INTRODUCTION: Leiomyosarcoma (LMS) is a rare, aggressive cancer with limited treatment options at the metastatic stage. The response to immune checkpoint inhibitors (ICIs) is inconsistent, likely due to intratumoral heterogeneity, which is more pronounced in large tumours such as retroperitoneal LMS. METHODS: This study examined heterogeneity in four large treatment-naive LMS tumours (ten samples per tumour) by analysing immune cells, tertiary lymphoid structures (TLSs), checkpoint molecules, and cytokine secretion across different tumour regions. RESULTS: Significant region-dependent differences were observed in immune components, with TLSs present only at tumour margins and inconsistently across samples from the same tumour. Expression levels of programmed cell death 1 (PD-1) and programmed death ligand 1 (PD-L1) varied within individual tumours, and shared immune patterns were identified in specific regions, including elevated indoleamine 2,3-dioxygenase 1, absence of a particular macrophage subpopulation, and reduced PD-1 and lymphocyte activation gene 3 (LAG-3) expression at organ-adjacent margins. Anti-LAG-3 blockade altered cytokine and checkpoint molecule levels in a region-specific manner. CONCLUSION: These findings highlight substantial intratumoral heterogeneity, which may contribute to the variable response to ICI therapy. As immune checkpoint molecule expression influences treatment eligibility, multiple biopsies from different tumour regions may be necessary to assess immune infiltration accurately and guide therapy decisions.

3rd Department of Surgery 1st Faculty of Medicine Charles University and University Hospital Motol Prague Czech Republic

Department of Immunology 2nd Faculty of Medicine Charles University and University Hospital Motol Prague Czech Republic

Department of Oncology 2nd Faculty of Medicine Charles University and University Hospital Motol Prague Czech Republic

Department of Oncology University Hospital General de Villalba Madrid Spain

Department of Pathology and Molecular Medicine 2nd Faculty of Medicine Charles University and University Hospital Motol Prague Czech Republic

Department of Surgical Oncology Netherlands Cancer Institute Antoni van Leeuwenhoek Hospital Amsterdam the Netherlands

Medical Oncology Department Fundacion Jimenez Diaz University Hospital Madrid Spain

Research Health Institute of Fundación Jiménez Díaz Madrid Spain

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