Not All FoxP3-Positive Lymphocytes Are Equal: Spatial Localization Predicts Survival in Pancreatic Cancer

In pancreatic cancer, location matters. We explored whether the spatial distribution of FoxP3-positive lymphocytes within the tumor microenvironment provides prognostic information and influences survival outcomes in resected PDAC.
Not All FoxP3-Positive Lymphocytes Are Equal: Spatial Localization Predicts Survival in Pancreatic Cancer
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Spatially resolved FoxP3 positive lymphocyte infiltration within the tumor microenvironment predicts survival in resected pancreatic ductal adenocarcinoma - Discover Oncology

Objective In pancreatic ductal adenocarcinoma (PDAC), immune and stromal components of the tumor microenvironment critically influence disease progression and survival. Although FoxP3 expression has been linked to prognosis, the clinical relevance of its spatial distribution remains unclear. This study aimed to evaluate the prognostic significance of FoxP3-positive lymphocytes in intratumoral (IT), peritumoral (PT), and tumor-associated stromal (T) compartments. Materials and methods Ninety-eight patients with PDAC who underwent surgical resection between 2015 and 2021 were retrospectively analyzed. FoxP3 expression was assessed immunohistochemically in IT, PT, and T compartments and categorized as low or high based on H-scores. Associations with clinicopathological variables, overall survival (OS), and disease-free survival (DFS) were analyzed using Kaplan–Meier and Cox proportional hazards models. Subgroup analyses were performed according to recurrence status and receipt of adjuvant chemotherapy. Results High FoxP3 expression in IT, PT, and T compartments was significantly associated with shorter OS. Although FoxP3 expression showed significant associations with DFS in Kaplan–Meier analyses, it did not retain independent significance in multivariate models. Tumor-associated stromal FoxP3 expression correlated with increased stromal response and advanced nodal stage, whereas high PT-FoxP3 expression was associated with positive surgical margins. In patients receiving adjuvant chemotherapy, Kaplan–Meier analyses showed no clear survival separation; however, compartment-specific prognostic effects of FoxP3 were preserved in multivariate analyses. Conclusion FoxP3-positive lymphocyte infiltration represents a clinically relevant prognostic biomarker in PDAC, with its impact on survival strongly dependent on spatial localization within the tumor microenvironment. Compartment-based evaluation of FoxP3 may improve risk stratification and provide a biologically meaningful framework for future immunologically informed therapeutic strategies in PDAC.

Representative FoxP3 immunohistochemical staining in pancreatic ductal adenocarcinoma demonstrating high (A), moderate (B), and low (C) lymphocyte infiltration within the tumor microenvironment.
Figure 1. Representative FoxP3 immunohistochemical staining patterns demonstrating strong, moderate, and weak expression across intratumoral (IT), peritumoral (PT), and tumor-associated stromal (T) compartments.Caption

Why Study FoxP3?

FoxP3-positive lymphocytes are commonly associated with regulatory T-cell activity and immune suppression. Although several studies have examined FoxP3 in pancreatic cancer, most evaluated it as a single measurement without considering where these immune cells were located.

We hypothesized that the biological significance of FoxP3-positive lymphocytes might depend on their spatial distribution within the tumor microenvironment.

To investigate this question, we analyzed 98 surgically resected PDAC cases and separately assessed FoxP3 expression in three distinct compartments:

  • Intratumoral (IT)
  • Peritumoral (PT)
  • Tumor-associated stromal (T)

This compartment-based approach enabled a more detailed characterization of the immune landscape surrounding pancreatic cancer.

High FoxP3 Expression Predicts Poorer Overall Survival

One of the most striking findings of our study was the consistent association between elevated FoxP3 expression and reduced overall survival.

Kaplan–Meier overall survival curves demonstrating worse survival in pancreatic ductal adenocarcinoma patients with high FoxP3 expression compared with low FoxP3 expression across stromal, peritumoral, and intratumoral compartments.
Figure 6. Kaplan–Meier overall survival curves according to FoxP3 expression in intratumoral, peritumoral, and tumor-associated stromal compartments

Across all evaluated compartments, patients with high FoxP3 expression demonstrated significantly shorter overall survival than those with low expression.

These findings suggest that immunosuppressive immune populations contribute to aggressive tumor behavior regardless of their precise anatomical location.

High FoxP3 Expression Also Predicts Earlier Recurrence

Overall survival represents only one aspect of clinical outcome. We therefore evaluated disease-free survival to determine whether FoxP3-positive lymphocytes were also associated with tumor recurrence.

ROC curves demonstrating the diagnostic performance of intratumoral, peritumoral, and stromal FoxP3 expression in pancreatic ductal adenocarcinoma. Sensitivity is plotted against specificity, with a cut-off value of 100 used for classification.

Figure 8. Kaplan–Meier disease-free survival curves according to FoxP3 expression.

Patients exhibiting higher FoxP3 expression experienced earlier recurrence following surgical resection. This finding suggests that FoxP3-associated immune suppression may influence not only mortality but also mechanisms driving disease progression and relapse.

 

Prognostic Effects Persist in Patients Receiving Adjuvant Therapy

An important question was whether FoxP3 retained prognostic significance among patients receiving postoperative chemotherapy.

Prognostic Impact of Compartment-Specific FoxP3 Expression on Overall and Disease-Free Survival
Figure 12. Forest plot demonstrating compartment-specific prognostic effects of FoxP3 expression in patients receiving adjuvant chemotherapy.

Interestingly, compartment-specific FoxP3 expression remained associated with survival outcomes even within this clinically important subgroup. These findings support the robustness of spatial immune profiling and suggest that FoxP3-related biology may remain relevant despite systemic treatment.

 

Why Spatial Pathology Matters

Traditional pathology has always relied on spatial information. Pathologists routinely evaluate tumor invasion, lymphovascular invasion, surgical margins, and many other features based on anatomical relationships.

Our findings suggest that immune biomarkers should be approached similarly.

Rather than simply determining whether immune cells are present, future pathology workflows may increasingly focus on where these cells are located and how they interact with surrounding structures.

Advances in digital pathology, artificial intelligence, multiplex imaging, and spatial transcriptomics may further enhance our ability to characterize these complex relationships.

 

Key Findings

🔬 98 resected PDAC patients were evaluated.

📍 FoxP3-positive lymphocytes were assessed separately in intratumoral, peritumoral, and stromal compartments.

📈 High FoxP3 expression predicted significantly shorter overall survival.

📉 High FoxP3 expression predicted shorter disease-free survival.

🧬 Spatial localization provided clinically meaningful prognostic information.

🚀 Spatial pathology approaches may improve future biomarker development and personalized treatment strategies.

Citation

Kandemir H, Solakoglu Kahraman D, Aktas S, Unal OU, Cagiral S. Spatially Resolved FoxP3 Positive Lymphocyte Infiltration Within the Tumor Microenvironment Predicts Survival in Resected Pancreatic Ductal Adenocarcinoma. Discover Oncology. 2026. DOI: 10.1007/s12672-026-05195-7

 

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Follow the Topic

Pancreatic Cancer
Life Sciences > Health Sciences > Clinical Medicine > Diseases > Gastrointestinal Diseases > Pancreatic disease > Pancreatic Cancer
Cancer Microenvironment
Life Sciences > Biological Sciences > Cancer Biology > Cancer Microenvironment
Tumour Immunology
Life Sciences > Biological Sciences > Immunology > Tumour Immunology
Regulatory T cells
Life Sciences > Biological Sciences > Anatomy > Haemic and Immune Systems > Immune system > Leukocytes > T cells > CD4-positive T cells > Regulatory T cells
Tumour Biomarkers
Life Sciences > Biological Sciences > Cancer Biology > Tumour Biomarkers
Disease-free Survival
Life Sciences > Health Sciences > Clinical Medicine > Prognosis > Disease-free Survival
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