{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,4,20]],"date-time":"2026-04-20T18:01:52Z","timestamp":1776708112717,"version":"3.51.2"},"reference-count":55,"publisher":"Public Library of Science (PLoS)","issue":"4","license":[{"start":{"date-parts":[[2026,4,20]],"date-time":"2026-04-20T00:00:00Z","timestamp":1776643200000},"content-version":"vor","delay-in-days":0,"URL":"http:\/\/creativecommons.org\/licenses\/by\/4.0\/"}],"funder":[{"DOI":"10.13039\/100000057","name":"National Institute of General Medical Sciences","doi-asserted-by":"publisher","award":["R35GM159993"],"award-info":[{"award-number":["R35GM159993"]}],"id":[{"id":"10.13039\/100000057","id-type":"DOI","asserted-by":"publisher"}]}],"content-domain":{"domain":["www.plosone.org"],"crossmark-restriction":false},"short-container-title":["PLoS One"],"abstract":"<jats:p>The ovarian tumor microenvironment (TME) is highly immunosuppressive, limiting immunotherapy effectiveness. We investigated whether the composition, ratios, and polarization of infiltrating immune cells provide prognostic value in ovarian cancer (OC). Our analysis revealed that immune ratios, including CD8\/Treg and CD8\/CD4, were more predictive of survival than absolute CD8\u2009+\u2009, CD4\u2009+\u2009, or Treg levels. Prior studies have reported associations between higher CD8\/Treg ratios and improved responses to immune checkpoint inhibitors, highlighting the importance of effector\u2013regulator balance; however, immunotherapy response was not evaluated in this cohort. Additionally, macrophage polarization proved to be crucial: pro-tumor M2-macrophages were associated with vascular invasion, persistent tumor, and worse survival, while higher na\u00efve M0-macrophage levels predicted improved outcomes. Surprisingly, anti-tumor M1-macrophages lacked prognostic significance, suggesting possible benefits in preserving an M0-macrophage pool. Neutrophil infiltration, though relatively uncommon, correlated with poor survival, supporting reports that neutrophils suppress T-cell responses. Immune infiltration was linked to aggressive features such as vascular invasion, reflecting both heightened recognition and compensatory recruitment of suppressive populations. Unsupervised clustering identified four immune-defined subtypes, with worse survival in clusters enriched for M2-macrophages and CD4\u2009+\u2009T-cells and depleted in M0-macrophages, particularly in advanced disease. Overall, our findings highlight the prognostic value of immune ratios, macrophage polarization, and neutrophil activity in OC, suggesting new avenues for risk stratification and future therapeutic investigation.<\/jats:p>","DOI":"10.1371\/journal.pone.0346746","type":"journal-article","created":{"date-parts":[[2026,4,20]],"date-time":"2026-04-20T17:27:51Z","timestamp":1776706071000},"page":"e0346746","update-policy":"https:\/\/doi.org\/10.1371\/journal.pone.corrections_policy","source":"Crossref","is-referenced-by-count":0,"title":["Analysis of ovarian cancer immune cell profile identifies immunosuppressive states associated with adverse clinical attributes and survival times"],"prefix":"10.1371","volume":"21","author":[{"ORCID":"https:\/\/orcid.org\/0009-0007-9659-4681","authenticated-orcid":true,"given":"Ana","family":"Moscoso","sequence":"first","affiliation":[],"role":[{"role":"author","vocabulary":"crossref"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-0971-0514","authenticated-orcid":true,"given":"Navid","family":"Mohammad Mirzaei","sequence":"additional","affiliation":[],"role":[{"role":"author","vocabulary":"crossref"}]},{"ORCID":"https:\/\/orcid.org\/0000-0001-6234-8449","authenticated-orcid":true,"given":"Leili","family":"Shahriyari","sequence":"additional","affiliation":[],"role":[{"role":"author","vocabulary":"crossref"}]}],"member":"340","published-online":{"date-parts":[[2026,4,20]]},"reference":[{"issue":"3","key":"pone.0346746.ref001","first-page":"209","article-title":"Global cancer statistics 2020: GLOBOCAN estimates of incidence and mortality worldwide for 36 cancers in 185 countries","volume":"71","author":"H Sung","year":"2021","journal-title":"CA: a cancer journal for clinicians"},{"key":"pone.0346746.ref002","unstructured":"World Cancer Research Fund. Ovarian Cancer Statistics: Number of New Cases Worldwide, 2022. 2023. https:\/\/www.wcrf.org\/preventing-cancer\/cancer-statistics\/ovarian-cancer-statistics\/"},{"key":"pone.0346746.ref003","volume-title":"Ovarian Cancer","author":"T Arora","year":"2023"},{"key":"pone.0346746.ref004","doi-asserted-by":"crossref","first-page":"160","DOI":"10.1016\/j.ygyno.2025.08.014","article-title":"Biology of ovarian cancer: Models, microenvironment, and therapeutics: 15th Biennial Rivkin Center Ovarian Cancer Research Symposium","volume":"201","author":"KB Chiappinelli","year":"2025","journal-title":"Gynecol Oncol"},{"issue":"3","key":"pone.0346746.ref005","doi-asserted-by":"crossref","first-page":"495","DOI":"10.1084\/jem.20111413","article-title":"Ovarian cancer progression is controlled by phenotypic changes in dendritic cells","volume":"209","author":"UK Scarlett","year":"2012","journal-title":"J Exp Med"},{"issue":"4","key":"pone.0346746.ref006","article-title":"Immune microenvironment in ovarian cancer: a complex barrier to immunotherapy","volume":"173","author":"Y Zhao","year":"2024","journal-title":"Immunology"},{"key":"pone.0346746.ref007","doi-asserted-by":"crossref","first-page":"895","DOI":"10.2147\/JIR.S503479","article-title":"Inflammation and Immune Escape in Ovarian Cancer: Pathways and Therapeutic Opportunities","volume":"18","author":"C Liu","year":"2025","journal-title":"J Inflamm Res"},{"issue":"9","key":"pone.0346746.ref008","doi-asserted-by":"crossref","first-page":"2967","DOI":"10.3390\/jcm9092967","article-title":"Epithelial Ovarian Cancer and the Immune System: Biology, Interactions, Challenges and Potential Advances for Immunotherapy","volume":"9","author":"AM Macpherson","year":"2020","journal-title":"J Clin Med"},{"issue":"16","key":"pone.0346746.ref009","doi-asserted-by":"crossref","first-page":"4037","DOI":"10.3390\/cancers14164037","article-title":"Dendritic Cell Vaccines: A Promising Approach in the Fight against Ovarian 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Immunol"},{"issue":"1","key":"pone.0346746.ref013","doi-asserted-by":"crossref","first-page":"1","DOI":"10.1016\/j.ygyno.2018.09.005","article-title":"Tumor-infiltrating T cells in epithelial ovarian cancer: predictors of prognosis and biological basis of immunotherapy","volume":"151","author":"W Wang","year":"2018","journal-title":"Gynecol Oncol"},{"issue":"3","key":"pone.0346746.ref014","doi-asserted-by":"crossref","first-page":"203","DOI":"10.1056\/NEJMoa020177","article-title":"Intratumoral T cells, recurrence, and survival in epithelial ovarian cancer","volume":"348","author":"L Zhang","year":"2003","journal-title":"N Engl J Med"},{"issue":"51","key":"pone.0346746.ref015","doi-asserted-by":"crossref","first-page":"18538","DOI":"10.1073\/pnas.0509182102","article-title":"Intraepithelial CD8+ tumor-infiltrating lymphocytes and a high CD8+\/regulatory T cell ratio are associated with favorable prognosis in ovarian cancer","volume":"102","author":"E Sato","year":"2005","journal-title":"Proc Natl Acad Sci U S A"},{"issue":"2","key":"pone.0346746.ref016","doi-asserted-by":"crossref","first-page":"174","DOI":"10.1016\/j.canlet.2016.04.038","article-title":"Tumor microenvironment: The culprit for ovarian cancer metastasis?","volume":"377","author":"Z Luo","year":"2016","journal-title":"Cancer Lett"},{"issue":"12","key":"pone.0346746.ref017","doi-asserted-by":"crossref","DOI":"10.1001\/jamaoncol.2017.3290","article-title":"Dose-Response Association of CD8+ Tumor-Infiltrating Lymphocytes and Survival Time in High-Grade Serous Ovarian Cancer","volume":"3","author":"Ovarian Tumor Tissue Analysis (OTTA) Consortium","year":"2017","journal-title":"JAMA Oncol"},{"key":"pone.0346746.ref018","doi-asserted-by":"crossref","first-page":"19","DOI":"10.1186\/1757-2215-7-19","article-title":"A high M1\/M2 ratio of tumor-associated macrophages is associated with extended survival in ovarian cancer patients","volume":"7","author":"M Zhang","year":"2014","journal-title":"J Ovarian Res"},{"issue":"5","key":"pone.0346746.ref019","doi-asserted-by":"crossref","DOI":"10.1172\/jci.insight.122311","article-title":"Mature neutrophils suppress T cell immunity in ovarian cancer microenvironment","volume":"4","author":"KL Singel","year":"2019","journal-title":"JCI Insight"},{"key":"pone.0346746.ref020","doi-asserted-by":"crossref","first-page":"12150","DOI":"10.1038\/ncomms12150","article-title":"Recommendations for myeloid-derived suppressor cell nomenclature and characterization standards","volume":"7","author":"V Bronte","year":"2016","journal-title":"Nat Commun"},{"issue":"5","key":"pone.0346746.ref021","doi-asserted-by":"crossref","first-page":"961","DOI":"10.1158\/1078-0432.CCR-12-2243","article-title":"New strategies in the treatment of ovarian cancer: current clinical perspectives and future potential","volume":"19","author":"S Banerjee","year":"2013","journal-title":"Clin Cancer Res"},{"key":"pone.0346746.ref022","doi-asserted-by":"crossref","first-page":"6685","DOI":"10.2147\/CMAR.S179189","article-title":"IL-6 and ovarian cancer: inflammatory cytokines in promotion of metastasis","volume":"10","author":"L Browning","year":"2018","journal-title":"Cancer Manag Res"},{"issue":"7","key":"pone.0346746.ref023","doi-asserted-by":"crossref","first-page":"773","DOI":"10.1038\/s41587-019-0114-2","article-title":"Determining cell type abundance and expression from bulk tissues with digital cytometry","volume":"37","author":"AM Newman","year":"2019","journal-title":"Nat Biotechnol"},{"issue":"6282","key":"pone.0346746.ref024","doi-asserted-by":"crossref","first-page":"189","DOI":"10.1126\/science.aad0501","article-title":"Dissecting the multicellular ecosystem of metastatic melanoma by single-cell RNA-seq","volume":"352","author":"I Tirosh","year":"2016","journal-title":"Science"},{"issue":"6294","key":"pone.0346746.ref025","doi-asserted-by":"crossref","first-page":"78","DOI":"10.1126\/science.aaf2403","article-title":"Visualization and analysis of gene expression in tissue sections by spatial transcriptomics","volume":"353","author":"PL St\u00e5hl","year":"2016","journal-title":"Science"},{"issue":"6","key":"pone.0346746.ref026","doi-asserted-by":"crossref","DOI":"10.1016\/j.cell.2018.08.039","article-title":"A Structured Tumor-Immune Microenvironment in Triple Negative Breast Cancer Revealed by Multiplexed Ion Beam Imaging","volume":"174","author":"L Keren","year":"2018","journal-title":"Cell"},{"issue":"2","key":"pone.0346746.ref027","doi-asserted-by":"crossref","first-page":"1879","DOI":"10.3934\/mbe.2021098","article-title":"Immune classification of osteosarcoma","volume":"18","author":"T Le","year":"2021","journal-title":"Math Biosci Eng"},{"issue":"5","key":"pone.0346746.ref028","doi-asserted-by":"crossref","first-page":"106596","DOI":"10.1016\/j.isci.2023.106596","article-title":"Investigating the spatial interaction of immune cells in colon cancer","volume":"26","author":"N Mohammad Mirzaei","year":"2023","journal-title":"iScience"},{"issue":"1843","key":"pone.0346746.ref029","first-page":"1563","article-title":"Modelling aspects of cancer dynamics: a review","volume":"364","author":"HM Byrne","year":"2006","journal-title":"Philos Trans A Math Phys Eng Sci"},{"key":"pone.0346746.ref030","article-title":"Heterogeneity of immune microenvironment in ovarian cancer and its clinical significance: a retrospective study","author":"Y Gao","year":"2020","journal-title":"Oncoimmunology"},{"issue":"1","key":"pone.0346746.ref031","doi-asserted-by":"crossref","first-page":"2032","DOI":"10.1038\/s41467-017-02289-3","article-title":"Estimation of immune cell content in tumour tissue using single-cell RNA-seq data","volume":"8","author":"M Schelker","year":"2017","journal-title":"Nat Commun"},{"issue":"1","key":"pone.0346746.ref032","doi-asserted-by":"crossref","first-page":"4338","DOI":"10.1038\/s41598-021-83767-z","article-title":"Immune classification of clear cell renal cell carcinoma","volume":"11","author":"S Su","year":"2021","journal-title":"Sci Rep"},{"issue":"7353","key":"pone.0346746.ref033","doi-asserted-by":"crossref","first-page":"609","DOI":"10.1038\/nature10166","article-title":"Integrated genomic analyses of ovarian carcinoma","volume":"474","author":"Cancer Genome Atlas Research Network","year":"2011","journal-title":"Nature"},{"issue":"6","key":"pone.0346746.ref034","doi-asserted-by":"crossref","first-page":"675","DOI":"10.1038\/s41587-020-0546-8","article-title":"Visualizing and interpreting cancer genomics data via the Xena platform","volume":"38","author":"MJ Goldman","year":"2020","journal-title":"Nat Biotechnol"},{"key":"pone.0346746.ref035","doi-asserted-by":"crossref","first-page":"257","DOI":"10.1038\/s41588-021-00791-5","article-title":"The NCI Genomic Data Commons","volume":"53","author":"AP Heath","year":"2021","journal-title":"Nat Genet"},{"issue":"5","key":"pone.0346746.ref036","doi-asserted-by":"crossref","first-page":"401","DOI":"10.1158\/2159-8290.CD-12-0095","article-title":"The cBio cancer genomics portal: an open platform for exploring multidimensional cancer genomics data","volume":"2","author":"E Cerami","year":"2012","journal-title":"Cancer Discov"},{"issue":"3","key":"pone.0346746.ref037","doi-asserted-by":"crossref","first-page":"537","DOI":"10.1213\/ANE.0b013e31829ed28f","article-title":"Wilcoxon-Mann-Whitney test used for data that are not normally distributed","volume":"117","author":"F Dexter","year":"2013","journal-title":"Anesth Analg"},{"issue":"3","key":"pone.0346746.ref038","doi-asserted-by":"crossref","first-page":"261","DOI":"10.1038\/s41592-019-0686-2","article-title":"SciPy 1.0: fundamental algorithms for scientific computing in Python","volume":"17","author":"P Virtanen","year":"2020","journal-title":"Nat Methods"},{"issue":"1","key":"pone.0346746.ref039","doi-asserted-by":"crossref","first-page":"289","DOI":"10.1111\/j.2517-6161.1995.tb02031.x","article-title":"Controlling the False Discovery Rate: A Practical and Powerful Approach to Multiple Testing","volume":"57","author":"Y Benjamini","year":"1995","journal-title":"Journal of the Royal Statistical Society Series B: Statistical Methodology"},{"issue":"4","key":"pone.0346746.ref040","article-title":"A review of digital cytometry methods: estimating the relative abundance of cell types in a bulk of cells","volume":"22","author":"T Le","year":"2021","journal-title":"Brief Bioinform"},{"key":"pone.0346746.ref041","unstructured":"Cui M. Introduction to the K-Means Clustering Algorithm Based on the Elbow Method. Geoscience and Remote Sensing. 2020. http:\/\/dx.doi.org\/10.23977\/geors.2020.030102"},{"key":"pone.0346746.ref042","first-page":"2825","article-title":"Scikit-learn: Machine Learning in Python","volume":"12","author":"F Pedregosa","year":"2011","journal-title":"Journal of Machine Learning Research"},{"key":"pone.0346746.ref043","volume-title":"Principal Component Analysis","author":"IT Jolliffe","year":"2002","edition":"2"},{"key":"pone.0346746.ref044","article-title":"Inferring tumour purity and stromal and immune cell admixture from expression data","author":"K Yoshihara","year":"2013","journal-title":"Nat Commun"},{"issue":"43","key":"pone.0346746.ref045","doi-asserted-by":"crossref","first-page":"15545","DOI":"10.1073\/pnas.0506580102","article-title":"Gene set enrichment analysis: a knowledge-based approach for interpreting genome-wide expression profiles","volume":"102","author":"A Subramanian","year":"2005","journal-title":"Proc Natl Acad Sci U S A"},{"issue":"4","key":"pone.0346746.ref046","doi-asserted-by":"crossref","first-page":"274","DOI":"10.4103\/0974-7788.76794","article-title":"Understanding survival analysis: Kaplan-Meier estimate","volume":"1","author":"MK Goel","year":"2010","journal-title":"Int J Ayurveda Res"},{"issue":"7447","key":"pone.0346746.ref047","doi-asserted-by":"crossref","first-page":"1073","DOI":"10.1136\/bmj.328.7447.1073","article-title":"The logrank test","volume":"328","author":"JM Bland","year":"2004","journal-title":"BMJ"},{"issue":"40","key":"pone.0346746.ref048","doi-asserted-by":"crossref","first-page":"1317","DOI":"10.21105\/joss.01317","article-title":"lifelines: survival analysis in Python","volume":"4","author":"C Davidson-Pilon","year":"2019","journal-title":"JOSS"},{"issue":"5","key":"pone.0346746.ref049","doi-asserted-by":"crossref","DOI":"10.1080\/2162402X.2018.1424672","article-title":"Prognosis of ovarian cancer is associated with effector memory CD8+ T cell accumulation in ascites, CXCL9 levels and activation-triggered signal transduction in T cells","volume":"7","author":"S Lieber","year":"2018","journal-title":"Oncoimmunology"},{"issue":"16","key":"pone.0346746.ref050","doi-asserted-by":"crossref","first-page":"9226","DOI":"10.1073\/pnas.151174198","article-title":"Immunosuppression by CD4+ regulatory T cells induced by chronic retroviral infection","volume":"98","author":"M Iwashiro","year":"2001","journal-title":"Proc Natl Acad Sci U S A"},{"key":"pone.0346746.ref051","article-title":"Neoadjuvant pembrolizumab reshapes the immune microenvironment in high-grade serous ovarian carcinoma","volume":"15","author":"M Kader","year":"2024","journal-title":"Nature Communications"},{"issue":"11","key":"pone.0346746.ref052","doi-asserted-by":"crossref","first-page":"549","DOI":"10.1016\/S1471-4906(02)02302-5","article-title":"Macrophage polarization: tumor-associated macrophages as a paradigm for polarized M2 mononuclear phagocytes","volume":"23","author":"A Mantovani","year":"2002","journal-title":"Trends Immunol"},{"key":"pone.0346746.ref053","doi-asserted-by":"crossref","first-page":"1640571","DOI":"10.3389\/fimmu.2025.1640571","article-title":"Editorial: Advancements in multi-omics and bioinformatics for the management of solid malignancies","volume":"16","author":"NM Elemam","year":"2025","journal-title":"Front Immunol"},{"key":"pone.0346746.ref054","first-page":"133","article-title":"Human tumor-infiltrating neutrophils can subvert adaptive immunity in cancer patients","author":"TR Emmons","year":"2021","journal-title":"Cancer Immunology Research"},{"issue":"2","key":"pone.0346746.ref055","first-page":"243","article-title":"Histopathological prognosticators in epithelial ovarian cancer: A retrospective cohort study","volume":"67","author":"SM Choudhury","year":"2024","journal-title":"Indian Journal of Pathology and Microbiology"}],"container-title":["PLOS One"],"original-title":[],"language":"en","link":[{"URL":"https:\/\/dx.plos.org\/10.1371\/journal.pone.0346746","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2026,4,20]],"date-time":"2026-04-20T17:28:03Z","timestamp":1776706083000},"score":1,"resource":{"primary":{"URL":"https:\/\/dx.plos.org\/10.1371\/journal.pone.0346746"}},"subtitle":[],"editor":[{"given":"Zhanzhan","family":"Li","sequence":"first","affiliation":[],"role":[{"role":"editor","vocabulary":"crossref"}]}],"short-title":[],"issued":{"date-parts":[[2026,4,20]]},"references-count":55,"journal-issue":{"issue":"4","published-online":{"date-parts":[[2026,4,20]]}},"URL":"https:\/\/doi.org\/10.1371\/journal.pone.0346746","relation":{},"ISSN":["1932-6203"],"issn-type":[{"value":"1932-6203","type":"electronic"}],"subject":[],"published":{"date-parts":[[2026,4,20]]}}}