Neutrophil:lymphocyte ratio and intraoperative use of ketorolac or diclofenac are prognostic factors in different cohorts of patients undergoing breast, lung, and kidney cancer surgery

R-ketorolac ameliorates cancer-associated cachexia and prolongs survival of tumour-bearing mice

BACKGROUND

Cancer-associated cachexia (CAC) is a debilitating syndrome associated with poor quality of life and reduced life expectancy of cancer patients. CAC is characterized by unintended body weight reduction due to muscle and adipose tissue loss. A major hallmark of CAC is systemic inflammation. Several non-steroidal anti-inflammatory drugs (NSAIDs) have been suggested for CAC treatment, yet no single medication has proven reliable. R-ketorolac (RK) is the R-enantiomer of a commonly used NSAID. The effect of RK on CAC has not yet been evaluated.

METHODS

Ten- to 11-week-old mice were inoculated with C26 or CHX207 cancer cells or vehicle control (phosphate-buffered saline [PBS]). After cachexia onset, 2 mg/kg RK or PBS was administered daily by oral gavage. Body weight, food intake and tumour size were continuously measured. At study endpoints, blood was drawn, mice were sacrificed and tissues were excised. Immune cell abundance was analysed using a Cytek® Aurora spectral flow cytometer. Cyclooxygenase (COX) activity was determined in lung homogenates using a fluorometric kit. Muscle tissues were analysed for mRNA and protein expression by quantitative real-time PCR and western blotting analysis, respectively. Muscle fibre size was determined on histological slides after haematoxylin/eosin staining.

RESULTS

Ten-day survival rate of C26-bearing animals was 10% while RK treatment resulted in a 100% survival rate (P = 0.0009). Chemotherapy resulted in a 10% survival rate 14 days after treatment initiation, but all mice survived upon co-medication with RK and cyclophosphamide (P = 0.0001). Increased survival was associated with a protection from body weight loss in C26 (-0.61 ± 1.82 vs. -4.48 ± 2.0 g, P = 0.0004) and CHX207 (-0.49 ± 0.33 vs. -2.49 ± 0.93 g, P = 0.0003) tumour-bearing mice treated with RK, compared with untreated mice. RK ameliorated musculus quadriceps (-1.7 ± 7.1% vs. -27.8 ± 8.3%, P = 0.0007) and gonadal white adipose tissue (-18.8 ± 49% vs. -69 ± 15.6%, P = 0.094) loss in tumour-bearing mice, compared with untreated mice. Mechanistically, RK reduced circulating interleukin-6 (IL-6) concentrations from 334 ± 151 to 164 ± 123 pg/mL (P = 0.047) in C26 and from 93 ± 39 to 35 ± 6 pg/mL (P = 0.0053) in CHX207 tumour-bearing mice. Moreover, RK protected mice from cancer-induced T-lymphopenia (+1.8 ± 42% vs. -49.2 ± 12.1% in treated vs. untreated mice, respectively). RK was ineffective in ameliorating CAC in thymus-deficient nude mice, indicating that the beneficial effect of RK depends on T-cells.

CONCLUSIONS

RK improved T-lymphopenia and decreased systemic IL-6 concentrations, resulting in alleviation of cachexia and increased survival of cachexigenic tumour-bearing mice, even under chemotherapy and independent of COX inhibition. Considering its potential, we propose that the use of RK should be investigated in patients suffering from CAC.

Preoperative High C-Reactive Protein to Albumin Ratio Predicts Short- and Long-Term Postoperative Outcomes in Elderly Gastric Cancer Patients

Individualized preoperative assessment of the general condition of elderly patients with gastric cancer is necessary for appropriate surgical treatment planning. This study investigated the efficacy of preoperative markers that could be easily calculated from preoperative peripheral blood to predict the short- and long-term postoperative outcomes of gastrectomy. In total, 571 patients who underwent R0 surgical resection for gastric cancer were enrolled. In the elderly patient group (≥65 years old), univariate analyses revealed that the incidence of postoperative complications was associated with poor performance status (p = 0.012), more comorbidities (p = 0.020), high C-reactive protein to albumin ratio (CAR, p = 0.003), total gastrectomy (p = 0.003), open approach (p = 0.034), blood transfusion (p = 0.002), and advanced cancer (p = 0.003). Multivariate analysis showed that a high CAR was associated with a high incidence of postoperative complications (p = 0.046). High CAR was also associated with poor OS (p = 0.015) and RFS (p = 0.035). However, these trends were not observed among younger patients (<65 years old). Preoperative CAR may play a significant role in predicting short- and long-term surgical outcomes, particularly in elderly patients with gastric cancer.

Prognostic Impact of Cancer Inflammation Prognostic Index for Non-small Cell Lung Cancer

PURPOSE

Cancer-inflammation prognostic index (CIPI) is calculated by multiplying the concentration of carcinoembryonic antigen by neutrophil-to-lymphocyte ratio. CIPI has been reported as a prognostic factor for colorectal cancer. Although carcinoembryonic antigen and neutrophil-to-lymphocyte ratio have been reported as prognostic factors for non-small cell lung cancer (NSCLC), it has not been investigated whether CIPI is a useful marker.

METHODS

We analyzed the prognostic factors, including CIPI, in 700 NSCLC patients treated by pulmonary resection. We also analyzed a subgroup of 482 patients with pathological stage I NSCLC.

RESULT

CIPI > 14.59 (P < 0.01), maximum standardized uptake value (SUVmax) > 5.35 (P < 0.01), lymphatic invasion (P = 0.01), and pathological stage (P < 0.01) were significant factors for relapse-free survival (RFS) in multivariate analysis. SUVmax > 5.35 (P < 0.01) and pathological stage (P < 0.01) were revealed as significant factors for overall survival in the multivariate analysis. In the subanalysis, CIPI > 14.88 (P = 0.01) and SUVmax > 5.07 (P < 0.01) were significant factors for RFS of pathological stage I NSCLC in multivariate analysis.

CONCLUSION

CIPI was a significant factor for RFS in NSCLC patients treated surgically, even in those with pathological stage I disease. SUVmax was also a significant factor for RFS and overall survival in NSCLC patients treated surgically, and for RFS in patients with pathological stage I NSCLC.

TRIAL REGISTRATION

The Institutional Review Board of Kanazawa Medical University approved the protocol of this retrospective study (Approval Number: I392), and written informed consent was obtained from all patients.

Diagnostic value of the neutrophil lymphocyte ratio in discrimination between tuberculosis and bacterial community acquired pneumonia: A meta-analysis

Background

We conducted a systematic review and meta-analysis, based on Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines, to evaluate current literature on diagnostic value of neutrophil to lymphocyte ratio (NLR) in discrimination between tuberculosis (TB) and bacterial community acquired pneumonia (B-CAP).

Methods

Literature search was conducted from July 20, 2023 using Scopus, PubMed, and Web of Science databases. STATA software (version 12.0; Stata Corporation) was used for all analyses.

Results

We found that patients with TB had significantly lower levels of NLR compared to those with B-CAP (SMD = -1.09, 95 %CI = -1.78- -0.40, P = 0.002). In the quality subgroup analysis, we found that patients with TB had significantly lower level of NLR compared to those with B-CAP consistent in moderate (SMD = -0.86, 95 %CI = -2.30, 0.57, P = 0.23) and high-quality studies (SMD = -1.25, 95 %CI = -2.07, -0.42). In the subgroup analysis based on continent, we found that patients with TB had significantly lower level of NLR compared to those with B-CAP in studies performed in Asian populations (SMD = -1.37, 95 %CI = -2.13, -0.61, P < 0.001), but not on African population (SMD = -0.02, 95 %CI = -1.06, 1.02, P = 0.97). The result of this study did not change after execution of sensitivity analysis. The pooled sensitivity of NLR was 0.86 (95% CI = 0.80, 0.91), and the pooled specificity was0.88 (95% CI = 0.69, 0.95).

Conclusion

Patients with TB had a significantly lower NLR levels compared to those with B-CAP, so we utilized this biomarker for distinguishing between the disorders.

Defining nomograms for predicting prognosis of early and late recurrence in gastric cancer patients after radical gastrectomy

There are few studies on the predictive factors of early recurrence (ER) and late recurrence (LR) of advanced gastric cancer (GC) after curative surgery. Our study aims to explore the independent predictors influencing the prognosis between ER and LR in patients with advanced GC after curative intent surgery respectively. And we will further develop nomograms for prediction of post recurrence survival (PRS). Data of patients with GC who received radical gastrectomy was retrospectively collected. Recurrence was classified into ER and LR according to the 2 years after surgery as the cutoff value. Multivariate Cox regression analyses were used to explore significant predictors in our analysis. Then these significant predictors were integrated to construct nomograms. The 1-, 2- and 3-year probabilities of PRS in patients with ER were 30.00%, 16.36% and 11.82%, respectively. In contrast, the late group were 44.68%, 23.40%, and 23.30%, respectively. Low body mass index (hazard ratio [HR] = 0.86, P = .001), elevated monocytes count (HR = 4.54, P = .003) and neutrophil-lymphocyte ratio (HR = 1.03, P = .037) at the time of recurrence were risk factors of PRS after ER. Decreased hemoglobin (HR = 0.97, P = .008) and elevated neutrophil-lymphocyte ratio (HR = 1.06, P = .045) at the time of recurrence were risk factors of PRS after LR. The calibration curves for probability of 1-, 2-, and 3-year PRS showed excellent predictive effect. Internal validation concordance indexes of PRS were 0.722 and 0.671 for ER and LR respectively. In view of the different predictive factors of ER and LR of GC, the practical predictive model may help clinicians make reasonable decisions.

Association of neutrophil-to-lymphocyte ratio with clinical, pathological, radiological, laboratory features and disease outcomes of invasive breast cancer patients: A retrospective observational cohort study

Inflammatory conditions play part in the progression of malignancies, and markers signifying growth of these factors can indicate prognosis. Neutrophil-to-lymphocyte (NLR) is used as a marker of subclinical inflammation that may become an integral part of workup to indicate prognosis and associated pathology. This study aims to explore the association of NLR ratio with clinical characteristics, radiological assessment and staging, histopathology, and disease outcomes of breast cancer. A retrospective cohort study was conducted in a tertiary care center to include breast cancer patients that were diagnosed between January 2001 and December 2020. Data including tumor size, lymph nodes, metastasis, histological grading, ER/PR/HER2-neu status, molecular subtypes, clinical staging); nodal findings (sentinel and axillary); pathology from frozen section; and disease outcomes were assessed. Multivariable regression and Kaplan-Meier survival curves were employed to indicate the association of NLR with breast cancer features and disease-free survival. A total of 2050 patients had a median age of 50 years, median NLR levels of 2.14, most common pathology ductal followed by lobular, and most common site of metastasis being lungs followed by bones. Disease-free rate was 7.6%, and a recurrence rate of 1.8%, while 1.6% deaths were reported. NLR was found associated with age, treatment outcomes, tumor size, lymph nodes, metastasis and clinical staging. Other positive correlations were with Ki67 proliferation index, molecular subtypes, and tumor size on frozen section (at transverse and craniocaudal dimensions). Negative correlations were seen with estrogen and progesterone receptors. However, NLR was not found predictable of disease-free survival (P = .160). Significant predictors of disease-free survival were histological grading, ER, PR status, molecular subtype, and Ki67 proliferation index. NLR being a readily available marker has shown novel findings in its association with tumor staging, disease outcomes and characteristics of breast malignancy.

Systemic Inflammation and Lung Cancer: Is It a Real Paradigm? Prognostic Value of Inflammatory Indexes in Patients with Resected Non-Small-Cell Lung Cancer

Background (1): Our goal was to investigate if and how pre-operative inflammatory status can influence the long-term prognosis of patients undergoing lung surgery for cancer. Materials and Methods (2): This prospective observational study includes the agreement of all operable patients to the study, who were referred to our department between 1 January 2017 and 30 December 2018. The inflammatory pre-operative status of the patients was investigated by calculating albumin, CPR (c-protein reactive), complete blood count (neutrophils, lymphocytes, platelets, hemoglobin), and some other indexes referring to inflammatory status, namely the HALP amalgamated index, platelet-to-lymphocyte ratio (PLR), neutrophil-to-lymphocytes ratio (NLR), systemic immune-inflammation index (SII), and advanced lung cancer inflammation Index (ALI). The follow-up ended in November 2021. Patient overall survival was assessed using the Kaplan-Meier method. The log-rank test was used to compare survival rates. Variables significantly associated with survival at univariate analysis were entered int Cox multivariate analysis (stepwise mode) to assess their independent character. Hazard ratios and their 95% confidence intervals were calculated. Variables associated with p < 0.05 were considered significative. Results (3): We enrolled 257 patients in our study. The overall survival of the cohort was as follows: 1 year, 96.1%; 3 year, 81.3%; and 4 year, 74.2%. Univariate analysis showed risk factors for overall survival as follows: Thoracoscore ≥ 2 (p = 0.002); histology (p = 0.002); HALP < 32.2 (p = 0.0002); SII ≥ 808.9 (p = 0.0004); ALI < 34.86 (p = 0.0005); NLr ≥ 2.29 (p = 0.01); hemoglobin < 13 g/dl (p = 0.01); PLR ≥ 196.1 (p = 0.005); pN+ (p < 0.0001); pleural invasion (p = 0.0002); and presence of vascular or lymphatic tumor emboli (p = 0.0002). Multivariate Cox analysis (stepwise model) identified Thoracoscore ≥ 2 (p = 0.02); histology, HALP < 32.2 (p = 0.004), and pN (p < 0.0001) as independent predictors of death. Conclusion (4): Pre-operative inflammatory status strongly influences long-term prognosis in patients affected by NSCLC and undergoing surgery.

Quitting smoking after a cancer diagnosis is associated with high-risk neutrophil-to-lymphocyte ratio among tobacco use-related cancer survivors

Quitting smoking could potentially minimize the risk of a high neutrophil-to-lymphocyte ratio (NLR) among tobacco use-related (TUR) cancer survivors. A total of 1263 TUR cancer survivors aged 20 to 85 years old were investigated using data from the National Health and Nutritional Examination Survey 1999-2018. The primary outcome was the NLR, which was defined as having two levels: high-risk (≥ 3) and low-risk (< 3). The association between smoking cessation time and a high-risk NLR level was analyzed using weighted logistic regression models. Overall, the current smoking rate of TUR cancer survivors was found to be 21.7%. Older age (75 years above), gender and respiratory-related cancers are covariables associated with high risk of NLR levels for individual who identified as Non-Hispanic White (NHW). Non-Hispanic Black (NHB) (n = 27) who quit smoking after a cancer diagnosis were associated with the highest risk of a high NLR (OR 4.83, 95% CI 1.40-16.61, p = 0.01) compared to NHB nonsmokers (n = 139). These findings suggest that the risk of a high NLR level is strongly associated with the time of smoking cessation in NHB TUR cancer survivors. As a result, NHB TUR cancer survivors should quit smoking as soon as possible because the benefits of quitting smoking were observed over the 5 year period following smoking cessation.

Quantifying causal effects from observed data using quasi-intervention

BACKGROUND

Causal inference is a crucial element within medical decision-making. There have been many methods for investigating potential causal relationships between disease and treatment options developed in recent years, which can be categorized into two main types: observational studies and experimental studies. However, due to the nature of experimental studies, financial resources, human resources, and patients' ethical considerations, researchers cannot fully control the exposure of the research participants. Furthermore, most existing observational research designs are limited to determining causal relationships and cannot handle observational data, let alone determine the dosages needed for medical research.

RESULTS

This paper presents a new experimental strategy called quasi-intervention for quantifying the causal effect between disease and treatment options in observed data by using a causal inference method, which converts the potential effect of different treatment options on disease into computing differences in the conditional probability. We evaluated the accuracy of the quasi-intervention by quantifying the impact of adjusting Chinese patients' neutrophil-to-lymphocyte ratio (NLR) on their overall survival (OS) (169 lung cancer patients and 79 controls).The results agree with the literature in this study, consisting of nine papers on cohort studies on the NLR and the prognosis of lung cancer patients, proving that our method is correct.

CONCLUSION

Taken together, the results imply that quasi-intervention is a promising method for quantifying the causal effect between disease and treatment options without clinical trials, and it could improve confidence about treatment options' efficacy and safety.

Development and validation of nomogram prognostic model for early-stage T1-2N0M0 small cell lung cancer: A population-based analysis

BACKGROUND

Survival outcomes of early-stage T1-2N0M0 small cell lung cancer (SCLC) patients differ widely, and the existing Veterans Administration Lung Study Group (VALSG) or TNM staging system is inefficient at predicting individual prognoses. In our study, we developed and validated nomograms for individually predicting overall survival (OS) and lung cancer-specific survival (LCSS) in this special subset of patients.

METHODS

Data on patients diagnosed with T1-2N0M0 SCLC between 2000 and 2015 were extracted from the Surveillance, Epidemiology, and End Results (SEER) database. All enrolled patients were split into a training cohort and a validation cohort according to the year of diagnosis. Using multivariable Cox regression, significant prognostic factors were identified and integrated to develop nomograms for 1-, 3-, and 5-year OS and LCSS prediction. The prognostic performance of our new model was measured by the concordance index (C-index) and calibration curve. We compared our latest model and the 8th AJCC staging system using decision curve analyses (DCA). Kaplan-Meier survival analyses were applied to test the application of the risk stratification system.

RESULTS

A total of 1,147 patients diagnosed from 2000 to 2011 were assigned to the training cohort, and 498 cases that were diagnosed from 2012 to 2015 comprised the validation cohort. Age, surgery, lymph node removal (LNR), and chemotherapy were independent predictors of LCSS. The variables of sex, age, surgery, LNR, and chemotherapy were identified as independent predictors of OS. The above-mentioned prognostic factors were entered into the nomogram construction of OS and LCSS. The C-index of this model in the training cohort was 0.663, 0.702, 0.733, and 0.658, 0.702, 0.733 for predicting 1-, 3-, and 5-year OS and LCSS, respectively. Additionally, in the validation cohort, there were 0.706, 0.707, 0.718 and 0.712, 0.691, 0.692. The calibration curve showed accepted prediction accuracy between nomogram-predicted survival and actual observed survival, regardless of OS or LCSS. In addition, there were significant distinctions in the survival curves of OS and LCSS between different risk groups stratified by prognostic scores. Compared with the 8th AJCC staging system, our new model also improved net benefits.

CONCLUSIONS

We developed and validated novel nomograms for individual prediction of OS and LCSS, integrating the characteristics of patients and tumors. The model showed superior reliability and may help clinicians make treatment strategies and survival predictions for early-stage T1-2N0M0 SCLC patients.

Association between Intraoperative Blood Transfusion, Regional Anesthesia and Outcome after Pediatric Tumor Surgery for Nephroblastoma

BACKGROUND

Recent data suggest that anesthesiologic interventions-e.g., the choice of the anesthetic regimen or the administration of blood products-might play a major role in determining outcome after tumor surgery. In contrast to adult patients, only limited data are available regarding the potential association of anesthesia and outcome in pediatric cancer patients.

METHODS

A retrospective multicenter study assessing data from pediatric patients (0-18 years of age) undergoing surgery for nephroblastoma between 2004 and 2018 was conducted at three academic centers in Europe. Overall and recurrence-free survival were the primary outcomes of the study and were evaluated for a potential impact of intraoperative administration of erythrocyte concentrates, the use of regional anesthesia and the choice of the anesthetic regimen. The length of stay on the intensive care unit, the time to hospital discharge after surgery and blood neutrophil-to-lymphocyte ratio were defined as secondary outcomes.

RESULTS

In total, data from 65 patients were analyzed. Intraoperative administration of erythrocyte concentrates was associated with a reduction in recurrence-free survival (hazard ratio (HR) 7.59, 95% confidence interval (CI) 1.36-42.2, p = 0.004), whereas overall survival (HR 5.37, 95% CI 0.42-68.4, p = 0.124) was not affected. The use of regional anesthesia and the choice of anesthetic used for maintenance of anesthesia did not demonstrate an effect on the primary outcomes. It was, however, associated with fewer ICU transfers, a shortened time to discharge and a decreased postoperative neutrophil-to-lymphocyte ratio.

CONCLUSIONS

The current study provides the first evidence for a possible association between blood transfusion as well as anesthesiologic interventions and outcome after pediatric cancer surgery.

Prognostic Value of Pretreatment Neutrophil-to-Lymphocyte Ratio in HER2-Positive Metastatic Breast Cancer

This study aimed to examine the prognostic value of the neutrophil-to-lymphocyte ratio (NLR) and other clinicopathological features in HER2+ MBC patients who received first-line anti-HER2 therapy. A total of 129 patients were assigned to NLR-low and NLR-high groups based on a cutoff value of 3.0 at baseline. Peripheral blood lymphocyte subsets and gene mutations in circulating tumor DNA were analyzed by flow cytometry and Next-generation sequencing, respectively. Survival was evaluated by the Kaplan−Meier method and Cox regression analysis. Of the 129 patients, 77 and 52 were assigned to the NLR-low (≤3) and NLR-high (>3) groups, respectively. Compared with NLR-high patients, the NLR-low patients had significantly longer median progression-free survival (PFS) (11.7 vs. 7.7 months) (p = 0.001, HR = 2.703 95% CI 1.543−4.736 and overall survival (OS) (37.4 vs. 28.7 months) (p = 0.044, HR = 2.254 95% CI 1.024−4.924). Furthermore, this association was independent of metastatic sites or estrogen receptor status. Peripheral blood CD3+ (p = 0.034) and CD4+ (p = 0.010) T cell numbers were significantly higher in the NLR-low group than the NLR-high group. The mutational profile of MBC was generally similar between the two groups. Baseline NLR was a prognostic factor of PFS and OS for patients with HER2+ MBC in the first-line setting. These results may facilitate the selection of patients who will benefit most from anti-HER2 treatment.

The clinical significance of perioperative inflammatory index as a prognostic factor for patients with retroperitoneal soft tissue sarcoma

BACKGROUND

The prognostic factors of retroperitoneal soft tissue sarcoma (STS) have been explored but not yet certain. This study evaluated the prognostic impact of various preoperative clinical parameters and inflammatory indices in primary STS, with a particular focus on the transition of inflammatory index before and after tumor resection in de-differentiated liposarcoma (DD-LPS).

METHODS

The clinical data of 113 patients with primary retroperitoneal STS receiving tumor resection were reviewed. Six variables (neutrophils, platelets, C-reactive protein (CRP), lymphocytes, albumin, and hemoglobin) in the blood samples were measured and nine inflammatory indices (neutrophil-lymphocyte ratio (NLR), CRP-lymphocyte ratio (CLR), platelet-lymphocyte ratio (PLR), neutrophil-albumin ratio (NAR), CRP-albumin ratio (CAR), platelet-albumin ratio (PAR), HALP (hemoglobin, albumin, lymphocyte and platelet), prognostic nutrition index (PNI), and modified Glasgow Prognostic Score (mGPS)) were calculated. The prognostic value of the indices was analyzed by univariate and multivariate analyses.

RESULTS

Elevated NLR, CLR, PLR, NAR, CAR, PAR, and mGPS were associated with a worse overall survival (p = 0.0124, 0.0011, 0.049, 0.0047, 0.0085, 0.0332, and 0.0086, respectively) in univariate analysis. Multivariate analysis showed that elevated CLR and DD-LPS were associated with poor overall survival (p = 0.0267 and 0.0218, respectively) in all retroperitoneal STS. In DD-LPD, patients with preoperative high CLR, whose postoperative CLR was normalized, demonstrated a favorable survival rate similar to those with preoperative low CLR.

CONCLUSIONS

Elevated CLR before surgery as well as DD-LPS were poor prognostic markers for overall survival in primary retroperitoneal STS. Perioperative CLR normalization may be related to a favorable prognosis in DD-LPS.

Immune Modulatory Effects of Nonsteroidal Anti-inflammatory Drugs in the Perioperative Period and Their Consequence on Postoperative Outcome

Nonsteroidal anti-inflammatory drugs are among the most commonly administered drugs in the perioperative period due to their prominent role in pain management. However, they potentially have perioperative consequences due to immune-modulating effects through the inhibition of prostanoid synthesis, thereby affecting the levels of various cytokines. These effects may have a direct impact on the postoperative outcome of patients since the immune system aims to restore homeostasis and plays an indispensable role in regeneration and repair. By affecting the immune response, consequences can be expected on various organ systems. This narrative review aims to highlight these potential immune system-related consequences, which include systemic inflammatory response syndrome, acute respiratory distress syndrome, immediate and persistent postoperative pain, effects on oncological and neurologic outcome, and wound, anastomotic, and bone healing.

Anesthesia Techniques and Long-Term Oncological Outcomes

Despite advances in cancer treatments, surgery remains one of the most important therapies for solid tumors. Unfortunately, surgery promotes angiogenesis, shedding of cancer cells into the circulation and suppresses anti-tumor immunity. Together this increases the risk of tumor metastasis, accelerated growth of pre-existing micro-metastasis and cancer recurrence. It was theorized that regional anesthesia could influence long-term outcomes after cancer surgery, however new clinical evidence demonstrates that the anesthesia technique has little influence in oncologic outcomes. Several randomized controlled trials are in progress and may provide a better understanding on how volatile and intravenous hypnotics impact cancer progression. The purpose of this review is to summarize the effect of the anesthesia techniques on the immune system and tumor microenvironment (TME) as well as to summarize the clinical evidence of anesthesia techniques on cancer outcomes.

Ultrasonographic assessment of renal perfusion in bitches with mammary carcinoma treated with long-term carprofen

The aim of this study was to evaluate renal hemodynamics, routine clinical and laboratory parameters used to estimate renal function, and clinical evolution during six months in bitches with mammary carcinomas that underwent mastectomy and were treated (TG) or not (CG) with carprofen for three months after surgery. Twenty-six bitches with mammary carcinoma were equally distributed into TG that received carprofen 4.4 mg/kg/day for 90 days and CG that did not receive anti-inflammatory medication. Renal artery Doppler flowmetry, contrast-enhanced ultrasound (CEUS) of renal parenchyma, haematological, biochemical and clinical analyses were obtained once a month. These data were compared between groups and time via analysis of variance (ANOVA) in a completely randomized design with repeated measures (P < 0.05). On B-mode ultrasound, the area of the renal artery was greater (P = 0.0003) in the TG. Regarding laboratory findings, haematocrit and haemoglobin were similar in both groups, showing a significant and gradual increase after three months of treatment; MCV, MHC, and MCHC were increased (P < 0.05) and lymphocyte and band counts decreased (P < 0.05) in the TG. Regarding biochemical tests, ALT was the only parameter with a significant difference, being higher (P = 0.0272) in the treated group. It can be concluded that the use of carprofen for 90 days causes minimal changes in renal perfusion, erythrocyte parameters and ALT activity, and reduces the proportion of blood inflammatory cells. Therefore, use of this medication can be carried out safely in patients who require auxiliary cancer treatment.

Women with Abnormal Mammographic Findings and High Neutrophil-to-Lymphocyte Ratio have the Worst Dietary Carbohydrate Quality Index

INTRODUCTION

There are gaps in knowledge in breast cancer prevention studies focusing on interactions among mammographic findings, inflammation, and diet, especially those related to carbohydrates.

OBJECTIVE

We aimed to verify the association among mammographic findings, inflammatory markers, and carbohydrate quality index (CQI) in women.

METHODOLOGY

This was a cross-sectional study of 532 women assisted in a healthcare service. The enrolled women were divided into two groups according to their mammographic findings: those without and those with abnormal mammographic findings. Two 24-hour dietary reminders were applied, and CQI was determined based on four components: fibers, glycemic index, ratio between whole and total grains, and ratio between solid and total carbohydrates. The neutrophil-to-lymphocyte ratio (NLR) was calculated as an inflammatory marker.

RESULTS

There were 178 (33.5%) women with abnormal mammographic findings, and 20 (3.8%) had NLR. There was no association between CQI and mammographic findings and NLR. Women with abnormal mammographic findings and high NLR had lower CQI (p = 0.039) and lower whole total ratio (p = 0.024).

CONCLUSION

Women with abnormal findings and high NLR had worse CQI and worse overall total grain ratio.

Perioperative NSAIDs and Long-Term Outcomes After cancer Surgery: a Systematic Review and Meta-analysis

Purpose of Review

This review investigated the use of perioperative non-steroidal anti-inflammatory drugs (NSAIDs) and long-term outcomes in cancer surgery patients, and whether this is dependent on cancer type, type of NSAID and timing of administration.

Findings

Perioperative NSAID use was found to be associated with longer disease-free survival (hazard ration, HR = 0.84 (95% CI, 0.73–0.97)) and overall survival (HR = 0.78 (95% CI, 0.64–0.94)). No difference was found between different types of NSAID for disease-free survival, although in overall survival ketorolac use was significant (HR = 0.63 (95% CI, 0.42–0.95)). Analysis on the timing of NSAID administration found no subgroup to be associated with cancer outcomes. The cancer-type analysis found an association with outcomes in breast and ovarian cancers. However, the level of certainty remains very low, mostly due to the heterogeneity and the retrospective nature of most studies.

Summary

Perioperative NSAID use may be associated with increased disease-free and overall survival after cancer surgery. This may be dependent on the type of cancer and type of NSAID, and further research is needed to support this. These data may inform future prospective trials, which are needed to determine the clinical impact, as well as optimal NSAID regimen.

Perioperative pain, analgesics and cancer-related outcomes: where do we stand?

Cancer-related pain is one of the most common and debilitating symptoms among cancer patients. Undertreated cancer-related pain interferes with daily activities and increases morbidity and mortality. While opioids continue to play an essential role in treating moderate to severe cancer-related pain, they are associated with many adverse effects including misuse. While preclinical and retrospective studies have shown a negative association between opioid use and cancer outcomes, randomized control trials demonstrate that opioid use does not influence cancer recurrence. Additionally, analgesics and adjuvants used for perioperatively or chronic pain control are unlikely to improve oncological outcomes. This article focuses on the pharmacological management of cancer-related pain and offers an overview regarding the use of these medications perioperatively and the cancer outcomes.

Neutrophil-to-lymphocyte ratio is correlated to driver gene mutations in surgically-resected non-small cell lung cancer and its post-operative evolution impacts outcomes

BACKGROUND

We sought to evaluate prognostic value of neutrophil-to-lymphocyte ratio (NLR) in surgically resected non-small cell lung cancer (NSCLC) and its correlation to oncogenic drivers. We retrospectively reviewed data of patients who underwent anatomic lung resection for NSCLC and whose mutational status was known, from 4 department of thoracic surgery, over the period 2008 to 2019. Primary endpoints were overall survival (OS) and time to recurrence (TTR). Clinical and molecular factors were investigated in the univariate and multivariate analysis for their association with the primary endpoints.

RESULTS

2027 patients were included in the analysis. Correlations between NLR and OS (R²=0.21), NLR and TTR (R²=0.085) were significant (P<0.0001), with corresponding Pearson R of -0.46 (P<0.0001) and -0.292 (P<0.001), respectively. ROC curve analysis defined NLR cut-off value at 4.07. In the univariable analysis, the median OS was 66 months (95% CI: 62.94 - 69.06) in case of pre-operative NLR ≤ 4.07 and 38 months (95% CI: 36.73 - 39.27) in case of pre-operative NLR > 4.07 (P<0.0001), with corresponding 5-y OS of 72% and 29% respectively. Median TTR was associated with pre-operative NLR. Median TTR was 25 months (95% CI: 21.52 - 28.48) in case of pre-operative NLR ≤ 4.07 and 17 months (95% CI: 16.04 - 17.96) in case of pre-operative NLR > 4.07 (P<0.0001), with corresponding 5-years TTR of 18% and 9% respectively. Significant correlations between NLR >4.07 and KRAS (Cramer's V = 0.082, P < 0.0001) and EGFR mutations (Cramer's V = 0.064, P = 0.004) were observed.

CONCLUSIONS

Low pre-operative NLR is associated with longer OS in patients with resected NSCLC. Low pre-operative NLR is not associated with longer TTR in multivariate analysis. Correlation between the high NLR and KRAS/EGFR mutations were observed.

Breast Cancer and Anaesthesia: Genetic Influence

Breast cancer is the leading cause of mortality in women. It is a heterogeneous disease with a high degree of inter-subject variability even in patients with the same type of tumor, with individualized medicine having acquired significant relevance in this field. The clinical and morphological heterogeneity of the different types of breast tumors has led to a diversity of staging and classification systems. Thus, these tumors show wide variability in genetic expression and prognostic biomarkers. Surgical treatment is essential in the management of these patients. However, the perioperative period has been found to significantly influence survival and cancer recurrence. There is growing interest in the pro-tumoral effect of different anaesthetic and analgesic agents used intraoperatively and their relationship with metastatic progression. There is cumulative evidence of the influence of anaesthetic techniques on the physiopathological mechanisms of survival and growth of the residual neoplastic cells released during surgery. Prospective randomized clinical trials are needed to obtain quality evidence on the relationship between cancer and anaesthesia. This document summarizes the evidence currently available about the effects of the anaesthetic agents and techniques used in primary cancer surgery and long-term oncologic outcomes, and the biomolecular mechanisms involved in their interaction.

Association between neutrophil-lymphocyte ratio change during living donor liver transplantation and graft survival

Preoperative neutrophil-lymphocyte ratio (NLR), has shown a predictive value in living donor liver transplantation (LDLT). However, the change in the NLR during LDLT has not been fully investigated. We aimed to compare graft survival between the NLR increase and decrease during LDLT. From June 1997 to April 2019, we identified 1292 adult LDLT recipients with intraoperative NLR change. The recipients were divided according to NLR change: 103 (8.0%) in the decrease group and 1189 (92.0%) in the increase group. The primary outcome was graft failure in the first year. In addition, variables associated with NLR change during LDLT were evaluated. During 1-year follow-up, graft failure was significantly higher in the decrease group (22.3% vs. 9.1%; hazard ratio 1.87; 95% confidence interval 1.10-3.18; p = 0.02), but postoperative complications did not differ between two groups. This finding was consistent for the overall follow-up. Variables associated with NLR decrease included preoperative NLR > 4, model for end-stage liver disease score, intraoperative inotropic infusion and red blood cell transfusion, and operative duration. The least absolute shrinkage and selection operator model yielded similar results. NLR decrease during LDLT appeared to be independently associated with graft survival. Further studies are needed to confirm our findings.

Perioperative Glucocorticoids are Associated with Improved Recurrence-Free Survival After Pancreatic Cancer Surgery: A Retrospective Cohort Study with Propensity Score-Matching

Purpose

Perioperative anesthetic management may affect long-term outcome after cancer surgery. This study investigated the effect of perioperative glucocorticoids on long-term survival in patients after radical resection for pancreatic cancer.

Methods

In this retrospective cohort study with propensity score-matching, patients who underwent radical resection for pancreatic cancer from January 2005 to December 2016 were recruited. Baseline and perioperative data including use of glucocorticoids for prevention of postoperative nausea and vomiting were collected. Patients were followed up by qualified personnel for cancer recurrence and survival. The primary outcome was the recurrence-free survival. Outcomes were compared before and after propensity matching. The association between perioperative glucocorticoid use and recurrence-free survival was analyzed with multivariable regression models.

Results

A total of 215 patients were included in the study; of these, 112 received perioperative glucocorticoids and 103 did not. Patients were followed up for a median of 74.0 months (95% confidence interval [CI] 68.3–79.7). After propensity score-matching, 64 patients remained in each group. The recurrence-free survivals were significantly longer in patients with glucocorticoids than in those without (full cohort: median 12.0 months [95% CI 6.0–28.0] vs 6.9 months [4.2–17.0], P<0.001; matched cohort: median 12.0 months [95% CI 5.8–26.3] vs 8.3 months [4.3–18.2], P=0.015). After correction for confounding factors, perioperative glucocorticoids were significantly associated with prolonged recurrence-free survivals (full cohort: HR 0.66, 95% CI 0.48–0.92, P=0.015; matched cohort: HR 0.54, 95% CI 0.35–0.84, P=0.007).

Conclusion

Perioperative use of low-dose glucocorticoids is associated with improved recurrence-free survival in patients following radical surgery for pancreatic cancer.

Postoperative, but not preoperative, inflammation-based prognostic markers are prognostic factors in stage III colorectal cancer patients

Background

Recent evidence suggests that both preoperative and postoperative inflammation-based prognostic markers are useful for predicting the survival of colorectal cancer (CRC) patients. However, associations between longitudinal changes in inflammation-based prognostic markers and prognosis are controversial.

Methods

The subjects of this study were 568 patients with stage III CRC between 2008 and 2014. Preoperative and postoperative neutrophil-to-lymphocyte ratio (NLR), lymphocyte-to-monocyte ratio (LMR), C-reactive protein/albumin ratio (CAR) and lymphocyte-to-C-reactive protein ratio (LCR) were calculated to assess the inflammatory state of subjects. Subjects were stratified into three groups for each marker: preoperatively low inflammatory state (normal group), preoperatively high but postoperatively low inflammatory state (normalised group) and persistently high inflammatory state (elevated group). Multivariable analyses for overall survival (OS) and recurrence-free survival (RFS) were performed to adjust for well-established clinicopathologic factors.

Results

For all assessed markers, the normalised group had a significantly better prognosis than the elevated group and a similar prognosis as the normal group for both OS and RFS.

Conclusions

Postoperative, but not preoperative, inflammation-based prognostic markers more accurately predict OS and RFS in patients with stage III CRC.

Multicentre randomised phase II study of the perioperative administration of flurbiprofen axetil in patients with non-small cell lung cancer: study protocol of the FLAX Study

INTRODUCTION

In patients with non-small cell lung cancer, surgical treatment with postoperative adjuvant chemotherapy is performed. However, the improvement of overall survival achieved by postoperative adjuvant chemotherapy may be insufficient in consideration of the deterioration of quality of life (QOL). Considering the relationships among surgical treatments, inflammation and carcinogenesis, non-steroidal anti-inflammatory drugs (NSAIDs) are a candidate postoperative treatment for preventing recurrence and maintaining QOL. In this study, we investigate the effects of the perioperative administration of flurbiprofen axetil on postoperative recurrence in patients with non-small cell lung cancer.

METHODS AND ANALYSIS

This study is a multicentre, parallel group, open label, randomised controlled trial. Patients clinically suspected of non-small cell lung cancer are randomly assigned to the flurbiprofen axetil group or the no-NSAIDs group. A total of 420 patients (210 per group) will be registered. The primary analysis will evaluate the treatment effect of flurbiprofen axetil on postoperative recurrence.

ETHICS AND DISSEMINATION

The study protocol was approved by the Clinical Research Review Board of Saitama Medical University in September 2019 (No. 192002) and will be approved by each institutional review board of all participating institutions before patient enrolment. This study complies with the latest version of the Declaration of Helsinki, Clinical Trial Act and related notifications. Results will be published in a peer-reviewed journal.

TRIAL REGISTRATION NUMBER

Japan Registry of Clinical Trials (jRCTs031190167; Pre-results) (https://jrct.niph.go.jp/).

Impact of Non-Steroidal Anti-Inflammatory Drugs on Recurrence and Survival after Melanoma Surgery: A Cohort Study

The aim of the study was to investigate if there was an association between intraoperative NSAID use and recurrence or survival. A cohort of patients who underwent sentinel lymph node biopsy for the treatment of cutaneous melanoma was retrospectively recruited. After applying inclusion and exclusion criteria, 516 were included (NSAIDs = 307). The 10-year melanoma-specific survival was 63.2%. Log-rank test showed no statistically significant differences in time to treatment failure, melanoma-specific survival, disease-free survival, and overall survival between the study groups. The current study did not support the use of intraoperative NSAIDs in preventing death or recurrence in patients with melanoma.

Development and validation of a prognostic model of resectable small-cell lung cancer: a large population-based cohort study and external validation

Background

Survival outcomes of patients with resected SCLC differ widely. The aim of our study was to build a model for individualized risk assessment and accurate prediction of overall survival (OS) in resectable SCLC patients.

Methods

We collected 1052 patients with resected SCLC from the Surveillance, Epidemiology, and End Results (SEER) database. Independent prognostic factors were selected by COX regression analyses, based on which a nomogram was constructed by R code. External validation were performed in 114 patients from Shandong Provincial Hospital. We conducted comparison between the new model and the AJCC staging system. Kaplan–Meier survival analyses were applied to test the application of the risk stratification system.

Results

Sex, age, T stage, N stage, LNR, surgery and chemotherapy were identified to be independent predictors of OS, according which a nomogram was built. Concordance index (C-index) of the training cohort were 0.721, 0.708, 0.726 for 1-, 3- and 5-year OS, respectively. And that in the validation cohort were 0.819, 0.656, 0.708, respectively. Calibration curves also showed great prediction accuracy. In comparison with 8th AJCC staging system, improved net benefits in decision curve analyses (DCA) and evaluated integrated discrimination improvement (IDI) were obtained. The risk stratification system can significantly distinguish the ones with different survival risk. We implemented the nomogram in a user-friendly webserver.

Conclusions

We built a novel nomogram and risk stratification system integrating clinicopathological characteristics and surgical procedure for resectable SCLC. The model showed superior prediction ability for resectable SCLC.

Prognostic value of neutrophil-lymphocyte ratio in critically ill patients with cancer: a propensity score matching study

BACKGROUND

Neutrophil-lymphocyte ratio (NLR) has shown a good prognostic value in many different type of malignancies. The purpose of this study was to investigate the relationship between NLR and the outcome of critically ill patients with cancer.

METHODS

We performed a single-institution, retrospective study of 1317 adult critically ill patients with cancer and determined the optimal cut-off for NLR by X-tile software. Propensity score matching (PSM) and inverse probabilities of treatment weighting (IPTW) were performed to control confounders. Cox proportional hazards model was used to evaluate the relationship between NLR and 28-day, 6-month and 1-year all-cause mortality. Kaplan-Meier method, subgroup analysis, and receiver operating characteristics (ROC) analysis were applied to assess the prognostic value of NLR.

RESULTS

The cut-off value for NLR was 17.6. Cox proportional hazards model demonstrated that high NLR (> 17.6) was independently associated with 28-day, 6-month and 1-year all-cause mortality with hazard ratio (HR) of 1.58 (1.29, 1.94), 1.51 (1.28, 1.77) and 1.45 (1.25, 1.69), respectively. The results were consistent with survival analyses (p < 0.001, log-rank test). The ROC analyses showed that the discrimination abilities of NLR were better than other blood-based biomarkers.

CONCLUSION

NLR is a promising prognostic indicator of survival in unselected critical ill patients with cancer.

Prognostic impact of neutrophil-to-lymphocyte ratio in renal cell carcinoma: a systematic review and meta-analysis

AIM

Estimate prognosis and clinical outcome of patients with localized or metastatic renal cell carcinoma (RCC) is an important issue which drive our medical decisions.

METHODS

We carried out a meta-analysis of available clinical studies exploring neutrophil-to-lymphocyte ratio (NLR) in RCC in order to evaluate if this ratio could be correlated to overall survival (OS) and progression-free survival (PFS) of patients with localized/metastatic RCC.

RESULTS

In overall population higher NLR resulted in worst OS and PFS (OS pooled hazard ratio of 1.80; 95% CI: 1.61-2.00; I² 45%; PFS pooled hazard ratio of 1.69; 95% CI: 1.42-2.01; I² 81%), this negative correlation was also confirmed in both metastatic and nonmetastatic patients.

CONCLUSION

The NLR ratio is a variable correlated to prognosis in RCC patients.

Harnessing cancer immunotherapy during the unexploited immediate perioperative period

The immediate perioperative period (days before and after surgery) is hypothesized to be crucial in determining long-term cancer outcomes: during this short period, numerous factors, including excess stress and inflammatory responses, tumour-cell shedding and pro-angiogenic and/or growth factors, might facilitate the progression of pre-existing micrometastases and the initiation of new metastases, while simultaneously jeopardizing immune control over residual malignant cells. Thus, application of anticancer immunotherapy during this critical time frame could potentially improve patient outcomes. Nevertheless, this strategy has rarely been implemented to date. In this Perspective, we discuss apparent contraindications for the perioperative use of cancer immunotherapy, suggest safe immunotherapeutic and other anti-metastatic approaches during this important time frame and specify desired characteristics of such interventions. These characteristics include a rapid onset of immune activation, avoidance of tumour-promoting effects, no or minimal increase in surgical risk, resilience to stress-related factors and minimal induction of stress responses. Pharmacological control of excess perioperative stress-inflammatory responses has been shown to be clinically feasible and could potentially be combined with immune stimulation to overcome the direct pro-metastatic effects of surgery, prevent immune suppression and enhance immunostimulatory responses. Accordingly, we believe that certain types of immunotherapy, together with interventions to abrogate stress-inflammatory responses, should be evaluated in conjunction with surgery and, for maximal effectiveness, could be initiated before administration of adjuvant therapies. Such strategies might improve the overall success of cancer treatment.

The Prognostic Value of Elevated Perioperative Neutrophil-Lymphocyte Ratio in Predicting Postoperative Atrial Fibrillation After Cardiac Surgery: A Systematic Review and Meta-Analysis

BACKGROUND

The neutrophil-lymphocyte ratio (NLR) is an emerging inflammatory perioperative biomarker which has been studied to predict the incidence of postoperative atrial fibrillation (POAF) after cardiac surgery. This systematic review and meta-analysis aimed to evaluate the prognostic accuracy of elevated perioperative NLR in predicting POAF after cardiac surgery.

METHODS

Multiple databases were searched from inception to May 2019 for prognostic studies on perioperative NLR and POAF following cardiac surgery. Maximally adjusted odds ratios (OR) with associated confidence intervals were obtained from each included study and pooled using random effects inverse variance modelling for preoperative NLR measurements, while standardised mean differences were pooled for postoperative NLR values. The significance of inter- and intra-study heterogeneity was explored using meta-regression.

RESULTS

1,799 unique studies satisfied selection criteria, from which 12 studies incorporating 9,262 participants were included. Elevated preoperative NLR significantly predicted POAF, with a pooled OR of 1.42 (95% CI 1.16-1.72). Multiple predefined covariates contributed to inter-study heterogeneity; however, only prevalence of hypertension (p=0.0055), history of congestive cardiac failure (p=0.0282) and average ejection fraction (p=0.0359) were significant effect modifiers. Elevated postoperative NLR was not a significant predictor of POAF (standardised mean difference 1.60 [95% CI -0.56-3.77] between POAF+ and POAF- groups).

CONCLUSIONS

Elevated preoperative NLR is a promising prognostic biomarker for POAF, but residual sources of heterogeneity remain. Larger scale validation studies are required to justify the integration of preoperative NLR testing into routine clinical practice.

Intraoperative ketorolac in high-risk breast cancer patients. A prospective, randomized, placebo-controlled clinical trial

BACKGROUND

Ketorolac has been associated with a lower risk of recurrence in retrospective studies, especially in patients with positive inflammatory markers. It is still unknown whether a single dose of pre-incisional ketorolac can prolong recurrence-free survival.

METHODS

The KBC trial is a multicenter, placebo-controlled, randomized phase III trial in high-risk breast cancer patients powered for 33% reduction in recurrence rate (from 60 to 40%). Patients received one dose of ketorolac tromethamine or a placebo before surgery. Eligible patients were breast cancer patients, planned for curative surgery, and with a Neutrophil-to-Lymphocyte Ratio≥4, node-positive disease or a triple-negative phenotype. The primary endpoint was Disease-Free Survival (DFS) at two years. Secondary endpoints included safety, pain assessment and overall survival.

FINDINGS

Between February 2013 and July 2015, 203 patients were assigned to ketorolac (n = 96) or placebo (n = 107). Baseline characteristics were similar between arms. Patients had a mean age of 55.7 (SD14) years. At two years, 83.1% of the patients were alive and disease free in the ketorolac vs. 89.7% in the placebo arm (HR: 1.23; 95%CI: 0.65-2.31) and, respectively, 96.8% vs. 98.1% were alive (HR: 1.09; 95%CI: 0.34-3.51).

CONCLUSIONS

A single administration of 30 mg of ketorolac tromethamine before surgery does not increase disease-free survival in high risk breast cancer patients. Overall survival difference between ketorolac tromethamine group and placebo group was not statistically significant. The study was however underpowered because of lower recurrence rates than initially anticipated. No safety concerns were observed.

TRIAL REGISTRATION

ClinicalTrials.gov NCT01806259.

Potential Benefit of Intra-operative Administration of Ketorolac on Breast Cancer Recurrence According to the Patient's Body Mass Index

Background

Nonsteroidal anti-inflammatory drugs (NSAIDs) are currently used in some countries as analgesics in primary cancer surgery. Retrospective studies suggest that NSAIDs could reduce breast cancer recurrences. Because NSAIDs also act on biological mechanisms present in patients with increased adiposity, we aimed at assessing whether the intra-operative administration of ketorolac or diclofenac would be associated with a reduction of recurrence in patients with elevated body mass index (BMI).

Methods

We considered two institutional retrospective series of 827 and 1007 patients evaluating the administration of ketorolac (n = 529 with, n = 298 without) or diclofenac (n = 787 with, n = 220 without). The BMI subgroups were defined as less than 25 kg/m2 (lean) and 25 or more kg/m2 (overweight and obese). Cumulative incidence estimation of distant metastases as well as Fine-Gray and Dixon-Simon models was used. These analyses were adjusted for clinico-pathological variables. All statistical tests were two-sided.

Results

The administration of ketorolac was statistically significantly associated with decreased incidence of distant recurrences (adjusted hazard ratio [aHR]= 0.59, 95% confidence interval [CI] = 0.37 to 0.96, P = .03). In particular, the association was evident in the high-body mass index (BMI) group of patients (aHR = 0.55, 95% CI = 0.31 to 0.96, P = .04). The administration of diclofenac was not statistically significantly associated with decreased incidence of distant recurrences, either in the global population or in the BMI subgroups.

Conclusions

These results show that the intra-operative administration of ketorolac, but not diclofenac, is statistically significantly associated with a reduction of distant recurrences in patients with increased BMI. Altogether, this study points to a potentially important repositioning of ketorolac in the intra-operative treatment of patients with elevated BMI that, if prospectively validated, might be as impactful as and cheaper than adjuvant systemic anticancer therapies.

Arachidonic Acid Metabolism and Kidney Inflammation

As a major component of cell membrane lipids, Arachidonic acid (AA), being a major component of the cell membrane lipid content, is mainly metabolized by three kinds of enzymes: cyclooxygenase (COX), lipoxygenase (LOX), and cytochrome P450 (CYP450) enzymes. Based on these three metabolic pathways, AA could be converted into various metabolites that trigger different inflammatory responses. In the kidney, prostaglandins (PG), thromboxane (Tx), leukotrienes (LTs) and hydroxyeicosatetraenoic acids (HETEs) are the major metabolites generated from AA. An increased level of prostaglandins (PGs), TxA₂ and leukotriene B4 (LTB₄) results in inflammatory damage to the kidney. Moreover, the LTB₄-leukotriene B4 receptor 1 (BLT1) axis participates in the acute kidney injury via mediating the recruitment of renal neutrophils. In addition, AA can regulate renal ion transport through 19-hydroxystilbenetetraenoic acid (19-HETE) and 20-HETE, both of which are produced by cytochrome P450 monooxygenase. Epoxyeicosatrienoic acids (EETs) generated by the CYP450 enzyme also plays a paramount role in the kidney damage during the inflammation process. For example, 14 and 15-EET mitigated ischemia/reperfusion-caused renal tubular epithelial cell damage. Many drug candidates that target the AA metabolism pathways are being developed to treat kidney inflammation. These observations support an extraordinary interest in a wide range of studies on drug interventions aiming to control AA metabolism and kidney inflammation.

Dual Actions of Ketorolac in Metastatic Ovarian Cancer

Cytoreductive surgery and chemotherapy are cornerstones of ovarian cancer treatment, yet disease recurrence remains a significant clinical issue. Surgery can release cancer cells into the circulation, suppress anti-tumor immunity, and induce inflammatory responses that support the growth of residual disease. Intervention within the peri-operative window is an under-explored opportunity to mitigate these consequences of surgery and influence the course of metastatic disease to improve patient outcomes. One drug associated with improved survival in cancer patients is ketorolac. Ketorolac is a chiral molecule administered as a 1:1 racemic mixture of the S- and R-enantiomers. The S-enantiomer is considered the active component for its FDA indication in pain management with selective activity against cyclooxygenase (COX) enzymes. The R-enantiomer has a previously unrecognized activity as an inhibitor of Rac1 (Ras-related C3 botulinum toxin substrate) and Cdc42 (cell division control protein 42) GTPases. Therefore, ketorolac differs from other non-steroidal anti-inflammatory drugs (NSAIDs) by functioning as two distinct pharmacologic entities due to the independent actions of each enantiomer. In this review, we summarize evidence supporting the benefits of ketorolac administration for ovarian cancer patients. We also discuss how simultaneous inhibition of these two distinct classes of targets, COX enzymes and Rac1/Cdc42, by S-ketorolac and R-ketorolac respectively, could each contribute to anti-cancer activity.

Perioperative Management May Improve Long-term Survival in Patients After Lung Cancer Surgery: A Retrospective Cohort Study

BACKGROUND:

Surgical resection is the main treatment for patients with non–small-cell lung cancer (NSCLC), but patients’ long-term outcome is still challenging. The purpose of this study was to identify predictors of long-term survival in patients after lung cancer surgery.

METHODS:

Patients who underwent surgery for NSCLC from January 1, 2006, to December 31, 2009, were enrolled into this retrospective cohort study. The primary outcome was the survival length after surgery. Predictors of long-term survival were screened with the multivariable Cox proportional hazard model.

RESULTS:

Postoperative follow-up was completed in 588 patients with a median follow-up duration of 5.2 years (interquartile range, 2.0–6.8). Two hundred ninety-one patients (49.5%) survived at the end of follow-up with median survival duration of 64.3 months (interquartile range, 28.5–81.6). The overall survival rates were 90.8%, 70.0%, and 57.1% at the end of the first, third, and fifth year after surgery, respectively. Limited resection (hazard ratio [HR], 1.46; 95% confidence interval [CI], 1.08–1.98; P = .013) and large tumor size (HR, 1.29; 95% CI, 1.17–1.42; P < .001) were associated with short survival; whereas high body mass index grade (HR, 0.82; 95% CI, 0.69–0.97; P = .021), highly differentiated tumor (HR, 0.59; 95% CI, 0.37–0.93; P = .024), dissection of mediastinal lymph node during surgery (HR, 0.45; 95% CI, 0.30–0.67; P < .001), and perioperative use of dexamethasone (HR, 0.70; 95% CI, 0.54–0.90; P = .006) were associated with long survival. No association was found between perioperative use of flurbiprofen axetil and long survival (HR, 0.80; 95% CI, 0.62–1.03; P = .086). However, combined administration of dexamethasone and flurbiprofen axetil was associated with longer survival (compared to no use of both: adjusted HR, 0.57; 95% CI, 0.38–0.84; P = .005).

CONCLUSIONS:

Certain factors in particular perioperative dexamethasone and flurbiprofen axetil therapy may improve patients’ long-term survival after surgery for NSCLC. Given the small sample size, these findings should be interpreted with caution, and randomized clinical trials are needed for further clarification.

Effect of Pretreatment Platelet Parameters on Survival in Limited Disease Small Cell Lung Cancer

Background: The aim of this study was to investigate the effect of platelet parameters before concurrent chemoradiotherapy (CCRT) on survival of patients with limited disease small cell lung cancer (LD-SCLC). Methods: This study consisted of patients who received CCRT due to LD-SCLC in the oncology clinic between 1997-2017. Examined platelet parameters included total platelet count (TPC), mean platelet volume, platelet distribution width, and platelet-lymphocyte ratio. The cut-off value for TPC was determined as 306x109/U (sensitivity: 62%, specificity: 75.5%), where patients below or equal to this level was classified as Group I, and those above as Group II. Results:The study included 90 patients whose mean age was 59 years (range: 42-83) and male ratio was 80.0% (n=72). Near three-fourths of patients (74.4%) were at clinical stage III. Among stage I-II patients, mOS was found as 126 months for Group I whereas it had not been reached in Group II (p=0.158). Stage III patients showed significantly lower mOS for Group 1 (16 [range: 14.1-17.8] months) compared to that in Group 2 (19.0 [range: 15.6-62.8] months; p=0.002). In multivariate analysis, Eastern Cooperative Oncology Group performance score (p=0.003), clinical stage (p<0.001), prophylactic cranial irradiation (p=0.004), and TPC (p=0.031) was determined as the most significant factors affecting survival. Conclusion: Our study suggests association of high baseline levels of TPC to improved survival in patients scheduled to undergo CCRT for LD-SCLC. Considering easiness and universal availability of TPC measurement, potential utilization of this biomarker may be promising to predict survival, albeit requiring validation by further well-designated prospective studies.

The effect of anesthetic techniques on neutrophil to lymphocyte ratio in patients undergoing infraumbilical surgeries

Background

Neutrophil to lymphocyte ratio (NLR) is a simple marker in peripheral blood and is used to assess inflammatory response and physiological stress during the peri-operative period. Anesthetic technique may influence NLR, thereby modulating the inflammatory response and surgical outcomes. The study aimed to evaluate the relationship between blood NLR and anesthetic techniques in patients undergoing infraumbilical surgeries.

Methods

Institutional ethical committee approval and patient consent were obtained. A prospective randomized double- blinded study was conducted between July 2017 and November 2017, involving 80 patients classified as the American Society of Anesthesiologists grade 1 and 2, aged 18–60 years, and scheduled for elective infraumbilical surgeries. Unwilling and those with infections were excluded. The patients were randomly divided into two groups: Group G (general anesthesia) and Group S (spinal anesthesia) as per the standardized protocol. Differential counts of leukocytes and NLR in the peripheral blood were obtained pre-operatively on the morning of surgery and at 2 h and 24 h after surgery in both the groups. The data were analyzed using appropriate statistical tests.

Results

The demographic parameters, basal total leukocyte count (TLC), and NLR were comparable between the groups. TLC and NLR were significantly higher in Group G as compared to that in Group S post-operatively. The post-operative rise in TLC and NLR from the basal values was significantly higher in Group G as compared to that in Group S.

Conclusions

General anesthesia was associated with a greater increase in TLC and NLR when compared with spinal anesthesia.

Nomogram prediction of overall survival for patients with non-small-cell lung cancer incorporating pretreatment peripheral blood markers

OBJECTIVES

The objective of this study is to build a novel prognostic nomogram in non-small-cell lung cancer (NSCLC) incorporating pre-treatment peripheral blood markers beyond known pathoclinical predictors.

METHODS

We analysed 7158 patients with NSCLC diagnosed between 1 January 1997 and 31 December 2012 from a single institution with a uniform medical record and routine follow-up information. Besides common clinicopathological factors, we investigated the prognostic value of the neutrophil to lymphocyte ratio, monocytes and haemoglobin level in peripheral blood before treatment. Patients were randomly assigned to training (4772 patients, 66.7%) or validation cohorts (2386 patients, 33.3%). Cox proportional hazards models determined the effects of multiple factors on overall survival (OS). A nomogram was developed to predict median survival and 1-, 3-, 5- and 10-year OS for NSCLC. The performance of the nomogram was assessed by a concordance index and calibration curve.

RESULTS

In the training cohort, the multivariate Cox model identified the neutrophil to lymphocyte ratio, monocytes and haemoglobin level before treatment as significant prognostic factors for OS independent of patient age, gender, smoking history of intensity and cessation, performance status, disease stage, tumour cell type and differentiation grade and therapies. All the significant prognostic variables were incorporated into a nomogram. In the validation cohort, the nomogram showed notable accuracy in predicting OS, with a concordance index of 0.81, and was well calibrated for predictions of OS.

CONCLUSIONS

The proposed nomogram incorporating peripheral blood markers and known prognostic factors could accurately predict individualized survival probability of patients with NSCLC. It could be used in treatment planning and stratification in clinical trials.

How Anesthetic, Analgesic and Other Non-Surgical Techniques During Cancer Surgery Might Affect Postoperative Oncologic Outcomes: A Summary of Current State of Evidence

The question of whether anesthetic, analgesic or other perioperative intervention during cancer resection surgery might influence long-term oncologic outcomes has generated much attention over the past 13 years. A wealth of experimental and observational clinical data have been published, but the results of prospective, randomized clinical trials are awaited. The European Union supports a pan-European network of researchers, clinicians and industry partners engaged in this question (COST Action 15204: Euro-Periscope). In this narrative review, members of the Euro-Periscope network briefly summarize the current state of evidence pertaining to the potential effects of the most commonly deployed anesthetic and analgesic techniques and other non-surgical interventions during cancer resection surgery on tumor recurrence or metastasis.

Preoperative elevated neutrophil-to-lymphocyte ratio (NLR) and derived NLR are associated with poor prognosis in patients with breast cancer: A meta-analysis

BACKGROUND

Preoperative neutrophil-lymphocyte ratio (NLR) and derived NLR (dNLR) have been suggested to be correlated with the prognosis of patients with breast cancer (BC). However, the results still remain controversial. Therefore, this study was to further evaluate the prognostic potential of preoperative NLR and dNLR for BC patients using a meta-analysis.

METHODS

Relevant articles were sought in PubMed and Cochrane Library databases up to September 2018. The associations between preoperative NLR/dNLR and overall survival (OS), disease-free survival (DFS) and recurrence-free survival (RFS) were assessed by the STATA software with the results presented as pooled hazard ratio (HR) with 95% confidence interval (CI).

RESULTS

Twenty-one studies were enrolled. Pooled results showed that elevated NLR was significantly associated with poorer OS (HR = 2.45, 95% CI: 1.69-3.54), DFS (HR = 1.54, 95% CI: 1.28-1.87) and RFS (HR = 4.05, 95% CI: 1.94-8.47) in BC patients undergoing surgery. High-preoperative dNLR was also significantly associated with worse OS (HR = 1.75, 95% CI: 1.39-2.19) and DFS (HR = 1.62, 95% CI: 1.09-2.41). Moreover, subgroup analysis showed significant associations between preoperative elevated NLR and poor prognosis were not changed by the stratification of ethnicity, cutoff of NLR, pathological stage, neoadjuvant, and adjuvant therapy.

CONCLUSION

Preoperative NLR and dNLR may be effective predictive biomarkers for prognosis in patients with BC. Detection of NLR and dNLR may be helpful to identify the patients who may benefit from the surgery.

Preoperative systemic inflammation and perioperative myocardial injury: prospective observational multicentre cohort study of patients undergoing non-cardiac surgery

BACKGROUND

Systemic inflammation is pivotal in the pathogenesis of cardiovascular disease. As inflammation can directly cause cardiomyocyte injury, we hypothesised that established systemic inflammation, as reflected by elevated preoperative neutrophil-lymphocyte ratio (NLR) >4, predisposes patients to perioperative myocardial injury.

METHODS

We prospectively recruited 1652 patients aged ≥45 yr who underwent non-cardiac surgery in two UK centres. Serum high sensitivity troponin T (hsTnT) concentrations were measured on the first three postoperative days. Clinicians and investigators were blinded to the troponin results. The primary outcome was perioperative myocardial injury, defined as hsTnT≥14 ng L^-1 within 3 days after surgery. We assessed whether myocardial injury was associated with preoperative NLR>4, activated reactive oxygen species (ROS) generation in circulating monocytes, or both. Multivariable logistic regression analysis explored associations between age, sex, NLR, Revised Cardiac Risk Index, individual leukocyte subsets, and myocardial injury. Flow cytometric quantification of ROS was done in 21 patients. Data are presented as n (%) or odds ratio (OR) with 95% confidence intervals.

RESULTS

Preoperative NLR>4 was present in 239/1652 (14.5%) patients. Myocardial injury occurred in 405/1652 (24.5%) patients and was more common in patients with preoperative NLR>4 [OR: 2.56 (1.92-3.41); P<0.0001]. Myocardial injury was independently associated with lower absolute preoperative lymphocyte count [OR 1.80 (1.50-2.17); P<0.0001] and higher absolute preoperative monocyte count [OR 1.93 (1.12-3.30); P=0.017]. Monocyte ROS generation correlated with NLR (r=0.47; P=0.03).

CONCLUSIONS

Preoperative NLR>4 is associated with perioperative myocardial injury, independent of conventional risk factors. Systemic inflammation may contribute to the development of perioperative myocardial injury.

CLINICAL TRIAL REGISTRATION

NCT01842568.