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Review
. 2022 Jun;193(3):545-553.
doi: 10.1007/s10549-022-06587-3. Epub 2022 Apr 16.

Standardization of the tumor-stroma ratio scoring method for breast cancer research

Sophie C Hagenaars  1 , Kiki M H Vangangelt  1 , Gabi W Van Pelt  1 , Zsófia Karancsi  2 , Rob A E M Tollenaar  1 , Andrew R Green  3 , Emad A Rakha  3 , Janina Kulka  2 , Wilma E Mesker  4
Affiliations
Review

Standardization of the tumor-stroma ratio scoring method for breast cancer research

Sophie C Hagenaars et al. Breast Cancer Res Treat. 2022 Jun.

Abstract

Purpose: The tumor-stroma ratio (TSR) has repeatedly proven to be correlated with patient outcomes in breast cancer using large retrospective cohorts. However, studies validating the TSR often show variability in methodology, thereby hampering comparisons and uniform outcomes.

Method: This paper provides a detailed description of a simple and uniform TSR scoring method using Hematoxylin and Eosin (H&E)-stained core biopsies and resection tissue, specifically focused on breast cancer. Possible histological challenges that can be encountered during scoring including suggestions to overcome them are reported. Moreover, the procedure for TSR estimation in lymph nodes, scoring on digital images and the automatic assessment of the TSR using artificial intelligence are described.

Conclusion: Digitized scoring of tumor biopsies and resection material offers interesting future perspectives to determine patient prognosis and response to therapy. The fact that the TSR method is relatively easy, quick, and cheap, offers great potential for its implementation in routine diagnostics, but this requires high quality validation studies.

Keywords: Artificial intelligence; Biomarker; Breast cancer; Protocol; Tumor microenvironment; Tumor-stroma ratio.

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Conflict of interest statement

The authors declare no potential conflicts of interest.

Figures

Fig. 1
Fig. 1
Examples of digitized tissue slides of a stroma-high (80% stroma) primary breast carcinoma (a), an intermediate (50% stroma), but still stroma-low tumor (b), and a stroma-low (10% stroma) primary breast carcinoma (c) which all meet the criterium for correct scoring of tumor cells being present on all four sides of the circular field of vision (field view with × 10 objective)
Fig. 2
Fig. 2
Digitized images of primary tumor tissue sections with tumor cells only present at two (a) or three (b) borders of the field of vision, therefore, invalid for correct assessment of the TSR on resection specimens (field view with × 10 objective)
Fig. 3
Fig. 3
Digitized tissue slide showing an example of an adjusted circle (0.51 mm2) to score the TSR on biopsy material (× 10 field view with digital microscope)
Fig. 4
Fig. 4
Circular annotation including a magnification of a primary breast tumor containing an area showing the characteristics of a biopsy effect (on the left side field view with × 10 objective). Note: the magnified image (right) was not used for TSR scoring, this was performed using the circular annotation (left)
Fig. 5
Fig. 5
Digitized image of tumor tissue containing a possible difficulty for scoring: a stroma-high mucinous tumor (× 10 field view with digital microscope)
See this image and copyright information in PMC

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