title: PD-L1, Galectin-9 and CD8+tumor-infiltrating lymphocytes are associated with survival in hepatocellular carcinoma.
abstract: Novel systemic treatments for hepatocellular carcinoma (HCC) are strongly needed. Immunotherapy is a promising strategy that can induce specific antitumor immune responses. Understanding the mechanisms of immune resistance by HCC is crucial for development of suitable immunotherapeutics. We used immunohistochemistry on tissue-microarrays to examine the co-expression of the immune inhibiting molecules PD-L1, Galectin-9, HVEM and IDO, as well as tumor CD8+lymphocyte infiltration in HCC, in two independent cohorts of patients. We found that at least some expression in tumor cells was seen in 97% of cases for HVEM, 83% for PD-L1, 79% for Gal-9 and 66% for IDO. In the discovery cohort (n = 94), we found that lack of, or low, tumor expression of PD-L1 (p< 0.001), Galectin-9 (p< 0.001) and HVEM (p< 0.001), and low CD8+TIL count (p= 0.016), were associated with poor HCC-specific survival. PD-L1, Galectin-9 and CD8+TIL count were predictive of HCC-specific survival independent of baseline clinicopathologic characteristics and the combination of these markers was a powerful predictor of HCC-specific survival (HR 0.29;p<0.001). These results were confirmed in the validation cohort (n = 60). We show that low expression levels of PD-L1 and Gal-9 in combination with low CD8+TIL count predict extremely poor HCC-specific survival and it requires a change in two of these parameters to significantly improve prognosis. In conclusion, intra-tumoral expression of these immune inhibiting molecules was observed in the majority of HCC patients. Low expression of PD-L1 and Galectin-9 and low CD8+TIL count are associated with poor HCC-specific survival. Combining immune biomarkers leads to superior predictors of HCC mortality.
authors.affiliation: Department of Gastroenterology and Hepatology, Erasmus MC-University Medical Center , Rotterdam, the Netherlands.
authors.forename: Kostandinos
authors.initials: K
authors.lastname: Sideras
authors.affiliation: Department of Pathology, Erasmus MC-University Medical Center , Rotterdam, the Netherlands.
authors.forename: Katharina
authors.initials: K
authors.lastname: Biermann
authors.affiliation: Department of Pathology, Academic Medical Center, University of Amsterdam , Amsterdam, the Netherlands.
authors.forename: Joanne
authors.initials: J
authors.lastname: Verheij
authors.affiliation: Academic Medical Center, Tytgat Institute for Liver and Intestinal Research, University of Amsterdam , Amsterdam, the Netherlands.
authors.forename: Bart R
authors.initials: BR
authors.lastname: Takkenberg
authors.affiliation: Department of Gastroenterology and Hepatology, Erasmus MC-University Medical Center , Rotterdam, the Netherlands.
authors.forename: Shanta
authors.initials: S
authors.lastname: Mancham
authors.affiliation: Department of Gastroenterology and Hepatology, Erasmus MC-University Medical Center , Rotterdam, the Netherlands.
authors.forename: Bettina E
authors.initials: BE
authors.lastname: Hansen
authors.affiliation: Department of Gastroenterology and Hepatology, Erasmus MC-University Medical Center , Rotterdam, the Netherlands.
authors.forename: Hannah M
authors.initials: HM
authors.lastname: Schutz
authors.affiliation: Department of Gastroenterology and Hepatology, Erasmus MC-University Medical Center , Rotterdam, the Netherlands.
authors.forename: Robert A
authors.initials: RA
authors.lastname: de Man
authors.affiliation: Department of Gastroenterology and Hepatology, Erasmus MC-University Medical Center , Rotterdam, the Netherlands.
authors.forename: Dave
authors.initials: D
authors.lastname: Sprengers
authors.affiliation: Department of Gastroenterology and Hepatology, Erasmus MC-University Medical Center , Rotterdam, the Netherlands.
authors.forename: Sonja I
authors.initials: SI
authors.lastname: Buschow
authors.affiliation: Department of Gastroenterology and Hepatology, Erasmus MC-University Medical Center , Rotterdam, the Netherlands.
authors.forename: Maddy C M
authors.initials: MC
authors.lastname: Verseput
authors.affiliation: Department of Gastroenterology and Hepatology, Erasmus MC-University Medical Center , Rotterdam, the Netherlands.
authors.forename: Patrick P C
authors.initials: PP
authors.lastname: Boor
authors.affiliation: Department of Gastroenterology and Hepatology, Erasmus MC-University Medical Center , Rotterdam, the Netherlands.
authors.forename: Qiuwei
authors.initials: Q
authors.lastname: Pan
authors.affiliation: Department of Experimental Surgery, Academic Medical Center, University of Amsterdam , Amsterdam, the Netherlands.
authors.forename: Thomas M
authors.initials: TM
authors.lastname: van Gulik
authors.affiliation: Department of Surgery, Erasmus MC-University Medical Center , Rotterdam, the Netherlands.
authors.forename: Turkan
authors.initials: T
authors.lastname: Terkivatan
authors.affiliation: Department of Surgery, Erasmus MC-University Medical Center , Rotterdam, the Netherlands.
authors.forename: Jan N M
authors.initials: JN
authors.lastname: Ijzermans
authors.affiliation: Academic Medical Center, Tytgat Institute for Liver and Intestinal Research, University of Amsterdam , Amsterdam, the Netherlands.
authors.forename: Ulrich H W
authors.initials: UH
authors.lastname: Beuers
authors.affiliation: Department of Oncology, Erasmus MC-University Medical Center, Erasmus MC Cancer Institute , Rotterdam, the Netherlands.
authors.forename: Stefan
authors.initials: S
authors.lastname: Sleijfer
authors.affiliation: Department of Gastroenterology and Hepatology, Erasmus MC-University Medical Center , Rotterdam, the Netherlands.
authors.forename: Marco J
authors.initials: MJ
authors.lastname: Bruno
authors.affiliation: Department of Gastroenterology and Hepatology, Erasmus MC-University Medical Center , Rotterdam, the Netherlands.
authors.forename: Jaap
authors.initials: J
authors.lastname: Kwekkeboom
keywords: Galectin-9; HVEM; IDO; PD-L1; hepatocellular carcinoma; tissue microarrays; tumor-infiltrating lymphocytes