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From the immune contexture to the Immunoscore: the role of

prognostic and predictive immune markers in cancer
Helen Angell1,2,3 and Jerome Galon1,2,3
The inherent complexity of multifactorial diseases such as
cancer renders the process of patient prognosis and prediction
of response to therapy extremely difficult. Many markers,
signatures, and methods have been described to evaluate the
prognosis of cancer patients, yet very few translate into the
clinic. Systems biology approaches have facilitated analysis of
the complex interaction between tumors and the host-immune
response, and allowed the definition of the immune contexture.
Here we review the potential of the immune contexture,
quantified by the Immunoscore, to provide a statistically strong
parameter for prognosis. Finally we introduce the concept that
the host-immune reaction could be the critical element in
determining response to therapy. The effect on the immune
response could be the underlying factor behind many of the
predictive makers.
INSERM, U872, Laboratory of Integrative Cancer Immunology, Paris,
Universite Paris Descartes, Paris, France
Centre de Recherche des Cordeliers, Universite Pierre et Marie Curie
Paris 6, Paris, France
Corresponding author: Galon, Jerome (

Current Opinion in Immunology 2013, 25:xxyy

This review comes from a themed issue on Cancer immunotherapy:
clinical translation
Edited by Tom Gajewski and Ton Schumacher

0952-7915/$ see front matter, Published by Elsevier Ltd.

The evolution of cancer is greatly influenced by the
complex milieu and microenvironment in which it develops, harboring tumorcell interactions with host endothelial cells, fibroblasts, blood vessels, lymph vessels,
immune cells, cytokines, chemokines and products of
cellular metabolism. The inherent complexity of such a
multifactorial disease renders the process of patient prognosis and prediction of response to therapy extremely
difficult. A good prognostic marker is a biomarker that
provides information on the likely course of the disease in
an untreated individual or regardless of treatment. However, a predictive biomarker can be used to identify
subpopulations of patients who are most likely to respond
to therapy.

Definition of immune contexture

Histological analysis of human tumors, in particular colorectal tumors (CRC), has highlighted the importance of
the combination of immune variables. Tumor immune
infiltrates include macrophages, dendritic cells (DC),
mast cells, natural killer (NK) cells, nave and memory
lymphocytes, B cells and effector T cells. Analysis of
these in situ immune components and their organization
has revealed large heterogeneity between tumor types
and also a broad patient-to-patient diversity. The role of
the immune system in controlling tumor progression and
its effect on tumor escape, and thus patient prognosis, is
becoming increasingly understood. We have previously
described these major immune parameters, associated
with survival, as the immune contexture [1]. The
immune contexture is defined as the type, functional
orientation, density and location of adaptive immune
cells within distinct tumor regions [1,2,3,4]. As summarized in Figure 1a, the parameters that establish the
immune contexture comprise the density of CD8+ cytotoxic T lymphocytes (CTL) and memory T cells
(CD45RO+), their location at the tumor center (CT)
and invasive margin (IM), combined with the quality
of tertiary lymphoid structures (TLS) and additional
functionality entities such as TH1-related factors (IFNG,
Tbet, IRF1, IL12), chemokines (CX3CL1, CXCL9,
CXCL10, CCL5, CCL2), adhesion molecules (MADCAM1, ICAM1, VCAM1) and cytotoxic factors (granzymes, perforin, granulysin).

Immune markers as prognostic markers

Traditionally, the anatomic extent of the tumor burden in
CRC and all solid tumors has been the most important
prognostic factor (Figure 1b). Data on the tumor burden
(T), combined with the presence of cancer cells in draining and regional lymph nodes (N) and evidence of
metastases (M), amalgamate to provide tumor staging
(AJCC/UICC-TNM classification). TNM stages estimate
patient postoperative outcome and the rationale for adjuvant therapy. Despite the prognostic power of this staging
system, it is becoming recognized within the cancer
community that clinical outcome can significantly vary
among patients within the same stage. The current classification provides limited prognostic information, and does
not predict response to therapy. Advances in this field
have alluded to the importance of the immune prevalence
within the tumor microenvironment. A strong lymphocyte infiltration has been reported to be associated with an
antitumor response and improved clinical outcome. This
correlation between the prevalence of tumor infiltrating
Current Opinion in Immunology 2013, 25:17

Please cite this article in press as: Angell H, Galon J. From the immune contexture to the Immunoscore: the role of prognostic and predictive immune markers in cancer, Curr Opin Immunol


2 Cancer immunotherapy: clinical translation

Figure 1








I1, I2, I3










Tumour Stage:



Tumour centre


Invasive margin



Key Parameters
CTLs (CD3+CD8+)
Memory T cells
Tumour centre (CT)
Invasive margin (IM)
Presence and quality of TLS
Th1 cell-associated factors
Cytotoxic factors
Chemokines, cytokines
Adhesion molecules

Characteristic : complex

Immune Reaction



Key Parameters


Key Parameters

Tumour (T)

Longitudinal extent of tumour burden


CTLs (CD3+CD8+)
Memory T cells (CD45RO+)

Lymph node

Presence of cancer cells in draining

and regional lymph nodes


Tumour centre (CT)

Invasive margin (IM)


Evidence of distant site metastases


Predefined cut points

Cox analysis
(ref. 23)


Cox analysis
(ref. 23)




1.38/0.09 ns 1.18/0.29 ns 1.43/0.10 ns

Characteristic : current standard classification



0.64/<0.0001 0.71/<0.0001 0.63/<0.0001

Characteristic : powerful, simple
Current Opinion in Immunology

Schematic representation and accompanying key parameters distinguishing the (a) immune contexture, including the tumor center, invasive margin
and tertiary lymphoid structures (TLS); (b) the TNM classification system, highlighting the current staging strategy and (c) the Immunoscore, illustrating
the importance of the immune reaction regardless of tumor burden. CT, tumor center; CTL, cytotoxic T lymphocyte; DSF, disease free survival; DSS,
disease specific survival; IM, invasive margin; OS, overall survival.

immune cells and patient outcome has been well documented in melanoma [58], ovarian [9,10,11], head and
neck [1214], bladder [15,16], breast [1720], urothelial
[16], colorectal [2,21,22,23,2440], renal [41], prostatic
[4244] and lung cancer [4549]. The majority of studies
have demonstrated that high densities of CD3+ T cells,
CD8+ cytotoxic T cells and CD45RO+ memory T cells
are associated with a longer disease free survival (DFS)
and/or improved overall survival (OS) [3].

Immunoscore as prognostic marker

Accumulating data, collected from large cohorts of
human cancers, have demonstrated the impact of
immune-classification, which has a prognostic value
that may add to the significance of the AJCC/UICC
TNM-classification. Derived from the immune contexture, a simple and powerful immune-classification has
been termed the Immunoscore (Figure 1c). The
Immunoscore (I) is based on the numeration of two
lymphocyte populations (CD3/CD45RO, or CD3/CD8
or CD8/CD45RO) quantified within the CT and IM.
These parameters provide a scoring system ranging
Current Opinion in Immunology 2013, 25:17

from Immunoscore 0 (I0), which has low densities of

both cell types in both regions; to Immunoscore 4 (I4),
having high densities of both cell populations in both
regions. The prognostic value of using these immune
criteria was demonstrated in patients with early stage
CRC (AJCC/UICC TNM stage III CRC) to predict
survival and relapse [27]. The five Immunoscore groups
were associated with dramatic differences in DFS and
OS (P < 0.0001). Five years after diagnosis, only 4.8%
of patients with high densities of CD8 and CD45RO
cells had tumor recurrence, and 86.2% survived. In
contrast, the tumor recurred in 75% of patients with
low densities of these cell populations and only 27.5%
survived [27].
Combined evidence illustrates the dependency of the
current staging stratification on factors of the immune
response. In particular, the nature, functional orientation,
density, and location of adaptive immune cells within
distinct tumor regions have been illustrated to have a
prognostic value that may be superior to the TNMclassification. Cox multivariate analysis shows that tumor

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Prognostic and predictive immune markers in cancer Angell and Galon 3

progression and invasion is statistically dependent on the

Immunoscore. Indeed, the immune pattern remained the
only significant criterion over the classical AJCC/UICC
TNM classification for DFS and OS [50]. In patients who
did not relapse, the density of CD8 infiltrates was inversely
correlated with T stage, whereas in patients with recurrence the number of CD8 cells was low, regardless of the T
stage of the tumor [23]. Thus, evidence supports the notion
to introduce immunological biomarkers, implemented as a
tool for the prediction of prognosis and response to therapy.
Incorporating the Immunoscore into traditional classification could result in a greatly improved prognostic and
potentially predictive tool [51,52]. Immunophenotyping
as part of routine diagnostic and prognostic assessment of
tumors may provide crucial novel prognostic information,
facilitate clinical decision-making including rational stratification of patient treatment and guide therapeutic strategies [53,54].

Additional prognostic markers

Prognostic markers are clinical measures used to estimate
an individual patients outcome, such as recurrence of
disease, and correlate with survival independently of
systemic therapy. These prognostic factors range from
simple measures such as the stage of disease or tumor
burden, to more complex markers, including genetic
mutations. Many of the important prognostic markers
have been established for numerous diseases, however,
the translation of new markers into the clinic is becoming
increasingly difficult. Established markers include the
amplification of the MYCN proto-oncogene as an
indicator of poor outcome in neuroblastoma [55]. The
number of lymph nodes has a strong influence on the
prognosis of recurrence-free survival in breast cancer
[56,57]. In addition, the mutational status of K-ras is also
used as a prognostic marker, for example in non small cell
lung cancer (NSCLC) [58].
The development of high throughput cDNA microarray
and tumor array technologies has led to the investigation of global gene and protein expression profiles,
which has begun to revolutionize the search for predictive and prognostic markers. The detection of subtle
changes in the genetic composition of different tumor
stages offers the possibility of defining more precise
clinical outcomes. Example predictors include the 70gene signature [59] and intrinsic-subtype classifiers
[60] in breast cancer, among many others in additional
disease settings [6164]. Unfortunately accuracies of
these predictors are still lower than 80% and thus it
remains difficult to identify a highly precise prognostic
biomarker for use across multiple patient cohorts. Studies have also attempted to find gene predictor lists in
ovarian cancer. Nine gene signatures were reported
with almost no common genes between each signature
(similarly to other cancer types) and none of these have
been implemented into the clinic.

Genomics-based technologies have resulted in significant

advances in cancer diagnostics and prognostics, wherein
genomic instability, caused during dysregulated proliferation, is becoming increasingly investigated for its role in
diagnostics. A mutation in the adenomatous polyposis coli
(APC) gene occurs in approximately 60% of CRC
patients, as well as many others and is being used as a
biomarker to determine the stage, disease recurrence and
to monitor disease progression or response to therapy in
esophageal cancer [65]. An increase in the level of hypermethylated APC in the blood is associated with poor
The success and global utilization of a prognostic marker
requires key features in its implementation, including
feasible in routine settings, simple, inexpensive, rapid,
robust, reproducible, quantitative, standardized, and
powerful. The Immunosore appears to fulfill these
requirements [52]. Many markers, signatures, and
methods have been described to evaluate the prognosis
of cancer patients. Yet very few such markers and laboratory assays translate into clinical practice or reach the
statistical power of the Immunoscore. It is acknowledged
that additional markers may be used to further refine the
prognostic value of the Immunoscore.

Predictive markers
Prognostic markers are useful to assess the risk of an
individual patient, however, they do not provide information on whether a therapeutic regime will be
beneficial. Thus, we require additional biomarkers to
aid in treatment selection. For example, HER-2 overexpression has been associated with improved response to
trastuzumab (monoclonal antibody against HER-2) in
breast cancer [66,67].
Numerous different therapeutic regimes are currently
used to treat cancer, including cytotoxic therapies such
as chemotherapy and radiotherapy. Antibody therapies
include cancer centric approaches (tyrosine kinase inhibitor), tumor microenvironment directed strategies (antiVEGF antibodies [68]) or immune focused intervention
such as anti-PD1 [69,70] and the anti-CTLA4 antibody
ipilimumab [71,72,73]. In addition, the implementation
of small molecule inhibitors is increasing, for example
BRAF inhibitors [74]. Immunotherapeutic approaches
include Toll-like receptor (TLR) agonists, DC based
vaccines, peptide vaccines and adoptive T cell therapy
(ACT) [75]. It is becoming apparent that the majority of
the aforementioned therapies have an impact on the
immune system [3] (Figure 2a).
The efficacy of an anticancer therapy is primarily evaluated by its ability to inhibit the proliferation of tumor
cells. Whether or not the tumor immune contexture
predicts therapeutic response is of paramount importance
in patient clinical management [3]. One of the hurdles
Current Opinion in Immunology 2013, 25:17

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4 Cancer immunotherapy: clinical translation

Figure 2

(a) Cancer Treatment

(b) Biomarkers

Impact on immune response











Abs Chemo Radio Small


Current Opinion in Immunology

(a) Schematic illustrating the impact of cancer treatments on the host immune response. (b) Diagrammatic representation depicting the potential
difference in overlap between immune and non-immune prognostic and predictive markers. ACT, adoptive cell transfer; TLR, toll-like receptor; ag,
agonist; Vac, vaccines; Abs, antibodies; Chemo, chemotherapy; Radio, radiotherapy; Small mol, small molecules.

related to the development of novel cancer immunotherapies is the absence of immune response biomarkers to
indicate the efficacy and kinetics of the antitumor
response. Current studies begin to highlight the interaction between tumor cell death, triggered by chemotherand
immunoadjuvant pathway that may contribute to the
success of the treatment. The prevalence of immune
infiltrates appears to predict clinical response to some
immunotherapies, including response to cancer vaccines
[76]. Breast cancer patients with a loss-of-function
mutation in TLR4 relapsed earlier after receiving anthracycline-based chemotherapy [77]. The survival benefit of
5-fluorouracil-based chemotherapy in CRC patients was
greatly improved with the presence of tumor infiltrating
lymphocytes (TILs, P = 0.02). Patients with increased
levels of perforation of the serosa wall also had improved
survival (P = 0.16) [78]. Since the presence of TILs
reflects an adaptive immune response and perforation
is associated with inflammatory response, results suggest
a potential interaction between the immune response and
To demonstrate the predictive value of a biomarker, one
needs a randomized trial in which a control arm of
untreated patients should be evaluated; otherwise, a
so-called predictive marker is likely to be prognostic as

An immune predictive marker is likely to be a

prognostic marker
A limitation in the accuracy of many predictive markers is
the assumption that tumor progression is largely a cellautonomous process with a cancer cell centric focus.
Current Opinion in Immunology 2013, 25:17

However, the presence of immune cells may reflect a

distinct underlying biology of the tumor, since gene
expression profiling and confirmatory assays have
revealed the presence of a broad signature of inflammation [79]. This signature includes evidence for innate
immune activation, chemokines for T cell recruitment,
immune effector molecules, and expression of immune
regulatory factors. Of the aforementioned therapeutic
strategies, the related predictive markers could in fact
be a reflection of a pre-existing immune contexture and of
the immune response to the therapy. Are predictive
markers biased depending on their influence on the
immune contexture? Does the patients original immune
status skew survival outcome, regardless of therapy?
Because of this, with a few exceptions, it is our opinion
that a predictive marker is likely to also be a prognostic
marker (Figure 2b). Since tumor molecular features and
immune reactions are inter-related, a comprehensive
assessment of these factors is critical [80]. Examining
the effects of tumorhost interactions on clinical outcome
and prognosis clearly represents an evolving interdisciplinary field. Pathological immunity evaluation may provide novel information on prognosis and help identify
patient cohorts more likely to benefit from immunotherapy.

Systems biology and large-scale analysis are powerful
approaches to uncover mechanisms associated with tumor
progression and tumor recurrence. Integrative analyses
evaluating the immune infiltrate in human cancers are of
major importance. We have previously described these
major immune parameters, associated with survival, as the
immune contexture. The immune contexture is defined

Please cite this article in press as: Angell H, Galon J. From the immune contexture to the Immunoscore: the role of prognostic and predictive immune markers in cancer, Curr Opin Immunol


Prognostic and predictive immune markers in cancer Angell and Galon 5

as the type, functional orientation, density and location of

adaptive immune cells within distinct tumor regions.
Compared to the immune contexture, no tumor
parameter associated with survival has been reported to
achieve the same level of significance in CRC. For routine
testing, a simple method has been proposed and defined
as the Immunoscore. The outcome of a current worldwide
task force to validate the Immunoscore in a multicenter
trial may result in its implementation as a new component
for the classification of cancer, designated TNM-I
(TNM-Immune). Furthermore, the immune contexture
and the Immunoscore may allow the prediction of
response to many immune-related therapies. Finally, it
is expected that defects in the immune contexture will
provide new therapeutic strategies to treat cancer.

We acknowledge all the scientists who made contributions to the area of
research reviewed here that were not cited due to space constraints. We
thank the members of the Laboratory of Integrative Cancer Immunology
for their invaluable contribution. The work performed in our laboratory was
supported by grants from the Institut National du Cancer (INCa), the
Canceropole Ile de France, INSERM, MedImmune, Qatar National
Research Fund under its National Priorities Research Program award
number NPRP09-1174-3-291, the European Commission (7FP, Geninca
Consortium, grant 202230), and the LabEx Immuno-oncology.

References and recommended reading

Papers of particular interest, published within the period of review,
have been highlighted as:
 of special interest
 of outstanding interest

Galon J, Fridman WH, Pages F: The adaptive immunologic

microenvironment in colorectal cancer: a novel perspective.
Cancer Res 2007, 67:1883-1886.
The first comprehensive review that described the immune contexture.


Galon J, Costes A, Sanchez-Cabo F, Kirilovsky A, Mlecnik B,

Lagorce-Pages C, Tosolini M, Camus M, Berger A, Wind P et al.:
Type, density, and location of immune cells within human
colorectal tumors predict clinical outcome. Science 2006,
The landmark study that shows that the type, the density and location of
adaptive immune cell infiltrates within tumors are better predictor of
patient survival than current histopathological staging of colorectal cancers.


Fridman WH, Pages F, Sautes-Fridman C, Galon J: The immune

contexture in human tumours: impact on clinical outcome. Nat
Rev Cancer 2012, 12:298-306.
Updated review that describes the immune contexture.


Mlecnik B, Tosolini M, Charoentong P, Kirilovsky A, Bindea G,

Berger A, Camus M, Gillard M, Bruneval P, Fridman WH et al.:
Biomolecular network reconstruction identifies T-cell homing
factors associated with survival in colorectal cancer.
Gastroenterology 2010, 138:1429-1440.
This paper describes systems biology approaches to analyze the complex interaction between tumors and host-immune response in human.
Using bioinformatics, hypotheses related to mechanisms of lymphocyte
chemo-attraction we formulated and validated experimentally.


Mackensen A, Ferradini L, Carcelain G, Triebel F, Faure F, Viel S,

Hercend T: Evidence for in situ amplification of cytotoxic Tlymphocytes with antitumor activity in a human regressive
melanoma. Cancer Res 1993, 53:3569-3573.


Clark WH Jr, Elder DE, Guerry Dt, Braitman LE, Trock BJ,
Schultz D, Synnestvedt M, Halpern AC: Model predicting survival
in stage I melanoma based on tumor progression. J Natl
Cancer Inst 1989, 81:1893-1904.


Sato E, Olson SH, Ahn J, Bundy B, Nishikawa H, Qian F,

Jungbluth AA, Frosina D, Gnjatic S, Ambrosone C et al.:
Intraepithelial CD8+ tumor-infiltrating lymphocytes and a high
CD8+/regulatory T cell ratio are associated with favorable
prognosis in ovarian cancer. Proc Natl Acad Sci U S A 2005,

10. Hamanishi J, Mandai M, Iwasaki M, Okazaki T, Tanaka Y,

Yamaguchi K, Higuchi T, Yagi H, Takakura K, Minato N et al.:
Programmed cell death 1 ligand 1 and tumor-infiltrating CD8+
T lymphocytes are prognostic factors of human ovarian
cancer. Proc Natl Acad Sci U S A 2007, 104:3360-3365.
11. Zhang L, Conejo-Garcia JR, Katsaros D, Gimotty PA,
Massobrio M, Regnani G, Makrigiannakis A, Gray H, Schlienger K,

Liebman MN et al.: Intratumoral T cells, recurrence, and
survival in epithelial ovarian cancer. N Engl J Med 2003,
This study conclusively shows the prognostic value of intratumoral T cells
in ovarian cancer.
12. Badoual C, Hans S, Rodriguez J, Peyrard S, Klein C, Agueznay
Nel H, Mosseri V, Laccourreye O, Bruneval P, Fridman WH et al.:
Prognostic value of tumor-infiltrating CD4+ T-cell
subpopulations in head and neck cancers. Clin Cancer Res
2006, 12:465-472.
13. Reichert TE, Scheuer C, Day R, Wagner W, Whiteside TL:
The number of intratumoral dendritic cells and zeta-chain
expression in T cells as prognostic and survival
biomarkers in patients with oral carcinoma. Cancer 2001,
14. Shibuya TY, Nugyen N, McLaren CE, Li KT, Wei WZ, Kim S,
Yoo GH, Rogowski A, Ensley J, Sakr W: Clinical significance of
poor CD3 response in head and neck cancer. Clin Cancer Res
2002, 8:745-751.
15. Nakakubo Y, Miyamoto M, Cho Y, Hida Y, Oshikiri T, Suzuoki M,
Hiraoka K, Itoh T, Kondo S, Katoh H: Clinical significance of
immune cell infiltration within gallbladder cancer. Br J Cancer
2003, 89:1736-1742.
16. Sharma P, Shen Y, Wen S, Yamada S, Jungbluth AA, Gnjatic S,
Bajorin DF, Reuter VE, Herr H, Old LJ et al.: CD8 tumor-infiltrating
lymphocytes are predictive of survival in muscle-invasive
urothelial carcinoma. Proc Natl Acad Sci U S A 2007,
17. Alexe G, Dalgin GS, Scanfeld D, Tamayo P, Mesirov JP, DeLisi C,
Harris L, Barnard N, Martel M, Levine AJ et al.: High expression of
lymphocyte-associated genes in node-negative HER2+ breast
cancers correlates with lower recurrence rates. Cancer Res
2007, 67:10669-10676.
18. Mahmoud SM, Paish EC, Powe DG, Macmillan RD, Grainge MJ,
Lee AH, Ellis IO, Green AR: Tumor-infiltrating CD8+
lymphocytes predict clinical outcome in breast cancer. J Clin
Oncol 2011, 29:1949-1955.
19. Marrogi AJ, Munshi A, Merogi AJ, Ohadike Y, El-Habashi A,
Marrogi OL, Freeman SM: Study of tumor infiltrating
lymphocytes and transforming growth factor-beta as
prognostic factors in breast carcinoma. Int J Cancer 1997,


Clemente CG, Mihm MC Jr, Bufalino R, Zurrida S, Collini P,

Cascinelli N: Prognostic value of tumor infiltrating lymphocytes
in the vertical growth phase of primary cutaneous melanoma.
Cancer 1996, 77:1303-1310.

20. Menegaz RA, Michelin MA, Etchebehere RM, Fernandes PC,

Murta EF: Peri- and intratumoral T and B lymphocytic
infiltration in breast cancer. Eur J Gynaecol Oncol 2008,


Tefany FJ, Barnetson RS, Halliday GM, McCarthy SW,

McCarthy WH: Immunocytochemical analysis of the cellular
infiltrate in primary regressing and non-regressing malignant
melanoma. J Invest Dermatol 1991, 97:197-202.

21. Naito Y, Saito K, Shiiba K, Ohuchi A, Saigenji K, Nagura H,

Ohtani H: CD8+ T cells infiltrated within cancer cell nests as a
prognostic factor in human colorectal cancer. Cancer Res
1998, 58:3491-3494.

Current Opinion in Immunology 2013, 25:17

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6 Cancer immunotherapy: clinical translation

22. Pages F, Berger A, Camus M, Sanchez-Cabo F, Costes A,

Molidor R, Mlecnik B, Kirilovsky A, Nilsson M, Damotte D et al.:
Effector memory T cells, early metastasis, and survival in
colorectal cancer. N Engl J Med 2005, 353:2654-2666.
This study shows the relationship between intratumoral memory T cells
and the absence of tumor emboli in colorectal cancers.
23. Mlecnik B, Tosolini M, Kirilovsky A, Berger A, Bindea G, Meatchi T,
 Bruneval P, Trajanoski Z, Fridman WH, Pages F et al.:
Histopathologic-based prognostic factors of colorectal
cancers are associated with the state of the local immune
reaction. J Clin Oncol 2011, 29:610-618.
This article describes and explains the dependency of tumor extension
and invasion on the immunoscore. See also editorial TNM-staging in
CRC, T is for T cells and M is for Memory (Ref. [50]).
24. Sinicrope FA, Rego RL, Ansell SM, Knutson KL, Foster NR,
Sargent DJ: Intraepithelial effector (CD3+)/regulatory (FoxP3+)
T-cell ratio predicts a clinical outcome of human colon
carcinoma. Gastroenterology 2009, 137:1270-1279.
25. Salama P, Phillips M, Grieu F, Morris M, Zeps N, Joseph D,
Platell C, Iacopetta B: Tumor-infiltrating FOXP3+ T regulatory
cells show strong prognostic significance in colorectal
cancer. J Clin Oncol 2009, 27:186-192.
26. Tosolini M, Kirilovsky A, Mlecnik B, Fredriksen T, Mauger S,
Bindea G, Berger A, Bruneval P, Fridman WH, Pages F et al.:
Clinical impact of different classes of infiltrating T cytotoxic
and helper cells (Th1, th2, treg, th17) in patients with colorectal
cancer. Cancer Res 2011, 71:1263-1271.
27. Pages F, Kirilovsky A, Mlecnik B, Asslaber M, Tosolini M, Bindea G,
Lagorce C, Wind P, Marliot F, Bruneval P et al.: In situ cytotoxic
and memory T cells predict outcome in patients with earlystage colorectal cancer. J Clin Oncol 2009, 27:5944-5951.
28. Camus M, Tosolini M, Mlecnik B, Pages F, Kirilovsky A, Berger A,
Costes A, Bindea G, Charoentong P, Bruneval P et al.:
Coordination of intratumoral immune reaction and human
colorectal cancer recurrence. Cancer Res 2009, 69:2685-2693.
29. Baker K, Zlobec I, Tornillo L, Terracciano L, Jass JR, Lugli A:
Differential significance of tumour infiltrating lymphocytes in
sporadic mismatch repair deficient versus proficient
colorectal cancers: a potential role for dysregulation of the
transforming growth factor-beta pathway. Eur J Cancer 2007,
30. Dalerba P, Maccalli C, Casati C, Castelli C, Parmiani G:
Immunology and immunotherapy of colorectal cancer. Crit Rev
Oncol Hematol 2003, 46:33-57.
31. Diederichsen AC, Hjelmborg JB, Christensen PB, Zeuthen J,
Fenger C: Prognostic value of the CD4+/CD8+ ratio of tumour
infiltrating lymphocytes in colorectal cancer and HLA-DR
expression on tumour cells. Cancer Immunol Immunother 2003,
32. Halama N, Michel S, Kloor M, Zoernig I, Pommerencke T, von
Knebel Doeberitz M, Schirmacher P, Weitz J, Grabe N, Jager D:
The localization and density of immune cells in primary
tumors of human metastatic colorectal cancer shows an
association with response to chemotherapy. Cancer Immun
2009, 9:1.
33. Harrison JC, Dean PJ, el-Zeky F, Vander Zwaag R: From Dukes
through Jass: pathological prognostic indicators in rectal
cancer. Hum Pathol 1994, 25:498-505.
34. Lee WS, Park S, Lee WY, Yun SH, Chun HK: Clinical impact of
tumor-infiltrating lymphocytes for survival in stage II colon
cancer. Cancer 2010, 116:5188-5199.
35. Lugli A, Karamitopoulou E, Panayiotides I, Karakitsos P, Rallis G,
Peros G, Iezzi G, Spagnoli G, Bihl M, Terracciano L et al.: CD8+
lymphocytes/tumour-budding index: an independent
prognostic factor representing a pro-/anti-tumour approach
to tumour host interaction in colorectal cancer. Br J Cancer
2009, 101:1382-1392.
36. Menon AG, Janssen-van Rhijn CM, Morreau H, Putter H,
Tollenaar RA, van de Velde CJ, Fleuren GJ, Kuppen PJ: Immune
system and prognosis in colorectal cancer: a detailed
immunohistochemical analysis. Lab Invest 2004, 84:493-501.
Current Opinion in Immunology 2013, 25:17

37. Nosho K, Baba Y, Tanaka N, Shima K, Hayashi M, Meyerhardt JA,

Giovannucci E, Dranoff G, Fuchs CS, Ogino S: Tumourinfiltrating T-cell subsets, molecular changes in colorectal
cancer, and prognosis: cohort study and literature review. J
Pathol 2010, 222:350-366.
38. Prall F, Duhrkop T, Weirich V, Ostwald C, Lenz P, Nizze H,
Barten M: Prognostic role of CD8+ tumor-infiltrating
lymphocytes in stage III colorectal cancer with and without
microsatellite instability. Hum Pathol 2004, 35:808-816.
39. Dahlin AM, Henriksson ML, Van Guelpen B, Stenling R, Oberg A,
Rutegard J, Palmqvist R: Colorectal cancer prognosis depends
on T-cell infiltration and molecular characteristics of the
tumor. Mod Pathol 2011, 24:671-682.
40. Nagtegaal ID, Marijnen CA, Kranenbarg EK, Mulder-Stapel A,
Hermans J, van de Velde CJ, van Krieken JH: Local and distant
recurrences in rectal cancer patients are predicted by the
nonspecific immune response; specific immune response has
only a systemic effect a histopathological and
immunohistochemical study. BMC Cancer 2001, 1:7.
41. Nakano O, Sato M, Naito Y, Suzuki K, Orikasa S, Aizawa M,
Suzuki Y, Shintaku I, Nagura H, Ohtani H: Proliferative activity of
intratumoral CD8(+) T-lymphocytes as a prognostic factor in
human renal cell carcinoma: clinicopathologic
demonstration of antitumor immunity. Cancer Res 2001,
42. Karja V, Aaltomaa S, Lipponen P, Isotalo T, Talja M, Mokka R:
Tumour-infiltrating lymphocytes: a prognostic factor of PSAfree survival in patients with local prostate carcinoma treated
by radical prostatectomy. Anticancer Res 2005, 25:4435-4438.
43. Richardsen E, Uglehus RD, Due J, Busch C, Busund LT: The
prognostic impact of M-CSF, CSF-1 receptor, CD68 and CD3
in prostatic carcinoma. Histopathology 2008, 53:30-38.
44. Vesalainen S, Lipponen P, Talja M, Syrjanen K: Histological
grade, perineural infiltration, tumour-infiltrating lymphocytes
and apoptosis as determinants of long-term prognosis in
prostatic adenocarcinoma. Eur J Cancer 1994, 30A:1797-1803.
45. Dieu-Nosjean MC, Antoine M, Danel C, Heudes D, Wislez M,
Poulot V, Rabbe N, Laurans L, Tartour E, de Chaisemartin L et al.:
Long-term survival for patients with non-small-cell lung
cancer with intratumoral lymphoid structures. J Clin Oncol
2008, 26:4410-4417.
46. Al-Shibli KI, Donnem T, Al-Saad S, Persson M, Bremnes RM,
Busund LT: Prognostic effect of epithelial and stromal
lymphocyte infiltration in non-small cell lung cancer. Clin
Cancer Res 2008, 14:5220-5227.
47. Hiraoka N, Onozato K, Kosuge T, Hirohashi S: Prevalence of
FOXP3+ regulatory T cells increases during the progression of
pancreatic ductal adenocarcinoma and its premalignant
lesions. Clin Cancer Res 2006, 12:5423-5434.
48. Ito N, Suzuki Y, Taniguchi Y, Ishiguro K, Nakamura H, Ohgi S:
Prognostic significance of T helper 1 and 2 and T cytotoxic 1
and 2 cells in patients with non-small cell lung cancer.
Anticancer Res 2005, 25:2027-2031.
49. Kawai O, Ishii G, Kubota K, Murata Y, Naito Y, Mizuno T, Aokage K,
Saijo N, Nishiwaki Y, Gemma A et al.: Predominant infiltration of
macrophages and CD8(+) T Cells in cancer nests is a
significant predictor of survival in stage IV nonsmall cell lung
cancer. Cancer 2008, 113:1387-1395.
50. Broussard EK, Disis ML: TNM staging in colorectal cancer: T is
for T cell and M is for memory. J Clin Oncol 2011, 29:601-603.
51. Galon J, Pages F, Marincola FM, Thurin M, Trinchieri G, Fox BA,
Gajewski TF, Ascierto PA: The immune score as a new possible
approach for the classification of cancer. J Transl Med 2012,
52. Galon J, Franck P, Marincola FM, Angell HK, Thurin M, Lugli A,

Zlobec I, Berger A, Bifulco C, Botti G et al.: Cancer classification
using the Immunoscore: a worldwide task force. J Transl Med
2012, 10:205.
A comprehensive review which describes the Immunoscore, and proposes the introduction of immune parameters into cancer classification.

Please cite this article in press as: Angell H, Galon J. From the immune contexture to the Immunoscore: the role of prognostic and predictive immune markers in cancer, Curr Opin Immunol


Prognostic and predictive immune markers in cancer Angell and Galon 7

53. Bindea G, Mlecnik B, Fridman WH, Pages F, Galon J: Natural

immunity to cancer in humans. Curr Opin Immunol 2010,
54. Pages F, Galon J, Dieu-Nosjean MC, Tartour E, Sautes-Fridman C,
Fridman WH: Immune infiltration in human tumors: a
prognostic factor that should not be ignored. Oncogene 2010,
55. Riley RD, Heney D, Jones DR, Sutton AJ, Lambert PC, Abrams KR,
Young B, Wailoo AJ, Burchill SA: A systematic review of
molecular and biological tumor markers in neuroblastoma.
Clin Cancer Res 2004, 10:4-12.
56. Galea MH, Ellis IO, Elston CW, Blamey RW: Node negative breast
cancer prognosis and DNA ploidy. Br J Surg 1992, 79:181.
57. Galea MH, Blamey RW, Elston CE, Ellis IO: The Nottingham
Prognostic Index in primary breast cancer. Breast Cancer Res
Treat 1992, 22:207-219.
58. Huncharek M, Muscat J, Geschwind JF: K-ras oncogene
mutation as a prognostic marker in non-small cell lung cancer:
a combined analysis of 881 cases. Carcinogenesis 1999,
59. vant Veer LJ, Dai H, van de Vijver MJ, He YD, Hart AA, Mao M,

Peterse HL, van der Kooy K, Marton MJ, Witteveen AT et al.: Gene
expression profiling predicts clinical outcome of breast
cancer. Nature 2002, 415:530-536.
Major article which describes one of the first gene signatures associated
with clinical outcome in cancer.
60. Sorlie T, Tibshirani R, Parker J, Hastie T, Marron JS, Nobel A,
Deng S, Johnsen H, Pesich R, Geisler S et al.: Repeated
observation of breast tumor subtypes in independent gene
expression data sets. Proc Natl Acad Sci U S A 2003,
61. Fan C, Oh DS, Wessels L, Weigelt B, Nuyten DS, Nobel AB, vant
Veer LJ, Perou CM: Concordance among gene-expressionbased predictors for breast cancer. N Engl J Med 2006,
62. Ma XJ, Wang Z, Ryan PD, Isakoff SJ, Barmettler A, Fuller A, Muir B,
Mohapatra G, Salunga R, Tuggle JT et al.: A two-gene expression
ratio predicts clinical outcome in breast cancer patients
treated with tamoxifen. Cancer Cell 2004, 5:607-616.
63. Chang HY, Nuyten DS, Sneddon JB, Hastie T, Tibshirani R,
Sorlie T, Dai H, He YD, vant Veer LJ, Bartelink H et al.:
Robustness, scalability, and integration of a wound-response
gene expression signature in predicting breast cancer
survival. Proc Natl Acad Sci U S A 2005, 102:3738-3743.
64. Paik S, Shak S, Tang G, Kim C, Baker J, Cronin M, Baehner FL,
Walker MG, Watson D, Park T et al.: A multigene assay to predict
recurrence of tamoxifen-treated, node-negative breast
cancer. N Engl J Med 2004, 351:2817-2826.
65. Fearnhead NS, Britton MP, Bodmer WF: The ABC of APC. Hum
Mol Genet 2001, 10:721-733.
66. Slamon DJ, Leyland-Jones B, Shak S, Fuchs H, Paton V,
Bajamonde A, Fleming T, Eiermann W, Wolter J, Pegram M et al.:
Use of chemotherapy plus a monoclonal antibody against
HER2 for metastatic breast cancer that overexpresses HER2.
N Engl J Med 2001, 344:783-792.
67. Vogel CL, Cobleigh MA, Tripathy D, Gutheil JC, Harris LN,
Fehrenbacher L, Slamon DJ, Murphy M, Novotny WF,
Burchmore M et al.: Efficacy and safety of trastuzumab as a

single agent in first-line treatment of HER2-overexpressing

metastatic breast cancer. J Clin Oncol 2002, 20:719-726.
68. Terme M, Pernot S, Marcheteau E, Sandoval F, Benhamouda N,
Colussi O, Dubreuil O, Carpentier AF, Tartour E, Taieb J: VEGFAVEGF Receptor pathway blockade inhibits tumor-induced
regulatory T cell proliferation in colorectal cancer. Cancer Res
2012, 73:539-549.
69. Topalian SL, Hodi FS, Brahmer JR, Gettinger SN, Smith DC,

McDermott DF, Powderly JD, Carvajal RD, Sosman JA, Atkins MB
et al.: Safety, activity, and immune correlates of anti-PD-1
antibody in cancer. N Engl J Med 2012, 366:2443-2454.
The landmark study that shows the clinical benefit of anti-PD-1 treatment.
70. Stagg J, Loi S, Divisekera U, Ngiow SF, Duret H, Yagita H,
Teng MW, Smyth MJ: Anti-ErbB-2 mAb therapy requires type I
and II interferons and synergizes with anti-PD-1 or anti-CD137
mAb therapy. Proc Natl Acad Sci U S A 2011, 108:7142-7147.
71. Ji RR, Chasalow SD, Wang L, Hamid O, Schmidt H, Cogswell J,
Alaparthy S, Berman D, Jure-Kunkel M, Siemers NO et al.: An
immune-active tumor microenvironment favors clinical
response to ipilimumab. Cancer Immunol Immunother 2012,
72. Hodi FS, ODay SJ, McDermott DF, Weber RW, Sosman JA,
Haanen JB, Gonzalez R, Robert C, Schadendorf D, Hassel JC

et al.: Improved survival with ipilimumab in patients with
metastatic melanoma. N Engl J Med 2010, 363:711-723.
The landmark study that shows the clinical benefit of anti-CTLA4 treatment.
73. Hamid O, Schmidt H, Nissan A, Ridolfi L, Aamdal S, Hansson J,
Guida M, Hyams DM, Gomez H, Bastholt L et al.: A prospective
phase II trial exploring the association between tumor
microenvironment biomarkers and clinical activity of
ipilimumab in advanced melanoma. J Transl Med 2011, 9:204.
74. Sharma A, Shah SR, Illum H, Dowell J: Vemurafenib: targeted
inhibition of mutated BRAF for treatment of advanced
melanoma and its potential in other malignancies. Drugs 2012,
75. Rosenberg SA, Restifo NP, Yang JC, Morgan RA, Dudley ME:
Adoptive cell transfer: a clinical path to effective cancer

immunotherapy. Nat Rev Cancer 2008, 8:299-308.
A comprehensive review which describes adoptive cell transfer.
76. Gajewski TF, Louahed J, Brichard VG: Gene signature in
melanoma associated with clinical activity: a potential clue to
unlock cancer immunotherapy. Cancer J 2010, 16:399-403.
77. Apetoh L, Tesniere A, Ghiringhelli F, Kroemer G, Zitvogel L:
Molecular interactions between dying tumor cells and the
innate immune system determine the efficacy of conventional
anticancer therapies. Cancer Res 2008, 68:4026-4030.
78. Morris M, Platell C, Iacopetta B: Tumor-infiltrating lymphocytes
and perforation in colon cancer predict positive response to 5fluorouracil chemotherapy. Clin Cancer Res 2008,
79. Ascierto ML, De Giorgi V, Liu Q, Bedognetti D, Spivey TL,
Murtas D, Uccellini L, Ayotte BD, Stroncek DF, Chouchane L et al.:
An immunologic portrait of cancer. J Transl Med 2011, 9:146.
80. Ogino S, Galon J, Fuchs CS, Dranoff G: Cancer immunology
analysis of host and tumor factors for personalized medicine.
Nat Rev Clin Oncol 2011, 8:711-719.

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