Prognostic and predictive value of tertiary lymphoid structures in TURBT materials; Should it be seated in routine pathological examination and can it be used in deciding on the treatment method?

doi:10.21203/rs.3.rs-3962802/v2

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Prognostic and predictive value of tertiary lymphoid structures in TURBT materials; Should it be seated in routine pathological examination and can it be used in deciding on the treatment method?

https://doi.org/10.21203/rs.3.rs-3962802/v2

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Purpose: This study aims to reveal the importance of tertiary lymphoid structures (TLS) in TURBT materials with a practical and applicable method in which the effect of a certain threshold value on survival and treatment response can be implicated.

Methods: TURBT materials that had not previously received any treatment (chemotherapy, radiotherapy, or immunotherapy) and were diagnosed for the first time at Mardin Training and Research Hospital between 2014 and 2022 were included in the study. The maximum number of TLS per 4x magnification field (Field diameter: 4,5 mm) was recorded.Grouping and statistical analysis of the TLS number were performed using threshold values of “≥1”, “≥2” and “≥3”.

Results

TLSs were more frequently found in high-grade tumors (p=0,008) and showed a strong association with stage progression (p<0,001). It was also significantly associated with many adverse histopathological parameters. Conversely,high TLS (≥1, ≥2, and ≥3) appeared to be associated with fewer recurrences (p=0,032, p=0,001, and p=0,018, respectively), and cases with higher TLS showed longer recurrence-free survival (p=0,089, p=0,023, p=0,037, respectively). TLS≥3 was found to be an independent parameter associated with favoarable RFS (p=0,019, HR=0,401) and multifocality was found to be an independent risk factor for RFS (p=0,023, HR=2,302).

Conclusion

This study is the first to demonstrate the relationship between the presence and specific thresholds of TLS in TURBT materials with prognostic parameters. Including this information in the routine pathological examination of TURBT materials will allow a more accurate approach to treatment and follow-up, especially in patients with NMIBC.

TURBT

Tertiary lymphoid structure

Bladder cancer

Prognosis

Recurrence

Bladder cancer (BC) is the 10th most common disease worldwide and is responsible for 2.1% of cancer-associated deaths [1]. In the USA, 82,290 new cases and 16,710 cancer-related deaths are estimated for 2023, and the 5-year relative survival is reported as 77.9% [2].Cystoscopy-guided transurethral resection of bladder tumor (TURBT) remains the cornerstone in the diagnosis and treatment of BC. It allows local staging, grading, and relief of symptoms, if present, and resection of all visible tumors when technically safe and feasible [3]. After the initial TURBT, non-muscle invasive tumors (NMIBC) can be divided into risk groups according to tumor number, size, recurrence rate, tumor stage, presence of carcinoma in situ (CIS), and tumor grade [4]. They can be managed with post-control endoscopic resection and risk-based intravesical therapy [5]. Despite the recurrence-reducing effects of the use of intravesical agents, recurrence remains an inevitable reality for BC patients. In a large-scale study carried out using a combined analysis of data from NMIBC patients most of them (78.4%) also received intravesical treatment; even in patients with low scores, the 1-year and 5-year recurrence rates were 15% and 31%, while in high-scored ones, this rate was calculated as 61% and 78%, respectively [6].

Today, histopathological evaluation includes histological parameters that allow the risk stratification mentioned above [7]. However, almost all of them are related to the epithelial part of the BC, and stromal features are ignored in the current approach. An accumulated amount of scientific data has revealed that the tumor stroma, the tumor microenvironment, or the host's immune response to the tumor plays an important role in determining the prognostic features and treatment regimen of patients in many types of solid tumors[8–14].At this point, the importance of tertiary lymphoid structures (TLSs) in regulating and maintaining the antitumor immune response in the tumor stroma is emphasized more day by day[15].TLSs reflect lymphoid neogenesis occurring in peripheral tissues as a result of long-term exposure to inflammatory signals mediated by chemokines and cytokines, and they develop in a variety of pathophysiological conditions, including autoimmune, and infectious diseases, transplanted organs, inflammatory disorders, and tumors[13].Recent publications focused that the presence or amount of TLS in many organ-origin tumors is associated with a better prognosis and is also a good predictor of the response to treatment[8, 9, 11, 12, 15, 16]. In addition, its increase in tissues after treatment can be used as a good indicator of the treatment effect and the development of antitumor immunity[17].

There are limited studies examining the importance of TLS in BC, and its prognostic and predictive impact is not fully understood. This study aims to define a TLS evaluation method that can be applied in routine pathological examination of TURBT materials and where the effect of a certain threshold value on survival and treatment response can be implicated.

2.1- Patient selection

The files of patients diagnosed with urothelial carcinoma diagnosed by TURBTmaterials between 2014 and 2022 in Mardin Training and Research Hospital were reviewed. Biopsies that had not received any treatment (chemotherapy, radiotherapy, or immunotherapy) before and where the diagnosis was made for the first time were included in the study.Demographic data, treatment and follow-up information, recurrence, and survival status of the patients were obtained from the patient cards in the hospital automation system, urology clinic, and pathology laboratory archive. Recurrence was considered in cases where the tumor was detected at least 3 months or later during routine controls after initial surgery.Patient files with insufficient data or materials were excluded.

2.2- Histopathologic evaluation

The slides of the cases were retrieved from the pathology laboratory archive. All slides were reviewed under a microscope (Nikon, ECLIPSE E100, Japan) in terms of tumor stage, grade, presence of carcinoma in situ, and necrosis.Previously described criteria were used to detect TLSs in tumor tissue[18] (Fig. 1A-F), and the maximum number of TLS per 4x magnification field (Field diameter: 4,5 mm) was recorded.

The receiver operating characteristic (ROC) curve was applied to determine the critical value of the TLS number predicting recurrence or survival. A critical cut-off value predicting survival status was not found, but a value “>1” was significant for recurrence [Sensitivity: 71,9, Specificity: 58,3, p = 0,003, Area under the ROC curve (AUC): 0,660, 95% Confidence interval: 0,554 to 0,765)] (Fig. 2).

Additionally, TLS was divided into 4 groups: “0, 1–2, 3–4,and ≥ 5.” With the log-rank test, no relationship was found between these groups and recurrence-free survival (RFS) (p = 0.182) or overall survival(OS) (p = 0.181), but it was observed that the 0 with 1–2, and the 3–4 with ≥ 5 curves tended to cruise together in the RFS graph (Fig. 3A).Thus, to demonstrate the importance of the presence of TLS in BC tissues and the cut-off values described above, grouping and statistical analysis of cases were performed using threshold values of “≥1”, “≥2” and “≥3”.

In addition, the critical values of patient age and tumor diameter on survival status were found to be “>67”[Sensitivity: 73,5, Specificity: 68,3, p < 0,001, Area under the ROC curve (AUC): 0,738, 95% Confidence interval: 0,631 to 0,845)] and “>3,5” [Sensitivity: 62,5, Specificity: 70,5, p = 0,002, Area under the ROC curve (AUC): 0,674, 95% Confidence interval: 0,565 to 0,783)], respectively.

Normality tests were applied to determine the distribution pattern of numerical data and expressed as median (minimum-maximum) or mean (± SD). Statistical analyses of the relationship between recurrence or RFS and TLS were performed on the NMIBC cohort, and the relationship with survival status or OS was performed on the whole cohort. To investigate the difference between the two groups, the t-test or the Man Whitney U test, as appropriate, was used. Chi-square (Pearson, Continuity correction, or Fisher exact test) tests were applied to analyze categorical variables. Kaplan Meier graphs were used in survival analysis, and the p-value was calculated using the log-rank test.The Cox proportional hazard model was used to determine the specific effects of factors on survival.

Medcalc statistical software (Version 22.014) was used to obtain the ROC curve. IBM SPSS base system (SPSS, Version 25.0, USA) was used for statistical analysis. A two-tailed p-value < 0,05 was considered statistically significant.

A total of 135 patients, 22 (16,3%) female and 113 (83,7%) male, aged varying from 22 to 107 (mean: 65,1 ± 12,7), were enrolled in the study.The majority of cases (n = 120, 88,9%) were high-grade. Tumor diameters varied from 0,5 to 10 (median: 3) cm and the most common locations were the lateral walls, base, ureteral orifices, and posterior wall, respectively.

At the last follow-up, 37 (27,4%) cases had recurrence (median RFS time: 15 months) at least once and 34 (25.2%) of them were exitus (median OS time: 27 months). Intravesical treatment (BCG, Epirubicin, Mitomycin C) was applied to 61 (45,2%) patients, and 4cases received systemic chemotherapy. BCG was applied to a total of 50 cases, 42 of them were after the initial surgery and 8 of them were in cases where recurrence was detected during follow-up. The characteristics of the cases are summarized in Table 1.

Table 1

The characteristics of the patients
Characteristics		n	%
Age (year)	22–107 (mean: 65,1 ± 12,7)
Gender	Female	22	16,3
Gender	Male	113	83,7
Grade	Low	15	11,1
Grade	High	120	88,9
Size (cm), median: 3 (0,5–10)	> 3,5	48	35,6
	≤ 3,5	79	58,5
	NK	8	5,9
Multiplicity	Unifocal	73	54,1
	Multifocal	57	42,2
	NK	5	3,7
Number of tumor focuses	Single	73	54,1
	2–3	37	27,4
	≥ 4	20	14,8
	NK	5	3,7
Primary site	Lateral wall	68	50,4
	Base	17	12,6
	Ureteric orifice	15	11,1
	Posterior	12	8,9
	Dome	8	5,9
	Bladder neck	6	4,4
	Anterior wall	1	0,7
	Diffuse	2	1,5
	NK	6	4,4
Stage	pTa	76	56,3
	pT1	49	36,3
	pT2	10	7,4
In situ	Present	50	37,0
In situ	Absent	85	63,0
Necrosis	Present	19	14,1
Necrosis	Absent	116	85,9
TLS	0	32	23,7
	1–2	35	25,9
	3–4	27	20,0
	≥ 5	41	30,4
Local treatment	Present	61	45,2
	BCG	50	37,1
	Epirubicin	10	7,4
	Mitomycin C	1	0,7
	Absent	71	52,6
	NK	3	2,2
Recurrens	Present	37	27,4
Recurrens	Absent	98	72,6
Survival	Alive	101	74,8
Survival	Exitus	34	25,2
Total		135	100.0
TLS: Tertiary lymphoid structure, RFS: Recurrence-free survival, OS: Overall survival

Table 2

The relationship of TLS thresholds and clinicopathological characteristics.
			TLS
Characteristics		n (%)	< 1	≥ 1	p	< 2	≥ 2	p	< 3	≥ 3	p
n (%)		135 (100,0)	32 (23,7)	103 (76,3)		46 (34,1)	89 (65,9)		67 (49,6)	68 (50,4)
Age (year)	(mean: 65,1 ± 12,7)		63,8 ± 12,3	65,5 ± 12,8	0,506	62,3 ± 12,6	66,6 ± 12,5	0,042	63,3 ± 13,3	66,9 ± 11,9	0,106
	> 67	57 (42,2)	13 (22,8)	44 (77,2)	0,996	16 (28,1)	41 (71,9)	0,283	26 (45,6)	31 (54,4)	0,425
	≤ 67	78 (57,8)	19 (24,4)	59 (75,6	0,996	30 (38,5)	48 (61,5)	0,283	41 (52,6)	37 (47,4)	0,425
Gender	Female	22 (16,3)	6 (27,3)	16 (72,7)	0,876	8 (36,4)	14 (63,6)	0,999	11 (50,0)	11 (50,0)	1,000
Gender	Male	113 (83,7)	26 (23,0)	87 (77,0)	0,876	38 (33,6)	75 (66,4)	0,999	56 (49,6)	57 (50,4)	1,000
Grade	Low	15 (11,1)	8 (53,3)	7 (46,7)	0,008	9 (60,0)	6 (40,0)	0,050	11 (73,3)	4 (26,7)	0,094
Grade	High	120 (88,9)	24 (20,0)	96 (80,0)	0,008	37 (30,8)	83 (69,2)	0,050	56 (46,7)	64 (53,3)	0,094
Size (cm)	> 3,5	48 (37,8)	7 (14,6)	41 (85,4)	0,098	10 (20,8)	38 (79,2)	0,026	18 (37,5)	30 (62,5)	0,037
	≤ 3,5	79 (62,2)	23 (29,1)	56 (70,9)		33 (41,8)	46 (58,2)		46 (58,2)	33 (41,8)
	NK	8
Multiplicity	Unifocal	73 (56,2)	22 (30,1)	51 (69,9)	0,090	32 (43,8)	41 (56,2)	0,011	44 (60,3)	29 (39,7)	0,008
	Multifocal	57 (43,8)	9 (15,8)	48 (84,2)		12 (21,1)	45 (78,9)		21 (36,8)	36 (63,2)
	NK	5
Focus number	1	73 (56,2)	22 (30,1)	51 (69,9)	0,140	32 (43,8)	41 (56,2)	0,022	44 (60,3)	29 (39,7)	0,020
	2–3	37 (28,5)	5 (13,5)	32 (86,5)		7 (18,9)	30 (81,1)		12 (32,4)	25 (67,6)
	≥ 4	20 (15,4)	4 (20,0)	16 (80,0)		5 (25,0)	15 (75,0)		9 (45,0)	11 (55,0)
	NK	5
Stage	pTa	76 (56,3)	29 (38,2)	47 (61,8)	< 0,001	39 (51,3)	37 (48,7)	< 0,001	51 (67,1)	25 (32,9)	< 0,001
	pT1	49 (36,3)	3 (6,1)	46 (93,9)		7 (14,3)	42 (85,7)		13 (26,5)	36 (73,5)
	pT2	10 (7,4)	0 (0,0)	10 (100,0)		0 (0,0)	10 (100,0)		3 (30,0)	7 (70,0)
In situ	Present	50 (37,0)	10 (20,0)	40 (80,0)	0,571	14 (28,0)	36 (72,0)	0,340	18 (36,0)	32 (64,0)	0,024
In situ	Absent	85 (63,0)	22 (25,9)	63 (74,1)	0,571	32 (37,6)	53 (62,4)	0,340	49 (57,6)	36 (42,4)	0,024
Necrosis	Present	19 (14,1)	1 (5,3)	18 (94,7)	0,044	2 (10,5)	17 (89,5)	0,038	3 (15,8)	16 (84,2)	0,003
Necrosis	Absent	116 (85,9)	31 (26,7)	85 (73,3)	0,044	44 (37,9)	72 (62,1)	0,038	64 (55,2)	52 (44,8)	0,003
Recurrens	Present	37 (27,4)	14 (37,8)	23 (62,2)	0,032	21 (56,8)	16 (43,2)	0,001	25 (67,6)	12 (32,4)	0,018
Recurrens	Absent	98 (72,6)	18 (18,4)	80 (81,6)	0,032	25 (25,5)	73 (74,5)	0,001	42 (42,9)	56 (57,1)	0,018
Survival	Alive	101 (74,8)	27 (26,7)	74 (73,3)	0,233	38 (37,6)	63 (62,4)	0,197	50 (49,5)	51 (50,5)	1,000
Survival	Exitus	34 (25,2)	5 (14,7)	29 (85,3)	0,233	8 (23,5)	26 (76,5)	0,197	17 (50,0)	17 (50,0)	1,000
TLS: Tertiary lymphoid structure

TLS was detected in 103 (76,3%) cases and its numbers varied between 1 and 19 (median: 3).TLSs were more frequently found in high-grade tumors (p = 0,008) and showed a strong association with stage progression (p < 0,001).Moreover, a significant relationship was found between high TLS and tumor diameter (TLS ≥ 2, p = 0,026), multifocality (TLS ≥ 3, p = 0,003), number of tumor foci (TLS ≥ 3, p = 0,020), presence of urothelial carcinoma in situ (TLS ≥ 3,p = 0,024), and necrosis (TLS ≥ 3,p = 0,003).In line with these findings, it was found that cases with high TLS (≥ 2) showed shorter OS (p = 0,025, Fig. 3F).

Alternatively, when analyzing the prognostic effect of TLS for each stage, patients with TLS ≥ 3 showed longer overall survival in the pTaand pT2stages. However, the results were not statistically significant (p = 0,204 and p = 0,201, respectively).

High TLS (≥ 1, ≥ 2, and ≥ 3) appeared to be associated with fewer recurrences (p = 0,032, p = 0,001, and p = 0,018, respectively), and cases with higher TLS showed longer recurrence-free survival (p = 0,089, p = 0,023, p = 0,037, respectively) (Fig. 3C, 3E, 3G). Table 2summarizesthe TLS and clinicopathological characteristics relationship for thresholds ≥ 1, ≥2, and ≥ 3.

The amount of TLS in patients who received BCG after the initial surgery (n = 42) was lower (median: 3, minimum-maximum: 0–7) in patients who had recurrence (n = 11) than in those who did not (median: 4, minimum-maximum: 0–15) (Fig. 4). However, this finding did not reach statistical significance (p = 0,267).

Multivariable analyses revealed that multifocalitywas found to be an independent risk factor predicting RFS(p = 0,023, HR = 2,302). Alternatively, TLS ≥ 3 was found to be an independent parameter associated with favoarable RFS (p = 0,019, HR = 0,401) (Table 3). Age (p < 0,001, HR: 0,153), stage (p = 0,022, HR: 0,312), tumor size (p = 0,008, HR: 0,335), presence of necrosis (p = 0,035, HR: 3,096), TLS ≥ 2 (p = 0,036, HR: 0,304) and TLS ≥ 3 (p = 0,004, HR: 3,523) were found to be independent risk factors predicting OS (Table 4).

Table 3

Factors affecting RFS by Cox regression analysis.
	Univariable					Multivariable (Backward: Wald)
	B	Sig.	Exp(B)	95,0% CI for Exp(B)		B	Sig.	Exp(B)	95,0% CI for Exp(B)
	B	Sig.	Exp(B)	Lower	Upper	B	Sig.	Exp(B)	Lower	Upper
Age (≤ 67/>67)	-0,421	0,210	0,657	0,340	1,268
In situ (+/-)	0,319	0,344	1,375	0,711	2,661
Grade (Low/High)	-0,523	0,332	0,593	0,206	1,704
Stage (pTa/pT1	0,049	0,887	1,050	0,537	2,053
Size (≤ 3,5/>3,5)	-0,285	0,451	0,752	0,359	1,576
Multiplicity (Unifocal/Multifocal)	0,486	0,160	1,625	0,826	3,199	0,834	0,023	2,302	1,120	4,731
Necrosis (+/-)	0,168	0,728	1,183	0,460	3,044
TLS (< 1/≥1)	-0,569	0,096	0,566	0,290	1,107
TLS (< 2/≥2)	-0,747	0,027	0,474	0,244	0,920
TLS (< 3/≥3)	-0,731	0,043	0,481	0,237	0,979	-0,913	0,019	0,401	0,187	0,860
TLS: Tertiary lymphoid structure, RFS: Recurrence-free survival

Table 4

Factors affecting OS by Cox regression analysis.
	Univariable					Multivariable (Backward: Wald)
	B	Sig.	Exp(B)	95,0% CI for Exp(B)		B	Sig.	Exp(B)	95,0% CI for Exp(B)
	B	Sig.	Exp(B)	Lower	Upper	B	Sig.	Exp(B)	Lower	Upper
Age (≤ 67/>67)	-1,588	< 0,001	0,204	0,095	0,438	-1,880	< 0,001	0,153	0,064	0,362
In situ (+/-)	0,148	0,675	1,160	0,580	2,317
Grade (Low/High)	-0,114	0,877	0,893	0,211	3,771	1,603	0,059	4,969	0,940	26,262
Stage (pTa/pT1-pT2	-1,285	< 0,001	0,277	0,132	0,580	-1,165	0,022	0,312	0,116	0,843
Size (≤ 3,5/>3,5)	-1,172	0,001	0,310	0,151	0,635	-1,093	0,008	0,335	0,148	0,756
Multiplicity (Unifocal/Multifocal)	-0,228	0,513	0,796	0,402	1,577
Necrosis (+/-)	-0,594	0,142	0,552	0,250	1,221	1,130	0,035	3,096	1,084	8,840
TLS (< 1/≥1)	-0,828	0,088	0,437	0,169	1,130
TLS (< 2/≥2)	-0,882	0,030	0,414	0,187	0,918	-1,190	0,036	0,304	0,100	0,928
TLS (< 3/≥3)	-0,143	0,678	0,867	0,442	1,701	1,259	0,004	3,523	1,488	8,338
TLS: Tertiary lymphoid structure, OS: Overall survival

The host immune response against tumors and its nature have been studied for a long time. Tumor-infiltrating lymphocytes (TILs) can be shown as the best-known representative one. The prognostic effect of TIL was initially demonstrated in melanomas, and despite its significant subjectivity in the assessment of the intensity and distribution, it has taken its place in pathological evaluation and reporting [19]. Similarly, one of the initial ones demonstrating the prognostic and predictive effect of TLS on tumors was conducted on melanomas[20].They were initially defined as tumor-localized ectopic lymph node-like structures identifiable in H&E sections and associated with the 12-chemokine gene expression signature.It was also proposed that cases with high levels of this signature have better patient outcomes and may be candidates for treatment with immune checkpoint molecules.In a study conducted at the approximate time as this study, a strong correlation has been detected between the 12-chemokine gene subset of the molecular profile and the presence of TLS (They defined it as ectopic lymph node-like structures) in colorectal carcinomas [14]. It was consistently associated with better patient survival, regardless of tumor stage, localization, microsatellite status, or treatment.Further studies have shown that TLS is associated with a favorable prognosis in most neoplasms including breast, pancreas, stomach, liver, lung,oral (Squamous cell carcinoma, SqCC), head and neck (SqCC), and oesophageal (SqCC) tumors regardless of the detection method[13, 16, 21].Moreover, there is also evidence that TLS has dual prognostic effects due to their spatial distribution (intratumoral/peritumoral), cellular composition, or possible effects of antitumor activity [22–26]. A recent study conducted on cholangiocarcinomas reported that intratumoral TLS is associated with a good prognosis and better efficacy of anti-PD-1 therapy, whereas a high abundance in the peritumoral localization is associated with lower immune response and poor prognosis [27]. A similar prognostic effect has been previously reported in the liver (Hepatocellular carcinoma) [24, 26] and breast tumors [25].Conversely, there is evidence that peritumoral TLS density and maturity may be useful parameters to predict long-term survival in patients and response to anti-PD-1 antibody treatment [21].

The invasive tumor margin is used to determine the TLS localization and is therefore applicable in tumor tissues removed in their entirety or materials where tissue orientation can be made[21, 23, 25].Since there are conflicting results regarding the prognostic effect of its localization and the absence of a specified assessment method in TURBT materials, we proposed and used the maximum number of TLS per 4x magnification field as practical and applicable. Since the majority of BC (approximately 80%) [4] consists of NMIBC and this rate exceeds 90% in TURBT materials [28], we think that this approach can be useful in the management of BC patients. In our cohort, consistently, NMIBC constituted the majority of cases (n = 125, 92,6%) and the distribution of TLS was mostly accumulated in the stroma of tumor papillae or bladder lamina propria (Fig. 1).

There are a few studies examining the prognostic effect of TLS on BC [10, 15, 29–31]. Koti et al. [31] in their pilot study, first demonstrated the relationship between the presence of TLS and tumor stage. They found that well-formed TLS was more common in MIBC compared to low-grade NMIBC. However, prognostic data were not available in their studies. As expected, and consistent with previous studies, higher TLS was associated with fewer recurrences and longer RFS in our work. On the other hand, we found shorter OS in cases with high TLS. We think that this situation is due to the correlation of TLS increase with poor prognostic parameters, especially an increase in grade and stage. Therefore, when applying the survival analysis separately for each stage, we observed longer OS in cases with high TLS (≥ 3) in pTa and pT2 tumors (p = 0,204).In a recent study by Ma et al. [32], they showed that TLSs were more common in MIBC than in NMIBC (67.8% vs 48.2%, p < 0,001), and the mean density of tumor-infiltrating lymphocytes was significantly higher in MIBC than in NMIBC (p < 0,001).In this study, we detected TLS more abundant in both MIBC (100,0%) and NMIBC (74,4%) cases than in their study, and similarly, there was a significant difference between both groups (p < 0,001). However, our study has some differences, such as evaluating only TURBT materials, presenting specific threshold values that predict recurrence and RFS, and having higher statistical significance in this regard.

Evidence demonstrates that the inflammatory response in the tumor microenvironment also reflects the genetic properties of BC. A multiomic data analysis on MIBC showed that high stromal TIL and TLS amounts were significantly associated with inflamed phenotype and favorable survival [8]. They also proposed that high inflammation was also associated with increased neoantigen load and mutation burden, and patients treated with adjuvant chemotherapy showed a favorable prognosis which was dependent on high sTILs. Consistent with these findings, Zhou et al. [15]found that class F, characterized by strong TLSs-related gene expression signature and associated with improved survival and a high response rate to PD-1 blockade. Blocking the PD-1/PD-L1 pathway has emerged as a new treatment method with durable response rates and effects on prolonging OS in patients with advanced-stage urothelial carcinoma [29, 30]. However, the treatment does not produce the expected effect in all patients but only occurs in a subset of them. These findings, combined with the evidence mentioned above, highlight the potential of immune subtypes and TLS signatures in deciding on treatments in BC, especially immunotherapy.

Interestingly, the scientific data to date have focused on the role of TLS in the response to immunotherapy via systemic administration. However, there is no publication on its role in the response to the local one (intravesical). In our work, although there was recurrence in a limited number of cases (n = 11) who received intravesical treatment (BCG) after initial TURBT (n = 42), the amount of TLS was higher in cases with recurrence (median: 3, min-max: 0–7) than in those without (median: 4, min-max: 0–15) (p = 0,267). Although it does not reach statistical significance, our study, in this respect, is also a pilot study that first provides preliminary data that TLS may be a predictor in the response to local immunotherapy in BC.

Herein, we demonstrated the presence and number of TLS in TURBT materials is an independent parameter in predicting recurrence and can be a candidate that is used to accurately determine patients who may benefit from BCG treatment. We recommend that our findings be confirmed with broader and more homogeneous series and it should be stated in the routine pathological assessment of TURBT materials, especially in NMIBC cases.

Funding

No funds, grants, or other support was received.

Ethical approval

This study was submitted to and approved by the MardinArtuklu University Non-Invasive Clinical Research Ethics Committee (decision date: 05.12.2023, decision number: 2023/12-16). This study was conducted in accordance with the ethical standards of the Declaration of Helsinki.

The final version of the article has been reviewed and approved by all authors.

Conflict of interest

The authors declare no conflict of interest.

All authors certify that they have no affiliations with or involvement in any organization or entity with any financial interest or non-financial interest in the subject matter or materials discussed in this manuscript.

Data availability: All data included in this study are available uponrequest by contact with the corresponding author.

Author contributions

All authors made substantial contributions to the conception and design, acquisition, analysis, and interpretation of data, took part in drafting the article or revising it critically for important intellectual content.

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The authors declare no competing interests.

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Prognostic and predictive value of tertiary lymphoid structures in TURBT materials; Should it be seated in routine pathological examination and can it be used in deciding on the treatment method?

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1- Introduction

2- Material and Method

2.1- Patient selection

2.2- Histopathologic evaluation

3- Statistical analyses

4- Results

5- Discussion

6- Conclusion

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