Disertasi

Peran Lingkungan Mikro Tumor terhadap Kesintasan Kanker Payudara Tiga Negatif Metastatik: Kajian terhadap Ekspresi CD4, CD8, FOXP3 CD163 dan PD-L1 = The Role of Tumor Microenvironment on Survival of Metastatic Triple Negative Breast Cancer: A Study on the Expression of CD4, CD8, FOXP3,CD163, and PD-L1.

Kanker payudara tiga negatif (KPTN) metastatik memiliki angka mortalitas tinggi. KPTN memiliki intensitas respons imun paling tinggi melalui infiltrasi sel limfosit T CD4, CD8, FOXP3, sel makrofag CD163 dan molekul PD-L1 di lingkungan mikro tumor. Namun peran respons imun tersebut dapat bersifat antitumor atau protumor yang memengaruhi mortalitas pasien KPTN metastatik. Untuk mengetahui peran infiltrasi CD4, CD8, FOXP3 CD163 dan PD-L1 terhadap mortalitas 1 tahun KPTN perlu dilakukan pada populasi metastatik. Penelitian nested case-control multisenter ini menggunakan sampel jaringan dari pasien yang berobat di RSUPN Cipto Mangunkusumo dan 6 RS di Jakarta pada tahun 2015 hingga 2020. Kriteria inklusi adalah pasien KPTN yang mengalami metastasis dari awal diagnosis dan diperoleh 103 subjek. Data klinis diperoleh dari rekam medis, sedangkan infiltrasi CD8, CD163 dinilai melalui pemeriksaan imunohistokimia (IHK). Khusus untuk CD4 dan FOXP3 dinilai dengan menggunakan metode IHK double staining, sedangkan ekspresi protein PD-L1 melalui IHK dan mRNA melalui RT-PCR. Analisis kesintasan diawali dengan mencari titik potong optimal kategori tinggi dan rendah dengan menggunakan kurva receiver operating characteristic (ROC), dilanjutkan kurva Kaplan-Meier dan analisis regresi Cox. Terdapat hubungan CD8, CD4, rasio CD4/FOXP3, rasio CD8/FOXP3, rasio CD8/CD163 dengan mortalitas 1 tahun pasien KPTN metastatik. Kelompok CD8 rendah memiliki hazard ratio(HR) 1,867 (p = 0,022; 95% IK 1 ,095–3,182), CD4 rendah memiliki HR 1,935 (p = 0,026; 95% IK 1 ,083–3,457), rasio CD4/FOXP3 rendah memiliki HR 2,020 (p = 0,015; 95% IK 1 ,145–3,564), rasio CD8/FOXP3 rendah memiliki HR 1,821 (p = 0,039; 95% IK 1 ,032–3,213), dan rasio CD8/CD163 rendah memiliki HR 2,169 (p = 0,006; 95% IK 1 ,254–3,752). Tidak terdapat hubungan antara FOXP3, CD163, IHK PD-L1 dan mRNA PD-L1 dengan mortalitas 1 tahun KPTN metastatik tetapi terdapat perbedaan rerata peringkat CD8, CD4, CD163, FOXP3 yang lebih tinggi pada IHK PD-L1 yang terekspresi dan terdapat rerata peringkat mRNA PD-L1 yang lebih tinggi pada derajat patologi tinggi. Mortalitas KPTN metastatik yang lebih tinggi pada CD8, CD4, rasio CD4/FOXP3, rasio CD8/FOXP3 dan rasio CD8/CD163 yang rendah menunjukkan bahwa terdapat peran sel imun dan rasio aktivitas imun antitumor dibandingkan protumor dalam kesintasan KPTN metastatik. Penilaian infiltrasi sel imun dan rasio di atas berpotensi digunakan sebagai faktor prognostik pasien KPTN metastatik.
Kata kunci : CD4, CD8, CD163, FOXP3, KPTN metastatik, mortalitas, PD-L1


Metastatic triple-negative breast cancer (TNBC) has a high mortality rate. TNBC has the highest intensity of immune response through infiltration of CD4, CD8, FOXP3 T lymphocytes, CD163 macrophage cells, and PD-L1 molecules in the tumor microenvironment. However, the role of the immune response can be antitumor or protumor, which affects the mortality of metastatic TNBC patients. To determine the role of infiltrating CD4, CD8, FOXP3 CD163 and PD-L1 on 1- year mortality of TNBC, it is necessary to conduct a study in a metastatic population. This multicenter nested case-control study used tissue samples from patients who sought treatment at Cipto Mangunkusumo Hospital and 6 hospitals in Jakarta from 2015 to 2020. Inclusion criteria were TNBC patients who experienced metastasis from the beginning of diagnosis. The 103 subjects were obtained. Clinical data were obtained from medical records, while infiltration of CD8, CD163 was assessed through immunohistochemical examination (IHC). Specifically for CD4 and FOXP3 assessed using the IHC double staining method, while PD-L1 protein expression through ICK and mRNA through RT-PCR. Survival analysis began with finding the optimal cut-off point for high and low categories using receiver operating characteristic (ROC) curves, followed by Kaplan-Meier curves and Cox regression analysis.There was an association of CD8, CD4, CD4/FOXP3 ratio, CD8/FOXP3 ratio, CD8/CD163 ratio with 1 -year mortality of metastatic TNBC patients. The low CD8 group had a hazard ratio (HR) of 1.867 (p = 0.022; 95% CI 1.095-3.182), low CD4 had an HR of 1.935 (p = 0.026; 95% CI 1.083-3.457), low CD4/FOXP3 ratio had an HR of 2.020 (p = 0.015; 95% CI 1.145-3.564), low CD8/FOXP3 ratio had an HR of 1.821 (p = 0.039; 95% CI 1.032-3.213), and low CD8/CD163 ratio had an HR of 2.169 (p = 0.006; 95% CI 1.254-3.752). There was no association of FOXP3, CD163, PD-L1 IHC and PD-L1 mRNA with 1 -year mortality of metastatic TNBC but there was a difference in the mean rank of CD8, CD4, CD163, FOXP3 which was higher in PD-L1 expressed IHC and there was a higher mean rank of PD-L1 mRNA in high pathology degree.The higher mortality of metastatic TNBC in CD8, CD4, CD4/FOXP3 ratio, CD8/FOXP3 ratio and low CD8/CD163 ratio indicated that there is a role of immune cells and the ratio of antitumor immune activity compared to protumor in the survival of metastatic TNBC. Assessment of immune cell infiltration and the above ratios could potentially be used as prognostic factors for metastatic TNBC patients.
Keywords: CD4, CD8, CD163, FOXP3, metastatic TNBC, mortality, PD-L1