Purpose The tumor-stroma ratio (TSR) has repeatedly proven to be a strong prognostic and predictive marker in breast cancer. However, clinical integration of the TSR to further improve patient selection for breast cancer treatment and clinical decision making remains to be defined. Therefore, we evaluated the added value of the TSR to the well-recognized PREDICT model for survival outcomes following adjuvant systemic therapy. Methods In total, 1770 patients from the Nottingham Breast Cancer Series were included. The incremental value of the TSR following addition to the PREDICT model regarding change in overall prediction model performance was evaluated based on Cox regression analyses and the area under the curve (AUC) for 5-, 10- and 15-year overall survival. Analyses were reported for the total patient group and stratified by molecular subgroups. Results The largest model performance improvement was observed in the triple-negative breast cancer (TNBC) subgroup. At 5 years, the AUC ameliorated from 63.9 (95% confidence interval 55.1-72.7) to 70.9 (63.4-78.3) (p = 0.05) with a hazard ratio (HR) of 2.58 (1.39-4.79, p = 0.003). For 10-year survival, the HR was 2.02 (1.21-3.39, p = 0.007), with a rise in the AUC from 64.0 (55.6-72.3) to 69.0 (61.3-76.6) (p = 0.1). At 15 years after clinical diagnosis, the AUC increased from 64.6 (54.0-75.2) to 71.6 (61.1-82.1) at borderline significance (p = 0.06), together with an HR of 2.02 (1.24-3.27, p = 0.005). Conclusion The AUC improved for the total patient cohort and all subgroups following the addition of the TSR, although the strongest and most significant model enhancements were observed in the TNBC subgroup.

BACKGROUND:Breast cancer is etiologically heterogeneous, but which risk factors differ in their associations across tumor subtypes remains unclear. We conducted a large, pooled analysis to evaluate independent, dose-response associations between breast cancer risk factors and quantitative tumor features. METHODS:Analyses of 15,731 invasive breast cancers from 24 studies evaluated associations (p-trend) between reproductive and hormonal factors, body mass index (BMI), alcohol, smoking, and family history in relation to quantitative immunohistochemistry measures on tissue microarrays (ER, PR, HER2, KI67, TP53) and tumor grade. Analyses in a subset of 10 population-based studies estimated subtype-specific odds ratios (ORs) comparing cases to controls. A Bayesian False Discovery Probability (BFDP) <0.2 was used to identify associations with strong statistical evidence. RESULTS:Nulliparity and later age at menopause were associated with higher ER-positivity (p-trend=0.021 and 0.001, respectively), with corresponding OR[ER+] (95% CI) = 1.49 (1.16-1.90) for nulliparous vs. parous and 1.07 (1.03-1.11) per 5 years. Current combined menopausal hormone therapy (MHT) use was associated with lower grade (p-trend<0.001), with OR [grade1] = 3.37 (2.69-4.21) for current vs. never users. Higher BMI was associated with lower ER-positivity and higher grade in premenopausal women (p-trend<0.001 and <0.001), with OR[ER+] = 0.80 (0.74-0.87) and OR[grade1] = 0.75 (0.63-0.88) per 5 units, and with higher PR-positivity and higher grade in postmenopausal women (p-trend<0.001 and <0.001), with OR[PR+] = 1.08 (1.03-1.14) and OR[grade 3] = 1.10 (1.04-1.17) per 5 units. CONCLUSION:This pooled analysis of 15,731 cases showed that nulliparity, age at menopause, MHT, and BMI have independent, dose-response associations with ER, PR, and grade, clarifying patterns of etiologic heterogeneity. Associations with HER2, KI67 and TP53, or other risk factors did not meet our threshold for strong evidence.

Despite advances in colorectal cancer (CRC) treatment, outcomes in advanced disease remain poor. Current therapies mainly target the epithelial compartment of the tumor, yet increasing evidence highlights the tumor microenvironment (TME), particularly the tumor stroma, as a prognostic and potentially predictive factor. This narrative review summarizes current evidence on stromal features as biomarkers and therapeutic targets in CRC. These stromal markers, such as fibroblast-associated protein (FAP), are associated with adverse outcomes, underscoring their clinical relevance. However, therapies directly targeting these stromal components have largely failed to improve survival as single agents. Combination strategies, stromal modulation integrated with established treatments, appear more promising. However, to date, stromal targeting remains challenging and has not led to standard-of-care treatment options. This highlights the need for more effective agents, the rational design of combination strategies, and improved patient selection. Combining stroma modulators with standard therapy, guided by stromal biomarkers, may enhance efficacy and help overcome the TME-induced resistance.

INTRODUCTION:Stage III colon cancer (CC) is routinely treated with resection followed by adjuvant chemotherapy (ACT). However, 50 % of patients are cured by surgical intervention alone, whilst another 30 % experience disease recurrence despite ACT. This study aimed to identify biomarkers prognostic of recurrence and/or predictive of response to ACT. MATERIALS AND METHODS:Prognostic value of clinicopathological features, transcriptional profiles and genomic mutations was examined for patients with microsatellite stable (MSS) and instable (MSI) CC receiving ACT, as well as in a sub-cohort of patients with minimal residual disease (MSS-MRD) detected by post-surgery circulating tumour DNA. RESULTS:In MSS patients (N = 199), recurrence was associated with pT4 and/or pN2 tumours (HR 3.5 [2.0-5.9], p < 0.001); CMS4 (HR 2.6 [1.2-5.4], p = 0.008); a high cancer-associated fibroblast (CAF) signature (HR 2.2 [1.4-3.6], p = 0.001); and SMAD4 mutations (HR 2.1 [1.1-4.2], p = 0.027). In the MSS-MRD sub-cohort (N = 23), lack of response to ACT was associated with a high CAF-signature (HR 5.3 [1.7-17], p = 0.002) and SMAD4 mutations (HR 3.4 [0.9-13], p = 0.060). DISCUSSION:A high CAF-signature and SMAD4 mutations have prognostic value for recurrence both in MSS CC and in MRD, indicating potential predictive value for response to ACT. This molecular profile provides leads to design novel therapies for patients resistant to standard ACT.

3134 Background: Patients with stage III colon cancer (CC) are routinely treated with resection followed by adjuvant chemotherapy (ACT). About half of patients are cured by surgery and hence overtreated with ACT, yet another ~30% experience recurrence and are currently undertreated. Only ~20% of patients are cured by ACT and we are unable to identify these patients. Prognostic value of circulating tumor DNA (ctDNA) and the tumor-stroma ratio (TSR) has been shown in separate studies. This study aimed to integrate these biomarkers with pTNM substage to better predict outcome in stage III CC patients treated with ACT. Methods: Patients with stage III CC who received radical resection followed by ACT were selected from the Prospective Dutch ColoRectal Cancer cohort (PLCRC) substudy PROVENC3 (Rubio-Alarcon AACR 2024). Blood was collected between surgery and ACT, to determine ctDNA status using Labcorp Plasma Detect. Based on a diagnostic H&E slide from the CC resection, the TSR was determined by a trained observer according to the United study (Polack ESMO open 2024). A stroma content of ≤50% was considered low and >50% high. The primary outcome was recurrence risk (RR), calculated from date of resection. Results: In the overall cohort (N = 207), the 3-year RR was 23.4% [17.3-29.1]. In total, 88 patients (43%) were stroma-high and had a higher recurrence risk (3-year RR 33.1% [22.5-42.3]) than the 119 stroma-low patients (3-year RR 16.0% [8.9-22.5]; HR 2.7 [1.6-4.6]). CtDNA was detectable after surgery in 28 patients (13.5%; HR 5.8 [3.3-10]), of whom 11 (39%) were stroma-high. T4/N2 stage was observed in 82 patients (HR 2.9 [1.7-5.0]), of whom 46 (56%) were stroma-high. TSR (HR 2.6 [1.5-4.6]) had added prognostic value to ctDNA (HR 7.6 [4.3-13]) and pTNM substage (HR 2.9 [1.7-5.0]) in a multivariable cox model (LRT p<0.001). Patients with no detectable ctDNA and stroma-low T1-3N1 CC were at low recurrence risk (N = 71; 3-year RR 2.9% [0-6.8]). In comparison, patients with no detectable ctDNA and a tumor that was either stroma-high or T4/N2 were considered intermediate risk (N = 68; 3-year RR 17.2% [7.4-26.0]; HR 5.4 [1.5-19]). Patients with detectable ctDNA and/or stroma-high T4/N2 CC had a high risk (N = 68; 3-year RR 50.2% [36.7-60.8]; HR 19 [5.9-62]). Conclusions: The tumor-stroma ratio has added value to post-surgery ctDNA and pTNM substage in predicting outcome in stage III CC patients treated with ACT. The recurrence risk in the third of patients with no detectable ctDNA and stroma-low T1-3N1 CC was only 3%. It is of interest to investigate whether this low risk would persist in a cohort treated with surgery only, to suggest whether these patients could be spared ACT in the future. The third of patients with detectable ctDNA, and/or stroma-high T4/N2 CC, had a 50% recurrence risk despite ACT, highlighting the need for alternative adjuvant treatment options for these patients.

BACKGROUND:Treatment decisions for locally advanced gastric adenocarcinoma rely on staging with gastroscopy, computed tomography (CT), and staging laparoscopy (SL). However, CT often fails to detect peritoneal and other distant metastases, and SL is an invasive procedure with complication risks and costs. Therefore, an accurate non-invasive imaging biomarker to detect such metastases could improve the care for gastric cancer patients. Radiolabeled fibroblast-activating protein inhibitors (FAPI), targeting stromal cancer-associated fibroblasts, are promising radiotracers. Preliminary Asian studies indicate that FAPI PET/CT outperforms [18F]FDG PET/CT in tracer uptake, tumor-to-background ratio and diagnostic sensitivity in gastric cancer. However, larger studies using FAPI PET/CT in homogeneous, representative cohorts are needed to validate and translate these findings to Western populations. This study evaluates the clinical impact and diagnostic accuracy of [18F]AlF-FAPI-74 PET/CT for optimizing patient staging, aiming to reduce futile toxic neoadjuvant and surgical treatments. This may help optimize treatment pathways, enhance quality of life (QoL), and reduce patient burden and healthcare costs. METHODS:This Dutch multicenter prospective clinical trial will recruit 250 patients with resectable, locally advanced gastric adenocarcinoma (cT3-4N0-3M0) as determined by gastroscopy and CT, planned for curative treatment. The modality under investigation is [18F]AlF-FAPI-74 PET/CT. The primary outcome is the proportion of patients in whom [18F]AlF-FAPI-74 PET/CT leads to a change in treatment intent. Secondary outcomes include diagnostic performance, patient burden from incidental or false-positive PET/CT findings, diagnostic delay, and clinicopathological correlation between [18F]AlF-FAPI-74 PET/CT and intra-operative findings during SL. The composite reference standard for 'true' (intraperitoneal) tumor burden includes SL-based peritoneal cancer index scores, biopsy, imaging and intra-operative findings. If [18F]AlF-FAPI-74 PET/CT proves reliable, its cost-effectiveness will be compared to the PLASTIC-study. Recruitment started July 3rd 2025 and will continue for 36 months. DISCUSSION:This study hypothesizes that [18F]AlF-FAPI-74 PET/CT can detect two-thirds of all gastric cancer patients with M1-disease according to the reference standard. Additionally, an [18F]AlF-FAPI-74 PET/CT scan may reduce healthcare costs, optimize treatment pathways and patients' QoL. The study findings will be relevant for countries with similar treatment algorithms and healthcare systems. TRIAL REGISTRATION:ClinicalTrials.gov, NCT07018661. This trial was registered prospectively on June 12th, 2025.

Self-supervised learning (SSL) automates the extraction and interpretation of histopathology features on unannotated hematoxylin-eosin-stained whole slide images (WSIs). We train an SSL Barlow Twins encoder on 435 colon adenocarcinoma WSIs from The Cancer Genome Atlas to extract features from small image patches (tiles). Leiden community detection groups tiles into histomorphological phenotype clusters (HPCs). HPC reproducibility and predictive ability for overall survival are confirmed in an independent clinical trial ( N = 1213 WSIs). This unbiased atlas results in 47 HPCs displaying unique and shared clinically significant histomorphological traits, highlighting tissue type, quantity, and architecture, especially in the context of tumor stroma. Through in-depth analyses of these HPCs, including immune landscape and gene set enrichment analyses, and associations to clinical outcomes, we shine light on the factors influencing survival and responses to treatments of standard adjuvant chemotherapy and experimental therapies. Further exploration of HPCs may unveil additional insights and aid decision-making and personalized treatments for colon cancer patients.

Previous literature extensively explored biomarkers to personalize treatment for breast cancer patients. The clinical need is especially high in patients with triple-negative breast cancer (TNBC) due to its aggressive nature and limited treatment modalities. This review aims to evaluate the value of tumor-infiltrating lymphocytes (TILs) and tumor-stroma ratio (TSR) as prognostic biomarkers in TNBC patients and assess their clinical potential. A literature search was conducted in PubMed, Embase, Emcare, Web of Science, and Cochrane Library. Papers comparing survival outcomes of TNBC patients with low/high or negative/positive TSR and immune cells were included. The most frequently mentioned subgroups of TILs were selected and reported in this review. Data from 43 articles on TILs and eight articles on TSR were included. Among TNBC patients, high CD8 expression was generally associated with better survival. Notable, the poor survival outcomes were related to high intra-tumoral PD-L1 expression, whereas high stromal PD-L1 expression more often was correlated with favorable outcomes. For the TSR, a high amount of stroma in the primary tumor of TNBC patients was consistently associated with worse survival. This review highlights that a high number of CD8-positive T-cells is a promising prognostic factor for TNBC patients. PD-L1 expression analyzed for intra-tumoral and stromal expression separately reports strong but contrasting information. Finally, the TSR shows potential to be an important prognostic marker, especially for TNBC patients. Utilizing both biomarkers, either on itself or combined, could enhance clinical decision-making and personalization of treatment.

OBJECTIVES:New methods are needed to detect pancreatic ductal adenocarcinoma (PDAC) earlier to improve outcomes. We previously reported that a panel of protein N-glycosylation traits (NGTs) discriminated PDAC from healthy-controls with an area under the curve (AUC) of 0.81-0.88. However, it remained unclear whether this panel accurately differentiates PDAC from other benign pancreatic disorders. Our study aims to evaluate the performance of the NGT panel in combination with CA19-9, in a diverse cohort, including PDAC cases, healthy-controls and controls with benign pancreatic disorders. METHODS:Protein N-glycosylation profiles were determined in plasma samples using an in-house developed mass spectrometry assay. CA19-9 levels were measured using routine immunoassay test. Results of total plasma NGTs and CA19-9 were evaluated separately as well as in combination. Logistic regression was performed to calculate odds ratios (ORs), AUC, sensitivity and specificity to determine the performance of NGTs and CA19-9 in distinguishing PDAC from controls. RESULTS:In total 221 individuals were included: 45 (20.4%) with PDAC, and 176 (79.6%) controls (53 healthy and 123 with benign pancreatic disease). The AUC for differentiating PDAC from the total control cohort based on the combination of the NGT panel and CA19-9 was 0.94 (95% CI, 0.90-0.97), with a sensitivity of 0.89 (95% CI, 0.78-0.98) and specificity of 0.86 (95% CI, 0.81-0.91). Comparison of PDAC cases with healthy-controls only, resulted in an AUC of 0.96 (95% CI, 0.93-0.99), with a sensitivity of 0.84 (95% CI, 0.73-0.93) and specificity of 0.98 (95% CI, 0.94-1.00). CONCLUSIONS:Both plasma NGTs and CA19-9 distinguish PDAC from a diverse-control cohort. The accuracy further improves when these readouts are combined, showing promise for future early detection methods.

AIMS:Tumour-stroma ratio (TSR) scores of biopsy material in rectal carcinoma (RC) could aid a biomarker-based, upfront and personalised treatment strategy selection for RC patients. In a large retrospective, multicentre cohort, we aimed to validate the predictive value of biopsy-scored TSR on neoadjuvant therapy response, and secondarily, disease-free and overall survival (DFS, OS). METHODS AND RESULTS:Scanned haematoxylin and eosin-stained RC biopsy slides were collected from Leiden University Medical Center (N = 116) and from the clinical PROCTOR-SCRIPT (N = 142) and RAPIDO (N = 271) trials. TSR was scored per protocol and categorised as stroma-low (≤ 50%) or stroma-high (> 50%). Major response was defined as tumour regression grade (TRG) 1 + 2 by Mandard, including pathological complete response. Ultimately, a large and varied cohort with 373 RC patients was established. Locally advanced RC was more often stroma-high (P < 0.001). We subsequently observed significantly lower major response rates in the stroma-high RC after a neoadjuvant treatment approach (hazard ratio = 0.63, 95% confidence interval = 0.41-0.99; P = 0.044). Despite correction for well-known risk factors in Cox hazard regression analysis, such as (y)pTNM substages or residual tumour status, the TSR had no singular significant influence on DFS nor OS in multivariate analysis (P = 0.438; P = 0.934, respectively). CONCLUSIONS:Biopsy-scored TSR can predict neoadjuvant therapy efficacy, as RC patients with stroma-high biopsies show less major response. However, patient survival is multifactorial, although response is an important predictor, influenced by TSR. Scoring TSR on RC biopsy material is a reliable histological parameter, implementation of which in treatment guidelines could improve upfront selection for a watch-and-wait strategy.

BACKGROUND:Colorectal cancer is highly prevalent. The stromal tumour microenvironment significantly influences tumour behaviour, and cancer-associated fibroblasts (CAFs), as major component of tumour stroma, are increasingly studied. Specifically, CAF-marker fibroblast activation protein (FAP) is gaining interest as tracer for imaging using radiolabelled FAP-inhibitor (FAPI). We describe patterns of FAP-expression, and associations to intratumoural stroma amount, establishing a biological background and potential future reference to pathology assessment. MATERIALS AND METHODS:Archival histological material from 125 stage-II/III CRC patients was collected. Haematoxylin-and-eosin staining was performed to determine the tumour-stroma ratio (TSR), indicating stromal percentages in primary tumours, lymph nodes (LNs) and biopsies. On immunohistochemistry stains, FAP-expression was semiquantitatively scored as little-no, heterogeneous, or moderate-high expression. Correlation of TSR and FAP-expression with Chi-square testing was assessed. Other patterns were also described, e.g. tumour epithelial FAP-expression. RESULTS:In total, 93 patients (40 stage-III colon [CC], 53 stage-II/III RC) were included. Correlation between 41 (44 %) stroma-high CRC (18/40 CC, 45 %; 23/53 RC, 43 %) with high FAP-expression was not significant (P = 0.428 CRC; P = 0.470 CC; P = 0.615 RC). The majority of CRC had any FAP-expression (78 CRC, 84 %), mostly the invasive front, and in most associated LN metastases (87 % CRC tumour-positive LN). However, FAP-expression was often heterogeneous, even staining healthy colon and lymphoid tissue. CONCLUSIONS:CRCs and LN metastases generally express FAP, but levels vary significantly between and within tumours and have no direct correlation with TSR. Care has to be taken translating FAPI-PET/CT results with e.g. disease extent and activity, emphasizing the importance of multidisciplinary approach.

In stages II and III hormone receptor positive (HR+) breast cancer, selecting patients for primary surgery (PS) or neoadjuvant therapy remains challenging. This study assessed the occurrence of minimally invasive surgery in the case of PS, neoadjuvant endocrine therapy (NET), and neoadjuvant chemotherapy (NACT). This cohort study included women diagnosed with stages II and III, HR+ breast cancer in 2020-2022 in the Netherlands. Women with positive human epidermal growth factor receptor 2 (HER2+) cancer were excluded. Outcomes focused on surgical techniques and additional treatment. Of the 7809 patients, 4046 (51.8%) underwent PS, 956 (12.2%) received NET and 2807 (35.9%) NACT. NET patients were older (median: 71 years [33-94]), while NACT patients had larger tumors and more lymph node involvement (p < .001). Breast-conserving surgery (BCS) was the first procedure in 2153 (53.2%) PS women, in 694 (72.6%) NET women and 1564 (55.7%) NACT cases. There was no difference regarding free surgical margins in NET versus NACT patients (p = .421). After adjusting for T-stage, BCS occurred significantly more frequently after NET (p < .001). Minimal invasive surgery on the axilla was common after NET (83.9%) and NACT (81.5%). In the PS group, 85% received adjuvant systemic therapy. Optimizing patient selection for neoadjuvant strategies could reduce surgical morbidity. NET was frequently associated with BCS, showed comparable surgical margin outcomes to NACT, and contributed to reduced axillary surgery. These findings suggest that NET is an effective strategy, compared to PS, to facilitate less invasive surgery on the breast and axilla, in HR+/HER2-, stages II and III breast cancer.

Background & aims: Sarcopenia and obesity are indicators for poor outcomes in colon cancer. Additionally, aggressive histopathologic tumor stromal features, such as a low tumor-stroma ratio (TSR) and low tumor-infiltrating lymphocytes (TILs) predict survival and treatment response. As their relationship remains underexplored, we studied the association between skeletal muscle mass, visceral adipose tissue (VAT), TSR, and TILs in patients with colon cancer. Methods: We studied 194 stage II/III colon carcinoma patients who underwent elective surgery. Preoperative computed tomography (CT) scans classified patients into four groups based on skeletal muscle index (normal/low) and visceral adipose tissue index (normal/high). Tumor tissues were assessed for TSR and TILs, and five-year disease recurrence and relative hazard were evaluated. Results: Among the patients, 56 (28.9 %) were classified as Normal Muscle, Normal VAT, 26 (13.4 %) as Normal Muscle, High VAT, 75 (38.7 %) as Low Muscle, Normal VAT, and 37 (19.1 %) as Low Muscle, High VAT. Patients with low skeletal muscle mass were more often male (62.5 % vs. 39 %, P = 0.005). Stromahigh tumors were less common in Low Muscle, Normal VAT patients (24 %) compared to Normal Muscle, High VAT (50 %), Low Muscle, High VAT (48.6 %), and Normal Muscle, Normal VAT (41.1 %) patients (P = 0.020). Tumors with low TILs were similarly distributed across groups (P = 0.679). Low Muscle, Normal VAT patients had a lower recurrence hazard compared to both Low Muscle, High VAT (hazard ratio [HR] 0.34, 95 % CI 0.12-0.98, P = 0.048) and Normal Muscle, Normal VAT (HR 0.31, 95 % CI 0.11-0.87, P = 0.027) patients. Conclusions: Low Muscle, Normal VAT colon cancer patients exhibited fewer aggressive tumor features and a lower recurrence risk compared to Low Muscle, High VAT patients. These findings highlight the importance of body composition in tumor biology and prognosis. (c) 2024 The Authors. Published by Elsevier Ltd on behalf of European Society for Clinical Nutrition and Metabolism. This is an open access article under the CC BY license (http://creativecommons.org/licenses/ by/4.0/).

Women with an inherited pathogenic variant (PV) in a breast cancer (BC) susceptibility gene, or familial predisposition (FP) have an increased risk to develop BC. There is a need for improvement of screening methods due to interval cancers and radiation exposure. The aim of the TESTBREAST study is to develop a blood test suitable for early diagnosis. Here, the clinical composition of participants is provided. From 2010 to 2022, 1108 women were included in the TESTBREAST study, with currently 750 participants suitable for serum analysis. The median follow‐up was 7 years [1–14]. Of the 1108 participants, 70% ( n = 728) had a PV. BC was diagnosed in 16.5% ( n = 124), mainly stage I‐II (68.5%), and mostly BRCA1 ( n = 47, 47%) and BRCA2 ( n = 29, 29%) carriers. Invasive cancer was diagnosed in 100 cases: 76% ( n = 76) had a PV with a median age of 49 [26–68] at diagnosis, whereas 24% ( n = 24) had a FP, with a median age of 51 years [25–65]. The general population (the Netherlands) is aged 61 years on average at diagnosis. Triple negative breast cancer (TNBC) occurred in 51% ( n = 39) of the TESTBREAST women with a PV, whereas this was 11% in the general population. Within the TESTBREAST cohort, BRCA carriers were younger at diagnosis and often had the aggressive TNBC subtype. Improvement of current screening methods for early detection is especially important for this group of high‐risk women to reduce interval cancers, exposure to radiation, and to improve survival.

Introduction: Esophageal cancer is the seventh most common cancer worldwide and typically tends to manifest at an older age. Marked heterogeneity in time-dependent functional decline in older adults results in varying grades of clinically manifest patient fitness or frailty. The biological age-related adaptations that accompany functional decline have been shown to modulate the non-malignant cells comprising the tumor microenvironment (TME). In the current work, we studied the association between biological age and TME characteristics in patients with esophageal adenocarcinoma. Methods: We comparatively assessed intratumoral histologic stroma quantity, tumor immune cell infiltrate, and blood leukocyte and thrombocyte count in 72 patients stratified over 3 strata of biological age (younger <70 years, fit older >= 70 years, and frail older adults >= 70 years), as defined by a geriatric assessment. Results: Frailty in older adults was predictive of decreased intratumoral stroma quantity (B = -14.66% stroma, p = 0.022) relative to tumors in chronological-age-matched fit older adults. Moreover, in comparison to younger adults, frail older adults (p = 0.032), but not fit older adults (p = 0.302), demonstrated a lower blood thrombocyte count at the time of diagnosis. Lastly, we found an increased proportion of tumors with a histologic desert TME histotype, comprising low stroma quantity and low immune cell infiltration, in frail older adults. Conclusion: Our results illustrate the stromal-reprogramming effects of biological age and provide a biological underpinning for the clinical relevance of assessing frailty in patients with esophageal adenocarcinoma, further justifying the need for standardized geriatric assessment in geriatric cancer patients. (c) 2024 The Author(s). Published by S. Karger AG, Basel

Background: The TNM (tumor - node - metastasis) Evaluation Committee of Union for International Cancer Control (UICC) and College of American Pathologists (CAP) recommended to prospectively validate the cost-effective and robust tumor - stroma ratio (TSR) as an independent prognostic parameter, since high intratumor stromal percentages have previously predicted poor patient-related outcomes. Patients and methods: The ' Uniform Noting for International application of Tumor-stroma ratio as Easy Diagnostic tool ' (UNITED) study enrolled patients in 27 participating centers in 12 countries worldwide. The TSR, categorized as stromahigh ( > 50%) or stroma-low ( < 50%), was scored through standardized microscopic assessment by certi fi ed pathologists, and effect on disease-free survival (DFS) was evaluated with 3-year median follow-up. Secondary endpoints were bene fi t assessment of adjuvant chemotherapy (ACT) and overall survival (OS). Results: A total of 1537 patients were included, with 1388 eligible stage II/III patients curatively operated between 2015 and 2021. DFS was signi fi cantly shorter in stroma -high ( n = 428) than in stroma-low patients ( n = 960) (3-year rates 70% versus 83%; P < 0.001). In multivariate analysis, TSR remained an independent prognosticator for DFS ( P < 0.001, hazard ratio 1.49, 95% con fi dence interval 1.17-1.90). As secondary outcome, DFS was also worse in stage II and III stroma -high patients despite adjuvant treatment (3-year rates stage II 73% versus 92% and stage III 66% versus 80%; P = 0.008 and P = 0.011, respectively). In stage II patients not receiving ACT ( n = 322), the TSR outperformed the American Society of Clinical Oncology (ASCO) criteria in identifying patients at risk of events (event rate 21% versus 9%), with a higher discriminatory 3-year DFS rate (stroma -high 80% versus ASCO high risk 91%). A trend toward worse 5-year OS in stroma -high was noticeable (74% versus 83% stroma-low; P = 0.102). Conclusion: The multicenter UNITED study unequivocally validates the TSR as an independent prognosticator, con fi rming worse outcomes in stroma -high patients. The TSR improved current selection criteria for patients at risk of events, and stroma -high patients potentially experienced chemotherapy resistance. TSR implementation in pathology diagnostics and international guidelines is highly recommended as aid in personalized treatment.

Introduction: The extracellular matrix (ECM) supports tumor progression by influencing tumor cell migration and invasion. This study examines the link between peritumoral ECM morphology and five-year recurrence risk in TNM Stage II colon cancer, using quantitative whole-slide ECM imaging. We hypothesize that loose ECM regions are associated with increased recurrence risk due to enhanced tumor budding (TB) or poorly differentiated clusters (PDC). Methods: In a case-control study of 100 TNM Stage II colon cancer patients (25 with recurrence and 75 controls matched by lymph node sampling and tumor extent), Picrosirius red-stained sections were imaged to quantify ten ECM parameters across 798 regions of interest (ROIs). Conditional logistic regression assessed associations between ECM morphologies, TB, PDCs, and recurrence. Results: Unsupervised clustering identified three ECM morphologies: dense fibrous, loose sparse, and complex tortuous. Dense fibrous ECM correlated strongly with recurrence (aOR 9.43, 95% CI 3.29-29.30, p < 0.001), while loose sparse and complex tortuous ECMs were associated with reduced recurrence risk (aOR 0.33, 95% CI 0.11-0.91, p = 0.040, and aOR 0.14, 95% CI 0.02-0.53, p = 0.012, respectively). TB was highest in loose sparse ECM (mean 9.3), and PDCs were highest in dense fibrous ECM (mean 5.5). Discussion: Our findings suggest that ECM morphology, particularly dense fibrous ECM, predicts recurrence in Stage II colon cancer, highlighting ECM profiling as a promising tool for patient stratification beyond traditional staging. ### Competing Interest Statement The authors have declared no competing interest.

Background The immune response in breast tumors has an important role in prognosis, but the role of spatial localization of immune cells and of interaction between subtypes is not well characterized. We evaluated the association between spatially resolved tissue infiltrating immune cells (TIICs) and breast cancer specific survival (BCSS) in a large multicenter study. Patients and methods Tissue microarrays with tumor cores from 17,265 breast cancer patients of European descent were stained for CD8, FOXP3, CD20, and CD163. We developed a machine learning based tissue segmentation and immune cell detection algorithm using Halo to score each image for the percentage of marker positive cells by compartment (overall, stroma, or tumor). We assessed the association between log transformed TIIC scores and BCSS using Cox regression. Results Total CD8+ and CD20+ TIICs (stromal and intra-tumoral) were associated with better BCSS in women with ER-negative (HR per standard deviation = 0.91 [95% CI 0.85 - 0.98] and 0.89 [0.84 - 0.94] respectively) and ER-positive disease (HR = 0.92 [95% CI 0.87 - 0.98] and 0.93 [0.86 - 0.99] respectively) in multi-marker models. In contrast, CD163+ macrophages were associated with better BCSS in ER-negative disease (0.94 [0.87 - 1.00]) and a poorer BCSS in ER-positive disease 1.04 [0.99 - 1.10]. There was no association between FOXP3 and BCSS. The observed associations tended to be stronger for intra-tumoral than stromal compartments for all markers. However, the TIIC markers account for only 7.6 percent of the variation in BCSS explained by the multi-marker fully-adjusted model for ER-negative cases and 3.0 percent for ER-positive cases. Conclusions The presence of intra-tumoral and stromal TIICs is associated with better BCSS in both ER-negative and ER-positive breast cancer. This may have implications for the use of immunotherapy. However, the addition of TIICs to existing prognostic models would only result in a small improvement in model performance. ### Competing Interest Statement The authors have declared no competing interest. ### Funding Statement BCAC was supported by Cancer Research UK grant: PPRPGM-Nov20\100002 and by core funding from the NIHR Cambridge Biomedical Research Centre (NIHR203312). The views expressed are those of the author(s) and not necessarily those of the NIHR or the Department of Health and Social Care. The B-CAST project was supported by the Horizon 2020 Research and Innovation Programs of the European Union B (grant number: 633784) and the NIHR Cambridge Biomedical Research Centre. AJB was supported by the NIH/Oxcam doctoral programme. The funding of the contributing studies is listed in Supplementary Table 8. ### Author Declarations I confirm all relevant ethical guidelines have been followed, and any necessary IRB and/or ethics committee approvals have been obtained. Yes The details of the IRB/oversight body that provided approval or exemption for the research described are given below: All participants provided written informed consent. The ethics committees or institutional review boards responsible for oversight of the individual studies are listed in Supplementary Table 9. I confirm that all necessary patient/participant consent has been obtained and the appropriate institutional forms have been archived, and that any patient/participant/sample identifiers included were not known to anyone (e.g., hospital staff, patients or participants themselves) outside the research group so cannot be used to identify individuals. Yes I understand that all clinical trials and any other prospective interventional studies must be registered with an ICMJE-approved registry, such as ClinicalTrials.gov. I confirm that any such study reported in the manuscript has been registered and the trial registration ID is provided (note: if posting a prospective study registered retrospectively, please provide a statement in the trial ID field explaining why the study was not registered in advance). Yes I have followed all appropriate research reporting guidelines, such as any relevant EQUATOR Network research reporting checklist(s) and other pertinent material, if applicable. Yes The tissue segmentation and TIIC scores generated by the Halo algorithm together with the phenotype data, the imputed datasets and the analysis code will be available at the European Genome Phenome Archive on publication (https://ega-archive.org/).

Epithelial cells acquire mesenchymal phenotypes through epithelial‐mesenchymal transition (EMT) during cancer progression. However, how epithelial cells retain their epithelial traits and prevent malignant transformation is not well understood. Here, we report that the long noncoding RNA LITATS1 ( LINC01137 , ZC3H12A‐DT ) is an epithelial gatekeeper in normal epithelial cells and inhibits EMT in breast and non‐small cell lung cancer cells. Transcriptome analysis identified LITATS1 as a TGF‐β target gene. LITATS1 expression is reduced in lung adenocarcinoma tissues compared with adjacent normal tissues and correlates with a favorable prognosis in breast and non‐small cell lung cancer patients. LITATS1 depletion promotes TGF‐β‐induced EMT, migration, and extravasation in cancer cells. Unbiased pathway analysis demonstrated that LITATS1 knockdown potently and selectively potentiates TGF‐β/SMAD signaling. Mechanistically, LITATS1 enhances the polyubiquitination and proteasomal degradation of TGF‐β type I receptor (TβRI). LITATS1 interacts with TβRI and the E3 ligase SMURF2, promoting the cytoplasmic retention of SMURF2. Our findings highlight a protective function of LITATS1 in epithelial integrity maintenance through the attenuation of TGF‐β/SMAD signaling and EMT.