CP0205

Asociación de los TILs con "outcomes"

en cáncer de mama

Tomás Pascual
Oncólogo médico, Hospital Clínic de Barcelona
Director científico, SOLTI
Is the breast cancer immunogenic?
The prevalence of somatic mutations across human cancer types.

• Not traditionally thought to be immunogenic

• Main risk factor are reproductive and hormonotherapy
• No apparent increased risk in organ transplantation or HIV patients “COLD” TUMORS
• Not carcinogen induced: low tumor mutational burden
• Not viral induced
Saltz J et al, Cell Reports 2018
Background: the immune system and tils
in breast cancer

They are a population of cells comprising a mixture of cytotoxic T cells and helper T cells, as well as B
cells, macrophages, natural killer cells, and dendritic cells.
 Background: TILs Analytical validity
TIL quantity on a H&E stained slide Multicolor IHC multispectral Flow cytometry

Gene expression analysis Map Structural Patterns

CD8

Gene expression and flow cytometry profiles demonstrate that TIL quantity, as assessed semiquantitatively on a H&E stained slide,
represents a sur-rogate for a pre-existing favourable host anti-tumor activated T cell response
Background: TILs as a continuous or
categorical measurement
N =3,561 samples N =2,009 samples

45 % 36% 19%

90%

0-10% TILS 11-59% TILS 60-100%

75%
50%
25%

Denkert C. et al, Lancet Oncology 2018

Loi S. et al, JCO 2013
 Background: TILs across breast cancer types

N =3,561 samples N = 2,009 samples

60% 56%

50% 44%
41%
40% 37%
32% 30%
29%
30%
19%
20%
13%
10%
0%
HR+/HER2- HER2+ TNBC
(N=1366) (N=1379) (N=906) N=2,009 N=1,079 N=297 N=256

<10% 11-59% >60%

Denkert C. et al, Lancet Oncology 2018 Loi S. et al, JCO 2013

 LPBC (TILs ≥ 60%) in HER2+ disease*

All patients HR-pos LPBC

N=2,741 6%
N=267
10% 39%

HR-neg
61%
15%
90%

1. Barroso-Sousa R, et al. Ann Oncol. 2019;

2. Perez EA, et al. JAMA Oncol. 2016;
3., Llombart-Cussac A et al. Lancet Oncol. 2017;
4. Ingold Heppner B, et al. Clin Cancer Res. 2016;
* Please note that this is combined data from the references cited. 5. Dieci MV, et al. Ann Oncol. 2019
 Clinical Validy of TILs in Breast Cancer
The prognostic value
TILs and response to TILs in residual
of TILs in early-stage
neoadjuvant therapy disease
breast cancer

The prognostic value

TILs and
of TILs in metastatic
Immunotherapy
breast cancer
 Clinical Validy of TILs in Breast Cancer
The prognostic value
TILs and response to TILs in residual
of TILs in early-stage
neoadjuvant therapy disease
breast cancer

The prognostic value

TILs and
of TILs in metastatic
Immunotherapy
breast cancer
 Adjuvant trials that have assessed TILs in
TNBC
Trial Treatment Subtype N Recurrence end points
Doxorubicin ER+/HER2- 1,079 Not significant
Cyclophosphamide HER2+ 297 Not significant
BIG 2-98
CMF
Docetaxel TNBC 256 For each 10% increment of sTILs: DFS, HR = 0.84 (95% CI: 0.74–0.98, P = 0.025)
Docetaxel ER+/HER2- 591 Not significant
Vinorelbine HER2+ 209 Predictive for higher trastuzumab benefit (P interaction = 0.025)
FinHER
FEC
±Trastuzumab TNBC 134 For each 10% increment of sTILs: DDFS, HR = 0.79 (95% CI: 0.64–0.98, P = 0.032)
Doxorubicin
E2197 and
Cyclophosphamide TNBC 481 For each 10% increment of sTILs: DFS, HR = 0.84 (95% CI 0.74–0.95, P = 0.005)
E1199
Docetaxel
CMF Anthracycline
For each 10% increment of sTILs: Breast cancer-free interval, HR = 0.87 (95% CI
IBCSG 22-00 Taxanes CM- TNBC 647
0.79–0.95, P = 0.003)
maintenance
Studies included ECOG2197, ECOG1199, BIG2-98, FinHER, Gustave Roussy, IBCSG
Pooled Anthracycline
TNBC 2148 22-00, PACS01, PACS04 and IEO.
analysis Taxane
For each 10% increment of sTILs: IDFS HR = 0.86 (95% CI: 0.80–0.93, P < 0.0001)
DDFS, distant disease-free survival; IDFS, invasive disease-free survival; DFS, disease-free survival; sTIL, stromal TIL.
In TNBC, each 10% increase in sTILs was associated with a ~15% reduced risk of relapse, respectively, and ~17% reduced
risk of death, respectively, regardless of chemotherapy type.
Loi S. et al, JCO 2013; Loi S. et al, Ann Oncol 2014; Adams S. et al, JCO 2013;
Pruneri et al, BCRT 2016; Loi S. et al, JCO 2019
TILs and Prognosis: A Pooled Analysis of
Early-Stage TNBC
In the multivariable model sTILs:
• Added significant independent prognostic information for all end points (iDFS; D-DFS and OS).
• Each 10% increment in sTILs corresponded to an iDFS hazard ratio of 0.87 (95% CI, 0.83-0.91) for iDFS,
0.83 (95% CI, 0.79-0.88) for D-DFS, and 0.84 (95% CI, 0.79 - 0.89) for OS.
• In node-negative patients with sTILs $ 30%, 3-year iDFS was 92% (95% CI, 89% to 98%), D-DFS was 97%
(95% CI, 95% to 99%), and OS was 99% (95% CI, 97% to 100%).

Loi S. et al, JCO 2019

Prognostic value of TILs in patients with
early-stage TNBC who did not receive
adjuvant chemotherapy

Park JH. et al, Ann Oncol 2019

TILs suggest a new prognostication in
early TNBC

https://cesp-proxy2.vjf.inserm.fr/shiny/prognosTILs/
 Adjuvant trials that have assessed TILs in
HER2+
Trial Treatment Subtype N Recurrence end points Interaction

Doxorubicin ER+/HER2- 1,079 Not significant

Cyclophosphamide HER2+ 297 Not significant
BIG 2-98
CMF
Docetaxel TNBC 256 For each 10% increment of sTILs: DFS, HR = 0.84 (P = 0.025)
Docetaxel ER+/HER2- 591 Not significant
Vinorelbine HER2+ 209 For each 10% increment of sTILs in pts with T: DDFS, HR = 0.82 Yes (P = .03)
FinHER
FEC
±Trastuzumab TNBC 134 For each 10% increment of sTILs: DDFS, HR = 0.79 (P = .032)
N9831 AC → P +/-H HER2+ 945 For increment of sTILs: DFS, HR = 0.79 (P = .002) in pts receiving not T Yes (P = .03)
For each 10% increment of sTILs in all DFS HR = 0.42 and with
NSABP-31 AC → P +/-H HER2+ 1581 No
trastuzumab DFS HR = 0.65.
10% TILs increments and DDFS was significant for pts randomized to
AC/FEC → D + H (9
ShortHER HER2+ 866 9 weeks of T (HR 0.60) but not for pts treated with 1 year of T (HR 0.89, Yes
wks vs 1 yr)
95% CI 0.71–1.12).
DDFS, distant disease-free survival; IDFS, invasive disease-free survival; DFS, disease-free survival; sTIL, stromal TIL.

Loi S. et al, JCO 2013; Loi S. et al, Ann Oncol 2014; Pérez E. et al, Jama
Oncol 2016; Kim RS. Et al. JNCI 2019; Dieci et al. Ann Oncol 2019
 Association of TILs with distant DFS in the
ShortHER trial for patients with HER2+ BC

HER2+ 9w
N = 1253
1 year

Antracicline Taxane Trastuzumab

Dieci et al. Ann Oncol 2019

 Clinical Validy of TILs in Breast Cancer
The prognostic value
TILs and response to TILs in residual
of TILs in early-stage
neoadjuvant therapy disease
breast cancer

The prognostic value

TILs and
of TILs in metastatic
Immunotherapy
breast cancer
 TILs, pCR and prognosis in different
subtypes of breast cancer

9125 enrolled in six clinical trials of

neoadjuvant chemotherapy

3771 included in pCR analysis

(TNBC: n=906; HER2-positive: n=1379, luminal–HER2-negative: n=1366)

2560 included in disease-free survival and overall survival analysis

(TNBC: n=632; HER2-positive: n=986, luminal–HER2-negative: n=832)
 TILs, pCR and prognosis in different
subtypes of breast cancer
pCR pCR pCR pCR
27.2% 10.5% 37.8% 36.7%
60%
49% 50%
50% 44%

pCR rate
9125 enrolled in six clinical trials of 39%
neoadjuvant chemotherapy 40%
32% 31% 31%
29%
30% 27%
20%
20%
11%
10% 6%
3771 included in pCR analysis
(TNBC: n=906; HER2-positive: n=1379, luminal–HER2-negative: n=1366) 0%
ALL HR+/HER2- HER2+ TNBC
Low (0-10%) Intermediate (11-59%) High (>60%)
2560 included in disease-free survival and overall survival analysis
(TNBC: n=632; HER2-positive: n=986, luminal–HER2-negative: n=832)

Denkert C. et al, Lancet Oncology 2018

 TILs, pCR and prognosis in different
subtypes of breast cancer
TNBC HER2+ HR+/HER2-
DFS
OS
5 Immune-related genomic biomarkers were
associated with higher pCR/response rates and
better EFS in CALGB 40601

Fernandez-Martinez A. et al, ESMO 2019

5 Immune-related genomic biomarkers were
associated with higher pCR/response rates and
better EFS in CALGB 40601

Fernandez-Martinez A. et al, ESMO 2019

 HER2+/HER2-E intrinsic subtype benefits
the most from the dual HER2 blockade
without chemotherapy

N=150
Stage II- 18 weeks
S
IIIA U
HER2+ Trastuzumab + Lapatinib R Primary
Breast + HR+: ET (Letrozole or Tamoxifen)
G endpoint pCR in
E
Cancer the breast
R
Y

Baseline Week 2
PAM50 PAM50

Prat et al. SABCS 2016; Lancet Oncol 2017

Early changes in TILs and Tumor
Cellularity in HER2+ BC
Retrospective Analysis from PAMELA trial (n=134/151)
Lapatinib + Trastuzumab (+ ET if HR+) for 18 weeks

pCR

CelTIL score D15

=
Tumor cellularity
+
TILs

Nuciforo et al. Ann Oncol 2017

 Clinical Validy of TILs in Breast Cancer
The prognostic value
TILs and response to TILs in residual
of TILs in early-stage
neoadjuvant therapy disease
breast cancer

The prognostic value

TILs and
of TILs in metastatic
Immunotherapy
breast cancer
Residual disease TILs and RCB in TNBC
patients after neoadjuvant chemotherapy

20% TIL cut-off point used is the median asd is arbitrarity chosen

Luen et al, Ann Oncol. 2018

Prognostic utility of TILs in residual tumor
after neoadjuvant chemotherapy with
trastuzumab for HER2+ BC

Kurozumi S. et al, Sci Rep 2019

 Clinical Validy of TILs in Breast Cancer
The prognostic value
TILs and response to TILs in residual
of TILs in early-stage
neoadjuvant therapy disease
breast cancer

The prognostic value

TILs and
of TILs in metastatic
Immunotherapy
breast cancer
Metastatic Breast Cancer: TIL it is Too Lat

Savas P. et al, CCR 2019

 Tumor infiltranting Lymphocites Changes
Paried primary and recurrent TNBC
TUMOR MUTATIONAL BURDEN TNBC SUBTYPE SHIFTS TUMOR INFILTRATING LYMPHOCYTES

• Totla N=55, 44 paired primary-metastatic samples.

• With some exceptions, TMB was low/intermediate (< 16 mutations/megabase) overall and relatively unchanged between
primary and metastatic disease.
• There were significant phenotype shifts between primary and metastatic TNBCs, decrease in the basal-like immune-
activated phenotype (BLIA, 37.0% to 14.3%) and an increase in the mesenchymal phenotype (MES 0% to 9.5%) and in
the Basal-Like Immune-Suppressed phenotype (BLIS 43.,5 to 61.9%).
• TILs were decreased significantly in metastatic TNBCs compared to primary TNBCs Hutchinson KE et al, CCR 2019
Trial Treatment Subtype N Recurrence end points
Docetaxel For each 10% increase in sTILs OS adjusted HR 0.89, 95% CI: 0.83−0.96, P =
HER2+
CLEOPATRA Trastuzumab +/- 678 0.0014 No significant association between TILs PFS (adjusted HR 0.95, 95%
First line
Pertuzsumab CI: 0.90−1.00, P = 0.063). Median TILs 10%
No significant difference in DFS between high and low-TIL groups (P =
52
Kashiwagi et al. Eribuline All 0.489) TNBC: high TILs (>10%) group had significantly longer DFS than the
(primary)
low-TIL group (P = 0.033)
HER2+ Overall H&E sTIL counts of greater than 5% (high) were present in 215
MA.31 T + H/L 614
First line cases (35%) but did not show significant prognostic or predictive effects.
TNBC, OS 11.8 and 62.9 m with low and high TILs (HR 0.29, p = 0.008).
HER2+ 94
Dieci et al. ----- CD8/FOXP3 ratio was also prognostic in TNBC. HER2+ BC, low TILs tumors
TNBC (mets)
showed better prognosis (OS 53.7 vs 39.9 months, p>0.05).
cyclophosphamide
At multivariable analysis, each 10% increase in TILs strongly predicted a
Montagna et al. capecitabine HR+/HER2- 92
worse TTP (HR: 1.27, p = 0.008)
vinorelbine

Luen SJ. et al, Lancet Oncol 2017; Kashiwagi et al, Plos ONE 2017; Luis S. et al,
JAMA Oncol 2017; Dieci MV. et al, BCR 2018; Montagna et al. Breast. 2017
TILs in advanced HER2-positive breast
cancer

Luen SJ. et al, Lancet Oncol 2017

 Modest ORR with checkpoint inhibitor
Monotherapy
Antibody Trial Study type Target Subtype Patients ORR
Avelumab JAVELIN, Phase 1 stratified for PD-L1 PD-L1 All 168 4.8%
Dirix. BCRT 2017 solid tumor
HER2 + 38 3.8%
TNBC 58 5.2%
PD-L1+ TNBC 9 22.2%

Pembrolizumab KEYNOTE-012, Phase 1b for PD-L1 PD-1 PD-L1+ TNBC 32 18.5%

Nanda. JCO 2016 positive solid tumours
KEYNOTE-028, Phase 1b for PD-L1 PD-L1+ HR+/HER2- 25 12%
Rugo. CCR 2018 positive solid tumours
KEYNOTE-086, Cohort A: Phase 2 BC >1L TNBC 170 4.7%
Adams. Ann Onc 2018
PD-L1 TNBC 108 4.8%
Adams. Ann Onc 2018 Cohort B: Phase 2 BC 1L PD-L1+ TNBC 84 23%

Atezolizumab Emens et al JAMA Onc Phase 1 stratified for PD-L1 PD-L1 TNBC 115 10%
2018 solid tumours
PD-L1+ TNBC 71 13%

Studies used different antibodies and cutoffs for determining PD-L1 positivity
High sTILs are Associated with Improved
Response Particularly in the First-Line Setting in
TNBC
Atezolizumab Pembrolizumab Pembrolizumab
(Cohort A: >2nd line) (Cohort B: 1st line)
40% 39.1%
Different levels by source of
sample (archival vs new) and
30%
organ site sampled:
Objective Response Rate (%)

LN>lung>liver

Metastatic breast cancer is a low

20% 19% TIL disease

10% 9% 8.7%
6.4%
1.9%
0%
TIL high2 TIL low TIL high2 TIL low TIL high TIL low
1</≥ Median
Schmid P, et al. AACR 2017; Adams. Ann Onc 2018; Adams. Ann Onc 2018
 ANTI-PD1/PDL1 and anti-HER2 in
metastatic BC
KATE 2 phase II study PANACEA phase II study

N=202
N=58
HER2+ LABC or MBC
•Prior taxane and Atezolizuamb + TDM1
trastuzumab HER2+ LABC or MBC
RANDOMIZATION

•Progression on •Prior trastuzumab or

metastatic therapy or 2:1 T-DM1 Pembrolizumab +
within 6 months of •No limit prior lines Trastuzumab
adjuvant therapy •Measurable disease
•Measurable disease Atezolizuamb + TDM1 • Tumor biopsy
sample <1year

Stratification by:
•Tumour PD-L1 IC status (IC0 [<1%] vs IC1/2/3 [≥1%])a
•World region (Western Europe vs North America vs rest of world)
•Presence of liver metastases (yes or no)
High sTILs are Associated with Improved
Responsein the HER2 positive
KATE 2 PANACEA
ESMO 2019; SABCS 2018 Loi et al. Lancet Oncol. 2018

TTO TDM1+ATEZO TDM-1 TRASTU/PEMBRO

PDL1 >1%tumor cells >1% tumor or stroma

% PDL1+ 84/202 (41.6%) 68/146 (53.5%)
ORR % 45.5% 43.5% 12%
ORR % PD-L1 + 54 % 33% 15%
ORR % PD-L1 - 40% 50% 0%
PFS 8.2m 6.8 m ≈ 2.6 m
PFS PD-L1 + 8.5 m 4.1 m 2.7 m
PFS6 58% 51% ≈ 20%
PFS 6 PDL1 + ≈ 60% ≈ 40% ≈ 26%
ORR TILs (>5%) 48% 38% 39% (PDL1+)
ORR TILs (<5%) 38% 48% 5% (PDL1+)

Loi et al. Lancet Oncol. 2018

 Clinical Utility of TILs in Breast Cancer
Identification of primary Refinement of the Prediction of responders
HER2+ and TNBC patients neoadjuvant pCR to immune checkpoint
with excellent prognoses endpoint blockade
Conclusion
• (1). A plethora of studies have established that the level of tumor-infiltrating
lymphocytes (TIL), as quantified using hematoxylin and eosin–stained slides,
predicts for better survival and response to neoadjuvant chemotherapy in early
stage TNBC

• (2)TILs also represent a simple measure of immune infiltration, which is in

reality a complex admixture of different arms of the adaptive and innate
immune systems.

• (3). In advanced disease, TILs also predict benefit from PD-1/PD-L1 axis
blockade

• (4). Concerted efforts to develop stromal TILs as a clinically relevant and

reproducible biomarkers are ongoing

• (5). These data pertain to assessment of TILs at a single timepoint. Immune

infiltration is however a dynamic entity, which is expected to be influenced by
tumor evolution and host factors, both of which are modulated by treatment.