Prognostic role of neutrophil-to-lymphocyte ratio in head and neck cancer: A meta-analysis

Development and Validation of a Nomogram for Predicting Radiation-Induced Temporal Lobe Injury in Nasopharyngeal Carcinoma

Background

The purpose was to develop and validate a nomogram for prediction on radiation-induced temporal lobe injury (TLI) in patients with nasopharyngeal carcinoma (NPC).

Methods

The prediction model was developed based on a primary cohort that consisted of 194 patients. The data was gathered from January 2008 to December 2010. Clinical factors associated with TLI and dose–volume histograms for 388 evaluable temporal lobes were analyzed. Multivariable logistic regression analysis was used to develop the predicting model, which was conducted by R software. The performance of the nomogram was assessed with calibration and discrimination. An external validation cohort contained 197 patients from January 2011 to December 2013.

Results

Among the 391 patients, 77 patients had TLI. Prognostic factors contained in the nomogram were Dmax (the maximum point dose) of temporal lobe, D1cc (the maximum dose delivered to a volume of 1 ml), T stage, and neutrophil-to-lymphocyte ratios (NLRs). The Internal validation showed good discrimination, with a C-index of 0.847 [95%CI 0.800 to 0.893], and good calibration. Application of the nomogram in the external validation cohort still obtained good discrimination (C-index, 0.811 [95% CI, 0.751 to 0.870]) and acceptable calibration.

Conclusions

This study developed and validated a nomogram, which may be conveniently applied for the individualized prediction of TLI.

Prognostic significance of pre-treatment neutrophil-to-lymphocyte ratio (NLR) in patients with oropharyngeal cancer treated with radiotherapy

Background

This study aimed to evaluate the prognostic value of pre-treatment NLR in patients with oropharyngeal cancer.

Methods

Patients who completed definitive radiotherapy (RT) for oropharyngeal cancer and had blood counts taken pre-RT from 2002 to 2013 were included. NLR was calculated as total neutrophil/lymphocytes. Survival rates were estimated using the Kaplan–Meier method. Univariable and multivariable analyses were conducted with linear and Cox regression methods. NLR was analysed posteriori and dichotomised on the discovered median.

Results

Eight hundred and forty-eight patients were analysed. The median pre-RT NLR was 3. Patients with NLR of <3 had improved overall survival (OS) than those with NLR ≥ 3 (5-year OS 85 vs 74%, p < 0.0001). OS differences remained significant when stratified according to HPV status (HPV-positive p = 0.011; HPV-negative p = 0.003). Freedom from any recurrence (FFR), locoregional control (LRC) and freedom of distant recurrence (FDR) were better in those with NLR < 3. The negative impact of elevated pre-RT NLR on OS (HR = 1.64, p = 0.001), FFR (HR = 1.6, p = 0.006) and LRC (HR = 1.8, p = 0.005) remained significant on multivariable analysis.

Conclusions

Pre-RT NLR is an independent prognostic factor in patients with oropharyngeal cancer regardless of HPV status. Patients with lower NLR had more favourable OS and disease control.

Oral Neutrophils: Underestimated Players in Oral Cancer

The composition of the oral milieu reflects oral health. Saliva provides an environment for multiple microorganisms, and contains soluble factors and immune cells. Neutrophils, which rapidly react on the changes in the microenvironment, are a major immune cell population in saliva and thus may serve as a biomarker for oral pathologies. This review focuses on salivary neutrophils in the oral cavity, their phenotype changes in physiological and pathological conditions, as well as on factors regulating oral neutrophil amount, activation and functionality, with special emphasis on oral cancer and its risk factors.

Prognostic value of immune-related genes and immune cell infiltration analysis in the tumor microenvironment of head and neck squamous cell carcinoma

BACKGROUND

Head and neck squamous cell carcinoma (HNSCC) is one of the few malignant tumors that respond well to immunotherapy. We aimed to investigate the immune-related genes and immune cell infiltration of HNSCC and construct a predictive model for its prognosis.

METHODS

We calculated the stromal/immune scores of patients with HNSCC from The Cancer Genome Atlas using the Estimation of STromal and Immune cells in MAlignant Tumor tissues using Expression data algorithm and investigated the relationship between the scores and patients' prognosis. Three machine learning algorithms (LASSO, Random Forest, and Rbsurv) were performed to screen key immune-related genes and constructed a predictive model. The immune cell infiltrating was calculated by the Tumor Immune Estimation Resource algorithm.

RESULTS

The stromal and immune scores significantly correlated with prognosis. A 6-gene signature was selected and displayed a robust predictive effect. The expressions of key genes were associated with immune infiltrating. GSE65858 validated the results.

CONCLUSION

Our study comprehensively analyzed the tumor microenvironment of HNSCC and constructed a robust predictive model, providing a basis for further investigation of therapy.

Activated neutrophils exert myeloid-derived suppressor cell activity damaging T cells beyond repair

Myeloid-derived suppressor cells (MDSCs) have the capacity to suppress T-cell-mediated immune responses and impact the clinical outcome of cancer, infections, and transplantation settings. Although MDSCs were initially described as bone marrow-derived immature myeloid cells (either monocytic or granulocytic MDSCs), mature neutrophils have been shown to exert MDSC activity toward T cells in ways that remain unclear. In this study, we demonstrated that human neutrophils from both healthy donors and cancer patients do not exert MDSC activity unless they are activated. By using neutrophils with genetically well-defined defects, we found that reactive oxygen species (ROS) and granule-derived constituents are required for MDSC activity after direct CD11b-dependent interactions between neutrophils and T cells. In addition to these cellular interactions, neutrophils are engaged in the uptake of pieces of T-cell membrane, a process called trogocytosis. Together, these interactions led to changes in T-cell morphology, mitochondrial dysfunction, and adenosine triphosphate depletion, as indicated by electron microscopy, mass spectrometry, and metabolic parameters. Our studies characterize the different steps by which activated mature neutrophils induce functional T-cell nonresponsiveness and irreparable cell damage.

Neutrophil-to-lymphocyte ratio as a prognostic indicator for overall and cancer-specific survival in squamous cell carcinoma of the head and neck

BACKGROUND

Neutrophil-to-lymphocyte ratio (NLR) is a biomarker that is correlated with systemic inflammation and poor prognosis in solid tumors. We investigated the value of NLR in predicting survival in a large population of head and neck cancer patients in the United States.

METHODS

We performed a retrospective cohort study of Veterans Affairs patients with head and neck squamous cell carcinoma (HNSCC) diagnosed between January 2000 and December 2017. We compared 5-year overall survival and cancer-specific survival for different NLR tertiles using cox proportional hazards modeling with adjustment for covariates.

RESULTS

The primary cohort consisted of 14 644 subjects of which 99% were male. Relative to patients with NLRs in the lower tertile, patients with NLRs in the top tertile had an 71% increased hazard of all-cause mortality (P < .001) and 44% increased hazard of cancer-specific mortality (P < .001) at 5 years.

CONCLUSIONS

Elevated NLR in HNSCC confers a poor prognosis.

A retrospective study on the prognostic value of preoperative C-reactive protein to albumin ratio in patients with oral cavity squamous cell carcinoma

Background

Although the C-reactive protein-to-albumin ratio (CAR) can predict poor outcomes in assorted cancers, its prognostic value in oral cavity squamous cell carcinoma (OSCC) remains unclear. We explored the value of preoperative CAR in predicting clinical outcomes in OSCC patients treated with radical surgery.

Methods

All the recommended cutoff values were defined analyzing receiver operating characteristic curves or overall survival (OS). Dichotomization was performed on the basis of optimal CAR cutoff, and we compared the clinicopathological features between groups. Kaplan-Meier analysis was also performed to compare OS curves between the two groups. Univariate and multivariate analyses using the Cox proportional hazards model were conducted to find the clinical characteristics that were most closely correlated with disease free survival (DFS) and overall survival (OS). A nomogram incorporated CAR and several clinicopathological factors was established to predict prognosis and its accuracy was evaluated using concordance index (c-index).

Results

In this retrospective study, a total of 326 patients with newly diagnosis of OSCC and received primary surgery between 2008 and 2017 were enrolled. Through the executed ROC curve analyses, the optimal CAR cutoff derived was 0.195 (area under the curve = 0.718, p < 0.001), with this cutoff exhibiting a discrimination ability superior to that of other inflammation-based prognostic scores after comparing the area under curves. Multivariate analysis demonstrated that CAR (≥0.195/<0.195) was associated with OS (hazard ratio 3.614; 95% CI [1.629-8.018]; p = 0.002) and DFS (hazard ratio 1.917; 95% CI [1.051-3.863]; p = 0.029). Kaplan-Meier analysis and log rank test revealed a significant difference in DFS and OS curves between patients with low CAR (<0.195) and those with high CAR (≥0.195; both p < 0.001). The c-index of the nomogram based on TNM system alone was 0.684 and could be increased to 0.801 if CAR and other clinicopathological factors were included.

Conclusions

Preoperative CAR could constitute an independent prognostic indicator for OS and DFS prediction in OSCC patients treated with curative surgery. The established nomogram that incorporated CAR and prognostic factors might increase the accuracy of prognostic prediction for patients with OSCC.

Inflammatory markers as prognostic factors of recurrence in advanced-stage squamous cell carcinoma of the head and neck

Background

Multiple immunologic parameters have provided useful prognostic and assessment significance in various cancers, including head-and-neck squamous cell carcinoma (scc). We sought to identify whether pretreatment inflammatory markers could prognosticate recurrence in patients with advanced (stage iii or iv) head-and-neck scc who underwent therapy with curative intent in a tertiary care centre between January 2010 and December 2012.

Methods

In a chart review, we recorded demographics; primary tumour characteristics; p16 status; pretreatment inflammatory markers, including body mass index (bmi), neutrophil-to-lymphocyte ratio (nlr), C-reactive protein (crp), and serum albumin; therapy received; and date of relapse, death, or last follow-up. The main outcome was relapse-free survival (rfs). Overall survival (os) was a secondary outcome.

Results

From among 235 charts reviewed, 118 cases were included: 86 oropharyngeal (50 p16-positive, 18 p16-negative, 17 p16 unavailable, 1 p16 indeterminate), and 32 non-oropharyngeal (7 p16-positive, 19 p16-negative, 6 p16 unavailable). Median follow-up was 2.45 years (25%-75% interquartile range: 1.65-3.3 years). In univariate analysis, p16 status, bmi, modified Glasgow prognostic score, and crp were significant for rfs, but in multivariate analysis, only p16 status, bmi, and crp remained significant. For os, only crp and nlr were significant in both the univariate and multivariate analyses. After adjustment for p16 status, nlr did not remain significant. After adjustment for p16 status, crp remained significant for both rfs and os.

Conclusions

In patients with head-and-neck scc, a stronger prognostic value is associated with human papillomavirus status than with nlr and many other factors, including bmi and albumin. However, even though few of our patients had high crp, serum crp remained significant despite p16-positive status.

Neutrophil-to-Lymphocyte Ratio and Platelet-to-Lymphocyte Ratio as Prognostic Hematologic Markers of Bell's Palsy: A Meta-analysis

OBJECTIVE

Bell's palsy (BP) is the most common cause of unilateral peripheral facial paralysis, and inflammation has been proposed as the main pathological cause. The study aim was to investigate the relationship between hematologic inflammatory markers, including the neutrophil-to-lymphocyte ratio (NLR) and platelet-to-lymphocyte ratio (PLR), and BP.

DATA SOURCES

The following key words were used to search PubMed and Scopus for English language articles: Bell's palsy, facial palsy, facial paresis or facial paralysis, neutrophil, lymphocyte, and platelet.

STUDY SELECTION

Articles related to BP with NLR or PLR data.

DATA EXTRACTION

The data included patient profiles, House-Brackmann score, treatment modality, NLR, and PLR.

DATA SYNTHESIS

Seven articles were selected. A random effect model was used to analyze the aggregated data. Six of these articles that included the NLR and two that included the PLR of BP and control patients were analyzed for the difference between BP and control patients. Three articles that included the NLR of the recovery and nonrecovery groups were analyzed for the relationship between NLR and recovery.

CONCLUSIONS

The NLR was significantly higher for the BP patients than for the controls. Furthermore, the NLR was significantly lower for the recovery group than for the nonrecovery group. A high NLR was associated with poor prognosis and related to the severity of facial nerve inflammation. There was no significant difference between the PLRs of the BP patients and controls. The NLR, but not the PLR, was found to be a useful prognostic indicator of BP.

Pre-treatment tumor size impacts on response to nivolumab in head and neck squamous cell carcinoma

OBJECTIVE

Baseline tumor size has been reported to be predictive of immune checkpoint inhibitor efficacy in melanoma and lung cancer. We investigated whether pre-treatment tumor size (PTS) is predictive of progression-free survival (PFS) and tumor shrinkage in head and neck squamous cell carcinoma (HNSCC) patients treated with nivolumab.

METHODS

We retrospectively assessed 37 patients who had measurable tumor lesions. PTS and post-treatment tumor size were defined as the sum of the size in all measurable lesions.

RESULTS

In univariate analysis, PTS below 42 mm, history of radiation therapy, and no use of cetuximab were significantly associated with longer PFS. Among them, small-PTS was an independent predictive factor for PFS in multivariate analysis (hazard ratio: 0.33, p = 0.022). In addition, significantly greater tumor shrinkage was observed for small-PTS than large-PTS (median: -10.0% vs. 23.1%, p = 0.033).

CONCLUSION

PTS may impact the response to nivolumab in HNSCC patients.

Pretreatment peripheral blood leukocytes are independent predictors of survival in oral cavity cancer

BACKGROUND

Inflammation and immune surveillance evasion are cancer hallmarks. Peripheral blood leukocytes (PBLs) represent both. The aim of the current study was to examine PBLs as predictors of outcomes in oral cavity squamous cell carcinoma (OSCC), and to find specific cutoffs with the goal of including PBLs as host factor in patients' preoperative risk assessment.

METHODS

Previously established head and neck squamous cell carcinoma (HNSCC) cutoffs were examined in an independent cohort of 1369 OSCC patients. Then optimal OSCC cutoffs were found and validated in the subset of patients with OSCC (n = 119) from the external HNSCC cohort. The PBLs analyzed were neutrophils, monocytes, and lymphocytes individually, the neutrophil-to-lymphocyte ratio (NLR), and a combined index using all PBLs called Systemic Inflammation Response Index (SIRI).

RESULTS

All parameters were significant predictors of survival using the previous cutoffs. However, OSCC cutoffs stratified survival outcomes better. Considering neutrophils ≤4.8 × 10⁹ /L as reference, patients with 4.8-9.1 × 10⁹ /L neutrophils had 1.536 times higher risk of death (95% CI, 1.295-1.822), and patients with ≥9.1 × 10⁹ /L had 3.076 times higher risk (95% CI: 2.170-4.360). All PBLs maintained independent prognostic capacity in multivariable analysis. Neutrophils, NLR, and SIRI were significant predictors of survival when validating OSCC cutoffs in the external validation cohort.

CONCLUSIONS

Pretreatment peripheral blood neutrophils, NLR, and SIRI are the most robust independent predictors of overall survival among all PBLs in OSCC. The authors report externally validated cutoffs that demonstrate the feasibility of including PBLs as host features in the preoperative prognostication of OSCC.

Immunotherapy in head and neck cancer: The great challenge of patient selection

The development of immune checkpoint inhibitors (ICIs) revolutionized the therapeutic landscape in head and neck cancer. However, the majority of patients present primary resistance to ICIs and do not benefit from use of these agents, highlighting the need of developing predictive biomarkers to better determine who will benefit from treatment with ICIs. Patient's related clinical characteristics, disease related features, pathological and molecular factors, as well as emerging immune predictive biomarkers can be considered for the selection of those patients who would be the best candidate for immunotherapy. We examined these factors, emerging from the results of currently available studies in head and neck squamous cell carcinoma (HNSCC), in order to provide a useful tool which could assist the oncologist in their clinical practice.

Prognostic Nomograms in Oral Squamous Cell Carcinoma: The Negative Impact of Low Neutrophil to Lymphocyte Ratio

Objectives: To investigate the prognostic significance of preoperative neutrophil to lymphocyte ratio (NLR) and the impact of different clinical-pathologic factors in a series of primary oral squamous cell carcinomas (OSCC).

Materials and Methods: All naive OSCCs treated with upfront surgery between 2000 and 2014 were retrospectively reviewed. Patients with distant metastasis, synchronous head and neck cancer, immunological disorders, or who had received previous chemotherapy and/or radiation of the head and neck area were excluded. The main outcomes were overall (OS), disease-specific (DSS), loco-regional free (LRFS), and distant metastasis free (DMFS) survivals. Univariate (Kaplan-Meier) and multivariate (Cox regression model) analysis were performed, and nomograms developed for each outcome. NLR was analyzed as a continuous variable using restricted cubic spline multivariable Cox regression models.

Results: One-hundred-eighty-two patients were included. Five-year estimates for LRFS, DMFS, DSS, and OS were 67, 83.7, 69.5, and 61.2%, respectively. NLR had a complex influence on survival and risk of recurrence: negative for very low and high values, while positive in case of intermediate ratios. At univariate analysis, T classification, 7th AJCC stage, nodal metastasis, perineural spread, and lymphovascular invasion were statistically significant. At multivariate analysis, extranodal extension (ENE) and perineural spread were the most powerful independent prognostic factors. NLR was an independent prognosticator for the risk of recurrence. In nomograms, NLR and ENE had the strongest prognostic effect.

Conclusions: In OSCC, very low preoperative NLR values have a negative prognostic impact on survival and recurrence, similarly to high ratios. ENE and perineural spread are the most important clinical-pathologic prognosticators.

Increased neutrophil lymphocyte ratio and platelet lymphocyte ratio in malignant parotid tumors

Introduction

Recently it has been reported that a high preoperative neutrophil–lymphocyte ratio and platelet–lymphocyte ratio may be related to increased recurrence risk, tumor aggressiveness, and worsened prognosis in various malignancies.

Objective

The objective of this research is to explore whether neutrophil–lymphocyte ratio and platelet–lymphocyte ratio in parotid tumors may or may not be used as a cancer marker.

Methods

This retrospective research has been conducted on a total of 228 patients consisting of 83 healthy persons and 145 patients with a mass in the parotid gland, who applied to a tertiary referral center and underwent surgery. Patients have been divided into two groups by their histopathological findings as malignant or benign parotid tumor. A third group consisting of healthy people has been defined as the control group. Also the malignant parotid tumor group has been divided into two subgroups as early stage and advanced stage. The groups have been compared in terms of neutrophil–lymphocyte ratio, platelet–lymphocyte ratio and other laboratory data.

Results

The average neutrophil–lymphocyte ratio values of malignant parotid tumor, benign parotid tumor, healthy control groups were 2.51, 2.01, 1.79 respectively and the difference was statistically significant (p < 0.001). There was no significant difference between advanced stage and early stage parotid tumor groups in terms of average neutrophil–lymphocyte ratio value (p = 0.782). In dual comparisons, the platelet–lymphocyte ratio value of patients in the malignant group was found out to be statistically significantly higher than that of benign and control groups (p < 0.001 and p = 0.001 respectively).

Conclusion

To the best of our knowledge our research is the first in the medical literature comparing neutrophil–lymphocyte ratio and platelet–lymphocyte ratio in patients with parotid tumor. neutrophil–lymphocyte ratio and platelet–lymphocyte ratio can serve as cost-effective, repeatable, easily accessible, and helpful inflammatory markers in order to distinguish patients with malignant parotid tumor from healthy people.

Anemia and neutrophil-to-lymphocyte ratio in laryngeal cancer treated with induction chemotherapy

OBJECTIVES/HYPOTHESIS

We studied the influence of the neutrophil-to-lymphocyte ratio (NLR) and anemia on the response to induction chemotherapy (IC) and survival outcomes in laryngeal cancer patients treated with a preservation protocol.

STUDY DESIGN

Retrospective single-center case series.

METHODS

We analyzed patients with T3 laryngeal cancer treated with IC using a preservation protocol. The NLR and hemoglobin levels were assessed before treatment and after IC. The response to chemotherapy was assessed using Response Evaluation Criteria in Solid Tumours 1.1 and World Heath Organization standards. The oncological endpoints were overall survival (OS) and disease-free survival (DFS).

RESULTS

Sixty-eight patients were analyzed. The median NLR and hemoglobin levels before and after IC were 2.76 and 14.5 g/dL, and 2.01 and 11.6 g/dL, respectively. The NLR and anemia before treatment were not correlated, and they were not associated with the response to chemotherapy. However, an NLR > 5 and anemia before treatment were both associated with shorter OS and DFS. Notably, they were the only factors found to be significantly associated with survival outcomes.

CONCLUSIONS

In laryngeal cancer, patients treated with a preservation protocol, a high NLR ratio, and anemia before IC were associated with shorter survival, independently of the response to chemotherapy.

LEVEL OF EVIDENCE

4 Laryngoscope, 130:E144-E150, 2020.

The prognosis of head and neck squamous cell carcinoma related to immunosuppressive tumor microenvironment regulated by IL-6 signaling

Evasion of immune surveillance is a significant factor in head and neck squamous cell carcinoma (HNSCC) carcinogenesis. IL-6 signaling is a critical mechanism for the induction of dysfunctional immune responses. In the present study, we examined the role of IL-6 in the prognosis of HNSCC regarding the immunosuppressive tumor microenvironment. We retrospectively analyzed the clinical outcomes of HNSCC patients and examined its correlation with the levels of IL-6 in tumors and circulating myeloid-derived suppressor cells (MDSCs) in peripheral blood. Furthermore, the relationships between IL and 6, programmed death ligand (PD-L1) expression, and immune response were examined in vitro and in vivo. Our data revealed that IL-6 overexpression was associated with the increased risk of developing disease failure and poor prognosis for HNSCC. The immunoreactivity of IL-6 in HNSCC specimens was positively linked to the staining of PD-L1 and the level of circulating MDSCs. By cellular and animal experiments, there were augmented radiation-induced increases in the expression of PD-L1 and the activation of MDSCs noted in IL-6-positive tumors. When IL-6 signaling was inhibited, the levels of PD-L1 and MDSC recruitment were significantly down-regulated. Furthermore, the neutrophil-to-lymphocyte ratio (NLR) was positively correlated with the levels of IL-6 and PD-L1 in tumor, and circulating MDSCs. In conclusion, IL-6 is a significant predictor of treatment outcome in HNSCC patients, and plays an important role in the induction of immunosuppressive tumor microenvironment mediated by increased MDSCs and PD-L1 expression. Furthermore, IL-6 combined with NLR can assist the clinician to make an informed decision regarding treatment options.

Tumor-Infiltrating T Cell Receptor-Beta Repertoires are Linked to the Risk of Late Chemoradiation-Induced Temporal Lobe Necrosis in Locally Advanced Nasopharyngeal Carcinoma

PURPOSE

Temporal lobe necrosis (TLN), a late complication of nasopharyngeal carcinoma (NPC) after concurrent chemoradiotherapy (CCRT), causes permanent neurologic deficits. We aimed to investigate the risk factors for the development of CCRT-induced TLN in locally advanced NPC patients.

METHODS AND MATERIALS

The incidence of CCRT-induced TLN was assessed in consecutive patients with NPC initially staged with T_3-4N_0-3M₀ receiving curative intensity modulated radiation therapy (IMRT) and cisplatin-based chemotherapy with long-term follow-up. The TLN risk was evaluated with radiation dose-volume histograms (a dosimetric risk indicator of organ injury) and the dynamics of blood circulating neutrophil-to-lymphocyte ratios (a clinical indicator of systemic inflammation) by linear and logistic regression models. High-throughput unbiased T cell receptor-beta (TCR_beta) sequencing was performed to correlate the different TCR_beta repertoires of NPC-infiltrating lymphocytes (a biological factor of the immune microenvironment) with TLN incidence.

RESULTS

In the era of modern IMRT-based CCRT, radiation doses of up to 74 Gy achieved local control rates of more than 90% in both T₃ and T₄ diseases but still induced a remarkably higher incidence of TLN in the T₄ patients (30.14%) compared with the rare incidence of TLN observed in the T₃ patients (2.78%) (P < .0001). We found that in the T₄ NPC patients, univariate and multivariate analyses showed the radiation tolerance dose-volume effect was not an absolutely independent factor influencing TLN occurrence. However, increased TLN risk was observed in association with higher pre-CCRT baseline and post-CCRT neutrophil-to-lymphocyte ratios. There was also a link between intratumoral TCR_beta repertoire subtypes and TLN incidence. Combining the inherent TCR_beta genomic susceptibility with the clinical variable neutrophil-to-lymphocyte ratio better predicted the risk of TLN for T₄ NPC patients after CCRT.

CONCLUSIONS

The associations of tumor-infiltrating lymphocyte repertoires and blood circulating neutrophil-to-lymphocyte ratios with TLN occurrence in T₄ NPC patients suggest that the immune and inflammatory milieus play roles in the late brain damage caused by CCRT. Modulated or provoked by CCRT locally and systemically, the reciprocal interactions of neutrophils and lymphocytes in the intracranial NPC-associated immune microenvironment could be a key driver of chronic TLN pathogenesis.

High pretreatment neutrophil-to-lymphocyte ratio as a predictor of poor survival prognosis in head and neck squamous cell carcinoma: Systematic review and meta-analysis

Background

The prognostic roles of neutrophil‐to‐lymphocyte ratio (NLR) and platelet‐to‐lymphocyte ratio (PLR) have been reported in head and neck squamous cell carcinoma (HNSCC), but their results remain controversial.

Methods

A total of 25 literatures with 28 cohorts involving 6847 HNSCC patients were included. The hazard ratio (HR) was pooled with 95% confidence interval (CI) using fixed‐effects or random‐effects models.

Results

High pretreatment NLR predicted poor overall survival (OS: HR = 1.68; 95% CI = 1.39‐2.03; P < .001), disease‐free survival (DFS: HR = 1.76; 95% CI = 1.42‐2.17; P < .001), progression‐free survival (PFS: HR = 1.53; 95% CI = 1.09‐2.14; P = .014), and cancer‐specific survival (CSS: HR = 1.45; 95% CI = 1.23‐1.71; P < .001) in HNSCC. However, the association between PLR and OS or DFS was not statistically significant.

Conclusion

The NLR can serve as a potential prognostic biomarker for patients with HNSCC.

Relation of baseline neutrophil-to-lymphocyte ratio to survival and toxicity in head and neck cancer patients treated with (chemo-) radiation

Background

A high neutrophil-to-lymphocyte ratio (NLR) is a marker of systemic inflammation and together with the platelet-to-lymphocyte ratio (PLR) is associated with worse outcomes in several solid tumors. We investigated the prognostic value of NLR and PLR in patients with head and neck squamous cell carcinoma (HNSCC) treated with primary or adjuvant (chemo)radiotherapy ((C)RT).

Methods

A retrospective chart review of consecutive patients with HNSCC was performed. Neutrophil-to-lymphocyte ratio and PLR were computed using complete blood counts (CBCs) performed within 10 days before treatment start. The prognostic role of NLR and PLR was evaluated with univariable and multivariable Cox regression analyses adjusting for disease-specific prognostic factors. NLR and PLR were assessed as log-transformed continuous variables (log NLR and log PLR). Endpoints of interest were overall survival (OS), locoregional recurrence-free survival (LRFS), distant recurrence-free survival (DRFS), and acute toxicity.

Results

We analyzed 186 patients treated from 2007 to 2010. Primary sites were oropharynx (45%), oral cavity (28%), hypopharynx (14%), and larynx (13%). Median follow-up was 49 months. Higher NLR was associated with OS (adjusted HR per 1 unit higher log NLR = 1.81 (1.16–2.81), p = 0.012), whereas no association could be shown with LRFS (HR = 1.49 (0,83-2,68), p = 0.182), DRFS (HR = 1.38 (0.65–3.22), p = 0.4), or acute toxicity grade ≥ 2. PLR was not associated with outcome, nor with toxicity.

Conclusion

Our data suggest that in HNSCC patients treated with primary or adjuvant (C)RT, NLR is an independent predictor of mortality, but not disease-specific outcomes or toxicity. Neutrophil-to-lymphocyte ratio is a readily available biomarker that could improve pre-treatment prognostication and may be used for risk-stratification.

The Predictive Value of Pretreatment Neutrophil-To-Lymphocyte Ratio in Esophageal Squamous Cell Carcinoma

BACKGROUND

The neutrophil-to-lymphocyte ratio (NLR) has been reported to be both a prognostic biomarker for cancer and associated with inflammation, but its predictive role in tumor immunity is not clear. The present study examined the correlations of the NLR and immune suppression with the prognoses in patients with esophageal squamous cell carcinoma (ESCC).

METHODS

We performed a retrospective review of 1168 patients who were newly diagnosed with stage T1N(+) and T2-T4 ESCC at our hospital. The NLR of each ESCC patient prior to treatment was calculated, and the associations of the NLR with various clinicopathological parameters and prognoses were then examined. In addition, correlations of the proportion of myeloid-derived suppressor cells (MDSCs) and level of interleukin (IL)-6 with the NLR were assessed in 242 ESCC patients.

RESULTS

An elevated NLR was significantly correlated with advanced-stage disease and reduced overall survival (OS) of ESCC patients. Furthermore, the levels of IL-6 in tumors and MDSCs in the peripheral circulation were significantly correlated with the prognoses of ESCC, and the NLR was positively correlated with MDSC levels in the circulation and IL-6 staining intensity in tumor specimens. Moreover, a high NLR was significantly associated with reduced OS in the 926 patients treated with concomitant chemoradiotherapy, but not in the 242 patients who underwent surgical intervention.

CONCLUSION

The NLR may represent a clinically useful biomarker to guide ESCC treatment decisions. Patients with a higher NLR may be an optimal subgroup for IL-6- and MDSC-targeted therapy.

Prognostic Significance of Sarcopenia With Inflammation in Patients With Head and Neck Cancer Who Underwent Definitive Chemoradiotherapy

Purpose: With growing evidence that inflammation and low muscularity play a role in the survival of cancer patients, we evaluated the prognostic implications of sarcopenia with systemic inflammation in patients who underwent definitive chemoradiotherapy (CCRT) for locally advanced head and neck cancer.

Materials and Methods: We analyzed 221 patients with head and neck cancer who received definitive CCRT between 2006 and 2015. The skeletal muscle area was measured using a single computed tomography image slice at the level of the third lumbar vertebra (L3). Sarcopenia was defined as an L3 muscle index of <49 cm²/m² for men and <31 cm²/m² for women.

Results: Patients with sarcopenia (n = 106) exhibited higher neutrophil/lymphocyte ratios (NLRs) than those without (n = 115); the former also had an inferior 3-year overall survival (OS) rate (62%) than the latter (76%, p = 0.037). Among patients with sarcopenia, those who also had high NLRs (n = 51) showed significantly poorer OS and progression-free survival (PFS). In the multivariate analysis, sarcopenia plus a high NLR remained the most significant predictor of poor OS and PFS. Patients with sarcopenia required more frequent interruption of RT; patients whose RT was interrupted for ≥5 days showed inferior disease control and OS.

Conclusions: Sarcopenia accompanied by systemic inflammation at initial diagnosis is associated with significantly inferior OS and PFS. Additionally, patients with sarcopenia required RT interruption more frequently. Intensive nutritional support and additional treatment methods are required for these patients while undergoing RT.

Optimal cutoff of pretreatment neutrophil-to-lymphocyte ratio in head and neck cancer patients: a meta-analysis and validation study

BACKGROUND

The prognostic role of neutrophil-to-lymphocyte ratio (NLR) has been proposed in head and neck squamous cell carcinoma (HNSCC). However, it is currently unclear which cutoff values of NLR could consistently and independently differentiate HNSCC patients to better and worse prognosis groups.

METHODS

We performed a meta-analysis of prognostic significance of pretreatment NLR values, using data extracted from 24 relevant articles. Main outcomes were overall survival (OS) and disease-free survival (DFS) in HNSCC patients. Pooled hazard ratio (HR) and 95% confidence intervals (95%CI) were calculated using the random effect model for outcomes. Impacts of NLR cutoff values across the studies were assessed with a meta-regression analysis. Results were validated using an independent data set of patients (n = 540).

RESULTS

Pretreatment high NLR values above the cutoff were significantly associated with shorter OS (HR = 1.96, 95%CI = 1.66-2.31) and DFS (HR = 1.90, 95%CI = 1.41-2.54). Of note, NLR cutoffs ranging from 1.9 to 6.0 did not affect HR of OS or DFS in meta-regression analyses. In an independent cohort, any NLR cutoff between 2 and 6 produced significant HR of OS, similarly. Instead of binary cutoffs, three subgroups of NLR (< 2, 2 to 6, and ≥ 6) showed significant differences of OS in survival analyses.

CONCLUSIONS

Meta-analyses confirmed that pretreatment NLR values above the cutoff were associated with shorter survival in HNSCC patients. However, the binary cutoffs of NLR values were variable across studies. Rather, pretreatment NLR values below 2 and above 6 using a three-tier classification (< 2, 2 to 6, and ≥ 6) could consistently imply better and worse prognosis in HNSCC patients, which could be readily translated to clinics.

DNA methylation derived systemic inflammation indices are associated with head and neck cancer development and survival

OBJECTIVES

Head and neck squamous cell carcinoma (HNSCC) is often associated with chronic systemic inflammation (SI). In the present study, we assessed if DNA methylation-derived SI (mdSI) indices: Neutrophil-to-Lymphocyte ratio (mdNLR) and Lymphocyte-to-Monocyte ratio (mdLMR) are associated with the presence of HNSCC and overall survival (OS).

MATERIALS AND METHODS

We used two peripheral blood DNA methylation datasets: an HNSCC case-control dataset (n = 183) and an HNSCC survival dataset (n = 407) to estimate mdSI indices. We then performed multivariate regressions to test the association between mdSI indices, HNSCC development and OS.

RESULTS

Multivariate logistic regression revealed that elevated mdNLR was associated with increased odds of being an HNSCC case (OR = 3.25, 95% CI = 2.14-5.34, P = 4 × 10-7) while the converse was observed for mdLMR (OR = 0.88, 95% CI = 0.81-0.90, P = 2 × 10-3). In the HNSCC survival dataset, HPV16-E6 seropositive HNSCC cases had an elevated mdLMR (P = 9 × 10-5) and a lower mdNLR (P = 0.003) compared to seronegative patients. Multivariate Cox regression in the HNSCC survival dataset revealed that lower mdLMR (HR = 1.96, 95% CI = 1.30-2.95, P = 0.0013) but not lower mdNLR (HR = 0.68, 95% CI = 0.46-1.00, P = 0.0501) was associated with increased risk of death.

CONCLUSION

Our results indicate that mdSI estimated by DNA methylation data is associated with the presence of HNSCC and overall survival. The mdSI indices may be used as a valuable research tool to reliably estimate SI in the absence of cell-based estimates. Rigorous validation of our findings in large prospective studies is warranted in the future.

Predictive Value of the Pretreatment Neutrophil-to-Lymphocyte Ratio in Head and Neck Squamous Cell Carcinoma

This study assessed the significance of the neutrophil-to-lymphocyte ratio (NLR) in head and neck squamous cell carcinoma (HNSCC), and the relationships of the NLR with the aldehyde dehydrogenase 1 (ALDH1) level in tumors and the proportion of myeloid-derived suppressor cells (MDSCs) in the peripheral circulation. In total, 227 HNSCC patients who had received curative treatment at our hospital were enrolled into the present study. The NLR of each HNSCC patient before treatment was calculated. The associations of NLR with various clinicopathological parameters and prognoses were then examined. In addition, correlations between the proportion of MDSCs and level of ALDH1 with the NLR were assessed. Our data revealed that an elevated NLR was significantly correlated with the risk of developing locoregional recurrence and with a reduced overall survival in HNSCC patients. Multivariate analyses revealed that the NLR pretreatment and surgical resection were significantly correlated with the rate of treatment failure and the overall survival rate in HNSCC patients. Furthermore, the levels of ALDH1 in tumors and MDSCs in the peripheral circulation were significantly correlated with the prognosis of HNSCC, and the NLR was positively correlated with MDSC levels in the circulation and ALDH1 staining intensity in tumor specimens. In conclusion, the NLR has power in predicting the expression of ALDH1 in tumors, the circulating level of MDSCs, and the prognosis in HNSCC. We suggest that the NLR is an important biomarker that can assist the clinician and patient in making informed decisions regarding treatment options for HNSCC patients.

Platelet count and platelet-lymphocyte ratio as prognostic markers for head and neck squamous cell carcinoma: Meta-analysis

BACKGROUND

Thrombocytosis is associated with the prognosis of various types of cancer. The purpose of this study was to quantify the prognostic impact of platelet count and platelet-lymphocyte ratio (PLR) in head and neck squamous cell carcinoma (HNSCC).

METHODS

We systematically searched electronic databases and identified articles reporting an association between platelet count or PLR and HNSCC prognosis. Hazard ratios (HRs) and 95% confidence intervals (CIs) for overall survival (OS) were extracted, and the pooled HRs were estimated using random effect models.

RESULTS

Eight studies that enrolled 4096 patients and 9 studies that enrolled 2327 patients were included in the platelet count and PLR analyses, respectively. A platelet count greater than the cutoff value was associated with poor OS (HR 1.81; 95% CI 1.16-2.82) and any PLR greater than the cutoff value was associated with poor OS (HR 1.64; 95% CI 1.13-2.37).

CONCLUSION

Elevated platelet count and PLR are associated with poor prognosis in patients with HNSCC.

Pretreatment serum lactate dehydrogenase as a prognostic indicator for oral cavity squamous cell carcinoma

OBJECTIVES

To examine whether lactate dehydrogenase (LDH) can predict the prognosis of oral cavity squamous cell carcinoma (OSCC) and to determine the optimal cut-off values for LDH.

METHODS

This retrospective study included 184 patients with OSCC, treated with surgery between 2006 and 2014. The association between LDH and T, N classification was investigated using the Mann-Whitney test. Cut-off values for LDH were determined with a recursive partitioning analysis (RPA). Survival rates were estimated using the Kaplan-Meier method. A Cox hazard model was used to assess the prognostic capability of LDH.

RESULTS

There was no association between LDH and T or N classification (p = .657, .619, respectively). RPA determined the cut-off values for LDH as 160 and 220 IU/L. The five year survival for low-, moderate-, and high-LDH groups were 87.7, 73.7, and 50.9%, respectively (p < .001). The hazard ratios (HRs) for death in moderate- and high-LDH groups were 2.92 (95%CI =1.02-12.30, p = .001) and 7.36 (95%CI =2.54-31.20, p < .001), respectively. The model including LDH-based stratification (Akaike's information criterion (AIC) = 516) was better than the model including clinical stage (AIC =528).

CONCLUSION

Pretreatment serum LDH is an independent prognostic factor for overall survival in patients with OSCC.