New immune phenotypes for treatment response in high-grade serous ovarian carcinoma patients

Abstract

Despite advances in surgical and therapeutic approaches, high-grade serous ovarian carcinoma (HGSOC) prognosis remains poor. Surgery is an indispensable component of therapeutic protocols, as removal of all visible tumor lesions (cytoreduction) profoundly improves the overall survival. Enhanced predictive tools for assessing cytoreduction are essential to optimize therapeutic precision. Patients' immune status broadly reflects the tumor cell biological behavior and the patient responses to disease and treatment. Serum cytokine profiling is a sensitive measure of immune adaption and deviation, yet its integration into treatment paradigms is underexplored. This study is part of the IMPACT trial (NCT03378297) and aimed to characterize immune responses before and during primary treatment for HGSOC to identify biomarkers for treatment selection and prognosis. Longitudinal serum samples from 22 patients were collected from diagnosis until response evaluation. Patients underwent primary cytoreductive surgery or neoadjuvant chemotherapy (NACT) based on laparoscopy scoring. Twenty-seven serum cytokines analyzed by Bio-Plex 200, revealed two immune phenotypes at diagnosis: Immune High with marked higher serum cytokine levels than Immune Low. The immune phenotypes reflected the laparoscopy scoring and allocation to surgical treatment. The five Immune High patients undergoing primary cytoreductive surgery exhibited immune mobilization and extended progression-free survival, compared to the Immune Low patients undergoing the same treatment. Both laparoscopy and cytoreductive surgery induced substantial and transient changes in serum cytokines, with upregulation of the inflammatory cytokine IL-6 and downregulation of the multifunctional cytokines IP-10, Eotaxin, IL-4, and IL-7. Over the study period, cytokine levels uniformly decreased in all patients, leading to the elimination of the initial immune phenotypes regardless of treatment choice. This study reveals distinct pre-treatment immune phenotypes in HGSOC patients that might be informative for treatment stratification and prognosis. This potential novel biomarker holds promise as a foundation for improved assessment of treatment responses in patients with HGSOC. ClinicalTrials.gov Identifier: NCT03378297.

Keywords: HGSOC; RM-ASCA; cytokines; inflammation; longitudinal; ovarian cancer; surgery.

Figure 1

Overview and timeline of the patients. The crosses indicate time points for collecting serum samples; the absence of a cross on the line indicates that serum samples were not obtained at this time point. ECOG, Eastern Cooperative Oncology Group Score; EOS, End of study; NACT, neoadjuvant chemotherapy; PCS, primary cytoreductive surgery; Post-surgery: samples taken 1 day after primary cytoreductive surgery; Pre-chemo: Samples taken day 42 after surgery (+/- 14 days); Pre-surgery: samples taken 1 day prior to primary cytoreductive surgery; R0: Complete cytoreductive surgery; R1: Optimal cytoreductive surgery, residual tumor size ≤1 cm; R2: suboptimal cytoreductive surgery; residual tumor size >1; SCS, surgical complexity score.

Figure 2

Heatmap with unsupervised hierarchical clustering of serum cytokine levels in all patients (n = 22) at inclusion. Each row represents one patient. The blocks to the left are color coded according to the predefined relevant subgroups (53). Progression-free survival (PFS) was separated into long vs short PFS based on the median value in the dataset (489 days). The color scale represents the serum concentrations of cytokines, with lower concentrations in blue and higher concentrations in red. The color scale is relative and scaled for inter-individual differences between patients for each cytokine. NACT, Neoadjuvant chemotherapy; PCS, primary cytoreductive surgery; PFS, Progression-free survival; R0, Complete cytoreductive surgery; R≠0, Residual tumor after surgery.

Figure 3

RM-ASCA analyses of longitudinal changes in the serum cytokine levels in all patients (n = 22). The waterfall plots (right panels) illustrate the longitudinal changes in the serum levels of each cytokine according to their contribution to the principal component (PC)1 scores (left panels). Higher scores correspond to decreased levels of cytokines with negative loading and higher levels of cytokines with positive loading. (A) All the patients and all the visits are presented (n = 22). (B) Changes related to cytoreductive surgery only (n = 11). (C) Changes related to laparoscopic surgery only (n = 20). (D) Overall treatment-related changes (n = 17). Only visits occurring in both study groups are included. Cytokine functional groups are color-coded as indicated, and black lines within the bars represent the 95% confidence interval.

Figure 4

RM-ASCA analysis illustrating cytokine trajectories categorized into Immune High (red) (n = 13) and Immune Low (green) (n = 9) patients. Both time and cytokine level variations are depicted, but the waterfall plots (right) primarily highlight the differences between the patient immune groups as these persists during the study period. Cytokine functional groups are color-coded as indicated, and black lines within the bars represent the 95% confidence interval.

Figure 5

Heatmap with unsupervised hierarchical clustering of all patients (n = 17) at the end of study. Each row represents one patient. The blocks to the left are color coded according to the predefined relevant subgroups (53). The cytokine classes are shown at the top. The color scale represents the serum concentrations of cytokines, with lower concentrations in blue and higher concentrations in red. The color scale is relative and scaled for inter-individual differences between patients for each cytokine. NACT, Neoadjuvant chemotherapy; PCS, Primary cytoreductive surgery; PFS, Progression-free survival; R0, Complete cytoreductive surgery; R≠0, Residual tumor after surgery.