Spatial distribution analysis of tertiary lymphoid structures in esophageal squamous cell carcinoma predicts patient survival and response to neoadjuvant chemo-immunotherapy

The prognostic and predictive significance of tertiary lymphoid structures (TLSs) exhibits spatial specificity in various cancers. However, the spatial distribution, phenotypic characteristics of TLSs in esophageal squamous cell carcinoma (ESCC) and their impact on prognosis and prediction are not yet fully understood. We performed multiplex immunofluorescence staining and digital image analysis on 87 untreated ESCC specimens to characterized TLSs expression and phenotypic characteristics, CD8 + T cells and PNAD+ high endothelial venules (HEVs) in different spatial regions of ESCC tissues using Panel-1 (CD20/CD21/CD23/ PNAD/CD8/Pan CK/DAPI). Panel-2 (CD20/CD3/Foxp3/DC-LAMP/Pan CK/DAPI) was used to evaluate the spatial distribution of TLS-related immune cells (CD20 + B cells, CD3 + T cells, Foxp3 + Treg cells, and LAMP+ mature DCs) within the tumor microenvironment of ESCC. Furthermore, the predictive value of TLSs and the clinical prognostic significance of TLSs at different spatial locations were assessed in an independent cohort of 15 ESCC patients who received neoadjuvant chemo- immunotherapy (NACI). In untreated ESCC, a high number/density of mature follicular TLSs (F-TLSs) in the stromal distal region (> 500 μm from the outer boundary of the tumour nests) was significantly associated with better overall survival (OS) in patients (number: p = 0.0092; density: p = 0.0268). Patients with distal high F-TLSs not only exhibited high densities of CD3 + T cells, CD8 + T cells, CD20 + B cells, LAMP + DCs, and PNAD+HEVs in the stromal regions, but this was also associated with increased CD8 + T cell infiltration within the tumour nests (p < 0.05). Additionally, it was correlated with a lower levels of Foxp3 + Treg cells in the stromal distal and tumour nests regions. In the NACI cohort, the total amount of TLSs significantly increased after treatment. The partial response (PR) group exhibited higher numbers and densities of F-TLSs post-treatment than the non-PR group (p < 0.05). High numbers/densities of total TLSs, early-TLSs, and F-TLSs in the stromal proximal region (≤ 500 μm from the outer boundary of the tumour nests) of post-treatment specimens were significantly associated with better OS (p < 0.05). Our research establishes that the prognostic value of TLSs is contingent upon their spatial location and maturation status. In untreated ESCC, distal mature F-TLSs is critical prognostic indicator; however, after NACI, TLSs quantity and spatial distribution were reshaped. Mature F-TLSs predicted treatment response, while treatment-induced expansion of TLSs localised at the proximal tumour-stroma interface is a key indicator for predicting favourable long-term survival.