Absolute lymphocyte count: a potential prognostic factor for Merkel cell carcinoma

Current status of Merkel cell carcinoma: Epidemiology, pathogenesis and prognostic factors

Merkel cell carcinoma (MCC) is an extremely rare cutaneous neuroendocrine cancer, with an incidence approximately 40 times lower than that of malignant melanoma; however, its significantly inferior survival rate compared to melanoma establishes MCC as the most lethal form of skin cancer. In recent years, a substantial body of literature has demonstrated a gradual increase in the incidence of MCC. Although the two factors that contribute to MCC, ultraviolet radiation and Merkel cell polyomavirus infection, have been well established, the specific pathogenesis of this disease remains unclear. Additionally, considering the high lethality and recurrence rates of MCC, as well as the absence of specific antitumor drugs, it is crucial to elucidate the factors that can accurately predict patients' outcomes. In this review, we summarized the significant advancements in the epidemiological characteristics, pathogenesis, and the factors that influence patient prognosis of MCC to enhance clinical practices and public health efforts.

Impact of the peripheral blood inflammatory indices and modified nomogram-revised risk index on survival of Extranodal Nasal-Type Natural Killer/T-Cell lymphoma

BACKGROUND

At present, peripheral blood markers are easily accessible information and clinically valuable prognostic indicators in extranodal nasal-type natural killer/T-cell lymphoma (ENKTCL). Nevertheless, the role of its comprehensive score in ENKTCL remains to be determined.

OBJECTIVE

Therefore, this study aimed to investigate the prognostic effect of the peripheral inflammation score on ENKTCL.

METHODS

The retrospective study included 183 patients with ENKTCL. Univariate Cox regression analyses and least absolute shrinkage and selection operator (LASSO) Cox regression were used to construct the inflammation-related prognostic index named Risk. Univariate and multivariate Cox regression analyses and regression adjustment with propensity score matching (PSM) were used to evaluate the prognostic ability of risk. The performance of the modified nomogram-revised risk index (NRI) by integrating risk was evaluated with the area under the time-dependent receiver operating characteristic (ROC) curve (AUC), decision curve analysis (DCA), and integrated Brier score (IBS).

RESULTS

The risk cut-off value, constructed by the lymphocyte count, platelet count, albumin level, LMR, and PNI, was -1.3486. Before PSM, multivariate analysis showed that risk was significantly associated with OS (HR = 2.577, 95% CI = 1.614-4.114, P< 0.001) and PFS (HR = 2.679, 95% CI = 1.744-4.114, P< 0.001). After PSM adjustment, risk was still an independent factor for OS (HR = 2.829, 95% CI = 1.601-5.001, P< 0.001) and PFS (HR = 2.877, 95% CI = 1.735-4.770, P< 0.001). With the NRI, the modified NRI by integrating risk increased the AUC and clinical net benefit and decreased the IBS.

CONCLUSIONS

Risk is an easily accessible and inexpensive indicator that may be used as a prognostic marker and could improve NRI predictive power in patients with ENKTCL.

Is Lymphocyte C-Reactive Protein Ratio Useful for Predicting Survival in Patients with Non-Metastatic Soft Tissue Sarcoma?

Background: Recently, the lymphocyte-to-CRP ratio (LCR) was found to have a prognostic role in many cancers. However, the clinical significance of LCR in patients with soft tissue sarcoma (STS) has not yet been established. This study aimed to determine whether LCR can predict disease-specific survival (DSS) and event-free survival (EFS) in patients with STS. Methods: In this study, 132 patients were enrolled. The mean follow-up periods were 76.5 months. Blood examinations were performed prior to treatment for all patients. Results: The 5-year DSS in patients with higher and lower LCR was 86.5% and 52.8%, respectively (p < 0.001). Patients with lower LCR had worse survival than those with higher LCR. The 5-year EFS in patients with higher and lower LCR was 66.2% and 31.2%, respectively (p < 0.001). On Receiver operating characteristic analysis, however, there was no significant difference in the area under curve (AUC) between CRP level (AUC = 0.72) and LCR (AUC = 0.711). Conclusions: LCR may be a prognostic factor for predicting oncological events in multivariate analysis, although ROC analysis could not show the superiority of LCR to CRP for predicting oncological outcomes in patients with STS.

High systemic inflammation score is associated with adverse survival in skull base chordoma

Background

The systemic inflammation score (SIS), based on preoperative lymphocyte to monocyte ratio (LMR) and albumin (ALB), was recently developed and is demonstrated to be a novel prognostic indicator in several cancers. However, data discussing the utility of SIS in chordoma are lacking. We aimed to investigate the distribution and the prognostic role of SIS in primary skull base chordoma patients undergoing surgery.

Material and methods

Preoperative SIS was retrospectively collected from 183 skull base chordoma patients between 2008 and 2014 in a single center. Its associations with clinical features and overall survival (OS) were further analyzed. The SIS-based nomogram was developed and evaluated by the concordance index (C-index), time-dependent receiver operating characteristic (ROC) curve, calibration curve, and decision curve analysis (DCA).

Results

The numbers of patients in the SIS 2, 1, and 0 group were 29 (15.8%), 60 (32.8%), 94 (51.4%), respectively. High SIS was associated with older age (p = 0.008), brainstem involvement of tumors (p = 0.039), and adverse OS (p < 0.001). Importantly, multivariate Cox analysis showed that high SIS independently predicts adverse OS. Furthermore, the nomogram based on SIS and clinical variables showed eligible performance for OS prediction in both training and validation cohorts.

Conclusions

The SIS is a promising, simple prognostic biomarker, and the SIS-based nomogram serves as a potential risk stratification tool for outcome in skull base chordoma patients.

Systemic inflammation score in locally advanced rectal cancer patients following total mesorectal excision

Objective

The objective of the study was to evaluate whether any association exists between systemic inflammation score (SIS) and adverse events (AEs) and survival of locally advanced rectal cancer patients treated with total mesorectal excision (TME) followed by adjuvant chemoradiotherapy.

Patients and methods

All of the 109 rectal cancer patients recruited between May 2008 and June 2015 were treated with TME followed by adjuvant chemoradiotherapy. The prognostic ability of SIS for overall survival (OS) was calculated by the receiver operating characteristic (ROC) curves.

Results

According to the classification of the SIS, 22 (20.2%), 59 (54.1%) and 28 (25.7%) patients were classified as a score of 2, 1 and 0, respectively. With an area under the curve (AUC) of 0.616, the SIS score of 1 was defined as the optimal cut-off value. Therefore, we divided the patients into the SIS-low group (SIS score of 1 or 0, n=87) and SIS-high group (SIS score of 2, n=22). Multivariate analysis indicated that SIS was associated with OS (HR 0.390, 95% CI 0.186–0.817, P=0.012). The 5-year OS rate in patients without adjuvant chemotherapy was lower than the patients with adjuvant chemotherapy (53.3% vs 75.8%, P=0.010). Multivariate analysis showed that adjuvant chemotherapy was associated with OS (HR 0.217, 95% CI 0.089–0.529, P=0.001). A marginal statistically significant difference was observed in terms of leukopenia during adjuvant chemoradiotherapy between the SIS-low group and the SIS-high group (P=0.05).

Conclusion

These results suggest that SIS might serve as an independent biomarker for predicting AEs and prognosis in locally advanced rectal cancer treated with TME followed by adjuvant chemoradiotherapy. Strengthening treatment may be administered to locally advanced rectal cancer with high SIS score obtained before adjuvant chemoradiotherapy.

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Systemic inflammation score is a prognostic marker after curative resection in gastric cancer

Background

The systemic inflammation score (SIS), as calculated from preoperative serum albumin level and lymphocyte‐to‐monocyte ratio, has been demonstrated to be a prognostic marker in cancer. The present study intended to investigate the prognostic role of SIS in gastric cancer patients after curative gastrectomy in comparison with other prognostic markers.

Methods

Preoperative SIS was retrospectively calculated in patients who underwent curative gastrectomy between 2007 and 2011 in Fudan University Shanghai Cancer Center. The prognostic accuracy of each score was compared utilizing time‐dependent receiver operating characteristics analysis.

Results

The higher SIS score was associated with older age, larger tumour size, a more advanced tumour‐nodes‐metastasis stage and lymph node status, deeper tumour invasion, the presence of lymphovascular invasion and a poorer overall survival and disease‐free survival. In time‐dependent receiver operating characteristics analysis, the SIS had a higher area under the curve for the prediction of 5‐year overall survival than the neutrophil lymphocyte ratio. The SIS maintained the predictive accuracy superiority throughout the observation period.

Conclusion

The SIS is a useful prognostic marker in gastric cancer patients after curative gastrectomy.

Differential Outcomes Among Immunosuppressed Patients With Merkel Cell Carcinoma: Impact of Immunosuppression Type on Cancer-specific and Overall Survival

OBJECTIVES

Merkel cell carcinoma (MCC) is a rare, aggressive neuroendocrine skin cancer with higher incidence among whites, elderly, and immunosuppressed patients. Although immunosuppressed MCC patients are at higher risk of recurrence and MCC-related death, it is unknown whether immunosuppression type is associated with differential outcomes.

MATERIALS AND METHODS

We retrospectively evaluated 89 nonmetastatic MCC patients with a diagnosis of chronic immunosuppression. Immunosuppression was categorized as chronic lymphocytic leukemia (31% of cohort), other hematologic malignancies (18%), solid organ transplant (21%), autoimmune disease (21%), and human immunodeficiency virus acquired deficiency syndrome (8%). Progression-free survival (PFS) and MCC-specific survival (MSS) were estimated with the cumulative incidence function. Overall survival (OS) was estimated by the Kaplan-Meier method.

RESULTS

With a median follow-up of 52 months, 53 deaths occurred (42 from MCC, 7 unknown, and 4 non-MCC). Two-year PFS, MSS, and OS were 30%, 55%, and 52%, respectively. Human immunodeficiency virus/acquired deficiency syndrome and solid organ transplant patients were diagnosed with MCC at a younger age (median 55 and 59 y, respectively) and with more advanced stage disease compared with other immunosuppressed subgroups. PFS did not significantly differ among the 5 immunosuppression subgroups (P=0.30), but significant differences were observed in MSS and OS (both P=0.01). Controlling for potential confounders for OS, including age and stage, immunosuppression type was still significantly associated with risk of death (P=0.01).

CONCLUSIONS

Among immunosuppressed MCC patients, recurrent MCC is the major cause of mortality. The risk of death from MCC differs among immunosuppression types, suggesting important biological differences in host-tumor immune interactions.

Inferior outcomes in immunocompromised Merkel cell carcinoma patients: Can they be overcome by the use of PD1/PDL1 inhibitors?

Cases of Merkel cell carcinoma have become increasingly more common in the last two decades, and its incidence has been predicted to climb further. Immunosenescence might explain in part the higher Merkel cell carcinoma prevalence in seniors aged 70 and older. This cancer might also be more aggressive in immunocompromised patients. In a subset of immunocompromised Merkel cell carcinoma patients, we identified significant lymphopenia and a more advanced disease stage compared with their immunocompetent counterparts. Time to death in this cohort was much shorter than in immunocompetent subjects, and their likelihood of death from Merkel cell carcinoma was five times higher. Avelumab approval in 2017 represents an important step forward in the therapy of Merkel cell carcinoma. Hopefully, PD1/PDL1 inhibitors will improve survival in immunocompromised Merkel cell carcinoma hosts, traditionally linked with inferior clinical outcomes.

Viral oncoprotein antibodies as a marker for recurrence of Merkel cell carcinoma: A prospective validation study

BACKGROUND

Merkel cell carcinoma (MCC) is an aggressive skin cancer with a recurrence rate of >40%. Of the 2000 MCC cases per year in the United States, most are caused by the Merkel cell polyomavirus (MCPyV). Antibodies to MCPyV oncoprotein (T-antigens) have been correlated with MCC tumor burden. The present study assesses the clinical utility of MCPyV-oncoprotein antibody titers for MCC prognostication and surveillance.

METHODS

MCPyV-oncoprotein antibody detection was optimized in a clinical laboratory. A cohort of 219 patients with newly diagnosed MCC were followed prospectively (median follow-up, 1.9 years). Among the seropositive patients, antibody titer and disease status were serially tracked.

RESULTS

Antibodies to MCPyV oncoproteins were rare among healthy individuals (1%) but were present in most patients with MCC (114 of 219 patients [52%]; P < .01). Seropositivity at diagnosis independently predicted decreased recurrence risk (hazard ratio, 0.58; P = .04) in multivariate analyses adjusted for age, sex, stage, and immunosuppression. After initial treatment, seropositive patients whose disease did not recur had rapidly falling titers that became negative by a median of 8.4 months. Among seropositive patients who underwent serial evaluation (71 patients; 282 time points), an increasing oncoprotein titer had a positive predictive value of 66% for clinically evident recurrence, whereas a decreasing titer had a negative predictive value of 97%.

CONCLUSIONS

Determination of oncoprotein antibody titer assists in the clinical management of patients with newly diagnosed MCC by stratifying them into a higher risk seronegative cohort, in which radiologic imaging may play a more prominent role, and into a lower risk seropositive cohort, in which disease status can be tracked in part by oncoprotein antibody titer. Cancer 2017;123:1464-1474. © 2016 American Cancer Society.

Postoperative Low Absolute Lymphocyte Counts may Predict Poor Outcomes of Hepatocellular Carcinoma After Liver Resection

Background:

The absolute lymphocyte counts (ALCs) have been reported as one of worse prognostic factors for hepatocellular carcinoma (HCC) patient after liver transplantation. The aim of this study was to assess the influence of ALCs on the outcomes of patients with hepatitis B virus (HBV)-related HCC within the Milan criteria following liver resection.

Methods:

Data of patients with HCC within the Milan criteria who received liver resection between January 2007 and June 2013 were reviewed, and perioperative ALCs were carefully monitored. All potential risk factors were statistically analyzed by uni- and multi-variate analyses. The receiver operating characteristic (ROC) curve was used to determine the optimal ALCs cut-off value to predict HCC recurrence after liver resection.

Results:

A total of 221 patients were enrolled in the current study. During the follow-up period, 106 patients experienced recurrence, and 38 patients died. Multivariate analysis suggested microvascular invasion (MVI), a tumor grade ≥2, and a low postoperative ALCs in the 1^st postoperative month increased the incidence of postoperative recurrence, besides, MVI, intraoperative transfusion, and a low postoperative ALCs in the 1^st postoperative month were associated with poor overall survival (OS). An ROC analysis showed that a cut-off value of 1.5 × 10⁹/L for ALCs in the 1^st postoperative month predicted postoperative recurrence. The 5-year recurrence-free survival (RFS) and OS rates of patients with low postoperative ALCs were 34.5% and 64.8%, respectively, which were significantly lower than those of patients with high postoperative ALC (58.5% for RFS and 86.5% for OS).

Conclusion:

Low ALCs in the 1^st postoperative month may be associated with high recurrence incidence and poor OS for patients with HBV-related HCC within the Milan criteria after liver resection.

A high neutrophil-to-lymphocyte ratio as a potential marker of mortality in patients with Merkel cell carcinoma: A retrospective study

BACKGROUND

The prognostic relevance of a high blood neutrophil-to-lymphocyte ratio (NLR) has been reported in many cancers, although, to our knowledge, not investigated in patients with Merkel cell carcinoma (MCC) to date.

OBJECTIVE

We assessed whether the NLR at baseline was associated with specific survival and recurrence-free survival in MCC.

METHODS

We retrospectively included MCC cases between 1999 and 2015 and collected clinical data, blood cell count at baseline, and outcome. A Cox model was used to identify factors associated with recurrence and death from MCC.

RESULTS

Among the 75 patients included in the study, a high NLR at baseline (NLR ≥4) was associated with death from MCC in univariate (hazard ratio 2.76, 95% confidence interval 1.15-6.62, P = .023) and multivariate (hazard ratio 3.30, 95% confidence interval 1.21-9.01, P = .020) analysis, but not with recurrence.

LIMITATIONS

Because of the retrospective design, we excluded patients with missing data and not all confounding factors that may influence the NLR were available.

CONCLUSION

A high NLR at baseline was independently associated with specific mortality in patients with MCC. The NLR seems to constitute an easily available and inexpensive prognostic biomarker at baseline.

A transient increase in eosinophils is associated with prolonged survival in men with metastatic castration-resistant prostate cancer who receive sipuleucel-T

Sipuleucel-T is an autologous cellular immunotherapy used to treat asymptomatic or minimally symptomatic metastatic castration-resistant prostate cancer (mCRPC). Traditional short-term indicators of clinical response commonly used with chemotherapy have not correlated with survival in patients treated with sipuleucel-T. This retrospective study aimed to evaluate laboratory parameters as possible early biomarkers associated with clinical benefit following sipuleucel-T treatment. Patients treated with sipuleucel-T from three randomized, controlled, phase III clinical trials in mCRPC were considered: IMPACT (NCT00065442; n = 512), D9901 (NCT00005947; n = 127), and D9902A (NCT01133704; n = 98). Patients from these trials were included in this study if their samples were analyzed by the central laboratory and if data were available from baseline and ≥ 1 posttreatment time point (n = 377). We found that sipuleucel-T treatment was associated with a transient increase in serum eosinophil count at week 6 that resolved by week 14 in 28% of patients (105 of 377). This eosinophil increase correlated with induced immune response, longer prostate cancer-specific survival [HR, 0.713; 95% confidence interval (CI), 0.525-0.970; P = 0.031], and a trend in overall survival (HR, 0.753; 95% CI, 0.563-1.008; P = 0.057). Median serum globulin protein levels also increased transiently, which was associated with antigen-specific antibody responses; however, this finding did not correlate with longer survival. We conclude that transient increases in eosinophils at week 6 may be a useful, objective, short-term indicator of global immune activation and survival benefit with sipuleucel-T in patients with mCRPC. This observation warrants prospective evaluation in future clinical trials.

Milestones in the staging, classification, and biology of Merkel cell carcinoma

Merkel cell carcinoma (MCC) is an aggressive skin cancer that is causally associated with ultraviolet light exposure and a recently discovered polyomavirus. Before 2010, MCC was staged using any of 5 unique systems in active use. In 2010, a consensus staging system for MCC was adopted worldwide and replaced these systems. This consensus system includes substages that reflect prognostic differences based on whether nodal evaluation was performed by pathologic analysis or clinical assessment alone. MCC-specific disease classification in ICD-9, to be expanded in the upcoming ICD-10, has improved the ability to track and manage this malignancy. Several biomarkers and histopathologic features have been identified that improve understanding of this cancer and may lead to future refinement of the current staging system. In 2008, the Merkel cell polyomavirus was discovered and is now thought to be a critical mechanism of transformation in at least 80% of MCCs. In patients who produce antibodies to the viral T-antigen oncoprotein, the titer increases and decreases with MCC disease burden and can be a clinically useful marker of recurrence. Diverse studies link CD8-positive T-cell function with outcomes in MCC and serve as the rational basis for ongoing trials of therapies to augment cellular immunity. This article reviews basic and translational research insights that will lead to improved staging, prognostic accuracy, and mechanism-based therapy for this often-lethal skin cancer.