ArticleESMO open2024
Results from the UNITED study: a multicenter study validating the prognostic effect of the tumor-stroma ratio in colon cancer.
Article in ESMO open, 2024. The graph could read no effect estimate from its abstract, so it casts no vote on the map. Cited by 17 papers, 1 of them a synthesis that pooled it.
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Who cites it
17 citing papers in PubMed, 1 synthesis or guideline pooled it.
- A scoping review of TSR analysis in colorectal cancer: implications for automated solutions.Oncology reviews · 2025Pooled it
- T1 Mapping-Derived Extracellular Volume Fraction for Non-Invasive Assessment of Tumor-Stroma Ratio in Rectal Cancer.Abdominal radiology (New York) · 2026Article
- Tumour-Stroma Ratio as a Predictive Biomarker for Neoadjuvant Therapy Efficacy in Rectal Cancer.Cancers · 2026Review
- Therapeutic Strategies Targeting the Tumor-Stromal Microenvironment in Colorectal Cancer: A Narrative Review.Targeted oncology · 2026Review
- A prospective study of tumor-stroma ratio in resected intrahepatic mass-forming cholangiocarcinoma: prognostic value and correlation with gadoxetic acid-enhanced MRI.European radiology · 2026Article
- Article
- Contrast-enhanced CT-derived extracellular volume fraction in preoperative prediction of tumor-stroma ratio in colorectal cancer.Abdominal radiology (New York) · 2026Article
- Artificial intelligence-based tumor-stroma ratio quantification reveals prognostic value and stromal-driven immunosuppression in colorectal cancer: an international validation study.Journal of translational medicine · 2026Article
- Mechanisms and Emerging Strategies to Overcome Immunotherapy Resistance in Cold Tumours of Colorectal Cancer.OncoTargets and therapy · 2026Review
- Automating tumor-stroma ratio quantification in colon cancer patients from the UNITED study.ESMO open · 2026Article
- Article
- Disease-Free Survival of Patients with Stage II Stroma-Rich Colorectal Adenocarcinomas with Microsatellite Stability.International journal of molecular sciences · 2025Article
- The tumour-stroma ratio as predictive aid towards a biopsy-based treatment strategy in rectal carcinoma.Histopathology · 2025Article
- Automated tumor-stroma ratio estimation for improved prognostic stratification of squamous cell carcinoma of the oral tongue.The journal of pathology. Clinical research · 2025Article
- Self-supervised learning reveals clinically relevant histomorphological patterns for therapeutic strategies in colon cancer.Nature communications · 2025Article
- The prognostic value of the tumor-stroma ratio compared to tumor-infiltrating lymphocytes in triple-negative breast cancer: a review.Virchows Archiv : an international journal of pathology · 2025Review
- Tumor-stroma ratio in colitis-associated colorectal cancer.Upsala journal of medical sciences · 2025Article
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20 authors.
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Abstract
backgroundThe TNM (tumor-node-metastasis) Evaluation Committee of Union for International Cancer Control (UICC) and College of American Pathologists (CAP) recommended to prospectively validate the cost-effective and robust tumor-stroma ratio (TSR) as an independent prognostic parameter, since high intratumor stromal percentages have previously predicted poor patient-related outcomes. PATIENTS AND
methodsThe 'Uniform Noting for International application of Tumor-stroma ratio as Easy Diagnostic tool' (UNITED) study enrolled patients in 27 participating centers in 12 countries worldwide. The TSR, categorized as stroma-high (>50%) or stroma-low (≤50%), was scored through standardized microscopic assessment by certified pathologists, and effect on disease-free survival (DFS) was evaluated with 3-year median follow-up. Secondary endpoints were benefit assessment of adjuvant chemotherapy (ACT) and overall survival (OS).
resultsA total of 1537 patients were included, with 1388 eligible stage II/III patients curatively operated between 2015 and 2021. DFS was significantly shorter in stroma-high (n = 428) than in stroma-low patients (n = 960) (3-year rates 70% versus 83%; P < 0.001). In multivariate analysis, TSR remained an independent prognosticator for DFS (P < 0.001, hazard ratio 1.49, 95% confidence interval 1.17-1.90). As secondary outcome, DFS was also worse in stage II and III stroma-high patients despite adjuvant treatment (3-year rates stage II 73% versus 92% and stage III 66% versus 80%; P = 0.008 and P = 0.011, respectively). In stage II patients not receiving ACT (n = 322), the TSR outperformed the American Society of Clinical Oncology (ASCO) criteria in identifying patients at risk of events (event rate 21% versus 9%), with a higher discriminatory 3-year DFS rate (stroma-high 80% versus ASCO high risk 91%). A trend toward worse 5-year OS in stroma-high was noticeable (74% versus 83% stroma-low; P = 0.102).
conclusionThe multicenter UNITED study unequivocally validates the TSR as an independent prognosticator, confirming worse outcomes in stroma-high patients. The TSR improved current selection criteria for patients at risk of events, and stroma-high patients potentially experienced chemotherapy resistance. TSR implementation in pathology diagnostics and international guidelines is highly recommended as aid in personalized treatment.
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