Lymphocyte counts independently predict overall survival in advanced cancer patients: a biomarker for IL-2 immunotherapy

PNI is useful for predicting the prognosis of patients with soft tissue sarcoma: A retrospective study

BACKGROUND

It is known that preoperative Prognostic Nutritional Index (PNI) is useful in predicting prognosis in gastrointestinal diseases and that preoperative improvement of nutritional status improves prognosis. However, there have been few large-scale reports examining the prognostic value of PNI in soft tissue sarcomas. Therefore, the aim of this study is to investigate whether the PNI can be useful for predicting overall survival in soft tissue sarcoma.

METHODS

Between January 2006 and March 2022 at our hospital, 111 patients with pathologically diagnosed soft tissue sarcoma were included, retrospectively. Several nutritional or inflammatory biomarkers such as PNI were calculated from the pretreatment blood sample results. The patients were classified into two groups (low and high groups) based on the median value of each parameter. Overall survival was analyzed by the Kaplan‒Meier method and log-rank test. Univariate and multivariate analyses using the Cox proportional hazards model were used to investigate prognostic factors for overall survival.

RESULTS

The median overall survival was 24.3 months (mean 37.3 months), and the high PNI group had a significantly longer overall survival than the low PNI group (p < 0.0001). PNI was the most significant univariate factor for overall survival among other nutritional and inflammatory parameters (HR: 5.64, 95% CI: 2.26-14.12, p = 0.0002). The multivariate proportional hazards model was built using variables with prognostic potential as suggested by previous analysis with respect to patient characteristics and PNI. As potential confounding factors, we included PNI, stage, age, and tumor location. PNI was also an independent prognostic factor in multivariate analysis (HR: 7.02, CI: 2.52-19.40, p = 0.0002).

CONCLUSION

PNI is a useful prognostic factor among various parameters for overall survival in patients with soft tissue sarcoma.

Clinical Translation of a Deep Learning Model of Radiation-Induced Lymphopenia for Esophageal Cancer

Purpose

Radiation-induced lymphopenia is a common immune toxicity that adversely impacts treatment outcomes. We report here our approach to translate a deep-learning (DL) model developed to predict severe lymphopenia risk among esophageal cancer into a strategy for incorporating the immune system as an organ-at-risk (iOAR) to mitigate the risk.

Materials and Methods

We conducted "virtual clinical trials" utilizing retrospective data for 10 intensity-modulated radiation therapy (IMRT) and 10 passively-scattered proton therapy (PSPT) esophageal cancer patients. For each patient, additional treatment plans of the modality other than the original were created employing standard-of-care (SOC) dose constraints. Predicted values of absolute lymphocyte count (ALC) nadir for all plans were estimated using a previously-developed DL model. The model also yielded the relative magnitudes of contributions of iOARs dosimetric factors to ALC nadir, which were used to compute iOARs dose-volume constraints, which were incorporated into optimization criteria to produce "IMRT-enhanced" and "intensity-modulated proton therapy (IMPT)-enhanced" plans.

Results

Model-predicted ALC nadir for the original IMRT (IMRT-SOC) and PSPT plans agreed well with actual values. IMPT-SOC showed greater immune sparing vs IMRT and PSPT. The average mean body doses were 13.10 Gy vs 7.62 Gy for IMRT-SOC vs IMPT-SOC for patients treated with IMRT-SOC; and 8.08 Gy vs 6.68 Gy for PSPT vs IMPT-SOC for patients treated with PSPT. For IMRT patients, the average predicted ALC nadir of IMRT-SOC, IMRT-enhanced, IMPT-SOC, and IMPT-enhanced was 281, 327, 351, and 392 cells/µL, respectively. For PSPT patients, the average predicted ALC nadir of PSPT, IMPT-SOC, and IMPT-enhanced was 258, 316, and 350 cells/µL, respectively. Enhanced plans achieved higher predicted ALC nadir, with an average improvement of 40.8 cells/µL (20.6%).

Conclusion

The proposed DL model-guided strategy to incorporate the immune system as iOAR in IMRT and IMPT optimization has the potential for radiation-induced lymphopenia mitigation. A prospective clinical trial is planned.

The relationship of different preoperative inflammatory markers with the prognosis of gastric carcinoma

BACKGROUND

It is aimed to determine the prognostic values of preoperative inflammatory biomarkers in patients undergoing curative surgery for gastric carcinoma and to contribute to the development of prognostic modeling.

OBJECTIVE

To investigate the effect of various different preoperative inflammatory markers on the prognosis of gastric carcinoma.

MATERIAL AND METHOD

The medical data and the mortality status of 91 patients who underwent total or subtotal gastrectomy operation for gastric carcinoma at Mersin City Training and Research Hospital between 2016 and 2020 were retrospectively reviewed from the hospital records and patient files. The patients' demographic characteristics, tumor location, histopathological diagnosis, pathological stage, tumor markers, and preoperative inflammatory and hematological markers were analyzed. Based on these data, tumor stage, metastatic lymph node ratio (MLR), lactate dehydrogenase albumin ratio (LAR), neutrophil-lymphocyte ratio (NLR), and platelet lymphocyte ratio (PLR) were calculated. The relationship between these parameters and postoperative survival was analyzed. Statistical analyses were performed with IBM SPSS for Windows, version 17.0 (IBM Corporation, Armonk, New York, United States).

RESULTS

The correlation analysis of the parameters affecting survival showed that, in addition to an advanced tumor stage, inflammatory parameters like NLR, PLR, and LAR adversely affected survival.

CONCLUSION

Preoperative NLR, PLR, LAR, and advanced tumor stage may help determine the survival of gastric carcinoma patients. Multiple studies with larger series are needed on this subject.

Lymphocyte-to-monocyte ratio after primary surgery is an independent prognostic factor for patients with epithelial ovarian cancer: A propensity score matching analysis

Background

The aim of this study was to elucidate the prognostic value of preoperative lymphocyte-to-monocyte ratio (LMR) after primary surgery in epithelial ovarian cancer (EOC) patients using a propensity score matching (PSM) analysis.

Methods

We retrospectively reviewed consecutive EOC patients who underwent primary surgery between January 2008 and December 2019. Patients were divided into two groups according to the optimal cutoff value of preoperative LMR. PSM (1:1) was conducted to eliminate confounding factors. A Cox proportional hazards model and the Kaplan-Meier estimator were employed to investigate the potential prognostic factors.

Results

A total of 368 EOC patients were included in this study. The optimal cutoff value of LMR was identified as 4.65. Low preoperative LMR was significantly correlated with low albumin, high CA125 level, more blood loss, a high likelihood of ascites, advanced FIGO stage, and poor differentiation (all p < 0.05). After matching, Kaplan-Meier curves showed that the group with LMR < 4.65 experienced significantly shorter OS (p = 0.015). Multivariate Cox analysis revealed that low LMR (HR = 1.49, p = 0.041), advanced FIGO stage (HR = 5.25, p < 0.001), and undefined residual disease (HR = 3.77, p = 0.002) were independent factors in predicting poor OS. A forest plot revealed that LMR had better prognostic value in younger EOC patients, patients with BMI ≥ 25 kg/m² and albumin ≥ 35 g/L, CA125 ≥ 35 U/L, patients who had undergone optimal surgery, and those who had completed chemotherapy. Additionally, low-LMR patients who had undergone incomplete chemotherapy had a shorter median OS compared with those who completed chemotherapy treatment (48.5 vs. 105.9 months, p = 0.026).

Conclusions

LMR could be used as an independent prognostic factor for EOC patients after primary surgery; a noticeable negative effect of LMR was observed among EOC patients with age < 65, good preoperative nutritional status, and more aggressive tumor biology, and among those who underwent optimal surgery. Completing adjuvant chemotherapy is essential to improve survival outcomes among EOC patients with LMR < 4.65 after surgery.

Can Systemic Immune-Inflammation Index Create a New Perspective for the IMDC Scoring System in Patients with Metastatic Renal Cell Carcinoma?

INTRODUCTION

The aim of the study was to evaluate impact of the systemic immune-inflammation index (SII) on prognosis and survival within the International Metastatic Renal Cell Carcinoma Database Consortium (IMDC) score groups.

METHODS

The records of 187 patients with metastatic renal cell carcinoma (RCC) were reviewed retrospectively. The SII was calculated as follows: SII = Neutrophil × Platelet/Lymphocyte. The patients were categorized into 2 groups based on a median SII of 730 (×109 per 1 L) as SII low (<730) and SII high (≥730). The Kaplan-Meier method was used for survival analysis and a Cox regression model was utilized to determine independent predictors of survival.

RESULTS

The median age was 61 years (range: 34-86 years). Kaplan-Meier tests revealed significant differences in survival between the SII-low and SII-high levels (27.0 vs. 12.0 months, respectively, p < 0.001). The Cox regression model revealed that SII was an independent prognostic factor. The implementation of the log-rank test in the IMDC groups according to the SII level provided the distinction of survival in the favorable group (SII low 49.0 months vs. SII high 11.0 months, p < 0.001), in the intermediate group (SII low 26.0 vs. SII high 15.0 months, p = 0.007), and in the poor group (SII low 19.0 vs. SII high 6.0 months, p = 0.019).

CONCLUSION

The SII was an independent prognostic factor and provided significant differences in survival for the favorable, intermediate, and poor IMDC groups. Thus, the SII added to the IMDC score may be clinically beneficial in predicting survival.

Proton therapy reduces the likelihood of high-grade radiation-induced lymphopenia in glioblastoma patients: phase II randomized study of protons vs photons

BACKGROUND

We investigated differences in radiation-induced grade 3+ lymphopenia (G3+L), defined as an absolute lymphocyte count (ALC) nadir of <500 cells/µL, after proton therapy (PT) or X-ray (photon) therapy (XRT) for patients with glioblastoma (GBM).

METHODS

Patients enrolled in a randomized phase II trial received PT (n = 28) or XRT (n = 56) concomitantly with temozolomide. ALC was measured before, weekly during, and within 1 month after radiotherapy. Whole-brain mean dose (WBMD) and brain dose-volume indices were extracted from planned dose distributions. Univariate and multivariate logistic regression analyses were used to identify independent predictive variables. The resulting model was evaluated using receiver operating characteristic (ROC) curve analysis.

RESULTS

Rates of G3+L were lower in men (7/47 [15%]) versus women (19/37 [51%]) (P < 0.001), and for PT (4/28 [14%]) versus XRT (22/56 [39%]) (P = 0.024). G3+L was significantly associated with baseline ALC, WBMD, and brain volumes receiving 5‒40 Gy(relative biological effectiveness [RBE]) or higher (ie, V5 through V40). Stepwise multivariate logistic regression analysis identified being female (odds ratio [OR] 6.2, 95% confidence interval [CI]: 1.95‒22.4, P = 0.003), baseline ALC (OR 0.18, 95% CI: 0.05‒0.51, P = 0.003), and whole-brain V20 (OR 1.07, 95% CI: 1.03‒1.13, P = 0.002) as the strongest predictors. ROC analysis yielded an area under the curve of 0.86 (95% CI: 0.79-0.94) for the final G3+L prediction model.

CONCLUSIONS

Sex, baseline ALC, and whole-brain V20 were the strongest predictors of G3+L for patients with GBM treated with radiation and temozolomide. PT reduced brain volumes receiving low and intermediate doses and, consequently, reduced G3+L.

Perioperative lymphocytopenia predicts mortality and severe complications after intestinal surgery

Background

Patterns of white blood cells differential count with low lymphocyte number have been associated with poor outcome following sepsis, burns and trauma. Lymphocytopenia, measured preoperatively or in response to surgical stress, may affect complications after bowel resection.

Methods

Clinical characteristics and white blood cells differential count values, measured both pre- and post-operatively of a cohort of patients submitted to intestinal resection and anastomosis from June 2014 to June 2017 in our General Surgery Division, were retrospectively analyzed. Multivariate logistic regression was used to determine the dependence of mortality and postoperative complications from the clinical characteristics of patients and white blood cells differential count values.

Results

A total of 301 consecutive patients were studied; 165 (54.8%) were male; mean age was 70 years. Overall, the rate of in-hospital 30-day mortality was 4%. Post-operative morbidity was observed in 124 (41.2%). On multivariate analysis, age adjusted Charlson Comorbidity Index, low preoperatively lymphocyte count, high preoperative monocyte count, high postoperative neutrophil count and anastomotic leak were independently associated with increased in-hospital mortality. Preoperative lymphocytopenia and rectal resection were independently associated with high morbidity rate, while low postoperative lymphocyte count was associated with an increased risk of anastomotic leak.

Conclusions

Perioperative lymphocytopenia is associated with 30-days mortality, severe complications and anastomotic leak after bowel resection surgery. These routinely available laboratory data could help to identify patients at high-risk for developing complications.

External validation of the systemic immune-inflammation index as a prognostic factor in metastatic renal cell carcinoma and its implementation within the international metastatic renal cell carcinoma database consortium model

BACKGROUND

We conducted a study to validate the influence of the systemic immune-inflammation index (SII) on overall survival (OS) in patients with metastatic renal cell carcinoma (mRCC) and to verify whether the implementation of the SII in place of neutrophil and platelet counts within the International Metastatic Renal Cell Carcinoma Consortium (IMDC) model might increase its prognostic accuracy.

PATIENTS AND METHODS

We retrospectively analyzed consecutive patients with mRCC, who were treated with first-line tyrosine kinase inhibitors from 2008 to 2016 in two major oncology centres in Poland. We stratified patients into low SII (< 730) and high SII (≥ 730) groups according to a recent literature report. We used multivariable Cox proportional hazards regressions (CPHRs) to assess the impact of the SII on OS and concordance, global 'goodness-of-fit', calibration and reclassification measures to quantify a potential prognostic benefit from the modification of the IMDC model.

RESULTS

Overall, 502 patients (294 with low and 208 with high SII) were included. Median OS was 36.7 months [95% confidence interval (CI) 30.4-41.5 months] and 17.0 months (95% CI 12.5-19.6 months) in the low and high SII groups, respectively. The SII status was significant in CPHRs with the hazard ratio ranging from 1.38 to 1.68. All prognostic accuracy measures favored the SII-modified-IMDC model over the original IMDC model.

CONCLUSIONS

Using an external dataset, we showed that high SII was an independent factor for poor OS. The addition of the SII to the IMDC model in place of neutrophil and platelet counts increased the model's prognostic performance.

Prognostic roles of neutrophil to lymphocyte ratio and platelet to lymphocyte ratio in ovarian cancer: a meta-analysis of retrospective studies

PURPOSE

The systemic inflammatory response markers have been reported to be associated with the prognosis of various cancers. We conducted this meta-analysis of retrospective studies to evaluate and identify the prognostic impact of neutrophil to lymphocyte ratio (NLR) and platelet to lymphocyte ratio (PLR) on ovarian cancer.

METHODS

PubMed, EMBASE, and China National Knowledge Infrastructure databases were included to search for eligible studies. The following terms were used: "neutrophil to lymphocyte ratio", "NLR", "platelet to lymphocyte ratio", "PLR", "ovarian cancer", "ovary cancer", "ovarian carcinoma", "ovary carcinoma", "ovarian neoplasm", "ovary neoplasm", "ovarian tumor", and "ovary tumor". The random-effects model was chosen to estimate the pooled HR with 95% CI. Heterogeneity between studies was assessed by Higgins I² value. The stability and heterogeneity of studies were analyzed by sensitivity analysis. Publication bias was examined by Egger's test and Begg's test with the funnel plots.

RESULTS

13 studies consisting of 3467 patients were considered for meta-analysis. We found that the high NLR had a poor prognostic impact on OS and PFS in ovarian cancer, with a pooled HR 1.70, 95% CI 1.35-2.15 and HR 1.77, 95% CI 1.48-2.12, respectively. Similarly, the results showed the high PLR adversely affected OS and PFS in ovarian cancer, with a pooled HR 2.05, 95% CI 1.70-2.48 and HR 1.85, 95% CI 1.53-2.25, respectively.

CONCLUSION

In conclusion, we found that both NLR and PLR had an unfavorable impact on PFS and OS of patients with ovarian cancer. Our meta-analysis supported that NLR/PLR could be effective prognostic predictors of ovarian cancer.

Efficacy of Cancer Chemotherapy in Relation to the Pretreatment Number of Lymphocytes in Patients with Metastatic Solid Tumors

The evidence of lymphocytopenia has been demonstrated to predict a poor prognosis in terms of survival in advanced cancer patients. This finding is not surprising because of the fundamental role of lymphocytes in mediating tumor cell destruction. Despite the importance of lymphocytes in the pathogenesis of cancer, there are only few data about the profile and the function of lymphocytes during the various antitumor therapies, and in particular the relation between lymphocyte pretreatment number and response to chemotherapy remains to be established. The present study was performed to evaluate whether the evidence of lymphocytopenia before the onset of treatment may influence the efficacy of chemotherapy in metastatic cancer patients affected by the most frequent tumor types. The study included 183 patients (lung cancer: 89; colorectal cancer: 63; breast cancer: 31), 95 of whom had been previously treated with chemotherapy. The chemotherapeutic regimens consisted of oxaliplatin plus 5-fluorouracil and folates in untreated colorectal cancer, weekly irinotecan in pretreated colorectal cancer, cisplatin plus gemcitabine or etoposide in untreated lung cancer, weekly vinorelbine in pretreated lung cancer, and taxotere in breast cancer patients who had been previously treated with anthracyclines. Lymphocyte count was considered to be abnormally low for values below 1500/mm3. Lymphocytopenia was found in 79/183 (43%) patients, without any significant differences in relation to tumor histology. A complete response (CR) was achieved in 6/104 patients with a normal lymphocyte count and in none of the 79 lymphocytopenic patients. A partial response (PR) was obtained in 39 patients with a normal lymphocyte count and in only eight patients with a low lymphocyte count prior to therapy. Therefore, irrespective of the type of chemotherapy, the objective tumor response rate (CR + PR) in lymphocytopenic patients was significantly lower than in patients with normal pretreatment lymphocyte counts (8/79 vs 45/104; p<0. 001). This study shows that the evidence of lymphocytopenia prior to chemotherapy is associated with a lower efficacy of treatment in terms of objective tumor regression rates in patients with metastatic solid tumors, and suggests that the action of chemotherapy may depend at least in part on an interaction with the antitumor immunity. Pretreatment lymphocyte count may represent a new, simple biological marker to be taken into consideration by oncologists in the chemotherapeutic treatment of metastatic cancer.

Pretreatment Neutrophil-to-Lymphocyte Ratio and Lymphocyte Recovery: Independent Prognostic Factors for Survival in Pediatric Sarcomas

BACKGROUND

Pretreatment neutrophil-to-lymphocyte ratio (NLR) and absolute lymphocyte count (ALC) recovery have been shown to be associated with prognosis in several types of cancer in adults. However, evidence in pediatric cancer is scarce. The aim of our study was to evaluate whether pretreatment NLR and lymphocyte recovery are prognostic factors in pediatric sarcomas.

MATERIALS AND METHODS

Study participants were identified from a retrospective cohort of 100 children with osteosarcoma (n=55), rhabdomyosarcoma (n=22), and Ewing sarcoma (n=23). Data for the hematological variables were obtained from medical records and analyzed with other known prognostic factors in univariate and multivariate analyses.

RESULTS

In multivariate analysis, NLR>2 was an independent prognostic factor for OS in patients with osteosarcoma (hazard ratio [HR], 2.27, 95% confidence interval [CI], 1.07-5.30; P=0.046) along with metastatic disease and poor histologic response; as well as in patients with rhabdomyosarcoma (HR, 4.76, 95% CI, 1.01-22.24; P=0.0237) along with metastatic disease and risk group. ALC recovery correlated for inferior OS in osteosarcoma (HR, 3.34, 95% CI, 1.37-8.12; P=0.008) and rhabdomyosarcoma (HR, 3.89; 95% CI, 1.01-14.89; P=0.0338).

CONCLUSIONS

Our study confirms that NLR and ALC recovery are independent prognostic factors for pediatric sarcomas, implying an important role of immune system in survival. Clinical utility of these prognostic biomarkers should be validated in larger pediatric studies.

Lymphocyte-Sparing Effect of Proton Therapy in Patients with Esophageal Cancer Treated with Definitive Chemoradiation

Purpose

To assess whether radiation treatment modality with proton beam therapy (PBT) or intensity-modulated radiation therapy (IMRT) is associated with lymphopenia in patients treated with definitive chemoradiation for esophageal cancer.

Methods and Materials

Patients with esophageal cancer treated with bimodality therapy (n = 448) between 2004 and 2016 were retrospectively reviewed. Patients treated with PBT were matched by propensity score with those treated with IMRT, based on key patient and disease factors, and stratified by clinical disease stage. Patients who developed early, distant metastatic disease within 1 month of completing radiation were excluded. Univariable and multivariable logistic regression were used to identify variables associated with increased risk of grade 4 lymphopenia. Multivariable Cox proportional hazards regression was used to assess factors associated with overall survival, disease-free survival, and locoregional relapse-free survival.

Results

Patients who had IMRT and PBT matched by propensity score (n = 220) were not different with respect to age, sex, stage, performance status, tumor location, histology, tumor target volume, or induction chemotherapy. Treatment with IMRT, compared with PBT (odds ratio [OR], 2.13; 95% confidence interval [95% CI], 1.19-3.81; P = .01), increased age (OR, 1.039/y increase; 95% CI, 1.003-1.076; P = .03), and greater planning target volume (OR, 3.47 per 1-unit increase in log (planning target volume); 95% CI, 1.67-7.21; P < .001), was associated with increased risk of grade 4 lymphopenia. Radiation modality was associated with lymphocyte reduction in patients with tumors in the lower esophagus (P = .005) but not for those with tumors in the upper or middle esophagus (P = 0.32).

Conclusions

In patients with esophageal cancer treated with definitive chemoradiation, PBT reduces the risk of severe, treatment-related lymphopenia, particularly in tumors of the lower esophagus.

Clinical Significance of Preoperative Neutrophil - to - Lymphocyte Ratio in Renal Cell Carcinoma

Introduction:

We investigated the prognostic significance of the neutrophil-to-lymphocyte ratio on tumor stage and Fuhrman nuclear grade in renal cell carcinoma.

Methods:

The records of 432 patients with RCC who underwent radical or partial nephrectomy between 2005 and 2014 were retrospectively reviewed. Patients were classified as group lower tumor stage(T1 + T2) and higher(T3 + T4). As like tumor stage, Fuhrman nuclear grade were classified lower (G1+G2) and higher(G3+G4) too. The best NLR cut off value was 3.01. Two sample t-test or Mann–Whitney U-test used for the continuous variables and a chi-square test or Fisher's exact test used for the categorical variables.

Results:

Among the 432 total patients analyzed in our study, there were 275 males (63.7%) and 157 females (36.3%). Mean laboratory values were CRP 2.73 ± 1.93 mg/dL (normal less than 0.3), neutrophil count 4,23 ± 1.46/μL, lymphocyte count 1,61 ± 0,61/μL and NLR 2.64 ± 1.24. According to our data, statistically pretreatment NLR significantly correlated with CRP (p<0.0001). And tumor patologic stage (p=0.08), tumor histologic grade (p<0.001) was significantly associated with NLR.

Discussion:

We compared the relationship of preoperative NLR and NC parameters with RCC tumor stage and grade. And NLR were found to have statistically significant higher T stage and grade at RCC. Further studies with more patients are needed to confirm our study.

Incorporating Neutrophil-to-lymphocyte Ratio and Platelet-to-lymphocyte Ratio in Place of Neutrophil Count and Platelet Count Improves Prognostic Accuracy of the International Metastatic Renal Cell Carcinoma Database Consortium Model

PURPOSE

The study investigated whether a replacement of neutrophil count and platelet count by neutrophil-to-lymphocyte ratio (NLR) and platelet-to-lymphocyte ratio (PLR) within the International Metastatic Renal Cell Carcinoma Database Consortium (IMDC) model would improve its prognostic accuracy.

MATERIALS AND METHODS

This retrospective analysis included consecutive patients with metastatic renal cell carcinoma treated with first-line tyrosine kinase inhibitors. The IMDC and modified-IMDC models were compared using: concordance index (CI), bias-corrected concordance index (BCCI), calibration plots, the Grønnesby and Borgan test, Bayesian Information Criterion (BIC), generalized R², Integrated Discrimination Improvement (IDI), and continuous Net Reclassification Index (cNRI) for individual risk factors and the three risk groups.

RESULTS

Three hundred and twenty-one patients were eligible for analyses. The modified-IMDC model with NLR value of 3.6 and PLR value of 157 was selected for comparison with the IMDC model. Both models were well calibrated. All other measures favoured the modified-IMDC model over the IMDC model (CI, 0.706 vs. 0.677; BCCI, 0.699 vs. 0.671; BIC, 2,176.2 vs. 2,190.7; generalized R², 0.238 vs. 0.202; IDI, 0.044; cNRI, 0.279 for individual risk factors; and CI, 0.669 vs. 0.641; BCCI, 0.669 vs. 0.641; BIC, 2,183.2 vs. 2,198.1; generalized R², 0.163 vs. 0.123; IDI, 0.045; cNRI, 0.165 for the three risk groups).

CONCLUSION

Incorporation of NLR and PLR in place of neutrophil count and platelet count improved prognostic accuracy of the IMDC model. These findings require external validation before introducing into clinical practice.

The Prognostic Value of Baseline Lymphocyte, Neutrophil, and Monocyte Counts in Locally Advanced Cervical Carcinoma Treated with Radiation

Background. To determine the prognostic significance of pretreatment levels of circulating lymphocyte (CLC), neutrophil (CNC), and monocyte (CMC) counts in patients with locally advanced cervical carcinoma (CC) treated with definitive radiation. Methods. A retrospective, dual-institution review of patients with Stage IB2-IVA CC from 2005 to 2015. Progression-free (PFS) and Overall Survival (OS) were determined for high and low CLC, CNC, and CMC groups. Multivariate analysis was used to confirm prognostic value of baseline leukocyte counts. Results. 181 patients were included. Median follow-up time was 26 (3–89) months. CNC had no effect on PFS or OS. PFS was similar between CMC groups; however, OS was significantly improved for patients with low CMC (62.5 versus 45.3 months, p = 0.016). High CLC was associated with improved PFS (48.5 versus 27.8 months, p = 0.048) and OS (58.4 versus 34.9 months, p = 0.048). On multivariate analysis, high CNC was associated with increased relapse risk (HR 1.12, p = 0.006) and low CLC was associated with increased mortality risk (HR 0.67, p = 0.027). Conclusion. This study demonstrates that leukocyte values can provide prognostic information in CC. These hypothesis-generating findings warrant further prospective investigations.

Dosimetric Predictors of Treatment-related Lymphopenia induced by Palliative Radiotherapy: Predictive Ability of Dose-volume Parameters based on Body Surface Contour

Background

Radiation-related lymphopenia has been associated with poor patient outcome. Our aim was to identify predictors of lymphopenia after palliative radiotherapy, with a focus on dose-volume parameters.

Patients and methods

To retrospectively assess patients with various cancers who had undergone palliative radiotherapy, we delineated three organs at risk: the volume enclosed by the body surface contour (body A), the volume left after excluding air, pleural effusion, ascites, bile, urine, and intestinal content (body B), and the volume of the bone marrow (BM). We then noted the absolute volume of the three organs at risk that had received 5-30 Gy, and assessed the predictive value for post-treatment lymphopenia of grade 3 or higher (LP3+).

Results

Of 54 patients, 23 (43%) developed LP3+. Univariate logistic regression analysis showed that body A V5, body A V10, body B V5, body B V10, the number of fractions, and splenic irradiation were significant predictors of LP3+ (p < 0.05). By multivariate analysis, body A V5, body A V10, body B V5, body B V10, and the number of fractions retained significance (p < 0.05). BM dose-volume parameters did not predict lymphopenia.

Conclusions

Higher body A and body B dose-volume parameters and a larger number of fractions may be predictors of severe lymphopenia after palliative radiotherapy.

Neutrophil and lymphocyte counts at diagnosis are associated with overall survival of pancreatic cancer: A retrospective cohort study

Neutrophil to lymphocyte ratio (NLR) has been found to be significantly associated with pancreatic cancer (PC) survival. However, no existing studies discussed the association between neutrophil count, lymphocyte count, and PC survival jointly. In this study, we aimed to analyze the influence of neutrophil and lymphocyte counts measured at disease diagnosis on the overall survival (OS) of PC. A total of 288 PC patients diagnosed between January 1, 2012, and December 31, 2013, were retrospectively selected from a population-based electronic inpatients database. Multivariate Cox model and restricted cubic spline (RCS) were used to estimate the associations between neutrophil count, lymphocyte count, and OS of PC. We found that a decreased lymphocyte count at diagnosis was significantly associated with OS of PC: for PC patients whose lymphocyte counts were less than 1.5 × 10/L, the hazard ratio (HR) was 1.82 (95% confidence interval: 1.37-2.40). Although abnormally increased baseline neutrophil count in general was not associated with OS of PC, RCS found a prominently deteriorated survival for PC patients whose baseline neutrophil counts were close to the cutoff point (7.0 × 10/L). Our study results indicate that neutrophil and lymphocyte counts at diagnosis may have prognostic relevance in PC survival, especially lymphocyte count. The clinical significance of neutrophil inhibition and lymphocyte promotion treatments in PC patients should be further discussed.

Pretreatment lymphopenia is an easily detectable predictive and prognostic marker in patients with metastatic esophagus squamous cell carcinoma receiving first-line chemotherapy

To explore the influence of pretreatment lymphopenia on the toxicity and efficacy of first‐line chemotherapy in patients with metastatic esophagus squamous cell carcinoma (ESCC). In total, 215 patients were included in this retrospective study. Correlations between pretreatment lymphopenia (lymphocyte count <1 × 10⁹/L) and the occurrence of toxicity and the efficacy of first‐line palliative chemotherapy were investigated. Pretreatment lymphopenia was found in 19.1% of the patients. The overall response rate (ORR) was 35.5% (65 of 183 patients). Patients with pretreatment lymphopenia had a lower ORR to chemotherapy compared with those without lymphopenia (22.2% vs. 38.8%, respectively; P = 0.045). Furthermore, the patients with pretreatment lymphopenia have higher grade 3–4 hematological toxicity than that of patients without pretreatment lymphopenia (19 of 41 patients, 46.3% vs. 54 of 174 patients, 31.0%; P = 0.048). Pretreatment lymphopenia was not correlated with grade 3–4 nonhematological toxicity. Multivariate analysis showed that pretreatment lymphopenia is an independent prognostic factor. Patients with pretreatment lymphopenia had a significantly shorter overall survival time than those without lymphopenia (8.2 months vs. 12.7 months; P = 0.020). This study shows that pretreatment lymphopenia is a good prognostic factor as well as a predictive factor for tumor response and chemotherapy‐related hematological toxicity in metastatic ESCC.

Lymphopenia and its association with survival in patients with locally advanced cervical cancer

OBJECTIVE

To evaluate the association between lymphopenia and survival in women with cervical cancer treated with primary chemoradiation.

METHODS

A single institution, retrospective analysis of patients with stage IB2-IVA cervical cancer who received upfront chemoradiation from 1998 to 2013 was performed. Complete blood counts from pre-treatment to 36 months post-treatment were analyzed. Lymphopenia and known prognostic factors were evaluated for an association with progression-free (PFS) and overall survival (OS).

RESULTS

Seventy-one patients met study criteria for whom 47 (66%) had a documented total lymphocyte count (TLC) two months after initiating chemoradiation. FIGO stage distribution was 6% Stage I, 46% Stage II, 45% Stage III and 3% Stage IV. Pre-treatment TLC was abnormal (<1000 cells/mm3) in 15% of patients. The mean reduction in TLC was 70% two months after initiating chemoradiation. Severe post-treatment lymphopenia (TLC <500 cells/mm3) was observed in 53% of patients; they experienced inferior median OS (21.2 vs. 45.0 months, P=0.03) and similar 25th percentile PFS (6.3 vs. 7.7 months, P=0.06) compared to patients without severe lymphopenia. Multivariate analysis demonstrated pre-treatment TLC ≥1000 cells/mm3 and post-treatment TLC >500 cells/mm3 had a 77% (HR: 0.23; 95% CI 0.05-1.03; P=0.053) and 58% decrease in hazards of death (HR: 0.42; 95%CI 0.12-1.46; P=0.17) respectively.

CONCLUSION

More than half of cervical cancer patients treated with chemoradiation experienced severe and prolonged lymphopenia. Although statistical significance was not reached, the findings suggest that pre- and post-treatment lymphopenia may be associated with decreased survival. Further research is warranted, given that lymphopenia could be a reversible prognostic factor.

Evaluation of neutrophil-to-lymphocyte ratio prior to prostate biopsy to predict biopsy histology: Results of 1836 patients

INTRODUCTION

We evaluate the role of NLR prior to prostate biopsy to predict biopsy histology and Gleason score in patients with prostate cancer.

METHODS

In this retrospective study, we evaluated data of patients underwent prostate biopsy between May 2005 and March 2015. We collected the following data: age, prostate-specific antigen (PSA), biopsy histology, Gleason score (GS) in prostate cancer patients, neutrophil counts, and lymphocyte counts. Patients were grouped as benign prostatic hyperplasia (BPH), prostate cancer, and prostatitis. The Chi square test was used to compare categorical variables and analysis of variance (ANOVA) was applied for continuous variables.

RESULTS

Data of 1836 patients were investigated. The mean age, total PSA and neutrophil-lymphocyte ratio (NLR) of the population were 66.8 ± 8.17 years, 9.38 ± 4.7 ng/dL, and 3.11 ± 1.71, respectively. Patients were divided as follows: 625 in the group with BPH history, 600 in the prostatitis group, and 611 in the prostate cancer histology group. The mean NLR of the prostatitis group was higher compared to the prostate cancer and BPH groups (p = 0.0001). The mean NLR of the prostate cancer group was significantly higher compared to the BPH group (p = 0.002). The GS 8-10 group had a significantly higher mean NLR compared to GS 5-6 (3.64 vs. 2.54, p = 0.0001) and GS 7 (3.64 vs. 2.58, p = 0.0001) patients.

CONCLUSIONS

NLR was found to differ with regard to histology of prostate biopsy and higher GS was associated with higher NLR in patients with prostate cancer. However prostatitis prevents the use of NLR in predicting prostate cancer before a prostate biopsy. Also, the retrospective nature and lack of multivariate analysis in this study somewhat limits the relevance of these results.

The Association Between Chemoradiation-related Lymphopenia and Clinical Outcomes in Patients With Locally Advanced Pancreatic Adenocarcinoma

OBJECTIVES

Lymphopenia is a common consequence of chemoradiation therapy yet is seldom addressed clinically. This study was conducted to determine if patients with locally advanced pancreatic cancer (LAPC) treated with definitive chemoradiation develop significant lymphopenia and if this affects clinical outcomes.

METHODS

A retrospective analysis of patients with LAPC treated with chemoradiation at a single institution from 1997 to 2011 was performed. Total lymphocyte counts (TLCs) were recorded at baseline and then monthly during and after chemoradiation. The correlation between treatment-induced lymphopenia, established prognostic factors, and overall survival was analyzed using univariate Cox regression analysis. Important factors identified by univariate analysis were selected as covariates to construct a multivariate proportional hazards model for survival.

RESULTS

A total of 101 patients met eligibility criteria. TLCs were normal in 86% before chemoradiation. The mean reduction in TLC per patient was 50.6% (SD, 40.6%) 2 months after starting chemoradiation (P<0.00001), and 46% had TLC<500 cells/mm. Patients with TLC<500 cells/mm 2 months after starting chemoradiation had inferior median survival (8.7 vs. 13.3 mo, P=0.03) and PFS (4.9 vs. 9.0 mo, P=0.15). Multivariate analysis revealed TLC<500 cells/mm to be an independent predictor of inferior survival (HR=2.879, P=0.001) along with baseline serum albumin (HR=3.584, P=0.0002), BUN (HR=1.060, P=0.02), platelet count (HR=1.004, P=0.005), and radiation planning target volume (HR=1.003, P=0.0006).

CONCLUSIONS

Severe treatment-related lymphopenia occurs frequently after chemoradiation for LAPC and is an independent predictor of inferior survival.

Elevated lymphocyte count at time of acute myeloid leukemia diagnosis is associated with shorter remission

In solid tumors, decreased absolute lymphocyte count (ALC) at diagnosis was found to be associated with poorer outcome, but there is only limited data on the impact of ALC in acute myeloid leukemia (AML). In this study we evaluated the prognostic value of ALC on outcome in 259 adult patients with AML who responded to induction therapy. Higher than normal ALC at diagnosis was associated with shorter remission (HR 4.06; p < 0.001), and decreased relapse free and overall survival (HR 3.47; p < 0.001 and HR 3.85; p < 0.001 respectively). Flow cytometry showed low frequency of natural killer (NK) cells and high frequency of CD4+ T cells (which includes the subset of T regulatory cells) in the high ALC group. Low frequency of NK cells and potentially high frequency of inhibitory T regulatory cells may result in weaker immune responses against residual leukemia and may explain the poorer outcome of the high ALC group.

An interferon signature identified by RNA-sequencing of mammary tissues varies across the estrous cycle and is predictive of metastasis-free survival

The concept that a breast cancer patient's menstrual stage at the time of tumor surgery influences risk of metastases remains controversial. The scarcity of comprehensive molecular studies of menstrual stage-dependent fluctuations in the breast provides little insight. To gain a deeper understanding of the biological changes in mammary tissue and blood during the menstrual cycle and to determine the influence of environmental exposures, such as low-dose ionizing radiation (LDIR), we used the mouse to characterize estrous-cycle variations in mammary gene transcripts by RNA-sequencing, peripheral white blood cell (WBC) counts and plasma cytokine levels. We identified an estrous-variable and hormone-dependent gene cluster enriched for Type-1 interferon genes. Cox regression identified a 117-gene signature of interferon-associated genes, which correlated with lower frequencies of metastasis in breast cancer patients. LDIR (10cGy) exposure had no detectable effect on mammary transcripts. However, peripheral WBC counts varied across the estrous cycle and LDIR exposure reduced lymphocyte counts and cytokine levels in tumor-susceptible mice. Our finding of variations in mammary Type-1 interferon and immune functions across the estrous cycle provides a mechanism by which timing of breast tumor surgery during the menstrual cycle may have clinical relevance to a patient's risk for distant metastases.

The preoperative lymphocyte to monocyte ratio predicts clinical outcomes in patients with stage II/III gastric cancer

Recently, lymphocyte to monocyte ratio (LMR) has been reported to be associated with clinical outcomes in some types of cancer but has not been explored in gastric cancer. In this study, we analyzed the association between LMR and clinical outcomes in stage II/III gastric cancer patients. Preoperative LMR calculated from peripheral lymphocyte and monocyte with corresponding clinical features from 426 stage II/III gastric cancer patients was noted. Kaplan-Meier method and Cox regression model were applied for overall survival (OS) and recurrence-free survival (RFS). Related with smaller tumor size (p<0.001), increased LMR could predict better OS [hazard ratio (HR), 0.688; 95% confidence interval (CI), 0.521-0.908, p=0.008] and was borderline significantly associated with better RFS (HR, 0.775; 95% CI, 0.592-1.01, p=0.06) in stage II/III gastric cancer patients through multivariable analysis. Subgroup analyses revealed that except stage III patients for RFS which yielded borderline significance (p=0.052), lower LMR was associated with poor clinical outcomes for patients regardless of different stages or whether the patients received adjuvant chemotherapy. The elevated preoperative LMR level was a significant favorable factor in the prognosis of stage II/III gastric cancer patients, especially for those with stage II. However, further validation of our findings is warranted.

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

OBJECTIVES

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

METHODS AND MATERIALS

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

RESULTS

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

CONCLUSIONS

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

Maintenance biotherapy with interleukin-2 and interferon for metastatic renal cell cancer

The term maintenance immunotherapy comprises at least two different therapeutic approaches: the continuation of immunotherapy beyond disease progression and the use of chronic immunotherapy after the achievement of an initial response (or disease stabilization) with more intensive treatment modalities, such as chemotherapy. The former therapeutic approach was proposed in renal cell carcinoma some years ago relying on several immunological considerations. Some years later, we have learned that it is feasible and endowed with a favorable therapeutic index; furthermore, its immunologic effects are well described and reproducible, and it has antitumor activity. However, due to the lack of adequate randomized Phase III studies, the actual impact of this treatment strategy on patient survival has not yet been proved. The rationale of this treatment, its immunological and clinical results, as well as its pitfalls and perspectives, will be presented and discussed in this review.

Emphasis of neutrophil-to-lymphocyte ratio in non-metastatic renal cell carcinoma

INTRODUCTION

We investigated the prognostic significance of the neutrophil-to-lymphocyte ratio on overall survival and tumor stage in non-metastatic renal cell carcinoma.

METHODS

The records of 229 patients with non-metastatic RCC (T1-4N0M0) were retrospectively reviewed. Patients were classified as group 1 (T1 + T2) and group 2 (T3 + T4). The significance of the differences between the groups in terms of averages and median values were investigated with Student's t-test and Mann-Whitney U test, respectively.

RESULTS

Patients were divided in two as group 1 (T1 + T2) and group 2 (T3 + T4), consisting of 208 and 21 patients, respectively. Between the two groups, the neutrophil-to-lymphocyte ratio (NLR) was found as 2.83 ± 2.15 and 4.79 ± 4.65, respectively (p = 0.02). We found that NLR had a distinctive feature at a cut-off value of 2.9.

DISCUSSION

NLR was higher in local advanced tumors. We observed that the cut-off value of NLR is only associated with tumor volume.

Lymphopenia is an independent predictor of inferior outcome in clear cell renal carcinoma

PURPOSE

A low absolute lymphocyte count is a likely index of poor systemic immunity that may be associated with aggressive features and inferior survival in patients with clear cell renal cell carcinoma.

MATERIALS AND METHODS

To determine the absolute lymphocyte count we retrospectively analyzed the preoperative blood count of 430 patients with a mean age of 60 years treated with primary surgical resection at our cancer center. Absolute lymphocyte count values as a continuous variable and at a level below 1,300 cells per μl, which was our lowest reference value, were correlated with nuclear grade, pathological stage and TNM stage. We used the Kaplan-Meier method to estimate overall survival, stratified by absolute lymphocyte count status.

RESULTS

As a continuous variable, low absolute lymphocyte count was associated with higher grade (p = 0.009), and higher pT stage (p = 0.034) and TNM stage (p <0.0001). Lymphopenia below 1,300 cells per μl was associated with high grade (p = 0.0043), pT stage (p = 0.051) and TNM stage (p <0.0001). At a median followup of 33.5 months lymphopenia was associated with inferior overall survival in a univariate model (p <0.0001), and on multivariate analysis independent of pT, N and M stages, patient age, grade, smoking history and comorbidities (p = 0.0102). Lymphopenia was also associated with inferior overall survival in a subset of young patients (age 60 years or less) with no distant metastasis (p = 0.014).

CONCLUSIONS

In 430 patients with clear cell renal cell carcinoma lymphopenia was associated with lower overall survival independent of pT and TNM stages, nuclear grade, age, tobacco smoking and comorbidity index.

Absolute lymphocyte count is associated with survival in ovarian cancer independent of tumor-infiltrating lymphocytes

BACKGROUND

The immune system strongly influences outcome in patients with ovarian cancer. In particular, the absolute lymphocyte count in peripheral blood (ALC) and the presence of tumor-infiltrating lymphocytes (TIL) have each been associated with favourable prognosis. However, the mechanistic relationships between ALC, TIL and prognosis are poorly understood. We hypothesized that high ALC values might be associated with stronger tumor immunity as manifested by increased TIL, decreased tumor burden and longer survival.

METHODS

ALC values were collected from patient records ≥ 2 years before, during or after primary treatment for high-grade serous ovarian cancer (HGSC). Lymphocyte subsets were assessed in peripheral blood by flow cytometry. CD8+ and CD20+ TIL were assessed by immunohistochemistry.

RESULTS

Overall, patients had normal ALC values two or more years prior to diagnosis of HGSC. These values were not predictive of disease severity or survival upon subsequent development of HGSC. Rather, ALC declined upon development of HGSC in proportion to disease burden. This decline involved all lymphocyte subsets. ALC increased following surgery, remained stable during chemotherapy, but rarely recovered to pre-diagnostic levels. ALC values recorded at diagnosis did not correlate with CD8+ or CD20+ TIL but were associated with progression-free survival.

CONCLUSIONS

Patients with high intrinsic ALC values show no clinical or survival advantage upon subsequent development of HGSC. ALC values at diagnosis are prognostic due to an association with disease burden rather than TIL. Therapeutic enhancement of ALC may be necessary but not sufficient to improve survival in HGSC.

Changes in Lymphocyte Count Induced by Repeated Cycles with Low-Dose Interleukin-2 and Interferon-α in 146 Patients with Renal Cell Carcinoma

Aims and Background

The exact mechanism by which recombinant interleukine-2 and interferon-a modulate the immunological response, inducing long-term responses in metastatic renal cell carcinoma, is still not clear. The aim of the study was to analyze the modifications in peripheral blood lymphocytes during cycles of low-dose immunotherapy as a marker of the biological response to the treatment in 146 patients with renal cell carcinoma (advanced and localized disease).

Methods and Study Design

Peripheral blood lymphocytes were evaluated before and after every cycle of treatment.

Results

We found a statistically significant overall difference between pre- and post-cycle values (mean increase of 39%). The differences between pre- and post-cycle lymphocyte counts for each cycle were significant. Also, the post-cycle lymphocyte count of each cycle remained higher than the baseline value. Furthermore, pre-cycle lymphocyte counts of each cycle were still higher than the baseline value, with no difference between a pre-cycle lymphocyte mean value and the other one (except that between the first and second cycle). From the end of each cycle, but before starting the next one, the absolute value of lymphocytes fell on the average by 15–30%, concurring with the fact that, even starting from pre-cycle values higher than baseline, the immune system remains sensitive to chronically repeated stimulation by immunotherapy. We also found that non-metastatic patients had a higher number of peripheral blood lymphocytes than metastatic patients, whereas the latter had a lower immune response to therapy.

Conclusions

The results support the idea that “maintenance” immunotherapy may not develop resistance over time in terms of biological response and thus may have a role as chronic therapy in combination with other drugs such as target therapy. We suppose that the immune system of patients with metastases is in a state of relative impairment, resulting in less sensitivity to immunostimulating agents.

The significant immunological characteristics of peripheral blood neutrophil-to-lymphocyte ratio and Fas ligand expression incidence in nephrectomized tumor in late recurrence from renal cell carcinoma

OBJECTIVE

In order to characterize the significance of immune system function in patients with advanced renal cell carcinoma (RCC), we investigated the interactive relationships among the following parameters: metastatic characteristics, expression of Fas ligand (FasL) in nephrectomized specimens, immunological parameters, and patient's prognosis.

MATERIALS AND METHODS

Thirty-five patients with advanced RCC were stratified into 3 groups according to the characteristics of metastasis timing, at first presentation (mFP), within 5 years of nephrectomy (early-recurrence), after 5 years (late-recurrence). Immunological parameters [hemoglobin, lymphocyte count, neutrophil/lymphocyte ratio (NLR), serum albumin, Eastern Cooperative Oncology Group (ECOG) performance status (PS), and Charlson Comorbidity Index], FasL expression in RCC, and patient prognosis from occurrence of metastasis were compared among the groups. Thirty-five patients were also stratified into 2 groups according to FasL positivity and individual parameters. Patient's prognosis and the remaining immunological parameters were compared between groups.

RESULTS

The NLRs of the late-recurrence group were significantly lower than those of the mFP (P = 0.0004) and early-recurrence (P = 0.013) groups. The FasL mRNA positivity of the late-recurrence group was significantly lower than those of the mFP (P = 0.001) and early-recurrence (P = 0.0277) groups. The prognosis of the late-recurrence group was significantly better than that of the early-recurrence group (P = 0.0255). NLRs were significantly lower in the FasL-negative group than in the -positive group (P = 0.0182). The cause-specific survival rates of the ECOG PS 0 group were significantly higher than that of the ECOG PS > 0 group (P < 0.0001).

CONCLUSIONS

Our results suggest the associations of the prognosis in advanced RCC with peripheral blood NLR and FasL expression in nephrectomized tumor. The characteristics of lower values of NLR and FasL expression positivity in late-recurrence compared with other metastatic timings suggest strong host immune activity, and may imply relatively long survival. On the other hand, elucidation of the patient's general condition obtained not only by chemical data but also by ECOG PS is crucial in the management of patients with advanced RCC.

Preoperative platelet lymphocyte ratio as an independent prognostic marker in ovarian cancer

INTRODUCTION

Ovarian cancer is associated with high mortality due to presentation at advanced stage and high recurrence following treatment with chemotherapy. Most of the prognostic variables in ovarian cancer, including stage and residual disease, are amenable for assessment only after surgery. Currently there are no established preoperative markers including, CA-125, that can predict overall survival in patients with ovarian cancer. The aim of our study was to evaluate the prognostic significance of the preoperative haematological markers platelet lymphocyte ratio (PLR) and neutrophil lymphocyte ratio (NLR) in patients with ovarian cancer.

METHOD

Preoperative PLR and NLR were evaluated in 235 patients undergoing surgery for ovarian cancer. The prognostic significance of both markers was then determined by both uni- and multivariate analytical methods.

RESULTS

High preoperative PLR (p < 0.001) and NLR (p = 0.001) were significantly associated with poor survival using univariate Cox survival analysis. The median overall survival in patients with a PLR of < 300 was 37.4 months (95% CI 26.1-48.7) and 14.5 months (95% CI 11.7-17.2) in those with a PLR of > 300. PLR (p = 0.03) but not NLR (p = 0.575) retained its significance as a prognostic marker on multivariate Cox's regression analysis, along with stage (p < 0.001) and residual disease (p = 0.015).

CONCLUSION

We have shown for the first time that PLR is a novel independent prognostic marker in patients with ovarian cancer.

The association of pre-treatment neutrophil to lymphocyte ratio with response rate, progression free survival and overall survival of patients treated with sunitinib for metastatic renal cell carcinoma

BACKGROUND

Sunitinib is a standard treatment for metastatic renal cell carcinoma (mRCC). The neutrophil to lymphocyte ratio (NLR), an index of systemic inflammation, is associated with outcome in several cancer types.

AIMS

To study the association of pre-treatment neutrophil to lymphocyte ratio with response rate, progression free survival (PFS) and overall survival (OS) of patients treated with sunitinib for mRCC.

METHODS

We retrospectively studied an unselected cohort of patients with mRCC, who were treated with sunitinib. Logistic regression model was used to analyse response rate. Cox regression models were fitted to identify risk factors associated with PFS and OS. We investigated how pre-treatment NLR is associated with these clinical outcomes after adjusting for confounding covariates. Regression tree for censored data method was used to find the best NLR cut-off value.

RESULTS

Between 2004 and 2011, 133 patients with mRCC were treated with sunitinib. One hundred and nine were included in the NLR analysis, from which were excluded patients without available data on pre-treatment NLR or with comorbidities/recent treatments known to be associated with a change of blood counts. Factors associated with PFS were low NLR ≤ 3 (HR = 0.285, p < 0.001), past nephrectomy (HR = 0.38, p = 0.035), sunitinib dose reduction/treatment interruption (HR = 0.6, p = 0.014) and the use of antiotensin system inhibitors (HR = 0.537, p = 0.008). Low NLR ≤ 3 was associated with OS (HR = 0.3, p = 0.043).

CONCLUSIONS

In patients with mRCC treated with sunitinib, pre-treatment NLR may be associated with PFS and OS. This should be investigated prospectively, and if validated applied in clinical practice and clinical trials.

Combined immunotherapy with low-dose IL-2 plus IFN-alpha for metastatic renal cell carcinoma: survival benefit for selected patients with lung metastasis and serum sodium level

OBJECTIVE

To clarify the survival benefit of immunotherapy for renal cell carcinoma patients with lung metastasis using low-dose interleukin-2 plus interferon-α, we examined survival outcomes and factors associated with prognosis.

METHODS

This was a multicenter prospective study. Nephrectomized renal cell carcinoma patients with lung metastasis were treated with interleukin-2 (0.7 × 10(6) unit, 5 days a week) and interferon-α (6 × 10(6) IU, 3 days a week) for the first 8 weeks, and then with both interleukin-2 and interferon-α, 2 or 3 days a week for 16 additional weeks.

RESULTS

Median follow-up period for 42 patients was 28.3 months (range: 4.2-43.8). Two-year overall survival rate was 82% and the probability of 3 year survival rate was 71%. Median progression-free survival was 10.4 months. While no difference was found in survival among patients assessed as complete response, partial response and no change, survival of patients assessed as NC or better was significantly better than those assessed as progressive disease (P < 0.0001). Furthermore, multivariate analyses identified pre-treatment serum sodium (P = 0.004) as an independent prognostic factor. The sodium level was also statistically associated with tumor response (p = 0.035). Patients with normal sodium level survived significantly longer (P = 0.0005) than those with low sodium level showing median survival of 12.2 months.

CONCLUSIONS

Combination immunotherapy with low-dose interleukin-2 plus interferon-α showed survival benefit for patients with lung metastasis whose tumor responded as no change or better. This combination immunotherapy could be beneficial for patients selected by metastatic organ and their pre-treatment serum sodium level.

The high-dose aldesleukin (IL-2) "select" trial: a trial designed to prospectively validate predictive models of response to high-dose IL-2 treatment in patients with metastatic renal cell carcinoma

For patients with metastatic renal cell carcinoma (RCC), the prognosis is poor. Despite the recent approval of drugs such as sorafenib, sunitinib, and temsirolimus, durable remissions of metastatic disease are rare. This is largely due to the fact that these drugs, while effective, do not result in the eradication of disease. In 1992, the FDA approved the use of high-dose interleukin-2 (IL-2) for the treatment of patients with metastatic RCC because of a small number of patients that achieved durable responses. However, IL-2 has not become a mainstay of treatment because of the expense and toxicity associated with this therapy. This review article discusses a phase II trial that investigates predictive biomarkers that might help clinicians identify the patient population with metastatic RCC that would benefit from IL-2 therapy and therefore limit patients who receive this toxic therapy to those most likely to benefit.

The effect of peripheral blood values on prognosis of patients with locally advanced gastric cancer before treatment

We aimed to investigate the prognostic significance of neutrophil, lymphocyte, platelet, mean platelet value (MPV), platelet-lymphocyte ratio (PLR) and neutrophil-lymphocyte ratio (NLR) in patients with locally advanced gastric cancer (LAGC). One hundred sixty-eight patients with LAGC who had been followed-up between 2004 and 2008 were included in present study. The results of hematological (platelet, lymphocyte, neutrophil and MPV) and biochemical (uric acid and LDH) parameters were evaluated before treatment. NLR was divided into two groups as <2.56 and ≥2.57 and PLR was also divided into two groups as ≤160 and >160. Platelet counts and lymphocyte counts were also divided into two groups; ≤300.000/mm3 and >300.000/mm3, and <1,500/mm3 and ≥1,500/mm3, respectively. Results were evaluated with Kaplan-Meier and Long-rank tests. The mean age of patients at diagnosis was 60.1±12.1 and 114 of patients (67.8%) were male. For 168 patients, 48 months overall survival (OS) rate was 45.2% and the median OS was 39 months (range 33-44). In patients whose PLR was less than 160 (n=54), the median OS was 45 months (range 38-52) and also for cases whose PRL was greater than 160 (n=114), the median OS was 27 months (range 22-32) (p=0.006). While for fifty patients whose lymphocyte counts were less than 1,500, the median OS was 27 months (range 21-33), in cases with high lymphocyte counts (≥1,500) (n=118), it was 41 months (range 35-48) (p=0.03). The median OS was 41 (range 34-48) and 30 (range 23-37) months in two platelets groups, respectively (p=0.24). However, in the patients whose NLR was less than 2.56 (n=107), median OS was better than with cases whose NLR was greater than or equal to 2.56 (42 vs. 27 months). Routine peripheral blood counts may be useful prognostic factor for evaluating the accuracy of risk stratification in patients with radically resected gastric cancer Our results need to be confirmed by study including larger sample size in future.

Clinical Deterioration in Community Acquired Infections Associated with Lymphocyte Upsurge in Immunocompetent Hosts

Clinical deterioration during the course of community-acquired infections can occur as a result of an exaggerated immune response of the host towards the inciting pathogens, leading to immune-mediated tissue damage. Whether a surge in the peripheral lymphocyte count can be used as a surrogate marker indicating the onset of immunopathological tissue damage is not known. In this study, we report the clinical presentations and outcomes of a cohort of immunocompetent patients with non-tuberculous community acquired infections who experienced clinical deterioration during hospital stay (n=85). 12 (14.1%) patients had a surge in lymphocyte count preceding their clinical deteriorations, and their diagnoses included viral pneumonitis , viral encephalitis , scrub typhus , leptospirosis , brucellosis , and dengue haemorrhagic fever . The clinical manifestations during deterioration ranged from interstitial pneumonitis , airway obstruction , CNS disturbances , and systemic capillary leak syndrome , all of which were thought to represent immunopathological tissue damages. When compared with patients without lymphocyte surge, these patients were more likely to be infected with fastidious/viral pathogens (0 vs 12; p<0.05), in addition to having lower mean baseline lymphocyte counts (403+/-181 vs 1143+/-686 cells/microl; p<0.05). We postulate that the peripheral lymphocyte count may be a useful surrogate marker indicating the presence of immunopathological damage during clinical deterioration in certain infectious diseases.

Prognostic factors for survival in metastatic renal cell carcinoma: update 2008

A variety of prognostic factor models to predict survival in patients with metastatic renal cell carcinoma have been developed. Diverse populations of patients with variable treatments have been used for these analyses. A variety of clinical, pathologic, and molecular factors have been studied, but current models use predominantly easily obtained clinical factors. These approaches are reviewed, and current approaches to further refine and develop these techniques are reviewed.

The application of high-dose interleukin-2 for metastatic renal cell carcinoma

Renal cell carcinoma (RCC) evokes an immune response, which has occasionally resulted in spontaneous and dramatic remissions [1-3]. In an attempt to reproduce or accentuate this response, various immunotherapeutic strategies have been studied. The most consistent anti-tumor activity has been reported with interferon alfa (IFN-alpha) and interleukin 2 (IL-2). In recent years, randomized trials have suggested that high-dose intravenous bolus IL-2 is superior in terms of response rate and possibly response quality to regimens that involve either low-dose IL-2 and IFN-alpha, intermediate- or low-dose IL-2 alone, or low-dose IFN-alpha alone. As this list of effective therapies for RCC grows, improvements in patient selection will be necessary to ensure that the only therapy capable of producing durable remissions will remain available to the patients who should receive it [4-7].

Pre-treatment neutrophil to lymphocyte ratio is elevated in epithelial ovarian cancer and predicts survival after treatment

PURPOSE

Inflammatory cells can both suppress and stimulate tumor growth, and the influence of inflammatory cells on clinical outcome has been the focus of many studies. The purpose of this study was to evaluate the effectiveness of the neutrophil to lymphocyte ratio (NLR), a measure of the systemic inflammatory response, as an additional discriminative biomarker in epithelial ovarian cancer and to determine whether it predicts survival and recurrence.

METHODS

We studied 192 patients with epithelial ovarian cancer, 173 with benign ovarian tumors, 229 with benign gynecologic disease, and 405 healthy controls. Serum CA125 levels and leukocyte counts according to subtypes were recorded prior to treatment in all study subjects. In epithelial ovarian cancer, the diagnostic usefulness of NLR, in combination with CA125, was evaluated. The correlation between NLR and overall and disease-free survival was analyzed using both univariate and multivariate analyses adjusting for the known prognostic factors (age, stage, cell type, and grade).

RESULTS

Preoperative NLR in ovarian cancer subjects (mean 6.02) was significantly higher than that in benign ovarian tumor subjects (mean 2.57), benign gynecologic disease subjects (mean 2.55), and healthy controls (mean 1.98) (P < 0.001). The sensitivity and specificity of NLR in detecting ovarian cancer was 66.1% (95% CI, 59.52-72.68%) and 82.7% (95% CI, 79.02-86.38%), respectively (cutoff value: 2.60). In early stage ovarian cancer, CA125 was not elevated in 19 out of 49 patients. Seven (36.8%) of these 19 patients were NLR positive. On Cox multivariate analysis, NLR positive, stage III/IV, and older age were independent poor prognostic factors, and being NLR positive was the most powerful predictive variable (Hazard Ratio = 8.42 [95% CI: 1.09-64.84], P = 0.041).

CONCLUSIONS

Our findings provide evidence for the association between NLR and epithelial ovarian cancer. Preoperative NLR, in combination with CA125, may represent a simple and cost-effective method of identifying ovarian cancers, and an elevated NLR may predict an adverse outcome in ovarian cancer.

Prospective study of the relationship between the systemic inflammatory response, prognostic scoring systems and relapse-free and cancer-specific survival in patients undergoing potentially curative resection for renal cancer

OBJECTIVE

To examine the prognostic value of markers of systemic inflammatory response, together with established scoring systems, in predicting relapse-free and cancer-specific survival in patients with primary operable renal cancer, as there is increasing evidence that such markers provide prognostic information, in addition to scoring systems, in patients with metastatic renal cancer.

PATIENTS AND METHODS

In all, 83 patients undergoing potentially curative nephrectomy for localized renal cancer were recruited. The University of California Los Angeles Integrated Staging System (UISS), 'Stage Size Grade Necrosis' (SSIGN) and Kattan scores were constructed. The systemic inflammatory response was assessed by counting white cells, neutrophils, lymphocytes and platelets, and measuring albumin and C-reactive protein (CRP) concentrations.

RESULTS

On multivariate analysis of the significant individual covariates, T stage (hazard ratio 2.38, 95% confidence interval 1.06- 5.36, P = 0.037), necrosis (3.73, 1.26-11.05, P = 0.018) and CRP (4.31, 1.20-15.49, P = 0.025) were significant independent predictors of relapse-free survival. On multivariate analysis of significant scoring systems and CRP, only UISS (3.50, 1.66-7.40, P = 0.001), SSIGN (2.83, 1.19-6.72, P = 0.018) and CRP (4.14, 1.16-14.73, P = 0.028) were significant independent predictors of relapse-free survival.

CONCLUSION

Elevated circulating CRP levels appear to be better than other markers of the systemic inflammatory response, and independent of established scoring systems, in predicting relapse-free and cancer-specific survival in patients undergoing potentially curative nephrectomy for renal cancer.