Multi-target Precision Classification of the Immune Microenvironment in Gastrointestinal Tumors and Its Clinical Adaptability to Treatment Strategies

Corresponding author: Zhanglin, stepinghuns2@163.com

DOI: 10.12201/bmr.202606.00026

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  Abstract: Background & Objective: Programmed death receptor-1 (PD-1)/programmed death ligand-1 (PD-L1) inhibitors show limited clinical benefit in gastrointestinal tumors with microsatellite stable (MSS)/proficient mismatch repair (pMMR) status. Traditional single-biomarker screening systems fail to meet the requirements for precision therapy. This study aimed to establish a multi-target immune microenvironment classification system incorporating regulatory T cell (Treg) markers, analyze the correlations between the classification and patients' clinical characteristics, treatment response, and prognosis, and provide evidence for individualized immunotherapy of gastrointestinal tumors. Methods: Archived tissue samples from 180 patients with advanced gastric adenocarcinoma or colorectal cancer were enrolled. Five markers, including CD8, PD-L1, LAG-3, TIGIT, and Foxp3 (a Treg marker), were detected, and unsupervised clustering analysis was used to classify the immune microenvironment. Demographic characteristics, tumor pathological features, treatment history, laboratory test results, and survival data were collected to analyze the associations between different subtypes and clinical features, treatment suitability, and prognostic value. A nomogram prediction model was constructed, and the predictive performance of the classification system was validated by ROC curve and decision curve analysis (DCA). Results: Based on immunohistochemical analysis, patients were stratified into 5 immune subtypes: immune-activated type (16.7%, 30/180), co-inhibitory type (30.0%, 54/180), immune-exhausted type (22.2%, 40/180), immune-imbalanced type (15.0%, 27/180), and immune-desert type (16.1%, 29/180). Significant associations were observed between each subtype and tumor differentiation, metastatic status, ECOG score, and levels of tumor markers (CEA, CA19-9) (all P<0.05). The median progression-free survival (mPFS) for the immune-activated type was 12.5 months, and median overall survival (mOS) was 28.0 months; for the immune-desert type, mPFS was only 2.0 months and mOS was only 7.0 months. Multivariate Cox regression analysis showed that immune classification was an independent prognostic factor, with hazard ratios (HR) for desert, imbalanced, and exhausted types relative to the activated type of 2.68 (P<0.001), 2.15 (P=0.002), and 1.82 (P=0.010), respectively. Patients with the immune-activated type achieved a disease control rate (DCR) of 64.7% with PD-1 inhibitor monotherapy. Those with the co-inhibitory type showed a DCR of 40.0% with PD-1 inhibitor plus chemotherapy, significantly superior to 31.5% with chemotherapy alone (P<0.05). Compared with the traditional PD-L1 CPS, the classification system in this study showed significantly higher AUC for predicting disease control rate (0.852 vs 0.644, ΔAUC=0.208, P<0.001), with a net reclassification index (NRI) of 0.42. Among 108 PD-L1-negative patients, the classification system identified 28.3% (31/108) co-inhibitory type patients as potential beneficiaries. The nomogram model integrating immune classification, ECOG score, and CEA level could individually predict 6-month PFS rate. Conclusion: A multi-target immune classification system incorporating Treg markers can more accurately reflect the characteristics of the immune microenvironment in gastrointestinal tumors, and is closely correlated with patients' clinical features, treatment suitability, and prognosis. It provides an important reference for formulating precision treatment strategies for gastrointestinal tumors.

  Key words: Gastrointestinal Neoplasms; Immune Microenvironment Classification; Multi-target Detection; Foxp3; Treatment Adaptability; Prognostic Stratification

  Submit time: 12 June 2026

  Copyright: The copyright holder for this preprint is the author/funder, who has granted biomedRxiv a license to display the preprint in perpetuity.
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