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

The role and participation of immune cells in the endometrial tumor microenvironment

The tumor microenvironment is surrounded by blood vessels and consists of malignant, non-malignant, and immune cells, as well as signalling molecules, which primarily affect the therapeutic response and curative effects of drugs in clinical studies. Tumor-infiltrating immune cells participate in tumor progression, impact anticancer therapy, and eventually lead to the development of immune tolerance. Immunotherapy is evolving as a promising therapeutic intervention to stimulate and activate the immune system to suppress cancer cell growth. Endometrial cancer (EC) is an immunogenic disease, and in recent years, immunotherapy has shown benefit in the treatment of recurrent and advanced EC. This review discusses the key molecular pathways associated with the intra-tumoral immune response and the involvement of circulatory signalling molecules. Specific immunologic signatures in EC which offer targets for immunomodulating agents, are also discussed. We have summarized the available literature in support of using immunotherapy in EC. Lastly, we have also discussed ongoing clinical trials that may offer additional promising immunotherapy options in the future. The manuscript also explored innovative approaches for screening and identifying effective drugs, and to reduce the financial burdens for the development of personalized treatment strategies. Collectively, we aim to provide a comprehensive review of the role of immune cells and the tumor microenvironment in the development, progression, and treatment of EC.

Preoperative Prognostic Nutritional Index Is a Prognostic Indicator of Cancer-Specific Survival in Patients Undergoing Endometrial Cancer Surgery

BACKGROUND

The prognostic nutritional index (PNI) reflects systemic inflammation and nutritional status. This study aimed to evaluate the effect of preoperative PNI on postoperative cancer-specific survival in patients with endometrial cancer (EC).

METHODS

Demographic, laboratory, and clinical data were retrospectively collected from 894 patients who underwent surgical resection of EC. Preoperative PNIs were determined from the serum albumin concentration and total lymphocyte count, which were measured within 1 month before surgery. Patients were classified into high PNI (n = 619) and low PNI (n = 275) groups according to the preoperative PNI cut-off value of 50.6. The stabilized inverse probability of treatment weighting (IPTW) method was used to reduce bias: a weighting cohort divided into high PNI (n = 615.4) and low PNI (n = 272.3) groups. The primary outcome measure was postoperative cancer-specific survival.

RESULTS

The postoperative cancer-specific survival rate was higher in the high PNI group than the low PNI group in the unadjusted cohort (93.1% vs. 81.5%; proportion difference [95% confidence interval; 95% CI], 11.6% [6.6-16.6%]; P < 0.001) and in the IPTW-adjusted cohort (91.4% vs. 86.0%; 5.4% [0.8-10.2%]; P = 0.021). In the multivariate Cox proportional hazard regression model in the IPTW-adjusted cohort, high preoperative PNI (hazard ratio [95% CI], 0.60 [0.38-0.96]; P = 0.032) was an independent determinant of postoperative cancer-specific mortality. The multivariate-adjusted restricted cubic spline curve for the Cox regression model showed a significant negative association between preoperative PNI and postoperative cancer-specific mortality (P < 0.001).

CONCLUSION

High preoperative PNI was associated with improved postoperative cancer-specific survival in patients undergoing surgery for EC.

Hematologic inflammatory indexes as a prognostic factor in endometrial cancer grading and staging

Background

Endometrial cancer is one the most popular types of cancer in women in the world, also a common type of cancer among Iranian females. Neutrophils to lymphocytes (NLR) and platelet to lymphocyte (PLR) ratios are two practical and available indicators in endometrial cancer. We examined their correlation in these patients and determined that they could be used as a prognostic factor in grading and staging this cancer. This study takes a practical approach and recommends a screening strategy for asymptomatic women diagnosed with cancer in its early stages.

Methods

Endometrial cancer patients were included in this cross-sectional study based on histological findings. NLR is known as the proportion of neutrophils to absolute lymphocytes, while PLR is known as the proportion of platelets to lymphocytes. The NLR and PLR were evaluated and their relationship to the grade and stage of cancer.

Results

PLR and NLR values were calculated, and the mean values were 4.917±5.870 and 16.019±18.963, respectively. NLR and PLR were more significant in group 2 patients. Additionally, a strong and statistically significant relationship existed between these two methods (p<0.001). For the NL and PL methods, the optimal cutting point was 3.66 and 13.26, respectively. The NL method had a specificity of 0.906 and a sensitivity of 0.564. The PL and NL zones had values of 0.697 and 0.725, respectively. Although there is no remarkable difference among these areas, the AUC of PL power is slightly better than the NL method. It demonstrates that they are capable of increasing detection power by more than 50%.

Conclusion

This study concluded that PLR and NLR were identified as independent prognostic items associated with the stage and grade of endometrial cancer.

Study on Preoperative Neutrophil/Lymphocyte (NLR) and Platelet/Lymphocyte Ratio (PLR) as a Predictive Factor in Endometrial Cancer

OBJECTIVE

To evaluate predictive factors between serum inflammatory markers and malignancy potential of endometrium.

METHODS

This retrospective study was conducted at the gynecological oncology unit, department of obstetrics and gynecology, at the faculty of medicine of Thammasat University. The study period was from 2017 to 2020. Endometrial cancer and benign gynecologic disease cases who underwent hysterectomy (with or without adnexectomy) during the study period were recruited. Demographic characteristics, histopathology reports and serum markers were also collected.

RESULTS

The study included a study group of 49 participants with endometrial cancer and a control group consisting of 119 cases of benign uterine disease. The study group had statistically significantly higher mean ages, proportional menopausal status and instances of underlying diseases when compared with the control group. Neutrophil/Lymphocyte ratios (NLR) and Platelet/Lymphocyte ratios (PLR) could not meaningfully predict the malignant potential of endometrium in hysterectomy specimens. NLR and PLR were statistically associated with depth of myometrial invasion (MI) in endometrial cancer cases. NLR equal to or greater than 1.93 predicted MI more than half thickness with sensitivity, specificity, accuracy, positive (PPV) and negative predictive value (NPV) at a percentage of 83.3, 52.8, 37.0, 90.5 and 60.4, respectively. PLR equal to or greater than 134.95 predicted MI of greater than fifty percent thickness with sensitivity, specificity, accuracy, PPV and NPV at 75.0, 55.6, 36.0, 87.0 and 60.4 percent, respectively.

CONCLUSION

NLR and PLR have positive associations with myometrial invasion of endometrial cancer.

Beyond mismatch repair deficiency? Pre-treatment neutrophil-to-lymphocyte ratio is associated with improved overall survival in patients with recurrent endometrial cancer treated with immunotherapy

OBJECTIVE

To determine the association of pre-treatment neutrophil-to-lymphocyte ratio (NLR) with progression-free survival (PFS) and overall survival (OS) for patients with recurrent endometrial cancer (EC) treated with immunotherapy.

METHODS

Recurrent EC patients treated with immunotherapy alone or in combination from 2016 to 2021 were included. Demographics, pre-treatment laboratory results, pathologic data, response at first radiographic assessment, and cancer outcomes were obtained from the medical record. Kaplan-Meier curves were generated to compare PFS and OS stratified by NLR.

RESULTS

The 106 patients included in the study were stratified by NLR <6 (n = 77, 72.6%) or NLR ≥6 (n = 29, 27.3%). Most had endometrioid pathology (59%), widely metastatic disease, and 36.8% had received ≥2 treatment lines before initiating immunotherapy. Mismatch repair deficiency (dMMR) was noted in 52 (49.1%) tumors. Most dMMR patients (94.3%) were treated with single-agent pembrolizumab, and most MMR proficient patients (78.7%) were treated with lenvatinb plus pembrolizumab. In the overall cohort, 40.2% (partial response (PR) 29.9%, complete response (CR) 10.4%) of patients with a NLR <6 responded at first radiographic assessment, compared to 31% (PR 27.5%, CR 3.4%) of patients with NLR ≥6 (p 0.691). Kaplan-Meier curves stratified by NLR <6 vs. ≥6 showed no difference in PFS. However, NLR <6 was associated with improved OS (p < 0.05). In the NLR < 6 group, the probability of survival at one year was 69% (95% CI: 58%, 82%), compared to 41% (95% CI: 26%, 67%) for the NLR > 6 group.

CONCLUSIONS

Pre-treatment NLR <6 was associated with improved OS for recurrent EC patients treated with immunotherapy. NLR holds promise as a predictive biomarker for survival after immunotherapy treatment for patients with recurrent EC.

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

PURPOSE

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

PATIENTS AND METHODS

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

RESULTS

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

CONCLUSION

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

Prognostic Implications of Immune-Related Genes' (IRGs) Signature Models in Cervical Cancer and Endometrial Cancer

Cervical cancer and endometrial cancer remain serious threats to women's health. Even though some patients can be treated with surgery plus chemoradiotherapy as a conventional option, the overall efficacy is deemed unsatisfactory. As such, the development for new treatment approaches is truly necessary. In recent years, immunotherapy has been widely used in clinical practice and it is an area of great interest that researchers are keeping attention on. However, a thorough immune-related genes (IRGs) study for cervical cancer and endometrial cancer is still lacking. We therefore aim to make a comprehensive evaluation of IRGs through bioinformatics and large databases, and also investigate the relationship between the two types of cancer. We reviewed the transcriptome RNAs of IRGs and clinical data based on the TCGA database. Survival-associated IRGs in cervical/endometrial cancer were identified using univariable and multivariable Cox proportional-hazard regression analysis for developing an IRG signature model to evaluate the risk of patients. In the end, this model was validated based on the enrichment analyses through GO, KEGG, and GSEA pathways, Kaplan-Meier survival curve, ROC curves, and immune cell infiltration. Our results showed that out of 25/23 survival-associated IRGs for cervical/endometrial cancer, 13/12 warranted further examination by multivariate Cox proportional-hazard regression analysis and were selected to develop an IRGs signature model. As a result, enrichment analyses for high-risk groups indicated main enriched pathways were associated with tumor development and progression, and statistical differences were found between high-risk and low-risk groups as shown by Kaplan-Meier survival curve. This model could be used as an independent measure for risk assessment and was considered relevant to immune cell infiltration, but it had nothing to do with clinicopathological characteristics. In summary, based on comprehensive analysis, we obtained the IRGs signature model in cervical cancer (LTA, TFRC, TYK2, DLL4, CSK, JUND, NFATC4, SBDS, FLT1, IL17RD, IL3RA, SDC1, PLAU) and endometrial cancer (LTA, PSMC4, KAL1, TNF, SBDS, HDGF, LTB, HTR3E, NR2F1, NR3C1, PGR, CBLC), which can effectively evaluate the prognosis and risk of patients and provide justification in immunology for further researches.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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