Neutrophil-to-Lymphocyte Ratio Predicts Survival After Whole-brain Radiotherapy in Non-small Cell Lung Cancer

Radiation-Induced Lymphopenia and Its Impact on Survival in Patients with Brain Metastasis

BACKGROUND

Differences in radiation-induced lymphopenia and prognosis between methods of radiotherapy (RT) for brain metastases remain unclear.

METHODS

In this retrospective analysis of patients who underwent whole-brain radiotherapy (WBRT) or stereotactic radiosurgery/radiotherapy (SRS/SRT) for brain metastases, baseline total lymphocyte count (TLC) data were obtained within 2 weeks before RT initiation. Follow-up TLC data were evaluated at 0-2, 2-4, and 4-8 weeks after RT completion. Persistent lymphopenia was defined as <800/μL at any time point.

RESULTS

Overall, 138 RT courses in 128 patients were eligible (94 WBRT; 44 SRS/SRT). In the WBRT courses, the median baseline TLC was 1325/μL (IQR: 923-1799). Follow-up TLC decreased significantly to 946/μL (626-1316), 992/μL (675-1291), and 1075/μL (762-1435) (p < 0.001). SRS/SRT courses showed no significant TLC decrease. Multivariate analysis revealed female sex, prior RT, baseline TLC < 800/μL, and WBRT use were significantly associated with persistent lymphopenia. In the WBRT group, overall survival was significantly different between those with and without persistent lymphopenia (median, 2.6 and 6.1 months; p < 0.001). However, there was no significant difference in survival in the SRS/SRT group (p = 0.60).

CONCLUSION

This study suggests SRS/SRT might be preferable for lymphocyte preservation in brain metastasis patients.

The indication of palliative whole-brain radiotherapy for patients with brain metastases: a simple prognostic scoring system in the era of stereotactic radiosurgery

BACKGROUND

Stereotactic irradiation has become the mainstay treatment for brain metastases (BM), and whole-brain radiotherapy (WBRT) is often used for symptom palliation. However, the survival time of patients with BM undergoing palliative WBRT (pWBRT) is limited, making it difficult to select patients who should receive treatment.

METHODS

We collected patient data from 2016 to 2022 at the Shizuoka Cancer Center and retrospectively analyzed the factors related to survival time. Overall survival (OS) was defined as the survival time after WBRT.

RESULTS

A total of 301 patients (median age, 66 years) who underwent pWBRT were included. The primary cancers were lung, breast, gastrointestinal tract, and other cancers in 203 (67%), 38 (13%), 33 (11%), and 27 (9%) patients, respectively. Median OS of all patients was 4.1 months. In the multivariate analysis, male sex (hazard ratio [HR]:1.4), Karnofsky Performance Status (KPS) ≤ 60 (HR:1.7), presence of extracranial metastasis (ECM) (HR:1.6), neutrophil-lymphocyte ratio (NLR) ≥ 5 (HR:1.6), and lactate dehydrogenase (LDH) ≥ upper limit of normal (ULN) (HR:1.3) were significantly associated with shorter OS (all P < 0.05). To predict the OS, we created a prognostic scoring system (PSS). We gave one point to each independent prognostic factor. Median OS for patients with scores of 0-2, 3, and 4-5 were 9.0, 3.5 and 1.7 months, respectively (P < 0.001).

CONCLUSIONS

Male sex, KPS ≤ 60, presence of ECM, NLR ≥ 5, and LDH ≥ ULN were poor prognostic factors for patients with BM undergoing pWBRT. By PSS combining these factors, it may be possible to select patients who should undergo pWBRT.

Evaluation of Potential Predictive Biomarkers for Defining Brain Radiotherapy Efficacy in Non-Small Cell Lung Cancer Patients with Brain Metastases: A Case Report and a Narrative Review

Non-small cell lung cancer (NSCLC) is the second most common cancer worldwide, resulting in 1.8 million deaths per year. Most patients are diagnosed with a metastatic disease. Brain metastases are one of the most common metastatic sites and are associated with severe neurological symptoms, shorter survival, and the worst clinical outcomes. Brain radiotherapy and systemic oncological therapies are currently used for controlling both cancer progression and neurological symptoms. Brain radiotherapy includes stereotactic brain ablative radiotherapy (SBRT) or whole brain radiotherapy (WBRT). SBRT is applied for single or multiple (up to ten) small (diameter less than 4 cm) lesions, whereas WBRT is usually applied for multiple (more than ten) and large (diameter greater than 4 cm) brain metastases. In both cases, radiotherapy application may be viewed as an overtreatment which causes severe toxicities without achieving a significant clinical benefit. Thus far, a number of scoring systems to define the potential clinical benefits derived from brain radiotherapy have been proposed. However, most are not well established in clinical practice. In this article, we present a clinical case of a patient with advanced NSCLC carrying a BRAFV600E mutation and brain metastases. We review the variables in addition to applicable scoring systems considered to have potential for predicting clinical outcomes and benefits of brain radiotherapy in patients with advanced NSCLC and brain metastases. Lastly, we highlight the unmet need of specific scoring systems for advanced NSCLC patients with brain metastases carrying oncogene alterations including BRAFV600E mutations.

[Efficacy and Safety of Radiotherapy Combined with Immunotherapy for Brain Metastases from Lung Cancer: A Meta-analysis]

BACKGROUND

Immunotherapy (IT) is recommended for the treatment of advanced non-small cell lung cancer (NSCLC), while brain radiotherapy (RT) is the mainstream treatment for patients with brain metastases (BM). This study aimed to investigate the efficacy and safety of combined use of RT and IT.

METHODS

The date was limited to May 1, 2022, and literature searches were carried out in CNKI, Wanfang, PubMed, EMBASE and Cochrane databases. Heterogeneity was judged using the I2 test and P value. Publication bias was assessed using a funnel plot. The quality of included studies was assessed using the Newcastle-Ottawa Scale (NOS). Statistical analysis was performed using Stata 16.0 software.

RESULTS

A total of 17 articles involving 2,636 patients were included. In the comparison of RT+IT group and RT group, no significant difference was found in overall survival (OS) (HR=0.85, 95%CI: 0.52-1.38, I2=73.9%, Pheterogeneity=0.001) and intracranial distance control (DBC) (HR=1.04, 95%CI: 0.55-1.05, I2=80.5%, Pheterogeneity<0.001), but the intracranial control (LC) in the RT+IT group was better than the RT group (HR=0.46, 95%CI: 0.22-0.94, I2=22.2%, Pheterogeneity=0.276), and the risk of radiation necrosis/treatment-related imaging changes (RN/TRIC) was higher than RT (HR=1.72, 95%CI: 1.12-2.65, I2=40.2%, Pheterogeneity=0.153). In the comparison between the RT+IT concurrent group and the sequential group, no significant difference was found in OS (HR=0.62, 95%CI: 0.27-1.43, I2=74.7%, Pheterogeneity=0.003) and RN/TRIC (HR=1.72, 95%CI: 0.85-3.47, I2=0%, Pheterogeneity=0.388) was different between the two groups. However, DBC in the concurrent treatment group was better than that in the sequential treatment group (HR=0.77, 95%CI: 0.62-0.96, I2=80.5%, Pheterogeneity<0.001).

CONCLUSIONS

RT combined with IT does not improve the OS of NSCLC patients with BM, but also increases the risk of RN/TRIC. In addition, compared with sequential RT and IT, concurrent RT and IT improved the efficacy of DBC.

Immunotherapy in NSCLC Patients With Brain and Leptomeningeal Metastases

Immunotherapy has now been integrated as a treatment strategy for most patients with non-small cell lung cancer (NSCLC). However, the pivotal clinical trials that demonstrated its impressive efficacy often did not include patients with active, untreated brain metastases or leptomeningeal carcinomatosis. Nevertheless, NSCLC is the most common tumor to metastasize to the brain, and patients develop brain and meningeal involvement in approximately 40 and 10% of cases, respectively. Consequently, the appropriate care of these patients is a recurrent clinical concern. Although there are many aspects that would merit further investigation to explain the mechanism of intracranial response to immune checkpoint inhibitors (ICPs), some data suggest that they are able to cross the blood–brain barrier, resulting in local tumor microenvironment modification. This results in a similar clinical benefit in patients with stable, previously treated brain metastases compared to the general population. Despite important limitations, some real-life studies have described that the ICPs’ efficacy was maintained also in less selected patients with untreated or symptomatic brain metastases. In contrast, few data are available about patients with leptomeningeal carcinomatosis. Nevertheless, neurological complications due to ICP treatment in patients with brain metastases have to be evaluated and carefully monitored. Despite the fact that limited data are available in the literature, the purpose of this review is to show that the multimodal treatment of these patients with brain metastases and/or leptomeningeal disease should be discussed during tracing of the history of the disease, participating in the local and possibly systemic control of NSCLC.

Exosomal miR-4466 from nicotine-activated neutrophils promotes tumor cell stemness and metabolism in lung cancer metastasis

Smoking is associated with lung cancer and has a profound impact on tumor immunity. Nicotine, the addictive and non-carcinogenic smoke component, influences various brain cells and the immune system. However, how long-term use of nicotine affects brain metastases is poorly understood. We, therefore, examined the mechanism by which nicotine promotes lung cancer brain metastasis. In this study, we conducted a retrospective analysis of 810 lung cancer patients with smoking history and assessed brain metastasis. We found that current smoker's lung cancer patients have significantly higher brain metastatic incidence compared to the never smokers. We also found that chronic nicotine exposure recruited STAT3-activated N2-neutrophils within the brain pre-metastatic niche and secreted exosomal miR-4466 which promoted stemness and metabolic switching via SKI/SOX2/CPT1A axis in the tumor cells in the brain thereby enabling metastasis. Importantly, exosomal miR-4466 levels were found to be elevated in serum/urine of cancer-free subjects with a smoking history and promote tumor growth in vivo, suggesting that exosomal miR-4466 may serve as a promising prognostic biomarker for predicting increased risk of metastatic disease among smoker(s). Our findings suggest a novel pro-metastatic role of nicotine-induced N2-neutrophils in the progression of brain metastasis. We also demonstrated that inhibiting nicotine-induced STAT3-mediated neutrophil polarization effectively abrogated brain metastasis in vivo. Our results revealed a novel mechanistic insight on how chronic nicotine exposure contributes to worse clinical outcome of metastatic lung cancer and implicated the risk of using nicotine gateway for smoking cessation in cancer patients.

Nicaraven prevents the fast growth of inflamed tumors by an anti-inflammatory mechanism

Inflammatory microenvironment is known to accelerate the progression of malignant tumors. We investigated the possible anti-inflammatory effect of nicaraven on slowing tumor growth. Tumor-bearing mice randomly received nicaraven injection (50 mg/kg daily, i.p, n = 8) or placebo treatment (n = 8) for 10 days, and then sacrificed for evaluations. Nicaraven administration effectively inhibited the fast growth of tumor, as a large tumor (> 1.0 g) developed finally in three of the eight mice received placebo treatment. Cytokines/chemokines array indicated that nicaraven reduced the levels of CXCL10 and SDF-1 in the tumor as well as the levels of IL-2 and MIP-2 in serum. Immunofluorescence staining showed that nicaraven significantly reduced the recruitment of macrophages and neutrophils in the tumor. Interestingly, western blot indicated that the expression of CD86, CD206, and NIMP-R14 was especially enhanced in the three large-size tumors, suggesting the potential role of nicaraven in preventing the hyper-inflammatory tumor microenvironment. Moreover, the expression of PARP-1 was downregulated, but the expression of phospho-p38 MAPK, phospho-MKK-3/6, and phospho-MSK-1 was upregulated in the large-size tumors, suggesting the involvement of p38 MAPK pathway in the anti-inflammatory effect of nicaraven. Taken together, our study suggests that nicaraven may effectively prevent the fast growth of inflamed tumors by an anti-inflammatory mechanism.

Serum lactate dehydrogenase is a predictive biomarker in patients with oropharyngeal cancer undergoing radiotherapy: Retrospective study on predictive factors

BACKGROUND

The present study aimed to evaluate the prognostic factors in human papillomavirus (HPV)-positive and HPV-negative oropharyngeal cancer (OPC) treated with definitive radiotherapy.

METHODS

We retrospectively evaluated 101 patients with OPC who underwent definitive radiotherapy between 2008 and 2018.

RESULTS

The median follow-up period of the surviving patients was 68 months (range, 8-164 months). The 5-year overall survival rate was 69.8%. Univariate analyses revealed that poor survival was associated with male sex, smoking ≥30 pack-years, Eastern Cooperative Oncology Group performance status ≥1, tumor-node-metastasis (TNM) stage III-IV (8th edition), HPV-negativity, serum lactate dehydrogenase (LDH) ≥202, C-reactive protein/albumin ratio ≥0.15, and lymphocyte-to-monocyte ratio <2.90. In multivariate analyses, poor survival was independently correlated with smoking ≥30 pack-years (p < 0.01) and LDH ≥202 (p = 0.02).

CONCLUSIONS

The present study suggested that high LDH levels predicted poor survival after definitive radiotherapy for patients with both HPV-positive and HPV-negative OPC.

Efficacy and Safety of Combined Brain Radiotherapy and Immunotherapy in Non-Small-Cell Lung Cancer With Brain Metastases: A Systematic Review and Meta-Analysis

BACKGROUND

Immune checkpoint inhibitors (ICIs) are recommended to treat advanced non-small-cell lung cancer (NSCLC), whereas brain radiotherapy (RT) is the mainstream therapy for patients with brain metastases (BMs). This systematic review and meta-analysis investigated whether the combination of brain RT and ICIs would generate a synergistic effect without unacceptable toxicity to treat NSCLC with BMs.

METHODS

Literature searching was performed in PubMed, Embase, Web Of Science, and The Cochrane Library up to December 20, 2020. Heterogeneity, sensitivity analysis, forest plots, and publication bias were analyzed using Stata 15.0.

RESULTS

Nineteen studies were included. In the comparison of the brain RT+ICIs arm and brain RT alone arm, the pooled effect size (ES) for overall survival (OS) (hazard ratio [HR] = 0.77; 95% confidence interval [CI] 0.71-0.83; I² = 0; P < .001; n = 4) and grade 3-4 neurological adverse events (AEs) (risk ratio [RR] = 0.91; 95% CI 0.41-2.02; I² = 26.5; P = .809; n = 4) indicated that the brain RT+ICIs model had significantly better systemic efficacy and similar neurological AEs compared with brain RT alone for NSCLC. Concurrent RT+ICIs were identified as the optimal model, which achieved the best efficacy without significantly increased AEs compared with sequential RT+ICIs.

CONCLUSIONS

Combined ICIs and brain RT exhibited favorable efficacy and acceptable toxicity for NSCLC patients with BMs, among which, the concurrent model might be the optimal option. Our results could guide the design of future randomized controlled trials and clinical practice.

Frontiers in Pharmacology: Review Manuscript Targeting of the Neutrophil as an Adjunctive Strategy in Non-Small Cell Lung Cancer

Lung cancer remains the leading cause of cancer mortality in the United States, with non-small cell lung cancer (NSCLC) accounting for around 85% of cases. Of particular concern is the poor responsiveness of this malignancy to therapy, resulting in a very low 5-year survival rate (17.4%) and a prominent tendency to progress to metastatic disease. A number of very recent studies, both pre-clinical and clinical, have implicated the neutrophil in both the pathogenesis and unsatisfactory response to therapy of NSCLC. In this context, movement of neutrophils into the tumor microenvironment (TME) is a common feature of NSCLC. Indeed neutrophils are the dominant type of immune cell in the NSCLC TME, creating a highly immunosuppressive milieu that is not only conducive to tumor growth and spread, but also represents a significant obstacle to the success of anti-tumor therapy, especially novel immunotherapies. The clinically relevant adverse impact of a neutrophil predominance both systemically and in the TME of patients with NSCLC is underscored by the negative prognostic value of both a persistent neutrophilia and, in particular, a high (≥5) neutrophil:lymphocyte ratio. On a more positive note, however, recognition of the involvement of the neutrophil in both the pathophysiology of NSCLC and treatment failure has enabled identification of neutrophil-targeted strategies that have the potential to serve as adjuncts to standard anti-cancer therapies, including immunotherapy. These strategies together with a consideration of the immunosuppressive, pro-tumorigenic properties of the neutrophil represent the major thrusts of this review.

Impact of neutrophil-to-lymphocyte ratio throughout the course of chemoradiotherapy on overall survival and distant failure in unresectable stage III non-small cell lung cancer

Purpose

Neutrophil-to-lymphocyte ratio (NLR) has been reported to be associated with treatment outcomes in various cancers; however, the optimal timing to measure NLR is unclear. In this study, “average-NLR” was newly devised, which reflects the NLR throughout the course of radiotherapy, and its usefulness was assessed for stage III non-small cell lung cancer (NSCLC) patients treated with chemoradiotherapy.

Materials and methods

A total of 111 patients who received definitive chemoradiotherapy for unresectable stage III NSCLC were reviewed. Patient/tumor-related factors, treatment-related, and NLR-related factors (average-NLR, pre- and post-radiotherapy NLR, NLR-nadir, NLR-maximum) were assessed using univariate and multivariate analyses.

Results

The median follow-up period was 43.8 months among the survivors. In the multivariate analysis, average-NLR and post-radiotherapy NLR were significant factors for the overall survival (OS) (p = 0.016 and 0.028) and distant failure (DF) (p = 0.008 and 0.040). For the patients with low, intermediate, and high average-NLR, the median OS was 41.2, 37.7, and 14.8 months, respectively, and the median DF free time was 52.5, 13.5, and 8.9 months, respectively.

Conclusion

Average-NLR and post-radiotherapy NLR were significant factors for the OS and DF. Average-NLR, which was available immediately after the completion of chemoradiotherapy, seemed to be helpful for treatment decisions.

Prognostic factors and survival after whole-brain radiotherapy for initial brain metastases arising from non-small cell lung cancer

Aim:

To identify prognostic factors and investigate patient survival after whole-brain radiotherapy (WBRT) for initial brain metastases arising from non-small cell lung cancer (NSCLC).

Methods:

Patients diagnosed with NSCLC between 1 January 2010 and 30 September 2019, and who received WBRT upon first developing a brain metastasis, were investigated. Overall survival was determined as related to age, sex, duration between initial examination and brain metastasis detection, stage at the first examination, presence of metastases outside the brain, blood analysis findings, brain metastasis symptoms, radiotherapy dose and completion, imaging findings, therapeutic course of chemotherapy and/or radiation therapy, histological type, and gene mutation status.

Results:

Thirty-one consecutive patients (20 men and 11 women) with a mean age of 63·8 years and median survival of 129 days were included. Multivariate analysis with stepwise testing was performed to investigate differences in survival according to gene mutation status, lactate dehydrogenase (LDH) level, irradiation dose, WBRT completion and Stage status. Of these, a statistically significant difference in survival was observed in patients with gene mutation status (hazard ratio: 0·31, 95% CI: 0·11–0·86, p = 0·025), LDH levels <230 vs. ≥230 IU/L (hazard ratio: 4·08, 95% CI: 1·45–11·5, p < 0·01) received 30 Gy, 30 Gy/10 fractions to 35 Gy/14 fractions, and 37·5 Gy/15 fractions (hazard ratio: 0·26, 95% CI: 0·09–0·71, p < 0·01), and stage IV versus non-stage IV (hazard ratio: 0·13, 95 CI:0·02–0·64, p < 0·01)

Findings:

Gene mutation, LDH, radiation dose and Stage are prognostic factors for patients with initial brain metastases who are treated with WBRT.

Brief review on the roles of neutrophils in cancer development

Neutrophils, which are traditionally regarded as a hallmark of inflammation, are also a member of the intratumoral immune cells. The roles of neutrophils in cancer development are diverse and undefined. So far, they are known to be involved in tumor initiation and tumor cell proliferation and metastasis. They show heterogeneity in both phenotypes and functions during early versus late stage of cancer development. Because they are also associated with the clinical outcomes of various types of solid tumors, cancer treatments that target neutrophils might be highly effective. In this review, we briefly cover the latest findings on the multiple roles of neutrophils in cancer development and point out the future directions as well.

Pre-stereotactic radiosurgery neutrophil-to-lymphocyte ratio is a predictor of the prognosis for brain metastases

PURPOSE

The neutrophil-to-lymphocyte ratio (NLR) has been reported to relate to the prognosis of various cancers. The aim of this study was to elucidate the efficiency of pre-treatment NLR as a predictor of outcomes of brain metastasis underwent gamma knife radiosurgery (GKRS).

METHODS

We analyzed 195 cases with brain metastasis underwent GKRS at our institution between January 2015 and April 2018. Patients' clinical and radiographic data were collected.

RESULTS

We identified 458 brain metastases in 195 patients. Optimal dichotomous cutoff values of NLR determined by receiver operating characteristic analysis for local control, distant control and overall survival (OS) were 2.48, 2.74 and 3.13, respectively. The actuarial local control rates of patients with high NLR were 87.4% at 6 months and 76.1% at 12 months, whereas that of patients with low NLR were 94.2% at 6 months and 88.3% at 12 months (P = 0.001). The actuarial distant control rates of patients with high NLR were 31.4% at 6 months and 18.9% at 12 months, whereas that of patients with low NLR were 58.5% at 6 months and 31.3% at 12 months (P = 0.001). The median OS of patients with high and low NLR were 10.0 months and 14.5 months, respectively (P = 0.001). Multivariate analysis demonstrates that high NLR independently predicts local failure (hazard ratio [HR], 2.281; P = 0.003), distant brain failure (HR 1.775; P = 0.002) and poorer overall survival (HR 1.494; P = 0.034).

CONCLUSION

The pre-SRS NLR, a systemic inflammatory marker for treatment response, inversely predicts local control, distant control and OS in patients with brain metastasis.

Neutrophils in the Tumor Microenvironment

Neutrophils are the first responders to inflammation, infection, and injury. As one of the most abundant leukocytes in the immune system, neutrophils play an essential role in cancer progression, through multiple mechanisms, including promoting angiogenesis, immunosuppression, and cancer metastasis. Recent studies demonstrating elevated neutrophil to lymphocyte ratios suggest neutrophil as a potential therapeutic target and biomarker for disease status in cancer. This chapter will discuss the phenotypic and functional changes in the neutrophil in the tumor microenvironment, the underlying mechanism(s) of neutrophil facilitated cancer metastasis, and clinical potential of neutrophils as a prognostic/diagnostic marker and therapeutic target.

Separating or combining immune checkpoint inhibitors (ICIs) and radiotherapy in the treatment of NSCLC brain metastases

With the advancement of imaging technology, systemic disease control rate and survival rate, the morbidity of brain metastases (BMs) from non-small cell lung cancer (NSCLC) has been riding on a steady upward trend (40%), but management of BMs from NSCLC remains obscure. Systemic therapy is anticipated to offer novel therapeutic avenues in the management of NSCLC BMs, and radiotherapy (RT) and immunotherapy have their own advantages. Recently, it was confirmed that immune checkpoint inhibitors (ICIs) and RT could mutually promote the efficacy in the treatment of BMs from NSCLC. In this paper, we provide a review on current understandings and practices of separating or combining ICIs and RT, which could provide a reference for the coming laboratory and clinical studies and contribute to the development of new approaches in NSCLC BMs.

Tumor-Associated Neutrophils in Cancer: Going Pro

The progression of cancer is not only about the tumor cell itself, but also about other involved players including cancer cell recruited immune cells, their released pro-inflammatory factors, and the extracellular matrix. These players constitute the tumor microenvironment and play vital roles in the cancer progression. Neutrophils—the most abundant white blood cells in the circulation system—constitute a significant part of the tumor microenvironment. Neutrophils play major roles linking inflammation and cancer and are actively involved in progression and metastasis. Additionally, recent data suggest that neutrophils could be considered one of the emerging targets for multiple cancer types. This review summarizes the most recent updates regarding neutrophil recruitments and functions in the tumor microenvironment as well as potential development of neutrophils-targeted putative therapeutic strategies.