Prognostic significance of neutrophil-to-lymphocyte ratio in biliary tract cancers: a systematic review and meta-analysis

Efficacy and safety of maintenance therapy with anlotinib for advanced cholangiocarcinoma after first-line chemotherapy and the variations in efficacy based on different neutrophil-to-lymphocyte ratio (NLR)

OBJECTIVE

This study aimed to evaluate the clinical efficacy and safety of anlotinib as maintenance therapy in patients with advanced cholangiocarcinoma following first-line chemotherapy.

METHODS

This retrospective study enrolled 154 patients with advanced biliary tract cancer admitted to the hospital between January 2020 and December 2022. All patients received first-line intravenous chemotherapy with gemcitabine combined with cisplatin, oxaliplatin, or tegafur. Among the 106 patients who achieved disease control, 47 received oral anlotinib hydrochloride (12 mg daily, 2 weeks on/1 week off) as maintenance therapy. Clinical efficacy, including ORR, DCR, DOR, PFS, and OS, was compared between the anlotinib maintenance and non-maintenance groups. Subgroup analysis based on NLR levels was also performed.

RESULTS

Among the 47 anlotinib maintenance patients, the ORR was 21.28% and the DCR was 51.06%. The median DOR was 36 weeks, and the median PFS was 43 weeks in the anlotinib group, versus 28 weeks and 38 weeks in the non-maintenance group, respectively. The median OS was not reached in the anlotinib group but was 48 weeks in the non-maintenance group. Patients receiving anlotinib maintenance had significantly longer DOR, PFS, and OS (all p < 0.05). Patients with low NLR levels had better survival benefits from anlotinib.

CONCLUSION

Maintenance therapy with anlotinib demonstrates potential efficacy and a reliable safety profile in patients with advanced cholangiocarcinoma following first-line treatment. The efficacy of anlotinib therapy appears to be influenced by NLR levels. Further validation with larger sample sizes is warranted to strengthen the robustness and reliability of the results.

Assessing causal associations of hyperparathyroidism with blood counts and biochemical indicators: a Mendelian randomization study

Background

The existing literature on the relationship of hyperparathyroidism with both blood counts and biochemical indicators primarily comprises observational studies, which have produced inconsistent findings. This study aimed to evaluate the causal relationship between hyperparathyroidism and blood counts and biochemical indicators.

Methods

Mendelian randomization (MR) analyses were conducted to investigate the associations between hyperparathyroidism and the identified 55 blood counts and biochemical indicators. The genome-wide association study (GWAS) for hyperparathyroidism data was obtained from FinnGen, while the GWASs for the blood counts and biochemical indicators were sourced from the UK Biobank (UKBB).

Results

The MR analysis using the inverse-variance weighted (IVW) method revealed potential causality between genetically predicted hyperparathyroidism and seven out of 55 blood counts and biochemical indicators. These markers include "Platelet count" (Beta = -0.041; 95% CI: -0.066, -0.016; p = 0.001), "Platelet distribution width (PDW)" (Beta = 0.031; 95% CI: 0.006, 0.056; p = 0.016), "Mean platelet volume (MPV)" (Beta = 0.043; 95% CI: 0.010, 0.076; p = 0.011), "Vitamin D" (Beta = -0.038; 95% CI: -0.063, -0.013; p = 0.003), "Calcium (Ca2+)" (Beta = 0.266; 95% CI: 0.022, 0.509; p = 0.033), "Phosphate" (Beta = -0.114; 95% CI: -0.214, -0.014; p = 0.025), and "Alkaline phosphatase (ALP)" (Beta = 0.030; 95% CI: 0.010, 0.049; p = 0.003).

Conclusion

The findings of our study revealed a suggestive causal relationship between hyperparathyroidism and blood cell count as well as biochemical markers. This presents a novel perspective for further investigating the etiology and pathological mechanisms underlying hyperparathyroidism.

The use of neutrophil-lymphocyte ratio for the prediction of refractory disease and coronary artery lesions in patients with Kawasaki disease

BACKGROUND

Kawasaki disease is a vasculitis that can lead to cardiac complications, including coronary artery disease and cardiogenic shock. Various scoring systems have been developed to determine those that will be refractory to routine intravenous immunoglobulin therapy or develop coronary artery disease. The objective of this study was to determine if the neutrophil-lymphocyte ratio could predict refractory disease and coronary artery lesions in patients with Kawasaki disease.

METHODS

A systematic review of the literature was performed to identify manuscripts describing comparisons of neutrophil-lymphocyte ratio between those who had refractory disease and those who did not, and between those who developed coronary artery lesions and those who did not. Mean difference was compared between groups. Areas under the curve were utilised to determine the pooled area under the curve.

RESULTS

12 studies with 5593 patients were included in the final analyses of neutrophil-lymphocyte ratio for the prediction of refractory disease. Neutrophil-lymphocyte ratio before therapy was higher in refractory disease with a mean difference of 2.55 (p < 0.01) and pooled area under the curve of 0.724. Neutrophil-lymphocyte ratio after therapy was higher in refractory disease with a mean difference of 1.42 (p < 0.01) and pooled area under the curve for of 0.803. Five studies with 1690 patients were included in the final analyses of neutrophil-lymphocyte ratio for the prediction of coronary artery lesions. Neutrophil-lymphocyte ratio before therapy was higher in coronary artery lesions with a mean difference of 0.65 (p < 0.01).

CONCLUSION

The use of neutrophil-lymphocyte ratio may help physicians in the identification of patients at risk of refractory disease and coronary artery lesions in patients with Kawasaki disease.

Safety and Effectiveness of Chemotherapy in Elderly Biliary Tract Cancer Patients

The safety and effectiveness of chemotherapy in elderly patients with biliary tract cancer (BTC) remain unclear. Therefore, we retrospectively reviewed patients who underwent chemotherapy for locally advanced, metastatic, or recurrent BTC at our institution from January 2016 to December 2021. Of the 283 included patients, 91 (32.5%) were aged 75 years or older when initiating chemotherapy. Elderly patients were more likely than non-elderly patients to receive monotherapy with gemcitabine or S-1 (58.7% vs. 9.4%, p < 0.001) and were less likely to experience grade 3-4 toxicities (55.4% vs. 70.2%, p = 0.015). The rates of termination due to intolerance (6.5% vs. 5.8%, p = 0.800) and transition to second-line chemotherapy (39.1% vs. 40.3%, p = 0.849) were similar between groups. In the overall cohort, age was not an independent predictor of overall survival (OS). Within the elderly cohort, there were no differences in severe adverse events between patients receiving monotherapy and combination therapy (50.0% vs. 63.2%, p = 0.211). Median OS was longer in the combination therapy group (10.4 vs. 14.1 months; p = 0.010); however, choice of monotherapy was not an independent predictor of overall survival. Monotherapy appears to be a viable alternative in selected elderly BTC patients.

Neutrophil-lymphocyte Ratio Predicts Clinical Response to Percutaneous Transhepatic Biliary Drainage in Acute Cholangitis

Background

Predicting response to biliary drainage is critical to stratify patients with acute cholangitis. Total leucocyte count (TLC) is one of the criteria for predicting the severity of cholangitis and is routinely performed. We aim to investigate the performance of neutrophil-lymphocyte ratio (NLR) in predicting clinical response to percutaneous transhepatic biliary drainage (PTBD) in acute cholangitis.

Patients and methods

This retrospective study comprised consecutive patients with acute cholangitis who underwent PTBD and had serial (baseline, day 1, and day 3) TLC and NLR measurements. Technical success, complications of PTBD, and clinical response to PTBD (based on multiple outcomes) were recorded. Univariate and multivariate analysis was performed to identify factors significantly associated with clinical response to PTBD. The sensitivity, specificity, and area under the curve of serial TLC and NLR for predicting clinical response to PTBD were calculated.

Results

Forty-five patients (mean age 51.5 years, range 22-84) met the inclusion criteria. PTBD was technically successful in all the patients. Eleven (24.4%) minor complications were recorded. Clinical response to PTBD was recorded in 22 (48.9%) patients. At univariate analysis, the clinical response to PTBD was significantly associated with baseline TLC (P = 0.035), baseline NLR (P = 0.028), and NLR at day 1 (P=0.011). There was no association with age, the presence of comorbidities, prior endoscopic retrograde cholangiopancreatography, admission to PTBD interval, diagnosis (benign vs. malignant), severity of cholangitis, organ failure at baseline, and blood culture positivity. At multivariate analysis, NLR-1 independently predicted the clinical response. Area under the curve of NLR at day 1 for predicting clinical response was 0.901. NLR-1 cut-off value of 3.95 was associated with sensitivity and specificity of 87% and 78%, respectively.

Conclusion

TLC and NLR are simple tests that can predict clinical response to PTBD in acute cholangitis. NLR-1 cut-off value of 3.95 can be used in clinical practice to predict response.

Long-Term Recurrence-Free and Overall Survival Differ Based on Common, Proliferative, and Inflammatory Subtypes After Resection of Intrahepatic Cholangiocarcinoma

INTRODUCTION

While generally associated with poor prognosis, intrahepatic cholangiocarcinoma (ICC) can have a heterogeneous presentation and natural history. We sought to identify specific ICC subtypes that may be associated with varied long-term outcomes and patterns of recurrence after liver resection.

METHODS

Patients who underwent curative-intent resection for ICC from 2000 to 2020 were identified from a multi-institutional database. Hierarchical cluster analysis characterized three ICC subtypes based on morphology (i.e., tumor burden score [TBS]) and biology (i.e., preoperative neutrophil-to-lymphocyte ratio [NLR] and CA19-9 levels).

RESULTS

Among 598 patients, the cluster analysis identified three ICC subtypes: Common (n = 300, 50.2%) (median, TBS: 4.5; NLR: 2.4; CA19-9: 38.0 U/mL); Proliferative (n = 246, 41.1%) (median, TBS: 8.8; NLR: 2.9; CA19-9: 71.2 U/mL); Inflammatory (n = 52, 8.7%) (median, TBS: 5.4; NLR: 12.6; CA19-9: 26.7 U/mL). Median overall survival (OS) (Common: 72.0 months; Proliferative: 31.4 months; Inflammatory: 22.9 months) and recurrence-free survival (RFS) (Common: 21.5 months; Proliferative: 11.9 months; Inflammatory: 9.0 months) varied considerably among the different ICC subtypes (all p < 0.001). Even though patients with Inflammatory ICC had more favorable T-(T1/T2, Common: 84.4%; Proliferative: 80.6%; Inflammatory: 86.5%) and N-(N0, Common: 14.0%; Proliferative: 20.7%; Inflammatory: 26.9%) disease, the Inflammatory subtype was associated with a higher incidence of intra- and extrahepatic recurrence (Common: 15.8%; Proliferative: 24.2%; Inflammatory: 28.6%) (all p = 0.01).

CONCLUSIONS

Cluster analysis identified three distinct subtypes of ICC based on TBS, NLR, and CA19-9. ICC subtype was associated with RFS and OS and predicted worse outcomes among patients. Despite more favorable T- and N-disease, the Inflammatory ICC subtype was associated with worse outcomes ICC subtype should be considered in the prognostic stratification of patients.

Klatskin Tumor: A Survival Analysis According to Tumor Characteristics and Inflammatory Ratios

Background and Objectives: The aim was to evaluate the association of inflammatory biomarkers with resectability and overall survival in hilar cholangiocarcinoma. Materials and Methods: We conducted a retrospective cohort study over 72 consecutive surgical cases of Klatskin tumor over an 11-year period. The sample was divided into two groups: 42 surgical resection cases and 30 unresectable tumors. Values of inflammatory ratios were compared according to the resectability. Log-rank test, univariate, and multivariate Cox proportional hazards models were used to evaluate the overall survival. Results: Subjects were between 42−87 years old (average age of 64.91 ± 9.15 years). According to the procedure: 58.33% benefited from resection (with a 30.95% R0 resection rate) and 41.66% had palliative surgery. Elevated NLR (neutrophil to lymphocyte ratio), PLR (platelet to lymphocyte ratio), and SII (systemic immune-inflammation index), and lower LMR (lymphocyte to monocyte ratio) at admission were associated with unresectable tumors (p < 0.01). For the multivariate Cox proportional hazard models, increased absolute values of NLR, PLR, and SII were associated with lower survival; no differences were observed for LMR absolute value. The cut-off value of NLR ≥ 6 was associated with lower survival. The median survival time for all subjects was 442 days, with 774 days for the resection group and 147 days for the group with palliative surgery. Conclusions: In hilar cholangiocarcinoma, inflammatory ratios are associated with tumor resectability. Tumor excision conferred an important advantage in survival. Elevated NLR, PLR, and SII values at admission significantly increased the hazard ratio. LMR had no influence on survival.

Multicentre match-paired analysis of advanced biliary cancer long-term survivors: The BILONG study

BACKGROUND

Advanced biliary cancers (ABC) are aggressive malignancies with a median overall survival (mOS) <12 months when treated with first-line chemotherapy. Nevertheless, a subset of patients experiencing longer survival has been described in the updated analysis of ABC-02 trial. We aimed to provide a real-world description of ABC long-term survivors (LS), identifying which factors impact on survival.

METHODS

Patients diagnosed with ABC at three Institutions between 2002 and 2019, and who survived ≥18 months, were retrospectively identified. We compared them with a control cohort (C) with a mOS <18 months, matched on age, gender, ECOG PS, disease status, primary tumor site, prior surgery, and treatment modality. Their clinical features, treatments, and outcome were analyzed.

RESULTS

A total of 78 patients was included, 39 in each group. Both LS and C cohorts had superimposable baseline characteristics, without significant differences. mOS was 29 (95%CI 24.6-33.5) and 9 months (95%CI 6.6-12.9) in the two groups, respectively. After performing a logistic regression analysis, three factors were significantly associated with long-term outcome: low neutrophil-to-lymphocyte ratio (NLR < 3) (Odds Ratio [OR] 0.38), achievement of objective response to treatment (OR 0.16), and the number of lines received (OR 0.29).

CONCLUSIONS

We described a considerable subset of ABC experiencing long-term survival with conventional chemotherapy in a real-world scenario. Beyond clinical factors, we identified low NLR as a prognostic determinant that may allow for a more accurate selection of long survivors. While waiting for a deeper molecular characterization of this subgroup, we propose NLR as a stratification factor for daily practice and clinical trials.

Comparison of Hematological Parameters Between First-Episode Schizophrenia and Anti-NMDAR Encephalitis

Background: First-episode schizophrenia (FES) and anti-NMDAR encephalitis are different disorders with similar psychiatric symptoms, and both diseases are associated with the inflammatory system. In this study, we compared hematological parameters and inflammation ratios in anti-NMDAR encephalitis, FES, and healthy control.

Methods: We enrolled 106 patients (53 FES patients and 53 anti-NMDAR encephalitis patients) and 59 healthy controls. The values of the neutrophil–lymphocyte ratio (NLR), platelet–lymphocyte ratio (PLR), monocyte–lymphocyte ratio (MLR), and systemic immune-inflammation index (SII) were used to evaluate inflammation. Other parameters such as the white blood cell (WBC), platelet (PLT), uric acid (UA), total bilirubin (TBIL), total bile acid (TBA), and serum albumin counts were also used to compare inflammation ratios between these two diseases.

Results: SII, NLR, PLR, MLR, and serum albumin levels were statistically significantly different between these three groups (p < 0.05). The values of SII, NLR, PLR, and MLR were significantly higher in the anti-NMDAR encephalitis group than those in the FES group (p < 0.05), and the values in both diseases were more increased than those in HC (p < 0.05). The serum albumin level was significantly lower in anti-NMDAR encephalitis than in FES (p < 0.05). WBC, neutrophil, lymphocyte, and monocyte counts showed significantly higher levels in the anti-NMDAR encephalitis group and FES group separately (p < 0.05). Other parameters like TBA, TBIL, and UA showed no difference between groups.

Conclusion: In summary, this is a relatively new study that is innovative by comparing some inflammation markers of peripheral blood in two diseases with clinically psychotic symptoms. These two diseases are related to the inflammatory system, proving that NMDAR dysfunction is related to psychotic symptoms. Besides, NLR, PLR, MLR, and serum albumin can be used as biomarkers to distinguish the two diseases. The serum albumin level in patients with anti-NMDAR encephalitis was lower than that in patients with schizophrenia.

Association of low skeletal muscle mass and systemic inflammation with surgical complications and survival after microvascular flap reconstruction in patients with head and neck cancer

Background

Skeletal muscle mass (SMM) and chronic inflammation are associated with postoperative complications and survival.

Methods

Patients with head and neck cancer (HNC) undergoing microvascular free flap reconstruction were included. SMM and neutrophil‐to‐lymphocyte ratio (NLR) were measured and their association with treatment outcomes analyzed.

Results

Five hundred and fifty‐four patients were included. Predictors for complications were elevated NLR in all flaps (OR 1.5), low SMM in radial forearm flap (OR 2.0), and elevated NLR combined with low SMM in fibula flap surgery (OR 4.3). Patients with solely elevated NLR were at risk for flap‐related complications (OR 3.0), severe complications (OR 2.2), and when combined with low SMM for increased length of hospital stays (LOS) (+3.9 days). In early‐stage HNC, low SMM (HR 2.3), and combined elevated NLR with low SMM (HR 2.6) were prognostics for decreased overall survival.

Conclusions

SMM and NLR are predictive for poor outcomes in patients with HNC undergoing microvascular reconstruction.

Prevalence and Clinicopathologic Features of Canine Metastatic Melanoma Involving the Central Nervous System: A Retrospective Analysis and Comparative Review

Background

Central nervous system (CNS) involvement is the leading cause of death in malignant melanoma. Rodent models, while vital to mechanistic investigation, have had limited success identifying effective therapies for melanoma brain metastases. The companion dog with de novo melanoma is a promising complementary model for developmental therapeutic investigation, as these tumors occur in an immunologically outbred host that has shared environmental exposures with humans. However, relatively little is known regarding the prevalence and clinicopathological features of canine melanoma metastasis to the CNS. To further validate the dog as an appropriate model for human metastatic melanoma, the aims of this study were to determine the rate of CNS metastasis and associated clinicopathologic features in canine malignant melanoma.

Methods

Medical records of dogs diagnosed with malignant melanoma from 1985-2019 at the University of California Davis Veterinary Medical Teaching Hospital were assessed retrospectively. Clinicopathologic features were compared between dogs with CNS metastasis (CNS+) and dogs without CNS metastasis (CNS-). Site of CNS involvement and associated neurological signs were analyzed via Wilcoxon-Mann-Whitney rank sum and Fisher’s exact tests. Survival data were analyzed via Kaplan-Meier estimates.

Results

CNS metastasis was identified in 38% of dogs in this study (20/53). The oral cavity was the most common site of primary melanoma in both groups [CNS+: n=12 (60%) vs. CNS-: n=22 (67%); p>0.99]. The total burden of metastatic disease was higher in the CNS+ group (CNS+: 4, 95% CI 3-5 vs. CNS-: 3, 95% CI 1-3; p<0.001). The cerebrum was the most common site of CNS metastasis (n=15, 75%) and seizures were the most observed neurological sign (n=9, 64%). There was no difference in overall survival between CNS+ and CNS- groups. However, the median survival time following onset of neurological signs was 9.5 days (95% CI 1-43), with 5 dogs euthanized within 24 hours of the onset of neurological signs.

Conclusions

Canine and human MM patients share similar rates of CNS metastasis and clinical presentation. This study will guide clinical management of canines with malignant melanoma and inform future studies using dogs with spontaneously occurring melanoma as a preclinical model for human melanoma brain metastases.

The association between hematologic parameters and intracranial injuries in pediatric patients with traumatic brain injury

OBJECTIVE

Analyzing the association between hematologic parameters and abnormal cranial computerized tomography (CT) findings after head trauma.

MATERIAL AND METHODS

A total of 287 children with isolated traumatic brain injury (TBI) were divided into the 'normal' (NG), 'linear fracture' (LFG) and 'intraparenchymal injury' groups (IPG) based on head CT findings. Demographical/clinical data and laboratory results were obtained from medical records.

RESULTS

The neutrophil-lymphocyte ratio was markedly higher in the LFG (p = 0.010 and p = 0.016, respectively) and IPG (p = 0.004 and p < 0.001, respectively) compared with NG. Lower lymphocyte-monocyte ratio (p = 0.044) and higher red cell distribution width-platelet ratio (RPR) (p = 0.030) were associated with intraparenchymal injuries. Patients requiring neurosurgical intervention had higher neutrophil-lymphocyte ratio (p = 0.026) and RPR values (p = 0.031) and lower platelet counts (p = 0.035). Lower levels of erythrocytes (p = 0.005), hemoglobin (p = 0.003) and hematocrit (p = 0.002) were associated with severe TBI and unfavorable outcome (p = 0.012, p = 0.004 and p = 0.006, respectively).

CONCLUSIONS

Hematologic parameters are useful in predicting the presence of abnormal cranial CT findings in children with TBI in association with injury severity; surgery need and clinical outcome.

DNA methylation-derived systemic inflammation indices and their association with oropharyngeal cancer risk and survival

BACKGROUND

Head and neck squamous cell carcinomas are associated with systemic inflammation (SI). We evaluated whether DNA methylation-derived SI (mdSI) indices are associated with oropharyngeal cancer risk and survival.

METHODS

Ninety-four oropharyngeal squamous cell carcinoma (OPSCC) cases and 57 controls with DNA methylation data were included. Logistic regression analysis and survival analysis were performed to test the association of mdSI indices with OPSCC risk and survival.

RESULTS

Higher methylation-derived neutrophil-to-lymphocyte ratio (mdNLR) was associated with increased risk of OPSCC (OR = 1.21, 95%CI: 1.11-1.40) while no association was found with methylation-derived lymphocyte-to-monocyte ratio (mdLMR). For 5-year overall survival, higher mdLMR was significantly associated with decreased risk of death (HR = 0.25, 95%CI: 0.10-0.64) while the converse was observed for mdNLR (HR = 2.48, 95%CI: 1.04-5.92).

CONCLUSION

We observed an association between mdSI indices and OPSCC risk and 5-year overall survival. It is possible to use mdLMR as an independent prognostic factor for OPSCC.

Red Cell Distribution Width and Gallbladder Cancer: Is It Really Useful?

PURPOSE

The data on the prognostic significance of red cell distribution width (RDW) in gallbladder cancers is sparse, especially in the potentially resectable cohort of patients. The aim was to assess the prognostic significance of RDW in gallbladder cancer patients undergoing surgery.

METHODS

Retrospective analysis of prospectively maintained database of gallbladder cancer patients undergoing surgery at a tertiary cancer institute from 2010 till 2018. Baseline values were collected. Patients were grouped as per the median RDW value and compared. Survival analysis was done using the Kaplan Meier method.

RESULTS

A total of 605 patients were included. The median follow up period was 23 months (range: 6-120 months). The median value of RDW was 14. Comparison between RDW > 14 and RDW < 14 groups showed no difference in outcomes. RDW did not predict overall survival or recurrences. However, in combined stages II and III, a statistically significant improvement in OS and DFS (p < 0.001) was noted in the RDW < 14 group.

CONCLUSION

RDW did not predict recurrence or survival in potentially resectable gallbladder cancer patients. However, in the subset of stages II and III in combination, lower RDW value was associated with better outcomes. More prospective studies are needed to conclusively establish the prognostic value of RDW.

The Addition of Peripheral Blood Inflammatory Indexes to Nomogram Improves the Predictive Accuracy of Survival in Limited-Stage Small Cell Lung Cancer Patients

Background

Accumulated evidence for systemic inflammation response in several solid tumors prompts a possibility of prediction of patients’ prognosis in a more accessible and valuable manner. However, the prognostic value of peripheral blood inflammatory markers in limited-stage small cell lung cancer (LS-SCLC) remains unclear. Therefore, we investigated the prognostic values of pretreatment inflammatory indexes in LS-SCLC patients.

Methods

We retrospectively identified 334 patients with LS-SCLC and collected their pretreatment serum levels of neutrophil, platelet, lymphocyte, leukocyte, hemoglobin, and albumin, then neutrophil-to-lymphocyte ratio (NLR), platelet-to-lymphocyte ratio (PLR), and systemic inflammation index (SII) were calculated. Patients were dichotomized as low-Risk or high-Risk group based on their corresponding cutoff values. Univariate and multivariate analyses were conducted with a Cox proportional hazards model. The least absolute shrinkage and selection operator (LASSO)-Cox regression analysis was performed to construct the inflammation-related prognostic scoring system named Risk for OS. Nomograms were established to provide prognostic information, allowing for more individualized prediction of survival.

Results

Higher pretreatment platelet, lymphocyte, and albumin were indicators of favorable overall survival (OS), whereas higher NLR and SII were accompanied by inferior OS. The prognosis of patients with high Risk was significantly worse than that with low Risk in both the training group and the validation group (both p < 0.001). Comparable area under the curve (AUC) values between the training group and the validation group were observed, yielding 1-, 3-, and 5-year OS rates of 67.3% vs. 69.2%, 66.8% vs. 69.5%, and 66.7% vs. 71.4%, respectively. Multivariate analyses revealed that Risk [hazard ratio (HR) = 0.551, p < 0.001] was an independent negative prognostic indicator for OS, which was further verified in the validation set. The addition of Risk to nomogram (C-index = 0.643) harbored improved predictive accuracy for OS when compared with that of clinical factors alone (C-index = 0.606); the AUC values of 1-, 3-, and 5-year OS rates were 71.7% vs. 66.4%, 73.5% vs. 66.6%, and 71.9% vs. 65.6%, respectively.

Conclusions

Pretreatment peripheral blood inflammatory indexes may be a noninvasive serum biomarker for poor prognosis in LS-SCLC. The addition of Risk to the nomogram model could serve as a more powerful, economical, and practical method to predict survival for patients with LS-SCLC.

Quality of Life and Symptom Management in Advanced Biliary Tract Cancers

Simple Summary

Patients with advanced BTC have poor prognosis and frequently experience symptoms that adversely impact their quality of life. In this review, we explore the potential complications of advanced BTC and its treatments. We also review the possible strategies and interventions available to manage these adverse events.

Abstract

Biliary tract carcinomas (BTCs) account for less than 1% of all cancers but are increasing in incidence. Prognosis is poor for BTC patients, with 5-year survival rates of less than 10%. While chemotherapy has been the mainstay treatment for patients with advanced BTC, immunotherapy and targeted therapies are being evaluated in numerous clinical trials and rapidly incorporated into clinical practice. As patients with BTC have reduced health-related quality of life (HRQoL) due to both tumor- and treatment-related symptoms, it is important for clinicians to recognize and manage these symptoms early. This review will highlight the anticipated complications from BTC and its systemic treatment, as well as their effects on HRQoL.

Serum Inflammation-based Scores in Endocrine Tumors

CONTEXT

Serum inflammation-based scores reflect systemic inflammatory response and/or patients' nutritional status, and may predict clinical outcomes in cancer. While these are well-described and increasingly used in different cancers, their clinical usefulness in the management of patients with endocrine tumors is less known.

EVIDENCE ACQUISITION

A comprehensive PubMed search was performed using the terms "endocrine tumor," "inflammation," "serum inflammation-based score," "inflammatory-based score," "inflammatory response-related scoring," "systemic inflammatory response markers," "neutrophil-to-lymphocyte ratio," "neutrophil-to-platelet ratio," "lymphocyte-to-monocyte ratio," "Glasgow prognostic score," "neutrophil-platelet score," "Systemic Immune-Inflammation Index," and "Prognostic Nutrition Index" in clinical studies.

EVIDENCE SYNTHESIS

The neutrophil-to-lymphocyte ratio and the platelet-to-lymphocyte ratio are the ones most extensively investigated in patients with endocrine tumors. Other scores have also been considered in some studies. Several studies focused in finding whether serum inflammatory biomarkers may stratify the endocrine tumor patients' risk and detect those at risk for developing more aggressive and/or refractory disease, particularly after endocrine surgery.

CONCLUSIONS

In this review, we summarize the current knowledge on the different serum inflammation-based scores and their usefulness in predicting the phenotype, clinical aggressiveness, and disease outcomes and prognosis in patients with endocrine tumors. The value of such serum inflammation-based scores in the management of patients with endocrine tumors has been emerging over the last decade. However, further research is necessary to establish useful markers and their cut-offs for routine clinical practice for individual diseases.

Real-World Evidence on Palliative Gemcitabine and Oxaliplatin (GemOx) Combination Chemotherapy in Advanced Biliary Tract Cancer

Simple Summary

Cancers of the biliary tract are rare but severe with high mortality rates. Randomised controlled trials suggest that chemotherapies such as gemcitabine and oxaliplatin (GemOx) may relieve symptoms and prolong life, but less is known on the efficacy and safety of such regimens in real life. The current paper assessed the real-world outcome of GemOx in all patients with advanced biliary tract cancer treated at any cancer centre in the South East Region of Sweden over a period of nine years. The median overall survival was nine months and time to disease progression five months. Prognostic factors such as performance status and gall bladder (rather than bile duct) localisation of the primary tumour were identified. Most patients received a lower dose of oxaliplatin than proposed by previous studies, which seemed feasible as few patients had severe adverse events. This study supports further use of GemOx as standard of care.

Abstract

Background: Gemcitabine and oxaliplatin (GemOx) is a standard combination regimen in advanced biliary tract cancer (BTC). There is limited evidence on its efficacy and safety in real life. Methods: A retrospective multicentre cohort study in the South East Region of Sweden, covering nine years (2011–2020) and three hospitals where GemOx was treatment of choice, was designed. Clinicopathological prognostic parameters were explored. Results: One hundred and twenty-one patients with advanced BTC were identified. Median overall and progression-free survival (OS and PFS) were 8.9 (95% CI = 7.2–10.6) and 5.3 (95% CI = 3.8–6.7) months. Performance status according to Eastern Cooperative Oncology Group (PS according to ECOG) 1–2 and primary gallbladder carcinoma were independent predictors for poor OS. PS and derived neutrophil/lymphocyte ratio were predictive for PFS. The most common severe type of myelosuppresion was grade 3 neutropenia that was recorded in 8%. Fifty-three (43.8%) experienced at least one episode of unplanned hospitalisation. One hundred and seventeen (97%) received oxaliplatin with lower dosage than was utilized in previous phase III trials (80–85 vs. 100 mg/m²) and a majority received further dose reductions of oxaliplatin and/or gemcitabine. Conclusion: The outcome of GemOx in advanced BTC appears comparable in controlled trials and real-world contexts. A lower dose of oxaliplatin seems more tolerable without compromising the outcome.

Pre-operative serum inflammation-based scores in patients with pituitary adenomas

OBJECTIVE

Full blood count (FBC) and serum inflammation-based scores reflect systemic inflammation and predict outcomes in cancer, but little is known in pituitary adenomas (PAs). We aimed to characterise FBC and inflammation-based scores in PA patients and investigate their usefulness in predicting challenging disease course.

METHODS

We studied 424 PA patients first operated at our centre with available pre-operative biochemical data. Patients with infection, malignancies, autoimmune or haematological conditions were excluded. Inflammation-based scores studied: Neutrophil-to-Lymphocyte Ratio (NLR), Platelet-to-Lymphocyte Ratio (PLR), Lymphocyte-to-Monocyte Ratio (LMR), Systemic Immune-Inflammation Index (SII), Neutrophil-Platelet Score (NPS), Prognostic Nutrition Index (PNI), and Glasgow Prognostic Score (GPS).

RESULTS

Cushing's disease patients had more platelets, leucocytes, neutrophils and monocytes, and higher NLR, NPS and SII. Serum inflammation-based scores didn't differ among non-Cushing PA subtypes. The glucocorticoid excess severity influenced leucocyte, eosinophil, basophil and platelet counts, and GPS in Cushing's disease. Patients with functioning non-Cushing PAs with suprasellar extension, cavernous sinus invasion and hypopituitarism had GPS ≥ 1, while NPS ≥ 1 was associated with suprasellar extension. More invasive and difficult to treat corticotrophinomas were associated with fewer platelets pre-operatively (< 299.5 × 10⁹/L predicting multimodal treatment). Non-functioning PA patients who suffered apoplexy had more leucocytes, neutrophils and monocytes, higher GPS ≥ 1 and fewer platelets; re-operated cases had fewer lymphocytes, higher NLR and PLR.

CONCLUSIONS

Serum inflammation-based scores may predict invasive/refractory PAs: GPS and PNI in non-functioning and functioning non-Cushing PAs; NPS in functioning non-Cushing PAs; NLR and PLR in non-functioning PAs. Platelets < 299.5 × 10⁹/L predict multimodal treatment in Cushing's disease. Further studies are needed to confirm these observations.

Defining the Risk of Early Recurrence Following Curative-Intent Resection for Distal Cholangiocarcinoma

BACKGROUND

Although multidisciplinary treatments including the use of adjuvant therapy (AT) have been adopted for biliary tract cancers, patients with distal cholangiocarcinoma (DCC) can still experience recurrence. We sought to characterize the incidence and predictors of early recurrence (ER) that occurred within 12 months following surgery for DCC.

PATIENTS AND METHODS

Patients who underwent resection for DCC between 2000 and 2015 were identified from the US multi-institutional database. Cox regression analysis was used to identify clinicopathological factors to develop an ER risk score, and the predictive model was validated in an external dataset.

RESULTS

Among 245 patients included in the analysis, 67 patients (27.3%) developed ER. No difference was noted in ER rates between patients who did and did not receive AT (28.7% vs. 25.0%, p = 0.55). Multivariable analysis revealed that neutrophil-to-lymphocyte ratio (NLR), peak total bilirubin (T-Bil), major vascular resection (MVR), lymphovascular invasion, and R1 surgical margin status were associated with a higher ER risk. A DIstal Cholangiocarcinoma Early Recurrence Score was developed according to each factor available prior to surgery [NLR > 9.0 (2 points); peak T-bil > 1.5 mg/dL (1 points); MVR (2 points)]. Cumulative ER rates incrementally increased among patients who were low (0 points; 10.6%), intermediate (1-2 points; 26.8%), or high (3-5 points; 57.6%) risk (p < 0.001) in the training dataset, as well as in the validation dataset [low (0 points); 3.4%, intermediate (1-2 points); 32.7%, or high risk (3-5 points); 55.6% (p < 0.001)].

CONCLUSIONS

Among patients undergoing resection for DCC, 1 in 4 patients experienced an ER. Alternative treatment strategies such as neoadjuvant chemotherapy may be considered especially among individuals deemed to be at high risk for ER.

Neutrophil-to-lymphocyte ratio is an independent predictor for survival outcomes in cervical cancer: a systematic review and meta-analysis

This updated meta-analysis sought to explore whether pretreatment neutrophil-to-lymphocyte ratio (NLR) could serve as an independent predictor for survival outcomes in patients with cervical cancer. We searched PubMed, Embase, Web of science and Scopus for studies on the association of pretreatment serum NLR with overall survival (OS) and progression-free survival (PFS) among patients with cervical cancer. Included studies with a hazard ratio (HR) and 95% confidence interval (CI) or a p-value were weighted by generic inverse-variance and pooled in a random effects meta-analysis. Subgroup analyses were conducted according to regions, NLR cut-off values and treatments. Publication bias was analyzed by Egger’s and Begg’s tests. A total of 14 studies comprising 6041 patients were included. The median cut-off value for NLR was 2.46 (range from 1.60 to 3.80). The higher NLR was associated to worse OS (HR 1.86, 95% CI 1.44–2.40) and PFS (HR 1.67, 95% CI 1.25–2.23), compared with lower NLR. This association still exited when analyzed according to regions, NLR cut-off values. Moreover, Significant association between NLR and OS was observed in studies which included patients with early stage disease and receiving radical surgeries. High NLR is independently associated with decreased OS and PFS in patients with cervical cancer. Pretreatment NLR is of independent value to predict the survival outcomes in patients with cervical cancer, regardless of regions and primary treatments.

The Prognostic Significance of Combined Pretreatment Fibrinogen and Neutrophil-Lymphocyte Ratio in Various Cancers: A Systematic Review and Meta-Analysis

Purpose

The prognostic value of a new scoring system, termed F-NLR, that combines pretreatment fibrinogen level with neutrophil-lymphocyte ratio has been evaluated in various cancers. However, the results are controversial. The purpose of this study was to comprehensively analyze the prognostic value of F-NLR score in patients with cancers.

Methods

An integrated search of relevant studies was conducted by screening the PubMed and Embase databases. Pooled hazard ratios, with 95% confidence intervals (CIs), for overall survival (OS) and disease-free survival (DFS)/progression-free survival (PFS) were calculated to estimate the prognostic significance of F-NLR score in patients with various tumors. A random effects model was used for comprehensive analysis, and subgroup and meta-regression analyses were used to explore sources of heterogeneity.

Results

Thirteen articles reporting data from of 4747 patients were included in the study. Pooled analysis revealed that high F-NLR score was significantly associated with poor OS (HR = 1.77; 95% CI, 1.51–2.08) and poor DFS/PFS (HR = 1.63; 95% CI, 1.30–2.05). Subgroup and meta-regression analyses did not alter the prognostic role of F-NLR score in OS and DFS/PFS.

Conclusions

Increased F-NLR score is significantly associated with poor prognosis in patients with cancers and can serve as an effective prognostic indicator.

Neutrophil to lymphocyte ratio and cancer prognosis: an umbrella review of systematic reviews and meta-analyses of observational studies

BACKGROUND

Although neutrophils have been linked to the progression of cancer, uncertainty exists around their association with cancer outcomes, depending on the site, outcome and treatments considered. We aimed to evaluate the strength and validity of evidence on the association between either the neutrophil to lymphocyte ratio (NLR) or tumour-associated neutrophils (TAN) and cancer prognosis.

METHODS

We searched MEDLINE, Embase and Cochrane Database of Systematic Reviews from inception to 29 May 2020 for systematic reviews and meta-analyses of observational studies on neutrophil counts (here NLR or TAN) and specific cancer outcomes related to disease progression or survival. The available evidence was graded as strong, highly suggestive, suggestive, weak or uncertain through the application of pre-set GRADE criteria.

RESULTS

A total of 204 meta-analyses from 86 studies investigating the association between either NLR or TAN and cancer outcomes met the criteria for inclusion. All but one meta-analyses found a hazard ratio (HR) which increased risk (HR > 1). We did not find sufficient meta-analyses to evaluate TAN and cancer outcomes (N = 9). When assessed for magnitude of effect, significance and bias related to heterogeneity and small study effects, 18 (9%) associations between NLR and outcomes in composite cancer endpoints (combined analysis), cancers treated with immunotherapy and some site specific cancers (urinary, nasopharyngeal, gastric, breast, endometrial, soft tissue sarcoma and hepatocellular cancers) were supported by strong evidence.

CONCLUSION

In total, 60 (29%) meta-analyses presented strong or highly suggestive evidence. Although the NLR and TAN hold clinical promise in their association with poor cancer prognosis, further research is required to provide robust evidence, assess causality and test clinical utility.

TRIAL REGISTRATION

PROSPERO CRD42017069131 .

Neutrophil-to-lymphocyte ratio predicts the severity of motor impairment in cerebral palsy children living at home and the rehabilitation center: A comparative study

The aim of the present study was to investigate the neutrophil-to-lymphocyte ratio (NLR) level in children with cerebral palsy (CP) living at home or the rehabilitation center. The correlation of NLR with different severities of motor impairment was assessed. This was a single-center, cross-sectional, observational study. A total of 80 CP children who were either living at home (n=34) or at the rehabilitation center (n=46) were included. Demographic characteristics, anthropometric parameters and complete blood counts were recorded, and the NLR values were calculated. The severity of motor impairment was evaluated and categorized according to the Gross Motor Functional Classification System (GMFCS) level. The mean age of CP participants was 8.52±1.92 years. The percentage of children with CP who were malnourished (underweight, stunted and wasted) was higher amongst those at the rehabilitation center compared with those living at home. The mean NLR of children with CP in the rehabilitation center was significantly higher compared with the patients living at home (P=0.003). Participants from the rehabilitation center had severe motor impairment (GMFCS levels IV-V) and significantly higher NLR values than those with mild motor impairments (GMFCS levels II-III; P=0.006). However, there were no differences in NLR values in relation to severity of motor impairment in CP children living at home. CP children had some degree of neuroinflammation and systemic inflammation. NLR may be a potential simple inflammatory parameter that may be used to predict the severity of the motor impairment, particularly in CP children living at a rehabilitation center.

Neutrophil to lymphocyte ratio as a prognostic marker in metastatic gallbladder cancer

BACKGROUND

Neutrophil-to-lymphocyte ratio (NLR) has been used as an inflammation based prognostic marker for various malignancies. This study evaluated the association between NLR and overall survival (OS) in patients with metastatic gallbladder cancer (GBC) METHODS: An optimal cut off point for NLR was identified by plotting spline-based hazard ratio curves to identify a threshold effect and patients were divided into two groups, ≥5 or <5. Kaplan-Meier curves were plotted for NLR≥5 and NLR<5 and OS between the two groups.

RESULTS

Of the 231 patients included, 138 (60%) had NLR <5 and 93 (40%) had NLR ≥5. There were no significant differences noted in gender, race, and administration of chemotherapy between the two groups. On univariable analysis, patients with NLR ≥5 had a significantly poor OS compared to those with NLR <5 (Median OS: 3.6 vs 8.7 months, p < 0.001). On multivariable analysis, adjusting for age, performance status, albumin, alkaline phosphatase, alanine aminotransferase, aspartate aminotransferase, bilirubin, platelet count and no administration of chemotherapy, NLR of ≥5 was associated with a worse OS compared to NLR <5 (HR: 1.70, 95%CI:1.20-2.39, p < 0.05).

CONCLUSION

The current study demonstrates that NLR ≥5 is an independent predictor of poor prognosis in patients with metastatic GBC.

Risk Stratification in Advanced Biliary Tract Cancer: Validation of the A.L.A.N. Score

Background

In addition to the clinical parameters, immune-inflammatory markers have emerged as prognostic factors in patients with advanced biliary tract cancer (ABC). The recently proposed A.L.A.N. score combines both in an easily applicable manner. The aim of this study was to perform the first external evaluation of this score.

Methods

All patients from our clinical registry unit who had unresectable ABC underwent first-line chemotherapy from 2006 to 2018 and met the inclusion criteria of the original study were included (n =  74). The A.L.A.N. score comprises the following parameters: actual neutrophil count, lymphocyte-to-monocyte ratio, albumin, and neutrophil-to-lymphocyte ratio (A.L.A.N.). Univariate and multivariate hazard regression analyses were performed to evaluate the score's parameters regarding overall survival (OS). The concordance index (C-index) and integrated Brier score (IBS) were calculated to evaluate the score's predictive performance.

Results

Low, intermediate, and high A.L.A.N. scores corresponded to median OS of 21.9, 11.4, and 4.3 months, respectively, resulting in a significant risk stratification (log-rank p=0.017). In multivariate analysis, a high-risk A.L.A.N. score remained an independent predictor of poor survival (p=0.016). Neutrophil-to-lymphocyte ratio was not a significant factor for poor OS in the analyses in the cohort. The score's ability to predict individual patient survival was only moderate with a C-index of 0.63.

Conclusions

The A.L.A.N. score can be used to identify risk groups with a poor prognosis prior to the start of chemotherapy. However, the ability of the score to predict individual patient outcome was only moderate; thus, it may only serve as a minor component in the complex interdisciplinary discussion.

Radiotherapy-Induced High Neutrophil-to-Lymphocyte Ratio is a Negative Prognostic Factor in Patients with Breast Cancer

Radiotherapy (RT) is the standard of care following breast-conserving operation in breast cancer patients. The neutrophil-to-lymphocyte ratio (NLR) reflects the systemic change caused as a result of the radiotherapy. We aimed to evaluate the association between RT and the change in NLR following the receipt of RT, and to investigate the prognostic impact. We retrospectively reviewed NLR values of breast cancer patients taken before the administration of the first and the last session of RT. The cut-off point for the NLR was determined using the Youden index and receiver operating characteristic (ROC) curve within the training set. Recurrence-free survival (RFS), distant metastasis free survival, and overall survival were the main outcomes. Patients with an NLR higher than 3.49 after RT were classified to an RT-induced high NLR group and showed a significantly higher recurrence rate compared to those with low NLR (p < 0.001). In a multivariate Cox proportional hazards model, RT-induced high NLR remained a significant prognostic factor (HR 2.194, 95% CI 1.230–3.912, p = 0.008 for tumor recurrence. We demonstrated that an increase in NLR over the course of RT has a negative impact on survival, putting these patients with RT-susceptible host immunity at a higher risk of tumor recurrence.

Clinical and prognostic value of neutrophil-lymphocyte ratio for patients with thyroid cancer: A meta-analysis

BACKGROUND

Although the malignant degree is relatively low and overall prognosis is excellent, some patients with thyroid cancer still experience metastasis during the follow-up, which leads to their possible death. Pretreatment neutrophil-to-lymphocyte ratio (NLR) has been recommended as a biomarker for the prediction of metastasis and prognosis in patients with cancers. However, its value in thyroid cancer remains inconclusive. This study aimed to comprehensively evaluate the prognostic and clinicopathological significance of NLR for thyroid cancer by a meta-analysis.

METHODS

Eligible studies were identified by searching PubMed, EMBASE, and Cochrane Library databases. The associations between NLR level and disease-free survival (DFS) or clinicopathological parameters were estimated by calculating hazard ratio (HR) or effect size with 95% confidence interval (CI).

RESULTS

Nine studies consisting of 3081 patients were enrolled. Results of meta-analysis showed that elevated NLR was not significantly associated with unfavorable DFS overall, but subgroup analysis of multivariate-adjusted studies demonstrated an elevation in pretreatment NLR predicted poor DFS (HR = 3.51, 95%CI = 1.42-8.70). Overall, a high level of NLR was significantly correlated with larger tumor size (standardized mean difference [SMD] = 0.49, 95%CI = 0.33-0.64), and metastasis status (risk ratio [RR] = 1.70, 95%CI = 1.10-2.64). The association with tumor size was still significant in the stratified analyses by country and histology type (Asian: SMD = 0.719, 95%CI = 0.44-0.98; non-Asian: SMD = 0.36, 95%CI = 0.17-0.56; medullary thyroid carcinoma: SMD = 0.57, 95%CI = 0.09-1.05; papillary thyroid carcinoma: SMD = 0.48, 95%CI = 0.31-0.64). The association between NLR and metastasis was only significant for papillary thyroid carcinoma subtype (RR = 1.82, 95%CI = 1.04-3.20).

CONCLUSION

Pretreatment NLR may serve as an excellent biomarker for prediction of tumor growth, metastasis, and prognosis in patients with thyroid cancer.

[Neutrophil-lymphocyte ratio at 14th week predicts loss of response to 52-week infliximab therapy in patients with Crohn's disease]

OBJECTIVE

Loss of response (LOR) has become an important clinical problem in patients with Crohn's disease receiving infliximab (IFX) treatment. Neutrophil-lymphocyte ratio (NLR) has been shown to correlate with the activity of inflammatory bowel disease (IBD), and NLR at the 14th week of IFX therapy potentially allows the prediction of sustained response to IFX in Crohn's patients. The aim of this study was to explore whether NLR at the 14th week of IFX therapy could predict the occurrence of LOR to IFX in Crohn's patients.

METHODS

Between January, 2012 and December, 2016, 54 patients with Crohn's disease underwent a 52-week treatment with IFX and successfully achieved response to the induction treatment in Zhongnan Hospital. We retrospectively examined their medical records and assessed the association between NLR at 14 weeks and LOR during IFX therapy.

RESULTS

Of the 54 patients, 15 (27.8%) showed LOR to IFX during the follow-up. We noted a significant increase in NLR at 14 weeks in the patients with LOR as compared with the patients with sustained response to IFX[3.51 (2.9-6.25) vs 1.77 (1.23-2.56), P=0.00]. Receiver-operating characteristic analysis showed that at the cut-off value of 2.75, NLR at 14 weeks was predictive of LOR within 52 weeks of IFX therapy with a sensitivity of 93.33% and a specificity of 84.62%, and the area under curve (AUC) of NLR was 0.903 (0.731-0.959). Univariate analysis revealed a significant correlation between relapse-free survival and the NLR at 14 weeks (P=0.00). Multivariate analysis identified NLR at 14 weeks as an independent prognostic factor for LOR with a hazard ratio of 1.851 (95% CI:1.096-3.026, P=0.021).

CONCLUSIONS

NLR at the 14th week during IFX therapy is a useful predictor for LOR in patients with Crohn's disease.

The prognostic impact of neutrophil-to-lymphocyte ratio (NLR) and lymphocyte-to-monocyte ratio (LMR) in patients with distal bile duct cancer

Background

A growing body of evidence suggests that inflammatory response markers such as the neutrophil-to-lymphocyte ratio (NLR) and lymphocyte-to-monocyte ratio (LMR) are associated with outcomes of various malignancies. However, no study has reported the prognostic value of NLR and LMR in patients with distal bile duct cancer (DBDC) to date. We investigated the prognostic significance of these inflammatory markers in patients with DBDC who underwent radical resection.

Methods

The study included 40 patients diagnosed with DBDC who underwent pancreaticoduodenectomy at Narita Red Cross Hospital between January 2000 and December 2017. The cutoff values for these markers were determined by receiver operating characteristic curve analysis. Survival curves are estimated for each group in the study considered separately using the Kaplan-Meier method. The association between overall survival (OS) and the NLR, LMR, and other prognostic factors was investigated using log-rank test and multivariate Cox proportional hazards regression analysis.

Results

Corresponding to the point with the maximum combined sensitivity and specificity on the ROC curve, the best cutoff value for NLR and LMR was determined to be 3.14 and 4.55, respectively. Most clinicopathological factors were not associated with the NLR and LMR based on these cutoff values. However, serum albumin levels were associated with both the NLR and LMR (P = 0.011 and P = 0.023, respectively), and serum carbohydrate antigen 19-9 (CA 19-9) levels were also associated with the LMR (P = 0.030). Univariate analysis showed that a high NLR (P < 0.001), low LMR (P = 0.002), hypoalbuminemia (P = 0.004), high serum CA 19-9 levels (P = 0.008), and lymph node metastasis (P = 0.033) were significantly associated with poor survival rates. Multivariate analysis showed that a high NLR (hazard ratio 5.799, 95% confidence interval 1.188–28.32, P = 0.030) and a low LMR (hazard ratio 4.837, 95% confidence interval 1.826–2.331, P = 0.025) were independent prognostic factors for OS.

Conclusion

Both NLR and LMR may serve as significant independent preoperative prognostic indicators of disease in patients with DBDC who undergo radical resection.

Prognostic role of the advanced lung cancer inflammation index in cancer patients: a meta-analysis

Background

Inflammation plays a critical role in the development and progression of cancers. The advanced lung cancer inflammation index (ALI) is thought to be able to reflect systemic inflammation better than current biomarkers. However, the prognostic significance of the ALI in various types of cancer remains unclear. Our meta-analysis aimed to comprehensively investigate the relationship between the ALI and oncologic outcomes to help physicians better assess the prognosis of cancer patients.

Methods

The PubMed, Embase, Cochrane Library, China National Knowledge Infrastructure, and Wanfang databases were searched for relevant studies. Hazard ratios (HRs) with 95% confidence intervals (95% CIs) were calculated and pooled from the included studies. Furthermore, a sensitivity analysis was performed to evaluate the reliability of the articles. Finally, Begg’s test, Egger’s test, and the funnel plot were applied to assess the significance of publication bias.

Results

In total, 1736 patients from nine studies were included in our meta-analysis. The median cutoff value for the ALI was 23.2 (range, 15.5–37.66) in the analyzed studies. The meta-analysis showed that there was a statistically significant relationship between a low ALI and worse overall survival (OS) in various types of cancer (HR = 1.70, 95% CI = 1.41–1.99, P < 0.001). Moreover, results from subgroup meta-analysis showed that the ALI had a significant prognostic value in non-small cell lung cancer, small cell lung cancer, colorectal cancer, head and neck squamous cell carcinoma, and diffuse large B cell lymphoma (P < 0.05 for all).

Conclusions

These results showed that a low ALI was associated with poor OS in various types of cancer, and the ALI could act as an effective prognostic biomarker in cancer patients.

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.

Prognostic significance of neutrophil-lymphocyte ratio in resectable pancreatic neuroendocrine tumors with special reference to tumor-associated macrophages

BACKGROUND

Recent studies have shown that the systemic inflammatory response induced by cancer leads to cancer progression. Neutrophil-to-lymphocyte ratio (NLR) is the most reliable marker to detect systemic inflammation. In this study, we investigated the significance of NLR in patients with well-differentiated pancreatic neuroendocrine tumors (PanNETs) according to the World Health Organization 2017 classification.

METHODS

We retrospectively collected data for patients with PanNET who underwent pancreatic resection with curative intent between January 2008 and December 2017 at six institutions. Clinicopathological factors, recurrence, and immunohistochemical staining of tumor-associated macrophages (TAMs) were analyzed in a total of 55 patients in this study.

RESULTS

High NLR (>3.41) in patients was significantly associated with higher white blood cell count, higher Ki-67 index, higher mitotic count, higher grade, higher incidence of lymph node metastasis, higher incidence of lymphatic and neural invasion, massive blood loss, and a large number of CD163-expressing TAMs. Recurrence-free survival of patients with high NLR was significantly poorer than that of patients with low NLR. Multivariate analysis identified high NLR, NET Grade 2 (G2) or Grade 3 (G3), and synchronous hepatic resection as independent risk factors for recurrence after curative resection.

CONCLUSIONS

NLR is a promising predictor of recurrence after pancreatectomy that needs to be further investigated and that accumulation of TAMs in the tumor could be one of the causes of NLR elevation.

Predicting the risk of pulmonary tuberculosis based on the neutrophil-to-lymphocyte ratio at TB screening in HIV-infected individuals

Background

The neutrophil to lymphocyte ratio (NL ratio) has been reported to be a predictive biomarker of tuberculosis (TB). We assessed the association between the NL ratio and the incidence of active TB cases within 1 year after TB screening among HIV-infected individuals in Thailand.

Methods

A day care center that supports HIV-infected individuals in northernmost Thailand performed TB screening and follow-up visits. We compared the baseline characteristics between the TB screening positive group and the TB screening negative group. The threshold value of NL ratio was determined by cubic-spline curves and NL ratios were categorized as high or low NL ratio. We assessed the association between NL ratio and progression to active TB within 1-year using the Cox-proportional hazard model.

Results

Of the 1064 HIV-infected individuals who screened negative for TB at baseline, 5.6% (N = 60) eventually developed TB and 26 died after TB diagnosis. A high NL ratio was associated with a higher risk of TB (adjusted hazard ratio (aHR) 2.19, 95% CI: 1.23–3.90), after adjusting for age, sex, ethnicity, CD4 counts, and other risk factors. A high NL ratio in HIV-infected individuals with normal chest X-ray predicted TB development risk. In particular, a high NL ratio with TB symptoms could predict the highest risk of TB development (aHR 2.58, 95%CI: 1.07–6.23).

Conclusions

Our results showed that high NL ratio increased the risk of TB. NL ratio combined with TB symptoms could increase the accuracy of TB screening among HIV-infected individuals.

Electronic supplementary material

The online version of this article (10.1186/s12879-019-4292-9) contains supplementary material, which is available to authorized users.

Second-line chemotherapy in biliary tract cancer: Outcome and prognostic factors

BACKGROUND & AIMS

The prognosis of biliary tract cancer (BTC) is poor. Standard treatment for advanced BTC is a chemotherapy (CT) with gemcitabine and cisplatin. Phase III evidence for a second-line (2L) CT is lacking. We aimed to investigate the feasibility of a 2L CT, to estimate the outcome and to identify prognostic markers.

METHODS

Patients of our institution with advanced BTC between 2000 and 2015 receiving CT were included. Data were analysed in univariate and multivariate analysis.

RESULTS

Three-hundred and fifteen and 144 patients (45.7%) received first-line (1L) and 2L CT respectively. The OS of patients receiving 2L CT was 16.67 and 9.9 months from the beginning of 1L and 2L CT respectively. The overall response rate and the disease control rate after 3 months were 9.7% and 33.6% respectively. Adverse events of grade 3 or more were observed in 26.1%. One patient died of gemcitabine-related haemolytic uraemic syndrome. Age of more than 70 years was not associated with a poor outcome. In multivariate analysis, CEA levels of >3 µg/L (P = 0.004, hazard ratio [HR] 1.89, 95% CI 1.22, 2.91), cholinesterase (CHE) levels of <5 kU/L (P = 0.001, HR 2.11, 95% CI 1.34, 3.31) and leukocytosis (P = 0.001, HR 2.90, 95% CI 1.51, 5.56) were associated with poor survival.

CONCLUSIONS

Despite a relevant toxicity, our data suggest that 2L CT may be feasible in fit BTC patients. CEA elevation, leukocytosis and low CHE levels are unfavourable prognostic markers. Results from prospective randomized trials are urgently awaited.

Cholangiocarcinoma: the quest for a second-line systemic treatment

Biliary tract cancers (BTC) are a heterogeneous group of epithelial neoplasms, with a poor prognosis. Advanced BTC remains a challenging, non-curable disease. Gemcitabine plus platinum chemotherapy is the standard of care as first-line (L1) therapy in this setting. Beyond failure of L1, available evidence to guide therapeutic decisions is scarce. Data from phase III studies are lacking and there is no validated strategy to date. In this review, we provide an overview of the systemic therapeutic options that can be proposed and unsolved questions in the management of patients with advanced BTC in the second-line (L2) setting. Criteria to select which patients should receive L2 therapy are ill defined and reliable prognostic tools and models to help estimate individual patient survival at the beginning of L2 are needed. Chemotherapy, mainly fluoropyrimidine-based yields modest survival results. There is insufficient evidence level to recommend a specific L2 chemotherapy regimen, and anti-epidermal growth factor receptor and antiangiogenic agents failed to demonstrate any survival improvement in a non-selected patient population. In recent years, knowledge about BTC molecular heterogeneity has considerably increased with the advent of high-throughput genomic and transcriptomic analyses, opening new avenues for targeted therapies. Patients with BTC may be particularly good candidates for biomarker-driven therapy in clinical practice. Among the ongoing developments, targeting of FGFR and IDH mutations and immune therapies hold many promises for the next future. In future L2 clinical trials, patients should be carefully characterized and stratified according to prognostic factors, disease subtype, and genetic drivers.

The relationship of blood cell-associated inflammatory indices and diabetic retinopathy: a Meta-analysis and systematic review

AIM

To explore the correlation between several blood cell-associated inflammatory indices including mean platelet volume (MPV), platelet distribution width (PDW), neutrophil to lymphocyte ratio (NLR) and platelet-lymphocyte ratio (PLR), and the presence and severity of diabetic retinopathy (DR).

METHODS

We searched for eligible studies from PubMed, EMBASE, Web of Science and CNKI up to December 13, 2017. Standardized mean difference (SMD) calculated with confidence interval (CI) of 95% was used to estimate the values of those indices.

RESULTS

A total of 31 studies were included in the present Meta-analysis. As compared with type 2 diabetes mellitus (T2DM) patients without DR, the values of MPV, PDW, NLR, and PLR were higher in patients with DR (SMD=0.67; 95%CI: 0.36 to 0.98; SMD=0.51; 95%CI: 0.27 to 0.75; SMD=0.77; 95%CI: 0.49 to 1.05 and SMD=1.18; 95%CI: 0.07 to 2.28). Additionally, it was also observed that MPV was closely correlated with the severity of DR.

CONCLUSION

MPV, PDW, NLR, and PLR could be recommended as diagnostic biomarkers for DR, and MPV could be applied to assess the severity of DR.

Predictive factors of the treatment outcome in patients with advanced biliary tract cancer receiving gemcitabine plus cisplatin as first-line chemotherapy

BACKGROUND

Few studies have clearly identified the prognostic factors in patients with advanced biliary tract cancer (BTC) receiving gemcitabine plus cisplatin (GC) which is acknowledged as standard chemotherapy regimen.

OBJECTIVES

The aim of this study was to identify predictive factors of the overall survival (OS) in advanced BTC patients receiving GC therapy.

METHODS

Data of 307 patients with advanced BTC who received GC therapy as the first-line chemotherapy at our institution from January 2007 to June 2017 were reviewed retrospectively. The patients were randomly assigned to the investigation or the validation dataset at the ratio of 2:1. Multivariate analysis was conducted to identify the prognostic factors, a prognostic index is proposed from the investigation dataset, and the usefulness of this index was confirmed in the validation dataset.

RESULTS

Multivariate analysis identified poor performance status, elevated serum lactate dehydrogenase, and elevated neutrophil-to-lymphocyte ratio as independent unfavorable predictors. The patients could be classified into three groups according to these factors, and it was found that the outcomes differed significantly among the three groups (P = 0.0002, good- vs. intermediate-prognosis groups; P = 0.005, intermediate- vs. poor-prognosis groups). When this index was applied to the validation dataset, the OS was confirmed to differ significantly among the three groups (P = 0.04, good- vs. intermediate-prognosis groups, P < 0.0001, intermediate- vs. poor-prognosis groups).

CONCLUSIONS

We identified three predictors of the OS in patients with advanced BTC receiving GC therapy in this study, based on which we could classify the patients into three risk groups.

Clinical significance of neutrophil-lymphocyte and platelet-lymphocyte ratios in bipolar patients: An 18-month prospective study

Neutrophil-lymphocyte ratio (NLR) and platelet-lymphocyte ratio (PLR) have recently been investigated as inexpensive and reproducible markers of systemic inflammation in many diseases. However, few studies evaluate clinical and prognostic value of NLR and PLR in psychiatric patients. The objective of this study is to investigate the clinical repercussions of NLR and PLR in patients with bipolar disorder (BD). An 18-month prospective study followed up eighty euthymic BD outpatients. Baseline data included an interviewer-administered questionnaire, behavioral scales and a blood count to calculate NLR and PLR. The occurrence of mood episodes and hospitalizations was assessed monthly for 18 months. Higher NLR and PRL were associated with more anxious symptoms and poorer functioning. BD patients with Night Eating Syndrome (NES) had higher PLR and tended to higher NLR. No association with other sleep parameters was evidenced. Higher NLR and PRL were also associated with more episodes and hospitalizations after 18 months. However, only higher baseline NLR was related to more (hypo)mania episodes. NLR and PLR are important prognostic factor for BD. This study suggested the importance of a simple blood count, an inexpensive and reproducible exam, in evaluating the course of the BD. Further studies must be performed to confirm these results.

Prognostic and clinicopathological significance of neutrophil-to-lymphocyte ratio in patients with oral cancer

Objectives: Many studies have examined the prognostic significance of the neutrophil-to-lymphocyte ratio (NLR) in oral cancer; however, the results are contradictory. We, therefore, conducted a meta-analysis aiming to clarify the prognostic value of the NLR in oral cancer patients. Methods: A literature search was conducted in the PubMed, Web of Science, and Embase databases. Stata version 12.0 was used for statistical analysis. Results: A total of 14 studies with 3216 patients were finally included. The results indicated that a high NLR was significantly associated with worse DFS (n=10, HR = 1.73, 95% confidence interval [CI] = 1.44–2.07, P<0.001). Similar results were observed for overall survival (OS) (n=9, HR = 1.61, 95% CI = 1.39–1.86, P<0.001). Moreover, a high NLR was also correlated with lymph node metastasis (n=7, odds ratio [OR] = 1.62, 95% CI = 1.32–1.98, P<0.001), advanced tumor stage (n=7, OR = 2.63, 95% CI = 2.12–3.25, P<0.001), T stage (n=6, OR = 3.22, 95% CI = 2.59–4.01, P<0.001), tumor differentiation (n=5, OR = 1.48, 95% CI = 1.03–2.11, P=0.033), and perineural invasion (n=4, OR = 1.83, 95% CI = 1.4–2.39, P<0.001). However, an elevated NLR was not correlated with gender. Conclusion: This meta-analysis showed that the NLR might be a potential independent prognostic factor in patients with oral cancer.

The impact of neutrophil-to-lymphocyte ratio and platelet-to-lymphocyte ratio among patients with intrahepatic cholangiocarcinoma

BACKGROUND

Neutrophil-to-lymphocyte ratio and platelets-to-lymphocyte ratio may be host factors associated with prognosis. We sought to determine whether neutrophil-to-lymphocyte and platelets-to-lymphocyte ratio were associated with overall survival among patients undergoing surgery for intrahepatic cholangiocarcinoma.

METHODS

Patients who underwent resection for intrahepatic cholangiocarcinoma between 1990 and 2015 were identified from 12 major centers. Clinicopathologic factors and overall survival were compared among patients stratified by neutrophil-to-lymphocyte ratio and platelets-to-lymphocyte ratio. Risk factors identified on multivariable analysis were included in a prognostic model and the discrimination was assessed using Harrell's concordance index (C index).

RESULTS

A total of 991 patients were identified. Median neutrophil-to-lymphocyte ratio and platelets-to-lymphocyte ratio were 2.7 (interquartile range [IQR]: 2.0-4.0) and 109.6 (IQR: 72.4-158.8), respectively. Preoperative neutrophil-to-lymphocyte ratio was elevated (≥5) in 100 patients (10.0%) and preoperative platelets-to-lymphocyte ratio (≥190) in 94 patients (15.2%). Patients with low and high neutrophil-to-lymphocyte ratio and platelets-to-lymphocyte ratio generally had similar baseline characteristics with regard to tumor characteristics. Overall survival was 37.7 months (95% confidence interval [CI]: 32.7-42.6); 1-, 3-, and 5-year overall survival was 78.8%, 51.6%, and 39.3%, respectively. Patients with an neutrophil-to-lymphocyte ratio <5 had a median survival of 47.1 months (95% CI: 37.9-53.3) compared with a median survival of 21.9 months (95% CI: 4.8-39.1) among patients with an neutrophil-to-lymphocyte ratio ≥5 (P = .001). In contrast, patients who had a platelets-to-lymphocyte ratio <190 vs platelets-to-lymphocyte ratio ≥190 had comparable long-term survival (P > .05). On multivariable analysis, an elevated neutrophil-to-lymphocyte ratio was independently associated with decreased overall survival (hazard ratio: 1.04, 95% CI: 1.01-1.07; P = .002). Patients could be stratified into low- versus high-risk groups based on standard tumor-specific factors such as lymph node status, tumor size, number, and vascular invasion (C index 0.62). When neutrophil-to-lymphocyte ratio was added to the prognostic model, the discriminatory ability of the model improved (C index 0.71).

CONCLUSION

Elevated neutrophil-to-lymphocyte ratio was independently associated with worse overall survival and improved the prognostic estimation of long-term survival among patients with intrahepatic cholangiocarcinoma undergoing resection.

Prognostic value of neutrophil-to-lymphocyte ratio in melanoma: Evidence from a PRISMA-compliant meta-analysis

BACKGROUND

A number of studies have investigated the prognostic impact of the neutrophil-to-lymphocyte ratio (NLR) in patients with melanoma but the results were controversial. Therefore, we conducted a meta-analysis to explore the prognostic value of NLR in melanoma.

METHODS

The databases of PubMed, Embase, and Web of Science were thoroughly searched. Associations between NLR and overall survival (OS) and progression-free survival (PFS) were investigated by pooling hazard ratio (HR) and 95% confidence interval (CI).

RESULTS

A total of 12 studies comprising 3207 patients were finally included in the meta-analysis. The results showed that a high NLR was associated with poor OS (HR = 2.23, 95% CI = 1.64-3.04, P < .001, random-effects model) and PFS (HR = 2.19, 95% CI = 1.78-2.69, P < .001, fixed-effects model). Subgroup analyses demonstrated that NLR was still associated with poor OS and PFS for patients in Western countries who were treated with ipilimumab. No significant publication bias was found in this meta-analysis.

CONCLUSION

This meta-analysis demonstrated that a high NLR was predictive of poor OS and PFS in patients with melanoma.

The expression and clinicopathological role of CDX2 in intrahepatic cholangiocarcinoma

The aim of this study was to examine the expression and clinicopathological role of caudal homeobox 2 (CDX2) in intrahepatic cholangiocarcinoma (ICC). CDX2 expression was determined immunohistochemically in 93 patients with ICC. The association between CDX2 expression and clinicopathological features of ICC was also examined in patients with ICC. Immunohistochemical staining for CDX2 was noted in 27 patients (29.03%); patients with CDX2-positive tumors had significant survival advantages over those with CDX2- negative tumors (median survival was 40 months for patients with CDX2-positive tumors and 13 months for patients with CDX2-negative tumors; the hazard ratio was 0.36, the 95% confidence interval was 0.22-0.59, and p < 0.001). The rate of CDX2 expression was 13.46% in patients with lymphatic invasion and 48.78% in patients without lymphatic invasion (χ² = 13.88, p < 0.01); positivity for CDX2 expression was significantly higher in patients with well-differentiated or moderately differentiated tumors than that in patients with poorly differentiated tumors (41.7% in patients with well-differentiated tumors, 47.6% in patients with moderately differentiated tumors, and 20.0% in patients with poorly differentiated tumors; Mann-Whitney U test, p = 0.01). In addition, CDX2 expression differed significantly in patients with ICC due to hepatolithiasis and patients with ICC not due to hepatolithiasis (36.51% and 13.33%, respectively, χ² = 5.30, p = 0.02). Positivity for CDX2 expression resulted in significant survival advantages for patients with ICC. CDX2 might be used as a prognostic marker in patients with ICC.