Clinical Significance of the Neutrophil-to-Lymphocyte Ratio in Endocrine Therapy for Stage IV Breast Cancer

Predictive Significance of Systemic Immune-Inflammation Index in Patients with Breast Cancer: A Retrospective Cohort Study

Background

Peripheral blood inflammation indices, including the neutrophil-to-lymphocyte ratio (NLR), platelet-to-lymphocyte ratio (PLR), and systemic immune-inflammation index (SII), have become research hotspots in the diagnosis, treatment, and prognosis prediction of breast cancer, whereas existing research findings remain controversial.

Methods

Data pertaining to 1808 breast cancer patients were collected retrospectively to analyze the predictive value of NLR/PLR/SII for breast cancer clinicopathological characteristics, chemotherapy response, and relapse. 1489, 258, and 53 eligible breast cancer patients entered into the three analyses, respectively. Logistic regression analyses were used to assess the correlation between these indices and poor response to chemotherapy. A predictive scoring model was established to predict chemotherapeutic responses based upon the odds ratio values of significant variables identified in logistic regression analyses.

Results

Higher pretherapeutic NLR/PLR/SII values were significantly correlated with higher tumor stage, triple-negative breast cancer, premenopausal status, and younger age. Logistic regression analyses indicated that pretherapeutic high SII (as a continuous variable or with a cut-off value of 586.40) and HER2-negative status were independent predictors of poor response to neoadjuvant chemotherapy. A first-in-class SII-based predictive scoring model well distinguished patients who might not benefit from neoadjuvant chemotherapy, with an area under the curve of 0.751. In HR-positive cancers, SII was more strongly associated with clinicopathological features and chemotherapy response. In addition, a receiver operating characteristic curve analysis indicated that the specificity of follow-up SII in identifying cancer relapse was greater than 98.0% at a cut-off value of 900.

Conclusion

As a predictor of breast cancer, especially in the HR-positive subtype, SII may eclipse NLR/PLR. SII-high patients are more likely to have a worse chemotherapy response and a higher risk of recurrence.

Pretreatment Neutrophil-to-Lymphocyte Ratio as Prognostic Biomarkers in Patients with Unresectable Hepatocellular Carcinoma Treated with Hepatic Arterial Infusion Chemotherapy Combined with Lenvatinib and Camrelizumab

Purpose

This study aimed to assess the prognostic significance of the neutrophil-lymphocyte ratio (NLR) in patients with unresectable hepatocellular carcinoma (u-HCC) treated with hepatic artery infusion chemotherapy (HAIC) combined with lenvatinib and camrelizumab.

Patients and Methods

We conducted a retrospective cohort study involving patients diagnosed with u-HCC who underwent HAIC combined with lenvatinib and camrelizumab. Patients were stratified into two cohorts using the median NLR as the cutoff point. We then assessed treatment response, overall survival (OS), progression-free survival (PFS), and adverse events in these patient groups.

Results

Between October 2020 and April 2022, a total of 88 patients were enrolled in the study. The overall cohort exhibited a median PFS of 7.9 months, while the median OS was not reached, and a median NLR of 3.46. Notably, the group with NLR<3.46 demonstrated significantly superior OS (not reached vs 9.6 months, p = 0.017) and PFS (18.3 vs 5.3 months, p = 0.0015) compared to the NLR≥3.46 group. Furthermore, multivariate analysis revealed that an alpha-fetoprotein (AFP) ≥ 400 ng/mL [hazard ratio (HR), 2.133; 95% confidence interval (CI), 1.102-4.126; p = 0.024], Barcelona Clinical Hepatocellular Carcinoma (BCLC) stage C (HR, 2.319; 95% CI, 1.128-4.764; p = 0.022), and NLR ≥3.46 (HR, 2.35; 95% CI, 1.239-4.494; p = 0.009) were identified as independent risk factors for OS. Additionally, multivariate analysis demonstrated that AFP ≥ 400 ng/mL, BCLC stage C, and NLR ≥ 3.46 were independent negative factors of PFS.

Conclusion

NLR can be associated with outcomes in patients with u-HCC treated with HAIC combined with lenvatinib and camrelizumab.

Circulating inflammatory cells in patients with metastatic breast cancer: Implications for treatment

Adaptive and innate immune cells play a crucial role as regulators of cancer development.

Inflammatory cells in blood flow seem to be involved in pro-tumor activities and contribute to breast cancer progression. Circulating lymphocyte ratios such as the platelet-lymphocytes ratio (PLR), the monocyte-lymphocyte ratio (MLR) and the neutrophil-lymphocyte ratio (NLR) are new reproducible, routinely feasible and cheap biomarkers of immune response. These indexes have been correlated to prognosis in many solid tumors and there is growing evidence on their clinical applicability as independent prognostic markers also for breast cancer.

In this review we give an overview of the possible value of lymphocytic indexes in advanced breast cancer prognosis and prediction of outcome. Furthermore, targeting the immune system appear to be a promising therapeutic strategy for breast cancer, especially macrophage-targeted therapies. Herein we present an overview of the ongoing clinical trials testing systemic inflammatory cells as therapeutic targets in breast cancer.

Baseline lymphopenia as prognostic factor in patients with metastatic breast cancer treated with palbociclib

Cyclin-dependent-kinase 4-6 inhibitors (CDK4/6i) have improved the management of hormone receptor (HR)⁺/human epidermal growth factor receptor (HER)2^- metastatic breast cancer (mBC). Currently, there are no valid prognostic factors for response to CDK4/6i. Baseline lymphopenia is reported as a prognostic factor in several types of cancer. The present retrospective study aimed to evaluate the effect of baseline absolute lymphocyte count (ALC) on response to palbociclib. Progression-free survival (PFS) was the primary endpoint. Secondary endpoints were overall survival (OS), best response and safety. A total of 114 patients treated for mBC between 2016 and 2019 were included. Median baseline ALC was 1.4 g/l (range, 0.2-4.3 g/l). A total of 65 (57%) and 49 (43%) patients had baseline ALC values of <1.5 and ≥1.5 g/l, respectively. Patients with baseline lymphopenia exhibited significantly shorter PFS (6 vs. 10 months; P=0.004) and OS (20 vs. 33 months; P=0.02). ALC <1.5 g/l independently predicted worse survival, as indicated by multivariate analysis (P=0.04; hazard ratio, 1.76; 95% confidence interval, 1.02-3.02). Patients with baseline ALC <1.5 g/l had significantly less partial response (14 vs. 22%; P=0.016) and more disease progression (46 vs. 20%; P=0.016) than those with ALC ≥1.5 g/l. ALC is a strong and easy-to-use dosage with prognostic factor for patients with HR⁺/HER2^- mBC treated with palbociclib and endocrine therapy. Lymphopenia may also be a predictive factor of early progression. These data need to be verified in a larger prospective study.

The Efficacy of Different Inflammatory Markers for the Prognosis of Patients with Malignant Tumors

Background

Inflammation is considered essential in cancer progression, as it affects the nutritional status and prognosis of patients. In this study, we aim to analyze the efficacy of various inflammatory markers in predicting prognosis in cancer patients.

Methods

Patients with malignant tumor were included as primary and validation cohort. Basic clinical information, anthropometric indicators, body composition analysis, and serological indicators were recorded. After proposing the optimal thresholds by time-dependent receiver operating characteristic (ROC), univariate and multivariate Cox regression analyses were performed to analyze the association between inflammatory markers and overall survival (OS). A nomogram was established to develop a scored-inflammatory marker system. Eight inflammatory models based on combinations of inflammatory markers were assessed. Cox regression analysis was used to analyze the relationship of each inflammatory model and mortality of participants. Then, subanalysis of specific tumor types was conducted by Cox regression. Logistic regression models were used to analyze the relationship between different inflammatory models and malnutrition.

Results

Univariate and multivariate Cox regression analyses indicated that pack-years of cigarette smoking, C-reactive protein (CRP), and systemic immune-inflammation index (SII) were related to the OS of cancer patients. A nomogram was constructed to develop a scored-inflammatory marker system. Among the eight inflammatory models, patients in model A had worst prognosis compared with patients in other models. Subanalysis next showed lung cancer, breast cancer and digestive system neoplasms patients in model A suffered the worst prognosis. Logistic regression indicated that model A was also with predictive value for malnutrition.

Conclusion

A scored-inflammatory marker system was established to predict the OS of cancer patients. The inflammatory models established in this study can be used to predict prognosis, as well as cancer-related malnutrition. Inflammatory model A suffered the worst OS and was with the predictive efficacy for malnutrition.

Effects of Primary Tumor Resection on Metastatic Breast Cancer Survival and the Predictive Power of Neutrophil: Lymphocyte Ratio on Prognosis

Objective

The aim was to investigate the effect of primary tumor resection (PTR) on survival in metastatic breast cancer patients and to assess the power of the neutrophil-to-lymphocyte ratio (NLR) regarding the prediction of prognosis in this patient group.

Materials and Methods

Female patients diagnosed with and starting treatment for metastatic breast cancer from 2003 to 2016 in the general surgery and oncology clinics at a single center were retrospectively reviewed. Pre-treatment NLR value and survival situations were evaluated.

Results

A total of 117 patients were enrolled. The disease-specific survival (DSS) of the patients was 41.4 months. When stratified into PTR and systemic treatment (ST) groups, there was no difference in the survival (p = 0.054); 43.5 months in the PTR group vs 30.7 months in the ST group. When hormone receptor (HR)-positive/human epidermal growth factor receptor 2 (HER2)-negative subgroups were analyzed, DSS was significantly longer (p = 0.02) in the PTR group (55.4 months) compared to the ST group (41.8 months). Finally, in patients with an NLR of <2.3, DSS was significantly longer (p = 0.03) in the PTR group (56.1 months) compared to the ST group (25.2 months).

Conclusion

These results suggest that DSS can be increased with PTR in selected patients with a diagnosis of metastatic breast cancer. NLR may be useful in selecting patients for appropraite treatment modality.

The decreased platelet-to-lymphocyte ratio could predict a good prognosis in patients with oligometastatic colorectal cancer: a single-center cohort retrospective study

BACKGROUND

Inflammation markers have an important effect on tumor proliferation, invasion, and metastasis. Oligometastatic disease (OMD) is an intermediate state between widespread metastases and locally confined disease, where curative strategies may be effective for some patients. We aimed to explore the predictive value of inflammatory markers in patients with oligometastatic colorectal cancer (OMCC) and build a nomogram to predict the prognosis of these patients.

METHODS

Two hundred nine patients with OMCC were retrospectively collected in this study. The Kaplan-Meier survival curves and Cox regression analysis were used to estimate overall survival (OS) and progression-free survival (PFS). A multivariate Cox analysis model was utilized to establish the nomogram. The concordance index (C-index), calibration curve, and receiver operating characteristics (ROC) were established to verify the validity and accuracy of the prediction model.

RESULTS

According to the multivariate analysis, decreased platelet-to-lymphocyte ratio (PLR) might independently improve OS in patients with OMCC (HR = 2.396, 95% CI 1.391-4.126, P = 0.002). Metastases of extra-regional lymph nodes indicated poor OS (HR = 2.472, 95% CI 1.247-4.903, P = 0.010). While the patients with early N stage had better OS (HR = 4.602, 95% CI 2.055-10.305, P = 0.001) and PFS (HR = 2.100, 95% CI 1.364-3.231, P = 0.007). Primary tumor resection (HR = 0.367, 95% CI 0.148-0.908, P = 0.030) and lower fibrinogen (HR = 2.254, 95% CI 1.246-4.078, P = 0.007) could significantly prolong the OS in patients with OMCC. PLR, metastases of extra-regional lymph nodes, N stage, primary tumor resection, and fibrinogen were used to make up the nomogram. The C-index and area under the curve (AUC) of the ROC in nomogram were 0.721 and 0.772 respectively for OS, showed good consistency between predictive probability of OS and actual survival.

CONCLUSIONS

Decreased PLR could predict a good prognosis in patients with OMCC. The nomogram including inflammatory factors and clinicopathological markers was credible and accurate to predict survivals in patients with OMCC.

Nicotine promotes breast cancer metastasis by stimulating N2 neutrophils and generating pre-metastatic niche in lung

Smoking has a profound impact on tumor immunity, and nicotine, which is the major addictive component of smoke, is known to promote tumor progression despite being a non-carcinogen. In this study, we demonstrate that chronic exposure of nicotine plays a critical role in the formation of pre-metastatic niche within the lungs by recruiting pro-tumor N2-neutrophils. This pre-metastatic niche promotes the release of STAT3-activated lipocalin 2 (LCN2), a secretory glycoprotein from the N2-neutrophils, and induces mesenchymal-epithelial transition of tumor cells thereby facilitating colonization and metastatic outgrowth. Elevated levels of serum and urine LCN2 is elevated in early-stage breast cancer patients and cancer-free females with smoking history, suggesting that LCN2 serve as a promising prognostic biomarker for predicting increased risk of metastatic disease in female smoker(s). Moreover, natural compound, salidroside effectively abrogates nicotine-induced neutrophil polarization and consequently reduced lung metastasis of hormone receptor-negative breast cancer cells. Our findings suggest a pro-metastatic role of nicotine-induced N2-neutrophils for cancer cell colonization in the lungs and illuminate the therapeutic use of salidroside to enhance the anti-tumor activity of neutrophils in breast cancer patients.

Smoking is known to impact tumor immunity and promote tumor progression. Here, the authors show that chronic nicotine exposure promotes the lung pre-metastatic niche formation by recruiting pro-tumor N2-neutrophils that release lipocalin-2.

Neutrophil-to-lymphocyte ratio predicts early mortality in females with metastatic triple-negative breast cancer

BACKGROUND

The aim of this study was to determine the utility of the neutrophil-to-lymphocyte ratio (NLR) as a biomarker for predicting early-mortality (<2 years) among females with metastatic triple-negative breast cancer (mTNBC).

METHODS

We reviewed 118 medical records of females with mTNBC. The cut-off value for the NLR (<2.5 and ≥2.5) was determined with receiver operating characteristic curves (area under the curve: 0.73; 95% CI: 0.62-0.85). Survival curves were estimated using the Kaplan-Meier method and compared with the Log-rank test. Multivariate Cox regression was used to identify the risk of mortality at two years. Moreover, we performed sensitivity analyses with different cut-off values and a subgroup analysis in females that only received chemotherapy.

RESULTS

The median follow-up was 24 months. Females with NLR ≥2.5 had a poor overall survival compared to females with NLR <2.5 (6% vs. 28%, p<0.001) at two years. This outcome remained when we stratified for females that only received chemotherapy (8% vs. 36%, p = 0.001). Multivariate analyses identified NLR ≥2.5 as a poor prognostic risk factor for mortality in the entire population (HR: 2.12, 95% CI: 1.32-3.39) and among females that received chemotherapy (HR: 2.68, 95% CI: 1.46-4.92).

CONCLUSION

The NLR is an accessible and reliable biomarker that predicts early mortality among females with mTNBC. Our results suggest that females with high NLR values have poor prognosis despite receiving standard chemotherapy. Health providers should evaluate the possibility to enroll these patients in novel immunotherapy trials.

A Rosetta Stone for Breast Cancer: Prognostic Value and Dynamic Regulation of Neutrophil in Tumor Microenvironment

Increasing evidence has revealed that the initiation and progression of breast cancer are greatly affected by the immune environment. Neutrophils are the most abundant leucocytes in circulation and act as the spearhead in inflammation, including in breast cancer. Circulating neutrophils are closely related to the prognosis of breast cancer patients, and tumor-infiltrating neutrophils have varied functions at different stages of breast cancer, such as antitumor or tumor-promoting neutrophils, which are termed N1 and N2 neutrophils, respectively. In this review, we will discuss the utility of circulating neutrophils for predicting prognosis and therapeutic efficacy and the underlying mechanisms of their chemotaxis, the dynamic regulation of their antitumor or protumor functions and their different spatial distributions in tumor microenvironment. Finally, we also discuss the possibility of targeting neutrophils as a therapeutic strategy in breast cancer.

Neutrophil to Lymphocyte Ratio as Prognostic and Predictive Factor in Breast Cancer Patients: A Systematic Review

Inflammatory blood markers (IBM), such as the neutrophil to lymphocyte ratio (NLR), have emerged as potential prognostic factors in various cancers, including breast cancer (BC), potentially allowing an easy, minimally invasive evaluation of a given cancer's prognosis and treatment outcome. We report here a systematic overview of the published data evaluating NLR as a prognostic factor or predictive factor for pathological complete response (PCR) and toxicity in early and advanced BC. A total of 45 articles were identified. NLR was found to be an independent prognostic factor for survival in most of the adjuvant treatment studies. However, no significant correlation was found between survival and NLR for early BC patients receiving neo-adjuvant chemotherapy (NACT) and advanced BC patients. Most studies failed to find a significant correlation between NLR and PCR after NACT. Finally, some data showed that IBM could be predictive of chemotherapy-related toxicity.

Neutrophil-lymphocyte ratio in metastatic breast cancer is not an independent predictor of survival, but depends on other variables

The prognostic impact of neutrophil-lymphocyte ratio (NLR) in metastatic breast cancer (MBC) has been previously evaluated in early and metastatic mixed breast cancer cohorts or without considering other relevant prognostic factors. Our aim was to determine whether NLR prognostic and predictive value in MBC was dependent on other clinical variables. We studied a consecutive retrospective cohort of patients with MBC from a single centre, with any type of first line systemic treatment. The association of NLR at diagnosis of metastasis with progression free survival (PFS) and overall survival (OS) was evaluated using Cox univariate and multivariate proportional hazard models. In the full cohort, that included 263 MBC patients, a higher than the median (>2.32) NLR was significantly associated with OS in the univariate analysis (HR 1.36, 95% CI 1.00–1.83), but the association was non-significant (HR 1.12, 95% CI 0.80–1.56) when other clinical covariates (performance status, stage at diagnosis, CNS involvement, visceral disease and visceral crisis) were included in the multivariate analysis. No significant association was observed for PFS. In conclusion, MBC patients with higher baseline NLR had worse overall survival, but the prognostic impact of NLR is likely derived from its association with other relevant clinical prognostic factors.

Prognostic value of neutrophil-to-lymphocyte ratio and platelet-to-lymphocyte ratio for breast cancer patients: An updated meta-analysis of 17079 individuals

Aims

This study aimed to evaluate the prognostic effect of neutrophil‐to‐lymphocyte ratio (NLR) and platelet‐to‐lymphocyte ratio (PLR) for patients with breast cancer (BC).

Methods

A literature search was performed by searching medical databases. Basic characteristics and prognostic data were extracted from included studies. Primary outcomes, such as overall survival (OS) and disease‐free survival (DFS), were synthesized and compared. Subgroup analyses were performed according to pathology, geographical region, cut‐off value, and tumor progression.

Results

A total of 39 studies comprising 17079 BC patients were included in this meta‐analysis. Among them, 28 studies with 142 64 BC patients investigated predicting role of NLR for OS, showing elevated NLR were associated poor prognosis (hazard ratio [HR]: 1.78, 95% confidence interval [CI]: 1.49‐2.13, P < 0.001). Twenty‐seven studies containing 115 04 patients explored the role of NLR in predicting DFS, showing elevated NLR was associated with poor DFS with HR of 1.60 (95% CI: 1.42‐1.96, P < 0.001). Twelve studies explored the role of PLR in predicting OS, showing patients with higher PLR were associated with a significantly worse prognosis with a pooled HR of 1.32 (95% CI: 1.11‐1.57, P = 0.002). Eleven studies with 5013 patients shown patients with elevated PLR were associated shorter DFS (HR: 1.43, 95% CI: 1.09‐1.86, P = 0.009). Subgroup analyses shown a greater magnitude of association between NLR and OS in triple‐negative BC patients than in HER2‐positive ones.

Conclusions

Our study suggested that elevated NLR and PLR were associated with poor OS as well as high risk of recurrence for BC patients. Subgroup analyses confirmed the prognostic effect of NLR and PLR in HER2‐positive BC patients. As easily accessible parameters, NLR and PLR should be identified as useful biomarkers in the management of BC.

Total lymphocyte count, neutrophil-lymphocyte ratio, and platelet-lymphocyte ratio as prognostic factors in advanced non-small cell lung cancer with chemoradiotherapy

Objective

The objective of this study was to investigate the prognostic significance and the efficacy evaluation of total lymphocyte count (TLC), neutrophil-to-lymphocyte ratio (NLR), and platelet-to-lymphocyte ratio (PLR) in advanced non-small cell lung cancer (NSCLC) patients treated with chemoradiotherapy.

Patients and methods

A total of 389 advanced NSCLC patients who received chemoradiotherapy from 2011 to 2016 were enrolled in this retrospective study. TLC, NLR, and PLR were analyzed with overall survival (OS). Survival data were identified with the Kaplan-Meier method and optimal cutoff values with receiver operating characteristic curves.

Results

The median OS for all patients was 18.37 months. Pretreatment and median baseline TLC was 2.47×10³/μL (±0.78); NLR, 3.15 (±3.96); and PLR, 143.82 (±91.77); corresponding cutoffs were 2.4, 3.4, and 136.1. Higher TLC was associated with superior median OS (21.78 vs 15.66 months, P<0.001), and higher NLR and PLR with worse median OS (NLR: 14.13 vs 23.8 months, P<0.001; PLR: 15.49 vs 22.04 months, P<0.001).

Conclusion

The lymphopenia indicators (TLC, NLR, and PLR) were significant prognostic indicators of survival in advanced NSCLC patients treated with chemoradiotherapy.

[Impact of the Pretreatment or Posttreatment NLR and PLR on the Response of First Line Chemotherapy and the Outcomes in Patients with Advanced Non-small Cell Lung Cancer]

背景与目的

中性粒细胞淋巴细胞比值(neutrophil-to-lymphocyte ratio, NLR)和血小板淋巴细胞比值(platelet-to-lymphocyte ratio, PLR)是机体系统性炎症的体现, 与多种肿瘤的预后有关。本研究旨在探讨NLR、PLR及其动态变化对非小细胞肺癌(non-small cell lung cancer, NSCLC)一线化疗疗效和预后的影响。

方法

回顾性分析68例2008年4月-2015年4月于北京大学第三医院接受一线化疗、符合入组标准的进展期NSCLC住院患者, 采集一线化疗前和2周期化疗后的NLR和PLR, 应用Kaplan-Meier方法进行生存分析, 单因素和Cox多因素分析NLR、PLR及其动态变化和各种临床特征与一线化疗疗效和总生存期(overall survival, OS)之间的关系。

结果

NLR在2周期化疗后显著下降, NLR2(2周期化疗后NLR)和NLR0(治疗前NLR)分别为(2.69±2.06)和(3.94±2.12)(P=0.000), PLR化疗前后无显著变化(P > 0.05);NLR2与一线化疗2周期和4周期的疗效显著相关(P < 0.05), 疾病进展患者中高NLR2的比例为100.0%, 显著高于部分缓解和疾病稳定组(P < 0.05);NLR0、NLR2和PLR0与OS显著相关(P < 0.05), 但与患者年龄、体力状况、病理类型、肿瘤分期、治疗状态、治疗方案均无关(P > 0.05);单因素分析显示OS与NLR0、NLR2、PLR0、二线治疗状态、二线方案选择、一线化疗2周期疗效、4周期疗效显著相关(P < 0.05), 与肿瘤分期、三线治疗状态及放疗状态无关(P > 0.05);多因素分析表明NLR0(P=0.004)、一线化疗4周期后疗效(P=0.022)、二线治疗状态(P=0.007)是OS的独立预测因素。

结论

治疗前NLR与NSCLC的预后显著相关, 化疗后NLR与一线治疗疗效显著相关。因此, NLR是预测进展期NSCLC一线化疗疗效和预后的理想指标, 也是治疗NSCLC潜在的干预靶点。