title: Standardized evaluation of tumor-infiltrating lymphocytes in breast cancer: results of the ring studies of the international immuno-oncology biomarker working group.
abstract: Multiple independent studies have shown that tumor-infiltrating lymphocytes (TIL) are prognostic in breast cancer with potential relevance for response to immune-checkpoint inhibitor therapy. Although many groups are currently evaluating TIL, there is no standardized system for diagnostic applications. This study reports the results of two ring studies investigating TIL conducted by the International Working Group on Immuno-oncology Biomarkers. The study aim was to determine the intraclass correlation coefficient (ICC) for evaluation of TIL by different pathologists. A total of 120 slides were evaluated by a large group of pathologists with a web-based system in ring study 1 and a more advanced software-system in ring study 2 that included an integrated feedback with standardized reference images. The predefined aim for successful ring studies 1 and 2 was an ICC above 0.7 (lower limit of 95% confidence interval (CI)). In ring study 1 the prespecified endpoint was not reached (ICC: 0.70; 95% CI: 0.62-0.78). On the basis of an analysis of sources of variation, we developed a more advanced digital image evaluation system for ring study 2, which improved the ICC to 0.89 (95% CI: 0.85-0.92). The Fleiss' kappa value for <60 vs ≥60% TIL improved from 0.45 (ring study 1) to 0.63 in RS2 and the mean concordance improved from 88 to 92%. This large international standardization project shows that reproducible evaluation of TIL is feasible in breast cancer. This opens the way for standardized reporting of tumor immunological parameters in clinical studies and diagnostic practice. The software-guided image evaluation approach used in ring study 2 may be of value as a tool for evaluation of TIL in clinical trials and diagnostic practice. The experience gained from this approach might be applicable to the standardization of other diagnostic parameters in histopathology.
authors.affiliation: Institute of Pathology, Charité Universitätsmedizin Berlin, Berlin, Germany.|German Cancer Consortium (DKTK), Partner site Berlin, Berlin, Germany.
authors.forename: Carsten
authors.initials: C
authors.lastname: Denkert
authors.affiliation: Institute of Pathology, Charité Universitätsmedizin Berlin, Berlin, Germany.|VMscope GmbH, Berlin, Germany.
authors.forename: Stephan
authors.initials: S
authors.lastname: Wienert
authors.affiliation: Service de Biostatistique et d'Epidémiologie; Institute Gustave Roussy, Villejuif, France.
authors.forename: Audrey
authors.initials: A
authors.lastname: Poterie
authors.affiliation: German Breast Group (GBG), Neu-Isenburg, Germany.|Clinic of Gynecology and Obstetrics, Sana Klinikum Offenbach, Offenbach, Germany.
authors.forename: Sibylle
authors.initials: S
authors.lastname: Loibl
authors.affiliation: Institute of Pathology, Charité Universitätsmedizin Berlin, Berlin, Germany.|German Cancer Consortium (DKTK), Partner site Berlin, Berlin, Germany.
authors.forename: Jan
authors.initials: J
authors.lastname: Budczies
authors.affiliation: Indiana University School of Medicine, Indianapolis, IN, USA.
authors.forename: Sunil
authors.initials: S
authors.lastname: Badve
authors.affiliation: Clinical Institute of Pathology, Medizinische Universität Wien, Wien, Austria.
authors.forename: Zsuzsanna
authors.initials: Z
authors.lastname: Bago-Horvath
authors.affiliation: Department of Pathology & Molecular Medicine, McMaster University, Hamilton, ON, Canada.
authors.forename: Anita
authors.initials: A
authors.lastname: Bane
authors.affiliation: Weill Cornell Medical College, Doha, Qatar.
authors.forename: Shahinaz
authors.initials: S
authors.lastname: Bedri
authors.affiliation: Harvard Medical School, Boston, MA, USA.
authors.forename: Jane
authors.initials: J
authors.lastname: Brock
authors.affiliation: Tumor Pathology Department, Maria Sklodowska-Curie Memorial Cancer Center and Institute of Oncology, Gliwice Branch, Gliwice, Poland.
authors.forename: Ewa
authors.initials: E
authors.lastname: Chmielik
authors.affiliation: Institut für Pathologie, Medizinische Hochschule Hannover, Hannover, Germany.
authors.forename: Matthias
authors.initials: M
authors.lastname: Christgen
authors.affiliation: Pathology, GZA Ziekenhuizen, Sint-Augustinus, Wilrijk, Belgium.
authors.forename: Cecile
authors.initials: C
authors.lastname: Colpaert
authors.affiliation: Radiation Oncology and Pathology, Weill Cornell Medical College, New York, NY, USA.
authors.forename: Sandra
authors.initials: S
authors.lastname: Demaria
authors.affiliation: Department of Pathology and Cytology GZA Hospitals, Wilrijk, Belgium.
authors.forename: Gert
authors.initials: G
authors.lastname: Van den Eynden
authors.affiliation: Department of Pathology University Hospitals Leuven, Leuven, Belgium.
authors.forename: Giuseppe
authors.initials: G
authors.lastname: Floris
authors.affiliation: Department of Pathology, Peter MacCallum Cancer Centre, Melbourne, VIC, Australia.
authors.forename: Stephen B
authors.initials: SB
authors.lastname: Fox
authors.affiliation: Anatomical Pathology, Vancouver Hospital, Vancouver, BC, Canada.
authors.forename: Dongxia
authors.initials: D
authors.lastname: Gao
authors.affiliation: Institute of Pathology, Charité Universitätsmedizin Berlin, Berlin, Germany.
authors.forename: Barbara
authors.initials: B
authors.lastname: Ingold Heppner
authors.affiliation: Division of Pathology, NSABP, Pittsburgh, PA, USA.
authors.forename: S Rim
authors.initials: SR
authors.lastname: Kim
authors.affiliation: Department of Pathology and Laboratory Medicine, University of Ottawa, Ottawa, ON, Canada.
authors.forename: Zuzana
authors.initials: Z
authors.lastname: Kos
authors.affiliation: Institut für Pathologie, Medizinische Hochschule Hannover, Hannover, Germany.
authors.forename: Hans H
authors.initials: HH
authors.lastname: Kreipe
authors.affiliation: UQ School of Medicine and Pathology Queensland, The University of Queensland Centre for Clinical Research, Brisbane, QLD, Australia.
authors.forename: Sunil R
authors.initials: SR
authors.lastname: Lakhani
authors.affiliation: ERTICa Research Team, Department of Pathology, Jean Perrin Comprehensive Cancer Center, University of Auvergne EA4677, Clermont-Ferrand, France.
authors.forename: Frederique
authors.initials: F
authors.lastname: Penault-Llorca
authors.affiliation: Division of Pathology and Laboratory Medicine, University of Milan, Milan, Italy.
authors.forename: Giancarlo
authors.initials: G
authors.lastname: Pruneri
authors.affiliation: ERTICa Research Team, Department of Pathology, Jean Perrin Comprehensive Cancer Center, University of Auvergne EA4677, Clermont-Ferrand, France.
authors.forename: Nina
authors.initials: N
authors.lastname: Radosevic-Robin
authors.affiliation: Department of Pathology, Yale University School of Medicine, New Haven, CT, USA.
authors.forename: David L
authors.initials: DL
authors.lastname: Rimm
authors.affiliation: Department of Pathology, Beth Israel Deaconess Medical Center, Boston, MA, USA.
authors.forename: Stuart J
authors.initials: SJ
authors.lastname: Schnitt
authors.affiliation: Institute of Pathology, Charité Universitätsmedizin Berlin, Berlin, Germany.|Department for Translational Molecular Pathology, University of Texas MD Anderson Cancer Center, Houston, TX, USA.
authors.forename: Bruno V
authors.initials: BV
authors.lastname: Sinn
authors.affiliation: Sektion Gynäkopathologie, Pathologisches Institut, University of Heidelberg, Heidelberg, Germany.
authors.forename: Peter
authors.initials: P
authors.lastname: Sinn
authors.affiliation: Anatomie Pathologique, Institut Jules Bordet, Brussels, Belgium.
authors.forename: Nicolas
authors.initials: N
authors.lastname: Sirtaine
authors.affiliation: Molecular Diagnostic Oncology, Department of Tissue Pathology and Diagnostic Oncology, Royal Prince Alfred Hospital, Camperdown, NSW, Australia.
authors.forename: Sandra A
authors.initials: SA
authors.lastname: O'Toole
authors.affiliation: Department of Pathology, European Institute of Oncology, University of Milan, Milan, Italy.
authors.forename: Giuseppe
authors.initials: G
authors.lastname: Viale
authors.affiliation: Department of Pathology, Netherlands Cancer Institute, Amsterdam, Netherlands.
authors.forename: Koen
authors.initials: K
authors.lastname: Van de Vijver
authors.affiliation: Jules Bordet Institute, Brussels, Belgium.
authors.forename: Roland
authors.initials: R
authors.lastname: de Wind
authors.affiliation: German Breast Group (GBG), Neu-Isenburg, Germany.
authors.forename: Gunter
authors.initials: G
authors.lastname: von Minckwitz
authors.affiliation: Institute of Pathology, Charité Universitätsmedizin Berlin, Berlin, Germany.
authors.forename: Frederick
authors.initials: F
authors.lastname: Klauschen
authors.affiliation: Department of Gynecology, Helios-Klinikum Berlin-Buch, Berlin, Germany.
authors.forename: Michael
authors.initials: M
authors.lastname: Untch
authors.affiliation: Department of Gynecology and Obstetrics, University Hospital Erlangen, Comprehensive Cancer Center Erlangen EMN, Friedrich-Alexander University Erlangen, Erlangen, Germany.
authors.forename: Peter A
authors.initials: PA
authors.lastname: Fasching
authors.affiliation: Department of Gynecology, Klinikum Südstadt Rostock, Rostock, Germany.
authors.forename: Toralf
authors.initials: T
authors.lastname: Reimer
authors.affiliation: Molecular Immunology Unit, Institut Jules Bordet, Brussels, Belgium.
authors.forename: Karen
authors.initials: K
authors.lastname: Willard-Gallo
authors.affiliation: Service de Biostatistique et d'Epidémiologie, Gustave Roussy, CESP, Inserm U1018, Univ. Paris Sud, Univ. Paris-Saclay, Villejuif, France.
authors.forename: Stefan
authors.initials: S
authors.lastname: Michiels
authors.affiliation: Division of Research and Clinical Medicine, Peter MacCallum Cancer Center, Melbourne, VIC, Australia.
authors.forename: Sherene
authors.initials: S
authors.lastname: Loi
authors.affiliation: Department of Pathology and Cytology GZA Hospitals, Wilrijk, Belgium.|Breast Cancer Translational Research Laboratory, Institut Jules Bordet, Brussels, Belgium.
authors.forename: Roberto
authors.initials: R
authors.lastname: Salgado
mesh_terms: D001943:Breast Neoplasms / Q000276:immunology*; D005260:Female; D006801:Humans; D007090:Image Interpretation, Computer-Assisted / Q000379:methods / Q000592:standards*; D016246:Lymphocytes, Tumor-Infiltrating / Q000276:immunology* / Q000473:pathology; D010338:Pathology, Clinical / Q000379:methods / Q000592:standards*