Background: Rectal cancer is common and frequently treated with neoadjuvant radiotherapy prior to surgery to reduce the risk of tumour recurrence. However, the therapeutic benefits and side effects of radiotherapy can vary between patients, and there are currently no validated biomarkers to predict treatment response. Tumour cell density (TCD) and tumour-infiltrating lymphocyte (TIL) density are proven prognostic biomarkers in colorectal cancer; however, their utility in predicting radiotherapy response remains unclear. We assessed the prognostic and predictive value of TCD and TIL density in rectal cancer patients treated with radiotherapy. Methods: TCD was quantified using a manual point-counting method in 253 pre-treatment biopsies and across the entire tumour area of 569 resection specimens from the MRC CR07 clinical trial, which randomised patients to either neoadjuvant short-course radiotherapy (SCRT) or straight to surgery (control). TIL density was measured in 102 biopsies and matched resection specimens (73 SCRT, 29 control) across different tumour areas using deep learning-based cell detection in MIM (HeteroGenius Ltd., Leeds, UK). Cutoffs for low/high-TCD and TIL density were both pre-defined and derived from survival data using the survminer R package. Survival analyses were performed to evaluate the predictive and prognostic value of TCD/TIL in relation to overall and cancer-specific survival. Results: TCD in the resection specimens was lower in the SCRT group (19.9%, IQR 12.9-26.7%) than the control group (34.3%, IQR 27.7-40.5%, p < 0.001). In control resections, low-TCD was associated with a higher risk of all-cause mortality (HR 2.20, 95% CI 1.41-3.44, p < 0.001) and cancer-related death (HR 2.69, 95% CI 1.41-5.13, p = 0.0026). In contrast, after SCRT, low resection TCD was associated with a reduced risk of death (HR 0.63, 95% CI 0.40-0.98, p = 0.04). In the SCRT group, low biopsy TCD prior to radiotherapy was associated with a reduced risk of cancer-related death (HR 0.34, 95% CI 0.13-0.89, p = 0.028). Across both trial arms, TIL density was higher in pre-treatment biopsies than resections (2492 vs. 1304/mm2, p < 0.001). Low biopsy TIL density was associated with an increased risk of all-cause mortality (HR 2.43, 95% CI 1.24-4.76, p = 0.01). The SCRT group had lower TIL density in the resection compared with controls (1210 vs. 1615/mm2, p < 0.001), and low resection TIL density across the whole tumour area was associated with a higher risk of death (HR 2.55, 95% CI 1.11-5.87, p = 0.027). Conclusions: Our findings support the role of TCD and TIL density as quantitative biomarkers in rectal cancer patients. TCD can be used to assess the degree of response to radiotherapy, and contrasting survival associations are observed between straight-to-surgery and SCRT-treated patients. This study raises the possibility of using TCD as both a prognostic and predictive biomarker. TIL density failed to show predictive value but demonstrated expected prognostic associations.

Within the colorectal cancer (CRC) tumour microenvironment, tumour infiltrating lymphocytes (TILs) and tumour cell density (TCD) are recognised prognostic markers. Measurement of TILs and TCD using deep-learning (DL) on haematoxylin and eosin (HE) whole slide images (WSIs) could aid management. HE WSIs from the primary tumours of 127 CRC patients were included. DL was used to quantify TILs across different regions of the tumour and TCD at the luminal surface. The relationship between TILs, TCD, and cancer-specific survival was analysed. Median TIL density was higher at the invasive margin than the luminal surface (963 vs 795 TILs/mm2, P = 0.010). TILs and TCD were independently prognostic in multivariate analyses (HR 4.28, 95% CI 1.87–11.71, P = 0.004; HR 2.72, 95% CI 1.19–6.17, P = 0.017, respectively). Patients with both low TCD and low TILs had the poorest survival (HR 10.0, 95% CI 2.51–39.78, P = 0.001), when compared to those with a high TCD and TILs score. DL derived TIL and TCD score were independently prognostic in CRC. Patients with low TILs and TCD are at the highest risk of cancer-specific death. DL quantification of TILs and TCD could be used in combination alongside other validated prognostic biomarkers in routine clinical practice.

[This corrects the article DOI: 10.1016/j.jpi.2024.100367.].

We recently proposed Stroma AReactive Invasion Front Areas (SARIFA), defined as direct tumor-adipocyte interaction at the invasion front, as a novel hematoxylin-and-eosin (H&E)-based histopathological prognostic biomarker in various cancers. Given that microsatellite instability, BRAF , and RAS mutation status are routinely tested for colorectal cancers (CRC), studying SARIFA’s additional prognostic value within these molecular subgroups is crucial. In addition, exploring whether the survival benefit from adjuvant therapy differs according to SARIFA-status may enhance patient treatment and outcome. SARIFA-status, BRAF , RAS , and DNA mismatch repair (MMR) status were available for 1726 CRC patients from the prospective Netherlands Cohort Study (NLCS, 1986–2006). In this study, we investigated (1) the relationship between SARIFA-status and CRC molecular characteristics, (2) the prognostic value of SARIFA-status within these molecular subgroups, and (3) whether SARIFA-status was associated with survival benefit from adjuvant therapy. SARIFA-positive CRCs more frequently showed a BRAF mutation compared to SARIFA-negative CRCs ( P <0.001). BRAF -mutant/MMR-proficient CRCs were enriched in SARIFA-positive cases. SARIFA-positivity was associated with poor CRC-specific (HR range : 1.47 to 1.78) and overall survival (HR range : 1.35 to 1.70) within all molecular subgroups except MMR-deficient CRCs. Patients with SARIFA-positive CRC showed a CRC-specific survival benefit from adjuvant therapy compared to surgery alone (HR CRC-specific : 0.59; 95% CI: 0.44-0.79), while no CRC-specific survival benefit was observed for patients with SARIFA-negative CRC. To conclude, our results indicate that SARIFA-positivity is more common in the aggressive subset of BRAF -mutant and BRAF -mutant/MMR-proficient CRCs. Moreover, SARIFA-positivity provides additional prognostic value within molecular subgroups based on BRAF , RAS , and MMR status, suggesting that it may enhance prognostic stratification of CRC patients.

BACKGROUND:Cancers of the oesophagus and stomach are a major cause of morbidity and mortality. Research is crucial to improving outcomes. However, to maximise value and impact, areas of focus should be prioritised in partnership with patients. OBJECTIVE:We undertook a comprehensive analysis of UK and Ireland patient and healthcare professional (HCP) priorities for research into oesophagogastric cancers across the domains of prevention, diagnosis and staging, treatment, palliative care and survivorship. DESIGN:A scoping exercise sourced research questions from patients and HCPs. These were consolidated and then confirmed by systematic review to represent a true research uncertainty. Research questions were scored on potential impact by an interdisciplinary group of HCPs and prioritised using a weighting derived from a patient survey. RESULTS:There were 835 (395 HCP, 440 patient) respondents to the scoping (n=455) and prioritisation (n=380) surveys. Across these, 4295 suggested research uncertainties were consolidated to 92 uncertainties that were prioritised. HCP respondents represented 25 professional groups from community and hospital settings. Patient weighting changed 22.2-46.3% of priority rankings established by HCPs. All domains were represented by the 20 highest priority questions, 5 of which focused on personalising and optimally combining treatment modalities. Two other key themes related to optimising nutrition and improving quality of life during and after treatment, including in patients not cured of their cancer. CONCLUSION:This work highlights the impact of patient input on HCP-ranked research priorities and provides a robust list of priorities to guide funders, policymakers and researchers to support and undertake impactful research.

We recently proposed Stroma AReactive Invasion Front Areas (SARIFA), defined as direct tumor-adipocyte interaction at the invasion front, as a novel hematoxylin-and-eosin (H&E)-based histopathological prognostic biomarker in various cancers. Given that microsatellite instability, BRAF , and RAS mutation status are routinely tested for colorectal cancers (CRC), studying SARIFA's additional prognostic value within these molecular subgroups is crucial. In addition, exploring whether the survival benefit from adjuvant therapy differs according to SARIFA-status may enhance patient treatment and outcome. SARIFA-status, BRAF , RAS , and DNA mismatch repair (MMR) status were available for 1726 CRC patients from the prospective Netherlands Cohort Study (NLCS, 1986-2006). In this study, we investigated (1) the relationship between SARIFA-status and CRC molecular characteristics, (2) the prognostic value of SARIFA-status within these molecular subgroups, and (3) whether SARIFA-status was associated with survival benefit from adjuvant therapy. SARIFA-positive CRCs more frequently showed a BRAF mutation compared to SARIFA-negative CRCs ( P <0.001). BRAF -mutant/MMR-proficient CRCs were enriched in SARIFA-positive cases. SARIFA-positivity was associated with poor CRC-specific (HR range : 1.47 to 1.78) and overall survival (HR range : 1.35 to 1.70) within all molecular subgroups except MMR-deficient CRCs. Patients with SARIFA-positive CRC showed a CRC-specific survival benefit from adjuvant therapy compared to surgery alone (HR CRC-specific : 0.59; 95% CI: 0.44-0.79), while no CRC-specific survival benefit was observed for patients with SARIFA-negative CRC. To conclude, our results indicate that SARIFA-positivity is more common in the aggressive subset of BRAF -mutant and BRAF -mutant/MMR-proficient CRCs. Moreover, SARIFA-positivity provides additional prognostic value within molecular subgroups based on BRAF , RAS , and MMR status, suggesting that it may enhance prognostic stratification of CRC patients.

BACKGROUND:Chronic abdominal pain affects 10-20% of all patients following abdominal surgery, with adhesions as a predominant cause. However, the biological mechanisms underlying adhesion-related pain are not fully elucidated. This study aimed to establish the morphological and molecular phenotype of adhesions in patients with and without chronic postoperative abdominal pain. METHODS:In this case-control study, biopsies of adhesions were obtained from patients with chronic postoperative abdominal pain (related to adhesions on cineMRI) and controls without pain, from two tertiary care and one secondary care hospital. Quantitative histological analysis of haematoxylin and eosin-stained sections was performed, while immunohistochemical (IHC) markers for nerve tissue (S100, calretinin and synaptophysin) were quantified through image analysis. RNA expression of genes (TRPV1, BDNF, TAC1, TACR1, NGF) was measured using real time quantitative polymerase chain reaction (RT-qPCR). Controls were matched to cases by sex, age, and prior surgery, accepting small variations due to patient availability. An independent two-sided t-test was used to detect differences in IHC and RT-qPCR analysis between groups. FINDINGS:Adhesions from 31 patients with pain were compared to those from 31 patients without pain, consisting of 48% connective tissue and 41% adipose tissue. Immunohistochemical analysis revealed increased nerve tissue in patients with pain (S100: median 597 ppm (range 92.2-3223.2 ppm) vs 151 ppm (range 15.2-1683.8 ppm) p < 0.001; calretinin: median 463 ppm (range 72.7-2996.5 ppm) vs 275 ppm (range 35.3-3194.8 ppm) p = 0.040). NGF showed a higher mRNA expression in adhesions from patients with pain compared to controls (p = 0.012). INTERPRETATION:This study suggests a distinct morphological and molecular phenotype of adhesions in patients experiencing adhesion-related pain, providing insights into underlying mechanisms. FUNDING:Veni grant from The Dutch Governmental Organisation for Health Research and Development (ZonMw grant number 91619035).

Background The definition of the circumferential resection margin (CRM) involvement for esophageal cancer varies between the Royal College of Pathologists (RCP) and College of American Pathologists (CAP). There are insufficient data regarding the prognostic relevance of different sites of involvement at the CRM. In this study, we examined the prognostic impacts of different CRM definitions and different radial margin locations. Methods This retrospective study included 449 patients who were treated by curative esophagectomy for esophageal or junctional cancers between 2010 and 2021. The distance of the closest tumour cells to the inked CRM was examined and site of CRM involvement was recorded. Patients with an involved longitudinal resection margin were excluded. Long-term follow up data were obtained from the hospital's electronic health records. Results Tumour cells at or within 1 mm from the CRM (CRM-RCP R1≤1 mm) was observed in 196 patients (43.7 %). CRM(≤1 mm) was associated with poorer overall survival (OS) and disease-free survival (DFS) compared to CRM-R0, p-values <0.001 for both. Tumour cells at the CRM (CRM-CAP R1-0 mm) was observed in 61 patients (13.6 %). Patients with CRM-0mm had poorer OS and DFS compared to CRM≤1 mm, p-values 0.039 and 0.013 respectively. Presence of tumour cells (CRM≤1 mm) at multiple locations of the CRM was related to poorer survival compared to a single location; (OS p-value 0.008, DFS p-value 0.05). The posterior margin was the most common positive single CRM-positive site (44 %), followed by anterior (39 %) and lateral sites (17 %). However, the anterior margins carried poorer OS and DFS compared to posterior and lateral sites, (p-values 0.37 and 0.39 respectively). Conclusion This study demonstrated that CRM involvement as defined by RCP was an independent prognostic factor for both survival and recurrence in esophageal cancer. It promoted the value of additional reporting CRM-0mm in CRM-R1 cases. The study also investigated the relative importance of reporting CRM-R1 location, which might be a useful prognostic tool in the future.

LBA331 Background: 10-20% of GC are HER-2 positive. The role of perioperative anti-HER2-directed treatment is yet undefined. Methods: This randomized, open-label phase II-trial investigates the benefit of perioperative chemotherapy (CT) alone or in combination with either T or T and P for HER-2+ gastric (GC) and esophagogastric junction cancer (EGJC). 172 patients (pts) with centrally confirmed, positive HER-2 status and resectable GC or EGJC (UICC TNM stages Ib-III) were included. Pts were randomized in a 1:2:2 ratio to: Arm A (CT alone) (35 pts); Arm B (CT+ T [8mg/kg, followed by 6mg every 3 weeks]) (67 pts); Arm C (CT + T+ P [840mg every 3 weeks]) (70 pts). CT was initially cisplatin (80 mg/m 2 d1) and capecitabine (2 x 1000 mg/m 2 /d d1) for 3 cycles before and after surgery. After publication of FLOT-4 (Al-Batran, Lancet 2019), the protocol was amended. CT changed to four cycles FLOT, with FOLFOX or CAPOX as alternative for pts ineligible for FLOT. In arm B and C, T and P were continued beyond CT at the same dose for a total of 17 cycles. Out of 172 pts randomized, 161 fulfilled all key eligibility criteria and started their allocated treatment (per protocol population). Centrally determined major pathological response rates (mpRR) were 33.3%, 53.3% and 37.9% in Arm A: B: C after amending the protocol while, in contrast, they were 8.3%, 16.7% and 12.5% before (ASCO 2024, abstract 4057). Here, we present progression-free-(PFS) and overall survival (OS) after a median follow-up of 4.3 years. Results: In Arm A: B: C, 63.6%, 64.7%, 50.4% and 51.9%, 61.0%, 47.9% of pts were progression-free at 3 and 5 years. As compared to CT alone, HRs for PFS versus CT+T were 0.88 (90% CI, 0.51 to 1.53) and for CT+T+P 1.40 (90% CI, 0.82 to 2.37). Survival rates at 3 and 5 years in arm A: B: C were 75.6%, 76.9%, 65.2% and 60.5%, 67.5% and 62.6 %. As compared to CT alone, HRs for OS for CT+T and CT+T+P were 0.89 (95% CI, 0.42 to 1.88)) and 1.29 (95% CI, 0.62 to 2.66). For results before and after amendment see table. Conclusions: Non-significant advantages in terms of PFS and OS were observed for the addition of T to CT before, but not after the amendment. CT+T+P was detrimental. These results reflect the challenge of using mpRR as surrogate for survival in the perioperative treatment of GC. Clinical trial information: NCT 02205047 . PFS and OS results before and after amendment. Before amendment: Arm PFS (%) at 3 Years (95% CI) Hazard Ratio (95% CI) OS (%) at 3 Years (95% CI) Hazard Ratio (95% CI) CT(N=14) 57.1(28.4, 78.0) 1.00 78.6(47.3, 92.5) 1.00 CT+T(N=26) 64.2(42.5, 79.5) 0.64(0.24, 1.72) 83.6(62.0, 93.5) 0.77(0.25, 2.44) CT+T+P(N=28) 50.4(30.1, 67.6) 1.18(0.48, 2.93) 68.3(46.3, 82.8) 1.28(0.44, 3.75) After amendment: CT(N=19) 68.4(42.8, 84.4) 1.00 73.3(47.2, 87.9) 1.00 CT+T(N=38) 65.0(47.5, 78.0) 1.12(0.46, 2.75) 72.2(54.3, 84.0) 0.99(0.37, 2.69) CT+T+P(N=36) 50.4 (32.9, 65.7) 1.62(0.67, 3.90) 62.2(42.6, 76.8) 1.30(0.49, 3.48)

We previously showed that Warburg subtyping (low/moderate/high), based on the expression of six glycolytic proteins and transcriptional regulators [glucose transporter 1 (GLUT1), pyruvate kinase M2 (PKM2), lactate dehydrogenase A (LDHA), monocarboxylate transporter 4 (MCT4), p53, and PTEN], holds independent prognostic value in colorectal cancer (CRC) patients. The present study aimed to investigate whether the expression level of one of the proteins (GLUT1, PKM2, LDHA, MCT4, p53, and PTEN) can act as a proxy for our previously identified six protein-based Warburg subtypes. Protein expression levels for individual Warburg-related proteins were available for 2,251 CRC patients from the Netherlands Cohort Study. Kaplan-Meier curves and Cox regression were used to explore associations between individual Warburg-related proteins and CRC-specific and overall survival. Previously identified associations between Warburg subtypes and CRC-specific and overall survival were adjusted for individual proteins, showing a significant association with survival in the current study. Multivariable-adjusted analyses showed that the expression of GLUT1, LDHA, MCT4, PKM2, or p53 was associated with neither CRC-specific nor overall survival. Decreasing PTEN expression was associated with significantly poorer overall survival (p-trendcategories = 0.026). Additional adjustment for PTEN expression had minimal impact on the previously identified association between Warburg subtypes and survival, and the six protein-based Warburg-high subtype remained a statistically significant predictor of overall survival (hazard ratio 1.15; 95% CI 1.01-1.32). In conclusion, our results emphasise that individual Warburg-related proteins cannot serve as a proxy or surrogate marker for Warburg subtyping, thereby highlighting the importance of combining the expression levels of multiple Warburg-related proteins when examining the prognostic significance of a complex biological pathway such as the Warburg effect.

Background: Regional lymph node (LN) status is a key prognostic factor in oesophageal cancer (OeC). Tumour- derived antigens can activate immune reactions in LNs, potentially reflecting the host's anti-tumour immune response. It remains unclear whether this response is homogeneous across all tumour negative LNs (LNneg) within individual OeC patients. Purpose: To investigate the hypotheses: (1) the host anti-tumour immune response is similar in all LNneg from an individual OeC patient reflected in a similar microarchitecture in all LNneg; and (2) immune response measured in the largest LNneg can represent that of all LNnegs. Methods: (y)pN0 patients from the Oe02 trial with at least two LNneg were included. Microarchitectural LN features (germinal centres (GermC), lymphocytes outside GermCs (lymphocytes), histiocytes) were morphometrically quantified. Linear mixed-effects models, intraclass correlation coefficients (ICC) and Bland-Altman plots were used to determine systematic bias, reliability/variability and agreement of LNneg micro- architecture measurements. Results: Linear mixed-effects models showed no systematic bias in LNneg microarchitectural features within a patient. The ICC revealed moderate variability for lymphocytes (ICC: 0.39; 95 %CI: 0.01- 0.61, p = 0.02)) and GermC (ICC: 0.50; 95 %CI: 0.22-0.68, p < 0.001), and high variability for histiocytes (ICC: 0.07 (95 %CI:- 0.45-0.40, p = 0.38). Bland-Altman plots showed that 5.0 % of GermC, 5.0 % of histiocytes and 8.5 % of lymphocyte measurements were outside the 95 % limits of agreement. Conclusions: This is the first study to systematically assess agreement of microarchitectural features in LNneg within an individual (y)pN0 OeC patient. The absence of systematic bias supports using largest LNneg as surrogate for OeC patient's overall anti-tumour immune response.

Background: Stroma AReactive Invasion Front Areas (SARIFA) is a novel prognostic histopathologic biomarker measured at the invasive front in haematoxylin & eosin (H&E) stained colon and gastric cancer resection specimens. The aim of the current study was to validate the prognostic relevance of SARIFA-status in colorectal cancer (CRC) patients and investigate its association with the luminal proportion of tumour (PoT). Methods: We established the SARIFA-status in 164 CRC resection specimens. The relationship between SARIFA-status, clinicopathological characteristics, recurrence-free survival (RFS), cancer-specific survival (CSS), and PoT was investigated. Results: SARIFA-status was positive in 22.6% of all CRCs. SARIFA-positivity was related to higher pT, pN, pTNM stage and high grade of differentiation. SARIFA-positivity was associated with shorter RFS independent of known prognostic factors analysing all CRCs (RFS: hazard ratio (HR) 2.6, p = 0.032, CSS: HR 2.4, p = 0.05) and shorter RFS and CSS analysing only rectal cancers. SARIFA-positivity, which was measured at the invasive front, was associated with PoT-low (p = 0.009), e.g., higher stroma content, and lower vessel density (p = 0.0059) measured at the luminal tumour surface. Conclusion: Here, we validated the relationship between SARIFA-status and prognosis in CRC patients and provided first evidence for a potential prognostic relevance in the subgroup of rectal cancer patients. Interestingly, CRCs with different SARIFA-status also showed histological differences measurable at the luminal tumour surface. Further studies to better understand the relationship between high luminal intratumoural stroma content and absence of a stroma reaction at the invasive front (SARIFA-positivity) are warranted and may inform future treatment decisions in CRC patients.

Background: Stromal tumour infiltrating lymphocytes (sTILs) and presence of tertiary lymphoid structures have been proposed as indicators of tumour-related immune response in breast cancer. An increased number of germinal centres (GCs) in lymph nodes is considered a sign of humoral immune reactivity. Aims: It is unclear whether a relationship exists between number and size of GCs within tumour positive sentinel lymph nodes (SLNpos), sTILs and tertiary lymphoid structures within matched primary breast cancer and breast cancer subtype. Methods: Axillary SLNpos from 175 patients with breast cancer were manually contoured in digitized haematoxylin and eosin stained sections. Total SLN area, GC number and GC area were measured in SLNpos with the largest metastatic area. To correct for SLN size, GC number and GC area were divided by SLN area. sTILs and presence of tertiary lymphoid structures were assessed in the primary breast cancer. Results: A higher GC number and larger GC area were found in patients with high sTILs (>= 2%) (both P < 0.001) and in patients with presence of tertiary lymphoid structures (P-GC number = 0.034 and P-GC area = 0.016). Triple negative and HER2-positive (N = 45) breast cancer subtypes had a higher GC number and higher sTILs compared to hormone receptor positive, HER2-negative breast cancer (N = 130) (P-GC number < 0.001 and P-sTILs= 0.001). Conclusion: This study suggests GCs measured within SLNpos might be useful indicators of the humoral anti-tumour immune response in breast cancer. Future studies are needed investigating underlying biological mechanisms and prognostic value of GCs in SLNs.

BACKGROUND:Long-term energy balance-related factors (i.e., lifestyle and physiologic factors that influence the equilibrium between energy intake and energy expenditure over an extended period) such as body mass index (BMI) are linked to colorectal cancer risk, but their impact on colorectal cancer survival is unclear. We explored associations between these long-term energy balance-related factors and survival and examined potential differences across metabolic Warburg-subtypes. METHODS:Associations between long-term energy balance-related factors and survival in the total series of patients with colorectal cancer (n = 2,347) obtained from the prospective Netherlands Cohort Study, as well as according to Warburg-subtype (Warburg-low: n = 652, Warburg-moderate: n = 802, Warburg-high: n = 797), were investigated using Cox regression analysis. RESULTS:Among the long-term energy balance-related factors studied, only increasing prediagnostic BMI was associated with a borderline significant poorer overall survival in patients with colorectal cancer [HR5kg/m2, 1.07; 95% confidence interval (CI), 0.99-1.15]. Stratified analyses showed that prediagnostic weight gain (HR5kg, 1.04; 95% CI, 0.99-1.09) and potentially increased height (HR5cm, 1.04; 95% CI, 0.98-1.11) were associated with poor overall survival only in patients with Warburg-high colorectal cancer. Increasing prediagnostic BMI was associated with poor survival only in patients with Warburg-moderate colorectal cancer (colorectal cancer-specific: HR5kg/m2, 1.12; 95% CI, 0.96-1.32; overall: HR5kg/m2, 1.20; 95% CI, 1.05-1.36). No consistent patterns were observed across energy restriction proxies. CONCLUSIONS:Maintaining a healthy prediagnostic BMI may be beneficial for colorectal cancer survival. Moreover, associations between prediagnostic BMI, weight change, early-life energy restriction, height, and colorectal cancer survival differed according to Warburg-subtypes. IMPACT:Understanding the biologic pathways involved in associations between energy balance-related factors and colorectal cancer survival could help refine prevention strategies in the future.

Supplementary Table 1 – Univariable hazard ratios (HRs) for associations between long-term energy balance-related factors and survival of colorectal cancer (CRC) patients within the Netherlands Cohort Study (NLCS, 1986-2006).

Abstract Background: Although many approaches based either on molecular investigations or on deep-learning algorithms applied to tissue sections have been proposed to stratify colorectal cancers (CRC) patients, clinical implementation of these novel cost-and time-consuming techniques is lacking, and conventional tumor-node-metastasis (TNM) staging remains one of the key factors to determine patient’s treatment. Hence, we developed a novel and solely Haematoxylin and Eosin (H&E) based histopathologic prognostic biomarker, called SARIFA (Stroma AReactive Invasion Front Areas, i.e., direct contact between tumor cells and fat cells). Materials/Methods: Based on a previous study, in which we could show that gene-expression based computational drug response prediction (oncoPredict) indicates a SARIFA-dependent differential drug sensitivity, we investigated whether SARIFA-status can predict which CRC patients might benefit from adjuvant therapy. SARIFA-status was established for 1,727 CRC patients from the prospective Netherlands Cohort Study. Multivariate-adjusted Cox regression analysis was performed (median follow-up: 4.79 years, with 1,463 deaths being observed in the first 10 years of follow-up [933, 63.8%, were CRC-related]). Only stages II to IV were included for further analysis regarding differential treatment response (n = 1,384). Results: In Multivariate-adjusted Cox regression analysis including patient age, sex, tumor location, pTNM stage, grade of differentiation, and mismatch repair status, SARIFA-positive CRC patients (n=496) benefitted significantly from adjuvant therapy (HRCRC-specific 0.59; 95% CI 0.44-0.78) compared to SARIFA-positive patients treated with surgery alone, which was not significant for SARIFA-negative CRC patients (HRCRC-specific 0.88; 95% CI 0.68-1.15). Regarding overall survival (OS), adjuvant therapy led to better OS outcomes regardless of SARIFA-status (HRoverall all patients 0.74; 95% CI 0.62-0.87). Conclusion: Our results suggest that SARIFA-positivity predicts a CRC-specific survival benefit from adjuvant therapy. As SARIFA-positivity is closely linked to an upregulation of lipid metabolism and an altered immune response, further studies are warranted to explore the potential benefit of not only conventional chemotherapy but also immunotherapy, targeted therapy as well novel drugs targeting lipid-metabolism. As SARIFA-status can be assessed fast and easily on for every cancer patient available H&E slides, SARIFA-status could serve as an ideal biomarker for a more detailed patient stratification in prospective clinical trials, and should be implemented into clinical routine if further validated. Citation Format: Nic G. Reitsam, Kelly Offermanns, Bianca Grosser, Jessica Zimmermann, Colinda Simons, Jakob N. Kather, Piet A. van den Brandt, Bruno Märkl, Heike I. Grabsch. Presence of Stroma AReactive Invasion Front Areas (SARIFA) - a potential novel histopathological tool for therapy response prediction in colorectal cancer [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2024; Part 1 (Regular Abstracts); 2024 Apr 5-10; San Diego, CA. Philadelphia (PA): AACR; Cancer Res 2024;84(6_Suppl):Abstract nr 6403.