Prognostic Value of the Preoperative Platelet-to-leukocyte Ratio for Oncologic Outcomes in Patients Undergoing Radical Cystectomy for Bladder Cancer

Perioperative factors and 30-day major complications following radical cystectomy: A single-center study in Thailand

Objective

This study aims to evaluate the prevalence of early postoperative complications of radical cystectomy, using standardized reporting methodology to assess perioperative characteristics and determine risk factors for major complications.

Materials and methods

A retrospective study included 254 consecutive bladder cancer patients undergoing RC between 2012 and 2020 at a urological cancer referral center. Postoperative complications within 30 days were recorded and graded according to the Clavien-Dindo classification (CDC). The study examined risk factors, including novel inflammatory-nutrition biomarkers and perioperative serum chloride.

Results

Total complications were observed in 135 (53 %). Of these, 47 (18.5 %) were high grade (CDC ≥ 3). Wound dehiscence was the most common complication, occurring in 14 (5.5 %) patients. Independent risk factors for major complications included an age-adjusted Charlson comorbidity index (ACCI) > 4 and thrombocytopenia (odds ratio [OR] 3.67 and OR 8.69). Preoperative platelet counts < 220,000/μL and albumin < 3 mg/dL were independent risk factors for wound dehiscence (OR 3.91 and OR 4.72). Additionally, postoperative hypochloremia was a risk factor for major complications (OR 13.71), while novel serum biomarkers such as neutrophil-to-lymphocyte ratio (NLR), platelet-to-lymphocyte ratio (PLR), systemic inflammatory response index (SIRI), and prognostic nutritional index (PNI) were not associated with early major complications.

Conclusion

Patients who have multiple comorbidities are at a greater risk of developing major complications after undergoing RC. Our result suggests that preoperative platelet counts and serum albumin levels are associated with wound dehiscence.

The impact of chemotherapy-naïve open radical cystectomy delay and perioperative transfusion on the recurrence-free survival: A perioperative parameters-based nomogram

Objective

To develop and internally validate a nomogram to predict recurrence-free survival (RFS) including the time to radical cystectomy (RC) and perioperative blood transfusion (PBT) as potential predictors.

Methods

Patients who underwent open RC and ileal conduit between January 1996 to December 2016 were split into developing (n=948) and validating (n=237) cohorts. The time to radical cystectomy (TTC) was defined as the interval between the onset of symptoms and RC. The regression coefficients of the independent predictors obtained by Cox regression were used to construct the nomogram. Discrimination, validation, and clinical usefulness in the validation cohort were assessed by the area under the curve, the calibration plot, and decision curve analysis.

Results

In the developing dataset, the 1-, 5-, and 10-year RFS were 83.0%, 47.2%, and 44.4%, respectively. On multivariate analysis, independent predictors were TTC (hazards ratio [HR] 1.07, 95% confidence interval [CI] 1.05-1.08, p<0.001), PBT (one unit: HR 1.40, 95% CI 1.03-1.90, p=0.03; two or more units: HR 1.72, 95% CI 1.29-2.29, p<0.001), bilateral hydronephrosis (HR 1.54, 95% CI 1.21-1.97, p<0.001), squamous cell carcinoma (HR 0.60, 95% CI 0.45-0.81, p=0.001), pT3-T4 (HR 1.77, 95% CI 1.41-2.22, p<0.001), lymph node status (HR 1.53, 95% CI 1.21-1.95, p<0.001), and lymphovascular invasion (HR 1.28, 95% CI 1.01-1.62, p=0.044). The areas under the curve in the validation dataset were 79.3%, 69.6%, and 76.2%, for 1-, 5-, and 10-year RFS, respectively. Calibration plots showed considerable correspondence between predicted and actual survival probabilities. The decision curve analysis revealed a better net benefit of the nomogram.

Conclusion

A nomogram with good discrimination, validation, and clinical utility was constructed utilizing TTC and PBT in addition to standard pathological criteria.

Predicting cerebral white matter lesions based on the platelet-to-white blood cell ratio in hypertensive patients

Hypertension is a common chronic disease affecting many people. White matter lesions (WMLs) are one of the imaging features of cerebrovascular disease. Predicting the possibility of developing syncretic WMLs in patients with hypertension may contribute to the early identification of serious clinical conditions. This study aims to build a model to identify patients who suffered from moderate-to-severe WMLs by using recognized WMLs risk factors including age and history of diabetes and a new factor named platelet-to-white blood cell ratio (PWR). A total of 237 patients were included in this study. The Affiliated ZhongDa Hospital of Southeast University Research Ethics Committee approved this study (Ethics No. 2019ZDSYLL189-P01). We developed a nomogram to predict the risk of syncretic WMLs in patients with hypertension using the above factors. Higher total scores on the nomogram indicated a higher risk of syncretic WMLs. This means older age, smaller PWR, and patients suffering from diabetes contributed to a greater chance for the patient to suffer from syncretic WMLs. We used a decision analysis curve(DCA) to determine the net benefit of the prediction model. The DCA we constructed showed that using our model to decide whether patients suffered from syncretic WMLs or not was better than assuming they all suffered from syncretic WMLs or all WMLs-free. As a result, the area under the curve of our model was 0.787. By integrating PWR, history of diabetes, and age, we could estimate integrated WMLs in hypertensive patients. This study provides a potential tool to identify cerebrovascular disease in patients with hypertension.

A novel platelet risk score for stratifing the tumor immunophenotypes, treatment responses and prognosis in bladder carcinoma: results from real-world cohorts

Background: Although the durable efficacy of immune checkpoint inhibitors (ICIs) in BLCA has been confirmed in numerous studies, not all patients benefit from their application in the clinic. Platelets are increasingly being found to be closely associated with cancer progression and metastasis; however, their comprehensive role in BLCA remains unclear. Methods: We comprehensively explored platelet expression patterns in BLCA patients using an integrated set of 244 related genes. Correlations between these platelet patterns with tumor microenvironment (TME) subtypes, immune characteristics and immunotherapy efficacies were explored. In addition, a platelet risk score (PRS) was generated for individual prognosis and verified the ability to predict prognosis, precise TME phenotypes, and immunotherapy efficacies. Results: Genes were clustered into two patterns that represented different TME phenotypes and had the ability to predict immunotherapy efficacy. We constructed a PRS that could predict individual prognosis with satisfactory accuracy using TCGA-BLCA. The results remained consistent when PRS was validated in the GSE32894 and Xiangya cohort. Moreover, we found that our PRS was positively related to tumor-infiltrating lymphocytes (TILs) in the TCGA-BLCA and Xiangya cohort. As expected, patients with higher PRS exhibited more sensitive to immunotherapy than patients with lower PRS. Finally, we discovered that a high PRS indicated a basal subtype of BLCA, whereas a low PRS indicated a luminal subtype. Conclusion: Platelet-related genes could predict TME phenotypes in BLCA. We constructed a PRS that could predict the TME, prognosis, immunotherapy efficacy, and molecular subtypes in BLCA.

Association of platelet-to-white blood cell ratio and platelet-to-neutrophil ratio with the risk of fatal stroke occurrence in middle-aged to older Chinese

Background

White blood cell (WBC) and neutrophil (NEUT) counts, which are commonly inflammatory markers, have been related to an increased risk of fatal stroke. However, it is unclear whether platelet-to-white blood cell ratio (PWR) and platelet-to-neutrophil ratio (PNR) are related to the risk of fatal stroke in middle-aged to older populations.

Method

In total, 27,811 participants without a stroke history at baseline were included and followed up for a mean of 14.3 years (standard deviation = 3.2), and 838 stroke deaths were recorded. The Cox proportional hazards regression was used to assess the relationships between the PWR and the PNR and the risk of fatal strokes.

Results

Compared to the 1^st quartile, an increased risk of fatal all stroke showed among the participants in the highest quartiles of both the WBC (adjusted hazard ratio (aHR) = 1.35, 95% confidence interval (CI) 1.09–1.66) and the NEUT (aHR = 1.45, 95% CI 1.18–1.79). The restricted cubic splines showed decreased trends in associations of the PWR and the PNR with the risk of fatal all stroke. A decreased risk of fatal all stroke showed in those with the highest quartiles for both the PWR (aHR = 0.73, 95% CI 0.53–1.00) and the PNR (aHR = 0.74, 95% CI 0.54–1.01). The participants with the 2^nd, the 3^rd and the 4^th change quartiles for the PWR and the PNR had weak decreasing trends for the risk of fatal all stroke, compared to those in the 1^st change quartile, and the significant associations were observed in those with an increase of 20% for the PWR with the risk of fatal haemarragic stroke (aHR = 0.47, 95% CI 0.22–0.95) and a decrease of 20% for the PNR with the risk of fatal all stroke (aHR = 1.33, 95% CI 0.99–1.79), compared to those with stable dynamic changes.

Conclusions

Higher neutrophil count and platelet-to-neutrophil ratio were associated with a contrary risk of fatal stroke, with an increased for the former and a decreased for the later. A potentially chronic inflammation should be paid close attention to stroke occurrence in relatively healthy middle-aged to older populations.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12877-022-03134-z.

Development of nomograms related to inflammatory biomarkers to estimate the prognosis of bladder cancer after radical cystectomy

Background

Bladder cancer is one of the most common carcinomas and it brings about huge social economic burden. There is not a reliable way to predict the prognosis of bladder patients. We develop the nomogram to predict the prognosis of bladder cancer patients.

Methods

A total of 127 bladder cancer patients after radical cystectomy were studied retrospectively. Their clinicopathological data were collected for statistical analysis.

Results

The level of albumin/globulin ratio (AGR), C-reactive protein/albumin ratio (CAR), neutrophil to lymphocyte ratio (NLR) and platelet to lymphocyte ratio (PLR) associated with pathological and hematological parameters like T stage and hemoglobin. Furthermore, the AGR was associated with overall survival (OS) and CAR, NLR, and PLR were associated with both OS and progression-free survival (PFS) (P<0.05). The multivariate analysis revealed that tobacco smoking, tumor T stage, M stage, NLR, CAR, and AGR were all independent predictors for OS of patients and tobacco smoking, tumor T stage, NLR, CAR, and AGR were independent predictors for PFS of patients. In addition, AGR, CAR, and NLR, as well as, the clinicopathological parameters in the development of nomograms with a C index of 0.901 (95% CI: 0.505-1.269) for OS, and 0.807 (95% CI: 0.755-0.858) for PFS. The nomograms were able to provide a prognosis of the OS with the area under the curve (AUC) =0.86. Further, tests assessed the PFS with the AUC =0.84.

Conclusions

This study demonstrates that the nomograms of the inflammatory biomarkers were able to predict prognosis of bladder cancer patients after radical cystectomy.

Prognostic value of pretreatment inflammatory markers in variant histologies of the bladder: is inflammation linked to survival after radical cystectomy?

PURPOSE

To investigate differences in standard preoperative inflammatory markers in patients with urothelial carcinoma (UC) and variant histologies undergoing radical cystectomy (RC) and determine its impact on survival.

METHODS

Patients undergoing RC at an academic high-volume center were retrospectively analyzed. Preoperatively taken CRP, leukocytes, hemoglobin (Hb), and thrombocytes were analyzed as routine inflammatory biomarkers. Log-rank tests and Kruskal-Wallis analysis were used to calculate for differences in survival and in blood levels of biomarkers.

RESULTS

886 patients with complete follow-up and UC or variant histology underwent RC at our institution between 2004 and 2019. Although variant histology presents with significantly higher t stage than UC, cancer-specific survival (CSS) of UC (1-year-CSS: 93%) is not significantly different to variant histology of UC with squamous differentiation (UCSD, 1-year-CSS: 81%), squamous cell carcinoma (SCC, 1-year-CSS: 82%), and adenocarcinoma (AC, 1-year-CSS: 81%). In UC, alterations in all biomarkers except leukocytes beyond routine cut-off values were associated with poor survival (p < 0.01), whereas Hb beyond cut-off values are associated with poor prognosis in SCC (p < 0.05). CRP levels are significantly elevated in UCSD and SCC at time of surgery compared to UC (p < 0.05).

CONCLUSION

Inflammatory biomarkers reveal distinctive patterns across UC and variant histologies of bladder cancer. As inflammation might play an important role in cancer progression, further research is warranted to understand those molecular mechanisms and their potential therapeutic impact in variant histology of bladder cancer.

Role of Systemic Inflammatory Response Markers in Urothelial Carcinoma

Urothelial carcinoma (UC) can occur in various parts of the urinary tract and occurs in different stages and grades. The disease recurs frequently and is monitored through a series of invasive tests, such as cystoscopy or ureteroscopy, over the lifetime of an individual. Although many researchers have attempted to stratify the risks of UC, with the majority being based on cancer characteristics and host factors such as performance status, a risk classification system has yet to be fully developed. Cancer affects various parts of the body through the systemic immune response, including changes in hormones, the number and ratio of white blood cells and platelets, and C-reactive protein (CRP) or albumin levels under the influence of neuroendocrine metabolism, hematopoietic function, and protein and energy metabolism, respectively. Herein, we reviewed various systemic inflammatory response markers (SIRs) related to UC, including CRP, albumin-globulin ratio, albumin, Glasgow prognostic score (GPS), modified GPS, neutrophil-lymphocyte ratio, and platelet-lymphocyte ratio. Our aim was to summarize the role of various SIRs in the treatment of patients with UC.

Meta-analysis of multiple hematological biomarkers as prognostic predictors of survival in bladder cancer

BACKGROUND

Accumulating emerging studies have demonstrated that systemic inflammation can obviously affect tumor occurrence and progression. Nevertheless, the prognostic value of hematological inflammation biomarkers in bladder cancer is controversial. Thus, we conducted a meta-analysis to evaluate the key hematological biomarkers with various clinical outcomes in bladder cancer.

METHODS

We used online databases PUBMED and EMBASE to search relevant studies published prior to August 2019. After collecting the basic characteristics and prognostic data from the studies included, overall survival (OS), cancer-specific survival (CSS) and progression-free survival (PFS) were used as primary results. Subgroup analyses were performed according to ethnicity, the number of samples, survival outcomes, the value of cut-off, follow-up time and metastasis stage.

RESULTS

Thirty-three independent studies with 17,087 bladder cancer patients were added in the present analysis. The collected results showed that the increased neutrophil-to-lymphocyte ratio was associated with a poor OS (hazard ratio [HR] = 1.48, 95% confidence interval [CI]: 1.32-1.67, P < .00001), CSS (HR = 1.71, 95%CI: 1.35-2.18, P < .0001) and PFS (HR = 1.59, 95%CI: 1.38-1.83, P < .00001). Additionally, the elevated platelet-to-lymphocyte ratio was related to a poor OS (HR = 1.29, 95% CI: 1.07-1.54, P = .007), CSS (HR = 1.14, 95%CI = 0.98-1.34, P = .02) and PFS (HR = 1.2, 95%CI: 1.08-1.34, P = .0008). Moreover, a decreased lymphocyte-to-monocyte ratio was associated with a poor OS (HR = 0.77, 95% CI: 0.70-0.84, P = .001), CSS (HR = 0.76, 95%CI: 0.70-0.84). An elevated modified Glasgow prognostic score was also associated with a poor OS (HR = 2.71, 95%CI: 1.08-2.82, P = .003), CSS (HR = 1.50, 95%CI: 0.56-4.05) and PFS (HR = 1.52, 95%CI: 1.23-1.88, P = .001).

CONCLUSIONS

Our study indicated that the pretreatment hematological biomarkers (neutrophil-to-lymphocyte ratio, platelet-to-lymphocyte ratio, lymphocyte-to-monocyte ratio, and modified Glasgow prognostic score) were predicative biomarkers of prognosis in bladder cancer patients. Further research is needed to conduct further prospective and multicenter studies to confirm our findings.

The role of neutrophil to lymphocyte ratio in patients with pTa non-muscle invasive bladder cancer

Introduction: The peritumoral inflammatory reaction has a substantial importance in the oncologic outcome of bladder cancer (BC). One biomarker proven to be practical and accessible is the NLR (neutrophil-to-lymphocyte ratio) for high risk non-muscle invasive bladder cancer (NMIBC). The aim of the study was to investigate the role of NLR as a prognostic biomarker for disease recurrence, progression and survival of p Ta (pathological assesment of the primary tumor) NMIBC.

Material and Methods: In our retrospective study we included 54 patients with pTa NMIBC from a total of 235 patients who underwent transurethral resection of bladder tumor (TURBT) during two consecutive years: January 2007 - December 2008 [median follow-up 106 months (interquartile range-IQR 68-116)]. Criteria for inclusion were: primary tumor, low-grade, with NLR available at 2 weeks prior to TURBT. NLR was considered altered if higher than 3.

Results: The median age of the patients included was 63 years (IQR 55 - 72). Most of the patients had NLR---lt---3 (37 patients). Median EORTC (European Organization of Research and Treatment of Cancer) Recurrence Score was 4 (IQR 1-6), while EORTC Progression Score was 3 (IQR 0-6), respectively. Recurrence occurred in 8 out of 54 (14.81 %) patients and progression was identified in 2 out of 54 (3.70 %) patients with muscle-invasive BC during follow-up. NLR---gt---3 was not associated with clinical and pathological factors. In multivariable Cox regression analyses NLR as a continuous variable was an independent predictive factor for recurrence. Recurrence-free survival (RFS) Kaplan-Meier analysis did not show a statistical significance between NLR groups: 82.67% vs. 64.12%, p=0.26. Kaplan-Meier analysis showed a lower Progression-free survival (PFS) in the NLR---gt---3 group: 94.12% vs. 100%, p=0.04. During follow-up (106 months) 18 patients deceased with no impact of NLR as a prognostic factor in multivariable analyses. Kaplan-Meier overall survival (OS) analysis showed a 10-year OS of 70.27% in the low NLR group compared with 58.82% in the high NLR group, p=0.45.

Conclusion: In this cohort, high NLR was associated with high recurrence rate in patients with Ta NMIBC. In low-risk NMIBC NLR could represent a valid biomarker for clinical usage regarding the intensity of follow-up schedule.

MicroRNA‑663b downregulation inhibits proliferation and induces apoptosis in bladder cancer cells by targeting TUSC2

The present study aimed to explore the role and underlying molecular mechanism of microRNA‑663b (miR‑663b) in the tumorigenesis of bladder cancer. The miR‑663b expression in human bladder cancer tissues and cell lines was measured determined reverse transcription‑quantitative polymerase chain reaction. TargetScan was used to predict the potential targets of miR‑663b, and a dual‑luciferase reporter assay was performed to validate tumor suppressor candidate 2 (TUSC2) as a target of miR‑663b. Cell Counting Kit‑8 was used for cell viability analysis, and cell apoptosis was evaluated by flow cytometry. In addition, western blot analysis was performed to detect protein expression in current study. The findings suggested that miR‑663b was upregulated in bladder cancer tissues and cell lines compared with normal tissue and cells. TUSC2 was validated as a direct target of miR‑663b and was negatively regulated by miR‑663b. miR‑663b inhibition significantly reduced the viability of T24 cells, and T24 cell apoptosis was markedly induced. In addition, miR‑663b inhibition enhanced the expression levels of p53 and p21 in T24 cells. Furthermore, the changes caused by miR‑663b inhibitor in T24 cells were eliminated by TUSC2 gene silencing. In conclusion, inhibition of miR‑663b reduced viability and induced apoptosis in bladder cancer cells by targeting TUSC2. These findings provide a promising novel therapeutic target for bladder cancer treatment.

The value of neutrophil-to-lymphocyte ratio for response and prognostic effect of neoadjuvant chemotherapy in solid tumors: A systematic review and meta-analysis

Introduction: The neutrophil-to-lymphocyte ratio (NLR) has been found to be an indicator of poor prognosis in many tumour types. However, little is known about the relationship between the NLR and patients with tumours who receive neoadjuvant chemotherapy (NAC) in terms of response rate and prognostic ability. We thus performed this meta-analysis to further investigate this relationship. Methods: An electronic systematic literature search for articles published before September 2017 was performed to explore the association between the pretreatment NLR and outcome in patients treated with NAC. Data were extracted by the reported odds ratios (ORs) and hazard ratios (HRs) with their 95% confidence intervals (CIs) for the response rate and the survival outcome, respectively. The results were pooled using the random-effect or fixed-effect model. Results: Thirty-three studies were eventually included in our study, and all were published no earlier than 2011. An NLR that was higher than the cut-off was associated with a lower pathological complete response (pCR) rate in patients with cancer (OR = 1.72, 95% CI, 1.26-2.33). A lower NLR was associated with better overall survival (OS) (HR = 1.58, 95% CI, 1.34-1.86), cancer-specific survival (CSS) (HR = 2.22, 95% CI, 1.32-3.74), disease-free survival (DFS) (HR = 1.32, 95% CI, 1.10-1.59) and recurrence-free survival (RFS) (HR = 1.90, 95% CI, 1.50-2.40). Conclusion: Overall, an NLR lower than the cut-off value indicated a greater chance for pCR and may predict good survival outcomes after NAC for patients with solid tumours. The use of the NLR for risk stratification before NAC should be further demonstrated by future large-scale prospective studies.

The Prognostic Value of Platelet-to-Lymphocyte Ratio in Urological Cancers: A Meta-Analysis

The relationship of platelet-to-lymphocyte ratio (PLR) and survival in urological cancers remained inconsistent in previous studies. Therefore, we performed a meta-analysis to assess the prognostic significance of PLR in patients with urological cancers. A literature search was performed in the PubMed, Embase, and Web of Science up to July, 2017 and study quality was obtained using the Newcastle-Ottawa Scale. To estimate the association of PLR and overall survival (OS) and other survival outcomes in urological cancers, we used pooled hazard ratios (HRs). Subgroup analyses were conducted on different ethnics, sample sizes and cut-off values. 20 high quality studies involving 7562 patients with urological cancers were included in this meta-analysis. High pretreatment PLR was significantly associated with poor OS in patients with urological cancers (pooled HR = 1.58). Elevated PLR was also correlated with other survival outcomes. However, we found that PLR was significantly relevant to the OS of patients with different types of urological cancers except bladder cancer (BCa, HR = 1.16, 95%CI: 0.96–1.41). In conclusion, elevated PLR was negatively related to the OS of patients with urological cancers, except in BCa. However, more large scale prospective studies with high quality are required in the future.

Prognostic value of lymphocyte-to-monocyte ratio among Asian lung cancer patients: a systematic review and meta-analysis

Purpose

Numerous studies have reported the prognostic significance of lymphocyte-to-monocyte ratio (LMR) in malignancies, but its prognostic value among lung cancer remains controversial. This meta-analysis aimed to explore the prognostic significance of LMR in lung cancer patients.

Results

Eight studies including 3954 patients were included in this meta-analysis. Pooled results indicated that low LMR was significantly associated with poorer progression-free survival (hazard ratio (HR): 1.431, 95% confidence interval (CI): 1.294–1.582, p < 0.001) and overall survival (OS) (HR: 1.651, 95% CI: 1.306–2.086, p < 0.001), compared with high LMR. Similar results were observed in subgroups regardless of treatment, LMR cut-off value, or districts. However, no significant correlation between the LMR and OS was observed in the small cell lung cancer (SCLC) subgroup (HR = 1.262, 95% CI: 0.864–1.841, p = 0.229).

Materials and Methods

Identified literatures were extracted and retrieved from PubMed, Embase, Web of Science, and the Cochrane Library databases; All eligible studies focused on the association between LMR and the prognosis of lung cancer.

Conclusions

Low LMR is associated with poor outcomes among lung cancer patients. Further studies are needed to discuss the correlation between LMR and lung cancer prognosis.

The clinical use of neutrophil-to-lymphocyte ratio in bladder cancer patients: a systematic review and meta-analysis

The aim of this study was to evaluate the evidence regarding the neutrophil-to-lymphocyte ratio (NLR) as a factor predictive of survival in bladder cancer patients. A search of PubMed and Embase for relevant studies between January 1, 1966 and November 10, 2016 was performed with the terms [NLR OR (neutrophil lymphocyte ratio)] AND [(bladder cancer) OR BCa OR NMIBC OR MIBC]. Inclusion required studies published in English containing bladder cancer patients and evaluating NLR as a predictive factor. Endpoints of NLR and survival data were extracted for pooled analysis. The pooled results showed that an elevated NLR was a predictor for poor overall survival (OS) [hazard ratio (HR) = 1.19, 95% confidence interval (CI) 1.07-1.31], cancer-specific survival (CSS) (HR = 1.40, 95% CI 1.17-1.69), recurrence-free survival (RFS) (HR = 1.58, 95% CI 1.24-2.03) and progression-free survival (PFS) (HR = 1.33, 95% CI 1.19-1.49) in patients with bladder cancer. Heterogeneity between studies was observed for OS, CSS and RFS, but not for PFS. Publication bias was detected for all these outcomes. Our results showed that elevated NLR might be valuable as a predictive factor of survival in bladder cancer patients.