Perioperative neutrophil:lymphocyte ratio and postoperative NSAID use as predictors of survival after lung cancer surgery: a retrospective study

How General and Inflammatory Status Impacts on the Prognosis of Patients Affected by Lung Cancer: State of the Art

Pulmonary cancer is often associated with systemic inflammation and poor nutritional status and these two aspects are strongly correlated and related to the scarce infiltration of a tumor by immune cells. We reviewed all English literature reviews from 2000 to 2024 from PubMed, Scopus and Google Scholar, including original articles, review articles, and metanalyses. We excluded non-English language articles and case reports/case series. Generally speaking, nutritional and inflammatory status largely affect medium and long-term prognosis in lung cancer patients. A correct stratification of patients could improve their preoperative general functional nutritional and inflammatory status, minimizing, therefore, possible treatment complications and improving long-term prognosis.

R-ketorolac ameliorates cancer-associated cachexia and prolongs survival of tumour-bearing mice

BACKGROUND

Cancer-associated cachexia (CAC) is a debilitating syndrome associated with poor quality of life and reduced life expectancy of cancer patients. CAC is characterized by unintended body weight reduction due to muscle and adipose tissue loss. A major hallmark of CAC is systemic inflammation. Several non-steroidal anti-inflammatory drugs (NSAIDs) have been suggested for CAC treatment, yet no single medication has proven reliable. R-ketorolac (RK) is the R-enantiomer of a commonly used NSAID. The effect of RK on CAC has not yet been evaluated.

METHODS

Ten- to 11-week-old mice were inoculated with C26 or CHX207 cancer cells or vehicle control (phosphate-buffered saline [PBS]). After cachexia onset, 2 mg/kg RK or PBS was administered daily by oral gavage. Body weight, food intake and tumour size were continuously measured. At study endpoints, blood was drawn, mice were sacrificed and tissues were excised. Immune cell abundance was analysed using a Cytek® Aurora spectral flow cytometer. Cyclooxygenase (COX) activity was determined in lung homogenates using a fluorometric kit. Muscle tissues were analysed for mRNA and protein expression by quantitative real-time PCR and western blotting analysis, respectively. Muscle fibre size was determined on histological slides after haematoxylin/eosin staining.

RESULTS

Ten-day survival rate of C26-bearing animals was 10% while RK treatment resulted in a 100% survival rate (P = 0.0009). Chemotherapy resulted in a 10% survival rate 14 days after treatment initiation, but all mice survived upon co-medication with RK and cyclophosphamide (P = 0.0001). Increased survival was associated with a protection from body weight loss in C26 (-0.61 ± 1.82 vs. -4.48 ± 2.0 g, P = 0.0004) and CHX207 (-0.49 ± 0.33 vs. -2.49 ± 0.93 g, P = 0.0003) tumour-bearing mice treated with RK, compared with untreated mice. RK ameliorated musculus quadriceps (-1.7 ± 7.1% vs. -27.8 ± 8.3%, P = 0.0007) and gonadal white adipose tissue (-18.8 ± 49% vs. -69 ± 15.6%, P = 0.094) loss in tumour-bearing mice, compared with untreated mice. Mechanistically, RK reduced circulating interleukin-6 (IL-6) concentrations from 334 ± 151 to 164 ± 123 pg/mL (P = 0.047) in C26 and from 93 ± 39 to 35 ± 6 pg/mL (P = 0.0053) in CHX207 tumour-bearing mice. Moreover, RK protected mice from cancer-induced T-lymphopenia (+1.8 ± 42% vs. -49.2 ± 12.1% in treated vs. untreated mice, respectively). RK was ineffective in ameliorating CAC in thymus-deficient nude mice, indicating that the beneficial effect of RK depends on T-cells.

CONCLUSIONS

RK improved T-lymphopenia and decreased systemic IL-6 concentrations, resulting in alleviation of cachexia and increased survival of cachexigenic tumour-bearing mice, even under chemotherapy and independent of COX inhibition. Considering its potential, we propose that the use of RK should be investigated in patients suffering from CAC.

Ketorolac modulates Rac-1/HIF-1α/DDX3/β-catenin signalling via a tumor suppressor prostate apoptosis response-4 (Par-4) in renal cell carcinoma

Renal cell carcinoma (RCC) is the most difficult-to-treat form of kidney cancer with a median 5-year survival of 10% under metastatic setting. In RCC, although cytoreductive nephrectomy is common, approximately 20-30% of patients will develop recurrent cancer after surgery, which highlights the need for an effective therapy. Rho-GTPases viz, Rac-1 and Cdc42 are the central regulators of cancer cell migration and invasion and thus metastasis in multiple cancer types. Hence, we elucidated the role of Ketorolac, a modulator Rho-GTPases against RCC through potentiation of tumor suppressor Par-4. The effect of Ketorolac alone and in combination on proliferation, apoptosis, cell-cycle progression, migration, tumor inhibition and their related markers were studied. Moreover, Ketorolac's impact on metastasis by influencing Rac-1/HIF-1α/DDX3/β-catenin signalling was studied with respect to its ability to modulate the expression of tumor suppressor Par-4, and this mechanism was confirmed by siRNA knockdown studies. Ketorolac induced cytotoxicity in a panel of renal cells including patient derived tumor cells with IC₅₀ 2.8 to 9.02 mM and 0.28 to 3.8 mM in monolayer and anchorage independent clonogenic assays respectively. Ketorolac caused significant down regulation of proliferation (Ki-67, Cyclin D1, pRB and DDX3), migration/invasion (Rac-1, Cdc42, and Tiam1), and angiogenesis (HIF-1α and VEGF) markers as studied by gene and protein expression. Moreover, it caused a significant upregulation of tumor suppressor Par-4 known to be downregulated in RCC. This mechanism was further confirmed by using siRNA knockdown studies where we could demonstrate a negative relation between the expression of Par-4 and Rac-1/Cdc42. Importantly, Ketorolac alone and in combination with Sunitinib showed tumor growth inhibition (TGI) of 73% and 86% respectively in xenograft model. This anti-tumor activity was further corroborated by down regulation of Rac-1/Cdc42/HIF-1α/DDX3/β-catenin signalling. This is the first report which implicates the role of Ketorolac against RCC by acting as a small molecule secretagogue causing upregulation of Par-4 in autocrine and paracrine manner. Consequently, these findings suggest that Par-4 can serve as a valuable therapeutic target and a prognostic marker for the treatment of RCC.

Systemic Inflammation and Lung Cancer: Is It a Real Paradigm? Prognostic Value of Inflammatory Indexes in Patients with Resected Non-Small-Cell Lung Cancer

Background (1): Our goal was to investigate if and how pre-operative inflammatory status can influence the long-term prognosis of patients undergoing lung surgery for cancer. Materials and Methods (2): This prospective observational study includes the agreement of all operable patients to the study, who were referred to our department between 1 January 2017 and 30 December 2018. The inflammatory pre-operative status of the patients was investigated by calculating albumin, CPR (c-protein reactive), complete blood count (neutrophils, lymphocytes, platelets, hemoglobin), and some other indexes referring to inflammatory status, namely the HALP amalgamated index, platelet-to-lymphocyte ratio (PLR), neutrophil-to-lymphocytes ratio (NLR), systemic immune-inflammation index (SII), and advanced lung cancer inflammation Index (ALI). The follow-up ended in November 2021. Patient overall survival was assessed using the Kaplan-Meier method. The log-rank test was used to compare survival rates. Variables significantly associated with survival at univariate analysis were entered int Cox multivariate analysis (stepwise mode) to assess their independent character. Hazard ratios and their 95% confidence intervals were calculated. Variables associated with p < 0.05 were considered significative. Results (3): We enrolled 257 patients in our study. The overall survival of the cohort was as follows: 1 year, 96.1%; 3 year, 81.3%; and 4 year, 74.2%. Univariate analysis showed risk factors for overall survival as follows: Thoracoscore ≥ 2 (p = 0.002); histology (p = 0.002); HALP < 32.2 (p = 0.0002); SII ≥ 808.9 (p = 0.0004); ALI < 34.86 (p = 0.0005); NLr ≥ 2.29 (p = 0.01); hemoglobin < 13 g/dl (p = 0.01); PLR ≥ 196.1 (p = 0.005); pN+ (p < 0.0001); pleural invasion (p = 0.0002); and presence of vascular or lymphatic tumor emboli (p = 0.0002). Multivariate Cox analysis (stepwise model) identified Thoracoscore ≥ 2 (p = 0.02); histology, HALP < 32.2 (p = 0.004), and pN (p < 0.0001) as independent predictors of death. Conclusion (4): Pre-operative inflammatory status strongly influences long-term prognosis in patients affected by NSCLC and undergoing surgery.

Tumor Necrosis Factor Alpha: Implications of Anesthesia on Cancers

Cancer remains a major public health issue and a leading cause of death worldwide. Despite advancements in chemotherapy, radiation therapy, and immunotherapy, surgery is the mainstay of cancer treatment for solid tumors. However, tumor cells are known to disseminate into the vascular and lymphatic systems during surgical manipulation. Additionally, surgery-induced stress responses can produce an immunosuppressive environment that is favorable for cancer relapse. Up to 90% of cancer-related deaths are the result of metastatic disease after surgical resection. Emerging evidence shows that the interactions between tumor cells and the tumor microenvironment (TME) not only play decisive roles in tumor initiation, progression, and metastasis but also have profound effects on therapeutic efficacy. Tumor necrosis factor alpha (TNF-α), a pleiotropic cytokine contributing to both physiological and pathological processes, is one of the main mediators of inflammation-associated carcinogenesis in the TME. Because TNF-α signaling may modulate the course of cancer, it can be therapeutically targeted to ameliorate clinical outcomes. As the incidence of cancer continues to grow, approximately 80% of cancer patients require anesthesia during cancer care for diagnostic, therapeutic, or palliative procedures, and over 60% of cancer patients receive anesthesia for primary surgical resection. Numerous studies have demonstrated that perioperative management, including surgical manipulation, anesthetics/analgesics, and other supportive care, may alter the TME and cancer progression by affecting inflammatory or immune responses during cancer surgery, but the literature about the impact of anesthesia on the TNF-α production and cancer progression is limited. Therefore, this review summarizes the current knowledge of the implications of anesthesia on cancers from the insights of TNF-α release and provides future anesthetic strategies for improving oncological survival.

Clinical significance of preoperative neutrophil‐lymphocyte ratio and platelet‐lymphocyte ratio in the prognosis of resected early‐stage patients with non‐small cell lung cancer: A meta‐analysis

BACKGROUND

Poor prognosis is linked to peripheral blood levels of preoperative platelet-lymphocyte ratio (PLR) and neutrophil-lymphocyte ratio (NLR) in many advanced cancers. Nevertheless, whether the correlation exists in resected early-stage cases with non-small cell lung cancer (NSCLC) stays controversial. Consequently, we performed a meta-analysis to explore the preoperative NLR and PLR's prognostic significance in early-stage patients with NSCLC undergoing curative surgery.

METHODS

Relevant studies that validated the link between preoperative NLR or PLR and survival results were found via the proceeding databases: PubMed, Embase, Cochrane Library, and Web of Science. The merged 95% confidence interval (CI) and hazard ratio (HR) was employed to validate the link between the NLR or PLR's index and overall survival (OS) and disease-free survival (DFS) in resected NSCLC cases. We used sensitivity and subgroup analyses to assess the studies' heterogeneity.

RESULTS

An overall of 21 studies were attributed to the meta-analysis. The findings indicated that great preoperative NLR was considerably correlated with poor DFS (HR = 1.58, 95% CI: 1.37-1.82, p < 0.001) and poor OS (HR = 1.51, 95% CI: 1.33-1.72, p < 0.001), respectively. Subgroup analyses were in line with the pooled findings. In aspect of PLR, raised PLR was indicative of inferior DFS (HR = 1.28, 95% CI: 1.04-1.58, p = 0.021) and OS (HR = 1.37, 95% CI: 1.18-1.60, p < 0.001). In the subgroup analyses between PLR and DFS, only subgroups with a sample size <300 (HR = 1.67, 95% CI: 1.15-2.43, p = 0.008) and TNM staging of mixed (I-II) (HR = 1.47, 95% CI: 1.04-2.07, p = 0.028) showed that the link between high PLR and poor DFS was significant.

CONCLUSIONS

Preoperative elevated NLR and PLR may act as prognostic biomarkers in resected early-stage NSCLC cases and are therefore valuable for guiding postoperative adjuvant treatment.

Perioperative Inflammatory Response and Cancer Recurrence in Lung Cancer Surgery: A Narrative Review

While surgical resection is the gold standard treatment for solid tumors, cancer recurrence after surgery is common. Immunosurveillance of remnant tumor cells is an important protective mechanism. Therefore, maintenance of anti-tumor cell activity and proper levels of inflammatory mediators is crucial. An increasing body of evidence suggests that surgery itself and perioperative interventions could affect these pathophysiological responses. Various factors, such as the extent of tissue injury, perioperative medications such as anesthetics and analgesics, and perioperative management including transfusions and methods of mechanical ventilation, modulate the inflammatory response in lung cancer surgery. This narrative review summarizes the pathophysiological mechanisms involved in cancer recurrence after surgery and perioperative management related to cancer recurrence after lung cancer surgery.

Assessing the Prognostic Value of the Neutrophil-to-Lymphocyte Ratio in Stage I Non-Small-Cell Lung Cancer with Complete Resection

Purpose. To explore the prognostic value of the neutrophil-to-lymphocyte ratio (NLR) in stage I non-small-cell lung cancer (NSCLC) undergoing surgery. Patients and Methods. Between 2014 and 2016, a total of 190 patients with postoperative pathology of stage I NSCLC who underwent radical surgery at Nanjing Chest Hospital were studied. Clinical data were analyzed and classified into low-risk, moderate-risk, and high-risk groups based on independent risk factors to assess the prognosis. Results. NLR was associated with histological type and gender, and patients with an elevated NLR have poor overall survival (OS). Lymphovascular invasion, red blood cell distribution width-standard deviation (RDW-SD), and carcinoembryonic antigen (CEA) were independent prognostic factors for progression-free survival (PFS) in postoperative patients with stage I NSCLC, while NLR, RDW-SD, and CEA were independent risk factors for OS. Both PFS and OS were shorter in the low-risk group than in the medium-risk and high-risk groups. Conclusions. NLR, RDW-SD, CEA, and lymphovascular invasion are independent risk factors for postoperative prognosis in patients with stage I NSCLC, and the combination has a predictive value.

Changes in Perioperative Platelet Lymphocyte Ratio Predict Survival in Oesophago-Gastric Adenocarcinoma

BACKGROUND

Platelet to lymphocyte ratio (PLR) is associated with survival in oesophageal cancer. We explored whether PLR changes during different stages of treatment correlate with survival outcomes.

METHODS

A retrospective single-centre study was performed. Consecutive patients who received neoadjuvant chemotherapy followed by surgery for oesophageal adenocarcinoma were identified. Changes in PLR were calculated during two time periods: the first spanning the neoadjuvant period (T1); the second the perioperative period (T2). Differences in PLR were calculated for clinicopathological variables during both T1 and T2 and for variables with regards to their association with median overall survival (OS). Variables found to be significant on univariate analysis were included in a multivariate Cox regression model. Using ROC analysis, optimal cut-offs for PLR changes were identified and plotted on a Kaplan-Meir curve.

RESULTS

Of the 370 patients identified, 110 (29.7%) were included in the analysis. During T1 a positive correlation was noted between higher positive lymph node ratio and PLR change. During T2, PLR change was positively higher in patients who suffered major postoperative complications. Median survival for the cohort as a whole was 42.3 months and 5-year OS was 57.3%. Survival at 5 years was associated with lower PLR changes during T2. On univaraite analysis, median OS was significantly less for patients with a tumour size > 3 cm, poor differentiation and change in PLR ≥ 43.4 during T2. The latter two variables remained significant on multivariate analysis. Using the same PLR threshold, the survival curve comparing changes in PLR during T2 remained statistically significant.

CONCLUSION

Perioperative PLR changes are highly prognostic of survival outcomes in patients treated for oesophageal adenocarcinoma.

Anesthesia and Oncology: Friend or Foe?

Cancer is a leading cause of death, and surgery is an important treatment modality. Laboratory research and retrospective studies have raised the suspicion that the choice of anesthetics for cancer surgery might affect the course of cancerous disease. The aim of this review is to provide a critical overview of the current state of knowledge. Inhalational anesthesia with volatiles or total intravenous anesthesia (TIVA) with propofol are the two most commonly used anesthetic techniques. Most data comparing volatile anesthetics with TIVA is from either in vitro or retrospective studies. Although conflicting, data shows a trend towards favoring propofol. Opioids are commonly used in anesthesia. Data on potential effects of opioids on growth and recurrence of cancer are scarce and conflicting. Preclinical studies have shown that opioids stimulate cancer growth through the µ-opioid receptor. Opioids also act as immunosuppressants and, therefore, have the potential to facilitate metastatic spread. However, the finding of an adverse effect of opioids on tumor growth and cancer recurrence by some retrospective studies has not been confirmed by prospective studies. Regional anesthesia has not been found to have a beneficial effect on the outcome of surgically treated cancer patients, but prospective studies are scarce. Local anesthetics might have a beneficial effect, as observed in animal and in vitro studies. However, prospective clinical studies strongly question such an effect. Blood products, which may be needed during extensive cancer surgery suppress the immune system, and data strongly suggest a negative impact on cancer recurrence. The potential effects of other commonly used anesthetic agents on the outcome of cancer patients have not been sufficiently studied for drawing valid conclusions. In conclusion, laboratory data and most retrospective studies suggest a potential advantage of TIVA over inhalational anesthesia on the outcome of surgical cancer patients, but prospective, randomized studies are missing. Given the state of weak scientific evidence, TIVA may be used as the preferred type of anesthesia unless there is an individual contraindication against it. Studies on the effects of other drugs frequently used in anesthesia are limited in number and quality, and have found conflicting results.

Intensity of perioperative analgesia but not pre-treatment pain is predictive of survival in dogs undergoing amputation plus chemotherapy for extremity osteosarcoma

The purpose of this bi‐institutional retrospective study was to determine whether, in dogs treated with limb amputation and adjunctive chemotherapy for osteosarcoma, oncologic outcomes are impacted by either: (1) baseline cancer pain severity, or (2) the approaches used for perioperative pain management. Data were extracted from the medical records of 284 dogs that underwent both limb amputation and chemotherapy (carboplatin and/or doxorubicin) between 1997 and 2017 for localized (non‐metastatic) osteosarcoma of the appendicular skeleton. Kaplan–Meier survival curves and Cox proportional hazard (PH) models were used to determine the impact that retrospectively scored baseline pain levels (high vs. low) and various analgesic and local anaesthetic treatments had on both metastasis‐free survival and all‐cause mortality. For the entire population, the median disease free interval and median overall survival times were 253 and 284 days, respectively. Baseline pain was rated as “low” in 84 dogs, and “high” in 190 dogs; pain severity had no detectable effect on either metastasis‐free survival or all‐cause mortality. When accounting for the potential influences of known prognostic factors, dogs treated with what was characterized as a high‐intensity perioperative analgesic plan (including both a non‐steroidal anti‐inflammatory drug [NSAID] and a bupivacaine‐eluting soaker catheter placed at the amputation site) had a higher probability of survival than dogs treated with a low‐intensity perioperative analgesic plan (neither an NSAID, nor a soaker catheter); the median overall survival times were 252 and 378 days, respectively (hazard ratio: 2.922; p = .020).

Immune Modulatory Effects of Nonsteroidal Anti-inflammatory Drugs in the Perioperative Period and Their Consequence on Postoperative Outcome

Nonsteroidal anti-inflammatory drugs are among the most commonly administered drugs in the perioperative period due to their prominent role in pain management. However, they potentially have perioperative consequences due to immune-modulating effects through the inhibition of prostanoid synthesis, thereby affecting the levels of various cytokines. These effects may have a direct impact on the postoperative outcome of patients since the immune system aims to restore homeostasis and plays an indispensable role in regeneration and repair. By affecting the immune response, consequences can be expected on various organ systems. This narrative review aims to highlight these potential immune system-related consequences, which include systemic inflammatory response syndrome, acute respiratory distress syndrome, immediate and persistent postoperative pain, effects on oncological and neurologic outcome, and wound, anastomotic, and bone healing.

Anesthesia Techniques and Long-Term Oncological Outcomes

Despite advances in cancer treatments, surgery remains one of the most important therapies for solid tumors. Unfortunately, surgery promotes angiogenesis, shedding of cancer cells into the circulation and suppresses anti-tumor immunity. Together this increases the risk of tumor metastasis, accelerated growth of pre-existing micro-metastasis and cancer recurrence. It was theorized that regional anesthesia could influence long-term outcomes after cancer surgery, however new clinical evidence demonstrates that the anesthesia technique has little influence in oncologic outcomes. Several randomized controlled trials are in progress and may provide a better understanding on how volatile and intravenous hypnotics impact cancer progression. The purpose of this review is to summarize the effect of the anesthesia techniques on the immune system and tumor microenvironment (TME) as well as to summarize the clinical evidence of anesthesia techniques on cancer outcomes.

Perioperative NSAIDs and Long-Term Outcomes After cancer Surgery: a Systematic Review and Meta-analysis

PURPOSE OF REVIEW

This review investigated the use of perioperative non-steroidal anti-inflammatory drugs (NSAIDs) and long-term outcomes in cancer surgery patients, and whether this is dependent on cancer type, type of NSAID and timing of administration.

FINDINGS

Perioperative NSAID use was found to be associated with longer disease-free survival (hazard ration, HR = 0.84 (95% CI, 0.73-0.97)) and overall survival (HR = 0.78 (95% CI, 0.64-0.94)). No difference was found between different types of NSAID for disease-free survival, although in overall survival ketorolac use was significant (HR = 0.63 (95% CI, 0.42-0.95)). Analysis on the timing of NSAID administration found no subgroup to be associated with cancer outcomes. The cancer-type analysis found an association with outcomes in breast and ovarian cancers. However, the level of certainty remains very low, mostly due to the heterogeneity and the retrospective nature of most studies. Perioperative NSAID use may be associated with increased disease-free and overall survival after cancer surgery. This may be dependent on the type of cancer and type of NSAID, and further research is needed to support this. These data may inform future prospective trials, which are needed to determine the clinical impact, as well as optimal NSAID regimen.

Perioperative pain, analgesics and cancer-related outcomes: where do we stand?

Cancer-related pain is one of the most common and debilitating symptoms among cancer patients. Undertreated cancer-related pain interferes with daily activities and increases morbidity and mortality. While opioids continue to play an essential role in treating moderate to severe cancer-related pain, they are associated with many adverse effects including misuse. While preclinical and retrospective studies have shown a negative association between opioid use and cancer outcomes, randomized control trials demonstrate that opioid use does not influence cancer recurrence. Additionally, analgesics and adjuvants used for perioperatively or chronic pain control are unlikely to improve oncological outcomes. This article focuses on the pharmacological management of cancer-related pain and offers an overview regarding the use of these medications perioperatively and the cancer outcomes.

Association Between Anesthesia Delivered During Tumor Resection and Cancer Survival: a Systematic Review of a Mixed Picture with Constant Themes

BACKGROUND

Surgery is required for cure of most solid tumors, and general anesthesia is required for most cancer surgery. The vast majority of cancer surgery is facilitated by general anesthesia using volatile inhalational agents such as isoflurane and sevoflurane. Only recently have the immunologic and oncologic effect of inhalational agents, and their alternative, propofol-based total intravenous anesthesia (TIVA), come under investigation.

METHODS

Between January 2019 and June 2020, English language articles on PubMed were searched for the keywords "Propofol" "TIVA" or "IV anesthesia" and either "cancer surgery" or "surgical oncology." Duplicates were removes, manuscripts classified as either in vitro, animal, translational, or clinical studies, and their results summarized within these categories.

RESULTS

In-vitro and translational data suggest that inhalational anesthetics are potent immunosuppressive and tumorigenic agents that promote metastasis, while propofol is anti-inflammatory, anti-tumorigenic, and prevents metastasis development. Clinically there is a recurring association, based largely on retrospective, single institution series, that TIVA is associated with significant improvements in disease-free interval and overall survival in a number of, but not all, solid tumors. The longer the surgery is, the more intense the surgical trauma is, the more aggressive the malignancy is, and the higher likelihood of an association is.

DISCUSSION

Prospective randomized trials, coupled with basic science and translational studies, are needed to further define this association.

A comparison of inflammation markers for predicting oncological outcomes after surgical resection of non-small-cell lung cancer: a validated analysis of 2,066 patients

Clinical and pathological predictors have proved to be insufficient in identifying high-risk patients who develop cancer recurrence after tumour resection. We aimed to compare the prognostic ability of various inflammation markers in patients undergoing surgical resection of lung cancer. We consecutively included 2,066 patients with stage I-III non-small-cell lung cancer undergoing surgical resection at the center between 2005 and 2015. We evaluated prognostic nutritional index, neutrophil-to-lymphocyte ratio, and platelet-to-lymphocyte ratio along with their perioperative changes. We conducted stepwise backward variable elimination and internal validation to compare the selected markers' predictive performance for postoperative recurrence-free survival and overall survival. Preoperative neutrophil-to-lymphocyte ratio independently predicts recurrence-free survival (HR: 1.267, 95% CI 1.064-1.509, p = 0.0079, on base-2 logarithmic scale) and overall survival (HR: 1.357, 95% CI 1.070-1.721, p = 0.0117, on base-2 logarithmic scale). The cut-off value is 2.3 for predicting both recurrence (sensitivity: 46.1% and specificity: 66.7%) and mortality (sensitivity: 84.2% and specificity: 40.4%). Advanced cancer stage, poor tumour differentiation, and presence of perineural infiltration were significantly correlated with higher preoperative neutrophil-to-lymphocyte ratio. We concluded that preoperative neutrophil-to-lymphocyte ratio is superior to prognostic nutritional index and platelet-to-lymphocyte ratio in predicting postoperative recurrence and mortality of patients undergoing surgical resection of non-small-cell lung cancer.

Effects of Anesthesia on Postoperative Recurrence and Metastasis of Malignant Tumors

It is difficult to control the recurrence and metastasis of malignant tumors; furthermore, anesthesia is considered one of the main influencing factors. There has been increasing clinical attention on the effects of anesthetic drugs and methods on postoperative tumor growth and metastasis. We reviewed the effects of anesthesia on tumor recurrence and metastasis; specifically, the effects of anesthetic agents, anesthesia methods, and related factors during the perioperative period on the tumor growth and metastasis were analyzed. This study can provide reference standards for rational anesthesia formulations and cancer-related pain analgesia protocols for surgical procedures in patients with malignant tumors. Moreover, it contributes toward an experimental basis for the improvement and development of novel anesthetic agents and methods.

High neutrophil-to-lymphocyte ratio associated with progression to critical illness in older patients with COVID-19: a multicenter retrospective study

This retrospective cohort study aimed to investigate the correlation of the neutrophil-to-lymphocyte ratio (NLR) with critical illness in older patients with COVID-19, and evaluate the prognostic power of the NLR at admission. We enrolled 232 patients with COVID-19, aged ≥60 y, in Zhejiang province from January 17 to March 3, 2020. Primary outcomes were evaluated until April 13. Cox regression was performed for prognostic factors. Twenty-nine (12.5%) patients progressed to critical illness. Age, shortness of breath, comorbidities including hypertension, heart disease, and chronic obstructive pulmonary disease, higher NLR, lower albumin levels, and multiple mottling and ground-glass opacity were associated with progression. In the multivariate analysis, older age (hazard ratio [HR] 1.121, confidence interval [CI] 1.070-1.174, P<0.001), heart disease (HR 2.587, CI 1.156-5.787, P=0.021), higher NLR (HR 1.136, CI 1.094-1.180, P < 0.001), and multiple mottling and ground-glass opacity (HR 4.518, CI 1.906-10.712, P<0.001) remained critical illness predictors. The NLR was independently associated with progression to critical illness; the relationship was significant and graded (HR: 1.16 per unit; 95% CI: 1.10-1.22; P for trend < 0.001). Therefore, NLR can be adopted as a prognostic tool to assist healthcare providers predict the clinical outcomes of older patients suffering from COVID-19.

Non-steroidal anti-inflammatory drugs and risk of mortality in lung cancer: A meta-analysis of 5 prospective cohorts studies

BACKGROUND

Non-steroidal anti-inflammatory drugs (NSAIDs) especially aspirin has been gained increasing attention due to its potential therapy against to lung cancer. Previous investigations have showed different findings in this issue. We studied the safety profile and efficacy of NSAIDs in treating lung cancer.

METHOD

Embase, Pubmed, and Cochrane Library databases were searched from January 2011 to February 2019. We identified the studies meeting a priori inclusion criteria and it also conducted a secondary review. This meta-analysis of 5 prospective studies was launched to evaluate the effect of NSAIDs for patients with lung cancer on the hazard risk (HR). We used the Random-Effect Model to assess pooled HR and between-study heterogeneity. Application of subgroup analysis, meta-regression, as well as sensitivity analysis was to pinpoint the exact sources of the observed heterogeneity.

RESULTS

5 Prospective Cohorts Studies, including 6017 patients with lung cancer were recruited in the final meta-analysis. In general, using of NSAIDs especially aspirin is not associated with mortality of lung cancer: pooled hazard ratio (HR) of 0.88 [95% confidence intervals (CI): 0.73-1.05] with low heterogeneity (Q = 6.95; I = 42.4%, P = .139). Egger (P = .665) and Begg (P = 1.000) test also showed little trial error in this meta-analysis.

CONCLUSION

NSAIDs did not increase the risk of mortality in patients with lung cancer.

Dual Actions of Ketorolac in Metastatic Ovarian Cancer

Cytoreductive surgery and chemotherapy are cornerstones of ovarian cancer treatment, yet disease recurrence remains a significant clinical issue. Surgery can release cancer cells into the circulation, suppress anti-tumor immunity, and induce inflammatory responses that support the growth of residual disease. Intervention within the peri-operative window is an under-explored opportunity to mitigate these consequences of surgery and influence the course of metastatic disease to improve patient outcomes. One drug associated with improved survival in cancer patients is ketorolac. Ketorolac is a chiral molecule administered as a 1:1 racemic mixture of the S- and R-enantiomers. The S-enantiomer is considered the active component for its FDA indication in pain management with selective activity against cyclooxygenase (COX) enzymes. The R-enantiomer has a previously unrecognized activity as an inhibitor of Rac1 (Ras-related C3 botulinum toxin substrate) and Cdc42 (cell division control protein 42) GTPases. Therefore, ketorolac differs from other non-steroidal anti-inflammatory drugs (NSAIDs) by functioning as two distinct pharmacologic entities due to the independent actions of each enantiomer. In this review, we summarize evidence supporting the benefits of ketorolac administration for ovarian cancer patients. We also discuss how simultaneous inhibition of these two distinct classes of targets, COX enzymes and Rac1/Cdc42, by S-ketorolac and R-ketorolac respectively, could each contribute to anti-cancer activity.

Perioperative Management May Improve Long-term Survival in Patients After Lung Cancer Surgery: A Retrospective Cohort Study

BACKGROUND:

Surgical resection is the main treatment for patients with non–small-cell lung cancer (NSCLC), but patients’ long-term outcome is still challenging. The purpose of this study was to identify predictors of long-term survival in patients after lung cancer surgery.

METHODS:

Patients who underwent surgery for NSCLC from January 1, 2006, to December 31, 2009, were enrolled into this retrospective cohort study. The primary outcome was the survival length after surgery. Predictors of long-term survival were screened with the multivariable Cox proportional hazard model.

RESULTS:

Postoperative follow-up was completed in 588 patients with a median follow-up duration of 5.2 years (interquartile range, 2.0–6.8). Two hundred ninety-one patients (49.5%) survived at the end of follow-up with median survival duration of 64.3 months (interquartile range, 28.5–81.6). The overall survival rates were 90.8%, 70.0%, and 57.1% at the end of the first, third, and fifth year after surgery, respectively. Limited resection (hazard ratio [HR], 1.46; 95% confidence interval [CI], 1.08–1.98; P = .013) and large tumor size (HR, 1.29; 95% CI, 1.17–1.42; P < .001) were associated with short survival; whereas high body mass index grade (HR, 0.82; 95% CI, 0.69–0.97; P = .021), highly differentiated tumor (HR, 0.59; 95% CI, 0.37–0.93; P = .024), dissection of mediastinal lymph node during surgery (HR, 0.45; 95% CI, 0.30–0.67; P < .001), and perioperative use of dexamethasone (HR, 0.70; 95% CI, 0.54–0.90; P = .006) were associated with long survival. No association was found between perioperative use of flurbiprofen axetil and long survival (HR, 0.80; 95% CI, 0.62–1.03; P = .086). However, combined administration of dexamethasone and flurbiprofen axetil was associated with longer survival (compared to no use of both: adjusted HR, 0.57; 95% CI, 0.38–0.84; P = .005).

CONCLUSIONS:

Certain factors in particular perioperative dexamethasone and flurbiprofen axetil therapy may improve patients’ long-term survival after surgery for NSCLC. Given the small sample size, these findings should be interpreted with caution, and randomized clinical trials are needed for further clarification.

Influence of perioperative anaesthetic and analgesic interventions on oncological outcomes: a narrative review

Surgery is an important treatment modality for the majority of solid organ cancers. Unfortunately, cancer recurrence following surgery of curative intent is common, and typically results in refractory disease and patient death. Surgery and other perioperative interventions induce a biological state conducive to the survival and growth of residual cancer cells released from the primary tumour intraoperatively, which may influence the risk of a subsequent metastatic disease. Evidence is accumulating that anaesthetic and analgesic interventions could affect many of these pathophysiological processes, influencing risk of cancer recurrence in either a beneficial or detrimental way. Much of this evidence is from experimental in vitro and in vivo models, with clinical evidence largely limited to retrospective observational studies or post hoc analysis of RCTs originally designed to evaluate non-cancer outcomes. This narrative review summarises the current state of evidence regarding the potential effect of perioperative anaesthetic and analgesic interventions on cancer biology and clinical outcomes. Proving a causal link will require data from prospective RCTs with oncological outcomes as primary endpoints, a number of which will report in the coming years. Until then, there is insufficient evidence to recommend any particular anaesthetic or analgesic technique for patients undergoing tumour resection surgery on the basis that it might alter the risk of recurrence or metastasis.

The prognostic role of neutrophil-lymphocyte ratio and platelet-lymphocyte ratio in patients with stage III non-small cell lung cancer treated with concurrent chemoradiotherapy

BACKGROUND

Neutrophil-lymphocyte ratio (NLR) and platelet-lymphocyte ratio (PLR) have been shown to be prognostic markers in various types of cancers. In this study, we retrospectively investigated the prognostic role of NLR and PLR in stage III non-small cell lung cancer patients (NSCLC) treated with concurrent chemoradiotherapy (CCRT).

MATERIALS AND METHODS

Seventy-nine stage III NSCLC patients treated with definitive CCRT were retrospectively evaluated. All patients received conformal RT with a total dose of 60-66 Gy with CCRT. The optimal cutoff values identified by receiver operating characteristic curve were 155 for PLR and 3.21 for NLR for overall survival (OS) and 142 and 3.21, respectively, for progression-free survival (PFS).

RESULTS

Median age of the study population was 58 years with 72 (91%) males. Stages IIIA, IIIB, and IIIC were found in 21 (26.6%), 48 (60.8%), and 10 (12.7%) patients, respectively. Patients with a PLR <155 had a significantly longer OS (P = 0.038) compared with patients who had a higher PLR. The NLR and other parameters were not found to be in correlation with OS. In multivariable analysis, the PLR and lymphocyte count were significantly associated with OS (hazard ratio [HR]: 2.29, 95% confidence interval [CI]: 1.29-4.08, P = 0.005 and HR: 2.00, 95% CI: 1.17-3.42, P = 0.011, respectively). The PLR and lymphocyte count were identified as independent prognostic factors of poor PFS (HR: 2.08, 95% CI: 1.17-3.69, P = 0.012 and HR: 1.83, 95% CI: 1.08-3.08, P = 0.024, respectively).

CONCLUSION

Our results support the prognostic role of pretreatment PLR and lymphocyte count in stage III NSCLC patients treated with concurrent radiotherapy.

The Relationship Between Neutrophil to Lymphocyte Ratio and Clinical Outcome in Pediatric Patients After Cardiopulmonary Bypass Surgery: A Retrospective Study

Background: The aim of this study was to investigate the prognostic role of the neutrophil to lymphocyte ratio (NLR) in pediatric patients undergoing open-heart surgery with cardiopulmonary bypass (CPB). Methods: A retrospective cohort study of 61 pediatric patients who underwent CPB in the First Affiliated Hospital of Nanjing Medical University from January 2017 to October 2018 was conducted. All perioperative clinical data, including neutrophil count, lymphocyte count, and C-reactive protein (CRP), were collected retrospectively. The prognostic value of NLR and its association with extubation time, duration of intensive care unit (ICU) stay and in-hospital stay were analyzed. Results: Neutrophil count, NLR, and CRP were significantly increased post-operative compared with pre-operative (p < 0.05). The increased post-operative levels of NLR were significantly associated with longer extubation time, as well as prolonged post-operative cardiac ICU stay (p < 0.05). Multivariate linear regression analysis revealed that elevated NLR displayed a significant independent association with extubation time and the duration of an ICU stay. Conclusion: Increased post-operative NLR followed by cardiac surgery with CPB in pediatric patients was associated with longer extubation time and a longer duration of an ICU stay.

Prognostic evaluation of patients with resectable lung cancer using systemic inflammatory response parameters

Lung cancer is one of the leading causes of cancer-associated mortality. C-reactive protein (CRP), albumin (ALB), globulin (GLB), lactate dehydrogenase (LDH), neutrophil-lymphocyte ratio (NLR) and platelet-to-lymphocyte ratio (PLR) have been identified as general parameters for systemic inflammatory response (SIR). Furthermore, these parameters are also associated with tumor development and metastasis. The present study aimed to investigate the predictive values of these SIR parameters in patients with resectable lung cancer. In total, 101 patients with resectable lung cancer were recruited in the present study. The patients were divided into two groups according to the median value of pre-treatment CRP, ALB, GLB, LDH, NLR or PLR values. The post-/pre-treatment ratios were defined as the ratio of pre-treatment blood parameter values and the corresponding values obtained following therapy. A ratio of ≤1.1 indicated that the values were not increased, while a ratio of >1.1 suggested that the values were increased following treatment. Patients with lower pre-treatment ALB levels had poorer overall survival (OS) rates, whereas GLB, LDH, CRP, NLR or PLR levels were not associated with outcomes. Whole course treatment (surgery combined with adjuvant chemotherapy) significantly increased the value of ALB, but decreased the value of NLR, whereas it had no effect on the values of LDH, CRP or PLR. Post-/pre-treatment LDH and PLR were associated with outcomes. Post-/pre-treatment ALB, GLB, CRP and NLR were not associated with outcomes. Multivariate analysis revealed that a low pre-treatment ALB level and increased post-/pre-treatment PLR were independent risk factors affecting OS. The receiver operating characteristic curve analysis demonstrated that an ALB value of 47.850 g/l was considered to be the optimal cut-off value for prognosis; the sensitivity was 28.8% and specificity was 95.9%. It was suggested that the pre-treatment ALB and post-/pre-treatment PLR may be potential prognostic factors in resectable lung cancer.

Peripheral monocytes and neutrophils predict response to immune checkpoint inhibitors in patients with metastatic non-small cell lung cancer

We carried out a retrospective cohort study on patients with metastatic non-small cell lung cancer (mNSCLC) to identify the peripheral blood count parameters associated with response to immune checkpoint inhibitors (ICIs). There were 17 males and 15 females. Their median age was 64.5 years (range 20-84). History of smoking was present in 25/32 (78%) patients. Twelve patients received pembrolizumab, 19 patients nivolumab, and one patient nivolumab followed by pembrolizumab. Responses were observed in 19/32 (59%) patients, all partial responses. There was no difference in the distribution of sex, age, and smoking status between responders and non-responders. The median time to response (TTR) was 12 weeks (range 6-24) and the median duration of response (DoR) was 24 weeks (range 7-112). Higher pre-therapy absolute monocyte counts (AMCs) correlated to shorter TTR (p = 0.03), but not to response rate or DoR. Within the group of responders, those with AMCs > 700/mm3 had a significantly shorter median TTR than those with AMCs ≤ 700/mm3 (8 weeks vs 12 weeks; p = 0.048). Although baseline absolute neutrophil counts (ANCs) did not have any prognostic value, ANCs after first dose predicted response to ICI (p = 0.02). Patients with ANCs ≤ 4200/mm3 after first dose were more likely to respond than those with ANCs > 4200/mm3 (OR = 6.8; 95% CI 1.1-41.8; p = 0.05). Analysis of AMC and ANC before and during therapy may, therefore, provide an easy method to identify those mNSCLC patients most likely to benefit from ICI therapy.

Neutrophil-lymphocyte ratio predicts recurrence in patients with resected stage 1 non-small cell lung cancer

Background

The aim was to determine the prognostic value of the neutrophil-lymphocyte ratio (NLR) in patients with completely resected stage 1 non-small cell lung cancer (NSCLC).

Methods

The study enrolled 382 NSCLC patients, and an optimal NLR cutoff value was determined by ROC analysis. Patients were divided by preoperative NLR into low (< 1.5, n = 99), intermediate (1.5 ≤ NLR < 3.5, n = 245), and high (NLR ≥ 3.5, n = 38) value groups. Serum diacron-reactive oxygen metabolites (d-ROMs) were assayed in 33 consecutive patients and used as an indicator of oxidative stress.

Results

The mean NLR in patients with high d-ROMs (> 300 U.CARR, n = 16) was 1.72 ± 0.67, which was significantly higher than that in patients with low d-ROMs (1.41 ± 0.39, n = 17; P = 0.018). The 3-, 5- and 10-year survival rates in the three NLR groups were 92, 77, and 59% (low); 82, 70, and 50% (intermediate); and 76, 58, and 32% (high) (P = 0.034). The 1-, 3- and 5-year recurrence-free survival rates in the three groups were 98, 90, and 86% (low), 91, 77, and 74% (intermediate); and 92, 77, and 68% (high) (P = 0.033). Multivariate analysis found that although NLR was not predictive of overall survival, high NLR was an independent risk factor of recurrence (hazard ratio: 2.03, 95% confidence interval: 1.17–3.79, P = 0.011) as were as age, pathological stage, tumor differentiation, and lymph-vascular invasion.

Conclusions

A low preoperative NLR predicted good prognosis, and was associated with low systemic inflammation status in patients with stage 1 NSCLC. It may be helpful when considering intervals of routine follow-up or choice of adjuvant therapy.

An inflammation-related nomogram for predicting the survival of patients with non-small cell lung cancer after pulmonary lobectomy

Background

Emerging inflammatory response biomarkers are developed to predict the survival of patients with cancer, the aim of our study is to establish an inflammation-related nomogram based on the classical predictive biomarkers to predict the survivals of patients with non-small cell lung cancer (NSCLC).

Methods

Nine hundred and fifty-two NSCLC patients with lung cancer surgery performed were enrolled into this study. The cutoffs of inflammatory response biomarkers were determined by Receiver operating curve (ROC). Univariate and multivariate analysis were conducted to select independent prognostic factors to develop the nomogram.

Results

The median follow-up time was 40.0 months (range, 1 to 92 months). The neutrophil to lymphocyte ratio (cut-off: 3.10, HR:1.648, P = 0.045) was selected to establish the nomogram which could predict the 5-year OS probability. The C-index of nomogram was 0.72 and the 5-year OS calibration curve displayed an optimal agreement between the actual observed outcomes and the predictive results.

Conclusions

Neutrophil to lymphocyte ratio was shown to be a valuable biomarker for predicting survival of patients with NSCLC. The addition of neutrophil to lymphocyte ratio could improve the accuracy and predictability of the nomogram in order to provide reference for clinicians to assess patient outcomes.

Prognostic significance of neutrophil-lymphocyteratio/platelet-lymphocyteratioin lung cancers: a meta-analysis

Setting

For now, hematological markers of inflammatory response have emerged as prognostic factors for patients with cancer. Many articles have confirm that neutrophil to lymphocyte ratio(NLR) and platelet–lymphocyte ratio (PLR) are relate with poor prognosis in various types of tumors.

Objective

To investigate the association between NLR/PLR and progression free survival (PFS), overall survival (OS) and clinicopathologic parameters in lung cancer patients.

Design

We performed relevant searches in PubMed database, Google Scholar, Springer Link. We included retrospective cohort studies that reported hazard ratios with 95% confidence intervals for the NLR or PLR and PFS or OS.

Results

Both high NLR (P < 0.00001) and high PLR (P = 0.01) were significantly predictive of poorer OS. It also demonstrated that elevated NLR predicted poorer PFS (P = 0.0002). High NLR was significantly associated with deeper Invasive of tumor, (P = 0.006) extensive lymph nodetastasis(N2–3) (P = 0.01), poor differentiation (P = 0.0002) and vascular invasion(P = 0.002). There was no evidence of publication bias. Subgroup analysis indicated that little evidence of heterogeneity. However, PLR has no prognostic significance for SCLC.

Conclusions

We provides further evidence in support of elevated NLR and PLR were predictors of poor OS and PFS in patients with lung cancer. Given this, NLR and PLR may be markers to report treatment outcomes.

Development and validation of a prognostic index for survival in non-small cell lung cancer: Results from a Tunisian cohort study

INTRODUCTION

Despite the continuous efforts made with the TNM system, the issue of heterogeneity of prognosis within the stages of non-small cell lung cancer (NSCLC) could not be resolved. Our aim was to identify prognostic factors and develop an index to predict NSCLC survival with greater accuracy.

METHODS

We conducted a survival study over 5 years on patients with NSCLC. Kaplan-Meier analysis followed by Cox regression modelling were used. Prognostic indices were derived, using either an additive or a multiplicative pattern, and were compared by their receiver operating characteristics (ROC) curves. We then proceeded to a risk stratification and validation of the index on the derivation cohort.

RESULTS

Two hundred and sixty-two NSCLC patients were included. Two models were constructed, using the following nine variables as prognostic factors: age, performance status, haemoglobin level, leucocyte count, calcium, lactate dehydrogenase, alkaline phosphatase levels, histological type and TNM stage. Four prognostic indices were derived, and the best one was picked and validated on a population of five risk groups. The higher the risk group, the shorter the survival.

CONCLUSIONS

This novel and simple prognostic tool could predict survival more accurately in patients with NSCLC.

Perioperative events influence cancer recurrence risk after surgery

Surgery is a mainstay treatment for patients with solid tumours. However, despite surgical resection with a curative intent and numerous advances in the effectiveness of (neo)adjuvant therapies, metastatic disease remains common and carries a high risk of mortality. The biological perturbations that accompany the surgical stress response and the pharmacological effects of anaesthetic drugs, paradoxically, might also promote disease recurrence or the progression of metastatic disease. When cancer cells persist after surgery, either locally or at undiagnosed distant sites, neuroendocrine, immune, and metabolic pathways activated in response to surgery and/or anaesthesia might promote their survival and proliferation. A consequence of this effect is that minimal residual disease might then escape equilibrium and progress to metastatic disease. Herein, we discuss the most promising proposals for the refinement of perioperative care that might address these challenges. We outline the rationale and early evidence for the adaptation of anaesthetic techniques and the strategic use of anti-adrenergic, anti-inflammatory, and/or antithrombotic therapies. Many of these strategies are currently under evaluation in large-cohort trials and hold promise as affordable, readily available interventions that will improve the postoperative recurrence-free survival of patients with cancer.

The role of the systemic inflammatory response in predicting outcomes in patients with operable cancer: Systematic review and meta-analysis

Cancer remains a leading causes of death worldwide and an elevated systemic inflammatory response (SIR) is associated with reduced survival in patients with operable cancer. This review aims to examine the evidence for the role of systemic inflammation based prognostic scores in patients with operable cancers. A wide-ranging literature review using targeted medical subject headings for human studies in English was carried out in the MEDLINE, EMBASE, and CDSR databases until the end of 2016. The SIR has independent prognostic value, across tumour types and geographical locations. In particular neutrophil lymphocyte ratio (NLR) (n = 158), platelet lymphocyte ratio (PLR) (n = 68), lymphocyte monocyte ratio (LMR) (n = 21) and Glasgow Prognostic Score/ modified Glasgow Prognostic Score (GPS/mGPS) (n = 60) were consistently validated. On meta-analysis there was a significant relationship between elevated NLR and overall survival (OS) (p < 0.00001)/ cancer specific survival (CSS) (p < 0.00001), between elevated LMR and OS (p < 0.00001)/CSS (p < 0.00001), and elevated PLR and OS (p < 0.00001)/CSS (p = 0.005). There was also a significant relationship between elevated GPS/mGPS and OS (p < 0.00001)/CSS (p < 0.00001). These results consolidate the prognostic value of the NLR, PLR, LMR and GPS/mGPS in patients with resectable cancers. This is particularly true for the NLR/GPS/mGPS which should form part of the routine preoperative and postoperative workup.

Value of neutrophil-to-lymphocyte ratio for predicting lung cancer prognosis: A meta-analysis of 7,219 patients

Current evidence suggests that the neutrophil-to-lymphocyte ratio (NLR) may be a biomarker for poor prognosis in lung cancer, although this association remains controversial. Therefore, a meta-analysis was performed to evaluate the association between NLR and lung cancer outcome. A systematic literature search was performed through the PubMed, Embase and Cochrane Library databases (until July 30, 2016), to identify studies evaluating the association between NLR and overall survival (OS) and/or progression-free survival (PFS) among patients with lung cancer. Based on the results of this search, data from 18 studies involving 7,219 patients with lung cancer were evaluated. The pooled hazard ratio (HR) suggested that elevated pretreatment NLR predicted poor OS [HR=1.46, 95% confidence interval (CI): 1.30-1.64] and poor PFS (HR=1.42, 95% CI: 1.15-1.75) among patients with lung cancer. Subgroup analysis revealed that the prognostic value of NLR for predicting poor OS increased among patients who underwent surgery (HR=1.50, 95% CI: 1.21-1.84) or patients with early-stage disease (HR=1.64, 95% CI: 1.37-1.97). An NLR cut-off value of ≥4 significantly predicted poor OS (HR=1.56, 95% CI: 1.31-1.85) and PFS (HR=1.54, 95% CI: 1.13-1.82), particularly in the cases of small-cell lung cancer. Thus, the results of the present meta-analysis suggested that an elevated pretreatment NLR (e.g., ≥4) may be considered as a biomarker for poor prognosis in patients with lung cancer.

The Effects of Anesthetics on Recurrence and Metastasis of Cancer, and Clinical Implications

Surgical resection of the primary tumor may enhance the metastasis and recurrence of cancer. The reaction of patients to surgery includes changes of the immune system, the inflammatory system and the neuroendocrine system. In the perioperative period, anesthetics are used both for anesthesia and analgesia. There are several studies showing that the progression of cancer can be influenced by many kinds of anesthetics, although most of these studies are preclinical and thus have not yet influenced clinical recommendations. This review summarizes recent studies regarding the effects of anesthetics on metastasis and recurrence of cancer.

Neutrophil-Lymphocyte Ratio Is a Prognostic Marker in Patients with Locally Advanced (Stage IIIA and IIIB) Non-Small Cell Lung Cancer Treated with Combined Modality Therapy

BACKGROUND

Neutrophil-lymphocyte ratio (NLR) is a measure of systemic inflammation that appears prognostic in localized and advanced non-small cell lung cancer (NSCLC). Increased systemic inflammation portends a poorer prognosis in cancer patients. We hypothesized that low NLR at diagnosis is associated with improved overall survival (OS) in locally advanced NSCLC (LANSCLC) patients.

PATIENTS AND METHODS

Records from 276 patients with stage IIIA and IIIB NSCLC treated with definitive chemoradiation with or without surgery between 2000 and 2010 with adequate data were retrospectively reviewed. Baseline demographic data and pretreatment peripheral blood absolute neutrophil and lymphocyte counts were collected. Patients were grouped into quartiles based on NLR. OS was estimated using the Kaplan-Meier method. The log-rank test was used to compare mortality between groups. A linear test-for-trend was used for the NLR quartile groups. The Cox proportional hazards model was used for multivariable analysis.

RESULTS

The NLR was prognostic for OS (p < .0001). Median survival in months (95% confidence interval) for the first, second, third, and fourth quartile groups of the population distribution of NLR were 27 (19-36), 28 (22-34), 22 (12-31), and 10 (8-12), respectively. NLR remained prognostic for OS after adjusting for race, sex, stage, performance status, and chemoradiotherapy approach (p = .004).

CONCLUSION

To our knowledge, our series is the largest to demonstrate that baseline NLR is a significant prognostic indicator in LANSCLC patients who received definitive chemoradiation with or without surgery. As an indicator of inflammatory response, it should be explored as a potential predictive marker in the context of immunotherapy and radiation therapy.

IMPLICATIONS FOR PRACTICE

Neutrophil-lymphocyte ratio measured at the time of diagnosis was associated with improved overall survival in 276 patients with stage IIIA and IIIB non-small cell lung cancer (NSCLC) treated with definitive chemoradiation with or without surgery. To our knowledge, our series is the largest to demonstrate that baseline neutrophil-lymphocyte ratio is a significant prognostic indicator in locally advanced NSCLC patients who received definitive chemoradiation with or without surgery. Neutrophil-lymphocyte ratio is an inexpensive biomarker that may be easily utilized by clinicians at the time of locally advanced NSCLC diagnosis to help predict life expectancy.

Platelet-to-Lymphocyte Ratio and Use of NSAIDs During the Perioperative Period as Prognostic Indicators in Patients With NSCLC Undergoing Surgery

BACKGROUND

Hematological biomarkers of inflammation such as the neutrophil-to-lymphocytic rate have been reported as predictors of survival in a variety of cancers. The aim of the present study was to investigate the prognostic value of the perioperative platelet-to-lymphocyte ratio in patients with non-small-cell lung cancer (NSCLC) and to elucidate the effects of the perioperative use of nonsteroidal anti-inflammatory drugs (NSAIDs) on tumor recurrence and survival in patients undergoing surgical resection for NSCLC.

METHODS

This retrospective study included data from 1,637 patients who underwent surgical resection for stage I, II, or III NSCLC. Perioperative data and tumor-related variables were included. Univariate and multivariable Cox proportional hazard ratio (HR) models were used to evaluate the association between perioperative platelet-to-lymphocyte ratio and NSAID use on recurrence-free survival (RFS) and overall survival (OS).

RESULTS

Multivariate analysis showed that a preoperative platelet-to-lymphocyte ratio of at least 180 was associated with reduced rates of RFS (HR = 1.22; 95% confidence interval [CI], 1.03-1.45; P = .019) and OS (HR = 1.33; 95% CI, 1.10-1.62; P = .004). Perioperative use of NSAIDs showed no statistically significant changes in RFS and OS rates (P = .72 and P = .44, respectively).

CONCLUSIONS

A higher preoperative inflammatory status is associated with decreased rates of RFS and OS in patients with NSCLC undergoing curative surgery. Perioperative use of NSAIDs was not found to be an independent predictor of survival.

The neutrophil-to-lymphocyte ratio: a narrative review

Cellular-mediated inflammatory response, lymphocytes, neutrophils, and monocytes are increasingly being recognised as having an important role in tumorigenesis and carcinogenesis. In this context, studies have suggested that the neutrophil-to-lymphocyte ratio (NLR) can be used as an independent prognostic factor in a variety of cancers. Particularly in breast cancer, several studies have shown that a high NLR is associated with shorter survival. Because the NLR can be easily determined from the full blood count, it could potentially provide a simple and inexpensive test cancer prognosis. This review addresses the possibilities and limitations of using the NLR as a clinical tool for risk stratification helpful for individual treatment of breast cancer patients. The potential underlying phenomena and some perspectives are discussed.

The neutrophil-to-lymphocyte ratio: a narrative review

Cellular-mediated inflammatory response, lymphocytes, neutrophils, and monocytes are increasingly being recognised as having an important role in tumorigenesis and carcinogenesis. In this context, studies have suggested that the neutrophil-to-lymphocyte ratio (NLR) can be used as an independent prognostic factor in a variety of cancers. Particularly in breast cancer, several studies have shown that a high NLR is associated with shorter survival. Because the NLR can be easily determined from the full blood count, it could potentially provide a simple and inexpensive test cancer prognosis. This review addresses the possibilities and limitations of using the NLR as a clinical tool for risk stratification helpful for individual treatment of breast cancer patients. The potential underlying phenomena and some perspectives are discussed.

The postoperative neutrophil-to-lymphocyte ratio and changes in this ratio predict survival after the complete resection of stage I non-small cell lung cancer

Purpose

Although numerous studies have demonstrated associations between the preoperative neutrophil-to-lymphocyte ratio (NLR) and long-term outcomes in patients with non-small cell lung cancer (NSCLC), the prognostic significance of postoperative NLR and change in NLR (ΔNLR) is unknown for patients who underwent complete resection of stage I NSCLC. The aim of this retrospective study was to evaluate the prognostic significance of postoperative NLR and ΔNLR in 123 patients with stage I NSCLC.

Patients and methods

This retrospective study included preoperative and postoperative data of 123 patients who underwent surgical resection for stage I NSCLC. The relationship between disease-free survival (DFS), overall survival (OS), and clinicopathological factors, including NLR, lymphocyte-to-monocyte ratio (LMR), platelet-to-lymphocyte ratio, and their changes, was analyzed using both univariate Kaplan–Meier and multivariate Cox regression methods.

Results

The 5-year DFS and OS rates in our cohort were 60.16% and 67.48%, respectively. Univariate analysis revealed that age (P=0.045), smoking status (P=0.033), preoperative NLR (P=0.032), postoperative NLR (P<0.001), ΔNLR (P=0.004), and change in LMR (ΔLMR) (P=0.025) were significant predictors of DFS and that age (P=0.039), smoking status (P=0.042), postoperative NLR (P<0.001), ΔNLR (P=0.004), and ΔLMR (P=0.011) were independent predictors of OS. Multivariate analysis confirmed that postoperative NLR (hazard ratio [HR] =2.435, P=0.001) and ΔNLR (HR =2.103, P=0.012) were independent predictors of DFS and that postoperative NLR (HR =2.747, P=0.001) and ΔNLR (HR =2.052, P=0.018) were significant prognostic factors of OS.

Conclusion

Our study reported for the first time that postoperative NLR and ΔNLR – but not preoperative NLR – were independent prognostic factors of DFS and OS in patients with stage I NSCLC who underwent complete resection. This easily available biomarker might be helpful in individual risk assessment.

Lack of Association Between Dexamethasone and Long-Term Survival After Non-Small Cell Lung Cancer Surgery

OBJECTIVE

To evaluate the association between the use of intraoperative dexamethasone with an increase in recurrence-free survival (RFS) and overall survival (OS) after non-small cell lung cancer (NSCLC) surgery.

DESIGN

This was a propensity score-matched (PSM) retrospective study.

SETTING

Single academic center.

PARTICIPANTS

The study comprised patients with stage I through IIIa NSCLC. Patients were excluded if they were younger than 18 years, had missing data, and died within 30 days after surgery.

MEASUREMENTS AND MAIN RESULTS

Primary outcomes of the study were RFS and OS. The data were PSM. RFS and OS were evaluated using univariate and multivariate Cox proportional hazards models after PSM to assess the association between intraoperative dexamethasone use and the primary outcomes. A p value of<0.05 was considered statistically significant. After PSM, 436 patients were included in each treatment group. Adjusting for significant covariates, the multivariate analysis demonstrated no association between the use of dexamethasone and RFS (hazard ratio [95% confidence interval]: 0.98 [0.78-1.24]; p = 0.915). The multivariate analysis also demonstrated no association between the administration of dexamethasone and OS (hazard ratio [95% confidence interval]: 1.08 [0.81-1.44]; p = 0.58).

CONCLUSIONS

This study demonstrated that intraoperative dexamethasone administration to NSCLC patients was not associated with a significant impact on RFS and OS. The results were similar to a previous study on ovarian cancer patients. A randomized controlled study should be conducted to confirm the results of this study.

Preoperative anemia, blood transfusion, and neutrophil-to-lymphocyte ratio in patients with stage i non-small cell lung cancer

Perioperative and postoperative blood transfusions (BT), anemia and inflammation are associated with poor survivals in patients with non-small cell lung cancer (NSCLC). This study investigated the impact of perioperative BT on the survival of patients with NSCLC taking into account their preoperative inflammatory status and the presence of anemia. Demographic, perioperative, and survival data for 861 patients with stage I NSCLC was collected retrospectively. The primary endpoints of interest were recurrence-free (RFS) and overall survival (OS). Before and after propensity score matching, univariate and multivariable Cox proportional hazards models were used to evaluate the association between covariates and survival. A neutrophil-to-lymphocyte ratio (NLR) < 5 (hazard ratio [HR]: 0.58, 95% CI: 0.38-0.87; p = 0.009) and normal Hb concentration (HR: 0.72, 95% CI: 0.72; p = 0.022) were independently associated with longer RFS. The administration of blood perioperatively was associated with a trend towards worse RFS (HR: 0.69, 95% CI: 0.47-1.02; p = 0.066). The multivariate analysis also revealed that an NLR < 5 (HR: 0.48, 95% CI: 0.3-0.76; p = 0.001) and the absence of BT (HR: 0.63, 95% CI: 0.4-0.98; p = 0.04) were significantly associated with lower mortality risk. The propensity score matching analysis did not confirm the association between BT and poor RFS (HR: 0.63, 95% CI: 0.35-1.1; p = 0.108) and OS (HR: 0.52, 95% CI: 0.26-1.04; p = 0.06). Inflammation and anemia are common finding in patients with stage 1 NSCLC. After adjusting for these two important confounders, this study confirms that previous reports demonstrating an association between BT and poor survival after NSCLC surgery.

The Neutrophil to Lymphocyte Ratio on Admission and Short-Term Outcomes in Orthogeriatric Patients

AIM

To investigate the association of the neutrophil to lymphocyte ratio (NLR) at admission with presence of fracture, comorbid conditions, and its prognostic value for short-term outcomes in orthogeriatric patients.

METHODS

On 415 consecutive patients (mean age 78.8 ±8.7[SD] years, 281 women, 255 with a non-vertebral bone fracture, including 167 with a hip fracture, HF) admitted to the Department of Orthopaedic Surgery at the Canberra hospital (2010 - 2011) data on clinical and laboratory characteristics were collected prospectively. The validation dataset included 294 consecutive patients (mean age 82.1 ± 8.0 years, 72.1% women) with HF.

RESULTS

Multivariate regression revealed four variables, presence of HF, hypoalbuminaemia (<33g/L), anaemia (<120g/L) and hyperparathyroidism (PTH>6.8 pmol/L), as independent determinants of admission NLR≥5.1. There was a dose-graded relationship between presence of fracture, especially HF, postoperative complications and levels of NLR categorized as tertiles. Compared to patients with NLR<5.1(first tertile), patients with NLR 5.1-8.5 (second tertile) had a 1.8-, 3.1-, 2.6-, and 2.5-fold higher risk for presence of any fracture, HF, developing postoperative myocardial injury (troponin I rise) and a high inflammatory response/infection (CRP>100mg/L after the 3rd postoperative day), respectively, while in subjects with NLR>8.5 (third tertile) these risks were 2.6-, 4.9-, 5.9- and 4.5-times higher, respectively; subjects with NLR>8.5 had a 9.7 times higher chance of dying in the hospital compared to patients with NLR 5.1-8.5; the NLR retained its significance on multivariate analyses. The NLR ≥5.1 predicted postoperative myocardial injury with an area under the curve (AUC) of 0.626, CRP>100mg/L with AUC of 0.631 and the NLR >8.5 predicted in-hospital mortality with an AUC of 0.793, showing moderately high sensitivity (86.7%, 80% and 90%, respectively) and negative predictive value (92.9%, 71.2%, 99.6%, respectively), but low specificity. Admission NLR was superior to other, except hypoalbuminaemia, prognostic markers; combined use of both NLR≥5.1 and albumin<33g/L only moderately increased the accuracy of prediction. The validation study confirmed the prognostic value of the admission NLR.

CONCLUSIONS

In orthogeriatric patients, high NLR on admission is an independent indicator of fracture presence, a significant risk factor and moderate predictor of postoperative myocardial injury, high inflammatory response/infection and in-hospital death.

Prognostic role of neutrophil to lymphocyte ratio in lung cancers: a meta-analysis including 7,054 patients

Background

Neutrophil to lymphocyte ratio (NLR) has recently been reported to be a poor prognostic indicator in lung cancer. However, the prognostic value of the NLR in patients with lung cancer still remains controversial. We performed a meta-analysis to evaluate the prognostic value of NLR in patients with lung cancer.

Methods

We performed a comprehensive literature search in PubMed, Ovid, the Cochrane Library, and Web of Science databases in May 2015. Studies were assessed for quality using the Newcastle–Ottawa Scale.

Results

Twenty-two studies with a total of 7,054 patients were included in this meta-analysis. The meta-analysis was performed to generate combined hazard ratios (HRs) for overall survival (OS) and progression-free survival (PFS). Our analysis results indicated that high NLR predicted poorer OS (HR, 1.51; 95% confidence interval [CI], 1.33–1.71; P<0.001) and PFS (HR, 1.33; 95% CI, 1.07–1.67; P=0.012) in patients with lung cancer. High NLR was also associated with poor OS in lung cancer treated by surgical resection (HR, 1.59; 95% CI, 1.26–1.99; P<0.001) and chemotherapy (HR, 1.15; 95% CI, 1.08–1.22; P<0.001). In addition, NLR cut-off value =5 (HR, 1.57; 95% CI, 1.16–2.12; P=0.003) and NLR cut-off value <5 (HR, 1.47; 95% CI, 1.28–1.69; P<0.001).

Conclusion

This meta-analysis result suggested that NLR should have significant predictive ability for estimating OS and PFS in patients with lung cancer and may be as a significant biomarker in the prognosis of lung cancer.

Serum human epididymis protein 4 is associated with the treatment response of concurrent chemoradiotherapy and prognosis in patients with locally advanced non-small cell lung cancer

AIM

To investigate the role of human epididymis protein 4 (HE4) in the diagnosis and prognosis of patients with locally advanced non-small cell lung cancer (LA-NSCLC) receiving concurrent chemoradiotherapy (CRT).

METHODS

A total of 218 patients with LA-NSCLC were enrolled. All patients underwent CRT. The treatment response to CRT was evaluated. The prognosis analysis was performed using relapse-free survival (RFS) and overall survival [1].

RESULTS

Our data show that the serum HE4 can discriminate patients who respond well to CRT from those who respond poorly. Higher serum HE4 had dramatically increased risk of being non-responders to CRT. Serum HE4 level is also associated with prognosis of patients after CRT. Patients with high HE4 level had shorter RFS and OS compared to those with low HE4 level.

CONCLUSION

Our data suggest that serum HE4 may be a useful prognostic biomarker for LA-NSCLC patients who underwent CRT.

Pretreatment Immune Parameters Predict for Overall Survival and Toxicity in Early-Stage Non-Small-Cell Lung Cancer Patients Treated With Stereotactic Body Radiation Therapy

INTRODUCTION

We determined whether pretreatment immunologic parameters could predict the outcomes and toxicity in early-stage non-small-cell lung cancer (NSCLC) patients treated with stereotactic body radiation therapy (SBRT).

PATIENTS AND METHODS

The pretreatment leukocyte, lymphocyte, and neutrophil counts, serum albumin levels, neutrophil-to-lymphocyte ratio (NLR,) and platelet-to-lymphocyte ratio (PLR) were evaluated to determine the association with locoregional control, distant metastasis-free survival (DMFS), disease-specific survival (DSS), overall survival (OS), and treatment-related toxicity. The survival rates were estimated with Kaplan-Meier analysis and multivariate analysis using the Cox proportional hazards model.

RESULTS

The data from 118 patients with a median follow-up period of 28.9 months were assessed. The 3-year local control, regional control, and DMFS rates were 97%, 87%, and 92%, respectively. The 3-year OS and DSS rates were 77% and 85%, respectively. On univariate analysis, none of the pretreatment immune parameters predicted for disease control. A higher NLR (P = .008), PLR (P = .002), neutrophil count (P = .059), and the presence of lymphocytopenia (P = .032) independently prognosticated for poor OS. Receiver operating characteristic curve analysis found NLRs > 2.18 and PLRs > 187.27 optimally predicted for poor 3-year OS (P = .0262 and P = .0089, respectively). A higher NLR predicted against the development of any symptomatic toxicity and against the development of symptomatic (grade ≥ 2) radiation pneumonitis on univariate analysis, and a higher serum albumin level independently predicted for the development of symptomatic radiation pneumonitis (P = .0491).

CONCLUSION

In the setting of SBRT, an elevated pretreatment NLR, PLR, and neutrophil count and the presence of lymphocytopenia independently predicted for poor OS. Patients who presented with higher NLRs and lower serum albumin levels experienced less treatment-related symptomatic toxicity.