Lima Luís, Oliveira Daniela, Tavares Ana, Amaro Teresina, Cruz Ricardo, Oliveira Maria J, Ferreira José A, Santos Lúcio
Experimental Pathology and Therapeutics Group, Portuguese Institute of Oncology, Porto, Portugal; ICBAS, Abel Salazar Biomedical Sciences Institute, University of Porto, Porto, Portugal; Núcleo de Investigação em Farmácia-Centro de Investigação em Saúde e Ambiente (CISA), School of Allied Health Sciences-Polytechnic Institute of Oporto, Porto, Portugal; Research Department, LPCC-Portuguese League Against Cancer (NRNorte), Portugal.
Experimental Pathology and Therapeutics Group, Portuguese Institute of Oncology, Porto, Portugal.
Urol Oncol. 2014 May;32(4):449-57. doi: 10.1016/j.urolonc.2013.10.012. Epub 2013 Nov 16.
Bacillus Calmette-Guérin (BCG) immunotherapy is the gold standard treatment for superficial bladder tumors with intermediate/high risk of recurrence or progression. However, approximately 30% of patients fail to respond to the treatment. Effective BCG therapy needs precise activation of the type 1 helper cells immune pathway. Tumor-associated macrophages (TAMs) often assume an immunoregulatory M2 phenotype and may directly interfere with the BCG-induced antitumor immune response. Thus, we aim to clarify the influence of TAMs, in particular of the M2 phenotype in stroma and tumor areas, in BCG treatment outcome.
The study included 99 patients with bladder cancer treated with BCG. Tumors resected before treatment were evaluated using immunohistochemistry for CD68 and CD163 antigens, which identify a lineage macrophage marker and a M2-polarized specific cell surface receptor, respectively. CD68(+) and CD163(+) macrophages were evaluated within the stroma and tumor areas, and high density of infiltrating cells spots were selected for counting. Hypoxia, an event known to modulate macrophage phenotype, was also assessed through hypoxia induced factor (HIF)-1α expression.
Patients in whom BCG failed had high stroma-predominant CD163(+) macrophage counts (high stroma but low tumor CD163(+) macrophages counts) when compared with the ones with a successful treatment (71% vs. 47%, P = 0.017). Furthermore, patients presenting this phenotype showed decreased recurrence-free survival (log rank, P = 0.008) and a clear 2-fold increased risk of BCG treatment failure was observed in univariate analysis (hazard ratio = 2.343; 95% CI: 1.197-4.587; P = 0.013). Even when adjusted for potential confounders, such as age and therapeutic scheme, multivariate analysis revealed 2.6-fold increased risk of recurrence (hazard ratio = 2.627; 95% CI: 1.340-5.150; P = 0.005). High stroma-predominant CD163(+) macrophage counts were also associated with low expression of HIF-1α in tumor areas, whereas high counts of CD163(+) in the tumor presented high expression of HIF-1α in tumor nests.
TAMs evaluation using CD163 is a good indicator of BCG treatment failure. Moreover, elevated infiltration of CD163(+) macrophages, predominantly in stroma areas but not in the tumor, may be a useful indicator of BCG treatment outcome, possibly owing to its immunosuppressive phenotype.
卡介苗（BCG）免疫疗法是治疗具有中/高复发或进展风险的浅表性膀胱肿瘤的金标准疗法。然而，约30%的患者对该治疗无反应。有效的BCG治疗需要精确激活1型辅助性T细胞免疫途径。肿瘤相关巨噬细胞（TAM）通常呈现免疫调节性M2表型，并可能直接干扰BCG诱导的抗肿瘤免疫反应。因此，我们旨在阐明TAM，特别是基质和肿瘤区域中M2表型对BCG治疗结果的影响。
该研究纳入了99例接受BCG治疗的膀胱癌患者。治疗前切除的肿瘤采用免疫组织化学方法评估CD68和CD163抗原，它们分别识别谱系巨噬细胞标志物和M2极化特异性细胞表面受体。在基质和肿瘤区域评估CD68(+)和CD163(+)巨噬细胞，并选择高密度浸润细胞斑进行计数。缺氧是已知可调节巨噬细胞表型的事件，也通过缺氧诱导因子（HIF）-1α表达进行评估。
与治疗成功的患者相比，BCG治疗失败的患者基质中CD163(+)巨噬细胞计数较高（基质中高但肿瘤中CD163(+)巨噬细胞计数低）（71%对47%，P = 0.017）。此外，呈现这种表型的患者无复发生存期缩短（对数秩检验，P = 0.008），单因素分析显示BCG治疗失败风险明显增加2倍（风险比 = 2.343；95%置信区间：1.197 - 4.587；P = 0.013）。即使对年龄和治疗方案等潜在混杂因素进行校正后，多因素分析仍显示复发风险增加2.6倍（风险比 = 2.627；95%置信区间：1.340 - 5.150；P = 0.005）。基质中占主导的高CD163(+)巨噬细胞计数也与肿瘤区域HIF-1α低表达相关，而肿瘤中高计数的CD163(+)在肿瘤巢中呈现HIF-1α高表达。
使用CD163评估TAM是BCG治疗失败的良好指标。此外，CD163(+)巨噬细胞浸润增加，主要在基质区域而非肿瘤中，可能是BCG治疗结果的有用指标，这可能归因于其免疫抑制表型。
