The association between the tumor immune microenvironments and clinical outcome in low‐grade, early‐stage endometrial cancer patients

Endometrial tumors show substantial heterogeneity in their immune microenvironment. This heterogeneity could be used to improve the accuracy of current outcome prediction tools. We assessed the immune microenvironment of 235 patients diagnosed with low‐grade, early‐stage endometrial cancer. Multiplex quantitative immunofluorescence was carried out to measure CD8, CD68, FOXP3, PD‐1, and PD‐L1 markers, as well as cytokeratin (CK), on tissue microarrays. Clustering results revealed five robust immune response patterns, each associated with specific immune populations, cell phenotypes, and cell spatial clustering. Most samples (69%) belonged to the immune‐desert subtype, characterized by low immune cell densities. Tumor‐infiltrating lymphocyte (TIL)‐rich samples (4%) displayed high CD8(+) T‐cell infiltration, as well as a high percentage of CD8/PD‐1(+) cells. Immune‐exclusion samples (19%) displayed the lowest CD8(+) infiltration combined with high PD‐L1 expression levels in CK(+) tumor cells. In addition, they demonstrated high tumor cell spatial clustering as well as increased spatial proximity of CD8(+)/PD‐1(+) and CK/PD‐L1(+) cells. FOXP3 and macrophage‐rich phenotypes (3% and 4% of total samples) displayed relatively high levels of FOXP3(+) regulatory T‐cells and CD68(+) macrophages, respectively. These phenotypes correlated with clinical outcomes, with immune‐exclusion tumors showing an association with tumor relapse. When compared with prediction models built using routine pathological variables, models optimized with immune variables showed increased outcome prediction capacity (AUC = 0.89 versus 0.78) and stratification potential. The improved prediction capacity was independent of mismatch repair protein status and adjuvant radiotherapy treatment. Further, immunofluorescence results could be partially recapitulated using single‐marker immunohistochemistry (IHC) performed on whole tissue sections. TIL‐rich tumors demonstrated increased CD8(+) T‐cells by IHC, while immune‐exclusion tumors displayed a lack of CD8(+) T‐cells and frequent expression of PD‐L1 in tumor cells. Our results demonstrate the capability of the immune microenvironment to improve standard prediction tools in low‐grade, early‐stage endometrial carcinomas. © 2022 The Authors. The Journal of Pathology published by John Wiley & Sons Ltd on behalf of The Pathological Society of Great Britain and Ireland.