{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,3,18]],"date-time":"2026-03-18T16:40:34Z","timestamp":1773852034191,"version":"3.50.1"},"reference-count":51,"publisher":"MDPI AG","issue":"1","license":[{"start":{"date-parts":[[2026,3,18]],"date-time":"2026-03-18T00:00:00Z","timestamp":1773792000000},"content-version":"vor","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/licenses\/by\/4.0\/"}],"content-domain":{"domain":[],"crossmark-restriction":false},"short-container-title":["Medical Sciences"],"abstract":"<jats:p>Background\/Objectives: Patients with local\/locally advanced gastric cancer (GC) undergo gastrectomy\/lymphadenectomy, but recurrences are common and the disease usually progresses to death. Tertiary lymphoid structures (TLS) of varying maturity can be observed in the immune microenvironment of the primary tumor. The aim of the study was to analyze the association of TLSs and their immune cellular composition with clinicopathological variables and overall survival (OS). Methods: In a cohort of 92 GC patients who underwent gastrectomy, the characteristics of tumor core TLSs were assessed and the density of cytotoxic CD8+ T cells and regulatory FOXP3+ T cells was analyzed. Results: Patients with TLS had a better OS than patients without TLS, 19.4 months vs. 9.2 months (p = 0.001). Immature TLSs were more frequently associated with lymphovascular invasion and regional lymph node metastasis (p = 0.014 and p = 0.034). Mature TLSs had a higher FOXP3+ T lymphocyte density and lower CD8+\/FOXP3+ ratio than immature TLSs (p = 0.029 and p = 0.013), and patients had a longer OS than patients with immature TLSs, 34.55 months vs. 15.2 months (p = 0.033). In patients with TLS-positive GC, cases with FOXP3+ T cells had a shorter OS, 12.7 months vs. 47.5 months (p &lt; 0.001). Conclusions: The presence of FOXP3+ cells in TLS is associated with significantly shorter OS of patients with local\/locally advanced GC.<\/jats:p>","DOI":"10.3390\/medsci14010145","type":"journal-article","created":{"date-parts":[[2026,3,18]],"date-time":"2026-03-18T10:11:12Z","timestamp":1773828672000},"page":"145","update-policy":"https:\/\/doi.org\/10.3390\/mdpi_crossmark_policy","source":"Crossref","is-referenced-by-count":0,"title":["FOXP3+ Cells in Tertiary Lymphoid Structures Have Adverse Impact on Overall Survival in Patients with Gastric Cancer"],"prefix":"10.3390","volume":"14","author":[{"given":"Ana","family":"Paparella Karaman","sequence":"first","affiliation":[{"name":"Department of Pathology, Forensic Medicine and Cytology, University Hospital of Split, 21000 Split, Croatia"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Tomislav","family":"Ivanovi\u0107","sequence":"additional","affiliation":[{"name":"Department of Surgery, University Hospital of Split, 21000 Split, Croatia"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Kre\u0161imir","family":"Mustapi\u0107","sequence":"additional","affiliation":[{"name":"Department of Surgery, University Hospital of Split, 21000 Split, Croatia"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"ORCID":"https:\/\/orcid.org\/0000-0003-2182-2890","authenticated-orcid":false,"given":"Katarina","family":"Vukojevi\u0107","sequence":"additional","affiliation":[{"name":"Department of Anatomy, Histology and Embryology, University of Split School of Medicine, 21000 Split, Croatia"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-4867-3648","authenticated-orcid":false,"given":"Luka","family":"Minarik","sequence":"additional","affiliation":[{"name":"Department of ENT, \u010cakovec County Hospital, 40000 \u010cakovec, Croatia"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Merica","family":"Glavina Durdov","sequence":"additional","affiliation":[{"name":"Department of Pathology, Forensic Medicine and Cytology, University Hospital of Split, 21000 Split, Croatia"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"ORCID":"https:\/\/orcid.org\/0009-0001-5342-4363","authenticated-orcid":false,"given":"Petar","family":"\u0110olonga","sequence":"additional","affiliation":[{"name":"Department of Pathology, Forensic Medicine and Cytology, University Hospital of Split, 21000 Split, Croatia"}],"role":[{"role":"author","vocabulary":"crossref"}]}],"member":"1968","published-online":{"date-parts":[[2026,3,18]]},"reference":[{"key":"ref_1","first-page":"229","article-title":"Global Cancer Statistics 2022: GLOBOCAN Estimates of Incidence and Mortality Worldwide for 36 Cancers in 185 Countries","volume":"74","author":"Bray","year":"2024","journal-title":"CA Cancer J. Clin."},{"key":"ref_2","doi-asserted-by":"crossref","unstructured":"Xie, Y., Peng, H., Hu, Y., Jia, K., Yuan, J., Liu, D., Li, Y., Feng, X., Li, J., and Zhang, X. (2025). Immune Microenvironment Spatial Landscapes of Tertiary Lymphoid Structures in Gastric Cancer. BMC Med., 23.","DOI":"10.1186\/s12916-025-03889-3"},{"key":"ref_3","doi-asserted-by":"crossref","first-page":"e009243","DOI":"10.1136\/jitc-2024-009243","article-title":"Mapping the Complexity and Diversity of Tertiary Lymphoid Structures in Primary and Peritoneal Metastatic Gastric Cancer","volume":"12","author":"Bos","year":"2024","journal-title":"J. Immunother. Cancer"},{"key":"ref_4","doi-asserted-by":"crossref","first-page":"19","DOI":"10.1111\/apm.13277","article-title":"Tertiary Lymphoid Structures and Gastric Cancer Prognosis","volume":"131","author":"Kemi","year":"2023","journal-title":"Acta Pathol. Microbiol. Immunol. Scand."},{"key":"ref_5","unstructured":"WHO Classification of Tumours Editorial Board (2019). Digestive System Tumours, International Agency for Research on Cancer. [5th ed.]."},{"key":"ref_6","unstructured":"Rugge, M., Carneiro, F., Fukayama, M., Yasui, W., Grabsch, H., and Znaor, A. (2019). Gastric Adenocarcinoma. WHO Classification of Tumours: Digestive System Tumours, International Agency for Research on Cancer."},{"key":"ref_7","doi-asserted-by":"crossref","first-page":"182","DOI":"10.1111\/his.13975","article-title":"The 2019 WHO Classification of Tumours of the Digestive System","volume":"76","author":"Nagtegaal","year":"2020","journal-title":"Histopathology"},{"key":"ref_8","doi-asserted-by":"crossref","unstructured":"Cancer Genome Atlas Research Network (2014). Comprehensive Molecular Characterization of Gastric Adenocarcinoma. Nature, 513, 202\u2013209.","DOI":"10.1038\/nature13480"},{"key":"ref_9","doi-asserted-by":"crossref","first-page":"449","DOI":"10.1038\/nm.3850","article-title":"Molecular Analysis of Gastric Cancer Identifies Subtypes Associated with Distinct Clinical Outcomes","volume":"21","author":"Cristescu","year":"2015","journal-title":"Nat. Med."},{"key":"ref_10","doi-asserted-by":"crossref","first-page":"150","DOI":"10.1159\/000350876","article-title":"Gastric Cancer Pathology and Underlying Molecular Mechanisms","volume":"30","author":"Grabsch","year":"2013","journal-title":"Dig. Surg."},{"key":"ref_11","doi-asserted-by":"crossref","first-page":"527","DOI":"10.1007\/s00428-024-03826-4","article-title":"Stroma AReactive Invasion Front Areas (SARIFA) Predict Poor Survival in Adenocarcinomas of the Stomach and Gastrooesophageal Junction: A Validation Study","volume":"485","author":"Ulase","year":"2024","journal-title":"Virchows Arch. Int. J. Pathol."},{"key":"ref_12","doi-asserted-by":"crossref","first-page":"73","DOI":"10.1007\/s10120-019-00983-3","article-title":"Infiltrating and Peripheral Immune Cell Analysis in Advanced Gastric Cancer According to the Lauren Classification and Its Prognostic Significance","volume":"23","author":"Pernot","year":"2020","journal-title":"Gastric Cancer"},{"key":"ref_13","doi-asserted-by":"crossref","unstructured":"Jiang, S., Liao, X., and Ding, X. (2024). Maturity and Density of Tertiary Lymphoid Structures Associate with Tumor Metastasis and Chemotherapy Response. Front. Med., 11.","DOI":"10.3389\/fmed.2024.1435620"},{"key":"ref_14","doi-asserted-by":"crossref","first-page":"570","DOI":"10.1038\/s41423-020-0457-0","article-title":"Tertiary Lymphoid Structures in Cancer-Considerations for Patient Prognosis","volume":"17","author":"Rhodes","year":"2020","journal-title":"Cell. Mol. Immunol."},{"key":"ref_15","doi-asserted-by":"crossref","first-page":"225","DOI":"10.1038\/s41392-024-01947-5","article-title":"Tertiary Lymphoid Structures in Diseases: Immune Mechanisms and Therapeutic Advances","volume":"9","author":"Zhao","year":"2024","journal-title":"Signal Transduct. Target. Ther."},{"key":"ref_16","doi-asserted-by":"crossref","first-page":"571","DOI":"10.1016\/j.it.2014.09.006","article-title":"Tertiary Lymphoid Structures in Cancer and Beyond","volume":"35","author":"Goc","year":"2014","journal-title":"Trends Immunol."},{"key":"ref_17","doi-asserted-by":"crossref","first-page":"2344","DOI":"10.1097\/JS9.0000000000000483","article-title":"Prediction Values of Tertiary Lymphoid Structures in the Prognosis of Patients with Left- and Right-Sided Colon Cancer: A Multicenter Propensity Score-Matched Study","volume":"109","author":"Mao","year":"2023","journal-title":"Int. J. Surg. Lond. Engl."},{"key":"ref_18","doi-asserted-by":"crossref","first-page":"4228","DOI":"10.1038\/s41467-025-59341-w","article-title":"Mature Tertiary Lymphoid Structures Evoke Intra-Tumoral T and B Cell Responses via Progenitor Exhausted CD4(+) T Cells in Head and Neck Cancer","volume":"16","author":"Li","year":"2025","journal-title":"Nat. Commun."},{"key":"ref_19","doi-asserted-by":"crossref","unstructured":"Chen, Y., Wu, Y., Yan, G., and Zhang, G. (2024). Tertiary Lymphoid Structures in Cancer: Maturation and Induction. Front. Immunol., 15.","DOI":"10.3389\/fimmu.2024.1369626"},{"key":"ref_20","doi-asserted-by":"crossref","first-page":"100063","DOI":"10.1016\/j.labinv.2023.100063","article-title":"Standardized Pathology Screening of Mature Tertiary Lymphoid Structures in Cancers","volume":"103","author":"Vanhersecke","year":"2023","journal-title":"Lab. Investig. J. Tech. Methods Pathol."},{"key":"ref_21","doi-asserted-by":"crossref","first-page":"374","DOI":"10.1016\/j.ccell.2023.02.016","article-title":"The Evolving Tumor Microenvironment: From Cancer Initiation to Metastatic Outgrowth","volume":"41","author":"Joyce","year":"2023","journal-title":"Cancer Cell"},{"key":"ref_22","doi-asserted-by":"crossref","unstructured":"Cozac-Sz\u0151ke, A.-R., Cozac, D.A., Negovan, A., Tinca, A.C., Vilaia, A., Cocuz, I.-G., Sab\u0103u, A.H., Niculescu, R., Chiorean, D.M., and Tomu\u021b, A.N. (2025). Immune Cell Interactions and Immune Checkpoints in the Tumor Microenvironment of Gastric Cancer. Int. J. Mol. Sci., 26.","DOI":"10.20944\/preprints202501.0608.v1"},{"key":"ref_23","doi-asserted-by":"crossref","unstructured":"Barone, F., Gardner, D.H., Nayar, S., Steinthal, N., Buckley, C.D., and Luther, S.A. (2016). Stromal Fibroblasts in Tertiary Lymphoid Structures: A Novel Target in Chronic Inflammation. Front. Immunol., 7.","DOI":"10.3389\/fimmu.2016.00477"},{"key":"ref_24","doi-asserted-by":"crossref","first-page":"205","DOI":"10.1038\/nri1786","article-title":"Lymphoid Neogenesis in Chronic Inflammatory Diseases","volume":"6","author":"Aloisi","year":"2006","journal-title":"Nat. Rev. Immunol."},{"key":"ref_25","doi-asserted-by":"crossref","first-page":"344","DOI":"10.1038\/ni1330","article-title":"Lymphoid Organ Development: From Ontogeny to Neogenesis","volume":"7","author":"Drayton","year":"2006","journal-title":"Nat. Immunol."},{"key":"ref_26","doi-asserted-by":"crossref","unstructured":"Saut\u00e8s-Fridman, C., Lawand, M., Giraldo, N.A., Kaplon, H., Germain, C., Fridman, W.H., and Dieu-Nosjean, M.-C. (2016). Tertiary Lymphoid Structures in Cancers: Prognostic Value, Regulation, and Manipulation for Therapeutic Intervention. Front. Immunol., 7.","DOI":"10.3389\/fimmu.2016.00407"},{"key":"ref_27","doi-asserted-by":"crossref","unstructured":"Colbeck, E.J., Ager, A., Gallimore, A., and Jones, G.W. (2017). Tertiary Lymphoid Structures in Cancer: Drivers of Antitumor Immunity, Immunosuppression, or Bystander Sentinels in Disease?. Front. Immunol., 8.","DOI":"10.3389\/fimmu.2017.01830"},{"key":"ref_28","doi-asserted-by":"crossref","first-page":"12139","DOI":"10.1073\/pnas.1412910111","article-title":"Fibroblastic Reticular Cells of the Lymph Node Are Required for Retention of Resting but Not Activated CD8+ T Cells","volume":"111","author":"Denton","year":"2014","journal-title":"Proc. Natl. Acad. Sci. USA"},{"key":"ref_29","doi-asserted-by":"crossref","first-page":"920","DOI":"10.1016\/j.it.2021.08.009","article-title":"Lymph Node Stromal Cells: Subsets and Functions in Health and Disease","volume":"42","author":"Grasso","year":"2021","journal-title":"Trends Immunol."},{"key":"ref_30","doi-asserted-by":"crossref","first-page":"350","DOI":"10.1038\/nri3846","article-title":"Lymph Node Fibroblastic Reticular Cells in Health and Disease","volume":"15","author":"Fletcher","year":"2015","journal-title":"Nat. Rev. Immunol."},{"key":"ref_31","doi-asserted-by":"crossref","first-page":"542","DOI":"10.1038\/nature10540","article-title":"Dendritic Cells Control Lymphocyte Entry to Lymph Nodes through High Endothelial Venules","volume":"479","author":"Moussion","year":"2011","journal-title":"Nature"},{"key":"ref_32","doi-asserted-by":"crossref","first-page":"eabf9419","DOI":"10.1126\/science.abf9419","article-title":"Tertiary Lymphoid Structures in Cancer","volume":"375","author":"Schumacher","year":"2022","journal-title":"Science"},{"key":"ref_33","doi-asserted-by":"crossref","first-page":"307","DOI":"10.1038\/s41568-019-0144-6","article-title":"Tertiary Lymphoid Structures in the Era of Cancer Immunotherapy","volume":"19","author":"Petitprez","year":"2019","journal-title":"Nat. Rev. Cancer"},{"key":"ref_34","doi-asserted-by":"crossref","first-page":"255","DOI":"10.5114\/aoms\/140622","article-title":"The Relationship of the Tertiary Lymphoid Structures with the Tumor-Infiltrating Lymphocytes and Its Prognostic Value in Gastric Cancer","volume":"20","author":"Zhang","year":"2024","journal-title":"Arch. Med. Sci."},{"key":"ref_35","doi-asserted-by":"crossref","first-page":"1948","DOI":"10.1016\/S0140-6736(18)32557-1","article-title":"Perioperative Chemotherapy with Fluorouracil plus Leucovorin, Oxaliplatin, and Docetaxel versus Fluorouracil or Capecitabine plus Cisplatin and Epirubicin for Locally Advanced, Resectable Gastric or Gastro-Oesophageal Junction Adenocarcinoma (FLOT4): A Randomised, Phase 2\/3 Trial","volume":"393","author":"Homann","year":"2019","journal-title":"Lancet Lond. Engl."},{"key":"ref_36","doi-asserted-by":"crossref","first-page":"11","DOI":"10.1056\/NEJMoa055531","article-title":"Perioperative Chemotherapy versus Surgery Alone for Resectable Gastroesophageal Cancer","volume":"355","author":"Cunningham","year":"2006","journal-title":"N. Engl. J. Med."},{"key":"ref_37","doi-asserted-by":"crossref","first-page":"2327","DOI":"10.1200\/JCO.2011.36.7136","article-title":"Updated Analysis of SWOG-Directed Intergroup Study 0116: A Phase III Trial of Adjuvant Radiochemotherapy versus Observation after Curative Gastric Cancer Resection","volume":"30","author":"Smalley","year":"2012","journal-title":"J. Clin. Oncol."},{"key":"ref_38","doi-asserted-by":"crossref","unstructured":"Yu, A., Cao, M., Zhang, K., Yang, Y., Ma, L., Zhang, X., Zhao, Y., Ma, X., Fan, Z., and Han, Z. (2023). The Prognostic Value of the Tertiary Lymphoid Structure in Gastrointestinal Cancers. Front. Immunol., 14.","DOI":"10.3389\/fimmu.2023.1256355"},{"key":"ref_39","doi-asserted-by":"crossref","unstructured":"Sun, H., Liu, Y., Cheng, W., Xiong, R., Gu, W., Zhang, X., Wang, X., Wang, X., Tan, C., and Weng, W. (2024). The Distribution and Maturation of Tertiary Lymphoid Structures Can Predict Clinical Outcomes of Patients with Gastric Adenocarcinoma. Front. Immunol., 15.","DOI":"10.3389\/fimmu.2024.1396808"},{"key":"ref_40","doi-asserted-by":"crossref","first-page":"1152","DOI":"10.1186\/s12967-024-05867-4","article-title":"Association of PD-1\u2009+\u2009Treg\/PD-1\u2009+\u2009CD8 Ratio and Tertiary Lymphoid Structures with Prognosis and Response in Advanced Gastric Cancer Patients Receiving Preoperative Treatment","volume":"22","author":"Liu","year":"2024","journal-title":"J. Transl. Med."},{"key":"ref_41","doi-asserted-by":"crossref","unstructured":"Yin, Y.-X., Ling, Y.-H., Wei, X.-L., He, C.-Y., Wang, B.-Z., Hu, C.-F., Lin, W.-P., Nie, R.-C., Chen, J.-W., and Lin, J.-L. (2022). Impact of Mature Tertiary Lymphoid Structures on Prognosis and Therapeutic Response of Epstein-Barr Virus-Associated Gastric Cancer Patients. Front. Immunol., 13.","DOI":"10.3389\/fimmu.2022.973085"},{"key":"ref_42","doi-asserted-by":"crossref","first-page":"e1378844","DOI":"10.1080\/2162402X.2017.1378844","article-title":"Maturation of Tertiary Lymphoid Structures and Recurrence of Stage II and III Colorectal Cancer","volume":"7","author":"Posch","year":"2018","journal-title":"Oncoimmunology"},{"key":"ref_43","doi-asserted-by":"crossref","first-page":"1251","DOI":"10.3126\/jpn.v8i1.19445","article-title":"Assessment of Lymphovascular Invasion in Gastric Carcinoma; Do They Always Indicate Lymph Node Metastasis?","volume":"8","author":"Pande","year":"2018","journal-title":"J. Pathol. Nepal."},{"key":"ref_44","doi-asserted-by":"crossref","first-page":"86","DOI":"10.1186\/s12957-024-03371-z","article-title":"Lymphovascular Invasion Is Associated with Poor Long-Term Outcomes in Patients with pT1N0-3 or pT2-3N0 Remnant Gastric Cancer: A Retrospective Cohort Study","volume":"22","author":"Sumiyoshi","year":"2024","journal-title":"World J. Surg. Oncol."},{"key":"ref_45","doi-asserted-by":"crossref","first-page":"527","DOI":"10.1016\/j.immuni.2022.02.001","article-title":"Tertiary Lymphoid Structures Generate and Propagate Anti-Tumor Antibody-Producing Plasma Cells in Renal Cell Cancer","volume":"55","author":"Meylan","year":"2022","journal-title":"Immunity"},{"key":"ref_46","doi-asserted-by":"crossref","unstructured":"Sun, H., Shi, Y., Ran, H., Peng, J., Li, Q., Zheng, G., He, Y., Liu, S., Chang, W., and Xiao, Y. (2023). Prognostic Value of Tertiary Lymphoid Structures (TLS) in Digestive System Cancers: A Systematic Review and Meta-Analysis. BMC Cancer, 23.","DOI":"10.1186\/s12885-023-11738-w"},{"key":"ref_47","doi-asserted-by":"crossref","first-page":"1875","DOI":"10.1016\/j.ejca.2008.05.017","article-title":"Intratumoural FOXP3-Positive Regulatory T Cells Are Associated with Adverse Prognosis in Radically Resected Gastric Cancer","volume":"44","author":"Perrone","year":"2008","journal-title":"Eur. J. Cancer"},{"key":"ref_48","doi-asserted-by":"crossref","first-page":"e1054598","DOI":"10.1080\/2162402X.2015.1054598","article-title":"Tumor Infiltration by Tbet+ Effector T Cells and CD20+ B Cells Is Associated with Survival in Gastric Cancer Patients","volume":"5","author":"Hennequin","year":"2016","journal-title":"Oncoimmunology"},{"key":"ref_49","doi-asserted-by":"crossref","first-page":"497","DOI":"10.1016\/j.cell.2020.05.039","article-title":"Multimodal Analysis of Composition and Spatial Architecture in Human Squamous Cell Carcinoma","volume":"182","author":"Ji","year":"2020","journal-title":"Cell"},{"key":"ref_50","doi-asserted-by":"crossref","first-page":"627","DOI":"10.1038\/s41576-021-00370-8","article-title":"Integrating Single-Cell and Spatial Transcriptomics to Elucidate Intercellular Tissue Dynamics","volume":"22","author":"Longo","year":"2021","journal-title":"Nat. Rev. Genet."},{"key":"ref_51","doi-asserted-by":"crossref","first-page":"227","DOI":"10.1038\/nrg3185","article-title":"Insights into the Regulation of Protein Abundance from Proteomic and Transcriptomic Analyses","volume":"13","author":"Vogel","year":"2012","journal-title":"Nat. Rev. Genet."}],"container-title":["Medical Sciences"],"original-title":[],"language":"en","link":[{"URL":"https:\/\/www.mdpi.com\/2076-3271\/14\/1\/145\/pdf","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2026,3,18]],"date-time":"2026-03-18T10:21:23Z","timestamp":1773829283000},"score":1,"resource":{"primary":{"URL":"https:\/\/www.mdpi.com\/2076-3271\/14\/1\/145"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2026,3,18]]},"references-count":51,"journal-issue":{"issue":"1","published-online":{"date-parts":[[2026,3]]}},"alternative-id":["medsci14010145"],"URL":"https:\/\/doi.org\/10.3390\/medsci14010145","relation":{},"ISSN":["2076-3271"],"issn-type":[{"value":"2076-3271","type":"electronic"}],"subject":[],"published":{"date-parts":[[2026,3,18]]}}}