Prognostic significance of systemic neutrophil and leukocyte alterations in surgically treated endometrial cancer patients: a monoinstitutional study

Pretreatment systemic inflammatory markers predict survival in endometrial cancer: A Japanese Gynecologic Oncology Group 2043 exploratory data analysis

OBJECTIVE

We investigated whether pretreatment systemic inflammatory markers are associated with survival outcomes in patients with endometrial cancer (EC).

METHODS

Data from the Japanese Gynecologic Oncology Group 2043 were analyzed. Patients who did not receive chemotherapy or were lost to follow-up were excluded. Associations of pretreatment systemic inflammatory markers, including the neutrophil-to-lymphocyte ratio (NLR), platelet-to-lymphocyte ratio (PLR), and hemoglobin, albumin, lymphocyte, and platelet (HALP) score, with progression-free survival (PFS) and overall survival (OS) were analyzed. The optimal NLR, PLR, and HALP score cutoff values for PFS and OS were determined. Survival estimates were calculated and compared using the Kaplan-Meier method and log-rank test.

RESULTS

We included 712 patients (median age: 55 [range, 28-74] years; body mass index [BMI]: 21.1 [15.2-38.6] kg/m2). For PFS, optimal NLR, PLR, and HALP score cutoff values were 1.48, 0.017, and 35.52, respectively, and for OS, the values were 1.88, 0.026, and 19.87, respectively. At optimal PFS-related cutoff values, NLR was associated with BMI; PLR with age, BMI, and clinical stage; and HALP score with BMI, clinical stage, and lymph node metastasis. At optimal OS-related cutoff values, NLR was associated with BMI, PLR, and BMI; the HALP score was associated with age and BMI. The HALP score was a prognostic factor for PFS (p = 0.025), while PLR and HALP scores were prognostic factors for OS (both p = 0.028).

CONCLUSIONS

Pretreatment systemic inflammatory markers are associated with survival outcomes in patients with EC, with the HALP score being a prognostic factor for PFS and OS.

Elevated Baseline Neutrophil Count Correlates with Worse Outcomes in Patients with Muscle-Invasive Bladder Cancer Treated with Chemoradiation

BACKGROUND

The role of inflammation in the development and prognosis of bladder cancer (BC) is now established. We evaluated the significance of neutrophil-to-lymphocyte ratio (NLR) and neutrophil count (PNN) in patients with localized BC treated with chemoradiation.

METHODS

Clinical characteristics and baseline biological data were retrospectively collected. We tested the association between NLR, PNN, and overall survival (OS) and progression-free survival (PFS).

RESULTS

One hundred and ninety-four patients were included. Median PNN was 4000.0/mm³ [1500.0-16,858.0] and median NLR was 2.6 [0.6-19.2]. In patients with NLR > 2.6, median OS and PFS were lower (OS: 25.5 vs. 58.4 months, p = 0.02; PFS: 14.1 vs. 26.7 months, p = 0.07). Patients with PNN > 4000/mm³ had significantly lower OS (21.8 vs. 70.1 months, p < 0.001) and PFS (13.7 vs. 38.8 months, p < 0.001). Contrary to NLR, PNN > 4000/mm³ was associated with shorter OS and PFS in multivariate analysis.

CONCLUSIONS

Elevated PNN at baseline was associated with worse OS and PFS. NLR was not an independent prognostic factor.

Prognostic Significance of Pretreatment Neutrophil-to-Lymphocyte Ratio, Platelet-to-Lymphocyte Ratio, or Monocyte-to-Lymphocyte Ratio in Endometrial Neoplasms: A Systematic Review and Meta-analysis

Aim

Neutrophil–lymphocyte ratio (NLR), platelet–lymphocyte ratio (PLR), or monocyte–lymphocyte ratio (MLR) has been shown to be related to the poor prognosis of cervical cancer, ovarian cancer, breast cancer, and other malignant tumors, but their role in predicting the prognosis of endometrial cancer is still controversial. Therefore, we conducted this meta-analysis to evaluate the effectiveness of NLR more accurately, PLR, or MLR in predicting the prognosis of endometrial cancer (EC).

Methods

This review systematically searched for relevant publications in databases of the Cochrane Library, PubMed, EMBASE, CNKI, WanFang, VIP, and CBM. Pooled hazard ratios (HR) with 95% confidence intervals (95% CI) were determined and used to explore the association between inflammatory biomarkers (NLR, PLR, and MLR) and overall survival (OS), progression-free survival (PFS), and disease-free survival (DFS) in a random-effects model. We also conducted subgroup analysis and publication bias in this meta-analysis. Stata 12.0 was used for statistical analysis.

Results

This meta-analysis contained 14 eligible studies including 5,274 patients. Our results showed that NLR or PLR was associated with OS [NLR: HR, 2.51; 95% CI, 1.70–3.71; p <0.001 in univariate analysis (Ua); HR, 1.87; 95% CI, 1.34–2.60; p <0.001 in multivariate analysis (Ma); PLR: HR, 2.50; 95% CI, 1.82–3.43; p <0.001 in Ua; HR, 1.86; 95% CI, 1.22–2.83; p = 0.004 in Ma], but MLR was not associated with OS (HR, 1.44; 95% CI, 0.70–2.95; p = 0.325 in Ua; HR, 1.01; 95% CI, 0.39–2.60; p =0.987 in Ma). A further subgroup analysis found that the correlations were not affected by race, cutoff value, sample size, or treatment. Our meta-analysis showed that NLR or PLR was associated with DFS (NLR: HR, 2.50; 95% CI, 1.38–4.56; p =0.003 in Ua; HR, 2.06; 95% CI, 1.26–3.37, P =0.004 in Ma; PLR: HR, 1.91; 95% CI, 1.30–2.81; p = 0.001 in Ua), and NLR was associated with PFS only in the univariate analysis (HR, 1.71; 95% CI, 1.04–2.81; p =0.035 in Ua; HR, 1.79; 95% CI, 0.65–4.89; P =0.257 in Ma), but MLR was not associated with DFS (HR, 0.36; 95% CI, 0.03–4.13; p =0.409 in Ua).

Conclusions

Our results indicated that pretreatment NLR and PLR were biomarkers of poor prognosis in patients with endometrial cancer. The results indicated that NLR or PLR was associated with OS and disease-free survival DFS, and NLR was associated with PFS only in univariate analysis, but MLR was not associated with OS or DFS.

Diagnostic and Therapeutic Values of Angiogenic Factors in Endometrial Cancer

Endometrial cancer (EC) is the most frequent gynecological malignancy in developed countries and requires a relatively invasive diagnostic evaluation and operative therapy as the primary therapeutic approach. Angiogenesis is one of the main processes needed for cancer growth and spread. The production of angiogenic factors (AFs) appears early in the process of carcinogenesis. The detection of AFs in plasma and tissue and a better understanding of the angiogenic properties of EC may contribute not only to earlier but also more specific diagnosis and consequently tailored and individual therapeutic approaches. AFs and their receptors also have high potential as binding sites for targeted cancer therapy. In this review, we discuss angiogenesis in EC and the characteristics of the AFs that most contribute to angiogenesis in EC. We also highlight therapeutic strategies that target angiogenesis as potential EC therapy.

Pre-treatment inflammatory parameters predict survival from endometrial cancer: A prospective database analysis

PURPOSE

Inflammation predisposes to tumorigenesis by damaging DNA, stimulating angiogenesis and potentiating pro-proliferative and anti-apoptotic processes. The aim of this study was to investigate whether pre-treatment biomarkers of systemic inflammation are associated with survival outcomes in endometrial cancer.

PATIENTS AND METHODS

Women with endometrial cancer were recruited to a prospective database study. Pre-treatment systemic markers of inflammation, including C-reactive protein (CRP), Glasgow Prognostic Score and lymphocyte-based ratios [neutrophil-lymphocyte ratio (NMR), monocyte-lymphocyte ratio (MLR), systemic immune-inflammation index (SII)], were analysed in relation to overall, endometrial cancer-specific and recurrence-free survival using Kaplan-Meier estimation and multivariable Cox regression.

RESULTS

In total, 522 women of mostly White British ethnicity, with a median age of 66 years (interquartile range (IQR), 56, 73) and BMI of 32 kg/m² (IQR 26, 39) were included in the analysis. Most had low-grade (67.2%), early-stage (85.4% stage I/II), endometrioid (74.5%) tumors. Women with pre-treatment CRP ≥5.5 mg/L had a 68% increase in overall (adjusted HR = 1.68, 95% CI 1.00-2.81, p = 0.049) and a two-fold higher cancer-specific mortality risk than those with CRP <5.5 mg/L (adjusted HR = 2.04, 95%CI 1.03-4.02, p = 0.04). Absolute lymphocyte count, NLR, MLR and SII were associated with adverse clinico-pathologic factors, but not overall, cancer-specific or recurrence-free survival in the multivariable analysis.

CONCLUSION

If confirmed in an independent cohort, CRP may offer a simple, low-cost test to refine pre-treatment risk assessment and guide personalised care in endometrial cancer. Our participants were mostly of White British ethnicity and further studies are needed to confirm the utility of CRP as a prognostic biomarker in other populations.

Preoperative leukocytosis correlates with unfavorable pathological and survival outcomes in endometrial carcinoma: A systematic review and meta-analysis

AIM

To meta-analytically examine the frequency and prognostic impact of preoperative leukocytosis in endometrial carcinoma (EC).

METHODS

Five major databases were searched till 01-February-2021. Studies that evaluated the frequency of preoperative leukocytosis or its correlation with pathological and survival outcomes in EC patients were included. Data were pooled as mean differences (MD), odds ratios (OR), or hazard ratios (HR) with 95% confidence intervals.

RESULTS

Nine retrospective studies, with low risk of bias, were included. The pooled prevalence of preoperative leukocytosis was 11.2% (95% CI: 8.2-14.3). There was a significant correlation between preoperative leukocytosis and FIGO stage III-IV (OR = 2.10, 95% CI: 1.60-2.75), ≥50% myometrial invasion (OR = 1.32, 95% CI: 1.02-1.72), lymph node involvement (OR = 1.83, 95% CI: 1.29-2.59), cervical involvement (OR = 2.29, 95% CI: 1.68-3.13), adnexal involvement (OR = 2.17, 95% CI: 1.42-3.31), and tumor size (MD = 1.10 cm, 95% CI: 0.63-1.58). However, preoperative leukocytosis did not significantly correlate with tumor grade II-III, non-endometrioid histology, peritoneal cytology, and lympho-vascular space involvement (p > 0.05). Additionally, preoperative leukocytosis correlated with higher rates of death (OR = 2.85, 95% CI: 2.03-4.00), tumor recurrence (OR = 2.36, 95% CI: 1.21-4.61), and worse overall survival at univariate and multivariate analyses (HR = 2.90, 95% CI: 2.24-3.75 and HR = 2.16, 95% CI: 1.59-2.94, respectively). As for disease-free survival, preoperative leukocytosis emerged as an independent prognostic factor on univariate (HR = 1.27, 95% CI: 1.16-1.39) but not multivariate (HR = 1.08, 95% CI: 1.00-1.18) analyses.

CONCLUSIONS

Preoperative leukocytosis is common and correlates with poor pathological and survival outcomes in EC patients.

High postoperative neutrophil-lymphocyte ratio and low preoperative lymphocyte-monocyte ratio predict poor prognosis in gastric cancer patients receiving gastrectomy with positive lavage cytology: a retrospective cohort study

BACKGROUND

Long-term outcomes in gastric cancer patients with positive lavage cytology (CY1) are generally poor. This multi-institutional retrospective cohort study aims to evaluate the clinical significance of the neutrophil-lymphocyte ratio (NLR) and the lymphocyte-monocyte ratio (LMR) in CY1 gastric cancer patients.

METHODS

A total of 121 CY1 gastric cancer patients without other non-curative factors, who underwent macroscopically curative resection, were enrolled in this study. The cutoff values of preoperative NLR (pre-NLR), postoperative NLR (post-NLR), preoperative LMR (pre-LMR), and postoperative LMR (post-LMR) were defined by the Contal and O'Quigley method as 2.3, 3.0, 2.5, and 3.2, respectively. A Cox proportional hazard model was used to identify the independent prognostic factors among NLR, LMR, and other clinicopathological factors.

RESULTS

There were significant differences in the overall survival (OS) between the two groups: high post-NLR groups vs. low post-NLR group (median survival time, months) (10.9 vs. 22.8, P = 0.006) and high pre-LMR group vs. low pre-LMR group (21.3 vs. 11.0, P = 0.001). The LMR value elevated significantly after gastrectomy (P = 0.020), although not in the NLR value (P = 0.733). On multivariate analysis, high post-NLR (hazard ratio = 1.506; 95% confidence interval = 1.047-2.167; P = 0.027), low pre-LMR (1.773; 1.135-2.769, 0.012), and no postoperative chemotherapy (1.558; 1.053-2.305, 0.027) were found to be independent prognostic factors for adverse OS.

CONCLUSIONS

Because a combination of high post-NLR and low pre-LMR may be an adverse prognostic marker in resectable CY1 gastric cancer patients, it is necessary to conduct a prospective trial to confirm a useful perioperative chemotherapeutic regimen for these patients.

Prognostic significance of bone marrow FDG uptake in patients with gynecological cancer

We investigated the prognostic significance and the underlying mechanism of increased bone marrow (BM) 2-(18F) fluoro-2-deoxy-D-glucose as a tracer (FDG)-uptake in patients with gynecological cancer. A list of patients diagnosed with cervical, endometrial, and ovarian cancer from January 2008 to December 2014 were identified. Then, through chart reviews, 559 patients who underwent staging by FDG-positron emission tomography (PET)/computed tomography (CT) and subsequent surgical resection were identified, and their clinical data were reviewed retrospectively. BM FDG-uptake was evaluated using maximum standardized uptake value (SUVmax) and BM-to-aorta uptake ratio (BAR). As a result, we have found that increased BAR was observed in 20 (8.7%), 21 (13.0%), 21 (12.6%) of cervical, endometrial, and ovarian cancer, respectively, and was associated with significantly shorter survival. Increased BAR was also closely associated with increased granulopoiesis. In vitro and in vivo experiments revealed that tumor-derived granulocyte colony-stimulating factor (G-CSF) was involved in the underlying causative mechanism of increased BM FDG-uptake, and that immune suppression mediated by G-CSF-induced myeloid-derived suppressor cells (MDSCs) is responsible for the poor prognosis of this type of cancer. In conclusion, increased BM FDG-uptake, as represented by increased BAR, is an indicator of poor prognosis in patients with gynecological cancer.

Preoperative neutrophil-to-lymphocyte, platelet-to-lymphocyte and monocyte-to-lymphocyte ratio as a prognostic factor in non-endometrioid endometrial cancer

Objective: Evaluate the prognostic value of neutrophil-lymphocyte ratio (NMR), platelet-lymphocyte ratio (PLR), and monocyte-lymphocyte ratio (MLR) in patients with non-endometrioid endometrial cancer. Method: Laboratory and clinicopathological data from 118 patients with non-endometrioid endometrial cancer who underwent surgical resection between January 2010 and December 2019 were reviewed. NLR, PLR and MLR were analyzed for correlations with recurrence and survival. The receiver operating characteristic (ROC) curves were generated for the NLR, PLR, and MLR. Optimal cut-off values were determined as the points at which the Youden index (sensitivity + specificity - 1) was maximal. Based on the results of the ROC curve analysis, the patients were grouped into high MLR and low MLR groups. Recurrence rate, disease-free survival, and overall survival were compared between the two groups. The prognostic factors were investigated using univariate and multivariate Cox proportional hazards model. Results: The optimal cut-off value of MLR was 0.191 (AUC, 0.718; p < 0.001). Significantly more patients in the high MLR group experienced recurrence (60.3% vs. 15.6%, p < 0.0001) and cancer-related deaths (46.6% vs. 13.3%, p = 0.003). In multivariate analysis, advanced stage and high MLR were independent prognostic factors for disease-free survival and overall survival. Conclusion: Elevated MLR was significantly associated poor clinical outcomes in patients with non endometrioid endometrial cancer. Our findings suggest that MLR may be clinically reliable and useful as an independent prognostic marker for patients with non-endometrioid endometrial cancer.

Incorporation of pretreatment leukocytosis and thrombocytosis into the FIGO staging system for prognosis in surgically treated endometrial cancer

OBJECTIVE

To investigate the impact of incorporating pretreatment leukocytosis and/or thrombocytosis in the FIGO staging system on prognostic prediction among women with surgically treated endometrial cancer.

METHODS

Retrospective review of clinical data from 900 women with endometrial cancer treated at Osaka University Hospital, Japan, between 2000 and 2016. The effect of concurrent leukocytosis and thrombocytosis on the prediction of recurrence and survival outcomes was evaluated via receiver operating characteristic (ROC) curve analysis and the Kaplan-Meier method.

RESULTS

Among 678 women with Stage I-III disease, pretreatment leukocytosis or thrombocytosis alone were not prognostic indicators, but concurrent pretreatment leukocytosis and thrombocytosis was associated with significantly shorter survival (PFS, P<0.001; OS, P=0.004). In contrast, pretreatment leukocytosis, pretreatment thrombocytosis, and concurrent pretreatment leukocytosis and thrombocytosis did not provide any prognostic information for women with Stage IV disease. In ROC curve analysis, incorporation of concurrent pretreatment leukocytosis and thrombocytosis into the FIGO staging system resulted in a higher area under the curve for predicting recurrence for women with Stages I-III disease (0.770 vs 0.755; P=0.045).

CONCLUSION

Incorporating concurrent pretreatment leukocytosis and thrombocytosis into the FIGO staging system might improve predictive performance and allow additional risk stratification for women with Stage I-III endometrial cancer.

Combination of preoperative neutrophil-lymphocyte ratio, platelet-lymphocyte ratio and monocyte-lymphocyte ratio: a superior prognostic factor of endometrial cancer

BACKGROUND

The preoperative peripheral blood neutrophil-lymphocyte ratio (NLR), platelet-lymphocyte ratio (PLR) and monocyte-lymphocyte ratio (MLR) have been reported to be associated with the prognosis of various cancers but are always discussed separately. The aim of this study is to bring the combination of NLR, PLR and MLR into the prognostic assessment system of endometrial cancer (EC) and establish a nomogram to provide an objective prediction model for clinical decisions.

METHODS

A total of 1111 patients with EC who had accepted surgical treatment during 2013-2017 were involved in the analysis. Their NLR, PLR, and MLR levels were obtained from a routine blood examination within 2 weeks before operation. Receiver operating characteristic curve (ROC) analysis was performed to determine optimal cutoffs. Chi-square tests analysed the associations of the ratios with other clinicopathological variables. The prognostic value was indicated by overall survival (OS) via Cox proportional hazards models and Kaplan-Meier analysis. R software was used to establish the nomogram based on the combination of NLR, PLR, MLR and other clinicopathological factors.

RESULTS

The median follow-up period was 40 months, and the median age was 56. The enrolled patients were stratified by cutoffs of 2.14 for NLR, 131.82 for PLR and 0.22 for MLR. Multivariate analyses demonstrated that high NLR over 2.14 (HR = 2.71, 95%CI = 1.83-4.02, P<0.001), high PLR over 131.82 (HR = 2.75, 95%CI = 1.90-3.97, P<0.001), and high MLR over 0.22 (HR = 1.72, 95%CI = 1.20-2.45, P = 0.003) were significantly associated with worse OS. The combined indicator, high NLR + high PLR + high MLR (HR = 4.34, 95%CI = 2.54-7.42, P<0.001), showed the highest prognostic value. The Harrell's concordance index of the nomogram was 0.847 (95% CI = 0.804-0.890), showing good discrimination and calibration of this model.

CONCLUSION

The combination of NLR, PLR, and MLR is a superior prognostic factor of EC. The nomogram involving the combination of NLR, PLR, MLR and other clinicopathological factors is recommended to predict OS for EC patients clinically.

Analysis of Systemic Inflammatory Factors and Survival Outcomes in Endometrial Cancer Patients Staged I-III FIGO and Treated with Postoperative External Radiotherapy

BACKGROUND

The causal link between elevated systemic inflammation biomarkers and poor survival has been demonstrated in cancer patients. However, the evidence for this correlation in endometrial cancer (EC) is too weak to influence current criteria of risk assessment. Here, we examined the role of inflammatory indicators as a tool to identify EC patients at higher risk of death in a retrospective observational study.

METHODS

A total of 155 patients surgically diagnosed with EC stage I-III FIGO 2009 and treated with postoperative External Beam Radiotherapy (EBRT) ± brachytherapy and chemotherapy according to ESMO-ESTRO-ESGO recommendation for patients at high risk of recurrence at the Gustave Roussy Institut, France, and Hospital Clínic, Spain, between 2008 and 2017 were evaluated. The impact of pre-treatment Neutrophil-to-Lymphocyte Ratio (NLR ≥ 2.2), Monocyte-to-Lymphocyte Ratio (MLR ≥ 0.18), Systemic Immune-Inflammatory Index (SII ≥ 1100) and lymphopenia (<1.0×109/L) on overall survival (OS), cancer-specific survival and progression-free survival was evaluated. Subsequently, a cohort of 142 patients within high-advanced risk groups according to ESMO-ESGO-ESTRO classification was evaluated.

RESULTS

On univariate analysis, NLR (HR = 2.2, IC 95% 1.1-4.7), SII (HR = 2.2, IC 95% 1.1-4.6), MLR (HR = 5.0, IC 95% 1.1-20.8) and lymphopenia (HR = 3.8, IC 95% 1.6-9.0) were associated with decreased OS. On multivariate analysis, NLR, MLR, SII and lymphopenia proved to be independent unfavorable prognostic factors.

CONCLUSIONS

lymphopenia and lymphocytes-related ratio are associated with poorer outcome in surgically staged I-III FIGO EC patients classified as high risk and treated with adjuvant EBRT and could be considered at cancer diagnosis. External validation in an independent cohort is required before implementation for patients' stratification.

Circulating Transcripts and Biomarkers in Uterine Tumors: Is There a Predictive Role?

PURPOSE OF REVIEW

Uterine cancer comprises endometrial carcinoma and the uterine sarcoma. Endometrial carcinomas are the most frequent variant and have early symptoms and a solid diagnostic work up, resulting in a rather fair prognosis. However, in case of advanced stage disease and relapse, treatment options are limited and prognosis is impaired. Uterine sarcomas are rare, often lacking symptoms and no diagnostic tool for correct pre-operative diagnosis are available. Prognosis is poor.

RECENT FINDINGS

Circulating biomarkers as a liquid biopsy could be beneficial as a diagnostic tool in uterine sarcomas. For both carcinomas and sarcomas, circulating biomarkers could be of use in predicting early disease recurrence. This review in endometrial carcinoma and uterine sarcoma focus on circulating biomarkers; such as proteins; circulating tumor cells; circulating tumor DNA; microRNA; and immune cells.

Prognostic values of pretreatment neutrophil-to-lymphocyte and platelet-to-lymphocyte ratios in endometrial cancer: a systematic review and meta-analysis

Purpose

Elevated inflammatory markers, including neutrophil-to-lymphocyte ratio (NLR) and platelet-to-lymphocyte ratio (PLR), have been identified as poor predictors of survival in several malignancies. This meta-analysis was performed to quantify the effect of pretreatment NLR and PLR on the survival of patients with endometrial cancer (EC).

Methods

This review systematically searched for relevant publications in databases of PubMed, Embase, and the Cochrane Library. Pooled hazard ratios (pHRs) with 95% confidence intervals (95% CIs) were determined and used to explore the association between inflammatory markers and overall survival (OS) and disease-free survival (DFS) in a random-effects model. Subgroup analysis, sensitivity analysis, and publication bias were also conducted in this meta-analysis.

Results

Nine articles comprising 3390 patients were included. NLR higher than the cutoff was associated with a shorter OS (pHR = 2.22, 95% CI 1.77–2.78) and poorer PFS (pHR = 1.81, 95% CI 1.35–2.41). Patients with elevated PLR had high risk of decreased OS (pHR = 1.99, 95% CI = 1.51–2.61) and unfavorable PFS (pHR = 2.02, 95% CI 1.45–2.80).

Conclusions

Elevated NLR and PLR during pretreatment are biomarkers of poor prognosis in patients with EC.

Electronic supplementary material

The online version of this article (10.1007/s00404-019-05372-w) contains supplementary material, which is available to authorized users.

The role of myeloid-derived suppressor cells in endometrial cancer displaying systemic inflammatory response: clinical and preclinical investigations

Systemic inflammatory responses including thrombocytosis, leukocytosis, or neutrophilia have gained attention as prognostic indicators in patients with various solid malignancies.current study, we aimed to investigate the clinical implications and underlying biological mechanism of the systemic inflammatory response in endometrial cancer. Clinical data from 900 patients with endometrial cancer were analyzed to investigate the association between pretreatment leukocytosis, thrombocytosis, and treatment outcome. Clinical samples, endometrial cancer cell lines, and a mouse model of endometrial cancer were used to examine the mechanisms responsible for systemic inflammatory response in endometrial cancer, focusing on the role of tumor-derived granulocyte colony-stimulating factor (G-CSF) and MDSCs. Then, we showed that pretreatment concurrent leukocytosis and thrombocytosis is associated with significantly shorter survival and decreased chemosensitivity among patients with endometrial cancer. In vitro and in vivo experiments revealed that tumor-derived G-CSF and G-CSF-mediated IL-6 production from the tumor microenvironment are involved in the development of leukocytosis and thrombocytosis in patients with endometrial cancer. Moreover, increased tumor-infiltrating MDSCs induced by tumor-derived G-CSF, MDSC-mediated T cell suppression, and MDSC-mediated cancer stem cell induction are responsible for progression and chemoresistance in this type of endometrial cancer. MDSC depletion using an anti-Gr-1 neutralizing antibody or inhibition of MDSC activity by celecoxib inhibited tumor growth and enhanced chemosensitivity in endometrial cancer displaying concurrent leukocytosis and thrombocytosis. In conclusion, Pretreatment concurrent leukocytosis and thrombocytosis are associated with significantly shorter survival and decreased chemosensitivity among patients with endometrial cancer. Combining MDSC-targeting treatments with current standard chemotherapies might have therapeutic efficacy for these patients.

Impact of systemic therapy on circulating leukocyte populations in patients with metastatic breast cancer

Tumors affect the immune system, locally and systemically. The frequencies of specific circulating immune cell populations correlate with disease progression as well as prognosis of the patients. Although largely neglected, conventional antitumoral therapies often possess immunomodulatory properties and affect the levels of specific immune cell populations. Most information, however, derive from animal or in vitro studies. As this could impact prognosis as well as response to therapy, further studies of the effects of treatment on circulating immune cells in patients are warranted. In this pilot study, we evaluated a wide panel of circulating immune cells over time (up to six months) in ten patients with metastatic breast cancer receiving standard antitumoral regimens. Overall, endocrine therapy tends to enrich for natural killer (NK) and natural killer T (NKT) cells in the circulation, whereas both chemotherapy and endocrine therapy reduce the levels of circulating monocytic myeloid-derived suppressor cells (Mo-MDSCs). This indicates that the systemic immunosuppressive profile observed in patients tends to revert over the course of systemic therapy and holds promise for future combination treatment with standard antitumoral agents and immunotherapy.

Neutrophilia and mortality in women with uterine carcinosarcoma

OBJECTIVE

The objective of this study was to investigate the relationship between pre-treatment absolute neutrophil count and clinical outcomes in patients with uterine carcinosarcoma.

METHODS

In an Institutional Review Board approved, retrospective cohort study of 103 patients with uterine carcinosarcoma, the pre-treatment absolute neutrophil count data were obtained from the medical records, along with clinical, pathologic, treatment, and outcome data. Kaplan-Meier survival estimates were calculated and compared by the log rank test. Univariable and multivariable Cox proportional hazard regression models were used to examine the relationship of pre-treatment absolute neutrophil count with progression-free survival and overall survival.

RESULTS

Uterine carcinosarcoma patients in the highest quartile of pre-treatment absolute neutrophil count had significantly reduced progression-free survival (p<0.001, log rank test), and overall survival (p<0.001, log rank test), compared with patients in the lower absolute neutrophil count quartiles. On multivariable analysis, high absolute neutrophil count was an independent poor prognostic factor for disease recurrence, HR 2.97 (95% CI 1.35 to 6.53, p=0.007) for highest versus lowest quartile absolute neutrophil count, and for mortality, HR 4.43 (95% CI 1.64 to 12.00, p= 0.003).

CONCLUSIONS

High pre-treatment absolute neutrophil count is an independent poor prognostic factor in patients with uterine carcinosarcoma and may be useful as a potential biomarker in clinical trials. The mechanistic relationship of neutrophilia and uterine carcinosarcoma progression merits further investigation.

Diagnostic Accuracy of Clinical Biomarkers for Preoperative Prediction of Lymph Node Metastasis in Endometrial Carcinoma: A Systematic Review and Meta-Analysis

BACKGROUND

In endometrial carcinoma (EC), preoperative classification is based on histopathological criteria, with only moderate diagnostic performance for the risk of lymph node metastasis (LNM). So far, existing molecular classification systems have not been evaluated for prediction of LNM. Optimized use of clinical biomarkers as recommended by international guidelines might be a first step to improve tailored treatment, awaiting future molecular biomarkers.

AIM

To determine the diagnostic accuracy of preoperative clinical biomarkers for the prediction of LNM in endometrial cancer.

METHODS

A systematic review was performed according to the Meta-analysis of Observational Studies in Epidemiology (MOOSE) guidelines. Studies identified in MEDLINE and EMBASE were selected by two independent reviewers. Included biomarkers were based on recommended guidelines (cancer antigen 125 [Ca-125], lymphadenopathy on magnetic resonance imaging, computed tomography, and ¹⁸F-fluorodeoxyglucose positron emission tomography/computed tomography [¹⁸FDG PET-CT]) or obtained by physical examination (body mass index, cervical cytology, blood cell counts). Pooled sensitivity, specificity, area under the curve (AUC), and likelihood ratios were calculated with bivariate random-effects meta-analysis. Likelihood ratios were classified into small (0.5-1.0 or 1-2.0), moderate (0.2-0.5 or 2.0-5.0) or large (0.1-0.2 or ≥ 5.0) impact.

RESULTS

Eighty-three studies, comprising 18,205 patients, were included. Elevated Ca-125 and thrombocytosis were associated with a moderate increase in risk of LNM; lymphadenopathy on imaging with a large increase. Normal Ca-125, cytology, and no lymphadenopathy on ¹⁸FDG PET-CT were associated with a moderate decrease. AUCs were above 0.75 for these biomarkers. Other biomarkers had an AUC <0.75 and incurred only small impact.

CONCLUSION

Ca-125, thrombocytosis, and imaging had a large and moderate impact on risk of LNM and could improve preoperative risk stratification.

IMPLICATIONS FOR PRACTICE

Routine lymphadenectomy in clinical early-stage endometrial carcinoma does not improve outcome and is associated with 15%-20% surgery-related morbidity, underlining the need for improved preoperative risk stratification. New molecular classification systems are emerging but have not yet been evaluated for the prediction of lymph node metastasis. This article provides a robust overview of diagnostic performance of all clinical biomarkers recommended by international guidelines. Based on these, at least measurement of cancer antigen 125 serum level, assessment of thrombocytosis, and imaging focused on lymphadenopathy should complement current preoperative risk stratification in order to better stratify these patients by risk.

The Ratio of Neutrophil to Lymphocyte is a Predictor in Endometrial Cancer

Objective: The aim of our study was to assess the prognostic value of the ratio of neutrophil to lymphocyte (NLR) for patients with surgically treated endometrial cancer (EC). Methods: We retrospectively reviewed 510 EC patients who were surgically treated between January 2010 and December 2016. We used receiver-operating characteristic (ROC) curve analysis to identify an optimal cut-off for NLR in predicting overall survival (OS), cancer-specific survival (CSS) and disease-free survival (DFS). Nonparametric tests were used to determine the associations between NLR and clinicopathologic characteristics. The Kaplan–Meier method and Cox proportional-hazards regression were used for survival analysis. Results: With a cut-off of 2.47, the 510 patients were divided into low NLR (NLR <2.47) and high NLR (NLR ≥2.47). Elevated NLR was associated with advanced stage (P=0.039), increased histology grade (P=0.005) and lymph node metastasis (P=0.041). Multivariable analysis suggested that NLR was an independent prognostic marker for OS (hazard ratio [HR] 4.7; 95% confidence interval [CI], 1.5-14.1; P =0.006), CSS (HR 3.6; 95% CI, 1.1-11.5; P =0.028) and DFS (HR 2.3; 95% CI, 1.0-5.2; P =0.044). Conclusion: NLR may be an independent prognostic indicator for OS, CSS and DFS. It could help clinicians with preoperative risk stratification and treatment strategy tailoring.

Independent predictors of survival in endometrium cancer: platelet-to-lymphocyte ratio and platelet/neutrophil/monocyte-to-lymphocyte ratio

Objective:

To evaluate the association between ratios of inflammatory markers and survival in endometrium cancer (EC).

Material and Methods:

Four hundred ninety-seven patients with epithelial EC were included. The evaluated ratios were neutrophil (N)/lymphocyte (L), neutrophil count divided by the lymphocyte count; platelet (P)/lymphocyte, platelets divided by the lymphocyte count; lymphocyte/monocyte (M), lymphocytes divided by the monocyte count; NM/L, neutrophil plus monocyte divided by the lymphocyte count; PNM/L, the sum total counts of platelets, neutrophils and monocytes divided by the lymphocyte count.

Results:

The median follow-up time was 24 months (1-129). Recurrence and exitus occurred in 34 (7%) and 18 (3.7%) patients, respectively. Metastasis in pelvic or para-aortic lymph nodes were significantly related only with low L/M. None of the inflammatory ratios were associated with disease-free survival. In multi-variant analysis, only high P/L (>168) and high PNM/L (>171) were related with a statistically significant hazard ratio for death of 2.91 (p=0.024) and 2.93 (p=0.023), respectively.

Conclusion:

The P/L and PNM/L were in relation with worse overall survival and also independent prognostic factors for OS.

The Highly Metastatic Nature of Uterine Cervical/Endometrial Cancer Displaying Tumor-Related Leukocytosis: Clinical and Preclinical Investigations

Purpose: The aim of this study was to investigate the metastatic potential of uterine cervical and endometrial cancer displaying tumor-related leukocytosis (TRL).Experimental Design: Clinical data on uterine cervical (N = 732) and endometrial cancer (N = 900) were collected, and the metastatic potential of TRL-positive cancer was evaluated in univariate and multivariate analyses. Tumor and blood samples obtained from patients with cervical cancer, cervical cancer cell lines, and a mouse model of cervical cancer were used to examine the mechanisms underlying the highly metastatic nature of TRL-positive cancer, focusing on tumor-derived G-CSF and the myeloid-derived suppressor cell (MDSC)-mediated premetastatic niche.Results: Pretreatment TRL was significantly associated with visceral organ metastasis in patients with uterine cervical or endometrial cancer. The patients with TRL-positive cervical cancer displayed upregulated tumor G-CSF expression, elevated G-CSF levels, and increased MDSC frequencies in the peripheral blood compared with the TRL-negative patients. In vitro and in vivo investigations revealed that MDSCs produced in response to tumor-derived G-CSF are involved in premetastatic niche formation, which promotes visceral organ metastasis of TRL-positive cancer. The depletion of MDSCs attenuated this premetastatic niche formation and effectively inhibited the visceral organ metastasis of TRL-positive cancer.Conclusions: Uterine cervical/endometrial cancer displaying TRL is a distinct clinical entity with high metastatic potential. Tumor-derived G-CSF and the MDSC-mediated premetastatic niche are responsible for the highly metastatic nature of this type of cancer. MDSC-targeting therapy might represent a potential strategy for combating metastasis derived from TRL-positive uterine cancer. Clin Cancer Res; 24(16); 4018-29. ©2018 AACR.

Preoperative Monocyte Count as a Mirror of Tumor Characteristics and Likelihood of Recurrence in Endometrial Carcinoma Cases

Background: Recently preoperative hematologic parameters have attracted attention for their capacity to predict tumor characteristics and recurrence. Considering the established role of tumor-associated macrophages (TAM) in the tumor microenvironment, we evaluated the role of the preoperative monocyte count as a surrogate for TAM. Methods: We retrospectively reviewed 166 patients with histopathologically proven endometrial cancers from January 2011 to March 2015 and assessed any association of preoperative monocyte count with tumor characteristics and recurrence. Results: The majority of patients had tumors with the following characteristics: endometrioid histology (83.1%), low grade (grade I-II, 71.7%) and stage I disease (68.1%). The mean ± SD monocyte, neutrophil and platelet counts were 8.23 x 109/L ± 3.56 x 109/L, 64.0 x 109/L ± 11.3 x 109/L and 261.6 x 109/L ± 74.6 x 109. Statistically significant associations were noted with between preoperative monocyte count and tumor stage (p value=0.044), recurrence (p value<0.001) and omentum involvement (p value< 0.001) but not with tumor grade (p value=0.897), depth of myometrium involvement (p value=0.479), lymphovascular space invasion (p value=0.269) and lymph node involvement (p value=0.377). Conclusion: An elevated preoperative monocyte count is related to more aggressive tumors and a higher recurrence rate in patients with endometrial cancer.

The Significance of Pretreatment Thrombocytosis and Its Association With Neutrophilia in Patients With Surgically Treated Endometrial Cancer

OBJECTIVE

The aim of this study was to investigate the prognostic significance of a pretreatment thrombocytosis and its association with neutrophilia in patients with surgically treated endometrial cancer.

METHODS

The baseline characteristics and outcome data of 508 patients with surgically treated endometrial cancer between January 2000 and December 2010 were collected and retrospectively reviewed. The patients were separated into 4 groups according to their platelet counts and the neutrophil counts, and the progression-free and overall survival rates of the 4 groups were compared. A Cox proportional hazards regression model was used to explore the independent prognostic factors.

RESULTS

Pretreatment thrombocytosis was found to be associated with advanced stage (P = 0.0186), nonendometrioid histology (P = 0.0139), a deeper myometrial invasion (P = 0.0103), lymphovascular space involvement (P = 0.0404), cervical involvement (P = 0.004), positive peritoneal cytology (P = 0.0198), lymph node metastasis (P = 0.0301), and more frequent treatment failure (P = 0.0006). Multivariate analysis demonstrated that an older age (hazard ratio [HR], 2.54; 95% confidence interval [CI], 1.46-4.51; P = 0.0009), advanced clinical stage (HR, 5.27; 95% CI, 2.94-9.86; P < 0.0001), lymphovascular space involvement (HR, 3.37; 95% CI, 1.74-7.07; P = 0.0002), and pretreatment thrombocytosis (HR, 4.99; 95% CI, 2.47-9.39; P < 0.0001) were significant predictors of survival. When examined according to clinical stage, pretreatment thrombocytosis was prognostically significant only in patients with stage III-IV disease. The neutrophil count in patients who display thrombocytosis was significantly greater than that observed in patients without thrombocytosis (median, 6702 vs 4406/μL; P < 0.0001). Moreover, patients who displayed both thrombocytosis and neutrophilia had significantly shorter survival than that in those with either thrombocytosis or neutrophilia alone.

CONCLUSIONS

Presence of thrombocytosis at the time of the initial diagnosis is an independent predictor of shorter survival in patients with advanced-stage (stages III-IV) endometrial cancer. Moreover, pretreatment thrombocytosis and concurrent neutrophilia are an independent predictor of shorter survival regardless of clinical stage.

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.

Persistent elevation of postoperative neutrophil-to-lymphocyte ratio: A better predictor of survival in gastric cancer than elevated preoperative neutrophil-to-lymphocyte ratio

Postoperative neutrophil-to-lymphocyte ratio change (NLRc) reflects the dynamic change of balance between host inflammatory response and immune response after treatment. In gastric cancer, an elevated initial NLR (iNLR) is reported to be a prognostic predictor, but the clinical application of the NLRc remains unclear. The NLRc was assessed in 734 patients undergoing total/subtotal gastrectomy and endoscopic submucosal dissection for gastric adenocarcinoma. The iNLR and NLRc were recorded within 10 days of the first diagnosis and 3–6 months after surgery, respectively. Using receiver operating characteristic (ROC) curves, we investigated the relationship between NLRc or iNLR and patient survival. The analysis revealed a higher predictive power for correlating patient survival with the NLRc compared with iNLR. NLRc was defined as negative (lower than iNLR) and positive (higher than iNLR). A positive NLRc was frequently observed in patients with advanced AJCC stage, local recurrence, distant metastasis, perineural invasion, and adjuvant chemotherapy (all p < 0.05). Univariate and multivariate analyses revealed a significant relationship between patient survival and NLRc (all p < 0.05) but no association between survival and iNLR. The NLRc could be a better indicator than iNLR for predicting survival in patients with gastric cancer.

Retrospective study of the prognostic significance of neutrophil-to-lymphocyte ratio for postsurgical outcomes of patients with endometrial carcinoma

OBJECTIVE

To evaluate the significance of postoperative inflammatory system response markers in predicting the prognosis of patients with endometrial cancer undergoing surgery.

METHODS

The present retrospective study included patients who underwent surgical treatment for pathology-confirmed endometrial cancer between January 1, 2007, and June 30, 2013, at the Affiliated Drum Tower Hospital, Nanjing University Medical School, Nanjing, China. Potential prognostic factors were investigated by Cox proportional hazards analysis and survival rates were compared using Kaplan-Meier analyses.

RESULTS

There were 185 patients with surgically treated endometrial cancer included. Multivariate analyses demonstrated that a preoperative neutrophil-to-lymphocyte ratio (NLR) above 1.81 (P=0.010) and a postoperative NLR above 7.54 (P=0.008) were both independently associated with lower disease free survival. Elevated preoperative and postoperative NLRs were associated with higher tumor stage (P=0.021 and P=0.009, respectively), and only elevated preoperative NLR was associated with lymph node involvement (P=0.023).

CONCLUSION

Preoperative and postoperative NLRs were independently associated with inflammatory system response markers and could be combined to evaluate the prognosis of patients with endometrial cancer following surgery.

The Lymphocyte-Monocyte Ratio Predicts Patient Survival and Aggressiveness of Endometrial Cancer

OBJECTIVE

We assessed the prognostic implications of preoperative lymphocyte-monocyte ratio (LMR) in patients with endometrial cancer (EC).

METHODS

We retrospectively examined the LMR as a prognostic variable in a cohort of 255 patients with EC who underwent surgical resection. Patients were categorized into two groups according to the LMR (LMR-low and LMR-high) using cutoff points determined by receiving operator characteristic (ROC) curve analysis. The primary objective was to correlate the LMR to clinicopathological factors; the secondary objective was to determine the survival significance of the LMR in patients with EC.

RESULTS

Using data from the entire cohort, the most discriminative LMR cutoff value selected on the ROC curve was 3.28 for both disease-free survival (DFS) and overall survival (OS). The LMR-low and LMR-high groups included 33 (12.9%) and 222 patients (87.1%), respectively. The 5-year DFS rates in the LMR-low and LMR-high groups were 64.5 and 93.9% (P < 0.0001), respectively, and the 5-year OS rates in the two groups were 76.7 and 96.5% (P < 0.0001), respectively. On multivariate analysis, we identified histologic grade, International Federation of Gynecology and Obstetrics (FIGO) stage, and LMR levels as the strongest prognostic factors affecting DFS (P = 0.0037, P < 0.0001, and P < 0.0001, respectively), and FIGO stage and the LMR as the strongest prognostic factors predicting OS (P < 0.0001 and P < 0.0001, respectively).

CONCLUSION

The LMR is an independent prognostic factor for both DFS and OS after surgical resection, and it provides additional prognostic value beyond standard clinicopathological parameters.

Significance of monocyte counts on tumor characteristics and survival outcome of women with endometrial cancer

OBJECTIVE

Tumor-associated macrophages are known to be associated with decreased survival of patients with endometrial cancer. Given the physiological link of circulating monocytes as a progenitor of tumor-associated macrophages, monocyte counts were examined for tumor characteristics and survival in endometrial cancer.

METHODS

A retrospective study was conducted to examine consecutive patients with endometrial cancer with all histologic types who underwent hysterectomy-based surgical staging between 2003 and 2013 (n=541). Preoperative monocyte counts were correlated to patient demographics, pathological findings, complete blood count results, and survival outcomes.

RESULTS

Median monocyte counts were 0.5×10(9)/L. Monocyte counts significantly correlated with all other complete blood count components, with neutrophil counts having the most significant association (r=0.52, p<0.001). Elevated monocyte counts (defined as >0.7×10(9)/L) when compared to lower counts were significantly associated with an increased risk of >50% myometrial tumor invasion (29.2% versus 22.0%, odds ratio [OR] 1.59, 95% confidence interval [CI] 1.01-2.45, p=0.045), pelvic lymph node metastasis (39.0% versus 18.8%, OR 2.76, 95%CI 1.35-5.62, p=0.007), and advanced-stage (stage I through IV, 18.5%, 24.6%, 32.5%, and 41.5%, p=0.001). In survival analysis, elevated monocyte counts were associated with decreased disease-free survival (5-year rates, 71.0% versus 84.5%, p=0.001) and overall survival (77.2% versus 89.3%, p<0.001). In multivariate analysis, elevated monocyte counts remained an independent prognostic factor for decreased disease-free (hazard ratio [HR] 1.74, 95% CI 1.02-2.96, p=0.041) and overall (HR 2.63, 95% CI 1.37-5.05, p=0.004) survival.

CONCLUSIONS

Elevated monocyte counts were associated with aggressive tumor features and poor survival outcomes of patients with endometrial cancer.