Nodal metastasis in cervical cancer occurs in clearly delineated fields of immune suppression in the pelvic lymph catchment area

In cervical cancer, high frequencies of regulatory T cells (Tregs) and immunosuppressive PD-L1(+) CD14(+) antigen-presenting cells dominate the microenvironment of tumor-positive lymph nodes (LN+). It is unknown whether this is restricted to LN+ or precedes metastasis, emanating from the primary tumor and spreading through tumor-draining lymph nodes (TDLNs). To investigate immunosuppression in the lymphatic basin of cervical tumors, all dissected TDLNs of five cervical cancer patients (in total 9 LN+ and 74 tumor-negative lymph nodes (LN-)) were analyzed for FoxP3(+) Tregs, CD8(+) T cells, HLA-DR+-and PD-L1(+) myeloid cells by immunohistochemistry. Tregs and PD-L1(+) cells were found to form an immunosuppressive cordon around metastatic tumor cells. Importantly, whereas high HLA-DR+-and PD-L1(+) cell rates were strongly associated with LN+, elevated Treg levels and decreased CD8(+) T cell/Treg ratios were found similar in LN+ and adjacent LN-, as compared to LNat more distant anatomical localizations. These data suggest that delineated fields of Treg-associated immune suppression in anatomically co-localized TDLNs enable metastasis by creating metastatic niches. This may be of importance for decisionmaking regarding (surgical) intervention in cervical cancer. Future efforts should include the implementation of immunotherapeutic regimens to overcome this immune suppression, establish loco-regional control and halt systemic tumor spread.