Combination of platelet count and neutrophil to lymphocyte ratio is a useful predictor of postoperative survival in patients with colorectal cancer

A Nomogram to Predict Adequate Lymph Node Recovery before Resection of Colorectal Cancer

Increased lymph node count (LNC) has been associated with prolonged survival in colorectal cancer (CRC), but the underlying mechanisms are still poorly understood. The study aims to identify new predictors and develop a preoperative nomogram for predicting the probability of adequate LNC (≥ 12). 501 eligible patients were retrospectively selected to identify clinical-pathological factors associated with LNC ≥ 12 through univariate and multivariate logistic regression analyses. The nomogram was built according to multivariate analyses of preoperative factors. Model performance was assessed with concordance index (c-index) and area under the receiver operating characteristic curve (AUC), followed by internal validation and calibration using 1000-resample bootstrapping. Clinical validity of the nomogram and LNC impact on stage migration were also evaluated. Multivariate analyses showed patient age, CA19-9, circulating lymphocytes, neutrophils, platelets, tumor diameter, histology and deposit significantly correlated with LNC (P < 0.05). The effects were marginal for CEA, anemia and CRC location (0.05 < P < 0.1). The multivariate analyses of preoperative factors suggested decreased age, CEA, CA19-9, neutrophils, proximal location, and increased platelets and diameter were significantly associated with increased probability of LNC ≥ 12 (P < 0.05). The nomogram achieved c-indexes of 0.75 and 0.73 before and after correction for overfitting. The AUC was 0.75 (95% CI, 0.70–0.79) and the clinically valid threshold probabilities were between 10% and 60% for the nomogram to predict LNC < 12. Additionally, increased probability of adequate LNC before surgery was associated with increased LNC and negative lymph nodes rather than increased positive lymph nodes, lymph node ratio, pN stages or AJCC stages. Collectively, the results indicate the LNC is multifactorial and irrelevant to stage migration. The significant correlations with preoperative circulating markers may provide new explanations for LNC-related survival advantage which is reflected by the implication of regional and systemic antitumor immune responses.

A novel scoring system associating with preoperative platelet/lymphocyte and clinicopathologic features to predict lymph node metastasis in early gastric cancer

BACKGROUND

Precise determination of the lymph node status is critical for determining appropriate treatment for early gastric cancer (EGC). This study attempted to establish a simple, effective risk scoring system to predict lymph node metastasis (LNM) in EGC by investigating the relationship between platelet-to-lymphocyte ratio (PLR) and neutrophil-to-lymphocyte ratio (NLR) and EGC LNM.

MATERIALS AND METHODS

We retrospectively reviewed 312 operable patients with EGC. The clinical utility of PLR and NLR was tested by receiver operating characteristic curves. The scoring system was developed using independent risk factors. Finally, 89 EGC patients were collected from prospective database to validate the scoring system's accuracy.

RESULTS

The optimal PLR and NLR cut-off values were 106 and 2.97, respectively. High NLR (P = 0.009) and PLR (P = 0.007) values were associated with LNM of EGC in univariate analyses, although only high PLR (P = 0.025) was an independent risk factor in multivariate analyses, together with age (P = 0.009), differentiation (P = 0.017), invasive depth (P < 0.001), and tumor size (P = 0.003). The scoring system's accuracy for retrospective and prospective data was 0.781 (95% confidence interval: 0.721-0.841) and 0.817 (95% confidence interval 0.714-0.920), respectively.

CONCLUSIONS

Preoperative PLR and NLR correlate with EGC LNM. Our scoring system is reliable, accurate, and effective in predicting LNM in EGC patients.

Neutrophil to Lymphocyte Ratio (NLR) and Derived Neutrophil to Lymphocyte Ratio (d-NLR) Predict Non-Responders and Postoperative Complications in Patients Undergoing Radical Surgery After Neo-Adjuvant Radio-Chemotherapy for Rectal Adenocarcinoma

In order to evaluate neutrophil-to-lymphocyte ratio (NLR) and derived neutrophil-to-lymphocyte ratio (d-NLR) in predicting response and complications in rectal cancer patients who underwent surgery after neo-adjuvant radio-chemotherapy, 87 patients were evaluated. Cutoffs before and after radio-chemotherapy were respectively 2.8 and 3.8 for NLR, and 1.4 and 2.3 for d-NLR. They were analyzed in relation to clinical and pathological outcomes. Patients with preoperative NLR and d-NLR higher than cutoffs had significantly higher rates of tumor regression grade response (TRG ≥ 4) and postoperative complications. Elevated NLR and d-NLR after radio-chemotherapy are associated with worse pathological and clinical outcome.

Association of preoperative levels of selected blood inflammatory markers with prognosis in gliomas

Background

Red cell distribution width (RDW), neutrophil–lymphocyte ratio (NLR), and platelet count (PLT) routinely tested as part of the complete blood count are indicative of systemic inflammation. The prognostic significance of NLR and PLT in cancer was demonstrated in many studies while the role of RDW has been hardly investigated. The present study aimed to assess the association of RDW, NLR, and PLT with survival and tumor grade in glioma patients.

Methods

Clinical data from 178 patients with primary gliomas treated in a single institution were retrospectively analyzed. Receiver operating characteristic curves for cutoff value determination, Kaplan–Meier survival analysis, various bivariate tests, and univariate and multivariate Cox regression analyses were performed.

Results

Patients with high RDW (≥13.95) and NLR (≥4) levels had worse overall survival (OS) (Wilcoxon test, P<0.026 and P<0.003, respectively) while the effect of thrombocytosis (≥400×10⁹/L) on prognosis was not significant. Besides, a strong association between RDW and NLR was found (Spearman’s rho =0.230, P<0.02; χ²=8.887, P<0.03; Mann–Whitney U-test, P<0.017). Moreover, RDW and NLR were significantly associated with tumor grade. In univariate Cox analysis, elevated NLR (hazard ratio, HR 1.385; confidence interval, CI 1.020–1.881, P<0.037), older age (HR 0.452, CI 0.329–0.621, P<0), and higher tumor grade (HR 1.624, CI 1.187–2.223, P<0.002) were associated with poor outcomes. In the multivariate analysis, tumor grade, age, and Karnofsky performance score were identified as being independently prognostic for OS.

Conclusion

Preoperative NLR and RDW values can help to evaluate disease progression and outcomes in patients with gliomas, thereby contributing to patient follow-up optimization.

The Preoperative Neutrophil-to-lymphocyte Ratio is a Novel Biomarker for Predicting Worse Clinical Outcomes in Non-muscle Invasive Bladder Cancer Patients with a Previous History of Smoking

PURPOSE

We speculated that a heterogeneous population of non-muscle invasive bladder cancer (NMIBC) patients with a previous history of smoking may be more precisely stratified by a biomarker associated with tumor aggressiveness and then focused on the preoperative neutrophil-to-lymphocyte ratio (pre-NLR), which is a simple index of systemic inflammation.

METHODS

Our study population comprised 605 patients initially diagnosed with NMIBC at our 3 institutions between 1995 and 2013. We analyzed the relationships between pre-NLR levels and clinical outcomes in NMIBC. A pre-NLR level of ≥2.2 was defined as elevated according to a calculation by a receiver-operating curve analysis.

RESULTS

In overall, a total of 296 patients (48.9 %) had pre-NLR ≥ 2.2, and the pre-NLR level was one of independent risk factors for tumor recurrence and stage progression. Among 344 patients with a previous history of smoking, 184 (53.5 %) had pre-NLR ≥ 2.2 and the pre-NLR level was one of independent risk factors for tumor recurrence and stage progression. The 5-year recurrence-free survival and progression-free survival rates in patients with pre-NLR < 2.2 were 66.3 and 97.5 %, respectively, which were significantly higher than those in their counterparts (31.7 and 90.4 %, p < 0.001). In either subgroup of patients who were current smokers (N = 175) or former smokers (N = 169), the pre-NLR level was the only independent risk factor for tumor recurrence. The pre-NLR level was not associated with tumor recurrence or stage progression in 261 nonsmoking patients.

CONCLUSIONS

Pre-NLR levels may be a useful marker for identifying worse clinical outcomes in NMIBC patients, particularly those with a previous history of smoking.

Prognostic clinical factors in pretreated colorectal cancer patients receiving regorafenib: implications for clinical management

BACKGROUND

We assessed the impact on survival of angiogenesis and inflammation-related factors, particularly LDH serum levels, platelet, neutrophil and lymphocyte counts, and neutrophil-to-lymphocyte ratio (NLR), in metastatic colorectal cancer patients receiving regorafenib monotherapy.

METHODS

LDH serum levels, neutrophil, lymphocyte and platelet counts were collected at the start of regorafenib monotherapy. Cut-off values were calculated by ROC curve analysis. Survival analyses were performed by Kaplan-Meier method, and multivariate analysis by Cox method.

RESULTS

A total of 208 patients were eligible for analysis. Among factors who were related with worse overall survival and who maintained their role at the multivariate analysis, high platelet count (Exp(b):1.4963, 95% CI:1.0130-2.2103, p = 0.0439) and high neutrophil/lymphocyte ratio (Exp(b):1.6963, 95% CI:1.0757-2.6751, p = 0.0237) were those who more deeply were related to worse overall survival. High lymphocyte count (Exp(b):0.4527, 95% CI:0.2801-0.7316, p = 0.0013) was correlated with improved overall survival.

CONCLUSIONS

High neutrophil, high platelet, low lymphocyte count and/or high NLR may represent negative prognostic factors in patients receiving regorafenib monotherapy. It is advisable that these factors are taken into account in the design of subsequent trials in colorectal cancer patients receiving this drug.

Usefulness of neutrophil-to-lymphocyte ratio and platelet-to-lymphocyte ratio in hormone-receptor-negative breast cancer

PURPOSE

We aimed to investigate the relationship between pretreatment neutrophil-to-lymphocyte ratio (NLR)/platelet-to-lymphocyte ratio (PLR) and the estimation of hormone-receptor-negative (HR-) breast cancer patients' survival in a Chinese cohort.

PATIENTS AND METHODS

Of 434 consecutive HR- nonmetastatic breast cancer patients treated between 2004 and 2010 in the Affiliated Hospital of Academy of Military Medical Sciences, 318 eligible cases with complete data were included in the present study. Kaplan-Meier analysis was performed to determine the overall survival (OS) and disease-free survival (DFS). Univariate and multivariate Cox proportional hazards models were used to test the usefulness of NLR and PLR.

RESULTS

Univariate analysis indicated that both elevated NLR and PLR (both P<0.001) were associated with poor OS. The utility of NLR remained in the multivariate analysis (P<0.001), but not PLR (P=0.104). The analysis results for DFS were almost the same as OS. Subgroup analysis revealed a significant association between increased NLR and PLR (P<0.001 and P=0.011) and poor survival in triple-negative breast cancer. However, for human epidermal growth factor receptor 2-positive breast cancer, only NLR was significantly associated with OS in the multivariate analysis (P=0.001).

CONCLUSION

The present study indicates that both increased NLR and PLR are associated with poor survival in HR-breast cancer patients. Meanwhile, NLR is independently correlated with OS and DFS, but PLR is not.

The neutrophil-to-lymphocyte ratio predicts major perioperative complications in patients undergoing colorectal surgery

AIM

The objective of the study was to evaluate the association between the neutrophil-to-lymphocyte ratio (NLR) and the occurrence of perioperative complications in patients undergoing colorectal surgery.

METHOD

A retrospective cohort study was conducted of patients who underwent resection for suspected or confirmed colorectal cancer from 2004 to 2012. Patient cohorts with a high vs low NLR were defined by receiver operating characteristic curve analysis. Univariate and multivariate logistic regression was used to determine whether patients with elevated NLR were more likely to suffer perioperative complications.

RESULTS

In all, 583 patients were included. A preoperative NLR greater than or equal to 2.3 was significantly associated with a major perioperative complication (OR 2.52, 95% CI 1.26-5.01). On multivariate analysis, a high NLR (OR 2.25, 95% CI 1.12-4.52) and Charlson Comorbidity Index ≥ 3 (OR 4.55, 95% CI 2.17-9.56) were significantly related to major morbidity. No relationships were found between an elevated preoperative NLR and complication type, although there was a trend towards the occurrence of anastomotic leakage.

CONCLUSION

Preoperative NLR ≥ 2.3 may be a risk factor for major surgical complications following colorectal resection. Further study is needed to validate this threshold and evaluate the clinical implications of these findings.

The Neutrophil-to-Lymphocyte Ratio as a Marker of Lymph Node Status in Patients with Rectal Cancer

AIM

The aim of the study was to investigate the role of the neutrophil-to-lymphocyte ratio (NLR) as a prognostic marker of rectal cancers.

METHODS

We undertook a retrospective review of patients with rectal cancer. Pre-treatment NLR was assessed for association and predictive values against clinicopathological staging and post-treatment outcomes.

RESULTS

A total of 140/180 cases were included in the final analysis [male:female 2:1; mean age 68 years (interquartile range 58-75)]. The pre-operative mean NLR was 5.4 ± 6.8. There was a strong positive correlation between NLR and C-reactive protein (Spearman's rho 64.3%, p < 0.001). A high NLR was associated with a positive nodal status on MRI (5.2 vs. 3.8, p = 0.03) and histopathological (4.8 vs. 3.8, p = 0.02) assessment. The NLR showed an average value for predicting MRI and pathological nodal status on receiver operating characteristic analysis [area under the curve = 0.72 (95% CI = 0.54-0.91), p = 0.031 and area under the curve = 0.64 (95% CI = 0.52-0.077), p = 0.021, respectively]. On multivariate analysis, the total lymph node retrieved at operation was the best predictor of pathological nodal involvement; NLR did not show any predictive value. Patients with an NLR >4 showed reduced recurrence-free (60 vs. 86 months, p = 0.52) and overall survival (57 vs. 84 months, p = 0.40) without statistical significance.

CONCLUSION

Raised pre-treatment NLR may indicate nodal involvement in patients with rectal cancer.

Can the neutrophil-to-lymphocyte ratio be used to predict recurrence and progression of non-muscle-invasive bladder cancer?

The aim of our study was to evaluate whether neutrophil-to-lymphocyte ratio (NLR) is a predictor of disease progression and recurrence in patients with primary non-muscle-invasive bladder cancer (NMIBC). This was a prospective study of 86 patients with newly diagnosed NMIBC. The patients were classified by the number of points assigned by the European Organization for Research and Treatment of Cancer risk tables. The correlation between progression score, recurrence score, age, mean platelet volume, red blood cell distribution width and NLR was assessed statistically. The same parameters were compared between the risk groups. A significant difference in NLR and age values was observed between recurrence and progression risk score groups. The relationships between NLR and recurrence and progression risk scores were no longer significant after correcting for the statistical effect of age on scores. Age was significantly different between groups after adjusting for NLR. Our study revealed that NLR and age were associated with patient age and bladder tumor progression and recurrence risk scores. After correcting for age, the significant relationship with NLR was lost, in contrast to some previous studies. We recommend that patient age should be corrected to avoid misleading results in NLR studies.

Prognostic role of the combination of platelet count and neutrophil-lymphocyte ratio in patients with hypopharyngeal squamous cell carcinoma

Hypopharyngeal squamous cell carcinoma (HPSCC) is an aggressive disease with poor prognosis; but has no established biomarkers on the order of human papilloma virus and p16 in oropharyngeal carcinoma. This study investigated pre-treatment serum markers, including the combination of platelet count and neutrophil-lymphocyte ratio (COP-NLR) as a prognosis predictor in patients with HPSCC treated in our hospital. We retrospectively reviewed electronic medical records of 118 consecutive patients treated with curative intent at our hospital between 2007 and 2013. Of these 118 patients, we enrolled 100 patients for whom we had sufficient data to analyze relationships between clinico-laboratory characteristics and survival, including the prognostic significance of pre-treatment serum markers and previous reported clinical factors. Multivariate analysis of clinico-laboratory characteristics associated COP-NLR with cancer-specific survival, as were lymph node metastases. Kaplan-Meier analysis and log-rank tests showed that the COP-NLR could stratify those patients into three independent groups (P = 0.003). COP-NLR might be a useful predictor of survival in patients with HPSCC.

Prediction of outcome in breast cancer patients using test parameters from complete blood count

The aim of this study was to evaluate the prognostic effect of test parameters from pretreatment complete blood count (CBC) for predicting outcome in breast cancer patients. A total of 162 patients with breast cancer and a long follow-up were enrolled in this study. Red cell indices (RCIs) and neutrophil-lymphocyte ratio (NLR) from CBC prior to treatment, as well as related clinical data, were retrospectively collected. We evaluated the association of RCI and NLR with tumor size, clinical stage, histological grade, estrogen receptor, progesterone receptor, and human epidermal growth factor receptor 2 status. We further performed survival analysis and Cox multivariate analysis, stratified by RCI and NLR median values, to evaluate their prognostic effects. In the disease-free survival (DFS) analysis, patients in the higher mean corpuscular hemoglobin (MCH) and NLR groups exhibited shorter DFS times compared with those in the lower MCH and NLR groups (P=0.017 for MCH and P=0.039 for NLR). The univariate analysis revealed that both MCH and NLR were significantly associated with DFS. The Cox multivariate analysis demonstrated that only MCH was an independent predictor associated with disease relapse (hazard ratio = 1.975, 95% confidence interval: 1.118-3.487, P=0.019), whereas no index was associated with overall survival. Our results suggest that MCH prior to treatment may be a predictive marker associated with DFS in breast cancer.

Clinical significance of pre-operative neutrophil lymphocyte ratio and platelet lymphocyte ratio as prognostic factors for patients with colorectal cancer

The present study aimed to investigate the independent prognostic values of the pre-operative neutrophil lymphocyte ratio (NLR) and platelet lymphocyte ratio (PLR) in patients with colorectal cancer (CRC). The present study retrospectively analyzed the data of 216 patients with CRC from a single hospital. The clinicopathological characteristics of the patients were compared and prognostic factors were evaluated. NLR and PLR were associated with tumor differentiation status and the tumor diameter, respectively, and PLR was also associated with the primary tumor classification (T classification). Furthermore, NLR and PLR were positively associated with each other (R2=0.5368; P<0.0001). Univariate analyses indicated that stage II and III patients with a high NLR (≥4.98; P<0.001) or PLR (≥246.36; P<0.001) possessed a significantly poorer 5-year OS rate compared with those with a low NLR or PLR. Post-operative adjuvant chemotherapy improved the 5-year OS rate in patients with a high NLR or PLR. Multivariate analyses indicated that NLR and PLR were independent prognostic factors [NLR, relative risk (RR)=4.074 and P<0.001; PLR, RR=2.029 and P=0.029] in patients with CRC, and were associated with the T classification, lymph node metastasis and post-operative adjuvant chemotherapy response of patients. Additionally, the area under the curve (AUC) was 0.748 for NLR (95% CI, 0.684-0.804; P<0.0001) and 0.690 for PLR (95% CI, 0.623-0.751; P<0.0001). The RR and AUC indicated that NLR was the superior predictive factor in patients with CRC. In conclusion, the pre-operative NLR and PLR were significant independent prognostic factors in patients with CRC, and NLR was more effective as a prognostic marker compared with PLR. Adjuvant chemotherapy appeared to be more effective in CRC patients with a higher NLR or PLR.

Preoperative Neutrophil to Lymphocyte Ratio as a Prognostic Factor in Patients with Non-metastatic Renal Cell Carcinoma

BACKGROUND

The neutrophil-to-lymphocyte ratio (NLR) is a strong predictor of mortality in patients with colorectal, lung, gastric cancer, pancreatic and metastatic renal cell carcinoma. We here evaluated whether preoperative NLR is an independent prognostic factor for non-metastatic renal cell carcinoma (RCC).

MATERIALS AND METHODS

Data from 327 patients who underwent curative or palliative nephrectomy were evaluated retrospectively. In preoperative blood routine examination, neutrophils and lymphocytes were obtained. The predictive value of NLR for non-metastatic RCC was analyzed.

RESULTS

The NLR of 327 patients was 2.72±2.25. NLR <1.7 and NLR ≥1.7 were classified as low and high NLR groups, respectively. Chi-square test showed that the preoperative NLR was significantly correlated with the tumor size (P=0.025), but not with the histological subtype (P=0.095)and the pT stage (P=0.283). Overall survival (OS) and disease-free survival (DFS) were assessed using the Kaplan-Meier method. Effects of NLR on OS (P=0.007) and DFS (P=0.011) were significant. To evaluate the independent prognostic significance of NLR, multivariate COX regression models were applied and identified increased NLR as an independent prognostic factor for OS (P=0.015), and DFS (P=0.019).

CONCLUSIONS

Regarding patient survival, an increased NLR represented an independent risk factor, which might reflect a higher risk for severe cardiovascular and other comorbidities. An elevated blood NLR may be a biomarker of poor OS and DFS in patients with non-metastatic RCC.

Tumor-Associated Macrophages and Neutrophils in Tumor Microenvironment

Distinct tumor microenvironment forms in each progression step of cancer and has diverse capacities to induce both adverse and beneficial consequences for tumorigenesis. It is now known that immune cells can be activated to favor tumor growth and progression, most probably influenced by the tumor microenvironment. Tumor-associated macrophages and tumor-associated neutrophils can exert protumoral functions, enhancing tumor cell invasion and metastasis, angiogenesis, and extracellular matrix remodeling, while inhibiting the antitumoral immune surveillance. Considering that neutrophils in inflammatory environments recruit macrophages and that recruited macrophages affect neutrophil functions, there may be various degrees of interaction between tumor-associated macrophages and tumor-associated neutrophils. Platelets also play an important role in the recruitment and regulation of monocytic and granulocytic cells in the tumor tissues, suggesting that platelet function may be essential for generation of tumor-associated macrophages and tumor-associated neutrophils. In this review, we will explore the biology of tumor-associated macrophages and tumor-associated neutrophils and their possible interactions in the tumor microenvironment. Special attention will be given to the recruitment and activation of these tumor-associated cells and to the roles they play in maintenance of the tumor microenvironment and progression of tumors.

Platelet-to-Lymphocyte Ratio: A Novel Prognostic Factor for Prediction of 90-day Outcomes in Critically Ill Patients With Diabetic Ketoacidosis

Diabetic ketoacidosis (DKA) is a life-threatening acute complication of diabetes mellitus and the novel systemic inflammation marker platelet-to-lymphocyte ratio (PLR) may be associated with clinical outcome in patients with DKA. This study aimed to investigate the utility of PLR in predicting 90-day clinical outcomes in patients with DKA. Patient data exacted from the Multiparameter Intelligent Monitoring in Intensive Care II (MIMIC II) database was analyzed. A cutoff value for PLR of 267.67 was determined using Youden index (P < 0.05) and used to categorize subjects into a high PLR group and a low PLR group. The hazard ratios (HRs) and 95% confidence intervals (CIs) for DKA were calculated across PLR. Clinical outcomes in our study were defined as intensive care unit (ICU) 90-day readmission and all-cause mortality. A total of 278 ICU admissions were enrolled and stratified by cutoff value of PLR. The incidence of readmission and mortality was 17.8% in the high PLR group, significantly higher than 7.4% in the low PLR group. In the multivariable model, after adjusting for known confounding variables including clinical parameters, comorbidities, laboratory parameters, the HRs for DKA were 2.573 (95% CI 1.239-5.345; P = 0.011), 2.648 (95% CI 1.269-5.527; P = 0.009), and 2.650 (95% CI 1.114-6.306; P = 0.028), respectively. The Kaplan-Meier survival curve showed that a high PLR level was associated with a higher risk for 90-day outcomes in patients with DKA. The authors report that higher PLR presents a higher risk for 90-day incidence of readmission and mortality in patients with DKA. It appears to be a novel independent predictor of 90-day outcomes in critically ill DKA patients in ICU units.

The Neutrophil-Platelet Score (NPS) Predicts Survival in Primary Operable Colorectal Cancer and a Variety of Common Cancers

INTRODUCTION

Recent in-vitro studies have suggested that a critical checkpoint early in the inflammatory process involves the interaction between neutrophils and platelets. This confirms the importance of the innate immune system in the elaboration of the systemic inflammatory response. The aim of the present study was to examine whether a combination of the neutrophil and platelet counts were predictive of survival in patients with cancer.

METHODS

Patients with histologically proven colorectal cancer who underwent potentially curative resection at a single centre between March 1999 and May 2013 (n = 796) and patients with cancer from the Glasgow Inflammation Outcome Study, who had a blood sample taken between January 2000 and December 2007 (n = 9649) were included in the analysis.

RESULTS

In the colorectal cancer cohort, there were 173 cancer and 135 non-cancer deaths. In patients undergoing elective surgery, cancer-specific survival (CSS) at 5 years ranged from 97% in patients with TNM I disease and NPS = 0 to 57% in patients with TNM III disease and NPS = 2 (p = 0.019) and in patients undergoing elective surgery for node-negative colon cancer from 98% (TNM I, NPS = 0) to 65% (TNM II, NPS = 2) (p = 0.004). In those with a variety of common cancers there were 5218 cancer and 929 non-cancer deaths. On multivariate analysis, adjusting for age and sex and stratified by tumour site, incremental increase in the NPS was significantly associated with poorer CSS (p<0.001).

CONCLUSION

The neutrophil-platelet score predicted survival in a variety of common cancers and highlights the importance of the innate immune system in patients with cancer.

The prognostic significance of preoperative leukocytosis and neutrophil-to-lymphocyte ratio in patients who underwent radical cystectomy for bladder cancer

INTRODUCTION

We evaluated the prognostic effects of hematologic parameters of preoperative leukocytosis and neutrophil-to-lymphocyte ratio (NLR) in patients who underwent radical cystectomy for bladder cancer.

METHODS

We retrospectively reviewed the medical records of 363 patients who underwent radical cystectomy for bladder cancer between January 1990 and June 2013. In total, 286 patients were included in the study. Age, gender, pathologic stage, lymph node involvement, preoperative hydronephrosis, histologic sub-type, surgical margin status, and lymphovascular invasion were recorded for each patient. Univariate and multivariate analysis were performed to determine the prognostic value of the preoperative clinical and laboratory parameters on disease-specific survival (DSS). Additionally, the correlation between leukocytosis and other factors were evaluated.

RESULTS

According to the univariate analysis preoperative leukocytosis and NLR were detected as negative prognostic factors on DSS. Preoperative leukocytosis, NLR, stage, lymph node involvement, histologic subtype, grade and age were independent prognostic factors for DSS, on multivariate analysis. Patients with leukocytosis had higher stage, grade and lymphovascular invasion.

CONCLUSIONS

Inexpensive, reproducible, and readily available peripheral blood count components of white blood cell count and NLR were independent prognostic factors, which can stratify DSS risks in bladder cancer patients who underwent radical cystectomy.

Pretreatment hematologic markers as prognostic factors in patients with nasopharyngeal carcinoma: Neutrophil-lymphocyte ratio and platelet-lymphocyte ratio

BACKGROUND

Pretreatment hematological markers of inflammatory response have emerged as prognostic factors for patients with cancer. In this study, we evaluated the prognostic significance of various hematologic parameters in patients with nasopharyngeal carcinoma (NPC).

METHODS

Clinical data from 251 patients with NPC were retrospectively collected. Neutrophil counts, lymphocyte counts, platelet counts, neutrophil-lymphocyte ratio (NLR), and platelet-lymphocyte ratio (PLR) were adopted as potential prognostic biomarkers. The Kaplan-Meier method and log-rank test were adopted to calculate and compare the progression-free survival (PFS) and overall survival (OS) rates. The Cox proportional hazards model was used to carry out univariate and multivariate analyses.

RESULTS

NLR ≥2.7 (hazard ratio [HR] = 2.01; 95% confidence interval [CI] = 1.23-3.29; p = .005) and PLR ≥167.2 (HR = 2.12; 95% CI = 1.35-3.33; p = .001) were significantly associated with shorter PFS, whereas PLR ≥163.4 (HR = 2.64; 95% CI = 1.25-5.60; p = .011) was correlated with poor OS.

CONCLUSION

Pretreatment NLR and PLR can be independent prognostic factors for patients with NPC. © 2015 Wiley Periodicals, Head Neck 38: E1332-E1340, 2016.

Prognostic impact of preoperative platelets to lymphocytes ratio (PLR) on survival for oesophageal and junctional carcinoma treated with neoadjuvant chemotherapy: A retrospective monocentric study on 153 patients

This study was designed to investigate the prognostic impact of elevated platelet to lymphocyte ratio (PLR) on survival for oesophageal and junctional adenocarcinoma (OJA) treated with neoadjuvant chemotherapy in a curative intent. From 2004 to 2014, 153 consecutive patients with OJA were included. PLR was measured at first diagnosis. Receiver Operating Characteristic curve analysis was performed to determinate PLR threshold. Cox multivariate model was used to assess correlation between PLR and survival. Cut-off value for PLR was 192, which identified 2 groups of patients: low (n = 122) and high PLR value (n = 31). Both groups were comparable by patient (age, sex, ASA score) and tumour characteristics (differentiation, TNM stage, location). Five year overall survival (OS) was 65%. OS and DFS were reduced in the high PLR group: p = 0.019 and p = 0.016, respectively. PLR was associated with increased recurrence (54.8% vs. 35.2%, p = 0.046) and cancer-related death (41.9% vs. 23.8%, p = 0.043) rates. On multivariate analysis, elevated PLR was associated with decreased DFS (HR = 2.85, 95%CI = 1.54-5.26, p = 0.001) and OS (HR = 2.47, 95%CI = 1.21-5.01, p = 0.012). This study demonstrates that elevated PLR is associated with poor OS and DFS for OJA treated with a curative intent and has the potential to be a useful prognostic biomarker for treatment planning.

Prognostic Significance of Combination of Preoperative Platelet Count and Neutrophil-Lymphocyte Ratio (COP-NLR) in Patients with Non-Small Cell Lung Cancer: Based on a Large Cohort Study

Introduction

The aim of this study was to investigate the prognostic significance of the combination of the preoperative platelet count and neutrophil-lymphocyte ratio (COP-NLR) for predicting postoperative survival of patients undergoing complete resection for non-small cell lung cancer (NSCLC).

Methods

The preoperative COP-NLR was calculated on the basis of data obtained.Patients with both an increased platelet count (>30.0×10⁴ mm^-3) and an elevated NLR (>2.3) were assigned a score of 2, and patients with one or neither were assigned as a score of 1 or 0, respectively.

Results

A total of 1238 NSCLC patients were enrolled in this analysis. Multivariate analysis using the 15 clinicolaboratory variables selected by univariate analyses demonstrated that the preoperative COP-NLR was an independent prognostic factor for DFS (HR: 1.834, 95%CI: 1.536 to 2.200, P<0.001) and OS (HR: 1.810, 95%CI: 1.587 to 2.056, P<0.001). In sub-analyses by tumor stage (I, II, IIIA), a significant association was found between DFS and OS and level of COP-NLR in each subgroup (P<0.001, P=0.002, P<0.001 for DFS, respectively; P<0.001, P=0.001, P<0.001 for OS). When the subgroup of patients with high-risk COP-NLR (score of 2) was analyzed, no benefit of adjuvant chemotherapy could be found (P=0.237 for DFS and P=0.165 for OS).

Conclusions

The preoperative COP-NLR is able to predict the prognosis of patients with NSCLC and divide these patients into three independent groups before surgery. Our results also demonstrate that high-risk patients based on the COP-NLR do not benefit from adjuvant chemotherapy. Independent validation of our findings is warranted.

Combination of platelet to lymphocyte ratio and neutrophil to lymphocyte ratio is a useful prognostic factor in advanced non-small cell lung cancer patients

BACKGROUND

The neutrophil to lymphocyte ratio (NLR) was recently shown to be a remarkable prognostic factor in tumors. Moreover, some studies have indicated that the combination of NLR and platelet to lymphocyte ratio (PLR) could be a better prognostic factor. As the combined prognostic value of NLR and PLR in non-small cell lung cancer (NSCLC) is not clear, we conducted this study to explore this further.

METHODS

A total of 366 primary NSCLC patients with stage III or IV were finally included. The neutrophil, platelet, and lymphocyte counts were recorded before treatment was initiated. NLR and PLR were calculated and NLR > 2.68 or PLR > 119.50 was defined as elevated. Univariate and multivariate survival analyses were conducted to test their prognostic value.

RESULTS

The median of NLR and PLR were 3.14 and 152.63, respectively, in all patients. It was indicated that PLR is linearly associated with NLR. PLR is associated with survival, but is not an independent prognostic factor. Removing NLR, PLR is an independent prognostic factor (overall survival [OS]: hazard ratio [HR] = 1.918, P = 0.003; progression-free survival [PFS]: HR = 1.822, P = 0.007 in condition of NLR ≤ 2.68). It was also indicated that elevated NLR is an independent prognostic factor (OS: HR = 1.778, P = 0.009; PFS: HR = 1.535, P = 0.022) in all patients.

CONCLUSIONS

PLR is a useful complement of NLR, thus, advanced NSCLC patients could be divided into three prognostic groups prior to treatment: poor: NLR > 2.68; moderate: NLR ≤ 2.68 and PLR > 119.50; and good: NLR ≤ 2.68 and PLR ≤ 119.50.

Preoperative Neutrophil-to-Lymphocyte Ratio is a Better Prognostic Serum Biomarker than Platelet-to-Lymphocyte Ratio in Patients Undergoing Resection for Nonmetastatic Colorectal Cancer

INTRODUCTION

Current risk stratification tools for patients with colorectal cancer (CRC) rely on final surgical pathology but may be improved with the addition of novel serum biomarkers. The objective of this study was to evaluate the utility of preoperative NLR and PLR in predicting long-term oncologic outcomes in patients with operable CRC.

METHODS

All patients who underwent curative resection for adenocarcinoma at a large tertiary academic hospital were identified. High NLR/PLR was evaluated preoperatively and defined by maximizing log-rank statistics. Recurrence-free survival (RFS) and overall survival (OS) were calculated using the Kaplan-Meier method and compared by the log-rank test. Univariate and multivariable Cox proportional hazard regression was used to identify associations with outcome measures.

RESULTS

A total of 549 patients were included in the study. High NLR (≥2.6) was associated with worse RFS (hazard ratio [HR] 2.03, 95 % confidence interval [CI] 1.48-2.79, p < 0.001) and OS (HR 2.25, 95 % CI 1.54-3.29, p < 0.001). High PLR (≥295) also was associated with worse RFS (HR 1.68, 95 % CI 1.06-2.65, p = 0.028) and OS (HR 1.81, 95 % CI 1.06-3.06, p = 0.028). In the multivariable model, high NLR retained significance for reduced RFS (HR 1.59, 95 % CI 1.1-2.28, p = 0.013) and OS (HR 1.91, 95 % CI 1.26-2.9, p = 0.002). Significantly more patients in the high NLR group were older at diagnosis, had mucinous adenocarcinoma, higher T stage, and advanced cancer stage.

CONCLUSIONS

High preoperative NLR in this series was shown to be a negative independent prognostic factor in patients undergoing surgical resection for nonmetastatic CRC. The prognostic utility of this serum biomarker may help to guide use of adjuvant therapies and patient counselling.

Prognostic performance of inflammation-based prognostic indices in patients with resectable colorectal liver metastases

A range of prognostic cellular indices of the systemic inflammatory response, namely the neutrophil-lymphocyte ratio (NLR), derived NLR (dNLR), platelet-lymphocyte ratio (PLR), lymphocyte-monocyte ratio (LMR), combination of platelet count and neutrophil-lymphocyte ratio (COP-NLR) and prognostic nutritional index (PNI), have been developed and found to have prognostic utility across varied malignancies. The current study is the first to examine the prognostic value of these six inflammatory scores in patients with resectable colorectal liver metastases (CRLM). Data from 302 consecutive patients undergoing surgery for resectable CRLM were evaluated. The prognostic influence of clinicopathological variables and the inflammatory scores NLR, dNLR, PLR, LMR, COP-NLR and PNI upon overall survival (OS) and cancer-specific survival (CSS) were determined by log-rank analysis and univariate and multivariate Cox regression analyses. High preoperative NLR was the only inflammatory variable independently associated with shortened OS (HR 1.769, 95 % CI 1.302-2.403, P < 0.001) or CSS (HR 1.927, 95 % CI 1.398-2.655, P < 0.001) following metastasectomy. When NLR was replaced by dNLR in analyses, high dNLR was independently associated with shortened OS (HR 1.932, 95 % CI 1.356-2.754, P < 0.001) and CSS (HR 1.807, 95 % CI 1.209-2.702, P = 0.004). The inflammatory scores PLR, LMR, COP-NLR and PNI demonstrated no independent association with either overall or cancer-specific survival in the study population. Our findings support high preoperative NLR and dNLR as independent prognostic factors for poor outcome in patients undergoing CRLM resection, with prognostic value superior to other cellular-based systemic inflammatory scores.

Preoperative neutrophil-to-lymphocyte ratio for prognostication of patients with distal bile duct carcinomas undergoing surgery

BACKGROUND

Surgical resection continues to be the current standard treatment for distal bile duct carcinoma (DBC), as no effective alternative treatment exists. However, even after resection, the long-term prognosis is poor. Simple biomarkers that can predict response or toxicity, and which are applicable to all community oncology settings worldwide, have not been identified. Differential white-cell counts, such as the neutrophil-to-lymphocyte ratio (NLR), as markers of inflammation, may be simple and readily available biomarkers. This study aimed to determine whether the NLR can be used as a predictor of surgical outcome in patients with DBC.

MATERIALS AND METHODS

We enrolled 91 DBC patients who had undergone pancreatoduodenectomy (PD) at a single institution between April 2000 and December 2013. Blood was sampled on admission for determination of NLR. An NLR of ≥5 was selected as the cut-off value for validation.

RESULTS

Seventeen patients had an NLR of ≥5 (Group 1; 18.7%), while 74 had an NLR of <5 (Group 2; 81.3%). The 1-, 3- and 5-year survival rates for Group 1 patients were 75.9, 34.5 and 34.5%, respectively, while those for Group 2 patients were 94.8, 55.2 and 46.6%, respectively (p = 0.02). There were no significant inter-group differences in clinicolaboratory background factors such as the mean operation time, bleeding volume, tumor size, CRP, neutrophil count and lactate dehydrogenase (LDH) level. On the other hand, there were significant inter-group differences for albumin level (p = 0.011), lymphocyte count (p = 0.001) and NLR (p < 0.001). Multivariate analyses were performed for factors such as gender, age, maximum tumor diameter, drainage method, operation time, bleeding volume, pathology, albumin, CRP, neutrophil count, lymphocyte count, LDH and NLR. The results revealed that NLR (odds ratio, 2.032; 95% CI, 0.999-4.134; p = 0.040) was associated with postoperative overall survival.

CONCLUSIONS

An NLR of ≥5 predicts a poor outcome in patients undergoing PD for DBC. NLR is an independent indicator of overall survival for such patients.

Uncut Roux-en-Y Reconstruction after Laparoscopic Distal Gastrectomy Can Be a Favorable Method in Terms of Gastritis, Bile Reflux, and Gastric Residue

Purpose

Laparoscopic distal gastrectomy (LDG) is a well-established procedure for the treatment of early gastric cancer. Several reconstruction methods can be adopted after LDG according to tumor characteristics and surgeon preference. This study aimed to compare the remnant gastric functions after different reconstructions.

Materials and Methods

In total, 221 patients who underwent LDG between March 2005 and October 2013 were reviewed retrospectively. The patients were classified into four groups based on the reconstructive procedure: Billroth I (BI) anastomosis, Billroth II (BII) with Braun anastomosis, Roux-en-Y (RY) reconstruction, or uncut RY reconstruction. Patient demographics, surgical outcomes, and postoperative endoscopic findings were reviewed and compared among groups.

Results

Endoscopic evaluations at 11.8±3.8 months postoperatively showed less frequent gastritis and bile reflux in the remnant stomach in the RY group compared to the BI and BII groups. There was no significant difference in the gastric residue among the BI, BII, and RY groups. The incidence of gastritis and bile reflux in the uncut RY group was similar to that in the RY group, while residual gastric content in the uncut RY group was significantly smaller and less frequently observed than that in the RY group (5.8% versus 35.3%, P=0.010).

Conclusions

RY and uncut RY reconstructions are equally superior to BI and BII with Braun anastomoses in terms of gastritis and bile reflux in the remnant stomach. Furthermore, uncut RY reconstruction showed improved stasis compared to conventional RY gastrojejunostomy. Uncut RY reconstruction can be a favorable reconstructive procedure after LDG.

The tumour-induced systemic environment as a critical regulator of cancer progression and metastasis

Recent pre-clinical and clinical research has provided evidence that cancer progression is driven not only by a tumour's underlying genetic alterations and paracrine interactions within the tumour microenvironment, but also by complex systemic processes. We review these emerging paradigms of cancer pathophysiology and discuss how a clearer understanding of systemic regulation of cancer progression could guide development of new therapeutic modalities and efforts to prevent disease relapse following initial diagnosis and treatment.

Baseline neutrophil-lymphocyte ratio (≥2.8) as a prognostic factor for patients with locally advanced rectal cancer undergoing neoadjuvant chemoradiation

Background

The neutrophil-lymphocyte ratio (NLR) has been proposed as an indicator of systemic inflammatory response and may predict the clinical outcome in some cancers, such as head and neck cancer and gastric cancer. However, the value of this ratio is variable in different cancers. Studies of the relationship between NLR and both survival and response to chemoradiation have been limited with respect to locally advanced rectal cancer.

Methods and materials

From 2006 to 2011, 199 consecutive locally advanced rectal cancer patients who were treated with neoadjuvant chemoradiation in the Shanghai Cancer Center were enrolled and analysed retrospectively. Tumor response was evaluated by pathological findings. The baseline total white blood cell count (WBC) and the neutrophil, lymphocyte, platelet counts were recorded. The neutrophil-lymphocyte ratio (NLR) and the relationship with clinical outcomes such as overall survival (OS) and disease-free survival (DFS) was analyzed.

Results

With ROC analysis, the baseline NLR value was found to significantly predict prognosis in terms of OS well in locally advanced rectal cancer patients. A multivariate analysis identified that a cut-off value of NLR ≥ 2.8 could be used as an independent factor to indicate decreased OS (HR, 2.123; 95% CI, 1.140-3.954; P = 0.018). NLR ≥ 2.8 was also associated with worse DFS in univariate analysis (HR, 1.662; 95% CI, 1.037-2.664; P = 0.035), though it was not significant in the multivariate analysis (HR, 1.363; 95% CI, 0.840-2.214; P = 0.210). There was no observed significant correlation of mean value of NLR to the response to neoadjuvant chemoradiation. The mean NLR in the ypT0-2 N0 group was 2.68 ± 1.38, and it was 2.77 ± 1.38 in the ypT3-4/N+ group, with no statistical significance (P = 0.703). The mean NLR in the TRG 0–1 group was 2.68 ± 1.42, and it was 2.82 ± 1.33 in the TRG 2–3 group with no statistical significance (P = 0.873).

Conclusions

An elevated baseline NLR is a valuable and easily available prognostic factor for OS in addition to tumor response after neoadjuvant therapy. Baseline NLR could be a useful candidate factor for stratifying patients and making treatment decisions in locally advanced rectal cancer.

Clinical significance of prognosis using the neutrophil-lymphocyte ratio and erythrocyte sedimentation rate in patients undergoing radical nephroureterectomy for upper urinary tract urothelial carcinoma

OBJECTIVES

To evaluate the clinical significance of preoperative erythrocyte sedimentation rate (ESR) and neutrophil-lymphocyte ratio (NLR) as prognostic factors in patients undergoing radical nephroureterectomy for upper tract urothelial carcinoma (UTUC).

PATIENTS AND METHODS

A total of 410 patients were retrospectively reviewed. An elevated NLR was defined as ≥2.5 and a normal ESR was considered to be in the range of 0-22 mm/h in men and 0-27 mm/h in women. Patients were divided into three groups: those with ESR and NLR in the normal range (group 0, n = 168), those with either elevated ESR or elevated NLR (group I, n = 169), and those with both elevated ESR and elevated NLR (group II, n = 73).

RESULTS

The median patient age was 64 years and the median follow-up duration was 40.2 months. In all, 35.6 and 41.2% of patients had elevated NLRs and ESRs, respectively. Group II was associated with advanced tumour status in terms of size, grade, stage, lymph node and margin status (P < 0.05). Preoperative ESR (hazard ratio [HR] 1.784, 95% confidence interval [CI] 1.173-2.712), NLR (HR 1.704, 95% CI 1.136-2.556), and prognostic grouping (HR 2.285, 95% CI 1.397-3.737 for group I; HR 2.962, 95% CI 1.719-5.102 for group II) were independent predictors of progression-free survival (PFS) in the multivariate model (P < 0.05). Prognostic grouping was also an independent prognostic factor for cancer-specific survival (CSS) and overall survival (OS). Time-dependent area under the receiver-operating characteristic curves showed that NLR plus ESR had a greater diagnostic value than NLR alone regarding oncological outcomes (P < 0.05).

CONCLUSIONS

Prognostic grouping using ESR and NLR was identified as an independent prognostic marker in patients with UTUC. The addition of ESR improved the prognostic value of NLR alone in predicting oncological outcomes. The combination of preoperative ESR and NLR might be a new prediction tool in patients with UTUC after radical nephroureterectomy.

The utility of the preoperative neutrophil-to-lymphocyte ratio in predicting severe cholecystitis: a retrospective cohort study

Background

To evaluate whether the neutrophil-to-lymphocyte ratio (NLR), as a prognostic indicator, in patients can differentiate between simple and severe cholecystitis.

Methods

A database of 632 patients who underwent cholecystectomy due to cholecystitis during approximately a seven-year span in a single institution was evaluated. Severe cholecystitis was defined when the cholecystitis was complicated by secondary changes, including hemorrhage, gangrene, emphysema, and perforation. The NLR was calculated at admission as the absolute neutrophil count divided by the absolute lymphocyte count. We used receiver operating characteristic curve analysis to identify the optimal value for the NLR in relation to the severity of cholecystitis. Thereafter, the differences in clinical manifestations according to the NLR cut-off value were investigated.

Results

Our study population comprised 503 patients with simple cholecystitis (79.6%) and 129 patients with severe cholecystitis (20.4%). The NLR of 3.0 could predict severe cholecystitis with 70.5% sensitivity and 70.0% specificity. A higher NLR (≥3.0) was significantly associated with older age (p =0.001), male gender (p =0.001), admission via the emergency department (p <0.001), longer operation time (p <0.001), higher incidence of postoperative complications (p =0.056), and prolonged length of hospital stay (LOS) (p <0.001). Multivariate analysis found that patient age ≥50 years (odds ratio [OR]: 2.312, 95% confidence interval [CI]: 1.472–3.630, p <0.001), preoperative NLR ≥3.0 (OR: 1.876, 95% CI: 1.246–2.825, p =0.003), and admission via the emergency department (OR: 1.764, 95% CI: 1.170–2.660, p =0.007) were independent factors associated with prolonged LOS.

Conclusions

NLR ≥3.0 was significantly associated with severe cholecystitis and prolonged LOS in patients undergoing cholecystectomy. Therefore, preoperative NLR in patients undergoing cholecystits due to cholecystitis seemed to be a useful surrogate marker for severe cholecystitis.

The combination of platelet count and neutrophil lymphocyte ratio is a predictive factor in patients with esophageal squamous cell carcinoma

OBJECTIVE: The prognostic value of inflammation indexes in esophageal cancer was not established. In this study, therefore, both prognostic values of Glasgow prognostic score (GPS) and combination of platelet count and neutrophil lymphocyte ratio (COP-NLR) in patients with esophageal squamous cell carcinoma (ESCC) were investigated and compared. METHODS: This retrospective study included 375 patients who underwent esophagectomy for ESCC. The cancer-specific survival (CSS) was calculated by the Kaplan-Meier method, and the difference was assessed by the log-rank test. The GPS was calculated as follows: patients with elevated C-reactive protein (> 10 mg/l) and hypoalbuminemia (< 35 g/l) were assigned to GPS2. Patients with one or no abnormal value were assigned to GPS1 or GPS0, respectively. The COP-NLR was calculated as follows: patients with elevated platelet count (> 300 × 10⁹/l) and neutrophil lymphocyte ratio (> 3) were assigned to COP-NLR2. Patients with one or no abnormal value were assigned to COP-NLR1 or COP-NLR0, respectively. RESULTS: The 5-year CSS in patients with GPS0, 1, and 2 was 50.0%, 27.0%, and 12.5%, respectively (P < .001). The 5-year CSS in patients with COP-NLR0, 1, and 2 was 51.8%, 27.0%, and 11.6%, respectively (P < .001). Multivariate analysis showed that both GPS (P = .003) and COP-NLR (P = .003) were significant predictors in such patients. In addition, our study demonstrated a similar hazard ratio (HR) between COP-NLR and GPS (HR = 1.394 vs HR = 1.367). CONCLUSIONS: COP-NLR is an independent predictive factor in patients with ESCC. We conclude that COP-NLR predicts survival in ESCC similar to GPS.

Stimulus-responsive ultrasound contrast agents for clinical imaging: motivations, demonstrations, and future directions

Microbubble ultrasound contrast agents allow imaging of the vasculature with excellent resolution and signal-to-noise ratios. Contrast in microbubbles derives from their interaction with an ultrasound wave to generate signal at harmonic frequencies of the stimulating pulse; subtracting the elastic echo caused by the surrounding tissue can enhance the specificity of these harmonic signals significantly. The nonlinear acoustic emission is caused by pressure-driven microbubble size fluctuations, which in both theoretical descriptions and empirical measurements was found to depend on the mechanical properties of the shell that encapsulates the microbubble as well as stabilizes it against the surrounding aqueous environment. Thus biochemically induced switching between a rigid 'off' state and a flexible 'on' state provides a mechanism for sensing chemical markers for disease. In our research, we coupled DNA oligonucleotides to a stabilizing lipid monolayer to modulate stiffness of the shell and thereby induce stimulus-responsive behavior. In initial proof-of-principle studies, it was found that signal modulation came primarily from DNA crosslinks preventing the microbubble size oscillations rather than merely damping the signal. Next, these microbubbles were redesigned to include an aptamer sequence in the crosslinking strand, which not only allowed the sensing of the clotting enzyme thrombin but also provided a general strategy for sensing other soluble biomarkers in the bloodstream. Finally, the thrombin-sensitive microbubbles were validated in a rabbit model, presenting the first example of an ultrasound contrast agent that could differentiate between active and inactive clots for the diagnosis of deep venous thrombosis.

Combination of platelet count and neutrophil to lymphocyte ratio is a useful predictor of postoperative survival in patients undergoing surgery for gastric cancer

OBJECTIVE

To investigate the clinical utility of the Combination of Platelet count and Neutrophil to Lymphocyte Ratio (COP-NLR) for predicting the postoperative survival of patients undergoing surgery for gastric cancer (GC).

METHODS

The COP-NLR was calculated on the basis of data obtained on the day of admission as follows: patients with both an elevated platelet count (>300 × 10(3) /µl) and an elevated NLR (>3) were allocated a score of 2, and patients showing one or neither were allocated a score of 1 or 0, respectively. Five hundred forty-four patients for whom data were sufficient to allow analysis of the relationship between clinicolaboratory characteristics and postoperative survival were enrolled.

RESULTS

Multivariate analysis using the 12 clinical characteristics selected by univariate analyses revealed that the COP-NLR was associated with OS (hazard ratio, 1.781; 95% C.I., 1.094-2.899; P = 0.020) along with age, tumor type, lymph node metastasis and albumin level. Kaplan-Meier analysis and log rank test demonstrated significant differences in both OS and cancer-specific survival among patients with COP-NLR 0, 1, and 2 (P < 0.001).

CONCLUSION

The COP-NLR is able to predict postoperative survival of patients with GC and classify such patients into three independent groups before surgery.

Association of neutrophil-lymphocyte ratio with glucose intolerance: an indicator of systemic inflammation in patients with type 2 diabetes

BACKGROUND

The neutrophil-lymphocyte ratio (NLR) has been demonstrated to be a better risk factor than total white blood cell count in the prediction of adverse outcomes in various medical conditions. This study analyzed the association of NLR with different grades of glucose tolerance and insulin resistance in Asian Indians.

SUBJECTS AND METHODS

Study subjects were recruited from Phase 3 of the Chennai Urban Rural Epidemiology Study (CURES). For this cross-sectional analysis, subjects with normal glucose tolerance (NGT) (n=237), impaired glucose tolerance (IGT) (n=63), and type 2 diabetes mellitus (DM) (n=286) were selected. The hemogram was done in all subjects using a five-part hematology analyzer (model SF-3000; Sysmex, Kobe, Japan). The NLR was calculated as the ratio between counts for neutrophils and total lymphocytes. Fasting insulin was measured by enzyme-linked immunosorbent assay, and insulin resistance was calculated using the homeostasis model assessment (HOMA-IR).

RESULTS

Subjects with DM showed a significantly higher NLR (2.2 ± 1.12) compared with IGT subjects (1.82 ± 0.63), who in turn had a higher ratio than NGT subjects (1.5 ± 0.41) (P<0.01). Pearson correlation analysis showed a significant positive correlation of NLR with glycated hemoglobin (r=0.411), fasting plasma glucose (r=0.378), and HOMA-IR (r=0.233) (P<0.001). Regression analysis showed a linear increase in NLR with increasing severity of glucose intolerance even after adjusting for age, waist circumference, blood pressure, triglycerides, and smoking.

CONCLUSIONS

This is the first report on the correlation of NLR with different grades of glucose intolerance and insulin resistance. NLR can be used as an adjuvant prognostic marker for macro- and microvascular complications in patients with glucose intolerance.

Platelets guide the formation of early metastatic niches

During metastasis, host cells are recruited to disseminated tumor cells to form specialized microenvironments ("niches") that promote metastatic progression, but the mechanisms guiding the assembly of these niches are largely unknown. Tumor cells may autonomously recruit host cells or, alternatively, host cell-to-host cell interactions may guide the formation of these prometastatic microenvironments. Here, we show that platelet-derived rather than tumor cell-derived signals are required for the rapid recruitment of granulocytes to tumor cells to form "early metastatic niches." Granulocyte recruitment relies on the secretion of CXCL5 and CXCL7 chemokines by platelets upon contact with tumor cells. Blockade of the CXCL5/7 receptor CXCR2, or transient depletion of either platelets or granulocytes prevents the formation of early metastatic niches and significantly reduces metastatic seeding and progression. Thus, platelets recruit granulocytes and guide the formation of early metastatic niches, which are crucial for metastasis.

Preoperative neutrophil-lymphocyte ratio predicts death among patients with localized clear cell renal carcinoma undergoing nephrectomy

OBJECTIVES

The neutrophil-lymphocyte ratio (NLR) is an indicator of the systemic inflammatory response. An increased pretreatment NLR has been associated with adverse outcomes in other malignancies, but its role in localized (M0) clear cell renal cell carcinoma (ccRCC) remains unclear. As such, we evaluated the ability of preoperative NLR to predict oncologic outcomes in patients with M0 ccRCC undergoing radical nephrectomy (RN).

METHODS AND MATERIALS

From 1995 to 2008, 952 patients underwent RN for M0 ccRCC. Of these, 827 (87%) had pretreatment NLR collected within 90 days before RN. Metastasis-free, cancer-specific, and overall survival was estimated using the Kaplan-Meier method and compared using the log-rank test. Multivariate models were used to analyze the association of NLR with clinicopathologic outcomes.

RESULTS

At a median follow-up of 9.3 years, 302, 233, and 436 patients had distant metastasis, death from ccRCC, and all-cause mortality, respectively. Higher NLR was associated with larger tumor size, higher nuclear grade, histologic tumor necrosis, and sarcomatoid differentiation (all, P < 0.001). A NLR ≥ 4.0 was significantly associated with worse 5-year cancer-specific (66% vs. 85%) and overall survival (66% vs. 85%). Finally, after controlling for clinicopathologic features, NLR remained independently associated with risks of death from ccRCC and all-cause mortality (hazard ratio for 1-unit increase: 1.02, P < 0.01).

CONCLUSIONS

Our results suggest that NLR is independently associated with increased risks of cancer-specific and all-cause mortality among patients with M0 ccRCC undergoing RN. Accordingly, NLR, an easily obtained marker of biologically aggressive ccRCC, may be useful in preoperative patient risk stratification.

Immuno-PCI: a proposal for the implementation of "seed and soil" concept in the treatment of peritoneal carcinomatosis from colorectal cancer

The advent of cytoreductive surgery and hyperthermic intraperitoneal chemotherapy has revolutionized the approach to peritoneal carcinomatosis of colorectal cancer origin in appropriately selected cases. However, the high postoperative morbidity and mortality following the procedure underlines the need for optimizing the patient selection criteria, finally aiming to establish a patient-tailored approach. The introduction of tools enabling the quantification of the peritoneal spread of the metastatic deposits has been of paramount importance in the decision-making and the estimation of the prognosis. However, we believe that it is high time to attempt a further evolution of the current practice, by incorporating in the above mentioned quantification scores parameters indicative of the immune-response against the disease progression, fact which will probably reflect more accurately the dynamics of cancer progression and will sequentially be a crucial step towards individualized treatment of peritoneal carcinomatosis.

Inflammation-based scores: a new method for patient-targeted strategies and improved perioperative outcome in cancer patients

Systemic inflammatory response (SIR) has actually been shown as an important prognostic factor associated with lower postoperative survival in several types of cancer. Thus, the challenge for physicians is to find specific, low-cost, and highly reliable inflammatory markers, clearly correlated with prognosis and able to preoperatively stratify patient's risk. Inflammation is a promising target to improve perioperative outcome, and data show that anti-inflammation techniques have a great potential in the perioperative period of cancer surgery. Inflammation scores could be useful to stratify patients with a potential better response to anti-inflammation strategies. Furthermore, inflammation scores could prevent failure of clinical trials by a better definition of patients to be included in such trials; inflammation scoring could clarify the real role of different drugs and techniques on outcome after cancer surgery, defining if different therapies are required for different patients. The role of this review is to focus on the currently available scores, in order to clarify their rationale and to analyze the actual evidence and limits, providing physicians with an updated overview of the possible inflammation-based prognostic scores for cancer patients undergoing surgery.

Depression in older patients with advanced colorectal cancer is closely connected with immunosuppressive acidic protein

Colorectal cancer (CRC) is one of the most common tumors. CRC patients are susceptible to suffering from depression. Whether the immune system of CRC patients with depression is impaired or stimulated is controversial. Possible reasons for this conflict are the involvement of confounding factors, such as the age of the patient, the stage of the CRC and the types of treatment in previous studies. To demonstrate clearly the relationship between depression and the immune system in the context of CRC, the present study included only older patients with advanced CRC who received only chemotherapy, and the study adopted immunosuppressive acidic protein (IAP) as an immune parameter for the first time. A total of 56 older patients with advanced CRC completed the Zung Self-Rating Depression Scale (SDS) and were divided into two groups according to SDS scores. The patients exhibiting depression were treated with fluoxetine until their symptoms remitted. The serum levels of IAP and the percentages of CD3-positive (CD3+), CD4+, CD8+ T lymphocytes and CD56+ natural killer (NK) cells and Neutrophil-lymphocyte ratio (NLR) were calculated at the time of enrollment and once the symptoms remitted. Correlation analyses revealed that the SDS score was positively associated with serum IAP levels but negatively associated with CD3 and CD4 levels. Among the depressed and non-depressed patients, serum IAP levels and the percentages of CD3 and CD4 cells were dramatically different. After the depression symptoms were treated, the IAP levels dramatically decreased, while the levels of CD3, CD4, CD8 and CD56 were unchanged. All of above suggested that IAP was closely correlated with depression and might be a relatively objective parameter for predicting depression.

Pretreatment neutrophil-to-lymphocyte ratio is associated with advanced pathologic tumor stage and increased cancer-specific mortality among patients with urothelial carcinoma of the bladder undergoing radical cystectomy

BACKGROUND

Pretreatment neutrophil-to-lymphocyte ratio (NLR) is a marker of systemic inflammation that has been associated with adverse survival in a variety of malignancies. However, the relationship between NLR and oncologic outcomes following radical cystectomy (RC) for urothelial carcinoma of the bladder (UCB) has not been well studied.

OBJECTIVE

To evaluate the association of preoperative NLR with clinicopathologic outcomes following RC.

DESIGN, SETTING, AND PARTICIPANTS

We identified 899 patients who underwent RC without neoadjuvant therapy at our institution between 1994 and 2005 and who had a pretreatment NLR.

OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS

Preoperative NLR (within 90 d prior to RC) was recorded. Recurrence-free, cancer-specific, and overall survival were estimated using the Kaplan-Meier method and compared using the log-rank test. Multivariate Cox proportional hazard and logistic regression models were used to analyze the association of NLR with clinicopathologic outcomes.

RESULTS AND LIMITATIONS

Median postoperative follow-up was 10.9 yr (interquartile range: 8.3-13.9 yr). Higher preoperative NLR was associated with significantly increased risks of pathologic, extravesical tumor extension (odds ratio [OR]: 1.07; p=0.03) and lymph node involvement (OR: 1.09; p=0.02). Univariately, 10-yr cancer-specific survival was significantly worse among patients with a preoperative NLR (≥2.7 [51%] vs. <2.7 [64%]; p<0.001). Moreover, on multivariate analysis, increased preoperative NLR was independently associated with greater risks of disease recurrence (hazard ratio [HR]: 1.04; p=0.02), death from bladder cancer (HR: 1.04; p=0.01), and all-cause mortality (HR: 1.03; p=0.01).

CONCLUSIONS

Elevated preoperative NLR among patients undergoing RC is associated with significantly increased risk for locally advanced disease as well as subsequent disease recurrence, and cancer-specific and all-cause mortality. These data suggest that serum NLR may be a useful prognostic marker for preoperative patient risk stratification, including consideration for neoadjuvant therapy and clinical trial enrollment.

Neutrophil lymphocyte ratio significantly improves the Framingham risk score in prediction of coronary heart disease mortality: insights from the National Health and Nutrition Examination Survey-III

BACKGROUND

Neutrophil lymphocyte ratio (NLR) has been shown to predict cardiovascular events in several studies. We sought to study if NLR predicts coronary heart disease (CHD) in a healthy US cohort and if it reclassifies the traditional Framingham risk score (FRS) model.

METHODS

We performed post hoc analysis of National Health and Nutrition Examination Survey-III (1998-94) including subjects aged 30-79 years free from CHD or CHD equivalent at baseline. Primary endpoint was death from ischemic heart disease. NLR was divided into four categories: <1.5, ≥1.5 to <3.0, 3.0-4.5 and >4.5. Statistical analyses involved multivariate Cox proportional hazards models as well as discrimination, calibration and reclassification.

RESULTS

We included 7363 subjects with a mean follow up of 14.1 years. There were 231 (3.1%) CHD deaths, more in those with NLR>4.5 (11%) compared to NLR<1.5 (2.4%), p<0.001. Adjusted hazard ratio of NLR>4.5 was 2.68 (95% CI 1.07-6.72, p=0.035). There was no significant improvement in C-index (0.8709 to 0.8713) or area under curve (0.8520 to 0.8531) with addition of NLR to FRS model. Model with NLR was well calibrated with Hosmer-Lemeshow chi-square of 8.57 (p=0.38). Overall net reclassification index (NRI) was 6.6% (p=0.003) with intermediate NRI of 10.1% (p<0.001) and net upward reclassification of 5.6%. Absolute integrated discrimination index (IDI) was 0.003 (p=0.039) with relative IDI of 4.3%.

CONCLUSIONS

NLR can independently predict CHD mortality in an asymptomatic general population cohort. It reclassifies intermediate risk category of FRS, with significant upward reclassification. NLR should be considered as an inflammatory biomarker of CHD.