Prognostic and diagnostic impact of fibrinogen, neutrophil-to-lymphocyte ratio, and platelet-to-lymphocyte ratio on thymic epithelial tumors outcome

Prognostic significance of preoperative creatine kinase in resected thymic epithelial tumors

Background

The preoperative serum creatine kinase (CK) concentration is a prognostic factor for malignant diseases. We investigated the significance of CK in surgically resected thymic epithelial tumors and the relationship between CK and clinicopathological factors.

Methods

We retrospectively evaluated the relationship between preoperative CK levels and prognosis in 120 patients with thymic epithelial tumors who underwent surgical resection at two centers. The cutoff for CK was determined by the standard value in our institution (<62 IU/L for men and <45 IU/L for women). The paravertebral muscle at the Th12 level was used to assess skeletal muscle area to investigate sarcopenia.

Results

Eighteen patients (15.0%) were categorized into the low CK group. The CK level was not associated with age, sex, performance status, myasthenia gravis, and pathological findings. Preoperative serum albumin and total cholesterol concentrations were significantly lower in the low CK group than in the normal CK group (both P<0.001). Moreover, the Th12 muscle index was lower in the low CK group (P=0.03), indicating that low CK was related to sarcopenia. Kaplan-Meier curve analysis illustrated that patients in the low CK group had significantly shorter disease-free survival (DFS) and overall survival (OS) than those in the normal CK group (P=0.03 and P=0.002, respectively). Multivariate analysis identified low CK as an independent prognostic factor for DFS (P=0.03) and OS (P=0.005).

Conclusions

Preoperative serum CK might reflect the host nutritional status in patients with resected thymic epithelial tumors; therefore, CK could be a biomarker of postoperative prognosis.

Ki67 Tumor Expression Predicts Treatment Benefit Achieved by Macroscopic Radical Lung-Preserving Surgery in Pleural Mesothelioma-A Retrospective Multicenter Analysis

Pleural mesothelioma (PM), linked to asbestos-induced inflammation, carries a poor prognosis. Therapy ranges from therapy limitation to aggressive multimodality treatment. Given the uncertainty about treatment benefits for patients, this study aimed to assess the role of Ki67 as a prognostic and predictive parameter in PM. Ki67 was measured in the specimens of 70 PM patients (17 female, 53 male) from two centers and correlated to overall survival (OS) and therapy outcome. The median OS was 16.1 months. The level of Ki67 expression was divided into low (≤15%) and high (>15%). A low value of Ki67 expression was associated with a longer OS (Ki67 ≤ 15%: 31.2 (95% CI 6.5-55.8) months vs. Ki67 > 15%: 11.1 (95% CI 7.7-14.6) months, p = 0.012). The 5-year survival represents 22% in the low Ki67 expression group, in contrast to 5% in the high Ki67 expression group. We found a significant interaction term of Ki67 with multimodality treatment (p = 0.031) translating to an OS of 48.1 months in the low expression Ki67 group compared to 24.3 months in the high Ki67 expression group when receiving surgery within multimodality therapy. Therefore, Ki67 stands out as a validated prognostic and, most importantly, novel predictive biomarker for treatment benefits, particularly regarding surgery within multimodality therapy.

Validation of Inflammatory Prognostic Biomarkers in Pleural Mesothelioma

Evoked from asbestos-induced inflammation, pleural mesothelioma represents a fatal diagnosis. Therapy ranges from nihilism to aggressive multimodality regimens. However, it is still unclear who ultimately benefits from which treatment. We aimed to re-challenge inflammatory-related biomarkers' prognostic value in times of modern immune-oncology and lung-sparing surgery. The biomarkers (leukocytes, hemoglobin, platelets, neutrophils, lymphocytes, monocytes, neutrophil-lymphocyte ratio (NLR), lymphocyte-monocyte ratio (LMR), platelet-lymphocyte ratio (PLR), C-reactive protein (CRP)) and clinical characteristics (age, sex, histology, therapy) of 98 PM patients were correlated to overall survival (OS). The median OS was 19.4 months. Significant OS advantages (Log-Rank) were observed in multimodal treatment vs. others (26.1 vs. 7.2 months, p < 0.001), surgery (pleurectomy/decortication) vs. no surgery (25.5 vs. 3.8 months, p < 0.001), a high hemoglobin level (cut-off 12 g/dL, 15 vs. 24.2 months, p = 0.021), a low platelet count (cut-off 280 G/L, 26.1 vs. 11.7 months, p < 0.001), and a low PLR (cut-off 194.5, 25.5 vs. 12.3 months, p = 0.023). Histology (epithelioid vs. non-epithelioid, p = 0.002), surgery (p = 0.004), CRP (cut-off 1 mg/dL, p = 0.039), and platelets (p = 0.025) were identified as independent prognostic variables for this cohort in multivariate analysis (Cox regression, covariates: age, sex, histology, stage, CRP, platelets). Our data verified the previously shown prognostic role of systemic inflammatory parameters in patients treated with lung-sparing surgery within multimodality therapy.

Prognostic factors and genetic markers in thymic epithelial tumors: A narrative review

Thymic epithelial tumors (TET) are a group of rare neoplasms of the anterior mediastinum comprising thymomas and thymic carcinomas. The carcinogenesis of TET is mostly unknown. Many studies, mostly retrospective case series, have tried to establish prognostic factors in TET. TET is a very heterogeneous group of tumors with many subtypes for which diagnosis and treatment remains a very challenging task. Despite the disparities among retrospective studies, there are some prognostic factors that are more pertinent such as the completeness of resection, TNM stage and the Masaoka-Koga classification. On the other hand, the identification of different genetic pathways that result in the pathogenesis of TET represents a fascinating field of study that could possibly lead to the development of new targeted therapies. The aim of this review is to discuss the different prognostic factors and genetic markers of TET. The meticulous use of national and international databases could provide sufficient number of patients in order to draw more valid conclusions.

Prognostic value of systemic inflammatory markers and the nutrition status in thymic epithelial tumors with complete resection

Background

Recent studies have shown that several systemic inflammatory markers and the nutrition status, including the neutrophil‐to‐lymphocyte ratio (NLR), monocyte‐to‐lymphocyte ratio (MLR), platelet‐to‐lymphocyte ratio (PLR), and prognostic nutritional index (PNI), are useful prognostic factors in several malignant tumors. The present study explored the prognostic value of the NLR, MLR, PLR, and PNI in thymic epithelial tumor (TET) patients who underwent complete resection.

Methods

A total of 158 TET patients who underwent complete resection were involved in the analysis. Their NLR, MLR, PLR, and PNI values were obtained from a blood examination within one month before the initiation of treatment. A receiver operating characteristic curve analysis was conducted to determine the optimal cutoff values.

Results

The enrolled patients were stratified by cutoffs of 4.35 for the NLR, 0.22 for the MLR, 130.18 for the PLR, and 44.02 for the PNI. A univariate analysis revealed that high‐grade malignant TET, including type B2 and B3 thymoma, thymic carcinoma, and thymic neuroendocrine tumor; an advanced Masaoka stage; a high NLR; a high MLR; and a low PNI were significant predictors of a poor disease‐free survival (DFS). A multivariate analysis confirmed that an advanced Masaoka stage (HR = 5.5557, p = 0.0007) and a high MLR (HR = 3.3371, p = 0.0264) were independent predictors of a poor DFS.

Conclusions

Our study demonstrated that the pretreatment MLR was an independent predictor of the DFS in patients with TETs who underwent complete resection.

The Prognostic Value of Preoperative Serum D-dimer Levels After Surgical Resection of Thymic Epithelial Tumors

Introduction

Thymic epithelial tumors are the most common mediastinal tumors. Despite the high survival rate after surgery, some patients still require postoperative adjuvant therapy and closer follow-up. Hematological indicators such as biochemical routines and coagulation indicators have been reported to be independently associated with the prognosis of various malignancies. Therefore, we included hematological indicators in the analysis.

Methods

The data of 105 patients with thymic epithelial tumors were retrospectively collected from Sun Yat-sen University Cancer Center, and the patients with missing preoperative hematological indicators were excluded. X-tile software was used to obtain the best cutoff value of each preoperative hematological indicator, and COX regression analysis and Kaplan-Meier survival curves were used to demonstrate statistically significant results.

Results

COX univariate regression analysis of all patients showed that Masaoka stage, T stage, WHO histologic types, D-dimer, albumin-fibrinogen ratio (AFR), Fibrinogen (Fbg) were associated with postoperative overall survival ( P < .05). T stage, WHO histologic types, D-dimer, and AFR were associated with postoperative recurrence-free survival ( P < .05). Finally, multivariate regression analysis showed that T stage, D-dimer levels were independently associated with postoperative overall survival (OS) and recurrence-free survival (RFS) in patients with thymic epithelial tumors.

Conclusions

For thymic epithelial tumors, higher preoperative D-dimer levels predict poorer survival and shorter recurrence-free survival. This may help guide postoperative adjuvant therapy and follow-up patterns in patients with thymic epithelial tumors.

Clinical Relevance of Elevated Soluble ST2, HSP27 and 20S Proteasome at Hospital Admission in Patients with COVID-19

Although, severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) represents one of the biggest challenges in the world today, the exact immunopathogenic mechanism that leads to severe or critical Coronavirus Disease 2019 (COVID-19) has remained incompletely understood. Several studies have indicated that high systemic plasma levels of inflammatory cytokines result in the so-called "cytokine storm", with subsequent development of microthrombosis, disseminated intravascular coagulation, and multiorgan-failure. Therefore, we reasoned those elevated inflammatory molecules might act as prognostic factors. Here, we analyzed 245 serum samples of patients with COVID-19, collected at hospital admission. We assessed the levels of heat shock protein 27 (HSP27), soluble suppressor of tumorigenicity-2 (sST2) and 20S proteasome at hospital admission and explored their associations with overall-, 30-, 60-, 90-day- and in-hospital mortality. Moreover, we investigated their association with the risk of ventilation. We demonstrated that increased serum sST2 was uni- and multivariably associated with all endpoints. Furthermore, we also identified 20S proteasome as independent prognostic factor for in-hospital mortality (sST2, AUC = 0.73; HSP27, AUC = 0.59; 20S proteasome = 0.67). Elevated sST2, HSP27, and 20S proteasome levels at hospital admission were univariably associated with higher risk of invasive ventilation (OR = 1.8; p < 0.001; OR = 1.1; p = 0.04; OR = 1.03, p = 0.03, respectively). These findings could help to identify high-risk patients early in the course of COVID-19.

Potential Prognostic Value of Preoperative Leukocyte Count, Lactate Dehydrogenase and C-Reactive Protein in Thymic Epithelial Tumors

Thymic epithelial tumors are the most common mediastinal tumors. Surgery is the mainstay of treatment and complete resection provides the best survival rate. However, advanced tumors often require multimodality treatment and thus we analyzed the prognostic potential of routine circulating biomarkers that might help to risk-stratify patients beyond tumor stage and histology. Preoperative values for white blood cell count (WBC), C-reactive protein (CRP) and lactate dehydrogenase (LDH) were analyzed in 220 thymic epithelial tumor patients operated between 1999 and 2018. Increased CRP levels (>1 mg/dl) were significantly more often measured in thymic carcinoma and neuroendocrine tumors when compared to thymoma. LDH serum activity was higher in thymic neuroendocrine tumors when compared to thymoma or thymic carcinoma. The median disease specific survival was significantly longer in thymoma cases than in thymic carcinoma and neuroendocrine tumors. Increased preoperative LDH level (>240 U/L) associated with shorter survival in thymus carcinoma (HR 4.76, p = 0.0299). In summary, higher CRP associated with carcinoma and neuroendocrine tumors, while LDH increased primarily in neuroendocrine tumors suggesting that biomarker analysis should be performed in a histology specific manner. Importantly, preoperative serum LDH might be a prognosticator in thymic carcinoma and may help to risk stratify surgically treated patients in multimodal treatment regimens.

Biomarkers for Malignant Pleural Mesothelioma-A Novel View on Inflammation

Malignant pleural mesothelioma (MPM) is an aggressive disease with limited treatment response and devastating prognosis. Exposure to asbestos and chronic inflammation are acknowledged as main risk factors. Since immune therapy evolved as a promising novel treatment modality, we want to reevaluate and summarize the role of the inflammatory system in MPM. This review focuses on local tumor associated inflammation on the one hand and systemic inflammatory markers, and their impact on MPM outcome, on the other hand. Identification of new biomarkers helps to select optimal patient tailored therapy, avoid ineffective treatment with its related side effects and consequently improves patient's outcome in this rare disease. Additionally, a better understanding of the tumor promoting and tumor suppressing inflammatory processes, influencing MPM pathogenesis and progression, might also reveal possible new targets for MPM treatment. After reviewing the currently available literature and according to our own research, it is concluded that the suppression of the specific immune system and the activation of its innate counterpart are crucial drivers of MPM aggressiveness translating to poor patient outcome.

Pretreatment serum neutrophil-to-lymphocyte and monocyte-to-lymphocyte ratios: Two tumor-related systemic inflammatory markers in patients with thymic epithelial tumors

OBJECTIVES

To understand underlying changes in pretreatment serum inflammatory markers associated with thymic epithelial tumors (TETs) development.

METHODS

A retrospective analysis of 113 TETs patients who underwent 18-fluorine fluorodeoxyglucose (¹⁸F-FDG) positron emission tomography combined computed tomography (PET/CT) one to two weeks before tumor resection or biopsy was performed. Pretreatment serum neutrophil, monocyte, platelet, and lymphocyte counts, and fibrinogen and C-reaction protein (CRP) concentrations were measured one day before surgery or biopsy. Neutrophil-to-lymphocyte ratio (NLR), monocyte-to-lymphocyte ratio (MLR), and platelet-to-lymphocyte ratio (PLR) were calculated by dividing corresponding cells counts by lymphocyte counts, respectively. The maximum standard uptake value (SUVmax) of ¹⁸F-FDG of primary TETs was applied to reflect tumor glycolytic activity. The student's t-test, one-way ANOVA analysis, Chi-square test, receiver operating characteristic curve analysis, and Logistic regression analysis were used for statistical analysis.

RESULTS

The serum NLR and MLR were significantly higher in TETs patients than in healthy volunteers (P both ≤ 0.001). High serum NLR and MLR were related to the thymic carcinomas (TCs) subtype, elevated Masaoka-Koga (M-K) tumor stage, and metastasis of TETs (P all < 0.005). High serum NLR and MLR were also associated with high SUVmax values of TETs (P all < 0.005), with increasingly differences between groups as the cut-off values defining low-SUVmax and high-SUVmax groups increased. With the medium cutoff of NLR, MLR, and SUVmax of 3.07, 0.25, and 8.00 respectively, the high NLR and MLR levels were significantly associated with high SUVmax level of TETs (P both < 0.005). Moreover, the incidences of co-high SUVmax/NLR and co-high SUVmax/MLR were higher in TETs patients older than 55 years, with TCs, in M-K stage IV, and with metastasis (P all < 0.05). Both the co-high SUVmax/NLR and co-high SUVmax/MLR increased the risk of TETs metastasis (P both < 0.001), while the co-high SUVmax/MLR was also an independent risk factor for TETs metastasis (odds ratio: 3.92, 95% confidence interval: 1.02-15.12, P = 0.047).

CONCLUSION

Pretreatment serum NLR and MLR of TETs patients are two tumor-progression- and tumor-glycolysis-related inflammatory markers. Enhanced tumor glycolytic activity and associated systemic inflammatory reaction may play a synergistic role in TETs metastasis.

Tumour cell PD-L1 expression is prognostic in patients with malignant pleural effusion: the impact of C-reactive protein and immune-checkpoint inhibition

Malignant pleural effusion (MPE) confers dismal prognosis and has limited treatment options. While immune-checkpoint inhibition (ICI) proved clinical efficacy in a variety of malignancies, data on the prognostic role of PD-L1 in MPE is scarce. We retrospectively studied PD-L1 tumour proportion score and Ki-67 index in pleural biopsies or cytologies from 123 patients (69 lung cancer, 25 mesothelioma, and 29 extrathoracic primary malignancies). Additionally, the impact of C-reactive protein (CRP) and platelet count was also analysed. Median overall survival (OS) after MPE diagnosis was 9 months. Patients with PD-L1 positive tumours (≥1%) had significantly shorter OS than patients with negative PD-L1 status (p = 0.031). CRP and Ki-67 index were also prognostic and remained independent prognosticators after multivariate analysis. Interestingly, Ki-67 index and CRP influenced the prognostic power of PD-L1. Finally, patients receiving ICI tended to have a longer median OS and CRP - but not PD-L1 - was a significant prognosticator in this subgroup. In summary, histological and circulating biomarkers should also be taken into account as potential biomarkers in ICI therapy and they may have an impact on the prognostic power of PD-L1. Our findings might help personalizing immune-checkpoint inhibition for patients with MPE and warrant further prospective validation.

High Neutrophil Count as a Negative Prognostic Factor for Relapse in Patients with Thymic Epithelial Tumor

PURPOSE

Preoperative neutrophil count is reportedly associated with poor prognosis in cancer patients. This study aimed to investigate the clinical significance of pre-treatment peripheral blood cell counts in patients with thymic epithelial tumors (TETs).

METHODS

A retrospective review of 71 patients with completely resected TETs [64 thymoma, 6 thymic carcinoma, and 1 thymic neuroendocrine tumor] between 2000 and 2018 was conducted. Associations between tumor recurrence and pre-treatment peripheral blood cell counts of leukocytes (WBC), neutrophils (Neut), lymphocytes (Lymph), monocytes (Mono), and platelets (Plt) were analyzed. Optimal cut-off points were selected using receiver operating characteristic curve analysis to predict tumor recurrence.

RESULTS

High WBC (≥ 7000), Neut (≥ 4450), and Plt (≥ 226 × 10³) counts had significantly poor relapse-free survival (RFS), but high Lymph (≥ 1950) and Mono (≥ 400) did not. High Neut had the strongest correlation with recurrence (area under curve, 0.800); we focused on the analysis between high-Neut and low-Neut groups. High Neut count significantly correlated with smoking history, pre-treatment C-reactive protein level, and advanced stage; high Neut count and aggressive histology tended to show correlations. RFS was significantly poorer in the high-Neut group than in the low-Neut group (p = 0.003), with 5-year RFS rates of 63.8% and 96.8%, respectively. High Neut count was a significant adverse predictor for RFS and cumulative incidence of recurrence (p = 0.005 and p < 0.001, respectively). The risk scoring system comprising high Neut count, advanced stage, and aggressive histology demonstrated better prognostic ability than any prognostic factors alone.

CONCLUSIONS

High Neut count significantly correlated with TET recurrence, suggesting a negative prognostic effect of latent inflammation in TET patients.

Preoperative lymphocyte-to-monocyte ratio versus platelet-to-lymphocyte ratio as a prognostic predictor for non-small cell lung cancer patients

Background

We investigated the prognostic value of the preoperative lymphocyte-to-mononuclear ratio (LMR) and platelet-to-lymphocyte ratio (PLR) in a large cohort of patients with non-small cell lung cancer (NSCLC).

Methods

Clinical-pathological data from 507 NSCLC patients at Taizhou Hospital of Zhejiang Province between 2010 and 2016 were retrospectively evaluated. X-tile software was used to assess the optimal cutoff levels for LMR and PLR. Univariate and multivariate Cox regression models were used to assess the prognostic factors.

Results

The median follow-up duration after surgical resection was 34.5 months. Patients were stratified into 2 groups by LMR (2.6 and > 2.6) and PLR (179.6 and > 179.6). Our results revealed that lower LMR (HR = 3.163 (1.821-5.493), P = 0.000), age (HR = 2.252 (1.412-3.592), P = 0.001), T stage (HR = 3.749 (2.275-6.179), P = 0.000), N stage (HR = 3.106 (1.967-4.902), P = 0.000), and cut edge (HR = 3.830 (1.077-13.618), P = 0.038) were considered to be independent indicators for overall survival (OS) of NSCLC patients. For disease-free survival (DFS), age, sex, T stage, N stage, LMR and cut edge were verified to be independent prognostic factors in patients with NSCLC.

Conclusions

In the study cohort, reduced LMR was a robust independent predictor for both OS and DFS in patients with NSCLC who underwent surgical resection.

Clinical prognostic scores for patients with thymic epithelial tumors

Several inflammation-based prognostic scores emerged in various types of cancer to predict clinical outcomes. So far, no accurate pre-treatment scoring systems exist for patients with thymic epithelial tumors (TETs), comprising thymomas and thymic carcinomas (TCs). Therefore, we sought to test the prognostic value of different clinical composite scores and their components, identify optimal cut-off values for TETs as well as combine predictive components to new suitable prognostic scores. One hundred eighty-four patients with TETs undergoing surgical tumor resection were analyzed. A significant advantage in Freedom-from-Recurrence and/or Cause-specific survival (CSS) was evident for patients with high Advanced-Lung- Cancer-Inflammation-Index, low CRP-Fibrinogen-Score (CFS), low Glasgow-Prognostic-Score (GPS), low high-sensitivity-modified GPS, low TET-adapted GPS (TET-aGPS) and low Systemic-Immune-Inflammation Index. On multivariable analysis high TET-aGPS (HR = 14.9;p = 0.001), incomplete resection status (HR = 13.5;p = 0.001) and TC (HR = 26.0;p = 0.001) were significant independent prognostic factors for worse CSS. The CFS had the highest coefficient of determination (R² = 0.188) to predict tumor recurrence of all composite scores, comprising CRP (R² = 0.141) and fibrinogen (R² = 0.158), the best single factor predictors. Inflammation-based prognostic scores and selected components are suitable to predict survival and/or tumor recurrence in TET patients undergoing primary surgery. Due to excellent long-term survival and frequent tumor recurrence, cut-off values were tailored to increase prognostic power.

Follistatin impacts Tumor Angiogenesis and Outcome in Thymic Epithelial Tumors

Tumor angiogenesis is a key factor in the progression of thymic epithelial tumors (TETs). Activin A, a member of the TGFβ family, and its antagonist Follistatin are involved in several human malignancies and angiogenesis. We investigated Activin A and Follistatin in serum and tumor tissue of patients with TETs in relation to microvessel density (MVD), WHO histology classification, tumor stage and outcome. Membranous Activin A expression was detected in all tumor tissues of TETs, while Follistatin staining was found in tumor nuclei and cytoplasm. Patients with TETs presented with significantly higher Activin A and Follistatin serum concentrations compared to healthy volunteers, respectively. Follistatin serum concentrations correlated significantly with tumor stage and decreased to physiologic values after complete tumor resection. Follistatin serum concentrations correlated further with MVD and were associated with significantly worse freedom from recurrence (FFR). Low numbers of immature tumor vessels represented even an independent worse prognostic factor for FFR at multivariable analysis. To conclude, the Activin A - Follistatin axis is involved in the pathogenesis of TETs. Further study of Follistatin and Activin A in TETs is warranted as the molecules may serve as targets to inhibit tumor angiogenesis and tumor progression.

Assessment of the prognostic role of neutrophil-to-lymphocyte ratio following complete resection of thymoma

BACKGROUND

The introduction of the new TNM staging system for thymic epithelial malignancies produced a significant increase in the proportion of patients with stage I disease. The identification of new prognostic factors could help to select patients for adjuvant therapies based on their risk of recurrence. Neutrophil-to-lymphocyte ratio (NLR) has recently gained popularity as reliable prognostic biomarker in many different solid tumors. The aim of this study is to assess the utility of NLR evaluation as a prognostic marker in patients with surgically-treated thymoma.

METHODS

A retrospective analysis was conducted among patients who underwent resection for thymoma in a single center. Patients were divided in two groups, under (low-NLR-Group = 47 patients, 60%) and above (high-NLR-Group = 32 patients, 40%) a ROC-derived NLR cut-off (2.27). Associations with clinical-pathological variables were analyzed; disease-free survival (DFS) was identified as the primary endpoint.

RESULTS

Between 2007 and 2017, 79 patients had surgery for thymoma. Overall 5-year DFS was 80%. Univariate survival analysis demonstrated that NLR was significantly related to DFS when patients were stratified for TNM stage (p = 0.043). Five-year DFS in the low-NLR-Group and in the high-NLR-Group were respectively 100 and 84% in stage I-II, and 66 and 0% in stage III. TNM stage resulted as the only independent prognostic factor at multivariate analysis, with hazard ratio of 3.986 (95% CI 1.644-9.665, p = 0.002).

CONCLUSIONS

High preoperative NLR seems to be associated to a shorter DFS in patients submitted to surgery for thymoma and stratified for TNM stage.