
The relationship between PD-L1 expression and clinicopathological characteristics and prognosis of Vietnamese gastric cancer patients
- Department of Pathology and Forensic Medicine, 103 Military Medical Hospital, Vietnam Military Medical University, Ha Noi, Viet Nam
- Division of Military Science, 103 Military Medical Hospital, Vietnam Military Medical University, Ha Noi, Viet Nam
Abstract
Background & objectives: Programmed Death Ligand 1 (PD-L1) is a putative biomarker response to an immune checkpoint blockade that is related to poor outcomes as well as treatment strategy of numerous carcinomas, including gastric cancer. However, there is still a lack of other biomarkers that can predict patient prognosis in clinical settings. For this reason, we investigated PD-L1 expression and Combined Positive Score (CPS), as well its association with histopathological characteristics in gastric cancer patients.
Methods: We collected clinicopathological data from 54 patients with gastric cancer who underwent surgery at 103 Military Medical Hospital, Vietnam, from December 2018 to November 2020. Immunohistochemistry staining of the tumor specimens for PD-L1 expression and CPS were evaluated and accessed relationship to patient characteristics and overall survival.
Results: PD-L1 with strong and moderate expression was 1.9% and 20.3%, and CPS >= 1 was 46.3%. PD-L1 expression and CPS had no statistical relationship with histopathological characteristics, with the exception that tumor location, which was significantly related to PD-L1 expression (p = 0.001). PD-L1 positivity and CPS1 were related to worse overall survival of gastric cancer patients.
Conclusions: Our data indicated that PD-L1 and CPS are independent prognostic markers and indicators for use in targeted therapy for gastric cancer patients.
Introduction
Gastric cancer (GC) is the fifth most common cancer globally1. Most cases have been reported in Eastern Asia, particularly in China, Japan, and South Korea2. According to the 2020 GLOBOCAN, gastric cancer was ranked as the fourth most common cancer in Vietnam after liver, lung, and breast cancers, with an average number of new cases of 17,906, with the 5-year prevalence rate at 24.64 per 100,0003. The causes of gastric cancer are still unclear, but some factors have been shown to increase risk. The most common risk factor is the microbe Helicobacter pylori, which contributes to cancer development4. Diet and lifestyle risk factors include obesity, a diet high in sodium and low in vegetables, smoked foods, smoking, and alcohol consumption. The cancer can also develop from some stomach diseases, such as gastroesophageal reflux, chronic gastritis, and stomach polyps. Hereditary factors also increase risk of contracting gastric cancer5.
Cancer immunotherapy has shown promising results in recent years. In some types of cancer, interaction between programmed death-ligand 1 (PD-L1) in cancer cells and programmed death-1 (PD-1) in T cells inhibits T cell function, thus helping to prevent the cancer cells from evading the immune system6. Currently, there are several approaches to locking interaction between PD-L1 and PD-1, such as the use of gene therapy or antagonistic monoclonal antibodies. Previously, a study by Su et al. used gene therapy to reprogram T cells by eliminating the PD-1 gene using the CRISPR-Cas9 technique; the results showed a significant reduction of PD-1 expression but did not affect the viability of T cells, suggesting a new strategy for cancer treatment7. Alternatively, the use of monoclonal antibodies to block immune checkpoint molecules has been shown to be a promising therapeutic strategy against several types of cancer8, 9 and the immune regulatory PD-1/PD-L1 axis has been used for immunotherapy for gastric cancer10. The National Comprehensive Cancer Network (NCCN) guidelines suggest that immunotherapeutic strategies be applied to patients with advanced-stage GC11. Some clinical trials have indicated that monoclonal antibodies targeting PD-L1 or its receptor PD-1 inhibit the PD-1/PD-L1 signaling pathway and enhance T-cell function, which improves outcomes in patients with GC, particularly in the advanced stage12, 13, 14. In a trial from CheckMate 032 (GC/GEJC cohort), there was a strong association between the combined assessment of PD-L1 expression with the CPS and the effectiveness of anti-PD-1 therapy15.
Beyond assessment PD-L1 expression and CPS, there are currently no biomarkers for evaluating the clinical efficacy of anti-PD-1/PD-L1 immunotherapy. In Vietnam, the evaluation of PD-L1 expression and CPS in gastric cancer patients is limited, thus constraining the access to anti-PD-1/PD-L1 therapy. Additionally, determining the association between PD-L1 expression and pathological features is essential but still controversial and not well-elucidated. Therefore, we investigate the relationship between PD-L1 expression with clinicopathological characteristics and the survival of Vietnamese patients with gastric cancer.
Methods
Patient cohort
We retrospectively enrolled 54 GC patients who had undergone curative gastrectomy at 103 Military Medical Hospital, Vietnam, between December 2018 and November 2020. All patients were diagnosed using pathological results of H&E staining specimens to identify gastric cancer and also underwent gastrectomy and scraping of regional nodes. These patients were not treated with chemoradiotherapy beforehand and were monitored after surgery. We selected patients with recurrent GC, metastatic cancer to the stomach, or a combination of these and other cancers. The Ethics Committee of 103 Military Medical Hospital approved all study procedures (code: 140/2016/IRB-MH103).
Patient characteristics
We collected data on patient features including tumor location, tumor size, gross appearance (based on the Bormann classification), histologic type (based on the Lauren classification), histopathology classification (based on the WHO classification of Tumors of the Digestive System, 201016), tumor differentiation, depth of invasion (T stage according to the 8 edition of the UICC/AJCC TNM classification17), lymph node status, and vascular invasion.
PD-L1 Immunohistochemistry
Tumor specimens in a paraffin-embedded block were cut into 3 µm thick sections. We carried out immunohistochemical (IHC) staining for PD-L1 (clone 73-10, rabbit anti-human monoclonal antibody, 10 mg/ml, Leica, UK) on an automated slide stainer (Leica ST5010 Auto Stainer XL, Leica Biosystems), following manufacturer instructions. The samples were deparaffinized in xylene and rehydrated using a series of ethanol. Sections were incubated with the primary antibody for 30 minutes, then the secondary antibody of biotin-labeled anti-rabbit IgG was applied for 8 minutes. After washing in PBS, signals were visualized by incubation with polymer solution for 8 minutes and then 3-3’-diaminobenzidine (DAB) for 30 seconds. Slides were counterstained with hematoxylin for 6 minutes before mounting. After each step, wash through Bond-was solution two times in 2 minutes. Positive and negative controls were used for IHC reactions. Tonsils were used as the positive control, as PD-L1 should show strong staining in the crypt epithelium and weak to moderate staining of the follicular macrophages in the germinal centers.
Evaluation of PD-L1 expression and CPS scoring
We evaluated the expression of PD-L1 and calculated CPS following the protocol of PD-L1 IHC 22C3 pharmDx, which is FDA-approved for diagnostic use18. We randomly examined four fields on the tumor site slide of each specimen at 400X magnification. The expression of PD-L1 was recorded according to the percentage of tumor-stained cells per total viable tumor cells. We defined less than 1%, 1 — 49%, and ≥ 50% as weak, moderate, and strong expressions, respectively. For calculating CPS, we used the formula as follows:
Based on CPS, we divided samples into two groups: CPS < 1 and CPS ≥ 1.
Statistical analysis
After collecting sufficient information, the data for categorical variables was shown by frequency and percentage. We used a chi-square test to analyze correlations between PD-L1 expression, CPS, and clinicopathological features. We used the Kaplan-Meier method to construct the survival curves and a log-rank test for survival comparison. Statistical analysis was performed using SPSS software ver. 20.0 (IBM, Armonk, NY, USA). A p-value < 0.05 was considered statistically significant.
Clinicopathological features of gastric cancer
Characteristics |
|
(%) |
---|---|---|
Tumor location |
Body |
3 (5.5) |
Lesser curvature |
17 (31.5) | |
Pylorus |
34 (63) | |
Tumor size |
< 5cm |
43 (79.6) |
≥ 5cm |
11 (20.4) | |
Bormann classification |
Polyp |
3 (5.6) |
Fungating |
6 (11.1) | |
Ulcerous-infiltrative |
37 (68.5) | |
Diffuse-infiltrative |
8 (14.8) | |
Lauren classification |
Diffuse |
33 (61.1) |
Intestinal |
8 (14.8) | |
Mixed |
13 (24.1) | |
WHO classification |
Tubular adenocarcinoma |
40 (74.1) |
Mucinous adenocarcinoma |
3 (5.6) | |
Signet ring cell carcinoma |
3 (5.6) | |
Undifferentiated carcinoma |
8 (14.8) | |
Tumor differentiation |
High |
5 (9.3) |
Mediated |
22 (40.7) | |
Poor |
17 (31.5) | |
Undifferentiated |
10 (18.5) | |
Depth of invasion (T stage) |
T1 |
2 (3.7) |
T2 |
11 (20.4) | |
T3 |
22 (40.7) | |
T4 |
19 (35.2) | |
Lymph node metastasis |
Positive |
27 (50) |
Negative |
27 (50) | |
Vascular invasion |
Positive |
3 (5.6) |
Negative |
51 (94.4) |
PD-L1 expression and CPS calculation
Parameters |
(%) | |
---|---|---|
PD-L1 expression |
Weak |
42 (77.8) |
Moderate |
11 (20.3) | |
Strong |
1 (1.9) | |
CPS |
< 1 |
29 (53.7) |
≥ 1 |
25 (46.3) |
Correlation of PDL1 expression with clinicopathological charecteristics
Characteristics |
PD-L1, n (%) |
p |
CPS, n (%) |
p | |||
---|---|---|---|---|---|---|---|
Weak |
Moderate |
Strong |
< 1 |
≥ 1 | |||
Tumour location | |||||||
Cardia |
2 (66.7) |
0 (0.0) |
1 (33.3) |
2 (66.7) |
1 (33.3) |
0.442 | |
Lesser curvature |
13 (76.5) |
4 (23.5) |
0 (0.0) |
0.001 |
7 (41.2) |
10 (58.8) | |
Polyrus |
27 (79.4) |
7 (20.6) |
0 (0.0) |
20 (58.8) |
14 (41.2) | ||
Tumour size | |||||||
< 5cm |
33 (76.7) |
9 (20.9) |
1 (2.3) |
0.853 |
23 (53.5) |
20 (46.5) |
0.950 |
≥ 5cm |
9 (81.8) |
2 (18.2) |
0 (0.0) |
6 (54.5) |
5 (45.5) | ||
Bormann classification | |||||||
Polyp type |
2 (66.7) |
1 (33.3) |
0 (0.0) |
0.473 |
2 (66.7) |
1 (33.3) |
0.178 |
Fungating |
6 (100.0) |
0 (0.0) |
0 (0.0) |
2 (33.3) |
4 (66.7) | ||
Ulcerous-infiltrative |
26 (70.3) |
10 (27.0) |
1 (2.7) |
23 (62.2) |
14 (37.8) | ||
Diffuse-infultrative |
8 (100.0) |
0 (0.0) |
0 (0.0) |
2 (25.0) |
6 (75.0) | ||
Lauren classification | |||||||
Diffuse |
26 (78.8) |
6 (18.2) |
1 (3.0) |
0.759 |
18 (54.5) |
15 (45.5) |
0.950 |
Intestinal |
7 (87.5) |
1 (12.5) |
0 (0.0) |
4 (50.0) |
4 (50.0) | ||
Mixed |
9 (69.2) |
4 (30.8) |
0 (0.0) |
6 (50.0) |
6 (50.0) | ||
WHO classification | |||||||
Tubular adenocarcinoma |
30 (75.0) |
9 (22.5) |
1 (2.5) |
0.903 |
20 (50.0) |
20 (50.0) |
0.383 |
Mucinous denocarcinoma |
3 (100.0) |
0 (0.0) |
0 (0.0) |
3 (100.0) |
0 (0.0) | ||
Signet ring cell carcinoma |
3 (100.0) |
0 (0.0) |
0 (0.0) |
2 (66.7) |
1 (33.3) | ||
Undifferentiated arcinoma |
6 (75.0) |
2 (25.0) |
0 (0.0) |
4 (50.0) |
4 (50.0) | ||
Tumour differentiation | |||||||
High |
5 (100.0) |
0 (0.0) |
0 (0.0) |
0.586 |
3 (60.0) |
2 (40.0) |
0.986 |
Mediated |
18 (81.8) |
4 (18.2) |
0 (0.0) |
12 (54.5) |
10 (45.5) | ||
Poor |
11 (64.7) |
5 (29.4) |
1 (5.9) |
9 (52.9) |
8 (47.1) | ||
Undifferentiated |
8 (80.0) |
2 (20.0) |
0 (0.0) |
5 (50.0) |
5 (50.0) | ||
Depth of invasion (T stage) | |||||||
T1 |
2 (100.0) |
0 (0.0) |
0 (0.0) |
0.873 |
1 (50.0) |
1 (50.0) |
0.902 |
T2 |
9 (81.8) |
2 (18.2) |
0 (0.0) |
6 (54.5) |
5 (45.5) | ||
T3 |
17 (77.3) |
4 (18.2) |
1 (4.5) |
13 (59.1) |
9 (40.9) | ||
T4 |
14 (73.7) |
5 (26.3) |
0 (0.0) |
9 (47.4) |
10 (52.6) | ||
Lymph node metastasis | |||||||
Positive |
22 (81.5) |
4 (14.8) |
1 (3.7) |
0.384 |
13 (48.1) |
14 (59.1) |
0.413 |
Negative |
20 (74.1) |
7 (25.9) |
0 (0.0) |
16 (59.3) |
11 (40.7) | ||
Vascular invasion | |||||||
Positive |
1 (33.3) |
2 (66.7) |
0 (0.0) |
0.122 |
1 (33.3) |
2 (66.7) |
0.467 |
Negative |
41 (80.4) |
9 (17.6) |
1 (2.0) |
28 (54.9) |
23 (45.1) |

Immunohistochemical staining for PD-L1 expression in gastric cancer tissue. A: PD-L1 negative. C-D: The expression of PD-L1 in gastric cancer according to the intensity weak (B), moderate (C), and strong (at x400 magnification).

Kaplan-Meier survival curve for overall survival after gastrectomy. A: The overall survival time (OS) of patients with positive PD-L1 was significantly shorter than patients with negative PD-L1 (p = 0.001). B: OS of patients with CPS ≥ 1 was significantly shorter than patients with CPS <1 (p = 0.047).
Results
Patients' clinicopathologic data and relationship with PD-L1 expression
We summarize the pathological characteristics of patients in
IHC results for PD-L1 expression are shown in Figure 1 and summarized in
We summarize the relationship between PD-L1 expression and CPS and pathological characteristics of GC patients in
Impact of PD-L1 expression and CPS on the survival of patients with gastric cancer
We evaluated PD-L1 expression and CPS with regard to overall survival in gastric cancer patients. This analysis defined samples with PD-L1 strong and moderate expression as positive and samples with weak expression as negative. Based on PD-L1 expression and CPS, overall survival is represented by the Kaplan–Meier curves in Figure 2. PD-L1-positive patients had lower overall survival than PD-L1-negative patients; the difference was statistically significant, with p = 0.001 (Figure 2A). Patients with CPS ≥ 1 had lower overall survival than patients with CPS < 1; the difference was statistically significant, with p = 0.047 (Figure 2B). The results showed a relationship between the expression of PD-L1 and CPS and the prognosis of gastric cancer patients.
Discussion
In this study, we divided PD-L1 expression into weak, moderate, and strong rankings, with ratios of 77.8%, 20.3%, and 1.9%, respectively. For comparison with other studies, we defined samples with PD-L1 strong and moderate expression as positive, with a combined percentage of 22.2% presence in patients (
Our results showed no relationship between the expression levels of PD-L1, CPS, and histopathological characteristics in gastric cancer patients, except regarding tumor location, which was significantly related to the expression level of PD-L1 (p = 0.001, chi-square test,
This study also had some limitations. The sample number was small, resulting in an analytical evaluation was not comprehensive. Additionally, the cut-off values for distinguishing between positive and negative PD-L1 expression still hold room for improvement.
Conclusions
Overexpression of PD-L1 and CPS ≥ 1 contribute to poor prognosis and reduced survival in gastric cancer patients. Our study indicates that CPS and PD-L1 expression are independent prognostic indicators, and that combination of these two indicators can improve strategies for targeting PD-1/PD-L1 inhibitors in therapy for gastric cancer patients.
Abbreviations
AJCC: American Joint Committee on Cancer; CPS: Combined positive score; DAB: 3-3’-diaminobenzidine; FDA: Food and Drug Administration; GC: Gastric cancer; GC/GEJC: Gastric or gastroesophageal junction cancer; GLOBOCAN: Global Cancer Incidence, Mortality And Prevalence; IBM: International Business Machines Corporation; IHC: Immunohistochemical; NCCN: National Comprehensive Cancer Network; NY: New York; PBS: Phosphate buffered saline; PD-1: Programmed death 1; PD-L1: Programmed Death Ligand 1; SPSS: Statistical Package for the Social Sciences; TNM: Tumor-node-metastasis; UICC: Union for International Cancer Control; UK: United Kingdom; USA: United States of America
Acknowledgments
We would like to thank the patients for joining the study and gratefully acknowledge the support for equipment and techniques from the Leica Biosystems branch in Vietnam.
Author’s contributions
Conceived and designed the study: TND NMH. Patient characteristics data and sample collection: TND NMH DTT TDT NTL NKT PVT NBD NMH DTC. Analyzed and interpreted the data: TND NMH TDT NKT DTC. Contributed to drafting and writing the article: TND NMH DTT TDT DTC. Involved in all aspects of the work through correspondence: NMH DTC. All authors read and approved the final manuscript.
Funding
None.
Availability of data and materials
Data and materials used and/or analyzed during the current study are available from the corresponding author on reasonable request.
Ethics approval and consent to participate
All patients provided informed consent for participation in the study. The Ethics Committee of 103 Military Medical Hospital (code: 140/2016/IRB-MH103) approved all study procedures.
Consent for publication
Not applicable.
Competing interests
The authors declare that they have no competing interests.