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PD-L1 diagnostics in the neoadjuvant setting: implications of intratumoral heterogeneity of PD-L1 expression in triple negative breast cancer for assessment in small biopsies

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Abstract

Purpose

PD-L1 expression is a predictive biomarker for anti-PD-L1 immunotherapy in triple negative breast cancer (TNBC). In the neoadjuvant setting, immunohistochemical (IHC) evaluation of PD-L1 expression can only be performed on small tissue biopsies. In our study we investigated heterogeneity of PD-L1 expression in TNBC, and how reliably PD-L1 expression in small tissue samples reflects PD-L1 expression in larger tumor sections in TNBC.

Methods

Tissue microarrays (TMAs) were constructed from surgical specimens of 110 patients with TNBC. TMAs contained 4 cores (1 mm in diameter) per patient. To evaluate PD-L1 expression, TMAs were stained with PD-L1 IHC 22C3 PharmDx. Single-core PD-L1 expression was compared to overall PD-L1 expression of each patient’s tumor, to ascertain how often small samples of tumor tissue show the same PD-L1 expression as larger tumor samples.

Results

Our study found substantial heterogeneity of PD-L1 expression between different TMA cores from the same patient. Heterogeneity was greater in immune cells (ICs) than in tumor cells, in large part due to the uneven distribution of ICs in the tumor. For IC PD-L1 expression, we found that sensitivity can be as low as 0.81 for detecting PD-L1 expression at the 1% threshold most commonly used in breast cancer. Negative predictive value for ICs was 0.7.

Conclusions

There is substantial heterogeneity of PD-L1 expression between small tissue samples from the same TNBC tumor, especially for IC expression. This poses challenges for evaluation of PD-L1 expression in the neoadjuvant setting. Negative biopsies should prompt further investigation, and multiple biopsies might be necessary.

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Acknowledgements

The authors wish to thank laboratory technicians Christina Grønhøj and Dorte Skriver-Jensen, and the laboratory of the Pathology Department, Herlev and Gentofte hospital for their work with TMA production and immunohistochemical staining.

Funding

The study was funded by the Pathology Department, Herlev and Gentofte Hospital, the Research Foundation of Herlev and Gentofte Hospital, Bent Bøgh and Inge Bøgh Foundation, Axel Muusfeldt Foundation, Mogens Ambt Balslev Memorial Foundation, Andersen Isted Foundation and HC Bechgaard and Mary Bechgaard Foundation.

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Authors and Affiliations

  1. Department of Pathology, Herlev and Gentofte Hospital, University of Copenhagen, Borgmester Ib Juuls vej 1, 2730, Herlev, Denmark

    E. S. Stovgaard, A. Roslind, E. Høgdall & E. Balslev

  2. Department of Pathology, Rigshospitalet, University of Copenhagen, Blegdamsvej 9, 2100, Copenhagen, Denmark

    M. Bokharaey

  3. Department of Pathology, Hvidovre Hospital, Kettegård Allé 30, 2650, Hvidovre, Denmark

    K. List-Jensen

  4. Department of Oncology, Herlev and Gentofte Hospital, University of Copenhagen, Borgmester Ib Juuls vej 1, 2730, Herlev, Denmark

    I. Kümler & D. Nielsen

Authors
  1. E. S. Stovgaard
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  2. M. Bokharaey
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  3. K. List-Jensen
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  4. A. Roslind
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  5. I. Kümler
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  6. E. Høgdall
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  7. D. Nielsen
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  8. E. Balslev
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Contributions

All authors contributed to the study conception and design. Material preparation, data collection, and analysis were performed by Elisabeth Specht Stovgaard. The first draft of the manuscript was written by Elisabeth Specht Stovgaard and all authors commented on previous versions of the manuscript. All authors read and approved the final manuscript.

Corresponding author

Correspondence to E. S. Stovgaard.

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Conflict of interest

The authors declare that they have no conflicts of interest.

Ethical approval

All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards. This research study was conducted retrospectively using material obtained for clinical purposes. The study was approved by the Danish Ethics Committee (Project Number H-15015306).

Informed consent

The material used in this study had previously been obtained for clinical purposes, and patients had been informed that the material could be used for research purposes unless they actively registered in The Danish Registry for Use of Tissue. The registry was consulted before use of material, and no patients in the study were registered.

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Stovgaard, E.S., Bokharaey, M., List-Jensen, K. et al. PD-L1 diagnostics in the neoadjuvant setting: implications of intratumoral heterogeneity of PD-L1 expression in triple negative breast cancer for assessment in small biopsies. Breast Cancer Res Treat 181, 553–560 (2020). https://doi.org/10.1007/s10549-020-05655-w

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  • DOI: https://doi.org/10.1007/s10549-020-05655-w

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