Reproducibility and validation of tumour stroma ratio scoring on oesophageal adenocarcinoma biopsies

doi:10.1016/j.ejca.2010.09.043

European Journal of Cancer

Volume 47, Issue 3, February 2011, Pages 375-382

https://doi.org/10.1016/j.ejca.2010.09.043 Get rights and content

Abstract

Background

Tumour stroma ratio (TSR) in histological sections of resected oesophageal adenocarcinomas proved to be a prognostic factor for patients’ survival. The objectives of this study were to assess inter- and intraobserver agreement for TSR scoring on biopsy material and to validate these biopsy results with the results derived from surgical specimens.

Methods

Biopsies and surgical specimens of 91 patients with oesophageal adenocarcinoma were available. TSR was determined on the original haematoxylin–eosin (H&E) tissue sections from primary tumour biopsies. To assess interobserver variation, TSR was scored by three pathologists as 0–25%, 25–50%, 50–75% or 75–100%. A second scoring was done to examine intraobserver variation. The definitive TSR biopsy score was compared with the corresponding resection specimen score. Kappa statistics were applied to evaluate agreement.

Results

Biopsies of 10 (11%) patients were rejected because of poor quality. For 81 TSR biopsy scores, interobserver correlations ranged between 0.239 and 0.486 (P < 0.001 for all). By classifying scores into two groups (<50% and ⩾50%), interobserver correlations ranged between 0.372 and 0.886 (P < 0.001 for all). Intraobserver agreement was substantial to near-perfect (κ = 0.780–0.848; P < 0.001 for all). Definitive TSR biopsy score showed moderate correlation with TSR scores on surgical specimens (κ = 0.506), but it was an independent prognostic factor for survival.

Conclusion

Reproducibility of tumour stroma ratio scoring on oesophageal adenocarcinoma biopsies was good. The ease of TSR scoring on H&E sections together with its correlation with patients’ survival may have clinical relevance in this era of neoadjuvant therapy.

Introduction

Partial oesophagectomy is the mainstay in potentially curative treatment for oesophageal cancer. Postoperative mortality has decreased substantially in recent years, mainly as a result of more precise preoperative staging and better patient selection.1, 2, 3 Still, many patients present with recurrences within two years after surgery and even in specialised high volume centres, 5-year survival rates rarely exceed 40%.4, 5, 6

Histopathological factors, such as extracapsular lymph node involvement and possibly genetic expression profiling of the tumour, are in relation with metastatic potential and survival.7, 8 The tumour micro-environment, including the supportive stromal component, plays a crucial role in the progression, growth and spread of cancers.9, 10, 11 Earlier, we found that the amount of stroma in direct relation to the tumour was an independent prognostic factor for survival in colon cancer12, 13 and breast cancer.¹⁴

Subsequently, we have investigated the tumour stroma ratio (TSR) on histological sections of oesophagectomy specimens.¹⁵ In a set of 93 patients who underwent resection for oesophageal adenocarcinoma, a significant difference in survival time was observed between patients with a high TSR (⩾50%) and patients with a low TSR (<50%). Patients with a low TSR showed a significantly worse survival. Since neoadjuvant therapies are increasingly used, and patient selection for multimodality treatment becomes even more important, assessment of prognostic factors is preferably done before the start of treatment. Therefore, TSR scoring should be validated on biopsy specimens.

The objectives of the present study were: (1) to assess inter- and intraobserver agreement for TSR scoring on oesophageal adenocarcinoma biopsies, and (2) to correlate these biopsy results with the results derived from the surgical specimens and with survival data.

Section snippets

Tissue selection

From the database of the Comprehensive Cancer Centre Leiden (CCCL), we had previously selected a consecutive series of 93 patients with oesophageal adenocarcinoma who underwent resection with curative intent between 1990 and 2004 at the Leiden University Medical Centre (LUMC) or the Reinier de Graaf Gasthuis in Delft (RdGG).¹⁵ Patients who were treated with neoadjuvant therapy were excluded, as were patients who died within 30 d after surgery. Patient, tumour and treatment characteristics were

Patient demographics

Archival biopsy material was available for 91 of the 93 patients who underwent oesophagectomy. Biopsies of 10 (11%) patients were unanimously rejected because of the poor quality of the tissue specimen. The median age of the 81 study patients was 64 (range 37–82) years. There were 66 men (81.5%) and 15 women (18.5%). Median follow-up was 23 (range 3–220) months.

Histopathological features

Overall, there were 486 TSR biopsy scores (81 slides, three observers and two scores per observer for each slide). A definitive TSR

Discussion

Our study results showed that TSR biopsy scoring in patients with oesophageal adenocarcinoma was reproducible. Biopsy results demonstrated moderate correlation with results derived from surgical specimens. The definitive TSR biopsy score was an independent prognostic factor for survival. A high score (TSR ⩾50%) was associated with better survival.

Concordant with our previous study results on surgical resection specimens, scoring of TSR on biopsy material was easy on H&E stained sections.

Conflict of interest statement

None declared.

Sources of support

None.

Financial disclosure

None.

References (23)

I. Rouvelas et al.
Survival after surgery for oesophageal cancer: a population-based study
Lancet Oncol
(2005)
E.F. Courrech Staal et al.
The stromal part of adenocarcinomas of the oesophagus: does it conceal targets for therapy?
Eur J Cancer
(2010)
N. Yanagisawa et al.
Stromogenic prostatic carcinoma pattern (carcinomas with reactive stromal grade 3) in needle biopsies predicts biochemical recurrence-free survival in patients after radical prostatectomy
Hum Pathol
(2007)
H.J. Stein et al.
Improved prognosis of resected esophageal cancer
World J Surg
(2004)
P.C. Enzinger et al.
Esophageal cancer
N Engl J Med
(2003)
J.R. Siewert et al.
Adenocarcinoma of the esophagogastric junction: results of surgical therapy based on anatomical/topographic classification in 1002 consecutive patients
Ann Surg
(2000)
T. Lerut et al.
Three-field lymphadenectomy for carcinoma of the esophagus and gastroesophageal junction in 174 R0 resections: impact on staging, disease-free survival, and outcome: a plea for adaptation of TNM classification in upper-half esophageal carcinoma
Ann Surg
(2004)
J.M. Omloo et al.
Extended transthoracic resection compared with limited transhiatal resection for adenocarcinoma of the mid/distal esophagus: five-year survival of a randomized clinical trial
Ann Surg
(2007)
S.M. Lagarde et al.
Extracapsular lymph node involvement in node-positive patients with adenocarcinoma of the distal esophagus or gastroesophageal junction
Am J Surg Pathol
(2006)
S.M. Lagarde et al.
Analysis of gene expression identifies differentially expressed genes and pathways associated with lymphatic dissemination in patients with adenocarcinoma of the esophagus
Ann Surg Oncol
(2008)

N. Wernert

The multiple roles of tumour stroma

Virchows Arch

(1997)

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The TSR score is a highly reproducible measurement with little intra-observer variation and has the potential to be used in everyday practice. TSR has recently been shown to be a promising outcome prediction tool for a variety of tumors, including breast, colon, hepatocellular, and esophageal cell carcinomas [87–90]. Therefore, the assessment of TSR can facilitate patient treatment decisions to prevent overtreatment and enable more precise individualized strategies.
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In the pursuit of personalized diagnostics and tailored treatments, quantitative protein tests contribute to a more precise definition of health and disease. The development of new quantitative protein tests should be driven by an unmet clinical need and performed in a collaborative effort that involves all stakeholders. With regard to the analytical part, mass spectrometry (MS)-based platforms are an excellent tool for quantification of specific proteins in body fluids, for example focused on cancer. The obtained readouts have great potential in determining tumor aggressiveness to facilitate treatment decisions, and can furthermore be used to monitor patient response. Internationally standardized TNM classifications of malignant tumors are beneficial for diagnosis, however treatment outcome and survival of cancer patients is poorly predicted. To this end, the importance of the tumor microenvironment has endorsed the introduction of the tumor-stroma ratio as a prognostic parameter in solid primary tumor types. Currently, the stromal content of tumor tissues is determined via routine diagnostic pathology slides. With the development of liquid chromatography (LC)-MS methods we aim at quantification of tumor-stroma specific proteins in body fluids. In this mini-review the analytical aspect of this developmental trajectory is further detailed.
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TSR in pre-treatment biopsies was estimated according to the method described by van Pelt et al. The degree of pathological response was assessed on the tumour resection according to tumour regression grading (TRG) by Mandard. The primary endpoint of this study was the difference in pathological response to nCRT between TSR-high and TSR-low groups.
We found that 26.2% of patients with major response was classified as TSR-high, while 73.8% of patients were classified as TSR-low. A high TSR in pre-treatment biopsies was associated with a lower chance of major-response to nCRT (OR = 0.37, 95%CI; 0.19–0.73), p = 0.004), independent of tumour stage and time between nCRT and surgery.
In rectal cancer, TSR in pre-treatment biopsies predicts pathologic response to nCRT, with a high TSR bringing twice the risk of poor to no response compared to low TSR. In future, assessment of TSR may fulfil a role in a therapeutic algorithm identifying patients who will or will not respond to nCRT prior to treatment initiation.
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Remarkably, both cohorts had an almost 50/50 distribution between the TSR categories, which is an uncommon observation since previous colorectal studies typically report a 30/70 ratio for stroma-high and stroma-low tumours, respectively [7,9,10,13,41–43]. However, if a sampling bias would have occurred, an underestimation of the stroma-high tumours would have been more sensible, which was apparent in two studies performed in colon- and oesophageal cancer [44,45]. In these studies, the TSR was determined in diagnostic biopsies and demonstrated the expected lower amount of stroma-high tumours.
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The ADC values between stroma-low and stroma-high tumours were not significantly different. Intra-class correlation (ICC) demonstrated a good level of agreement for the ADC measurements, ranging from 0.84–0.86 for single slice and 0.86–0.90 for the whole-volume protocol. No correlation was observed between the TSR and ADC values, with ADC_mean r_s= -0.162 (p= 0.38) and ADC_min r_s= 0.041 (p= 0.82) for the single-slice and r_s= -0.108 (p= 0.55) and r_s= 0.019 (p= 0.92) for the whole-volume measurements in the training cohort, respectively. Results from the validation cohort were consistent; ADC_mean r_s= -0.022 (p= 0.86) and ADC_min r_s = 0.049 (p= 0.69) for the single-slice and r_s= -0.064 (p= 0.59) and r_s= -0.063 (p= 0.61) for the whole-volume measurements.
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Reproducibility and validation of tumour stroma ratio scoring on oesophageal adenocarcinoma biopsies

Abstract

Background

Methods

Results

Conclusion

Introduction

Section snippets

Tissue selection

Patient demographics

Histopathological features

Discussion

Conflict of interest statement

Sources of support

Financial disclosure

Lancet Oncol

Eur J Cancer

Hum Pathol

Improved prognosis of resected esophageal cancer

World J Surg

Esophageal cancer

N Engl J Med

Adenocarcinoma of the esophagogastric junction: results of surgical therapy based on anatomical/topographic classification in 1002 consecutive patients

Ann Surg

Three-field lymphadenectomy for carcinoma of the esophagus and gastroesophageal junction in 174 R0 resections: impact on staging, disease-free survival, and outcome: a plea for adaptation of TNM classification in upper-half esophageal carcinoma

Ann Surg

Extended transthoracic resection compared with limited transhiatal resection for adenocarcinoma of the mid/distal esophagus: five-year survival of a randomized clinical trial

Ann Surg

Extracapsular lymph node involvement in node-positive patients with adenocarcinoma of the distal esophagus or gastroesophageal junction

Am J Surg Pathol

Analysis of gene expression identifies differentially expressed genes and pathways associated with lymphatic dissemination in patients with adenocarcinoma of the esophagus

Ann Surg Oncol

The multiple roles of tumour stroma

Virchows Arch