Background: Tumor-infiltrating lymphocytes (TILs) are known to influence disease progression and treatment response in clear cell renal cell carcinoma. This study aimed at evaluating the prognostic and predictive relevance of T and B cell infiltration patterns in patients with metastatic clear cell renal cell carcinoma (mRCC-cc) treated sequentially with tyrosine kinase inhibitors (TKIs) and the immune checkpoint inhibitor nivolumab. Methods: In this retrospective cohort study, immune cell densities (CD3+, CD8+ T cells and CD20+ B cells) were analyzed by immunohistochemistry and quantified using digital image analysis software QuPath in distinct tumor regions of primary tumor: tumor center (TC), inner margin (IM), outer margin (OM), and peritumoral (PT) region. Samples were obtained from 36 patients with mRCC-cc treated with TKIs in the first line and sequentially with nivolumab in the second or third-line setting. Associations between immune cell densities, clinicopathological features, and survival outcomes were assessed using univariable and multivariable Cox regression models. Progression-free survival (PFS), overall survival (OS), and objective response rate (ORR) were evaluated. Results: Densities of all immune cells were significantly higher in the OM and PT regions than in the TC and IM. Older age correlated with lower CD8+ T cell and CD20+ B cell densities, whereas higher tumor grade was associated with increased CD20+ B cell infiltration in IM. High CD20+ B cell density in IM and OM was significantly associated with shorter PFS during first-line TKI therapy (hazard ratio (HR) = 3.30, P = 0.015 and HR = 3.25, P = 0.016, respectively). In contrast, an intermediate CD8+ T cell density in the PT region was associated with longer PFS during sequential nivolumab treatment (HR = 0.26, P = 0.007). No significant associations between immune cell densities and ORR or OS were observed. Conclusions: Our findings suggest that spatial localization and density of tumor-infiltrating CD20+ B cells are potential predictors of poor PFS on TKIs, whereas higher CD8+ T cell infiltration in peritumoral areas may be a potential predictor of prolonged PFS on nivolumab. These immune-cell-based parameters may refine prognostic models and help guide treatment selection in mRCC-cc.

ARON Research Foundation ETS Macerata Italy; Galleria del Commercio n 6 62100 Macerata Italy

Department of Cancer Epidemiology German Cancer Research Center Im Neuenheimer Feld 280 69120 Heidelberg Germany

Department of Oncology and Radiotherapeutics Faculty of Medicine and University Hospital in Pilsen Charles University Czech Republic Alej Svobody 80 304 60 Pilsen

Department of Pathology Faculty of Medicine in Pilsen University Hospital Pilsen Charles University Prague 30460 Pilsen Czech Republic

Department of Urology Faculty of Medicine and University Hospital in Pilsen Charles University Czech Republic Edvarda Beneše 1128 13 301 00 Pilsen Czech Republic

Laboratory of Cancer Treatment and Tissue Regeneration Biomedical Center Faculty of Medicine in Pilsen Charles University Alej Svobody 1665 76 32300 Pilsen Czech Republic

Laboratory of Translational Cancer Genomics Biomedical Center Faculty of Medicine in Pilsen Charles University Alej Svobody 1665 76 32300 Pilsen Czech Republic

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Bray F, Laversanne M, Sung H, Ferlay J, Siegel RL, Soerjomataram I. et al. Global cancer statistics 2022: GLOBOCAN estimates of incidence and mortality worldwide for 36 cancers in 185 countries. CA Cancer J Clin. 2024;74:229–63. PubMed

Ferlay J ea. Global Cancer Observatory: Cancer Today (version 1.1). 2024). 2024.

Escudier B, Porta C, Schmidinger M, Rioux-Leclercq N, Bex A, Khoo V. et al. Renal cell carcinoma: ESMO Clinical Practice Guidelines for diagnosis, treatment and follow-updagger. Ann Oncol. 2019;30:706–20. PubMed

Rini BI, Campbell SC, Escudier B. Renal cell carcinoma. Lancet. 2009;373:1119–32. PubMed

Fisher R, Gore M, Larkin J. Current and future systemic treatments for renal cell carcinoma. Semin Cancer Biol. 2013;23:38–45. PubMed

Dabestani S, Thorstenson A, Lindblad P, Harmenberg U, Ljungberg B, Lundstam S. Renal cell carcinoma recurrences and metastases in primary non-metastatic patients: a population-based study. World J Urol. 2016;34:1081–6. PubMed

Haas NB, Manola J, Dutcher JP, Flaherty KT, Uzzo RG, Atkins MB. et al. Adjuvant Treatment for High-Risk Clear Cell Renal Cancer: Updated Results of a High-Risk Subset of the ASSURE Randomized Trial. JAMA Oncol. 2017;3:1249–52. PubMed PMC

Bosma NA, Warkentin MT, Gan CL, Karim S, Heng DYC, Brenner DR. et al. Efficacy and Safety of First-line Systemic Therapy for Metastatic Renal Cell Carcinoma: A Systematic Review and Network Meta-analysis. Eur Urol Open Sci. 2022;37:14–26. PubMed PMC

Mazza C, Escudier B, Albiges L. Nivolumab in renal cell carcinoma: latest evidence and clinical potential. Ther Adv Med Oncol. 2017;9:171–81. PubMed PMC

Kobayashi M, Morita T, Chun NA, Matsui A, Takahashi M, Murakami T. Effect of host immunity on metastatic potential in renal cell carcinoma: the assessment of optimal in vivo models to study metastatic behavior of renal cancer cells. Tumour Biol. 2012;33:551–9. PubMed

Raman R, Vaena D. Immunotherapy in Metastatic Renal Cell Carcinoma: A Comprehensive Review. Biomed Res Int. 2015;2015:367354. PubMed PMC

J DASP, RS DES, CM DASDA, TC DAS, Livinalli IC, Bertoncelli ACZ. et al. An Overview of Renal Cell Carcinoma Hallmarks, Drug Resistance, and Adjuvant Therapies. Cancer Diagn Progn. 2023;3:616–34. PubMed PMC

Dagogo-Jack I, Shaw AT. Tumour heterogeneity and resistance to cancer therapies. Nat Rev Clin Oncol. 2018;15:81–94. PubMed

Braun DA, Hou Y, Bakouny Z, Ficial M, Sant' Angelo M, Forman J. et al. Interplay of somatic alterations and immune infiltration modulates response to PD-1 blockade in advanced clear cell renal cell carcinoma. Nat Med. 2020;26:909–18. PubMed PMC

Barthelemy P, Albiges L, Escudier B, Narciso B, Bigot P, Chehimi M. et al. Nivolumab in patients with advanced renal cell carcinoma in France: interim results of the observational, real-world WITNESS study. ESMO Open. 2024;9:103602. PubMed PMC

Terme M, Colussi O, Marcheteau E, Tanchot C, Tartour E, Taieb J. Modulation of immunity by antiangiogenic molecules in cancer. Clin Dev Immunol. 2012;2012:492920. PubMed PMC

Vuong L, Kotecha RR, Voss MH, Hakimi AA. Tumor Microenvironment Dynamics in Clear-Cell Renal Cell Carcinoma. Cancer Discov. 2019;9:1349–57. PubMed PMC

Klatte T, Rossi SH, Stewart GD. Prognostic factors and prognostic models for renal cell carcinoma: a literature review. World J Urol. 2018;36:1943–52. PubMed

Galon J, Bruni D. Tumor Immunology and Tumor Evolution: Intertwined Histories. Immunity. 2020;52:55–81. PubMed

Drake CG, Stein MN. The Immunobiology of Kidney Cancer. J Clin Oncol. 2018: JCO2018792648. PubMed

Pignon JC, Jegede O, Shukla SA, Braun DA, Horak CE, Wind-Rotolo M. et al. irRECIST for the Evaluation of Candidate Biomarkers of Response to Nivolumab in Metastatic Clear Cell Renal Cell Carcinoma: Analysis of a Phase II Prospective Clinical Trial. Clin Cancer Res. 2019;25:2174–84. PubMed PMC

Ross-Macdonald P, Walsh AM, Chasalow SD, Ammar R, Papillon-Cavanagh S, Szabo PM, Molecular correlates of response to nivolumab at baseline and on treatment in patients with RCC. J Immunother Cancer. 2021. 9. PubMed PMC

Shohdy KS, Pillai M, Abbas KS, Allison J, Waddell T, Darlington E. et al. Immune biomarker evaluation of sequential tyrosine kinase inhibitor and nivolumab monotherapies in renal cell carcinoma: the phase I TRIBE trial. Immunooncol Technol. 2024;22:100712. PubMed PMC

Murakami T, Tanaka N, Takamatsu K, Hakozaki K, Fukumoto K, Masuda T. et al. Multiplexed single-cell pathology reveals the association of CD8 T-cell heterogeneity with prognostic outcomes in renal cell carcinoma. Cancer Immunol Immunother. 2021;70:3001–13. PubMed PMC

Kessel A, Haj T, Peri R, Snir A, Melamed D, Sabo E. et al. Human CD19(+) CD25(high) B regulatory cells suppress proliferation of CD4(+) T cells and enhance Foxp3 and CTLA-4 expression in T-regulatory cells. Autoimmun Rev. 2012;11:670–7. PubMed

Pylayeva-Gupta Y, Das S, Handler JS, Hajdu CH, Coffre M, Koralov SB. et al. IL35-Producing B Cells Promote the Development of Pancreatic Neoplasia. Cancer Discov. 2016;6:247–55. PubMed PMC

Zhou M, Wen Z, Cheng F, Ma J, Li W, Ren H. et al. Tumor-released autophagosomes induce IL-10-producing B cells with suppressive activity on T lymphocytes via TLR2-MyD88-NF-kappaB signal pathway. Oncoimmunology. 2016;5:e1180485. PubMed PMC

Lee-Chang C, Rashidi A, Miska J, Zhang P, Pituch KC, Hou D. et al. Myeloid-Derived Suppressive Cells Promote B cell-Mediated Immunosuppression via Transfer of PD-L1 in Glioblastoma. Cancer Immunol Res. 2019;7:1928–43. PubMed PMC

Xiao X, Lao XM, Chen MM, Liu RX, Wei Y, Ouyang FZ. et al. PD-1hi Identifies a Novel Regulatory B-cell Population in Human Hepatoma That Promotes Disease Progression. Cancer Discov. 2016;6:546–59. PubMed

Griss J, Bauer W, Wagner C, Simon M, Chen M, Grabmeier-Pfistershammer K. et al. B cells sustain inflammation and predict response to immune checkpoint blockade in human melanoma. Nat Commun. 2019;10:4186. PubMed PMC

Helmink BA, Reddy SM, Gao J, Zhang S, Basar R, Thakur R. et al. B cells and tertiary lymphoid structures promote immunotherapy response. Nature. 2020;577:549–55. PubMed PMC

Lin Z, Liu L, Xia Y, Chen X, Xiong Y, Qu Y. et al. Tumor infiltrating CD19(+) B lymphocytes predict prognostic and therapeutic benefits in metastatic renal cell carcinoma patients treated with tyrosine kinase inhibitors. Oncoimmunology. 2018;7:e1477461. PubMed PMC

Damsky W, Jilaveanu L, Turner N, Perry C, Zito C, Tomayko M. et al. B cell depletion or absence does not impede anti-tumor activity of PD-1 inhibitors. J Immunother Cancer. 2019;7:153. PubMed PMC

Hendry S, Salgado R, Gevaert T, Russell PA, John T, Thapa B. et al. Assessing Tumor-infiltrating Lymphocytes in Solid Tumors: A Practical Review for Pathologists and Proposal for a Standardized Method From the International Immunooncology Biomarkers Working Group: Part 1: Assessing the Host Immune Response, TILs in Invasive Breast Carcinoma and Ductal Carcinoma In Situ, Metastatic Tumor Deposits and Areas for Further Research. Adv Anat Pathol. 2017;24:235–51. PubMed PMC

Galon J, Lanzi A. Immunoscore and its introduction in clinical practice. Q J Nucl Med Mol Imaging. 2020;64:152–61. PubMed

Therasse P, Arbuck SG, Eisenhauer EA, Wanders J, Kaplan RS, Rubinstein L. et al. New guidelines to evaluate the response to treatment in solid tumors. European Organization for Research and Treatment of Cancer, National Cancer Institute of the United States, National Cancer Institute of Canada. J Natl Cancer Inst. 2000;92:205–16. PubMed

Larrinaga G, Redrado M, Loizaga-Iriarte A, Perez-Fernandez A, Santos-Martin A, Angulo JC. et al. Spatial expression of fibroblast activation protein-alpha in clear cell renal cell carcinomas revealed by multiplex immunoprofiling analysis of the tumor microenvironment. Cancer Immunol Immunother. 2025;74:53. PubMed PMC

Trailin A, Ali E, Ye W, Pavlov S, Cervenkova L, Vycital O. et al. Prognostic assessment of T-cells in primary colorectal cancer and paired synchronous or metachronous liver metastasis. Int J Cancer. 2025;156:1282–92. PubMed PMC

Trailin A, Cervenkova L, Ambrozkiewicz F, Ali E, Kasi P, Palek R, T- and B-Cells in the Inner Invasive Margin of Hepatocellular Carcinoma after Resection Associate with Favorable Prognosis. Cancers (Basel) 2022. 14. PubMed PMC

Fridman WH, Zitvogel L, Sautes-Fridman C, Kroemer G. The immune contexture in cancer prognosis and treatment. Nat Rev Clin Oncol. 2017;14:717–34. PubMed

Jiang Y, Li Y, Zhu B. T-cell exhaustion in the tumor microenvironment. Cell Death Dis. 2015;6:e1792. PubMed PMC

Monjaras-Avila CU, Lorenzo-Leal AC, Luque-Badillo AC, D'Costa N, Chavez-Munoz C, Bach H. The Tumor Immune Microenvironment in Clear Cell Renal Cell Carcinoma. Int J Mol Sci. 2023. 24. PubMed PMC

Pan Q, Wang L, Chai S, Zhang H, Li B. The immune infiltration in clear cell Renal Cell Carcinoma and their clinical implications: A study based on TCGA and GEO databases. J Cancer. 2020;11:3207–15. PubMed PMC

Zhang D, Ni Y, Wang Y, Feng J, Zhuang N, Li J. et al. Spatial heterogeneity of tumor microenvironment influences the prognosis of clear cell renal cell carcinoma. J Transl Med. 2023;21:489. PubMed PMC

Chen L, Yin L, Qi Z, Li J, Wang X, Ma K. et al. Gene expression-based immune infiltration analyses of renal cancer and their associations with survival outcome. BMC Cancer. 2021;21:595. PubMed PMC

Kim JH, Kim GH, Ryu YM, Kim SY, Kim HD, Yoon SK. et al. Clinical implications of the tumor microenvironment using multiplexed immunohistochemistry in patients with advanced or metastatic renal cell carcinoma treated with nivolumab plus ipilimumab. Front Oncol. 2022;12:969569. PubMed PMC

Hu J, Chen Z, Bao L, Zhou L, Hou Y, Liu L. et al. Single-Cell Transcriptome Analysis Reveals Intratumoral Heterogeneity in ccRCC, which Results in Different Clinical Outcomes. Mol Ther. 2020;28:1658–72. PubMed PMC

Siska PJ, Rathmell JC. T cell metabolic fitness in antitumor immunity. Trends Immunol. 2015;36:257–64. PubMed PMC

Li L, Goedegebuure SP, Gillanders WE. Preclinical and clinical development of neoantigen vaccines. Ann Oncol. 2017;28:xii11–xii7. PubMed PMC

Nikolich-Zugich J. Aging of the T cell compartment in mice and humans: from no naive expectations to foggy memories. J Immunol. 2014;193:2622–9. PubMed PMC

Carril-Ajuria L, Desnoyer A, Meylan M, Dalban C, Naigeon M, Cassard L, Baseline circulating unswitched memory B cells and B-cell related soluble factors are associated with overall survival in patients with clear cell renal cell carcinoma treated with nivolumab within the NIVOREN GETUG-AFU 26 study. J Immunother Cancer. 2022. 10. PubMed PMC

Sharonov GV, Serebrovskaya EO, Yuzhakova DV, Britanova OV, Chudakov DM. B cells, plasma cells and antibody repertoires in the tumour microenvironment. Nat Rev Immunol. 2020;20:294–307. PubMed

Somasundaram R, Zhang G, Fukunaga-Kalabis M, Perego M, Krepler C, Xu X. et al. Tumor-associated B-cells induce tumor heterogeneity and therapy resistance. Nat Commun. 2017;8:607. PubMed PMC

Tao H, Lu L, Xia Y, Dai F, Wang Y, Bao Y. et al. Antitumor effector B cells directly kill tumor cells via the Fas/FasL pathway and are regulated by IL-10. Eur J Immunol. 2015;45:999–1009. PubMed PMC

Shi JY, Gao Q, Wang ZC, Zhou J, Wang XY, Min ZH. et al. Margin-infiltrating CD20(+) B cells display an atypical memory phenotype and correlate with favorable prognosis in hepatocellular carcinoma. Clin Cancer Res. 2013;19:5994–6005. PubMed

Stenzel PJ, Schindeldecker M, Tagscherer KE, Foersch S, Herpel E, Hohenfellner M. et al. Prognostic and Predictive Value of Tumor-infiltrating Leukocytes and of Immune Checkpoint Molecules PD1 and PDL1 in Clear Cell Renal Cell Carcinoma. Transl Oncol. 2020;13:336–45. PubMed PMC

Anwaier A, Xu W, Liu W, Wei S, Tian X, Qu Y. et al. Tumor microenvironment-based signatures distinguish intratumoral heterogeneity, prognosis, and immunogenomic features of clear cell renal cell carcinoma. J Natl Cancer Cent. 2023;3:236–49. PubMed PMC

Tumeh PC, Harview CL, Yearley JH, Shintaku IP, Taylor EJ, Robert L. et al. PD-1 blockade induces responses by inhibiting adaptive immune resistance. Nature. 2014;515:568–71. PubMed PMC

McDermott DF, Huseni MA, Atkins MB, Motzer RJ, Rini BI, Escudier B. et al. Clinical activity and molecular correlates of response to atezolizumab alone or in combination with bevacizumab versus sunitinib in renal cell carcinoma. Nat Med. 2018;24:749–57. PubMed PMC

Sobottka B, Nienhold R, Nowak M, Hench J, Haeuptle P, Frank A. et al. Integrated Analysis of Immunotherapy Treated Clear Cell Renal Cell Carcinomas: An Exploratory Study. J Immunother. 2022;45:35–42. PubMed PMC

Braun DA, Street K, Burke KP, Cookmeyer DL, Denize T, Pedersen CB. et al. Progressive immune dysfunction with advancing disease stage in renal cell carcinoma. Cancer Cell. 2021;39:632–48. e8. PubMed PMC

Davis D, Tretiakova MS, Kizzar C, Woltjer R, Krajbich V, Tykodi SS. et al. Abundant CD8+ tumor infiltrating lymphocytes and beta-2-microglobulin are associated with better outcome and response to interleukin-2 therapy in advanced stage clear cell renal cell carcinoma. Ann Diagn Pathol. 2020;47:151537. PubMed

Teke K, Yaprak Bayrak B, Yuksekkaya M, Uslubas AK, Kosem ME, Yilmaz H. et al. Prognostic value of immunological profile based on CD8+ and FoxP3+ T lymphocytes in the peritumoral and intratumoral subsites for renal cell carcinoma. Int Urol Nephrol. 2020;52:2289–99. PubMed

Selvi I, Demirci U, Bozdogan N, Basar H. The prognostic effect of immunoscore in patients with clear cell renal cell carcinoma: preliminary results. Int Urol Nephrol. 2020;52:21–34. PubMed

Giraldo NA, Becht E, Vano Y, Petitprez F, Lacroix L, Validire P. et al. Tumor-Infiltrating and Peripheral Blood T-cell Immunophenotypes Predict Early Relapse in Localized Clear Cell Renal Cell Carcinoma. Clin Cancer Res. 2017;23:4416–28. PubMed

Hajiran A, Chakiryan N, Aydin AM, Zemp L, Nguyen J, Laborde JM. et al. Reconnaissance of tumor immune microenvironment spatial heterogeneity in metastatic renal cell carcinoma and correlation with immunotherapy response. Clin Exp Immunol. 2021;204:96–106. PubMed PMC

Akerla J, Helminen O, Vayrynen JP, Parkkinen A, Jarvenpaa H, Bohm J. et al. CD3+ and CD8+ T cell-based immune cell score as a prognostic factor in clear-cell renal cell carcinoma. Acta Oncol. 2024;63:105–10. PubMed PMC