Role of inflammatory indices in management of hepatocellular carcinoma-neutrophil to lymphocyte ratio

Improving clinical outcomes of patients with hepatocellular carcinoma: Role of antiviral therapy, conversion therapy, and palliative therapy

In this editorial, I comment on three articles published in the recent issue of the World Journal of Gastrointestinal Oncology. Hepatocellular carcinoma (HCC) is an important public health concern, and there are three articles on the theme of HCC in this issue. I focus on the articles by Mu et al, Chu et al, and Ma et al for this editorial. While these articles may be considered as low-quality evidence, and the results cannot be generalized to non-hepatitis-B or C virus patients, the discussion of the results is important. In addition, though all the articles are from China, the relevance of the results is not minuscule. As resection is the main form of curative treatment modality owing to a donor liver shortage, surgeons need to be aware that preoperative long-course antiviral therapy can improve clinical outcomes by reducing postoperative liver dysfunction and recurrence of HCC following resection. Similarly, patients with super-giant HCC (defined as ≥ 15 cm diameter) should also be carefully considered for liver resection, and if it is unresectable upfront, then a combination of liver-directed therapy and systemic therapy may downstage HCC. If, following downstaging, the patient qualifies for liver resection based on locally prevalent resectability criteria, then such therapy is labelled as conversion (from unresectable to resectable) therapy. In unresectable patients treated by a combination of treatment options, serological markers like neutrophil-to-lymphocyte ratio and alpha-fetoprotein are reported to predict treatment responses, thus enabling personalized medicine.

Development and validation of a clinical factors and body fat distribution-based nomogram to predict refractoriness of transarterial chemoembolization in hepatocellular carcinoma

Background

Transarterial chemoembolization (TACE) is an important treatment modality for hepatocellular carcinoma (HCC). However, some patients may develop TACE refractoriness during treatment. We aimed to construct a prediction model incorporating computed tomography (CT) body composition and clinical factors to preoperatively predict the risk of developing TACE refractoriness in patients with HCC, enabling the rapid identification of patients at high risk of TACE refractoriness.

Methods

This study included 128 HCC patients treated with TACE who were randomly assigned to the training (n=89) and validation groups (n=39) in a 7:3 ratio. Multiple body-composition parameters were outlined from CT images of the third lumbar vertebra level of each patient. Standardized values of body-composition parameters were calculated, such as visceral-to-subcutaneous adipose tissue area ratio (VSR). Multifactor logistic regression analysis was performed to identify independent predictors of TACE-refractoriness in patients and to develop predictive models. High- and low-risk subgroup analyses were performed for the predictive model.

Results

Alpha-fetoprotein (AFP) level (P=0.041), tumor size (P=0.001), and VSR (P=0.043) were independent risk factors for TACE refractoriness. The combined clinical-body composition model had an area under the curve (AUC) value of 0.875 in the training cohort and an AUC value of 0.837 in the validation cohort. Calibration curves and decision curves revealed the specific optimal performance and clinical utility of the combined model. Subgroup analysis showed differences in predicted TACE refractoriness between the high- and low-risk groups (P<0.001).

Conclusions

The combined clinical-body fat distribution model has the good performance in predicting a patient's risk of TACE refractoriness preoperatively and can help clinicians make the best clinical decisions in advance for the treatment of high-risk patients.

Prognostic value of neutrophil to lymphocyte ratio and platelet counts during chemotherapy in patients with advanced gastric cancer

OBJECTIVES

To investigate the predictive significance of dynamic changes in the neutrophil to lymphocyte ratio (NLR) and platelet counts (PLTs) in patients with advanced gastric cancer (GC) during chemotherapy.

METHODS

A total of 259 advanced GC patients receiving chemotherapy were enrolled and grouped by high or low NLR with a cut value of 2.5 and PLT with cut value of 300×109/L. The Kaplan-Meier survival model and the Log-rank test were carried out to determine the comparison on the overall survival differences. Cox regression analysis was employed to carry out both univariate and multivariate regression studies, aiming to explore potential prognostic factors acting independently.

RESULTS

Higher pre-chemotherapy NLR exhibited an association with metastasis and advanced grade of Borrmann type, and higher NLR of pre- or post-chemotherapy GC patients was related with Borrmann type grade. Moreover, higher PLT counts are associated with advanced grades of Borrmann type. Interestingly, patients with lower post-chemotherapy NLR or decreasing NLR hold better overall response rate and disease control rate than those with higher NLR or increasing NLR. Furthermore, patients with high post-chemotherapy NLR alone or higher post-chemotherapy NLR plus higher post-chemotherapy PLT.

CONCLUSION

Our study suggested that high post-chemotherapy NLR and post-chemotherapy PLT might be adverse prognostic markers in advanced GC patients undergoing chemotherapy.

Hemogram-Derived Ratios in the Prognosis of Acute Diverticulitis

Background and Objectives: It is crucial to quickly identify those patients who need immediate treatment in order to avoid the various complications related to acute diverticulitis (AD). Although several studies evaluated the neutrophil-to-lymphocyte ratio (NLR) suggesting its predictive value in assessing the severity of AD, results have been inconclusive. Therefore, we aimed to assess the relationship between the neutrophil-to-lymphocyte ratio (NLR), the platelet-to-lymphocyte ratio (PLR), the monocyte-to-lymphocyte ratio (MLR), and systemic immune inflammation (SII) with the severity of AD, the ability to predict the presence or absence of complications, and the recurrence rate, based on the values of inflammatory markers. Materials and Methods: We retrospectively reviewed 147 patients diagnosed with AD between January 2012 to February 2023. Patients were divided into 2 groups, uncomplicated and complicated AD. The characteristics and full blood count between both groups were compared. Results: A total of 65 (44.22%) patients were classified as having complicated AD. The area under the ROC curve (AUROC) defining a Hinchey score ≥ 1b was as follows: SII, 0.812 (95% confidence interval (CI), 0.73 -0.888); NLR, 0.773 (95% CI, 0.676-0.857); PLR, 0.725 (95% CI, 0.63-0.813); MLR: 0.665 (95% CI, 0.542 -0.777). An SII cutoff value of > 1200 marked the highest yield for diagnosing complicated AD, with a sensitivity of 82% and a specificity of 76%. The cumulative recurrence rate was not significantly different in the groups of SII ≥ median vs. SII < median (p = 0.35), NLR ≥ median vs. NLR < median (p = 0.347), PLR ≥ median vs. PLR < median (p = 0.597), and MLR ≥ median vs. MLR < median (p = 0.651). Conclusions: Our study indicates that SII, NLR, and PLR are statistically significant and clinically useful classifying ratios to predict higher Hinchey scores. However, they cannot predict recurrences.

Prognostic prediction of the platelet-to-lymphocyte ratio in hepatocellular carcinoma: a systematic review and meta-analysis

Background

Platelet-to-lymphocyte ratio (PLR) has been used to predict the prognosis of patients with hepatocellular carcinoma (HCC) with inconsistent results. This meta-analysis aimed to clarify the prognostic value of PLR in patients with HCC.

Methods

We systematically retrieved relevant literature published in the PubMed, Embase, Web of Science, and Cochrane databases up to November 20, 2021. The primary outcomes were the hazard ratios (HRs) and their 95% confidence intervals (CIs) for overall survival (OS), and secondary study outcomes were recurrence-free survival (RFS), disease-free survival (DFS), progression-free survival (PFS). All statistical analyses were conducted by Review Manager 5.4.1 and STATA 16.0 software.

Results

A total of 21 studies comprising 8,779 patients were included in this meta-analysis. Pooled results suggested that a high PLR was significantly associated with poor OS (HR: 1.34, 95% CI: 1.18-1.52, P<0.00001; I²=59%, P=0.0005), RFS or DFS (HR: 1.35, 95% CI: 1.13-1.63, P=0.001; I²=69%, P=0.002), and PFS (HR: 1.55, 95% CI: 1.09-2.22, P=0.02; I²=73%, P=0.02). The subgroup analysis for OS showed, when the PLR cutoff value was greater than 150, the heterogeneity decreased to 0 (HR: 1.48, 95% CI: 1.33-1.68, P<0.00001; I²=0%, P=0.56); when the HBsAg positive population was increased to 100%, the heterogeneity decreased to 0 (HR: 1.46, 95% CI: 1.22-1.73, P<0.0001; I²=0%, P=0.45); compared with other regions in the world, it was more significant in China (HR: 1.43, 95% CI: 1.26-1.62, P<0.00001; I²=52%, P=0.01). In addition, scatter plot showed that the HR was negatively correlated with the proportion of patients with liver cirrhosis.

Conclusions

This meta-analysis suggests that PLR is a negative correlation prognostic biomarker for HCC, high PLR values indicate poor OS, RFS, DFS and PFS, especially in hepatitis B virus (HBV) related patients.

Prognostic Nutritional Index and Neutrophil/Lymphocyte Ratio Can Serve as Independent Predictors of the Prognosis of Hepatocellular Carcinoma Patients Receiving Targeted Therapy

Objective

The prognostic nutritional index (PNI) is an immunonutritional indicator, and the neutrophil/lymphocyte ratio (NLR) reflects the inflammatory status. This research intends to determine the implications of NLR and PNI in evaluating the outcome of hepatocellular carcinoma (HCC) patients undergoing targeted therapy (TT).

Methods

We retrospectively analyzed 83 patients' records with sorafenib treatment for advanced HCC in the Second Affiliated Hospital of Anhui Medical University. Patient records comprised general data and blood routines. The PNI and NLR values were calculated using the serum albumin levels (ALB), neutrophil (NEU) count, and lymphocyte (LY) count. The optimal thresholds of the PNI and NLR for predicting HCC patients' outcomes were calculated by X-tile. Patients were further assigned to low- and high-groups of PNI and NLR according to their thresholds. By using the Cox proportional hazards regression models, univariate and multivariate analyses were conducted to identify risk factors influencing the patient's prognosis.

Results

The participants were assigned to the corresponding low-PNI (≤42.9; n = 10) and high-PNI (>42.9; n = 73) groups, as well as low-NLR (≤2.4; n = 64) and high-NLR (>2.4; n = 19) groups based on the critical values of PNI (42.9) and NLR (2.4) obtained through the X-tile calculation. A higher overall survival (OS) rate was observed in the high-PNI group and low-NLR group, than in the low-PNI group and high-NLR group, respectively. The disease control rate showed no evident difference between the groups. The PNI and NLR were of high reliability in predicting the OS of patients. Cox multivariate analysis identified the independence of the PNI and NLR as prognostic factors for patients receiving TT for advanced HCC.

Conclusions

The pretreatment PNI and NLR levels have great prognostic implications for advanced HCC patients receiving TT. A higher PNI and a lower NLR suggest a higher postoperative survival rate.

Predictive Value of Preoperative Neutrophil-to-Lymphocyte Ratio in Patients with Hepatocellular Carcinoma after Transarterial Chemoembolization Combined with Radiofrequency Ablation

PURPOSE

To determine the predictive value of preoperative inflammatory markers in hepatocellular carcinoma (HCC) prognosis after transarterial chemoembolization (TACE) combined with radiofrequency ablation (RFA).

MATERIALS AND METHODS

A total of 161 patients with HCC who underwent TACE combined with RFA were enrolled in this retrospective study. Receiver operating characteristic (ROC) curve analysis was used to decide the cutoff value of the neutrophil-to-lymphocyte ratio (NLR), the lymphocyte-to-monocyte ratio (LMR), the platelet-to-lymphocyte ratio (PLR), and the prognostic nutritional index (PNI). The relationship between preoperative NLR, LMR, PLR, PNI, and survival outcomes was analyzed using Kaplan-Meier curves and multivariate Cox regression analyses.

RESULTS

The cutoff value of NLR for the best discrimination of HCC prognosis was 2.95. The median recurrence-free survival (RFS) of the low NLR (≤ 2.95) group was longer than that of the high NLR (>2.95) group (29 months vs. 20 months, P = 0.013). The median overall survival (OS) of the low NLR group was longer than that of the high NLR group (60 months vs. 38 months, P = 0.006). Multivariate analysis showed that the tumor size (≤ 3cm vs. >3cm), tumor number (single vs. multiple), and NLR (≤2.95 vs. >2.95) were independent predictors of the PFS and OS. LMR, PLR, and PNI did not have any prognostic significance.

CONCLUSION

NLR was confirmed as an independent predictive biomarker for hepatocellular carcinoma prognosis after TACE combined with RFA.

Neutrophil-Lymphocyte Ratio in Patients with Hypertriglyceridemic Pancreatitis Predicts Persistent Organ Failure

Background

The neutrophil–lymphocyte ratio (NLR) has been proposed as a surrogate marker of inflammation with prognostic value in various diseases. Our objective was to investigate the predictive value of the NLR as an indicator of persistent organ failure (POF) in patients with hypertriglyceridemic pancreatitis (HTGP).

Methods

We retrospectively reviewed the data from patients with HTGP between 2016 and 2019. The NLR was obtained at admission. The diagnostic performance of the NLR for POF was evaluated by the area under the receiver operator characteristics curve (AUROC). Multivariate logistic regression determined whether elevated NLR was independently associated with POF.

Results

Of the 446 patients enrolled, 89 (20.0%) developed POF. Patients with POF showed a significantly higher NLR than those without POF (P < 0.001). A positive trend for the association across increasing NLR quartiles and the incidence of POF was observed (P_trend < 0.001). The AUROC of NLR to predict POF was 0.673 (95% confidence interval, 0.627-0.716). With a cut-off of NLR > 6.56, the sensitivity and specificity were 73.0% and 55.7%, respectively. Multivariate analysis suggested that high NLR (>6.56) was independently associated with POF (odds ratio, 2.580; 95% confidence interval, 1.439-4.626; P = 0.001). Patients with a high NLR (>6.56) had a worse overall clinical course in HTGP.

Conclusion

Elevated NLR was significantly associated with an increased risk of developing POF and could be an early independent predictor of POF in patients with HTGP.

Prognostic Value of Circulating Tumour DNA in Asian Patients with Hepatocellular Carcinoma: A Systematic Review and Meta-Analysis

BACKGROUND

Circulating tumour DNA (ctDNA) is a noninvasive method of detecting tumours, and its prognostic significance in hepatocellular carcinoma (HCC) patients is controversial. We conducted a systematic review of published research data to evaluate the prognostic value of ctDNA in HCC patients.

METHODS

The PubMed, Embase, Web of Science, Cochrane Library, and Scopus databases were searched to identify eligible studies reporting disease-free survival (DFS) and overall survival (OS) stratified by ctDNA prior to January 2022. We evaluated the quality and design of these studies. The hazard ratio (HR) was used to combine the survivorship curve and univariate and multivariate results of the included studies.

RESULTS

In total, 8 articles were included, encompassing 577 HCC patients. The results of survival curve analysis showed that ctDNA was related to poor OS and DFS, and the effect sizes were HR = 2.44, 95% CI (1.42, 4.20), P=0.001; HR = 2.63, 95% CI (1.96, 3.53), P < 0.001. The univariate analysis results showed that ctDNA was related to poor OS (HR = 4.48, 95% CI (1.17, 13.70), P=0.003). The combined results of multivariate analysis showed that ctDNA was related to a shorter risk of OS (HR = 3.74, 95% CI (1.45, 9.65), P=0.006). The univariate and multivariate descriptive analysis results showed that ctDNA was related to shorter DFS, and the effect sizes were HR = 3.28, 95% CI (1.23, 11.30), P=0.011; HR = 3.01, 95% CI (1.11, 10.5), P < 0.001.

CONCLUSION

The evidence provided by this analysis suggests that ctDNA may be a prognostic biomarker and is negatively correlated with the survival of HCC patients. Mutations in the TERT and SOCS3 promoters in ctDNA are associated with poor prognosis and are expected to become good targets for liquid biopsy and to help select treatment strategies.

Platelet-Lymphocyte and Neutrophil-Lymphocyte Ratio for Prediction of Hospital Outcomes in Patients with Abdominal Trauma

Background

The platelet-to-lymphocyte ratio (PLR) and neutrophil-to-lymphocyte ratio (NLR) reflect the patient inflammatory and immunity status. We investigated the role of on-admission PLR and NLR in predicting massive transfusion protocol (MTP) activation and mortality following abdominal trauma.

Methods

A 4-year retrospective analysis of all adult abdominal trauma patients was conducted. Patients were classified into survivors and nonsurvivors and low vs. high PLR. The discriminatory power for PLR and NLR to predict MTP and mortality was determined. Multivariate logistic regression analysis was performed for predictors of mortality.

Results

A total of 1199 abdominal trauma patients were included (18.7% of all the trauma admissions). Low PLR was associated with more severe injuries and greater rates of hospital complications including mortality in comparison to high PLR. On-admission PLR and NLR were higher in the survivors than in nonsurvivors (149.3 vs. 76.3 (p = 0.001) and 19.1 vs. 13.7 (p = 0.009), respectively). Only PLR significantly correlated with injury severity score, revised trauma score, TRISS, serum lactate, shock index, and FASILA score. Optimal cutoffs of PLR and NLR for predicting mortality were 98.5 and 18.5, respectively. The sensitivity and specificity of PLR were 81.3% and 61.1%, respectively, and 61.3% and 51.3%, respectively, for NLR. The AUROC for predicting MTP was 0.69 (95% CI: 0.655–0.743) for PLR and 0.55 (95% CI: 0.510–0.598) for NLR. To predict hospital mortality, the area under the curve (AUROC) for PLR was 0.77 (95% CI: 0.712–0.825) and 0.59 (95% CI: 0.529–0.650) for the NLR. On multivariate logistic regression analysis, the age, Glasgow Coma Scale, sepsis, injury severity score, and PLR were independent predictors of mortality.

Conclusion

On-admission PLR but not NLR helps early risk stratification and timely management and predicts mortality in abdominal trauma patients. Further prospective studies are required.

Role of peripheral inflammatory biomarkers, transforming growth factor-beta and interleukin 6 in predicting peritoneal adhesions following repeat cesarean delivery

BACKGROUND

Repeat cesarean deliveries (CDs) pose a risk in the development of intra-abdominal adhesions.

AIM

We aimed to examine the incidence and severity of adhesions in repeat CDs using a specific scoring system and assess the predictive power of the pre-operative value of transforming growth factor (TGF)-β and interleukin (IL)-6 with selected peripheral inflammatory biomarkers (PIBs) in the prediction of adhesion formation.

METHODS

This prospective study enrolled 91 pregnant women at term, who had previously undergone at least one or more scheduled CDs. PIBs, namely C-reactive protein, white blood cell count, neutrophil-to-lymphocyte ratio, platelet-to-lymphocyte ratio, and systemic immune-inflammation index, TGF-β, and IL-6 were studied according to the presence and location of adhesions.

RESULTS

There was a significant difference only in the variables of the number of CDs, post-operative adhesion index (PAI) score, IL-6, and TGF-β on the presence of adhesion (p < 0.05). The linear regression model revealed that the effect of the number of CDs, PAI score, and IL-6 values on TGF-β was significant (p < 0.05). The effect of the PAI score on TGF-β was higher than that of IL-6. As a reciprocal relationship, the effect of the TGF-β value on the PAI score was also higher than that of IL-6.

CONCLUSION

In patients with a history of repeat CDs, the preoperative determination of TGF-β seems to be an important independent predictor of POA. The adverse events due to post-operative adhesion caused by repeat CDs can be overcome by detecting high-risk patients with a comprehensive assessment and individualized intervention integrated into overall patient management.

Systemic Immune-Inflammation Index (SII) Can Be an Early Indicator for Predicting the Severity of Acute Pancreatitis: A Retrospective Study

Objective

Systemic immune-inflammation index (SII) is a new systemic inflammatory prognostic indicator associated with outcomes in patients with different tumors. Studies have shown an association between SII and many chronic/acute inflammatory diseases. This study aimed at exploring whether SII can be used as an effective parameter for predicting the severity of acute pancreatitis (AP).

Methods

A total of 101 acute pancreatitis patients were enrolled in this study (mild acute pancreatitis (MAP): n = 73 and severe acute pancreatitis (SAP): n = 28). Patient demographics and SII were analyzed using the chi-square test, Student’s t-test, and Mann–Whitney U-test. A receiver operating characteristic curve was generated to test the potential of using neutrophil to lymphocyte ratio (NLR), platelet to lymphocyte ratio (PLR), and SII to predict AP’s severity. Logistic regression analysis was performed to determine major risk factors.

Results

Patients with SII value ≥2207.53 had a higher probability of having SAP (sensitivity = 92.9%, specificity = 87.7%, and AUC = 0.920), and SII was a significantly better predictive value than PLR and NLR. Logistic regression analysis results showed SII could differentiate MAP from SAP as a major risk factor.

Conclusion

This study has shown that SII is a potential indicator for predicting the severity of acute pancreatitis. The findings suggested that SII is more sensitive and specific than NLR and PLR in predicting the severity of acute pancreatitis.

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

Background

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

Aim

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

Methods

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

Results

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

Conclusion

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

Perioperative steroid administration reduces overall complications in patients undergoing liver resection: A meta-analysis

BACKGROUND

Hepatic resection (HR) results in an inflammatory response that can be modified by perioperative steroid administration. However, it remains to be determined if this response's attenuation translates to a reduction in complications.

AIM

To evaluate if perioperative administration of steroids reduces complications following HR.

METHODS

A systematic review of randomized controlled trials (RCTs) was conducted on PubMed, Embase, and Cochrane Central Register of Controlled Trials to evaluate the effect of perioperative steroid (compared to placebo or no intervention) use in patients undergoing HR. Clinical outcomes were extracted, and meta-analysis was performed.

RESULTS

8 RCTs including 590 patients were included. Perioperative steroid administration was associated with significant reduction in postoperative complications [odds ratios: 0.58; 95% confidence intervals (CI): 0.35-0.97, P = 0.04]. There was also improvement in biochemical and inflammatory markers, including serum bilirubin on postoperative day 1 [MD: -0.27; 95%CI: (-0.47, -0.06), P = 0.01], C-reactive protein on postoperative day 3 [MD: -4.89; 95%CI: (-5.83, -3.95), P < 0.001], and interleukin-6 on postoperative day 1 [MD: -54.84; 95%CI: (-63.91, -45.76), P < 0.001].

CONCLUSION

Perioperative steroids administration in HR may reduce overall complications, postoperative bilirubin, and inflammation. Further studies are needed to determine the optimal dose and duration and patient selection.

Neutrophil-Induced Liver Injury and Interactions Between Neutrophils and Liver Sinusoidal Endothelial Cells

Neutrophils are the most abundant type of leukocytes with diverse functions in immune defense including production of reactive oxygen species, bacteriocidal proteins, neutrophil extracellular traps, and pro-inflammatory mediators. However, aberrant accumulation of neutrophils in host tissues and excessive release of bacteriocidal compounds can lead to unexpected injury to host organs. Neutrophil-mediated liver injury has been reported in various types of liver diseases including liver ischemia/reperfusion injury, nonalcoholic fatty liver disease, endotoxin-induced liver injury, alcoholic liver disease, and drug-induced liver injury. Yet the mechanisms of neutrophil-induced hepatotoxicity in different liver diseases are complicated. Current knowledge of these mechanisms are summarized in this review. In addition, a substantial body of evidence has emerged showing that liver sinusoidal endothelial cells (LSECs) participate in several key steps of neutrophil-mediated liver injury including neutrophil recruitment, adhesion, transmigration, and activation. This review also highlights the current understanding of the interactions between LSECs and neutrophils in liver injury. The future challenge is to explore new targets for selectively interfering neutrophil-induced liver injury without impairing host defense function against microbial infection. Further understanding the role of LSECs in neutrophil-induced hepatotoxicity would aid in developing more selective therapeutic approaches for liver disease.

Prognostic Value of the Preoperative Lymphocyte-C-Reactive Protein Ratio in Hepatocellular Carcinoma Patients Treated with Curative Intent: A Large-Scale Multicentre Study

Purpose

This study aimed to evaluate the prognostic value of the lymphocyte-C-reactive protein ratio (LCR) score, a novel inflammation-based score based on lymphocytes and C-reactive protein, in hepatocellular carcinoma (HCC) patients treated with curative intent.

Patients and Methods

A total of 1158 HCC patients undergoing surgical resection or radiofrequency ablation with curative intent were recruited from 3 different centres and divided into a primary cohort (n=716) and a validation cohort (n=442). Univariate and multivariate analyses were performed to identify variables associated with overall survival (OS). The discriminatory accuracy of seven inflammation-based scores was compared by using the concordance index (C-index).

Results

The LCR score differentiated HCC patients into two groups with distinct prognoses (1-, 3-, and 5-year OS rates and median OS: 92.9%, 81.9%, 73.3% and 99.2 months and 79.8%, 56.6%, 49.7% and 69.1 months; P<0.001). Multivariate analysis showed that LCR score, AFP, ALBI score, tumour size, and TNM stage were independently associated with OS. When patients were stratified according to different disease states, the LCR score could still differentiate HCC patients into two groups with distinct prognoses (all P<0.005). The LCR score demonstrated a markedly superior C-index of 0.621 compared with the other inflammation-based scores (0.503–0.590). These findings were supported by the validation cohort.

Conclusion

The preoperative LCR score is a novel, stable, and clinically feasible prognostic marker for patients with HCC, independent of liver function, tumour characteristics, and treatment allocation and is superior to other inflammation-based scores in terms of its prognostic ability.

Prediction of Patient Survival Following Hepatic Resection in Early-Stage Hepatocellular Carcinoma with Indexed Ratios of Aspartate Aminotransferase to Platelets: A Retrospective Cohort Study

Purpose

To predict patient survival in early-stage hepatocellular carcinoma (HCC) following hepatic resection. We evaluated the prognostic potential of the aspartate aminotransferase to platelet ratio index (APRI) in order to use it to model a nomogram.

Patients and Methods

We randomized 901 early-stage HCC patients treated with hepatic resection at our center into training and validation cohorts that were followed from January 2009 to December 2012. X-tile software was used to establish the APRI cut-off threshold in the training cohort. The validation cohort was subsequently assessed to determine threshold value accuracy. Data generated from the multivariate analysis in the training cohort were used to design a prognostic nomogram. Decision curve analyses (DCA), concordance index values (C-index) and calibration curves were used to determine the performance of the nomogram.

Results

X-tile software revealed that the optimal APRI cut-off threshold in the training cohort that distinguished between patients with different prognoses was 0.9. We, therefore, validated its prognostic value. Multivariate analyses showed that poor overall survival was associated with APRI above 0.9, blood loss of more than 400 mL, liver cirrhosis, multiple tumors, tumor size greater than 5 cm, microvascular invasion and satellite lesions. When the independent risk factors were integrated into the prognostic nomogram, it performed well with accurate predictions. Indeed, the performance was better than comparative prognosticators (P<0.05 for all) with 0.752 as the C-index (95% CI: 0.706–0.798). These results were verified by the validation cohort.

Conclusion

APRI was a noninvasive and accurate predictive indicator for patients with early-stage HCC. Following hepatic resection to treat early-stage HCC, individualized patient survival predictions can be aided by the nomogram based on APRI.

Carbohydrate antigen 19-9 - tumor marker: Past, present, and future

Carbohydrate antigen 19-9 (CA 19-9) is a cell surface glycoprotein complex most commonly associated with pancreatic ductal adenocarcinoma (PDAC). Koprowski first described it in 1979 using a mouse monoclonal antibody in a colorectal carcinoma cell line. Historically, it is one of the most commonly used tumor markers for diagnosing, managing, and prognosticating PDAC. Additionally, elevated CA 19-9 levels are used as an indication for surgery in suspected benign pancreatic conditions. Another common application of CA 19-9 in the biliary tract includes its use as an adjunct in diagnosing cholangiocarcinoma. However, its clinical value is not limited to the hepatopancreatobiliary system. The reality is that the advancing literature has broadened the clinical value of CA 19-9. The potential value of CA 19-9 in patients' workup extends its reach to gastrointestinal cancers - such as colorectal and oesophageal cancer - and further beyond the gastrointestinal tract - including urological, gynecological, pulmonary, and thyroid pathologies. Apart from its role in investigations, CA 19-9 presents a potential therapeutic target in PDAC and acute pancreatitis. In a bid to consolidate its broad utility, we appraised and reviewed the biomarker's current utility and limitations in investigations and management, while discussing the potential applications for CA 19-9 in the works for the future.

The Significance of Platelet-Albumin-Bilirubin (PALBI) Grade in Hepatocellular Carcinoma Patients Stratified According to Platelet Count

Background

Platelet–albumin–bilirubin (PALBI) has been demonstrated to be superior to conventional Child–Pugh (C-P) grade in evaluating liver function and prognosis of HCC patients. However, both thrombocytosis and thrombocytopenia are unfavorable for HCC survival. The aim of this study was to preliminarily investigate the prognostic value of PALBI in HCC patients with thrombocytopenia and excluding thrombocytopenia.

Methods

In this retrospective cohort study, we reviewed 465 cases of HCC patients who underwent radical surgery. PALBI grade was calculated based on preoperative serological examinations. The primary outcomes were overall survival (OS) and recurrence-free survival (RFS), which were assessed by Kaplan–Meier method and Cox regression. The prognostic performances of PALBI and other models were estimated by using the concordance index (C-index).

Results

During a median follow-up time of 28 months, 31.6% (147/465) of patients died and 33.5% (156/465) experienced recurrence. Multivariate analyses revealed that both thrombocytosis and thrombocytopenia were independently associated with poor OS and RFS compared with normal platelet count (PLT) in HCC patients. Stratified analysis further revealed that PALBI was a significant predictor for HCC survival in patients excluding thrombocytopenia but not in patients with thrombocytopenia. In particular, in HCC patients excluding thrombocytopenia, the combination of tumor size with PALBI (C-index = 0.730, 95% CI: 0.674–0.786) may be superior to the classical Barcelona Clinic Liver Cancer (BCLC) and Cancer of Liver Italian Program (CLIP) staging systems in predicting survival.

Conclusion

In conclusion, PALBI grade, in particular the combination with tumor size, is an effective model for discriminating survival in HCC patients excluding thrombocytopenia but not in thrombocytopenic HCC patients.

Fibrinogen/Lymphocyte Count Ratio Can Be Used as a New Indicator of Prognosis in Patients with Hepatocellular Carcinoma After Radical Resection

Purpose

Preoperative fibrinogen levels are associated with the development, recurrence and metastasis of malignant tumors. This study was designed to investigate the clinical value of preoperative fibrinogen/lymphocyte count ratio (FLR) index in hepatocellular carcinoma (HCC).

Patients and Methods

The clinical data of 479 patients with HCC who underwent radical resection were retrospectively analyzed. The correlation between FLR and clinicopathological features was analyzed by chi-square test or non-parametric test. The overall survival (OS) and progression-free survival (PFS) were analyzed by Kaplan–Meier method.

Results

The optimal cut-off value of FLR was determined as 1.6 according to the receiver operating characteristic curve (ROC) analysis, in order to predict prognosis for HCC patients after radical resection. It was further found that FLR level was correlated with tumor size, TNM stage, microvascular invasion and prognosis. Multivariate Cox regression analyses found that FLR was an independent predictor for postoperative OS (overall survival) (p = 0.002) and PFS (progression-free survival) (p = 0.001) in patients with HCC; and the 1-, 3- and 5-year OS and PFS of HCC patients in the FLR ≤1.6 level group were significantly higher than those in the FLR >1.6 level group.

Conclusion

Preoperative FLR level is a novel and effective predictor of prognosis in patients with HCC, and elevated FLR level is associated with poor prognosis in patients with HCC.