Local immunosuppressive microenvironment underlies reduced responsiveness to imiquimod treatment in recurrent or residual cervical HSIL

Gynecologic Oncology Reports, vol. 65, pp. 102121

Abstract

Objective: The topical immune modifier imiquimod is used as alternative treatment for cervical high-grade squamous intraepithelial lesions (cHSIL). While its clinical efficacy in primary cHSIL (pcHSIL) is approximately 60%, this is only 33% for recurrent or residual cHSIL (rrcHSIL) due to reasons that are not well understood. Since the immune microenvironment plays a key role in response to imiquimod in pcHSIL, we performed an in depth comparison of the pcHSIL to the rrcHSIL immune microenvironment. Methods: Transcriptome analysis was performed using the nCounter® Human PanCancer IO360™ panel on 6 pcHSIL and 6 rrcHSIL. Multispectral immunofluorescence (13 markers) was used to analyze T- and myeloid-cell composition of pcHSIL (n = 40) and rrcHSIL (n = 10). Differences in pre-treatment immune infiltrates of rrcHSIL were related to clinical response after imiquimod. Results: Transcriptomic analyses revealed lower expression of genes involved in leukocyte activation, immune cell recruitment, T cell engagement, lymphocyte and B cell infiltration in rrcHSIL compared to pcHSIL. Gene set enrichment analysis (GSEA) supported these findings, demonstrating decreased IL2-STAT 5 signaling in rrcHSIL. Immunofluorescence staining results corroborated the transcriptomic data, with rrcHSIL displaying lower intraepithelial infiltration with CD4+(Tbet + ) T cells, and (CD14 + )CD68 + CD163- M1-like macrophages, but higher numbers of CD8+(PD1 + ) T cells and CD68 + CD163 + M2-like macrophages. RrcHSIL non-responders to imiquimod exhibited an even more immunosuppressive microenvironment than complete responders, characterized by increased infiltration of CD4 + FoxP3 + regulatory T cells and (CD14 + )CD68 + CD163 + M2-like macrophages and CD14 + HLADR- monocytic myeloid derived suppressor cells. Conclusions: The limited efficacy of imiquimod in rrcHSIL may be explained by a strong immunosuppressive microenvironment.

Authors 9

1. Caroline L. P. Muntinga corresponding

   Catharina Ziekenhuis · Maastricht University

   Affiliation as printed

   Department of Gynecology and Obstetrics, Catharina Ziekenhuis Eindhoven, Michelangelolaan 2, 5623 EJ Eindhoven, the Netherlands

   GROW - School for Oncology and Reproduction, Maastricht University, Universiteitssingel 40, 6229 ER Maastricht, the Netherlands

2. A.J. van de Sande

   Erasmus MC · Sint Franciscus Gasthuis · Erasmus MC Cancer Institute

   Affiliation as printed

   Department of Gynecologic Oncology, Erasmus MC Cancer Center, University Medical Center, Dr. Molewaterplein 40, 3015 GD Rotterdam, the Netherlands

   Department of Gynecology and Obstetrics, Franciscus Gasthuis and Vlietland, Kleiweg 500, 3045 PM Rotterdam, the Netherlands

3. M.J.P. Welters Aachen Department of Medical Oncology Oncode Institute

   Leiden University · Leiden University Medical Center

   Affiliation as printed

   Department of Medical Oncology, Oncode Institute, Leiden University Medical Centre, Albinusdreef 2, 2333 ZG Leiden, the Netherlands

4. Loes F. S. Kooreman

   Maastricht University Medical Centre · Maastricht University

   Affiliation as printed

   Department of Pathology, Maastricht Universitair Medisch Centrum, P. Debyelaan 25, 6229 HX Maastricht, the Netherlands

   GROW - School for Oncology and Reproduction, Maastricht University, Universiteitssingel 40, 6229 ER Maastricht, the Netherlands

5. R.L.M. Bekkers

   Catharina Ziekenhuis · Maastricht University

   Affiliation as printed

   Department of Gynecology and Obstetrics, Catharina Ziekenhuis Eindhoven, Michelangelolaan 2, 5623 EJ Eindhoven, the Netherlands

   GROW - School for Oncology and Reproduction, Maastricht University, Universiteitssingel 40, 6229 ER Maastricht, the Netherlands

6. Heleen J. van Beekhuizen

   Erasmus MC · Erasmus MC Cancer Institute

   Affiliation as printed

   Department of Gynecologic Oncology, Erasmus MC Cancer Center, University Medical Center, Dr. Molewaterplein 40, 3015 GD Rotterdam, the Netherlands

7. Sjoerd H. van der Burg Aachen Department of Medical Oncology Oncode Institute

   Leiden University · Leiden University Medical Center

   Affiliation as printed

   Department of Medical Oncology, Oncode Institute, Leiden University Medical Centre, Albinusdreef 2, 2333 ZG Leiden, the Netherlands

8. PJ de Vos van Steenwijk

   Maastricht University Medical Centre · Maastricht University

   Affiliation as printed

   Department of Gynecology and Obstetrics, Maastricht Universitair Medisch Centrum, P. Debyelaan 25, 6229 HX Maastricht, the Netherlands

   GROW - School for Oncology and Reproduction, Maastricht University, Universiteitssingel 40, 6229 ER Maastricht, the Netherlands

9. EMG Van Esch

   Catharina Ziekenhuis · Erasmus MC · Erasmus MC Cancer Institute

   Affiliation as printed

   Department of Gynecologic Oncology, Erasmus MC Cancer Center, University Medical Center, Dr. Molewaterplein 40, 3015 GD Rotterdam, the Netherlands

   Department of Gynecology and Obstetrics, Catharina Ziekenhuis Eindhoven, Michelangelolaan 2, 5623 EJ Eindhoven, the Netherlands