Neutrophil-To-Lymphocyte and Platelet-To-Lymphocyte Ratios as Prognostic Markers of Survival in Patients with Head and Neck Tumours-Results of a Retrospective Multicentric Study

CT-assessed sarcopenia and prognostic nutritional index are associated with poor prognosis in oral squamous cell carcinoma

PURPOSE

Recently, it has been reported that sarcopenia and nutritional evaluation are associated with the prognosis of patients with cancer; however, there are only a few detailed reports on oral cancer. This single-center retrospective study aimed to analyze the relationship between computed tomography (CT)-assessed sarcopenia (CT-SP), immunocompetence, nutritional status, and the prognosis of patients with oral squamous cell carcinoma (OSCC).

METHODS

This retrospective study included patients who underwent radical therapy with surgery for OSCC between January 2014 and January 2021. Skeletal muscle in the third cervical vertebra (C3) was measured using preoperative cervical CT, and the skeletal muscle index (SMI) was calculated. Nutritional status were investigated using blood tests. The correlation between each parameter and prognosis was analyzed. The primary predictor variables were SMI, ECOG performance status, BMI, and nutritional status. The primary outcome variable was the 5-year overall survival rate (OS) and the secondary outcome variable was 5-year disease-specific survival rate (DSS).

RESULTS

One hundred sixty-three patients were registered retrospectively. The number of patients with CT-SP was 76 (52%). In the univariate analysis, CT-SP, prognostic nutritional index (PNI), and lymphocyte-monocyte ratio (LMR) were associated with poor prognosis, with statistically significant differences in OS and DSS. In the multivariate analysis, only CT-SP was identified as an independent prognostic factor for DSS. CT-SP was significantly correlated with the PNI.

CONCLUSION

CT-SP was associated with a significant decrease in survival rate in patients with OSCC. Furthermore, CT-SP was correlated with the PNI.

Prognostic value of circulating tumor cells combined with neutrophil-lymphocyte ratio in patients with hepatocellular carcinoma

BACKGROUND

Circulating tumor cell (CTC) count and neutrophil-to-lymphocyte ratio (NLR) are both closely associated with the prognosis of hepatocellular carcinoma (HCC).

AIM

To investigate the prognostic value of combining these two indicators in HCC.

METHODS

Clinical data were collected from patients with advanced HCC who received immune therapy combined with targeted therapy at the Department of Oncology, the Affiliated Hospital of Southwest Medical University, Sichuan, China, from 2021 to 2023. The optimal cutoff values for CTC programmed death-ligand 1 (PD-L1) (+) > 1 or CTC PD-L1 (+) ≤ 1 and NLR > 3.89 or NLR ≤ 3.89 were evaluated using X-Tile software. Patients were categorized into three groups based on CTC PD-L1 (+) counts and NLR: CTC-NLR (0), CTC-NLR (1), and CTC-NLR (2). The relationship between CTC-NLR and clinical variables as well as survival rates was assessed.

RESULTS

Patients with high CTC PD-L1 (+) expression or NLR at baseline had shorter median progression-free survival (mPFS) and median overall survival (mOS) than those with low levels of CTC PD-L1 (+) or NLR (P < 0.001). Meanwhile, patients in the CTC-NLR (2) group showed a significant decrease in mPFS and mOS. Cox regression analysis revealed that alpha-fetoprotein (AFP), CTC PD-L1 (+), and CTC-NLR were independent predictors of OS. The time-dependent receiver operating characteristic curve showed that the area under the curve of CTC-NLR at 12 months (0.821) and 18 months (0.821) was superior to that of AFP and CTC PD-L1 (+).

CONCLUSION

HCC patients with high CTC PD-L1 (+) or NLR expression tend to exhibit poor prognosis, and a high baseline CTC-NLR score may indicate low survival. CTC-NLR may serve as an effective prognostic indicator for patients with advanced HCC receiving immunotherapy combined with targeted therapy.

Prognostic Significance of Pre-Treatment Neutrophil-Lymphocyte Ratio and Platelet-Lymphocyte Ratio in Head and Neck Malignancies

Introduction

Carcinoma is the second most common cause of death worldwide. The neutrophil-lymphocyte ratio (NLR) and the platelet-lymphocyte ratio (PLR) are essential markers of inflammation and tumorigenesis in various cancers including head and neck cancers. Pretreatment platelet- lymphocytic ratio can be used as an independent predictor of mortality whereas neutrophil- lymphocytic ratio is an independent predictor of recurrence. The main aim of this study is to compare the pre-treatment neutrophil lymphocyte ratio and platelet-lymphocyte ratio in the patients of head and neck malignancies with those of the control group.

Material and Method

100 patients with histologically diagnosed cases of head and neck malignancies. Age and sex matched healthy subjects attending Otorhinolaryngology out-patient department for any other complaints (100 control subjects). Complete blood count had been done to calculate absolute neutrophil count and absolute lymphocyte count.

Results

The mean age of the subjects in the study group was 55.73 ± 11.56 years. In control group, the mean age group was 54.11 ± 10.46 years. NLR and PLR significantly increased in cases than controls. NLR associated with T stage, histological type and histological grade but not with site and nodal involvement. PLR associated with T stage, metastasis but not with the histological grade, histological type, site and nodal involvement.

Conclusion

From this study, we conclude that pre-treatment NLR and PLR were closely associated both with the size of primary tumor and also with the stage of malignant disease in patients of head and neck malignancies.

Prognostic value of haematological parameters and [18F]FDG PET/CT metabolic parameters in head and neck cancer

AIM

To determine the usefulness of neutrophil/lymphocyte (N/L) and platelet/lymphocyte (P/L) ratios as well as quantitative [18F]FDG PET/CT parameters as prognostic factors for overall survival (OS), cancer-specific survival (CSS) and progression-free survival (PFS) in patients with head and neck squamous cell carcinoma (HyN).

MATERIAL AND METHODS

Sixty-six patients (56 men) diagnosed with HyN carcinoma were retrospectively assessed over an 8-year interval. Maximum SUV (SUVmax), metabolic tumour volume (MTV) and total lesion glycolysis (TLG) parameters were determined from the PET/CT study at diagnosis. After treatment with chemoradiotherapy, patient survival was assessed. The Cox regression model and the Kaplan-Meier method were used to analyse prognostic factors and survival curves.

RESULTS

Median follow-up was 50.4 months, with 39 recurrences-progressions and 39 deaths. In the univariate analysis, metabolic parameters, except SUVmax, were predictive factors for all three survivals and the two blood parameters were predictive for OS and EFS. TLG was the only predictive factor in the multivariate analysis. The three survival curves were significantly different for the metabolic parameters and the OS curve for the N/L ratio. Correlations were seen between N/L ratio, MTV and TLG. No correlations were demonstrated between P/L ratio and metabolic parameters.

CONCLUSION

The use of haematological and metabolic markers would allow to identify patients with a high risk of recurrences and por survival and to individualise treatment by applying more aggressive therapies.

The Prognostic Value of Platelet-Lymphocyte Ratio, Neutrophil-Lymphocyte Ratio, and Monocyte-Lymphocyte Ratio in Head and Neck Squamous Cell Carcinoma (HNSCC)-A Retrospective Single Center Study and a Literature Review

INTRODUCTION

Neutrophil-to-lymphocyte ratio (NLR), lymphocyte-to-monocyte ratio (LMR), and pallets-to-lymphocyte ratio (PLR) are currently validated as cheap and accessible biomarkers in different types of solid tumors, including head and neck cancers (HNC).

THE PURPOSE OF THE STUDY

To evaluate the possible purposes and biomarker value of NLR, PLR, and MLR recorded pre-treatment (radiotherapy/chemotherapy) in HNC.

MATERIALS AND METHODS

From 190 patients with HNC included in the oncology records in the oncology outpatient clinic of the Craiova County Emergency Hospital (from January 2002 to December 2022), 39 cases met the inclusion criteria (squamous cell carcinoma and the possibility to calculate the pre-treatment (chemotherapy/radiotherapy) value of NLR, PLR, and MLR. Overall survival (OS) values were correlated with NLR, PLR, and MLR.

RESULTS

The median values for NLR, PLR, and MLR were 6.15 (1.24-69), 200.79 (61.3-1775.0), and 0.53 (0.12-5.5), respectively. In the study, the mean values for NLR, PLR, and MLR of 2.88, 142.97, and 0.36, respectively, were obtained. The median OS in the study group was 11 months (1-120). Although a negative Pearson's correlation was present, the relationship between the variables was only weak, with values of R = 0.07, p = 0.67, R = 0.02, p = 0.31, and R = 0.07, p = 0.62 being related to NLR, PLR, and MLR, respectively, in correlation with OS. The median values of NLR, PLR, and MLR were calculated (1.53, 90.32, and 0.18, respectively) for the HNC cases with pre-treatment values of NLR < 2 and for the HNC cases with NLR values ≥ 6 (23.5, 232.78, and 0.79, respectively). The median OS for cases with NLR < 2 and NLR ≥ 6 were 17.4 and 13 months, respectively.

CONCLUSIONS

The comparative analysis of the data highlights a benefit to OS for cases low values of NLR. The role of not only borderline NLR values (between 2 and 6) as a prognostic marker in HNSCC but also the inclusion of PLR and MLR in a prognostic score must also be defined in the future. Prospective studies with more uniformly selected inclusion criteria could demonstrate the value of pre-treatment NLR, PLR, and MLR for treatment stratification through the intensification or de-escalation of non-surgical curative treatment in HNSCC.

A Retrospective Analysis of the Association of Neutrophil-Lymphocyte Ratio (NLR) with Anemia in the Saudi Population

Background: The link between inflammation and anemia is well established but fluctuations in the emerging inflammatory index, neutrophil-lymphocyte ratio (NLR), in anemic subjects remain ambiguous. The purpose of this study is to address the prevailing knowledge gaps regarding the association of NLR with anemia in the Saudi population. Methods: Laboratory results of NLR, C-reactive protein (CRP), and hemoglobin for 14,261 subjects were obtained from Al Borg Diagnostics and retrospectively analyzed. Means, risk measures, and the diagnostic performance of NLR for anemia were examined in age- and gender-wise comparisons. Results: NLR was significantly elevated in anemic individuals and those with high NLR had a significantly lower Hb concentration. Moreover, elevated NLR was more prevalent in anemic subjects (PR: 1.87, 95% CI: 1.46-2.40, p < 0.0001) and carried a greater risk for the condition (OR: 1.91, 95% CI: 1.47-2.48, p < 0.0001) as did CRP. These observations demonstrated distinct age- and gender-specific patterns. However, both parameters were of no value in the diagnosis of anemia as seen from receiver operating characteristic curves. Conclusions: Altogether, these findings indicate that elevated NLR is associated with anemia, which suggests its usefulness for monitoring rather than diagnosing anemia associated with inflammation in Saudi subjects. Further examination of this association in longitudinal studies is needed.

Correlation of the Neutrophil-to-Lymphocyte Ratio with the Middle Ear Risk Index in Patients with Chronic Otitis Media

This study aimed to investigate the neutrophil-to-lymphocyte ratio (NLR) and severity of the chronic otitis media according to middle ear risk index (MERI) scores. The NLR and middle ear risk index were calculated for 210 chronic otitis media (COM) patients retrospectively. NLR compared between COM patients and 159 participants in control group. Pearson correlation analysis was performed for NLR and MERI. In addition, The cut-off value, sensitivity, and specificity for NLR were determined in COM according to the severity of the disease with ROC analysis. The average of NLR in all patients was 1.94 ± 0.89. NLR was calculated as 2.05 ± 1.03 in the patients with COM and 1.79 ± 0.64 in the control group (p = 0.006, 95% CI 0.07-0.44, t test). According to the ROC analysis, the cut-off point was determined as 1.95 for moderate and severe disease in MERI. For the cut of a NLR = 1.95, sensitivity was calculated as 48.5% and the specificity 57.1% for moderate and severe COM. MERI score was found significantly higher in patients with postoperative graft perforation (p < 0.001, 95% CI 0.7-1.8). NLR has not related significantly with the MERI score according to linear regression analysis (p = 0.927). NLR was found to be significantly higher in chronic otitis media patients compared to the control group. But NLR was not related to the severity of the disease classified with MERI. The cut-off value, sensitivity and sensitivity rates of NLR obtained was not available for clinically use.

Prognostic implications of preoperative systemic inflammatory markers in oral squamous cell carcinoma, and correlations with the local immune tumor microenvironment

Purpose

The aim of this study was to investigate the prognostic significance of preoperative inflammatory markers in peripheral blood of patients with oral squamous cell carcinoma (OSCC), and to establish correlations with the infiltrate of macrophages and lymphocytes in the local immune tumor microenvironment (TME).

Materials and Methods

Neutrophil-lymphocyte ratio (NLR), platelet-lymphocyte ratio (PLR), lymphocyte-monocyte ratio (LMR), and systemic immune-inflammation index (SII) were retrospectively evaluated in a cohort of 348 OSCC patients, and correlated with overall (OS) and disease-specific survival (DSS). Immunohistochemical analysis of tumoral and stromal infiltration of CD8+, CD4+, FOXP3+ and CD20+ lymphocytes and CD68+ and CD163+ macrophages was performed in a subset of 119 OSCC patient samples, and correlations further assessed.

Results

NLR, SII, and LMR were significantly associated with a poorer OS in univariate analysis; however, only NLR remained a significant independent predictor in the multivariate analysis (HR = 1.626, p = 0.04). NLR and SII were inversely and significantly correlated with stromal infiltration of CD8+, CD4+, and CD20+ lymphocytes. Moreover, a significant correlation between LMR was also found to significantly associate with stromal infiltration of CD8+, CD4+, and CD20+ lymphocytes, stromal CD68+ and CD163+ macrophages, and also tumoral infiltration of CD4+ and CD20+ lymphocytes.

Conclusions

Preoperative NLR, SII, and LMR may serve as valuable systemic markers to predict OSCC patient survival, with NLR emerging as an independent predictor of poor OS. Moreover, strong significant correlations were exclusively observed between systemic inflammatory markers and the local stromal infiltration of lymphocytes in the TME.

Combination of Preoperative Circulating Tumor Cell Count and Neutrophil-Lymphocyte Ratio for Prognostic Prediction in Hepatocellular Carcinoma Patients after Curative Hepatectomy

Background

Both the preoperative neutrophil-lymphocyte ratio (NLR) and circulating tumor cell count (CTC) are associated with poor prognosis in hepatocellular carcinoma (HCC). The purpose of this study was to explore the prognostic value of these two indices (CTC-NLR) in HCC.

Methods

We retrospectively collected demographic and clinical data, including NLR and CTC, from 97 patients with HCC who underwent curative hepatectomy at our institution from March 2014 to May 2017. X-Tile software was used to confirm the optimal cut-off value of NLR and CTC for predicting overall survival (OS) in this study. OS were also analyzed using Kaplan-Meier and Cox regression methods. Based on preoperative CTC and NLR, patients were divided into three groups: CTC-NLR (0), CTC-NLR (1), and CTC-NLR (2). Relationships of CTC-NLR with clinicopathological factors and survival were evaluated.

Results

Preoperatively, CTC positively correlated with NLR. Patients with NLR and CTC higher than the cut-offs had shorter OS than patients with low NLR and CTC. Kaplan-Meier analysis, and log-rank tests revealed significantly lower OS among patients with CTC-NLR scores of 0, 1, and 2. Uni- and multivariate analyses showed that CTC-NLR (hazard ratio 2.050, P = 0.005), CTC (hazard ratio 2.285, P = 0.032), and NLR (hazard ratio 1.902, P = 0.048) were independent predictor of OS. A time-dependent ROC curve indicated that the prognostic efficacy of the CTC-NLR at 1 year (0.714) was better than that of NLR (0.687) and CTC (0.590); the prognostic efficacy of the CTC-NLR at 2 years (0.746) was better than that of NLR (0.711) and CTC (0.601); the prognostic efficacy of the CTC-NLR at 3 years (0.742) was better than that of NLR (0.694) and CTC (0.629).

Conclusions

HCC patients with higher NLR and CTC tend to show shorter OS. Preoperative CTC-NLR may be associated with poor survival and might be a reliable prognostic predictor in HCC after curative hepatectomy.

Pre-treatment hematological parameters as a cost effective predictive marker for response to concurrent chemo radiation in locally advanced cervical cancer

INTRODUCTION

Locally advanced cervical cancer is still a major cause of mortality in developing countries. Recently, personalized medicine has changed the treatment paradigm for many solid cancers but no robust biomarkers has yet been validated for predicting response to chemo radiation in cervical cancer patients.

AIM

To assess the role of hematological parameters as a cost-effective predictive marker of response to concurrent chemo radiation in cervical cancer patients.

MATERIALS AND METHOD

This is a retrospective analysis of 90 cervical cancer patients treated with concurrent chemo radiation in a tertiary cancer center. Clinical details of the patients were extracted from the case records. For end point evaluation, the pre-treatment levels of hemoglobin, neutrophil, lymphocyte, platelet, platelet lymphocyte ratio (PLR) and neutrophil lymphocyte ratio (NLR) were compared and statistically analyzed between responders and non-responders. The optimal cutoff values of hematological parameters were estimated by the receiver operating characteristics (ROC) curve.

RESULT

Out of 90 patients, 60 (66.66%) were complete responders and remaining 30 (33.33%) were non-responders. The mean value of platelet, NLR, and PLR was significantly higher in the non-responder group. ROC curve analysis showed the optimal cut-off value of pre-treatment Hb, PLT, NLR and PLR to be 11 gm/dl, 3, 177 × 109/L, and 70 respectively.

CONCLUSION

Our study suggests that simple hematological markers like NLR, PLT count and PLR could be used as a cost effective pretreatment predictive marker for response to chemo radiation in cervical cancer patients.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

Pre-treatment neutrophil-to-lymphocyte ratio is an independent prognostic factor in head and neck squamous cell carcinoma: Meta-analysis and trial sequential analysis

Inflammation seems to play a critical role in the development and progression of different cancers. Neutrophil-to-lymphocyte ratio (NLR) is an easily measurable marker of systemic inflammation. The purpose of this systematic review and meta-analysis was to evaluate the prognostic role of the pre-treatment NLR, in terms of overall survival (OS) and disease-free survival (DFS), in patients with primary head and neck squamous cell carcinoma (HNSCC) treated by surgery alone or followed by chemo/radiotherapy. This systematic review was performed according to the guidelines reported in the Cochrane Handbook and the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) statement. Meta-analysis of OS and DFS was performed using the inverse of variance test. Fixed-effect models were used on the basis of the presence of heterogeneity. Risk of bias assessment and trial sequential analysis (TSA) were also performed; the quality of the evidence was evaluated via the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) approach. The analysis revealed that a higher value of pre-treatment NLR correlates with a statistically significant decrease of OS (HR, 1.56; 95% CI: [1.35, 1.80]; p < 0.00001) and a lower DFS (HR, 1.64; 95% CI: [1.30, 2.07]; p < 0.0001) in HNSCC patients.

Evaluation of Sarcopenia, Frailty, and Inflammation on Adverse Events and Survival Outcomes in Patients with Oral Cavity Squamous Cell Carcinoma under Adjuvant Chemoradiotherapy

In this study, we aimed to evaluate the prognostic impact of sarcopenia, five-item modified frailty index (mFI-5), neutrophil/lymphocyte ratio (NLR), and platelet/lymphocyte ratio (PLR) in patients with oral cavity squamous cell carcinoma (OSCC) treated with adjuvant chemoradiotherapy (CRT) and their survival outcomes. We retrospectively enrolled 175 patients with OSCC undergoing adjuvant CRT between 2011 and 2018, who were divided into groups with (n = 112) and without (n = 63) sarcopenia. Logistic regression analysis and Cox proportional hazards models were used to determine prognostic factors for CRT-related toxicity, three-year overall survival (OS), and disease-free survival (DFS). Sarcopenia and high PLR were independently associated with CRT-induced anemia (CIA); advanced tumor stage was related to poor three-year OS. CRT and survival did not differ by mFI-5 and NLR. Our results indicate that sarcopenia and high PLR are significant predictors of adjuvant CRT, increasing toxicity outcomes and indicating worse short-term OS. Accurately identifying sarcopenia and high PLR in patients with OSCC is critical to help better select candidates for adjuvant CRT to improve their outcomes.

Pretreatment Blood Markers in the Prediction of Occult Neck Metastasis: A 10-Year Retrospective Study

Introduction

The purpose of this study was to clarify the role of inflammatory blood markers in the management of early-stage (T1-T2) oral squamous cell carcinoma (OSCC) of the tongue in patients with a clinically negative neck. 

Materials and methods

We undertook a retrospective chart review of 102 patients with early-stage OSCC of the tongue, subjected to tumor resection and elective neck dissection. Based on postsurgical histopathological examination results, we divided our cohort into pN+ and pN0 groups. Afterwards, we analyzed the role of pretreatment inflammatory blood markers in predicting occult neck metastasis. We also evaluated neutrophil-lymphocyte ratio (NLR) association with the depth of invasion (DOI) of the primary tumor.

Results

We found a significant association of NLR (p=0.001) and monocyte-lymphocyte ratio (p=0.011) with neck status on univariate analysis. Multivariate analysis showed that only NLR (p=0.02) was an independent risk factor for occult metastasis among inflammatory blood markers. Receiver Operating Characteristic curve analysis and Younden’s Index determined the NLR value of 2.96 as the most adequate cut-off value for neck status prediction. NLR values of pretreatment workup also had a significant association with the DOI of the primary tumor (p=0.018).

Conclusion

Our study supports the role of pretreatment NLR in predicting occult neck metastasis in early-stage OSCC of the tongue. It also sheds some light over the potential of NLR as a predictor of the primary tumor’s DOI.

Neutrophil-Lymphocyte Ratio and Circulating Tumor Cells Counts Predict Prognosis in Gastrointestinal Cancer Patients

Purpose

The purpose of this study is to explore the prognostic value of associating pre-treatment neutrophil–lymphocyte ratio (NLR) with circulating tumor cells counts (CTCs) in patients with gastrointestinal cancer.

Materials and Methods

We collected the related data of 72 patients with gastric cancer (GC) and colorectal cancer (CRC) who received different therapies from August 2016 to October 2020, including age, gender, primary tumor location, TNM stage, tumor-differentiation, NLR, CTCs, disease-free survival (DFS) and overall survival (OS). We chose the optimal cut-off value of NLR >3.21 or NLR ≤3.21 and CTC >1 or CTC ≤1 by obtaining receiver operating characteristic (ROC) curve. The Kaplan–Meier survival analysis and Cox regression analysis were used to analyze DFS and OS. To clarify the role of the combination of NLR and CTCs counts in predicting the prognosis, we analyzed the DFS and OS when associated NLR and CTCs counts.

Results

A high NLR (>3.21) was associated with shorter DFS (P <0.0001) and OS (P <0.0001). Patients with high CTCs level (>1) had shorter DFS (P = 0.001) and OS (P = 0.0007) than patients with low CTCs level. Furthermore, patients who had both higher NLR and higher CTCs counts had obvious shorter DFS (P <0.0001) and OS (P <0.0001).

Conclusions

Patients with higher NLR and more CTCs respectively tended to have poor prognosis with shorter DFS and OS, which might be regarded as predictors of gastrointestinal cancer. In particular, associating NLR and CTCs counts might be a reliable predictor in patients with gastrointestinal cancer.

Systemic immune responses are associated with molecular characteristics of circulating tumor cells in head and neck squamous cell carcinoma

Systemic immunity mediated by circulating immune cells may affect clinical features, as well as the characteristics of circulating tumor cells (CTCs) in patients with head and neck squamous cell carcinoma (HNSCC). The present study aimed to analyze the influence of circulating immune cells, using their markers, on clinical features to investigate the association between systemic immunity and the molecular characteristics of CTCs. Circulating immune-cell markers were associated with disease progression and clinical outcomes in patients with HNSCC. Meanwhile, there was no significant association between the presence of CTCs and systemic immune-related markers. Moreover, phosphatidylinositol-4,5-bisphosphate 3-kinase catalytic subunit a expression in CTCs was significantly associated with higher lymphocyte counts (P=0.035) and an increased prognostic nutrition index (P=0.0157). Patients with CTCs expressing CD47 exhibited significantly higher neutrophil (P=0.0031) and monocyte (P=0.0016) counts. Patients with CTCs expressing programmed cell death 1 ligand 2 exhibited lower C-reactive protein (CRP) levels (P=0.0271) and a decreased CRP/albumin ratio (P=0.0207). The current results suggested that the interaction between CTCs and circulating immune cells may provide survival advantages via molecular alterations to CTCs.

Synergies Radiotherapy-Immunotherapy in Head and Neck Cancers. A New Concept for Radiotherapy Target Volumes-"Immunological Dose Painting"

The combination of immune checkpoint inhibitors and definitive radiotherapy is investigated for the multimodal treatment of cisplatin non-eligible locally advanced head and neck cancers (HNC). In the case of recurrent and metastatic HNC, immunotherapy has shown benefit over the EXTREME protocol, being already considered the standard treatment. One of the biggest challenges of multimodal treatment is to establish the optimal therapy sequence so that the synergistic effect is maximal. Thus, superior results were obtained for the administration of anti-CTLA4 immunotherapy followed by hypofractionated radiotherapy, but the anti-PD-L1 therapy demonstrates the maximum potential of radio-sensitization of the tumor in case of concurrent administration. The synergistic effect of radiotherapy–immunotherapy (RT–IT) has been demonstrated in clinical practice, with an overall response rate of about 18% for HNC. Given the demonstrated potential of radiotherapy to activate the immune system through already known mechanisms, it is necessary to identify biomarkers that direct the “nonresponders” of immunotherapy towards a synergistic RT–IT stimulation strategy. Stimulation of the immune system by irradiation can convert “nonresponder” to “responder”. With the development of modern techniques, re-irradiation is becoming an increasingly common option for patients who have previously been treated with higher doses of radiation. In this context, radiotherapy in combination with immunotherapy, both in the advanced local stage and in recurrent/metastatic of HNC radiotherapy, could evolve from the “first level” of knowledge (i.e., ballistic precision, dose conformity and homogeneity) to “level two” of “biological dose painting” (in which the concept of tumor heterogeneity and radio-resistance supports the need for doses escalation based on biological criteria), and finally to the “third level“ ofthe new concept of “immunological dose painting”. The peculiarity of this concept is that the radiotherapy target volumes and tumoricidal dose can be completely reevaluated, taking into account the immune-modulatory effect of irradiation. In this case, the tumor target volume can include even the tumor microenvironment or a partial volume of the primary tumor or metastasis, not all the gross and microscopic disease. Tumoricidal biologically equivalent dose (BED) may be completely different from the currently estimated values, radiotherapy treating the tumor in this case indirectly by boosting the immune response. Thus, the clinical target volume (CTV) can be replaced with a new immunological-clinical target volume (ICTV) for patients who benefit from the RT–IT association (Image 1).