, Clinical research funding from Eli Lilly and Novartis and is a Paid advisor to Eli Lilly, Novartis, and G1 Therapeutics. J.v.d.L. is member of the scientific advisory boards of Philips, the Netherlands and ContextVision, Sweden and receives research funding from Philips, the Netherlands and Sectra, Sweden. S.A. reports Research funding to institution from Merck, Genentech, BMS, Novartis, Celgene and Amgen and is an uncompensated consultant /steering committee member for Merck, Genentech and BMS. T.O.N. has consulted for Nanostring and received compensation and has intellectual property rights/ownership interests from Bioclassifier LLC [not related to the subject material under consideration]. S.L. receives research funding to institution from Novartis, Bristol Meyers Squibb, Merck, Roche-Genentech, Puma Biotechnology, Pfizer and Eli Lilly, has acted as consultant (not compensated) to Seattle Genetics, Pfizer, Novartis, BMS, Merck, AstraZeneca and Roche-Genentech and acted as consultant (paid to her institution) to Aduro Biotech. S.R.L. has received travel and educational funding from Roche/Ventana. A.M. is an equity holder in Elucid Bioimaging and in Inspirata Inc., a scientific advisory consultant for Inspirata Inc, has served as a scientific advisory board member for Inspirata Inc, Astrazeneca, Bristol Meyers-Squibb and Merck, has sponsored research agreements with Philips and Inspirata Inc, is involved in a NIH U24 grant with PathCore Inc, and 3 different R01 grants with Inspirata Inc. and his technology has been licensed to Elucid Bioimaging and Inspirata Inc. G.C. is on the advisory boards of Roche, BMS, Pfizer, Seattle Genetics and Ellipsis, and reports personal fees from Roche, BMS, Pfizer, Seattle Genetics, and Ellipsis, outside of the submitted work. J.H. is the director and owner of Vivactiv Ltd. J.H. is the director and owner of Slide Score B. V. F.P.L. reports funding from Astrazeneca, BMS, Roche, MSD, Pfizer, Novartis, Sanofi, Eli Lilly. J.B. reports consultancies from Insight Genetics, BioNTech AG, Biotheranos-tics, Pfizer, RNA Diagnostics and OncoXchange, research funding from Thermo Fisher Scientific, Genoptix, Agendia, NanoString Technologies, Stratifyer GmbH and Biotheranostics, applied for patents, including Jan 2017: Methods and Devices for Predicting Anthracycline Treatment Efficacy, US utility—15/325,472; EPO— 15822898.1; Canada—not yet assigned; Jan 2017: Systems, Devices and Methods for Constructing and Using a Biomarker, US utility—15/328,108; EPO—15824751.0; Canada—not yet assigned; Oct 2016: Histone gene module predicts anthracycline benefit, PCT/CA2016/000247; Dec 2016: 95-Gene Signature of Residual Risk Following Endocrine Treatment, PCT/CA2016/000304; Dec 2016: Immune Gene Signature Predicts Anthracycline Benefit, PCT/CA2016/000305. M.A.S. reports consulting work for Achilles Therapeutics. C.S. reports receipt of grants/research support from Pfizer, AstraZeneca, BMS and Ventana; receipt of honoraria, consultancy, or SAB Member fees from Pfizer, Novartis, GlaxoSmithKline, MSD, BMS, Celgene, AstraZeneca, Illumina, Sarah Canon Research Institute, Genentech, Roche-Ventana, GRAIL, Medicxi; Advisor for Dynamo Therapeutics; Stock shareholder in Apogen Biotechnologies, Epic Bioscience, GRAIL; Co-Founder & stock options in Achilles Therapeutics. A.H.B. is the co-founder and CEO of PathAI. J.K. is an employee of PathAI. D.D. is on the advisory board for Oncology Analytics, Inc, and a consultant for Novartis. D.L.R. is on the advisory board of Amgen, Astra Zeneca, Cell Signaling Technology, Cepheid, Daiichi Sankyo, GSK, Konica/Minolta, Merck, NanoString, Perkin Elmer, Ventana, Ultivue; receives research support from Astra Zeneca, Cepheid, Navigate BioPharma, NextCure, Lilly, Ultivue; instrument support from Ventana, Akoya/Perkin Elmer, NanoString; paid consultant for Biocept; received travel honoraria from BMS, founder and equity holder for PixelGear and received royalty from Rarecyte. A.T. reports benefits from ICR’s Inventors Scheme associated with patents for one of PARP inhibitors in BRCA1/2 associated cancers, as well as honoraria from Pfizer, Vertex, Prime Oncology, Artios, honoraria and stock in InBioMotion, honoraria and financial support for research from AstraZeneca, Medivation, Myriad Genetics and Merck Serono. This work includes contributions from, and was reviewed by, individuals at the FDA. This work has been approved for publication by the agency, but it does not necessarily reflect official agency policy. Certain commercial materials and equipment are identified in order to adequately specify experimental procedures. In no case does such identification imply recommendation or endorsement by the FDA, nor does it imply that the items identified are necessarily the best available for the purpose. This work includes contributions from, and was reviewed by, individuals who received funding from the National Institutes of Health, the U.S. Department of Veterans Affairs and the Department of Defense. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health, the U.S. Department of Veterans Affairs, the Department of Defense, or the United States Government. Publisher Copyright: © 2020, The Author(s).

PY - 2020/5/12

Y1 - 2020/5/12

N2 - Stromal tumor-infiltrating lymphocytes (sTILs) are important prognostic and predictive biomarkers in triple-negative (TNBC) and HER2-positive breast cancer. Incorporating sTILs into clinical practice necessitates reproducible assessment. Previously developed standardized scoring guidelines have been widely embraced by the clinical and research communities. We evaluated sources of variability in sTIL assessment by pathologists in three previous sTIL ring studies. We identify common challenges and evaluate impact of discrepancies on outcome estimates in early TNBC using a newly-developed prognostic tool. Discordant sTIL assessment is driven by heterogeneity in lymphocyte distribution. Additional factors include: technical slide-related issues; scoring outside the tumor boundary; tumors with minimal assessable stroma; including lymphocytes associated with other structures; and including other inflammatory cells. Small variations in sTIL assessment modestly alter risk estimation in early TNBC but have the potential to affect treatment selection if cutpoints are employed. Scoring and averaging multiple areas, as well as use of reference images, improve consistency of sTIL evaluation. Moreover, to assist in avoiding the pitfalls identified in this analysis, we developed an educational resource available at www.tilsinbreastcancer.org/pitfalls.

AB - Stromal tumor-infiltrating lymphocytes (sTILs) are important prognostic and predictive biomarkers in triple-negative (TNBC) and HER2-positive breast cancer. Incorporating sTILs into clinical practice necessitates reproducible assessment. Previously developed standardized scoring guidelines have been widely embraced by the clinical and research communities. We evaluated sources of variability in sTIL assessment by pathologists in three previous sTIL ring studies. We identify common challenges and evaluate impact of discrepancies on outcome estimates in early TNBC using a newly-developed prognostic tool. Discordant sTIL assessment is driven by heterogeneity in lymphocyte distribution. Additional factors include: technical slide-related issues; scoring outside the tumor boundary; tumors with minimal assessable stroma; including lymphocytes associated with other structures; and including other inflammatory cells. Small variations in sTIL assessment modestly alter risk estimation in early TNBC but have the potential to affect treatment selection if cutpoints are employed. Scoring and averaging multiple areas, as well as use of reference images, improve consistency of sTIL evaluation. Moreover, to assist in avoiding the pitfalls identified in this analysis, we developed an educational resource available at www.tilsinbreastcancer.org/pitfalls.

U2 - 10.1038/s41523-020-0156-0

DO - 10.1038/s41523-020-0156-0

M3 - Article

SN - 2374-4677

VL - 6

JO - npj Breast Cancer

JF - npj Breast Cancer

IS - 1

M1 - 17

ER -

Pitfalls in assessing stromal tumor infiltrating lymphocytes (sTILs) in breast cancer

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