The ratios of CD8⁺ T cells to CD4⁺CD25⁺ FOXP3⁺ and FOXP3^- T cells correlate with poor clinical outcome in human serous ovarian cancer

Ovarian cancer is an immune reactive malignancy with a complex immune suppressive network that blunts successful immune eradication. This suppressive microenvironment may be mediated by recruitment or induction of CD4⁺ regulatory T cells (Tregs). Our study sought to investigate the association of tumor-infiltrating CD4⁺CD25⁺FOXP3⁺ Tregs, and other immune factors, with clinical outcome in serous ovarian cancer patients. We performed immunofluorescence and quantification of intraepithelial tumor-infiltrating triple positive Tregs (CD4⁺CD25 ⁺FOXP3⁺), as well as CD4⁺CD25 ⁺FOXP3^-, CD3⁺ and CD8⁺ T cells in tumor specimens from 52 patients with high stage serous ovarian carcinoma. Thirty-one of the patients had good survival (i.e. > 60 months) and 21 had poor survival of < 18 months. Total cell counts as well as cell ratios were compared among these two outcome groups. The total numbers of CD4 ⁺CD25⁺FOXP3⁺ Tregs, CD4⁺CD25 ⁺FOXP3^-, CD3⁺ and CD8⁺ cells were not significantly different between the groups. However, higher ratios of CD8⁺/CD4⁺CD25⁺FOXP3⁺ Treg, CD8 ⁺/CD4⁺ and CD8/CD4+CD25+FOXP3- cells were seen in the good outcome group when compared to the patients with poor outcome. These data show for the first time that the ratios of CD8⁺ to both CD4 ⁺CD25⁺FOXP3⁺ Tregs and CD4⁺CD25 ⁺FOXP3^- T cells are associated with disease outcome in ovarian cancer. The association being apparent in ratios rather than absolute count of T cells suggests that the effector/suppressor ratio may be a more important indicator of outcome than individual cell count. Thus, immunotherapy strategies that modify the ratio of CD4⁺CD25⁺FOXP3 ⁺ Tregs or CD4⁺CD25⁺FOXP3^- T cells to CD8⁺ effector cells may be useful in improving outcomes in ovarian cancer.