Elevated Preoperative Neutrophil-Lymphocyte Ratio Is Associated with Poor Prognosis in Hepatocellular Carcinoma Patients Treated with Liver Transplantation: A Meta-Analysis. Gastroenterol Res Pract. 2016;2016:4743808. [PMID: 26843858 PMCID: PMC4710922 DOI: 10.1155/2016/4743808]

Diagnostic and prognostic relevance of inflammatory markers in surgically treated thymic epithelial tumors: An international multicenter study

BACKGROUND

Complementary prognostic markers are needed in thymic epithelial tumors (TETs) to aid patient stratification and determine the most appropriate follow-up strategies. This study aimed to assess the diagnostic and prognostic relevance of blood-based inflammatory markers in a large cohort of surgically treated TET patients.

MATERIAL AND METHODS

A total of 743 TET patients who underwent surgical resection between 1999-2021 were included in this multicenter study. Inflammatory markers were recorded from the most recent preoperative blood cell count prior to surgery. Measured variables were rescaled and harmonized to obtain comparable values across the participating centers.

RESULTS

Preoperative CRP was significantly higher in TET patients with increased tumor size (vs. those with T1 tumors, p = 0.035). Likewise, neutrophil-to-lymphocyte ratio (NLR) (p = 0.002) and platelet-to-lymphocyte ratio (PLR) (p < 0.001) were both significantly higher in thymic carcinomas than in thymomas. Notably, increased NLR and PLR were mainly attributed to significantly decreased lymphocyte levels in thymic carcinoma patients. Concerning survival outcomes, we found that elevated PLR and fibrinogen influenced overall survival (OS) (p = 0.002 and p = 0.018, respectively) and cause-specific survival (CSS) (p = 0.002 and p = 0.009, respectively) independently of other variables in our multivariate models, and they constituted negative prognosticators in TETs. Elevated CRP had an independent negative impact only on OS. Although elevated NLR was linked with impaired prognosis in our univariate model (p = 0.008), its independent prognostic significance could not be validated.

CONCLUSIONS

Using the so-far largest cohort of surgically treated TET patients, our study demonstrates that CRP, PLR, and NLR have diagnostic significance in TETs, while elevated PLR and fibrinogen constitute independent negative prognosticators for OS and CSS. Accordingly, the current multicenter study offers additional guidance in developing personalized surveillance protocols in thymoma and thymic carcinoma.

Associations between peripheral whole blood cell counts derived indexes and cancer prognosis: An umbrella review of meta-analyses of cohort studies

Meta-analyses have reported conflicting data on the whole blood cell count (WBCC) derived indexes (neutrophil-to-lymphocyte ratio [NLR], platelet-to-lymphocyte ratio [PLR], and lymphocyte-to-monocyte ratio [LMR]) and cancer prognosis. However, the strength and quality of this evidence has not been quantified in aggregate. To grade the evidence from published meta-analyses of cohort studies that investigated the associations between NLR, PLR, and LMR and cancer prognosis. A total of 694 associations from 224 articles were included. And 219 (97.8%) articles rated as moderate-to-high quality according to AMSTAR. There were four associations supported by convincing evidence. Meanwhile, 165 and 164 associations were supported by highly suggestive and suggestive evidence, respectively. In this umbrella review, we summarized the existing evidence on the WBCC-derived indexes and cancer prognosis. Due to the direction of effect sizes is not completely consistent between studies, further research is needed to assess causality and provide firm evidence.

Subcutaneous adipose tissue/neutrophil-to-lymphocyte ratio is a potential biomarker in patients with hepatocellular carcinoma undergoing liver resection

OBJECTIVE

Both subcutaneous adipose tissue (SAT) and neutrophil-to-lymphocyte ratio (NLR) are associated with the prognosis of hepatocellular carcinoma (HCC). Subcutaneous adipose tissue is an immunonutritional indicator, and NLR reflects the inflammatory status. The purpose of this study was to ascertain the validity of SAT/NLR as potential prognostic biomarkers in HCC patients who are undergoing liver resection.

METHODS

This retrospective study encompassed the sequential enrollment of 682 patients diagnosed with HCC who underwent liver resection. The patients were categorized into high and low SAT/NLR groups using the median value, and forward stepwise logistic regression was utilized to ascertain independent predictors for one-year HCC recurrence. In order to minimize the influence of confounding variables, a propensity score matching (PSM) analysis was conducted between patients in high and low SAT/NLR groups. The Kaplan-Meier method was employed to assess and compare the recurrence-free survival (RFS) and overall survival (OS) between the two groups.

RESULTS

The study divided patients into two groups based on their SAT/NLR levels: high SAT/NLR (≥35.34) and low SAT/NLR (<35.34) groups. Forward stepwise logistic regression analysis revealed that low SAT/NLR (p < 0.001), tumor size ≥50 mm (p < 0.001), alpha-fetoprotein level >200 ng/mL (p < 0.001), and presence of liver cirrhosis (p < 0.001) were significantly associated with one-year recurrence of HCC. Moreover, the results suggest that RFS and OS were significantly shorter in the low SAT/NLR group compared to the high SAT/NLR group, both before and after PSM (p < 0.05).

CONCLUSIONS

The preoperative biomarker SAT/NLR shows potential as a prognostic biomarker for one-year recurrence and prognosis in patients with HCC undergoing liver resection.

Significant association between high neutrophil-lymphocyte ratio and poor prognosis in patients with hepatocellular carcinoma: a systematic review and meta-analysis

Objective

Whether neutrophil-lymphocyte ratio (NLR) is an applicative predictor of poor prognosis in patients with hepatocellular carcinoma (HCC) remains controversial. In response to the current conflicting data, this meta-analysis was conducted to gain a comprehensive and systematic understanding of prognostic value of NLR in HCC.

Methods

Several English databases, including PubMed, EMBASE, and the Cochrane Library, with an update date of February 25, 2023, were systematically searched. We set the inclusion criteria to include randomized controlled trial (RCT) studies that reported the prognostic value of serum NLR levels in patients with HCC receiving treatment. Both the combined ratio (OR) and the diagnosis ratio (DOR) were used to assess the prognostic performance of NLR. Additionally, we completed the risk of bias assessment by Cochrane Risk of Bias Assessment Tool.

Results

This meta-analysis ultimately included 16 studies with a total of 4654 patients with HCC. The results showed that high baseline NLR was significantly associated with poor prognosis or recurrence of HCC. The sensitivity of 0.67 (95% confidence interval [CI]. 0.59-0.73); specificity of 0.723 (95% CI: 0.64-0.78) and DOR of 5.0 (95% CI: 4.0-7.0) were pooled estimated from patient-based analyses. Subsequently, the combined positive likelihood ratio (PLR) and negative likelihood ratio (NLHR) were calculated with the results of 2.4 (95% CI: 1.9-3.0) and 0.46 (95% CI: 0.39-0.56), respectively. In addition, area under the curve (AUC) of the summary receiver operating characteristic (SROC) reflecting prognostic accuracy was calculated to be 0.75 (95% CI: 0.71-0.78). The results of subgroup analysis suggested that high NLR was an effective predictive factor of poor prognosis in HCC in mainland China as well as in the northern region.

Conclusion

Our findings suggest that high baseline NLR is an excellent predictor of poor prognosis or relapse in patients with HCC, especially those from high-incidence East Asian populations.

Systematic review registration

https://www.crd.york.ac.uk/prospero/#recordDetails, identifier CRD42023440640.

Predictors of Hepatocellular Carcinoma Early Recurrence in Patients Treated with Surgical Resection or Ablation Treatment: A Single-Center Experience

Introduction: Hepatocellular carcinoma (HCC) is the sixth most diagnosed malignancy and the fourth leading cause of cancer-related death worldwide, with poor overall survival despite available curative treatments. One of the most crucial factors influencing survival in HCC is recurrence. The current study aims to determine factors associated with early recurrence of HCC in patients with BCLC Stage 0 or Stage A treated with surgical resection or local ablation. Materials and Methods: We retrospectively enrolled 58 consecutive patients diagnosed with HCC within BCLC Stage 0 or Stage A and treated either by surgical resection or local ablation with maximum nodule diameter < 50 mm. In the first year of follow-up after treatment, imaging was performed regularly one month after treatment and then every three months. Each case was discussed collectively by the Liver Multidisciplinary Group to decide diagnosis, treatment, follow-up, and disease recurrence. Variables resulting in statistically significant difference were then studied by Cox regression analysis; univariately and then multivariately based on forward stepwise Cox regression. Results are represented in hazard ratio (H.R.) with 95% confidence interval (C.I.). Results: There was no statistically significant difference in recurrence rates (34.8 vs. 45.7%, log-rank test, p = 0.274) between patients undergoing surgical resection and local ablation, respectively. Early recurrence was associated with male gender (HR 2.5, 95% C.I. 1.9−3.1), nodule diameter > 20 mm (HR 4.5, 95% C.I. 3.9−5.1), platelet count < 125 × 103 cell/mm3 (HR 1.6, 95% C.I. 1.2−1.9), platelet-lymphocyte ratio < 95 (HR 2.1, 95% C.I. 1.7−2.6), lymphocyte-monocyte ratio < 2.5 (HR 1.9, 95% C.I. 1.4−2.5), and neutrophil-lymphocyte ratio > 2 (HR 2.7, 95% C.I. 2.2−3.3). Discussion and Conclusions: Our results are in line with the current literature. Male gender and tumor nodule dimension are the main risk factors associated with early HCC recurrence. Platelet count and other combined scores can be used as predictive tools for early HCC recurrence, although more studies are needed to define cut-offs.

Usefulness of neutrophil-to-lymphocyte ratio (NLR) as a prognostic predictor after treatment of hepatocellular carcinoma." Review article

The neutrophil-to-lymphocyte ratio (NLR) is an inflammatory marker which has been investigated as a prognostic indicator in post-therapeutic recurrence and survival of patients with HCC. Our aim was to review all studies that assessed the prognostic value of pre-treatment NLR in predicting patient survival, cancer recurrence, and graft survival in patients undergoing various therapies for HCC. We searched the database of PubMed and Google Scholar to review all studies that have the word "NLR" and the word "HCC." We included all studies that assessed pre-treatment NLR as a prognostic factor in predicting outcomes in HCC patients. We excluded studies that assessed the correlation between post-treatment NLR or dynamic changes in NLR after treatment and HCC outcomes in an effort to minimize the confounding effect of each treatment on NLR. We reviewed 123 studies that studied the correlation between pre-treatment NLR and patient survival, 72 studies that evaluated the correlation between pre-treatment NLR and tumor recurrence, 21 studies that evaluated the correlation between NLR and tumor behavior, and 4 studies that assessed the correlation between NLR and graft survival. We found a remarkable heterogeneity between the methods of the studies, which is likely responsible for the differences in outcomes. The majority of the studies suggested a correlation between higher levels of pre-treatment NLR and poor outcomes. We concluded that NLR is a reliable and inexpensive biomarker and should be incorporated into other prognostic models to help determine outcomes following HCC treatment.

Liver transplantation for hepatocellular carcinoma: Improving eligibility without compromising outcomes

Background

In the context of liver transplantation for hepatocellular carcinoma (HCC), traditional transplant criteria appear restrictive. The objective of the current study was to determine risk factors for recurrence and improve transplant eligibility in patients with HCC.

Materials and methods

This was a retrospective study of patients who underwent living donor liver transplant (LDLT) for HCC (n = 219). Largest tumor diameter, tumor number, AFP and neutrophil to lymphocyte ratio were assessed. Multivariate analysis was performed to develop risk scores. The new model was compared with seven previously published transplant criteria using receiver operator curves.

Results

Largest tumor size >3.7 cm [HR:2.6, P = 0.02], and AFP > 600 ng/ml [HR:4.7, P = 0.001] were independent predictors of recurrence. Patients with risk scores of 0, 1–3, 4–6 and 7–9 had recurrence rate of 5.9%, 12.5%, 25% and 58.4% respectively. When compared with Milan criteria, Metro ticket 2.0, AFP model and Samsung criteria; transplant eligibility increased by 31.5%, 22.9%, 8.7%, and 7% respectively. Recurrence rate with the current model was 16/199 (8%) (P < 0.0001) and was comparable with other transplant criteria (6.9–9.1%). On ROC analysis, only Milan criteria (AUC = 0.7, P = 0.001) and the current model (AUC = 0.66, P = 0.01) showed significance for recurrence. All patients with high risk scores within Milan criteria had recurred at 3 years (P = 0.03).

Conclusions

Low AFP can be used to select patients for LDLT outside traditional criteria for HCC, with comparable recurrence rates.

•

There is an unmet need to expand transplant pool for hepatocellular carcinoma.

•

We developed a model, based on tumor size cutoff of 3.7 cm, any tumor number, and AFP cutoff of 600 ng/ml; and compared it with other transplant criteria.

•

There was considerable expansion in transplant pool with comparable outcomes.

Response Prediction in Immune Checkpoint Inhibitor Immunotherapy for Advanced Hepatocellular Carcinoma

Simple Summary

Hepatocellular carcinoma is the most common liver malignancy. In the population with an advanced stage of the disease, outcomes could be disappointed by treating with molecular targeting agents because of low treatment response rates. It has gained improving effects of immune checkpoint inhibitor as an emerging treatment for advanced HCC (Hepatocellular carcinoma). However, this novel treatment regimen is quite expensive; to select suitable patients prior to treatment is crucial in daily practice. Here, we intend to present the effect of immunotherapy in treating advanced hepatocellular carcinoma in the real world and to assess potential factors predicting treatment responses for patient selection.

Abstract

Immune checkpoint inhibitors (ICI) have been applied to treat advanced stage hepatocellular carcinoma (HCC) and obtain promising effects. However, tumor response to treatment was unpredictable. A predicting biomarker of objective response or disease-control is an unmet need for patient selection. In this study, 45 advanced HCC patients who failed to sorafenib treatment and received nivolumab, 3 mg/kg bi-weekly, were included. Tumor responses to nivolumab treatment were assessed by the modified response evaluation criteria in solid tumors (mRECIST) criteria. Tumor responses were correlated to clinical characteristics to find out response predictors. In this small series, the prevalence of extrahepatic nodal metastasis, distant metastasis, and portal vein thrombus among the patients were 22.2% (n = 10), 48.9% (n = 22), and 42.2% (n = 19), respectively. The pre-treatment tumor size was 7.2 ± 4.2 cm in maximal diameter, and the calculated total tumor volume was 619.0 ± 831.1 cm³. Among 45 patients, 3 patients had partial response (PR), 11 had stable disease (SD), and the other 31 had progression of disease. By correlating clinical data to the patients with PR and SD, serum neutrophil-to-lymphocyte ratio (NLR) (hazard ratio (HR) = 2.04) and patient-generated subjective global assessment (PG-SGA) score (HR = 2.30) were the independent factors in multivariate analysis. By receiver operating characteristic curve analysis, pre-treatment NLR ≤ 2.5 and PG-SGA score < 4 were the cutoff points to predict tumor response to ICI treatment. In conclusion, biomarkers to predict tumor response for HCC are still lacking in this costly ICI therapy. In this study, NLR ≤ 2.5 and PG-SGA score < 4 indicated disease-control, and can be applied as biomarkers to select the right patients to receive this costly therapy.

Postoperative Trends and Prognostic Values of Inflammatory and Nutritional Biomarkers after Liver Transplantation for Hepatocellular Carcinoma

Simple Summary

Inflammatory biomarkers have a strong prognostic value in surgically treated patients with hepatocellular carcinoma (HCC), but the underlying pathogenic mechanism has not been completely clarified. Conversely, nutritional biomarkers predict the outcomes after hepatic resection for HCC but not after liver transplantation (LT). Indeed, the impact of LT on the recipient’s nutritional status is heterogeneous, while the data on the patient’s outcome after LT in terms of inflammatory status are limited. Therefore, to address these unsolved questions, we conducted a retrospective analysis on 324 HCC patients treated with LT, exploring the postoperative trend up to 1 year post-LT and the prognostic value of the Platelet-to-Lymphocyte Ratio (PLR), Neutrophil-to-Lymphocyte Ratio (NLR), Controlling Nutritional Status (CONUT), Prognostic Nutritional Index (PNI). It was found that at 1 year post-LT, the nutritional status of liver-transplanted HCC patients significantly improved while their inflammatory state tended to persist. Consequently, post-LT PLR and NLR maintained a prognostic value for LT outcome while post-LT CONUT and PNI acquired it.

Abstract

Preoperative inflammatory biomarkers such as the Platelet-to-Lymphocyte Ratio (PLR) and the Neutrophil-to-Lymphocyte Ratio (NLR) strongly predict the outcome in surgically treated patients with hepatocellular carcinoma (HCC), while nutritional biomarkers such as the Controlling Nutritional Status (CONUT) and the Prognostic Nutritional Index (PNI) show an analogue prognostic value in hepatic resection (HR) but not in liver transplant (LT) cases. Data on the impact of LT on the inflammatory and nutritional/metabolic function are heterogeneous. Therefore, we investigated the post-LT trend of these biomarkers up to postoperative month (POM) 12 in 324 HCC patients treated with LT. Inflammatory biomarkers peaked in the early post-LT period but at POM 3 leveled off at values similar (NLR) or higher (PLR) than pre-LT ones. CONUT and PNI worsened in the early post-LT period, but at POM 3 they stabilized at significantly better values than pre-LT. In LT recipients with an overall survival >1 year and no evidence of early HCC recurrence, 1 year post-LT NLR and PNI independently predicted patient overall survival, while 1 year post-LT PLR independently predicted late tumor recurrence. In conclusion, at 1 year post-LT, the nutritional status of liver-transplanted HCC patients significantly improved while their inflammatory state tended to persist. Consequently, post-LT PLR and NLR maintained a prognostic value for LT outcome while post-LT CONUT and PNI acquired it.

Treatment strategy of adding transcatheter arterial chemoembolization to sorafenib for advanced stage hepatocellular carcinoma

Background

Therapeutic effect and immunosuppressor cell alteration in adding transcatheter arterial chemoembolization (TACE) to sorafenib for advanced stage hepatocellular carcinoma (HCC) remain unclear.

Aims

To examine the therapeutic effect and immunosuppressor cell alteration in adding TACE to sorafenib.

Methods

Forty‐four advanced stage HCC patients were divided into group A (n = 17) treated by sorafenib (400‐600 mg/day) alone and group B patients (n = 27) treated by sorafenib and TACE. The frequency of regulatory T‐cells and myeloid‐derived suppressor cells (MDSC), and patients' outcomes were examined. Advanced HCC patients' survival was improved by adding TACE to sorafenib if N/L was reduced from ≥2.5 to <2.5 by TACE.

Results

The median (interquartile) follow‐up for all patients was 8.5 (3.5 to 15.5) with a range from 1 to 71 months. The median (interquartile) survival was 5.0 (2.3‐11.3) months for group A and 11.0 (5.0‐19.0) months for group B patients (P = .024). In group A, the patients (n = 8) with neutrophil‐to‐lymphocytes ratio (N/L) < 2.5 had better survival than the patients (n = 9) with N/L ≥ 2.5 (P = .006). In group B, 6 of 13 patients with N/L ≥ 2.5 had N/L reduction to <2.5 after combination therapy of sorafenib and TACE, and their 6‐month, 1‐year and 2‐year survival were improved (P = .013). For immune cell examination, the frequency of CD4⁺ and CD8⁺ T‐lymphocytes, regulatory T‐cell and MDSC were not altered by sorafenib treatment. However, actual number of lymphocytes had a tendency to increase (from 978.5 ± 319.4/mm³ prior to treatment to 1378.0 ± 403.3/mm³, P = .086) for the patients with N/L reduction.

Conclusion

Immunosuppressor cells were not altered by sorafeinb. Patients' survival was improved if N/L ≥ 2.5 was reduced to <2.5 by TACE.

Neutrophil to lymphocyte ratio and albumin bilirubin grade in hepatocellular carcinoma: A systematic review

BACKGROUND

Hepatocellular carcinoma (HCC) is a frequent cause of cancer related death globally. Neutrophil to lymphocyte ratio (NLR) and albumin bilirubin (ALBI) grade are emerging prognostic indicators in HCC.

AIM

To study published literature of NLR and ALBI over the last five years, and to validate NLR and ALBI locally in our centre as indicators of HCC survival.

METHODS

A systematic review of the published literature on PubMed of NLR and ALBI in HCC over the last five years. The search followed the guidelines of the preferred reporting items for systematic reviews and meta-analyses. Additionally, we also investigated HCC cases between December 2013 and December 2018 in our centre.

RESULTS

There were 54 studies describing the relation between HCC and NLR and 95 studies describing the relation between HCC and ALBI grade over the last five years. Our local cohort of patients showed NLR to have a significant negative relationship to survival (P = 0.011). There was also significant inverse relationship between the size of the largest HCC nodule and survival (P = 0.009). Median survival with alpha fetoprotein (AFP) < 10 KU/L was 20 mo and with AFP > 10 KU/L was 5 mo. We found that AFP was inversely related to survival, this relationship was not statically significant (P = 0.132). Mean survival for ALBI grade 1 was 37.7 mo, ALBI grade 2 was 13.4 months and ALBI grade 3 was 4.5 mo. ALBI grades performed better than Child Turcotte Pugh score in detecting death from HCC.

CONCLUSION

NLR and ALBI grade in HCC predict survival better than the conventional alpha fetoprotein. ALBI grade performs better than Child Turcotte Pugh score. These markers are done as part of routine clinical care and in cases of normal alpha fetoprotein, these markers could give a better understanding of the patient disease progression. NLR and ALBI grade could have a role in modified easier to learn staging and prognostic systems for HCC.

Leucocyte ratios are biomarkers of mortality in patients with acute decompensation of cirrhosis and acute-on-chronic liver failure

BACKGROUND

In patients with cirrhosis, progression to acute decompensation (AD) and acute-on-chronic liver failure (ACLF) has been associated with poor prognosis. Differential leucocyte ratios might predict mortality in systemic inflammatory conditions.

AIM

To evaluate differential leucocyte ratios as prognostic biomarkers in patients with cirrhosis.

METHODS

Patients with AD and ACLF were recruited from four centres in three countries. Peripheral blood differential leucocytes were measured (three centres using flow cytometry) on hospital admission and at 48 hours. Ratios were correlated to model for end-stage liver disease (MELD), chronic liver failure-sequential organ failure (CLIF-SOFA), suspected/culture-positive bacterial infection and survival.

RESULTS

Nine hundred twenty-six patients (562 (61%) male, median age 55 (25-94) years) were studied. Overall, 350 (37%) did not survive to hospital discharge. Neutrophil-lymphocyte ratio (NLR) and monocyte-lymphocyte ratio (MLR) were elevated in patients with AD and ACLF who died during their hospital stay. On multivariate analysis NLR retained statistical significance independently of CLIF-SOFA or MELD. NLR >30 was associated with an 80% 90-day mortality in patients with ACLF but not AD. On sensitivity analysis for subgroups (alcohol-related liver disease and suspected sepsis), NLR and MLR retained statistically robust accuracy for the prediction of mortality. Significant predictive accuracy was only observed in centres using flow cytometry.

CONCLUSION

Leucocyte ratios are simple and robust biomarkers of outcome in ACLF, which are comparable to CLIF-SOFA score but dependent on leucocyte quantification method. NLR and MLR may be used as screening tools for mortality prediction in patients with acutely deteriorating cirrhosis.

Inflammation Score System using Preoperative Inflammatory Markers to Predict Prognosis for Hepatocellular Carcinoma after Hepatectomy: A Cohort Study

Background: This study developed a novel inflammation score system to predict survival outcomes using preoperational inflammatory markers in hepatocellular carcinoma (HCC) after surgery.

Materials and Methods: An inflammation score system was developed using five preoperative inflammatory markers based on the clinical data of 455 HCC patients (training cohort) receiving radical resection in the Eastern Hepatobiliary Surgery Hospital. The system was validated using a cohort from a different hospital (external validation). Kaplan-Meier curves and log-rank test were used to compare the survival of patients with different inflammation scores. A nomogram including inflammation scores for survival prediction was created to exhibit the risk factors of overall survival (OS).

Results: The patients in the low-score group showed better OS and recurrence-free survival (RFS) in the training and external validation cohorts than those from the high-score group. Subgroup analysis showed that compared with patients in the training cohort from the high-score group, stage I (eighth TNM stage) patients in the low-score group exhibited better prognosis results, whereas the findings for Stage II and III patients were different. Multivariate Cox analysis revealed that high inflammation score is an independent risk factor of OS and RFS. The nomogram established using the inflammation score with the C-index value of 0.661 (95% confidence interval=0.624-0.698) revealed a good three- and five-year calibration curves.

Conclusions: The inflammation score system based on five preoperative inflammatory markers well predicted the survival of HCC patients after surgery, especially in those at the early stage (Stage I).

A novel machine learning algorithm to predict disease free survival after resection of hepatocellular carcinoma

Background

Due to organ shortage, liver transplantation (LT) in hepatocellular carcinoma (HCC) patients can only be offered subsidiary to other curative treatments, including liver resection (LR). We aimed at developing and validating a machine-learning algorithm (ML) to predict which patients are sufficiently treated by LR.

Methods

Twenty-six preoperatively available routine laboratory values along with standard clinical-pathological parameters [including the modified Glascow Prognostic Score (mGPS), the Kings Score (KS) and the Model of Endstage Liver Disease (MELD)] were retrieved from 181 patients who underwent partial LR due to HCC in non-cirrhosis or compensated cirrhosis from January 2007 through March 2018 at our institution. These data were processed using a Random Forest (RF)-based workflow, which included preprocessing, recursive feature elimination (RFE), resampling, training and cross-validation of the RF model. A subset of untouched patient data was used as a test cohort. Basing on the RF prediction, test data could be stratified according to high (HR) or low risk (LR) profile characteristics.

Results

RFE analysis provided 6 relevant outcome predictors: mGPS, aPTT, CRP, largest tumor size, number of lesions and age at time of operation. After down-sampling, the predictive value of our model was 0.788 (0.658-0.919) for early DFS. 16.7% of HR and 74.2% of LR patients survived 2 years of follow-up (P<0.001).

Conclusions

Our RF model, based solely on clinical parameters, proved to be a powerful predictor of DFS. These results warrant a prospective study to improve the model for selection of suitable candidates for LR as alternative to transplantation. The predictive model is available online: tiny.cc/hcc_model.

Prognostic significance of inflammatory indices in hepatocellular carcinoma treated with transarterial chemoembolization: A systematic review and meta-analysis

Objectives

To investigate the association between inflammatory indices and clinical outcomes of hepatocellular carcinoma (HCC) patients treated with transarterial chemoembolization (TACE) by performing meta-analysis.

Methods

A systematic literature search for relevant studies published up to August 2019 was performed by using PubMed, Web of Science, EMBASE, China National Knowledge Internet (CNKI) and Wanfang databases. Pooled hazard ratios (HR) or odds ratio (OR) and 95% confidence intervals (95% CI) were calculated.

Results

A total of 5280 patients from 22 studies were finally enrolled in the meta-analysis. The results demonstrated that elevated preoperative NLR, PLR, and CRP was associated with poor OS in HCC patients treated by TACE (HR = 1.81, P<0.00001; HR = 1.56, P = 0.007; HR = 1.45, P<0.00001, respectively). In addition, high NLR was significantly correlated with the presence of tumor vascular invasion (OR = 1.49, P = 0.002). Elevated PLR tended to be correlated with higher incidence of tumor size>3 cm (OR = 2.42, P = 0.005).

Conclusions

Elevated preoperative NLR, PLR, and CRP are associated with poor prognosis in HCC patients treated with TACE. These inflammatory indices may be convenient, accessible, affordable and dependable biomarkers with prognostic potential for HCC patients treated by TACE.

Prognostic role of pretreatment blood lymphocyte count in patients with solid tumors: a systematic review and meta-analysis

Background

To evaluate the prognostic value of pretreatment lymphocyte counts with respect to clinical outcomes in patients with solid tumors.

Methods

Systematic literature search of electronic databases (Pubmed, Embase and Web of Science) up to May 1, 2018 was carried out by two independent reviewers. We included Eligible studies assessed the prognostic impact of pretreatment lymphocytes and had reported hazard ratios (HR) with 95% confidence intervals (CIs) for endpoints including overall survival (OS) and progression-free survival (PFS). Only English publications were included.

Results

A total of 42 studies comprising 13,272 patients were included in this systematic review and meta-analysis. Low pretreatment lymphocyte count was associated with poor OS (HR = 1.27, 95% CI 1.16–1.39, P < 0.001, I² = 58.5%) and PFS (HR = 1.27, 95% CI 1.15–1.40, P < 0.001, I² = 25.7%). Subgroup analysis disaggregated by cancer type indicated that low pretreatment lymphocytes were most closely associated with poor OS in colorectal cancer followed by breast cancer and renal cancer.

Conclusions

Low pretreatment lymphocyte count may represent an unfavorable prognostic factor for clinical outcomes in patients with solid tumors.

Prognostic significance of elevated preoperative neutrophil-to-lymphocyte ratio for patients with colorectal cancer undergoing curative surgery: A meta-analysis

BACKGROUND

Preoperative neutrophil-to-lymphocyte ratio (NLR) has been suggested as a useful predictive factor for prognosis in patients with various cancers. However, the prognostic value of NLR in patients with colorectal cancer (CRC) remains controversial. Therefore, the goal of this study was to perform a meta-analysis to evaluate the prognostic value of NLR in patients with CRC undergoing curative surgery.

METHODS

PubMed, EMBASE and Cochrane Library databases were searched to screen the relevant studies. Pooled hazard ratio (HR) with 95% confidence interval (CI) was used to assess the associations of preoperative NLR and overall survival (OS), disease-free survival (DFS), recurrence free survival (RFS) and disease specific survival (DSS) by STATA 13.0 software.

RESULTS

Sixteen studies involving 5897 patients were included in our meta-analysis. Our pooled results demonstrated that high NLR was associated with poor OS (HR: 1.66, 95%CI: 1.36-2.02, P < .001), DFS (HR = 1.54, 95%CI: 1.18-2.02, P = .002), RFS (HR = 2.31, 95%CI: 1.68-3.17, P < .001) and DSS (HR = 2.27; 95% CI: 1.75-2.96, P < .001). When the patients were stratified according to country, sample size, NLR cut-off, follow up and postoperative chemotherapy, high NLR was still significantly correlated with OS. The limitation was that the majority of enrolled studies were retrospective.

CONCLUSION

Preoperative NLR may be an effective predictive biomarker for prognosis in patients with CRC. Detection of NLR may be beneficial to identify the high-risk patients who need other antitumor therapies in addition to surgery.

Prognostic value of neutrophil-to-lymphocyte ratio and platelet-to-lymphocyte ratio in gastric cancer

The neutrophil-to-lymphocyte ratio (NLR) and platelet-to-lymphocyte ratio (PLR) have been presented to be a prognostic indicator in several types of cancer. However, these issues have not been concluded yet. The present study was therefore performed to determine the prognostic value of NLR and PLR in gastric cancer (GC).A total of 182 GC patients, diagnosed between January 2011 and January 2014, were enrolled in the study. The clinicopathological parameters, laboratory analyses, and outcomes were collected. The association between NLR, PLR, and clinicopathological characters was analyzed with univariate and multivariate analyses.NLR was significantly related to age (P = .026), surgery (P = .006), node status (P = .004), and clinical stage (P = .009). The median overall survival (OS) and progression-free survival (PFS) were poor in the High-NLR group (OS: 36.0 vs 20.5 months, P < .001, PFS: 33.0 vs 12.0 months, P < .001) and High-PLR group (OS: 31.5 vs 18.5 months, P = .003, PFS: 26.0 vs 11.0 months, P = .01). Multivariate analyses indicated both surgery [for OS hazard ratio (HR) = 2.092, 95% confidence interval (95% CI): 1.345-3.253, P = .001; for PFS HR = 1.939, 95% CI: 1.259-2.988, P = .003] and NLR (for OS HR = 1.585, 95% CI: 1.011-2.485, P = .045) were independent prognostic factors.Elevated NLR and PLR were related with poor prognosis in GC patients before treatment. The NLR was an independent prognostic factor for OS. More studies should be conducted to address the potential prognostic value of NLR and PLR in GC.

Pretreatment neutrophil-lymphocyte ratio: useful prognostic biomarker in hepatocellular carcinoma

Hepatocellular carcinoma (HCC) is the most common liver malignancy and the third most common cause of cancer-related deaths. Liver resection (LR) and liver transplantation (LT) are the only curative modalities for HCC. Despite recent advances and the adoption of the Milan and University of California, San Francisco, criteria, HCC recurrence after LR and LT remains a challenge. Several markers and prognostic scores have been proposed to predict tumor aggressiveness and supplement radiological data; among them, neutrophil–lymphocyte ratio (NLR) has recently gained significant interest. An elevated NLR is thought to predispose to HCC recurrence by creating a protumorigenic microenvironment through both relative neutrophilia and lymphocytopenia. In the present review, we attempted to summarize the published work on the role of pretreatment NLR as a prognostic marker for HCC following LR and LT. A total of 13 LT and 18 LR studies were included from 2008 to 2015. Pretransplant NLR was most often predictive of HCC recurrence, recurrence-free survival, and overall survival. NLR was, however, more variably and less clearly associated with worse outcomes following LR.

Preoperative plasma fibrinogen is associated with poor prognosis in esophageal carcinoma: a meta-analysis

PURPOSE

The aim of this meta-analysis was to investigate preoperative plasma fibrinogen (PPF) as a prognostic marker in esophageal carcinoma (EC) by meta-analysis.

METHODS

Relevant studies were sought in the databases including Pubmed, Web of Science, Cochrane library, and Wanfang databases up to Oct 10th, 2017. Hazard ratios (HRs) with corresponding 95% confidence intervals (CIs) were used as effective value, and pooled HRs were synthesized by STATA 14.0 to assess the prognostic impact of PPF on EC patients.

RESULTS

A total of 8 studies with 2827 patients were collected in this meta-analysis. Our results revealed that high PPF was significantly associated with poor OS (HR = 1.90, 95% CI 1.56-2.33, P = 0.000; HR = 1.76, 95% CI 1.28-2.42, P = 0.000) and poor DFS (HR = 1.91, 95% CI 1.50-2.43, P = 0.000; HR = 1.51, 95% CI 1.16-1.97, P = 0.000) in EC patients from univariate and multivariate analysis results, respectively, which suggested that EC patients with high PPF will suffer from high postoperative mortality and recurrence rate.

CONCLUSION

High PPF was significantly associated with poor OS and DFS in EC patients. Fibrinogen can serve as a prognostic marker and even a future targeting molecule during the treatment of EC patients.

Neutrophil-to-lymphocyte and aspartate-to-alanine aminotransferase ratios predict hepatocellular carcinoma prognosis after transarterial embolization

The neutrophil-to-lymphocyte ratio (NLR) reflects the systematic inflammatory status, and the aspartate aminotransferase-to-alanine aminotransferase ratio (AAR) is a biomarker of liver fibrosis and cirrhosis. These values can be conveniently obtained from routine blood tests; however, their combined clinical utility has not been extensively studied in patients with hepatocellular carcinoma (HCC) undergoing transarterial chemoembolization (TACE). This study aimed to investigate the prognostic value of NLR-AAR in patients with unresectable HCC undergoing TACE. Data for 760 patients with newly diagnosed HCC were retrospectively evaluated. The NLR-AAR was calculated as follows: patients in whom both the NLR and AAR were elevated according to the receiver operating characteristic (ROC) curve analysis were assigned a score of 2; patients showing an elevation in one or neither of these indicators were assigned a score of 1 or 0, respectively. Univariate and multivariate analyses were performed to identify the clinicopathological variables associated with overall survival. An ROC curve was also generated and the area under the curve (AUC) was calculated to evaluate the discriminatory ability of each index at 1, 3, and 5 years of follow-up, as well as overall. The NLR-AAR consistently had a greater AUC value at 1 year (0.669), 3 years (0.667), and 5 years (0.671) post-TACE compared with either NLR or AAR alone. The median survival times of patients with a NLR-AAR of 0, 1, and 2 were 31.0 (95% confidence interval [CI] 24.0-38.0), 15.0 (95% CI 11.2-18.8), and 5.0 (95% CI 4.0-5.9) months, respectively (P < .001). Multivariate analysis showed that the NLR-AAR, elevated total bilirubin level, and vascular invasion were independently associated with overall survival. NLR and AAR, when combined to produce an inflammation-based index and fibrosis score, is an independent marker of poor prognosis in patients with HCC receiving TACE.

Prognostic factors and predictors of sorafenib benefit in patients with hepatocellular carcinoma: Analysis of two phase III studies

BACKGROUND & AIMS

Sorafenib, an oral multikinase inhibitor, significantly prolonged overall survival (OS) vs. placebo in patients with unresectable hepatocellular carcinoma (HCC) in two phase III studies, SHARP (Sorafenib HCC Assessment Randomized Protocol) and Asia Pacific (AP). To assess prognostic factors for HCC and predictive factors of sorafenib benefit, we conducted a pooled exploratory analysis from these placebo-controlled phase III studies.

METHODS

To identify potential prognostic factors for OS, univariate and multivariate (MV) analyses were performed for baseline variables by Cox proportional hazards model. Hazard ratios (HRs) and median OS were evaluated across pooled subgroups. To assess factors predictive of sorafenib benefit, the interaction term between treatment for each subgroup was evaluated by Cox proportional hazard model.

RESULTS

In 827 patients (448 sorafenib; 379 placebo) analyzed, strong prognostic factors for poorer OS identified from MV analysis in both treatment arms were presence of macroscopic vascular invasion (MVI), high alpha-fetoprotein (AFP), and high neutrophil-to-lymphocyte ratio (NLR; ⩽ vs. >median [3.1]). Sorafenib OS benefit was consistently observed across all subgroups. Significantly greater OS sorafenib benefit vs. placebo was observed in patients without extrahepatic spread (EHS; HR, 0.55 vs. 0.84), with hepatitis C virus (HCV) (HR, 0.47 vs. 0.81), and a low NLR (HR, 0.59 vs. 0.84).

CONCLUSIONS

In this exploratory analysis, presence of MVI, high AFP, and high NLR were prognostic factors of poorer OS. Sorafenib benefit was consistently observed irrespective of prognostic factors. Lack of EHS, HCV, and lower NLR were predictive of a greater OS benefit with sorafenib.

LAY SUMMARY

This exploratory pooled analysis showed that treatment with sorafenib provides a survival benefit in all subgroups of patients with HCC; however, the magnitude of benefit is greater in patients with disease confined to the liver (without extrahepatic spread), or in those with hepatitis C virus, or a lower neutrophil-to-lymphocyte ratio, an indicator of inflammation status. These results help inform the prognosis of patients receiving sorafenib therapy and provide further refinements for the design of trials testing new agents vs. sorafenib. Clinical Trial Numbers: NCT00105443 and NCT00492752.

Impact of neutrophil to lymphocyte ratio on survival for hepatocellular carcinoma after curative resection

BACKGROUND

Neutrophil-lymphocyte ratio (NLR) represents a pro-tumor inflammatory environment and host immunity. The aim of this study was to examine the effect of subsequent NLR for hepatocellular carcinoma (HCC) after liver resection.

METHODS

A total of 672 patients had liver resection for HCC were included in this study. NLR at diagnosis of HCC and HCC recurrence were collected. NLR at 2.5 was used as cut-off value to calculate its prognostic effect.

RESULTS

According to NLR cut-off value, the patients with NLR >2.5 had larger tumor size, higher histology grade, and higher rates of tumor multiplicity and vascular invasion. After a median follow-up of 76.3 months, 437 (65.0%) patients had tumor recurrence. The 1-, 3- and 5-year recurrence-free survival were 77.4%, 55.2% and 44.8% in NLR ≤2.5 group, compared to 64.1%, 45.2% and 35.5% in NLR >2.5 group (P = 0.016). When patients had tumor recurrence, 5-year post-recurrent survival was best in the patients staying with NLR ≤2.5 all the time and decreased from 45.9% to 24.6% if NLR was ≤2.5 at resection and became >2.5 at recurrence (P = 0.013).

CONCLUSION

High NLR was an independent unfavorable prognostic factor. Subsequent change of NLR between liver resection and HCC recurrence could predict post-recurrent survival.

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

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

Prognostic value of red blood cell distribution width in hepatocellular carcinoma

Red blood cell distribution width (RDW) is a simple, inexpensive, routinely measured and automatically reported blood test parameter, which reflects the degree of anisocytosis of red blood cells in peripheral blood. RDW was found to be associated with and retain clinical significance for assessing disease severity and outcomes in a number of hematological and solid malignancies. Motley of interacting clinical and biochemical factors have an impact on the red cell population biology. Malignancies per se can act as a causative factor, or anisocytosis may develop as a result of chronic inflammation. RDW has also been shown to be affected by nutritional status, which is typically deranged in malignancies. RDW is shown to be a clinically useful marker of disease severity and level of fibrosis in liver cirrhosis of various causes such as hepatitis B, hepatitis C and non-alcoholic fatty liver disease. Whether liver cirrhosis patients with higher RDW are at increased risk of hepatocellular cancer is yet to be determined, but several lines of evidence confirm that RDW has clinical significance in hepatocellular carcinoma (HCC). In this review, we specifically discuss the current literature about the association between RDW and HCC. The available evidences were summarized and the potential underlying mechanisms were analyzed.

Prognostic significance of neutrophil-to-lymphocyte ratio in diffuse large B-cell lymphoma: A meta-analysis

Background

Neutrophil-to-lymphocyte ratio (NLR) has been investigated as a prognostic marker in patients with diffuse large B-cell lymphoma (DLBCL); however, the results remain controversial. This study aimed to explore the association between NLR and survival outcomes and clinicopathological factors in DLBCL.

Methods

Relevant studies were retrieved by searching PubMed, Embase, Web of Science, and China National Knowledge Infrastructure (CNKI) databases. The last search was updated on February 17, 2017. Hazard ratios (HRs) and odds ratios (ORs) and their 95% confidence intervals (CIs) were used as effective measures in the meta-analysis. Random-effects models and fixed-effects models were used for analyses. Meta-regression was performed. Publication bias was assessed using Begg’s test. Stata version 12.0 was used for all analyses.

Results

A total of 9 studies with 2297 patients were included in the meta-analysis. The pooled results showed that NLR was a significant indicator for poor overall survival (OS) (HR = 1.84, 95% CI = 1.52–2.22, p<0.001) and poor progression-free survival (PFS) (HR = 1.64, 95% CI = 1.36–1.98, p<0.001). NLR remained a significant biomarker for OS and PFS regardless of location, sample size or cut-off value. In addition, high NLR was also associated with Ann Arbor stage (OR = 2.09, 95% CI = 1.14–3.81, p = 0.017), lactate dehydrogenase level (OR = 2.74, 95% CI = 1.16–6.46, p = 0.021), extranodal disease (OR = 1.63, 95% CI = 1.06–2.52, p = 0.027), and International Prognostic Index score (OR = 2.44, 95% CI = 1.03–5.08, p = 0.043). However, NLR was found to have no significant association with sex (OR = 0.89, 95% CI = 0.71–1.11, p = 0.29), age (OR = 1.18, 95% CI = 0.94–1.48, p = 0.152), European Cooperative Oncology Group performance status score (OR = 1.78, 95% CI = 0.71–4.46, p = 0.217), or presence of B symptoms (OR = 1.56, 95% CI = 0.7–3.48, p = 0.278).

Conclusion

In conclusion, our meta-analysis demonstrated that NLR has a strong association with worse OS and PFS in patients with DLBCL. NLR could be recommended as an inexpensive prognostic biomarker in DLBCL.

The Preoperative Neutrophil-to-lymphocyte Ratio is a Novel Biomarker for Predicting Worse Clinical Outcomes in Non-muscle Invasive Bladder Cancer Patients with a Previous History of Smoking

PURPOSE

We speculated that a heterogeneous population of non-muscle invasive bladder cancer (NMIBC) patients with a previous history of smoking may be more precisely stratified by a biomarker associated with tumor aggressiveness and then focused on the preoperative neutrophil-to-lymphocyte ratio (pre-NLR), which is a simple index of systemic inflammation.

METHODS

Our study population comprised 605 patients initially diagnosed with NMIBC at our 3 institutions between 1995 and 2013. We analyzed the relationships between pre-NLR levels and clinical outcomes in NMIBC. A pre-NLR level of ≥2.2 was defined as elevated according to a calculation by a receiver-operating curve analysis.

RESULTS

In overall, a total of 296 patients (48.9 %) had pre-NLR ≥ 2.2, and the pre-NLR level was one of independent risk factors for tumor recurrence and stage progression. Among 344 patients with a previous history of smoking, 184 (53.5 %) had pre-NLR ≥ 2.2 and the pre-NLR level was one of independent risk factors for tumor recurrence and stage progression. The 5-year recurrence-free survival and progression-free survival rates in patients with pre-NLR < 2.2 were 66.3 and 97.5 %, respectively, which were significantly higher than those in their counterparts (31.7 and 90.4 %, p < 0.001). In either subgroup of patients who were current smokers (N = 175) or former smokers (N = 169), the pre-NLR level was the only independent risk factor for tumor recurrence. The pre-NLR level was not associated with tumor recurrence or stage progression in 261 nonsmoking patients.

CONCLUSIONS

Pre-NLR levels may be a useful marker for identifying worse clinical outcomes in NMIBC patients, particularly those with a previous history of smoking.

Role of inflammation and infection in the pathogenesis of human acute liver failure: Clinical implications for monitoring and therapy

Acute liver failure is a rare and devastating clinical condition. At present, emergency liver transplantation is the only life-saving therapy in advanced cases, yet the feasibility of transplantation is affected by the presence of systemic inflammation, infection and resultant multi-organ failure. The importance of immune dysregulation and acquisition of infection in the pathogenesis of acute liver failure and its associated complications is now recognised. In this review we discuss current thinking regarding the role of infection and inflammation in the pathogenesis of and outcome in human acute liver failure, the implications for the management of such patients and suggest directions for future research.