Immunoscore Is Prognostic in Low-Risk and High-Risk Stage III Colon Carcinomas Treated With Adjuvant Infusional Fluorouracil, Leucovorin, and Oxaliplatin in a Phase III Trial.

Abstract

The recommended duration of adjuvant fluoropyrimidine and oxaliplatin chemotherapy for patients with stage III colon cancer is based on tumor classification into clinically low-risk (T_1-3 N₁) and high-risk (T₄ or N₂) groups. We determined whether Immunoscore can enhance prognostication within these risk groups. Patients with stage III colon carcinomas (N = 600) were randomly selected from the infusional fluorouracil, leucovorin, and oxaliplatin arm of adjuvant trial NCCTG N0147 (Alliance for Clinical Trials in Oncology). Tumors were evaluated for Immunoscore that quantifies CD3⁺ and CD8⁺ T-cell densities in the tumor center and invasive margin by digital image analysis. Disease-free survival (DFS) by Immunoscore was analyzed using a multivariable Cox regression model in each risk group with adjustment for covariates including <i>KRAS</i>, <i>BRAF</i>^<i>V600E</i>, and mismatch repair status. Of 559 cancers with Immunoscore data, 299 (53.5%) were classified as clinically low-risk (T_1-3 N₁) and 260 (46.5%) as clinically high-risk (T₄ and/or N₂). Among patients with low-risk tumors, those with Immunoscore-Low versus Immunoscore-High tumors had significantly worse 5-year DFS rates (77.5% <i>v</i> 91.8%; hazard ratio, 1.70; 95% CI, 1.03 to 2.79; <i>P</i> = .037). Among patients with high-risk tumors, those with Immunoscore-Low versus Immunoscore-High tumors also had significantly worse DFS (55.3% <i>v</i> 70.3%; hazard ratio, 1.65; 95% CI, 1.11 to 2.47; <i>P</i> = .013). Tumors that were low-risk/Immunoscore-Low had similar outcomes as did tumors that were high-risk/Immunoscore-High (<i>P</i> = .174). Prognostication was significantly improved in multivariable models where Immunoscore was added to clinical risk parameters and limited biomarkers (likelihood ratio test <i>P</i> = .0003). Immunoscore can refine patient prognosis beyond clinical risk group classification, suggesting its potential utility for adjuvant decision making.