# Impact of stromal maturity and proportion on prognosis and immune landscape in colorectal cancer

## TL;DR

This study shows that combining measures of stromal maturity and proportion in colorectal cancer improves survival prediction and reveals links to an immunosuppressive tumor environment.

## Contribution

The novel Stromal Maturity and Proportion Score (SMAPS) integrates stromal features to provide stronger prognostic value than existing methods.

## Key findings

- SMAPS was a stronger predictor of cancer-specific mortality compared to TSR and DR classifications alone.
- High SMAPS correlated with lower densities of antitumor immune cells like CD3+ T cells and M1-like macrophages.
- Alcian blue staining was associated with immature stroma and corresponding immune cell patterns.

## Abstract

Tumour microenvironment and cancer cells have constant interaction affecting cancer progression. Tumour-stroma ratio (TSR) in the tumour centre and desmoplastic reaction (DR) classification at the invasive margin are prognostic factors based on stroma evaluation on H&E slides. However, their combined value and immunological associations remain poorly defined. This study examines the prognostic and immunological value of TSR, DR, and their combination in two large colorectal cancer cohorts.

Two colorectal cancer cohorts (N = 1,876) were analyzed. We introduced a three-tiered Stromal Maturity and Proportion Score (SMAPS) based on the presence of high (>50%) TSR and myxoid stroma (immature DR classification). Alcian blue staining was used to further quantify myxoid stroma. Multiplex immunohistochemistry combined with digital image analyses, was utilized to study immune cell densities associated with SMAPS, TSR, DR, and Alcian blue intensity.

In the study cohort (N = 1,100), SMAPS was a stronger predictor of cancer-specific mortality [HR for high (vs. low) SMAPS 2.01 (95% CI 1.47–2.75), p < 0.0001] compared to TSR [HR for stroma-high (vs. stroma-low) 1.49 (95% CI 1.15–1.93), p = 0.003] and DR classification [HR for immature (vs. mature) 1.84 (95% CI 1.39–2.45), p < 0.0001]. High SMAPS, stroma-high TSR, and immature DR correlated with lower densities of CD3+ T cells, B cells, M1-like macrophages, CD66B+ granulocytes, and mast cells. Alcian blue staining was associated with immature DR and corresponding immune cells. The validation cohort (N = 776) confirmed the association of SMAPS with survival and T cell densities.

TSR and DR are independent prognostic factors for cancer-specific survival. SMAPS is a promising prognostic tool that integrates stromal maturity at the invasive margin and stromal proportion in the tumour centre. SMAPS has stronger prognostic value compared to TSR and DR classifications alone. A high stromal proportion and myxoid content are associated with an immunosuppressive microenvironment characterized by lower densities of antitumourigenic immune cells.

Stromal Maturity and Proportion Score (SMAPS), integrating desmoplastic reaction (DR) classification at the invasive margin and tumour-stroma ratio (TSR) in the tumour centre, demonstrated stronger prognostic value compared to DR and TSR classification alone. Stroma-high TSR, myxoid stroma, and high SMAPS were associated with an immunosuppressive microenvironment characterized by lower densities of antitumourigenic immune cells. Alcian blue stain was associated with myxoid stroma and corresponding immune cell findings.