Prognostic significance of the neutrophil-to-lymphocyte ratio in primary liver cancer: a meta-analysis

Prognostic impact of preoperative nutritional and immune inflammatory parameters on liver cancer

The immune response to tissue damage or infection involves inflammation, a multifaceted biological process distinguished by immune cell activation, mediator secretion, and immune cell recruitment to the site of injury. Several blood-based immune-inflammatory biomarkers with prognostic significance in malignancies have been identified. In this issue of the World Journal of Gastrointestinal Surgery, they examined the prognosis of liver cancer radical resection in relation to preoperative systemic immune-inflammation and nutritional risk indices. Comparing older and younger individuals often reveals compromised nutritional and immunological statuses in the former. Therefore, performing preoperative evaluations of the nutritional status and immunity in geriatric patients is critical. In addition to being a primary treatment modality, radical resection is associated with a significant mortality rate following surgery. Insufficient dietary consumption and an elevated metabolic rate within tumor cells contribute to the increased probability of malnutrition associated with the ailment, consequently leading to a substantial deterioration in prognosis. Recent studies, reinforce the importance of nutritional and immune-inflammatory biomarkers. Prior to surgical intervention, geriatric nutritional risk and systemic immune-inflammatory indices should be prioritized, particularly in older patients with malignant diseases.

High neutrophil-lymphocyte ratio indicates a worse response to ursodeoxycholic acid in primary biliary cholangitis: a retrospective cohort study

BACKGROUND

Primary biliary cholangitis (PBC) is a chronic cholestatic liver disease characterized by inflammation of the interlobular bile ducts. Ursodeoxycholic acid (UDCA) is the only FDA approved first-line therapy for PBC, but up to 40% of patients with PBC have an incomplete response to UDCA. Neutrophil-to-lymphocyte (NLR) has been used to predict prognosis in various liver diseases. There is limited evidence on the treatment response to UDCA in PBC patients. Our study aimed to evaluate the relationship between NRL and the response to UDCA treatment in PBC patients.

METHODS

A total of 257 primary biliary cholangitis (PBC) patients treated with UDCA (13-15 mg/kg/d) were enrolled in this retrospective study. The response to treatment was evaluated based on alkaline phosphatase levels ≤1.67 times the upper limit of the normal value after 12 months of UDCA treatment. Multivariable logistic regression analysis was performed to investigate the association between NLR at baseline and the response to 12 months of UDCA treatment after adjusting for important confounding variables. The stability of the results was evaluated by unadjusted and adjusted models.

RESULTS

The results of multiple regression analysis showed that NLR at baseline was positively associated with the nonresponse to UDCA treatment after adjustments for potential confounders (age, sex, BMI, hypertension, arterial plaque, thyroid disease, jaundice, albumin, globulin, total bile acid, ALP, GGT, LDLC, total cholesterol, hemoglobin, and APTT) (OR = 1.370, 95% CI 1.066-1.761). These results reveal that NLR is an independent risk factor for UDCA treatment nonresponse.

CONCLUSIONS

Our results suggest that PBC patients with a high NLR had a worse response to UDCA therapy.

Delayed-Type Hypersensitivity: An Excellent Indicator of Anti-tumor Immunity With Wilms' Tumor 1 (WT1) Dendritic Cell Vaccine Therapy

INTRODUCTION

It is a well-known fact that anti-tumor immunity is a crucial long-term survival factor in cancer. Wilms' tumor 1 (WT1) dendritic cell vaccine therapy (WT1-DC) is an immuno-cell therapy that has been implemented against various cancers as a tumor-specific immunotherapy targeting the common cancer antigen WT1.

METHODS

Seven doses of WT1-DC vaccine were administered to six patients, three of whom had stage IV lung cancer with metastases and the other three had stage IV pancreatic cancer with metastases, all of whom were receiving chemotherapy and had similar physical conditions. Their immune response was assessed using delayed-type hypersensitivity (DTH) and immune profile status (IPS) such as blood neutrophil percentage, lymphocyte percentage, and neutrophil-to-lymphocyte (N/L) ratio.

RESULTS

In lung cancer, DTH increased with repeated DC administration, and IPS improved with it, whereas in pancreatic cancer, DTH did not increase, and IPS worsened from the fifth inoculation. Fever in the 37° range was observed after DC administration in lung cancer, but not in pancreatic cancer.

CONCLUSION

These results suggest that DTH and IPS are correlated in dynamics and that DTH is a good indicator of the state of anti-tumor immunity. Since IPS is a prognostic factor in advanced cancer, the magnitude of DTH due to WT1-DC inoculation is a useful indicator to estimate the patient's prognosis. Although DTH is an extremely simple test, its clinical significance has not been fully investigated. The present study demonstrates the importance of DTH in cancer treatment with WT1-DC.

Prognostic Significance of Neutrophil-Lymphocyte Ratio in Patients of High-Grade Glioma Undergoing Adjuvant Chemoradiation: A Prospective Study

PURPOSE

High-grade gliomas are highly fatal disease with poor prognosis despite multimodality management. Inflammatory biomarkers are widely used for prognostication in various solid malignancies to stratify high risk patients. The current research was conducted to investigate whether any change in neutrophil-lymphocyte ratio (NLR) during adjuvant chemoradiotherapy has any prognostic significance in high-grade glioma patients.

MATERIALS AND METHODS

Seventy-three biopsy proven high-grade glioma patients treated with adjuvant chemoradiotherapy were enrolled in this study. Haematological parameters were collected before treatment, weekly during treatment, and at 4th week after chemoradiotherapy along with baseline characteristics. Overall survival (OS) was determined using Kaplan-Meier curve. Variables found statistically significant in univariate analysis by Cox regression model were subjected to final multivariable analysis.

RESULTS

The median follow-up was around 17 months with a median OS of 17.2 months (95%CI 14.7-23). The best prognosis was seen in patients who had a baseline NLR< 3.5 with decline in NLR during treatment achieving a 1-year survival of 100% and median overall survival of 36.5 months. Patients who had baseline NLR ≥3.5 without a decline in NLR had worst prognosis with a 1-year survival of 25% (95%CI 9.4%-66.6%) and median OS of 7.1 months. On multivariate analysis, age [HR 1.025, p=0.040)], ECOG performance status≤1 [HR 0.089, p<0.001], extent of surgery [HR 0.305, p=0.001] and decline in NLR during treatment [HR 0.452, p=0.026] were found to be significant predictors of OS.

CONCLUSION

This study demonstrated that NLR is a cost-effective biomarker that has prognostic significance in predicting overall survival for high-grade glioma patients.

WT1 Dendritic Cell Vaccine Therapy Improves Immune Profile and Prolongs Progression-Free Survival in End-Stage Lung Cancer

WT1-pulsed dendritic cell (WT1-DC) therapy was performed for end-stage squamous cell lung cancer that rapidly worsened soon after completion of carboplatin and paclitaxel. A rapid improvement in immune profile was observed with the initiation of WT1-DC. Docetaxel and ramucirumab were initiated as second-line agents during WT1-DC. The improvement of the immune profile status continued, and at the same time, the cancer showed a predominant shrinkage. Progression-free survival was over 577 days, and the patient was able to lead a normal daily life with a performance status of 1. These findings suggest that WT1-DC improves the immune profile, and this may contribute to the long-lasting and sustained effect of chemotherapy.

Neutrophil-to-lymphocyte ratio as a prognostic factor for patients with urothelial carcinoma of the bladder following radical cystectomy

Introduction

The pre-treatment neutrophil-to-lymphocyte ratio (NLR) has been associated with adverse pathology or survival in a variety of malignancies, including urothelial carcinoma of the bladder (UCB) treated with radical cystectomy (RC). Whether the prognostic value of NLR is retained, or even increased, when measured postoperatively remains to be studied. In this study, we evaluated the association of preoperative and postoperative NLR with oncological outcomes following RC.

Material and methods

The NLR was recorded in 132 consecutive patients with UCB treated with open RC: before surgery (NLR1), postoperatively within 2 days (NRL2), between 7 and 15 days after RC before discharge (NLR3), and a few days before recurrence or last available follow-up (NLR4).

Results

When assessed by multivariate analysis NLR1 remained independently associated with a significantly increased risk of extravesical disease (pT 3-4) (OR = 1.4, p <0.01) and lymphovascular invasion (LVI) (OR = 1.40, 95% CI 1.09-1.83, p <0.01). NLR4 was independently associated with a significantly increased risk of cancer-specific mortality (CSM) (HR = 1.14, 95%CI 1.03-1.24, p = 0.013). In a postoperative model, NLR3 was found to be an independent predictor of all-cause mortality (ACM) [HR = 1.11, 95% CI 1.02-1.21, p = 0.01]. NLR1 was associated with a significantly increased risk of recurrence in the univariable preoperative model [HR = 1.9, 95%CI 1.00-3.65, p = 0.05], while in the postoperative model NLR4 remained independently associated with a significantly increased risk of recurrence (HR = 1.13, 95%CI 1.04-1.23, p = 0.03).

Conclusions

In patients with UCB treated with RC, the NLR is associated with more advanced tumour stage, LVI, lymph node metastasis, and higher CSM. Furthermore, the variation of the NLR after surgery might play a role in predicting higher ACM and recurrence-free survival.

Non-Invasive Methods for the Prediction of Spontaneous Bacterial Peritonitis in Patients with Cirrhosis

Spontaneous bacterial peritonitis (SBP) is a potentially fatal complication in patients with liver cirrhosis. Early diagnosis and prompt treatment of SBP are vital to shorten hospital stays and reduce mortality. According to society guidelines, patients with cirrhosis and ascites who are admitted to the hospital should have diagnostic paracentesis. However, for various reasons, paracentesis may be delayed or not performed. Therefore, recent research has focused on identifying non-invasive parameters useful in SBP prediction which require urgent antibiotic therapy if rapid and secure paracentesis is not possible or there is insufficient experience with this method. In this review, we discuss the non-invasive methods available to predict SBP.

Preoperative systemic inflammatory response index predicts the prognosis of patients with hepatocellular carcinoma after liver transplantation

Background

Preoperative inflammatory status plays an important role in the prognosis of malignancy. We sought to explore the value of preoperative inflammatory biomarkers in predicting long-term outcomes of liver transplantation (LT) in patients with hepatocellular carcinoma (HCC).

Method

Patients who underwent LT for HCC in our hospital between January 2010 and June 2020 were included in this study. Demographic, clinical, laboratory, and outcome data were obtained. The area under the curve (AUC) of the receiver operating characteristic curve was used to evaluate the predictive value of inflammatory biomarkers. The effectiveness of inflammatory biomarkers in predicting outcomes was analyzed by univariate and multivariate Cox proportional hazards analyses.

Results

A total of 218 patients were included in the study, with a mean age of 53.9 ± 8.5 years. The AUC of neutrophil-to-lymphocyte ratio (NLR), platelet-to-lymphocyte ratio (PLR), monocyte-to-lymphocyte ratio (MLR), systemic immune inflammation index (SII), and systemic inflammatory response index (SIRI) for overall survival (OS) were 0.741, 0.731, 0.756, 0.746, and 0.749, respectively. Cox proportional hazards model indicated that SIRI &gt; 1.25 was independently associated with low OS [hazard ratio (HR) = 2.258, P = 0.024]. PLR &gt; 82.15 and SIRI &gt; 0.95 were independently associated with low disease-free survival (HR = 1.492, P = 0.015; and HR = 1.732, P = 0.008, respectively). In the survival analysis, the prognosis of patients with high preoperative SIRI and PLR was significantly worse (P &lt; 0.001).

Conclusion

SIRI and PLR were useful prognostic markers for predicting patients with HCC after LT.

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.

Prognostic and Predictive Factors in Patients with Advanced HCC and Elevated Alpha-Fetoprotein Treated with Ramucirumab in Two Randomized Phase III Trials

PURPOSE

Ramucirumab is an effective treatment for patients with advanced hepatocellular carcinoma (aHCC) and baseline alpha-fetoprotein (AFP) ≥400 ng/mL. We aimed to identify prognostic and predictive factors of response to ramucirumab in patients with aHCC with AFP ≥400 ng/mL from the phase III REACH and REACH-2 randomized trials.

PATIENTS AND METHODS

Patients with aHCC, Child-Pugh class A with prior sorafenib treatment were randomized in REACH and REACH-2 (ramucirumab 8 mg/kg or placebo, biweekly). Meta-analysis of individual patient-level data (pooled population) from REACH (AFP ≥400 ng/mL) and REACH-2 was performed. A drug exposure analysis was conducted for those with evaluable pharmacokinetic data. To identify potential prognostic factors for overall survival (OS), multivariate analyses were performed using a Cox proportional hazards regression model. To define predictors of ramucirumab benefit, subgroup-by-treatment interaction terms were evaluated.

RESULTS

Of 542 patients (316 ramucirumab, 226 placebo) analyzed, eight variables had independent prognostic value associated with poor outcome (geographical region, Eastern Cooperative Oncology Group performance score ≥1, AFP >1,000 ng/mL, Child-Pugh >A5, extrahepatic spread, high neutrophil-to-lymphocyte ratio, high alkaline phosphatase and aspartate aminotransferase). Ramucirumab survival benefit was present across all subgroups, including patients with very aggressive HCC [above median AFP; HR: 0.64; 95% confidence interval (CI): 0.49-0.84] and nonviral aHCC (HR: 0.56; 95% CI: 0.40-0.79). While no baseline factor was predictive of a differential OS benefit with ramucirumab, analyses demonstrated an association between high drug exposure, treatment-emergent hypertension (grade ≥3), and increased ramucirumab benefit.

CONCLUSIONS

Ramucirumab provided a survival benefit irrespective of baseline prognostic covariates, and this benefit was greatest in patients with high ramucirumab drug exposure and/or those with treatment-related hypertension.

Establishment of a prediction model for disease progression within one year in newly diagnosed multiple myeloma patients

Multiple myeloma is still an incurable disease In the past decade, with the continuous progress of treatment methods, the progression-free survival of patients has been prolonged, but some patients still progress in the early stage of the disease. Our research analyses the clinical laboratory indicators of newly diagnosed multiple myeloma (NDMM) patients, to obtain the relevant factors of disease progression within one year in MM patients and to establish a prediction model.

108 MM patients treated in our hospital from January 2015 to January 2020 were retrospectively analyzed. After univariate and multivariate logistic regression analyses, the related factors of disease progression within one year in NDMM patients were obtained, and a prediction model was established.

Treatment regimen containing at least two targeted drugs (OR = 0.226, 95% CI 0.068-0.753), increased lactate dehydrogenase(LDH, OR = 3.452, 95% CI 1.101-10.826) and increased serum corrected calcium(OR =  4.466, 95% CI 1.346-14.811) were identified as potential predictors by statistical analysis. The prediction model was obtained: x = -2.042-1.489 × treatment regimen (including at least two targeted drug assignment as 1, otherwise 0) + 1.239 ×LDH (U/L, lactate dehydrogenase elevation assignment as 1, normal as 0) +1.496 × serum corrected calcium (mmol/L, serum corrected calcium elevation assignment as 1, normal as 0). Receiver operating characteristic curve analysis showed that the model has good predictive performance.

The possibility of disease progression within one year can be predicted by the prediction model. The model can be used as a reference for clinicians to make individualized treatment plans for patients so that patients can obtain better treatment effects.

Real-Life Clinical Data of Lenvatinib versus Sorafenib for Unresectable Hepatocellular Carcinoma in Italy

Background

Lenvatinib has been approved in Italy since October 2019 as a first-line therapy for advanced hepatocellular carcinoma (HCC) and to date data on effectiveness and safety of lenvatinib are not available in our region. To fill this gap, we performed a multicentric analysis of the real-world treatment outcomes with the propensity score matching in a cohort of Italian patients with unresectable HCC who were treated with either sorafenib or lenvatinib.

Aims and Methods

To evaluate the effectiveness of sorafenib and lenvatinib as primary treatment of advanced HCC in clinical practice we performed a multicentric analysis of the treatment outcomes of 288 such patients recruited in 11 centers in Italy. A propensity score was used to mitigate confounding due to referral biases in the assessment of mortality and progression-free survival.

Results

Over a follow-up period of 11 months the Cox regression model showed 48% reduction of death risk for patients treated with lenvatinib (95% CI: 0.34-0.81; p = 0.0034), compared with those treated with sorafenib. The median PFS was 9.0 and 4.9 months for lenvatinib and sorafenib arm, respectively. Patients treated with lenvatinib showed a higher percentage of response rate (29.4% vs 2.8%; p < 0.00001) compared with patients treated with sorafenib. Sorafenib was shown to be correlated with more HFSR, diarrhea and fatigue, while lenvatinib with more hypertension and fatigue.

Conclusion

Our study highlighted for the first time the efficacy and safety of lenvatinib in an Italian cohort of patients.

The Prognostic Values of Neutrophil-to-lymphocyte Ratio and Platelet-to-Lymphocyte Ratio at Baseline in Predicting the In-hospital Mortality in Black African Patients with Advanced Hepatocellular Carcinoma in Palliative Treatment: A Comparative Cohort Study

Background

The prognostic values of the neutrophil-to-lymphocyte ratio (NLR) and the platelet-to-lymphocyte ratio (PLR) in predicting the in-hospital mortality of Black African patients with advanced hepatocellular carcinoma (HCC) in palliative treatment is unknown.

Aim

To determine the prognostic value of NLR and PLR compared with that of Child–Turcotte–Pugh (CTP), model for end-stage liver disease (MELD) scores and the Barcelona clinic liver cancer staging system (BCLC).

Methods

The cutoffs, accuracies and association with the mortality of these prognostic scores were determined using a time-dependent area under receiver operating characteristic curves (AUC), the log rank test and Cox proportional hazards ratio.

Results

A total of 104 patients with advanced HCC (median age=49.5 years, males=58.7%) were enrolled. All were hospitalized for an enlarged liver mass of at least 15.4 cm in size in the right thoracic quadrant. Overall, 46 (44.2%) patients died in hospital during follow-up. Patients with NLR >2.5 (log rank test=7.11, p=0.01) or PLR >92 (log rank test=5.63, p=0.02) had poor survival. Factors associated with the in-hospital mortality were the MELD score (p=0.01), NLR (p=0.03) and hemoglobin level (p=0.02). NLR exhibits better and stable accuracy in predicting the in hospital mortality at time points of 30 (AUC=0.618), 60 (AUC=0.680) and 90 (AUC=0.613) days of follow-up, compared with CTP, MELD scores, BCLC and PLR. However, PLR displayed an enhanced accuracy over 90 days of follow up (AUC=0.688).

Conclusion

NLR is useful in predicting the in-hospital mortality in Black African patients with advanced stage HCC in clinical practice. NLR and PLR may be used concomitantly for long-term follow-up.

Neutrophils: Driving inflammation during the development of hepatocellular carcinoma

The relationship between immune and inflammatory responses in hepatocellular carcinoma (HCC) has garnered significant interest. In the peripheral blood and tumour microenvironment (TME), neutrophils, which are innate immune cells, crucially respond to various inflammatory factors, leading to tumour progression. To some extent, they affect the clinical treatment strategy and survival among HCC patients. A high circulating neutrophil-to-lymphocyte ratio is a reliable factor that can be used to predict poor outcomes in HCC patients. However, the mechanisms underlying the protumoural effects of circulating neutrophils remain poorly understood. Besides, the distinct role and function of neutrophils at the site of HCC remain relatively unclear, which is partially attributed to their substantial heterogeneity compared with other immune cells. In this review, we firstly discuss the current information available, detailing distinct subsets, functional phenotypes, and the impact of circulating and tumour-infiltrating neutrophils on tumourigenesis in HCC. Furthermore, we describe recent pre-clinical and clinical studies concerning neutrophils for evaluating the feasibility of targeting diverse protumoural aspects to improve therapeutic efficacy, thus paving the way for neutrophil-based treatment, especially in combination with immunotherapy.

Pretreatment Neutrophil-to-Lymphocyte Ratio: A Prognostic Biomarker of Survival in Patients With Epithelial Ovarian Cancer

Background

Inflammation is pathognomonic of all stages of tumor formation, and therefore, there is renewed interest in systemic inflammatory response (SIR) markers including haematological inflammatory markers such as neutrophil-to-lymphocyte ratio (NLR) as prognostic predictors in several cancers.

Aim

This study was aimed to investigate the effect of pretreatment peripheral blood NLR on the survival prognosis of patients with epithelial ovarian cancer (EOC).

Methods

We identified 93 patients with a complete clinical record from a cohort of 155 patients who received treatment for EOC between 2009 and 2018. Patients’ sociodemographic and clinicopathologic characteristics, and updated three-year follow-up status were extracted from medical records. Pretreatment peripheral blood NLR was calculated by dividing the neutrophil count by the lymphocyte count. We employed the receiver operating characteristic (ROC) curve to identify the optimal cut-off value of the NLR in estimating progression-free survival (PFS) and overall survival (OS). The PFS and OS were assessed using the Kaplan-Meier method, and survival differences were compared using the Log Rank (Mantel-Cox) test. Independent prognostic predictors were determined using Cox regression analysis.

Results

According to the ROC curves, the optimal cut-off values for the NLR were 2.23 and 1.93 for PFS and OS, respectively. A high NLR was associated with poor PFS (P = 0.033) and OS (P = 0.013) in the univariate analyses. In the multivariate analyses, a high NLR was still an independent predictor of OS (hazard ratio [HR] = 2.23; 95% CI, 1.08 to 4.61) but not PFS (hazard ratio [HR] = 2.43; 95% CI, 0.95 to 6.27).

Conclusion

The NLR at an optimum cut-off value of 1.93 is an independent prognostic predictor of OS in patients with EOC.

Blood-based prognostic biomarkers in Crohn's Disease patients on biologics: a promising tool to predict endoscopic outcomes

OBJECTIVE

There is a growing need for biomarkers to predict therapeutic outcome in Crohn's disease (CD).

MAIN OUTCOME MEASURES

The aim was to evaluate whether NLR (neutrophil-to-lymphocyte ratio), PLR (platelet-to-lymphocyte ratio), ELR (eosinophil-to-lymphocyte ratio), and ENLR (eosinophil*neutrophil-to-lymphocyte ratio), could be prognostic biomarkers of endoscopic response (ER) when starting biologics.

RESEARCH DESIGN AND METHODS

Patients with CD who started biologics were enrolled. Multivariate analysis was used to evaluate whether NLR, PLR, ELR and ENLR at baseline and at w12 could predict ER (Simple Endoscopic Score for Crohn's disease [SES-CD] ≤2 or SES-CD≤2 and Rutgeerts i0-i1) after 52 weeks of treatment. Area under the curve (AUC) was calculated to find the cutoffs.

RESULTS

107 patients were included. Patients who achieved ER had significantly lower baseline NLR (p = 0.025), ELR (p = 0.013), and ENLR (p = 0.020) compared with those without ER; results after 12 weeks of treatment for ELR (p = 0.006) and ENLR (p = 0.003). AUC was 0.64 (p = 0.003), 0.67 (p = 0.006) and 0.65 (p = 0.014) for NLR, ELR and ENLR.

CONCLUSIONS

Low NLR, ELR and ENLR can predict ER and could be used in clinical practice for a better management of CD patients.

Neutrophil-to-lymphocyte ratio is associated with malnutrition risk estimated by the Royal Free Hospital-Nutritional Prioritizing Tool in hospitalized cirrhosis

BACKGROUND

Liver cirrhosis is characterized by immune dysfunction, contributing to malnutrition. We previously revealed neutrophil-to-lymphocyte ratio (NLR) as an indicator of disordered immune system. Herein we aimed to (1) determine the optimal NLR cutoff that best predicts malnutrition risk and (2) clarify the association between NLR and nutrition status.

METHODS

A total of 135 hospitalized patients with cirrhosis were included. Immune dysfunction was evaluated by levels of serum C-reactive protein (CRP), NLR, and other parameters. Malnutrition was screened by a risk score referring to the Royal Free Hospital-Nutritional Prioritizing Tool (RFH-NPT). Receiver operating characteristic (ROC) curve was implemented to determine the best NLR cutoff that predicts malnutrition risk. Correlation between NLR and indicators of hepatic and physical function (handgrip strength) were also examined. Multivariable logistic regression was used to assess the association between NLR and malnutrition risk.

RESULTS

ROC curve revealed that the optimum cutoff to predict malnutrition risk was NLR > 4.2, with a sensitivity of 47.2%, specificity of 81.0%, negative predictive value of 58.0%, and positive predictive value of 74.5%, respectively. Patients with NLR > 4.2 exhibited a higher RFH-NPT score, serum platelet-to-lymphocyte ratio, and CRP. A positive correlation was found between NLR values and Child-Turcotte-Pugh (r = 0.22; P = .010), model for end-stage liver disease (r = 0.36; P < .001), and RFH-NPT scores (r = 0.31; P < .001). NLR was a risk factor for malnutrition independently of alcoholic liver disease and presence of ascites.

CONCLUSIONS

Immune dysfunction measured by NLR was associated with malnutrition risk estimated by RFH-NPT in cirrhosis.

Peripheral Inflammatory Blood Markers in Diagnosis of Glioma and IDH Status

Objective  Gliomas are the most common intracranial tumors. Histopathology and neuroimaging are the main modalities used for diagnosis and treatment response monitoring. However, both are expensive and insensitive methods and can cause neurological deterioration. This study aimed to develop a minimally invasive peripheral inflammatory biomarker for diagnosis of glioma, its grade, and isocitrate dehydrogenase (IDH) status. Materials and Methods  Patients undergoing surgery for glioma, acoustic neuroma, and meningioma between January 2019 and December 2019 were included. Preoperative neutrophil/lymphocyte ratio (NLR), derived NLR (dNLR), platelet/lymphocyte ratio (PLR), lymphocyte/monocyte ratio (LMR), eosinophil/lymphocyte ratio (ELR), and prognostic nutritional index (PNI) were calculated. Histopathology and immunohistochemistry (IHC) staining were done postoperatively. Results  A total of 154 patients of glioma, 36 patients of acoustic neuroma, 58 patients of meningioma, and 107 healthy controls were included. dNLR showed the maximum area under the curve (AUC) (0.656639) for diagnosis of glioma from other tumors and among combinations. dNLR +NLR showed the maximum AUC (0.647865). Maximum AUC for glioblastoma multiforme (GBM) versus other grades and among combinations was shown by NLR (0.83926). NLR + dNLR had the maximum AUC (0.764794). NLR showed significant p value in differentiating IDH wild from IDH mutant GBM. Conclusion  dNLR has the maximum diagnostic value in diagnosing glioma from other tumors. NLR (AUC = 0.83926) showed the highest accuracy for GBM diagnosis and may be a parameter in predicting the grade of glioma; also, it has maximum diagnostic value in differentiating IDH wild GBM from IDH mutant GBM. These peripheral inflammatory parameters may prove to be sensitive and cost-effective markers for glioma diagnosis, predicting grade of glioma, monitoring of treatment response, and in predicting recurrence.

Laboratory parameters as predictors of prognosis in uterine cervical neoplasia

OBJECTIVES

The aims of study were to assess platelet counts, neutrophil-lymphocyte ratio (NLR), platelet-lymphocyte ratio (PLR), RWD (red cells distribution width) and fasting glucose in patients with cervical intraepithelial neoplasia (CIN) and invasive cervical cancer; and to relate these parameters to prognostic factors and survival in cervical cancer.

STUDY DESIGN

We evaluated the patients with confirmed diagnosis of invasive cervical cancer (n = 102), and CIN (n = 102). Histological type, NLR, PLR, RDW, platelets count, fasting glucose, staging, overall survival (OS), and disease-free survival (DFS) were evaluated. The results of laboratory parameters were assessed by Mann-Whitney test. A receiver operating characteristic (ROC) curve was used to determine the best cut-off values. Survival was verified by the Kaplan-Meyer method followed by the Gehan-Breslow test. Multivariate analysis was performed using Cox regression. The level of significance was less than 0.05.

RESULTS

Comparing CIN and invasive malignancies, higher values of NLR, PLR, RDW and fasting glucose were found in cancer patients (p < 0.0001, p = 0.011, p = 0.0153 and p = 0.0096, respectively). In cervical cancer, higher NLR and PLR values were found at stage II to IV when compared to stage I (p = 0.0066 and p = 0.005, respectively). ROC curves were performed. In invasive neoplasms, the cut-off values for NLR and PLR in the comparison between stage I and greater than I were 4 and 165.45, respectively. For survival curves, there was lower OS and DFS in patients with NLR greater than 4 (p = 0.0004 and p = 0.0153, respectively) and PLR greater than 165.45 (p = 0.0319 and p = 0.0362, respectively). After multivariate analysis, only NLR remained as an independent factor in DFS (HR = 6.095, 95 % CI = 1.120-33.177, p = 0.037) and OS (HR = 4.522, 95 % CI = 1.241-16.479, p = 0.022) CONCLUSION: Higher NLR is associated to lower OS and DFS in invasive uterine cervical neoplasia, and can be considered an independent factor of worse prognosis.

Systemic Inflammatory Indicators as Prognosticators in Glioblastoma Patients: A Comprehensive Meta-Analysis

Background: Inflammation plays an important role in tumorigenesis. Previous studies have reported the prognostic value of several peripheral inflammatory markers in glioma patients, including the neutrophil-to-lymphocyte ratio (NLR). However, it still remains unclear whether inflammatory markers can independently predict the prognosis of glioblastoma (GBM) patients. The present study aims to explore the prognostic value of systemic inflammatory markers, including neutrophils, lymphocytes, platelets, the NLR, and the platelet-to-lymphocyte ratio (PLR), in patients with GBM.

Methods: A comprehensive systemic search and review was performed using the PubMed, EMBASE, and Cochrane Library databases to identify all the relevant literature (published before June 30, 2020) that evaluated the association between any of these inflammatory markers and survival in GBM.

Results: There were 2 (634 patients), 3 (723 patients), 2 (237 patients), 8 (1,225 patients), and 3 (505 patients) studies examining the correlation of survival with neutrophils, lymphocytes, platelets, the NLR, and the PLR, respectively. An elevated NLR and elevated neutrophil and platelet counts were associated with worse overall survival (OS) in GBM patients (NLR: hazard ratio [HR] = 1.63, 95% confidence interval [CI]: 1.23–2.15, p = 0.0007; neutrophil count: HR = 1.46, 95% CI:1.16–1.83, p = 0.001; platelet count: HR = 1.58, 95% CI: 1.42–1.77, p < 0.00001). However, there was no significant association between the PLR or the absolute lymphocyte count and OS in GBM patients.

Conclusion: The NLR and the absolute neutrophil and platelet counts may be valuable and convenient peripheral inflammatory markers to evaluate the prognosis of GBM patients. Further prospective studies are needed to verify its reliability.

Novel Prognostic Biomarkers of Mucosal Healing in Ulcerative Colitis Patients Treated With Anti-TNF: Neutrophil-to-Lymphocyte Ratio and Platelet-to-Lymphocyte Ratio

BACKGROUND

Anti-tumor necrosis factor drugs (anti-TNFs) are widely used for the treatment of ulcerative colitis (UC). However, many patients experience loss of response during the first year of therapy. An early predictor of clinical remission and mucosal healing is needed. The neutrophil-to-lymphocyte ratio (NLR) and platelet-to-lymphocyte ratio (PLR) are markers of subclinical inflammation poorly evaluated in UC patients treated with anti-TNFs. The aim of this multicenter study was to evaluate whether NLR and PLR could be used as prognostic markers of anti-TNF treatment response.

METHODS

Patients with UC who started anti-TNF treatment in monotherapy were evaluated. Patients with concomitant corticosteroid treatment ≥20 mg were excluded. We calculated NLR, PLR, and fecal calprotectin before treatment and after induction. The values of NLR and PLR were correlated with clinical remission and mucosal healing at the end of follow-up (54 weeks) using the Mann-Whitney U test and then multivariate analysis was conducted.

RESULTS

Eighty-eight patients were included. Patients who reached mucosal healing after 54 weeks of therapy displayed lower levels of both baseline NLR and PLR (P = 0.0001 and P = 0.04, respectively); similar results were obtained at week 8 (P = 0.0001 and P = 0.001, respectively). Patients who presented with active ulcers at baseline endoscopic evaluation had higher baseline NLR and PLR values compared with those without detected ulcers (P = 0.002 and P = 0.0007, respectively).

CONCLUSIONS

BothNLR and PLR showed a promising role as early predictors of therapeutic response to anti-TNF therapy in UC patients. If confirmed in larger studies, classification and regression trees proposed in this article could be useful to guide clinical decisions regarding anti-TNF treatment.

Statin Use is Protective Against Hepatocellular Carcinoma in Patients With Nonalcoholic Fatty Liver Disease: A Case-control Study

BACKGROUND AND GOAL

The incidence of nonalcoholic fatty liver disease (NAFLD)-associated hepatocellular carcinoma (HCC) is rising. We aimed to characterize risk factors for NAFLD-HCC development.

METHODS

We performed a retrospective case-control study of HCC cases from a cohort of NAFLD patients who underwent at least 2 computed tomography scans. NAFLD-HCC cases confirmed on contrast imaging and/or biopsy were included. Controls were NAFLD patients without HCC matched by sex and age. Clinical variables were assessed. Visceral adipose tissue and subcutaneous adipose tissue were measured by computed tomography at 2 timepoints: before HCC diagnosis and at diagnosis.

RESULTS

We identified 102 subjects [34 HCC cases, 68 controls, 65% (n=66) males, mean age: 69 y] from 2002 to 2016. Cirrhosis was present in 91%. In multivariate analysis, statin use was protective against HCC [odds ratio (OR)=0.20, 95% confidence interval (CI): 0.07-0.60, P=0.004], while hypertension was a risk factor for HCC (OR=5.80, 95% CI: 2.01-16.75, P=0.001). In multivariate analysis, visceral adipose tissue in males was higher before HCC diagnosis and declined by HCC diagnosis in 86%, which was a significant difference compared with controls (OR=2.78, 95% CI: 1.10-7.44, P=0.04).

CONCLUSIONS

In a cohort of NAFLD-HCC patients, statin use was protective against HCC, while hypertension conferred an increased risk. Visceral adiposity at baseline was not a risk factor, but was higher in male patients before HCC development, declining in the majority by HCC diagnosis.

Pretreatment Neutrophil-to-Lymphocyte Ratio (NLR) May Predict the Outcomes of Advanced Non-small-cell Lung Cancer (NSCLC) Patients Treated With Immune Checkpoint Inhibitors (ICIs)

Background: Recent studies have demonstrated the predictive value of pretreatment neutrophil-to-lymphocyte ratio (NLR) in advanced cancers; however, the role of NLR in patients with advanced non-small-cell lung cancer (NSCLC) treated with immune checkpoint inhibitors (ICIs) remained to be explored. Thus, we aimed to investigate whether pretreatment NLR was associated with the outcomes of advanced NSCLC patients treated with ICIs.

Methods: A comprehensive literature research was first conducted in PubMed, the Cochrane Central Library, and Embase for studies that evaluated the association between pretreatment NLR and survival of advanced NSCLC patients with ICIs treatment. We then conducted a retrospective study in Chinese People's Liberation Army (PLA) General Hospital (Beijing, China) to validate these findings.

Results: A total of 17 eligible studies with 2,106 patients were included in our meta-analysis, of which, 12 studies reported progression-free survival (PFS), and 13 studies reported overall survival (OS). The pooled results showed that high pretreatment NLR was significantly associated with poorer PFS (HR = 1.44, 95% CI 1.26–1.65; P < 0.001) and OS (HR = 2.86, 95% CI 2.11–3.87; P < 0.001) compared with those with low pretreatment NLR. Subgroup analysis demonstrated that the association between baseline NLR and PFS remained significant except that the cut-off value of NLR was 3 (HR = 1.48, 95% CI 0.93–2.37; P = 0.098) and region of Asia (HR = 1.55, 95% CI 1.00–2.39; P = 0.051). These results were further validated in our retrospective study that patients with pretreatment NLR ≥ 6.0 had shorter PFS (median: 5.0 vs. 9.1 months, HR = 1.39; 95% CI 1.01–1.91; P = 0.02) and OS (median: 10.0 vs. 17.3 months, HR = 1.71; 95% CI 1.18–2.46; P < 0.001) compared with those with NLR < 6.0. The associations between NLR and survival were consistent in subgroup analysis stratified by age, gender, ECOG PS, histology, stage, smoking history, treatment, and prior lines of therapy. Dynamics of NLR (dNLR) that increased ≥3.0 from baseline was also significantly associated with worse PFS (median: 3.1 vs. 9.1 months; P = 0.01) and OS (median: 6.8 vs. 17.0 months; P < 0.0001).

Conclusions: Our study demonstrates that pretreatment NLR and dNLR from baseline are associated with the outcomes of advanced NSCLC patients treated with ICIs; however, it warrants further prospective studies.

Dynamic Changes in the Neutrophil-to-Lymphocyte Ratio Predict the Prognosis of Patients with Hepatocellular Carcinoma Undergoing Transarterial Chemoembolization

Purpose

To examine the effect of dynamic changes in neutrophil-to-lymphocyte ratio (NLR) on tumor response and overall survival (OS) in patients with hepatocellular carcinoma (HCC) undergoing transarterial chemoembolization (TACE).

Patients and Methods

Data from 181 patients with HCC were retrospectively collected. White blood cell, neutrophil and lymphocyte counts, and the NLR were obtained 1–3 days before as well as 3–6 weeks and 3 months after TACE. Patients were divided into two groups at each time point according to the mean value of NLR, and also divided into continuous decrease, fluctuating increase-decrease (I-D), fluctuating decrease-increase (D-I), and continuous increase groups according to the dynamic changes in the NLR. The dynamic changes in blood counts and NLR were analyzed using repeated-measures ANOVA. The odds ratios (ORs) for tumor response in different NLR groups were examined using a multivariate logistic regression model. Finally, the prognostic value of the dynamic changes in the NLR was examined using Cox regression models.

Results

Continuous decline of white blood cell counts, neutrophil counts and lymphocyte counts were observed at 3–6 weeks and 3 months after TACE treatment. The NLR increased slightly and then decreased substantially in responders, while it increased slightly and then significantly in non-responders, with a significant interaction effect of Time × Tumor response (P = 0.005). NLR grouping before TACE, 3–6 weeks and 3 months after TACE was not associated with tumor response, and only 3 months after TACE did, it shows a significant difference in univariate survival analyses (NLR > 2.5 vs NLR ≤ 2.5, hazard ratio [HR] = 2.442, 95% confidence interval (CI): 1.545, 3.860). The changes in the NLR were significantly correlated with tumor response and OS. Non-responders for TACE were more common in the continuous NLR increase group (OR = 6.230, 95% CI: 1.848–21.001) and in the fluctuating D-I group (OR = 5.702, 95% CI: 1.480–21.957). Multivariate analyses revealed that these two patient groups also showed poorer OS (HR = 2.351, 95% CI: 1.120–4.605 and HR = 2.320, 95% CI: 1.187–4.533, respectively).

Conclusion

Dynamic changes in the NLR may be better predictors of tumor response and OS than static NLR values, but more data are needed.

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.

Hemotologic Indices for Predicting Internal Organ Involvement in Henoch-Schönlein Purpura (IgA vasculitis)

Henoch-Schönlein purpura is the most common vasculitis of childhood. This study investigated the values of hematologic indices that can help predict internal organ involvement. The study included 112 patients followed up between January 2007 and May 2017 and 81 healthy children. Leukocyte, neutrophil, monocyte, lymphocyte and platelet counts, neutrophil-to-lymphocyte ratio (NLR), platelet-to-lymphocyte ratio (PLR), and C-reactive protein (CRP) levels were compared between patients with and without internal organ involvement. Overall, 57 (50.8%) patients had internal organ involvement. Leukocyte, neutrophil, and monocyte counts, NLR, and CRP levels were significantly higher in patients with internal organ involvement than in patients without internal organ involvement. There was no difference between the groups in terms of lymphocyte count, platelet count, and PLR. The cutoff values were found to be ≥10.8×10/L [area under the curve (AUC), 0.734] for leukocyte, ≥6.0×10/L (AUC, 0.665) for neutrophil, ≥0.710×10/L (AUC, 0.681) for monocyte, ≥3.95×10/L (AUC, 0.609) for NLR, and 2.41 mg/dL (AUC, 0.635) for CRP. Logistic regression analysis revealed that leukocyte count is a risk factor for internal organ involvement. Leukocyte, neutrophil, monocyte counts, NLR, and CRP levels are useful in predicting internal organ involvement in the acute phase of Henoch-Schönlein purpura. Leukocyte count is an important risk factor for internal organ involvement and its predictive value is more reliable than the other hematologic indices.

Tumor-Infiltrating Lymphocytes and Macrophages in Intrahepatic Cholangiocellular Carcinoma. Impact on Prognosis after Complete Surgery

BACKGROUND

Immune infiltrate impacts prognosis of several tumors. To assess the prognostic impact of tumor-infiltrating lymphocytes and macrophages in patients undergoing resection for intrahepatic cholangiocellular carcinoma (ICC).

METHODS

All consecutive patients undergoing surgery for ICC between 2008 and 2016 were considered. Inclusion criteria were complete resection and follow-up > 12 months. Tissue sections were immunostained for CD3+, CD4+, CD8+, Foxp3+, and CD68+. The number of positive cells was quantified using a computer-aided image analysis system. Different cut-off values were tested as predictors of overall survival (OS).

RESULTS

Fifty-three patients were analyzed. ICC were T1 in 28 patients, multifocal in 11, and N+ in 13. After a median follow-up of 42 months, 5-year OS was 52.1%. The following immune infiltrate values were associated with better OS: CD3+ > 0.10% (5-year OS 63.3% vs. 13.6% if ≤ 0.10%, p = 0.001); CD8+ > 0.10% (56.2% vs. 28.6% if ≤ 0.10%, p = 0.051); Foxp3+ absent (59.4% vs. 16.0% if present, p = 0.049). CD4+ and CD68+ infiltrates were not associated with OS. Three-year OS rates in patients with 0, 1, and ≥ 2 negative prognostic factors were 73.6%, 47.3%, and 14.3%, respectively (p < 0.001). CD3+ infiltrate stratified prognosis in T1 tumors (3-year OS 71.7% if CD3+ > 0.10% vs. 14.3% if ≤ 0.10%, p < 0.001).

CONCLUSIONS

Tumor-infiltrating lymphocytes are associated with prognosis of ICC patients after complete surgery. CD3+ and CD8+ infiltrate is associated with higher survival and lower recurrence risk, while Foxp3+ infiltrate is associated with worse prognosis. CD3+ infiltrate allows refining prediction of prognosis in early tumors.

Predictive utility of neutrophil-to-lymphocyte ratio and platelet-to-lymphocyte ratio in intraductal papillary neoplasm of the bile duct

Aim of the study

Intraductal papillary neoplasm of the bile duct (IPNB) can present at various stages of the disease. Each stage needs different treatment. The neutrophil-to-lymphocyte ratio (NLR) and the platelet-to-lymphocyte ratio (PLR) have been described as predictive markers for several tumors. There has been no investigation on the role of NLR and PLR in IPNB.

Material and methods

We retrospectively reviewed the medical records of 112 patients who underwent curative-intent hepatic resection for IPNB between January 2007 and December 2011. All clinical parameters and survival were analyzed for their association with NLR and PLR.

Results

For prediction of malignancy, the best respective cut-off for NLR and PLR was 2.74 and 130, with area under the ROC curve being 0.662 and 0.763. For micro-papillary IPNB, both markers well predict malignancy and lymph node involvement. The respective area under the ROC curve of NLR and PLR for prediction of malignancy was 0.78 and 0.88. Both markers had an area under the ROC curve for prediction of lymph node involvement of 1.0. The median overall survival of those with PLR < 130 was 86.4 months compared with 45.0 months for those with PLR > 130 (p = 0.02).

Conclusions

NLR and PLR seem likely candidates for predicting malignancy, lymph node involvement, and survival of the patients. PLR performed better than NLR for all predictions. The markers worked very well for micro-papillary IPNB; however, we recommend using these markers in conjunction with the radiologic appearance of tumors.

Inflammatory markers in intrahepatic cholangiocarcinoma: Effects of advanced liver disease

BACKGROUND

To investigate the neutrophil-to-lymphocyte ratio (NLR), platelet-to-lymphocyte ratio (PLR), and systemic immune-inflammation index (SII) as prognostic biomarkers in intrahepatic cholangiocarcinoma (ICC) with a focus on viral hepatitis and liver status.

METHODS

In this retrospective cohort study, patients from the institutional cancer registry with ICC from 2005 to 2016 were stratified by treatment group. Baseline inflammatory markers were dichotomized at the median. Overall survival (OS) was assessed via Kaplan-Meier curves and Cox proportional hazard models. Multiple patient, liver, and tumor factors were included in the multivariable analysis (MVA).

RESULTS

About 131 patients (median age 65 years, 52% male, 76% Caucasian) had a median OS of 13.0 months. Resection/interventional oncology with/without systemic therapy had improved survival vs systemic therapy alone in Child-Pugh A patients (P < 0.01). In Child-Pugh B/C patients, this survival difference became nonsignificant (P = 0.22). Increased NLR and SII were associated with decreased survival (P < 0.01), while dichotomized PLR was not (P = 0.3). On MVA, increased NLR remained an independent prognostic factor (HR 1.6, P < 0.05). In Child-Pugh class A (n = 94), low-NLR had higher OS vs high-NLR (25.4 vs 12.2 months, P < 0.01). In Child-Pugh class B/C (n = 28), NLR did not have a significant effect on median OS (low- vs high-NLR: 6.7 vs 2.9 months, P = 0.2). Child-Pugh class acted as an effect modifier on MVA for NLR (P = 0.0124).

CONCLUSIONS

The NLR has a stronger impact as a prognostic marker in ICC over the PLR and SII. This survival effect is decreased in advanced liver disease.

Coming of a precision era of the staging systems for intrahepatic cholangiocarcinoma?

Intrahepatic cholangiocarcinoma (ICC) is the second most common primary liver cancer. Appropriate treatment of this aggressive and heterogeneous cancer requires accurate staging and prognostic stratification, as does patient selection for clinical trials. Over the past two decades, several staging systems and prognostic models for ICC have been developed. Most include independent prognostic factors such as tumor extent, clinical parameters and histopathological features and are inaccurate. Accumulating findings offer new insights into the genetic and molecular basis of ICC progression. Hence, staging systems and prognostic models that incorporate in clinicalpathological factors, molecular and genomic information, and tumor biomarkers, and hence more accurately estimate prognosis, will become a reality. This review summarizes the current staging systems and prognostic models for ICC and highlights the need to establish more precise and personalized systems and models that incorporate tumor biologic factors.

Prognostic significance of pretreatment neutrophil-to-lymphocyte ratio in older patients with metastatic cancer

BACKGROUND

Treatment options for older patients with malignancies remain suboptimal. An accurate prognostic stratification could inform treatment decisions, which can potentially improve patient outcomes. Here, we sought to investigate whether the neutrophil-to-lymphocyte ratio (NLR) may have prognostic significance in patients with metastatic malignant tumors, with a special focus on older individuals.

METHODS

We retrospectively reviewed the clinical records of 3981 patients with histology-proven metastatic cancer who underwent radiotherapy between 2000 and 2013. The pretreatment NLR was determined within 7 days before treatment initiation. Patients aged ≥65 years were considered as older. We analyzed the prognostic significance of NLR for overall survival (OS) across all age groups.

RESULTS

Compared with their younger counterparts, older patients showed a higher NLR (P < 0.001) and a lower OS (P < 0.001). Multivariate analysis revealed that a pretreatment NLR below the median was an independent favorable predictor of OS in both older (hazard ratio [HR]: 0.669, 95.0% CI: 0.605-0.740; P < 0.001) and younger patients (HR: 0.704; 95.0% CI: 0.648-0.765; P < 0.001). Regardless of age, patients who underwent systemic therapy showed more favorable OS, especially when NLR was low. In the older subgroup, the OS of patients with a low pretreatment NLR who did not undergo systemic therapy and of those with high pretreatment NLR who underwent systemic therapy was similar.

CONCLUSION

A low pretreatment NLR predicts a more favorable OS in older patients with metastatic cancer. The most favorable OS was observed in patients with a low pretreatment NLR who received systemic therapy.

Neutrophil/lymphocyte ratio and lymphocyte/monocyte ratio in ulcerative colitis as non-invasive biomarkers of disease activity and severity

Background

Apart from endoscopic interventions, readily attainable cost-effective biomarkers for ulcerative colitis (UC) assessment are required. For this purpose, we evaluated differential leucocytic ratio, mainly neutrophil–lymphocyte ratio (NLR) and lymphocyte-monocyte ratio (LMR) as simple available indicators of disease activity in patients with ulcerative colitis.

Methods

Study conducted on 80 UC patients who were classified into two groups of 40 each according to Mayo score and colonoscopic findings. Group 1 (active UC) and group 2 (inactive UC). Another 40 group-matched healthy participants were enrolled. White blood cell count, NLR, LMR, C-reactive protein, and Erythrocyte sedimentation rate were measured and recorded.

Results

Significant elevation of NLR was observed in active UC group compared to inactive UC and controls (2.63 ± 0.43, 1.64 ± 0.25, 1.44 ± 0.19 respectively; p < 0.0001). The optimal NLR cut-off value for active UC was > 1.91, with a sensitivity and a specificity of 90% and 90% respectively. The mean LMRs of active UC was significantly lower compared with inactive UC patients and controls (2.25 ± 0.51, 3.58 ± 0.76, 3.64 ± 0.49 respectively; p < 0.0001). The cut-off value of LMR for determining the disease activity was ≤ 2.88 with a sensitivity of 90% and a specificity of 90%. NLR, LMR, and CRP were found to be significant independent markers for discriminating disease activity (p = 0.000). Besides, NLR was significantly higher in patients with pancolitis and positively correlated with endoscopically severe disease.

Conclusion

NLRs and LMRs are simple non-invasive affordable independent markers of disease activity in UC.

Preoperative systemic inflammatory markers in low- and high-grade gliomas: A retrospective analysis of 171 patients

Purpose

Preoperative neutrophil-lymphocyte ratio (NLR), platelet-lymphocyte ratio (PLR) and lymphocyte-monocyte ratio (LMR) are recognized as prognostic markers of grade of gliomas. The aim of this study was to determine whether preoperative levels of NLR, PLR, and LMR differ between low- and high-grade gliomas.

Methods

Retrospective analysis of preoperative neutrophil, lymphocyte, monocyte, and platelet counts and NLR, PLR, and LMR were performed in 171 patients who underwent glioma surgery. The results were compared between low- and high-grade gliomas.

Results

Neutrophil count was significantly increased while lymphocyte count significantly decreased in high-grade gliomas (HGGs). NLR and PLR were significantly higher in HGGs but LMR was significantly reduced in HGGs. NLR and PLR correlated with glioma grade and only NLR showed highest accuracy predicting higher grade.

Conclusions

Levels of preoperative NLR value can help to evaluate disease progression and predict higher grade of glioma.

Research progress of P2X7 receptor in inflammatory bowel disease

Inflammatory bowel disease is a chronic nonspecific inflammatory disease of the intestine. Its pathogenesis is not yet fully understood. It may be related to heredity, environmental triggers, infection, immune dysfunction and other factors. Purinergic receptor (P2X7R) ligand-gated ion channel is closely related to inflammation and widely expressed in intestinal cells. Previous studies have shown that ATP/P2X7R signal is involved in the pathogenesis of intestinal inflammation, but its specific mechanism needs further study. This article reviews the research progress of P2X7 receptor in inflammatory bowel disease.

Impact of diabetes mellitus on the prognostic value of the neutrophil-lymphocyte ratio in renal cell carcinoma

The aim of the present study was to evaluate the effect of diabetes mellitus (DM) on the neutrophil-lymphocyte ratio (NLR)-based prediction of the prognosis of patients with renal cell carcinoma (RCC). The data of 662 patients who had undergone nephrectomy for RCC between January 2004 and July 2014 were retrospectively reviewed. X-tile analysis was used to determine the optimal cutoff value for the NLR. Kaplan-Meier curves were drawn and the log-rank test was applied to determine the impact of the NLR (high vs. low) on the overall survival (OS) and metastasis-free survival (MFS). Univariate and multivariate Cox regression analyses were used to identify prognostic factors for OS and MFS. The median follow-up period after surgery was 50.35 months (range, 30.30–85.08 months). The optimal cutoff value of the NLR was determined to be 3.2 using X-tile software. In the analysis of total subjects, patients with a high NLR (≥3.2) had significantly worse OS and MFS rates than those with a low NLR (<3.2) (21.60% vs. 78.40%, P=0.001 for OS and 21.60% vs. 78.40%, P<0.0001 for MFS). In the non-DM subgroup, the OS and MFS rates of patients with a high NLR were significantly worse compared with those of patients with a low NLR (21.69% vs. 78.31%, P=0.003 for OS and 21.69% vs. 78.31%, P<0.001 for MFS). In the DM subgroup, although a high NLR was still associated with the MFS (NLR≥3.2, 21.43% vs. NLR<3.2, 78.57%; P=0.015), it was no longer associated with the OS (NLR≥3.2, 21.43% vs. NLR<3.2, 78.57%; P=0.192). Furthermore, multivariate analysis identified the NLR as a risk factor for OS and MFS in all patients [hazard ratio (HR)=1.77, 95% confidence interval (CI): 1.04–3.01, P=0.037; and HR=2.31, 95% CI: 1.45–3.70, P<0.001, respectively) and in the non-DM subgroup (HR=2.03, 95% CI: 1.05–3.93, P=0.036; and HR=2.57, 95% CI: 1.47–4.49, P=0.001, respectively), but not in the DM subgroup (P>0.05). In conclusion, DM is a factor that impairs the evaluation of the prognosis of RCC using NLR.

Prognostic significance of neutrophil/prealbumin ratio for intrahepatic cholangiocarcinoma undergoing curative resection

BACKGROUND

This study aimed to clarify the prognostic significance of neutrophil/prealbumin ratio index (NPRI) for overall survival (OS) and recurrence free survival (RFS) of ICC after curative surgery.

METHODS

Two-hundred and seventy-six ICC patients who underwent curative resection from December 2006 to April 2017 were recruited and analyzed retrospectively. The correlations between clinicopathological features and NPRI were analyzed. OS and RFS were calculated using Kaplan-Meier curve, and cox univariate and multivariate analyses were used to identify the prognostic factors.

RESULTS

The optimal cut-off value of NPRI determined by ROC curve was 1.74 and the patients were divided into high-value and low-value groups. High-value NPRI was associated with higher risk of postoperative complications (p = 0.035) and longer hospitalization (p = 0.004).Univariate and multivariate cox analyses demonstrated that NPRI was an independent predictor for OS (p = 0.015) and RFS (p = 0.004) in ICC after curative resection. Furthermore, NPRI was also a significant predictor for OS and RFS in different subgroups of ICC, including CA19-9<35U/mL, single tumor, no vascular invasion, no local invasion and AJCC stages I + II.

CONCLUSIONS

NPRI was an independent prognostic predictor for ICC after curative resection. It would have high clinical values due to its convenience.

Nomograms based on inflammatory biomarkers for predicting tumor grade and micro-vascular invasion in stage I/II hepatocellular carcinoma

Background: Increasing evidences reveal that inflammation plays a critical role in tumorigenesis and progression. We aimed to develop the nomograms based on inflammatory biomarkers to predict micro-vascular invasion (MVI) and tumor grade in stage I/II hepatocellular carcinoma (HCC).Methods: A retrospective cohort of 627 patients with stage I/II HCC between January 2007 and December 2014 was included in the study. Logistic regression was performed to identify the independent risk factors of tumor grade and MVI. The significant predictors including neutrophil-to-lymphocyte ratio (NLR), derived neutrophil-to-lymphocyte ratio (dNLR), lymphocyte-to-monocyte ratio (LMR), tumor volume age, and tumor size were subsequently incorporated to build the nomograms. The prediction accuracies of the nomograms were evaluated using the area under the receiver operating characteristic (ROC) curve.Results: The independent risk factors for tumor grade were NLR, dNLR, and tumor volume (P<0.001, P=0.001, and P<0.001, respectively), which were assembled into tumor grade nomogram. MVI nomogram was developed by dNLR, LMR, age, and tumor size (P<0.001, P<0.001, P<0.001, and P=0.001, respectively) which were the independent predictors for MVI. The area under the ROC curve of nomograms for predicting tumor grade and MVI were 0.727 (95% confidence intervals [CI]: 0.690-0.761) and 0.839 (95% CI: 0.808-0.867), respectively. Patients who had a nomogram score of less than 100 and 79 were considered to have high possibility of moderate grade and have low risks of MVI presence, respectively.Conclusion: We successfully developed nomograms predicting tumor grade and MVI based on inflammatory biomarkers with high accuracy, leading to a rational therapeutic choice for stage I/II HCC.

Pretreatment Inflammation-Based Markers Predict Survival Outcomes in Patients with Early Stage Hepatocellular Carcinoma After Radiofrequency Ablation

The prognostic significance of various systemic inflammation‐based markers has been explored in different cancers after surgery. This study aimed to investigate whether these markers could predict outcomes in patients with early-stage hepatocellular carcinoma (HCC) undergoing radiofrequency ablation (RFA). One hundred eighteen patients with newly diagnosed HCC within the Milan criteria receiving RFA as initial therapy were retrospectively enrolled. Pretreatment inflammation-based markers including the neutrophil to lymphocyte ratio (NLR), platelet to lymphocyte ratio (PLR) and prognostic nutritional index (PNI), together with other clinicopathologic parameters were collected. Cumulative overall survival (OS) and recurrence-free survival (RFS) were estimated by the Kaplan-Meier method and by multivariate analysis using Cox proportional hazard model. The 1-, 3-, and 5-year OS rates of patients were 90%, 67%, and 52%, respectively. Kaplan-Meier curves showed that baseline high NLR ≥ 2.5 (p = 0.006), low PNI < 40 (p = 0.005), history of end-stage renal disease (ESRD) (p = 0.005), non-Child-Pugh class A (p = 0.001) and elevated alpha-fetoprotein (AFP) ≥ 200 ng/mL (p = 0.005) significantly associated with the poor OS, whereas high PLR ≥ 100 did not. By multivariate analysis, high NLR ≥ 2.5 (hazard ratio (HR) 1.94; 95% confidence interval (CI), 1.05–3.59; p = 0.034), low PNI < 40 (HR 0.38; 95% CI, 0.20–0.72; p = 0.003), ESRD history (HR 3.60; 95% CI, 1.48–8.76; p = 0.005) and elevated AFP ≥ 200 ng/mL (HR 4.61; 95% CI, 1.75–12.13; p = 0.002) were independent factors. An elevated AFP level of ≥200 ng/mL was the significant factor associated with intrahepatic new RFS by univariate and multivariate analyses. In conclusion, pretreatment NLR and PNI are simple and useful predictors for OS in patients with early-stage HCC after RFA.

The impact of skeletal muscle mass on survival outcome in biliary tract cancer patients

Low skeletal muscle mass is frequently observed in cancer patients and is known to be a poor prognostic factor for survival outcomes. The purposes of our study were to determine the prevalence of sarcopenia and its relation to mortality in biliary tract cancer. Body composition measurements (skeletal muscle index, total fat mass, bone mineral content) were evaluated by using dual-energy x-ray absorptiometry in 75 biliary tract cancer patients before chemotherapy. Muscle strength was measured by handgrip strength and gait speed. Overall survival and its associated factors were determined. The mean appendicular muscle mass was 17.8±2.7 kg in men and 14.0±2.1 kg in women (p < 0.05). Sarcopenia was diagnosed in 46 patients (61.3%) and higher proportion of men was classified as sarcopenia than women (69.0% vs 35.3%, p < 0.05). Multivariable analysis adjusted for chemotherapy regimen and age revealed that high appendicular muscle mass independently predicted better survival outcomes (HR 0.40; 95% CI, 0.18 to 0.88; p = 0.023). Sarcopenia is common in biliary tract cancer patients and low appendicular muscle mass was associated with poor survival outcome.

The prognostic significance of preoperative neutrophil-lymphocyte ratio in patients with hepatocellular carcinoma receiving hepatectomy: A systematic review and meta-analysis

BACKGROUND AND AIMS

Numerous reports have indicated that preoperative Neutrophil-Lymphocyte ratio (NLR) was correlated with the prognosis of hepatocellular carcinoma who underwent hepatectomy. However, the results still remained controversial. Therefore, the present meta-analysis of 17 studies was performed to evaluate the prognostic value of preoperative NLR in HCC patients.

METHOD

Databases of PubMed, Embase, Cochrane Library and Web of Science were retrieved. Hazard Ratio (HR) or Odds Ratio (OR) with its 95% confidence intervals (CI) was used to evaluate the association between preoperative NLR and the prognosis or clinical features of HCC patients.

RESULT

A total of 17 studies eventually were included in this meta-analysis. Elevated preoperative NLR had a close relationship with the overall survival (OS) (HR 1.52; 95% CI 1.37-1.69), recurrence-free survival (RFS) (HR 1.64; 95% CI 1.44-1.87) and disease-free survival (DFS) (HR 1.50; 95% CI 1.35-1.67) of hepatocellular carcinoma. Additionally, preoperative NLR was also associated with tumor vascular invasion (OR 2.08; 95% CI 1.60-2.70), HBV (OR 0.68; 95% CI 0.51-0.90) and large tumor size (OR: 4.07; 95% CI 2.60-6.37).

CONCLUSION

The present meta-analysis indicated that preoperative NLR had significant association with the prognosis of hepatocellular carcinoma patients and may be an effectively prognostic indicator.

Neutrophil-lymphocyte ratio is associated with prognosis in patients who underwent potentially curative resection for gastric cancer

BACKGROUND AND OBJECTIVES

The role of inflammation in cancer development is a well-known phenomenon that may be represented by the neutrophil-lymphocyte ratio (NLR). The present research intends to determine the impact of NLR on the survival outcome of patients with gastric cancer (GC), and to evaluate its use as a stratification factor for the staging groups.

METHODS

Data regarding clinical characteristics, surgery, pathology, and follow-up were retrospectively collected from our single-center prospective database. Blood samples were obtained before surgery.

RESULTS

A total of 383 patients (231 males) who underwent gastrectomy with lymphadenectomy were evaluated between 2009 and 2016. NLR established cutoff was 2.44, and patients were divided in NLR ≥2.44 (hNLR) and <2.44 (lNLR). hNLR patients (38.4% of the cases) had lower disease-free survival and overall survival (OS) compared to lNLR patients (P = 0.047 and P = 0.045, respectively). Risk stratification according to NLR value was done in same tumor depth (T4 and <T4), stage (III and <III) and lymph node status (N+ and N-) group of patients. The OS was significantly lower when NLR was high in same tumor depth (P = 0.032) and stage (P = 0.020), but not in same lymph node status patients (P = 0.184). In a multivariate analysis, NLR was an independent factor of worse OS (HR 1.50 95%CI 1.27-4.21, P = 0.048).

CONCLUSION

A high NLR was an independent risk factor for reduced survival in GC patients submitted to potentially curative resection. Calculating NLR is easily reproducible and may be incorporated in pre-operative evaluation.

Non-secretion of AFP and neutrophil lymphocyte ratio as predictors for survival in hepatocellular carcinoma patients treated with sorafenib: a large UK cohort

Background

Sorafenib is the current standard of care for patients with advanced or metastatic hepatocellular carcinoma. Currently no universally agreed model exists correlating the Neutrophil Lymphocyte ratio (NLR) and non-secretion of AFP with the survival of HCC patients treated with sorafenib.

Patients and Methods

We retrospectively analysed patient records with a confirmed diagnosis of HCC treated with sorafenib between April 2009 and March 2014. Survival analysis was performed using the Kaplan–Meier method and Cox regression.

Results

Patients separated into groups based on NLR (≤3 or >3), or AFP secretion profile (<7 ng/ml or ≥7 ng/ml) derived diverging Kaplan–Meier curves for overall survival (OS). The median OS in those with NLR ≤3.0 was 9.0 months (95% CI: 7.7–11.1 months) and in those with NLR >3.0 it was 6.0 months (95% CI: 4.9–8.2 months) [HR 1.32 (95% CI: 0.96–1.80)]. The median overall survival post sorafenib was higher in the “non-secretor” AFP group. OS for AFP <7 ng/ml was 10.0 months (95% CI: 7.7–19.3 months) compared to AFP ≥7ng/ml: 6.6 months (95% CI: 5.3–8.4 months) [HR 1.64 (95% CI: 1.15–2.33)].

Conclusion

NLR and AFP non - secretion at diagnosis are potential significant prognosticators for overall survival from initiation of sorafenib.

Clinical Predictors for Neutrophil-to-Lymphocyte Ratio Changes in Patients with Chronic Hepatitis B Receiving Peginterferon Treatment

BACKGROUND

A lower neutrophil-to-lymphocyte ratio (NLR) was found to be associated with better clinical outcomes in hepatitis B-related liver cirrhosis and hepatocellular carcinoma. We aimed to identify pre-therapeutic variables capable of predicting NLR changes in patients with hepatitis B receiving peginterferon therapy.

PATIENTS AND METHODS

The baseline clinicopathological data were analyzed to correlate with NLR changes before and 1 year after peginterferon treatment in 71 patients with hepatitis B.

RESULTS

Univariate analysis revealed that pre-treatment NLR itself negatively predicted NLR changes following peginterferon treatment (odds ratio(OR)=0.320, p=0.013). Further analysis identified pre-treatment NLR, hemoglobin and hepatitis B surface antigen level as independent predictors for NLR changes (adjusted p=0.028, 0.005, and 0.028, respectively). A predictive score composed of these three factors had an area under the curve of 76.5% (p<0.001).

CONCLUSION

Pretreatment NLR, hemoglobin and hepatitis B surface antigen level in combination, effectively predicted NLR changes following peginterferon treatment.

Prognostic role of neutrophil-to-lymphocyte ratio in head and neck cancer: A meta-analysis

BACKGROUND

Neutrophils play substantial roles in cancer progression. Previous reports demonstrated the prognostic impact of the pretreatment neutrophil-to-lymphocyte ratio (NLR) in various types of solid cancers. The purpose of this study was to quantify the prognostic impact of NLR on head and neck squamous cell carcinoma (HNSCC).

METHODS

We systematically searched electronic databases, identified articles regarding NLR and HNSCC mortality, and extracted hazard ratios (HRs) and 95% confidence intervals (CIs). Pooled HRs for overall survival (OS) and disease-specific survival (DSS) were estimated using random effect models.

RESULTS

Nineteen studies enrolling 3770 patients were included in the analyses. Overall, NLR greater than the cutoff value was associated with poorer OS and DSS (HR 1.69; 95% CI 1.47-1.93; P < .001 and HR 1.88; 95% CI 1.20-2.95; P = .006, respectively).

CONCLUSION

Elevated NLR predicts worse outcomes in patients with HNSCC.

Prognostic utility of baseline neutrophil-to-lymphocyte ratio in patients receiving immune checkpoint inhibitors: a review and meta-analysis

INTRODUCTION

Systemic inflammation is associated with prognosis in solid tumors. The neutrophil-to-lymphocyte ratio (NLR) is a marker for the general immune response to various stress stimuli. Studies have shown correlation of NLR to outcomes in immune checkpoint blockade, peripheral neutrophil count to intratumor neutrophil population, and NLR to intratumoral levels of myeloid-derived suppressor cells. Studies have shown elevated peripheral blood regulator T cells accompanied by elevated NLR are associated with poor outcomes further highlighting the importance of inflammation in the prognosis of cancer patients.

METHODS

We performed a meta-analysis of published articles on the utility of baseline NLR in predicting outcomes in patients treated with immune checkpoint inhibitors (ICIs) using Review Manager, version 5.3. Seven studies on the prognostic utility of NLR in ICI treatment were included in this analysis. For outcomes of interest, the hazard ratios (HRs) were computed. Subgroup analyses were planned based on type of malignancy and type of immune checkpoint inhibitor.

RESULTS/DISCUSSION

A high NLR resulted in worse overall survival (OS) (HR, 1.92; 95% CI, 1.29-2.87; p=0.001) and progression-free survival (PFS; HR, 1.66; 95% CI, 1.38-2.01; p<0.00001) across types of malignancies studied (melanoma, non-small-cell lung cancer, and genitourinary cancer). Subgroup analysis across different types of malignancies treated with ICI showed similar results for OS and PFS. The single study on genitourinary cancers also showed worse OS and PFS (OS: HR, 1.82; 95% CI, 1.29-2.87; p=0.001 and PFS: HR, 1.83; 95% CI, 0.97-3.44; p=0.06). A high NLR also showed worse OS and PFS across all ICIs (ipilimumab, nivolumab, and unspecified or pooled pembrolizumab and nivolumab; OS: HR, 1.92; 95% CI, 1.29-2.87; p=0.001 and PFS: HR, 1.66; 95% CI, 1.38-2.01; p<0.00001). Subgroup analysis by type of ICI showed similar results.

CONCLUSION

A high NLR is associated with poorer outcomes across studies. This shows that NLR has the potential as a readily available prognostic indicator for patients receiving ICI based on available studies. Studies utilizing more stringent design may serve to better determine the utility of this tool.

Can combined blood neutrophil to lymphocyte ratio and C-reactive protein be used for diagnosis of spontaneous bacterial peritonitis?

BACKGROUND AND OBJECTIVE

Spontaneous bacterial peritonitis (SBP) is diagnosed by the presence of ≥250 polymorphonuclear neutrophils (PMN)/mm³ in the ascites and the absence of surgically treatable cause of intra-abdominal infection. Blood neutrophil lymphocytic ratio (NLR) is an inexpensive and simple test for inflammation. C-reactive protein (CRP) is an inflammatory marker used for the diagnosis and follow-up of many diseases and morbidities. We aimed to evaluate the clinical utility of combined blood NLR and CRP as a non-invasive test for SBP diagnosis.

METHODS

Blood NLR was calculated, and CRP value determined in 180 cirrhotic patients with ascites (126 with and 54 without SBP). Sensitivity and specificity of combined blood NLR and CRP values for SBP diagnosis were estimated by receiver operator characteristic curve.

RESULTS

Both blood NLR and CRP values were significantly higher in SBP (p < 0.001). For SBP diagnosis, a blood NLR of >2.89 had a sensitivity 80.3% and specificity 88.9%. CRP >11.3 mg/dL had a sensitivity 88.9% and specificity 92.6%. In logistic regression analysis, combined blood NLR and CRP had a sensitivity 95.1% and specificity 96.3% at the same cut off values.

CONCLUSIONS

Combined NLR and CRP could be used as a novel, simple, low-cost, non-invasive test for SBP diagnosis.

Combination of AKT inhibitor ARQ 092 and sorafenib potentiates inhibition of tumor progression in cirrhotic rat model of hepatocellular carcinoma

The prognosis of patients with advanced hepatocellular carcinoma (HCC) is very poor. The AKT pathway is activated in almost half of HCC cases and in addition, long term exposure to conventional drug treatment of HCC, sorafenib, often results in over-activation of AKT, leading to HCC resistance. Therefore, it is important to assess the safety and the efficacy of selective allosteric AKT inhibitor ARQ 092 (Miransertib) in combination with sorafenib.

Here, we demonstrated in vitro that the combination of ARQ 092 with sorafenib synergistically suppressed proliferation, promoted apoptosis, and reduced migration. To test the effect of the combination in vivo, rats with diethylnitrosamine-induced cirrhosis and fully developed HCC were randomized and treated with vehicle, sorafenib, ARQ 092 or the combination of ARQ 092 with sorafenib; (n=7/group) for 6 weeks. Tumor progression, size of tumors and the mean tumor number were significantly reduced by the combination treatment compared to the control or single treatments. This effect was associated with a significant increase in apoptotic response and reduction in proliferation and angiogenesis. Sirius red staining showed a decrease in liver fibrosis. Moreover, treatments improved immune response in blood and in tumor microenvironment.

Thus, the combination of ARQ 092 with sorafenib potentiates inhibition of tumor progression and gives the possibility of therapeutic improvement for patients with advanced HCC.