Neutrophil-lymphocyte ratio predicts the prognosis of patients with hepatocellular carcinoma after liver transplantation

Predictive values of sarcopenia and systemic inflammation-based markers in advanced hepatocellular carcinoma after hepatectomy

BACKGROUND

Sarcopenia accompanied by systemic inflammation is associated with poor prognosis in patients with advanced hepatocellular carcinoma (HCC). However, the effect of sarcopenia combined with systemic inflammation on the prognosis of patients with advanced HCC who underwent hepatectomy is unclear. This study aimed to evaluate the effect of sarcopenia and inflammation on the prognosis of patients with advanced HCC.

METHODS

This retrospective study included 151 patients recruited between July 2010 and December 2022. We defined advanced HCC as that presenting with vascular invasion or tumor size ≥2 cm or multiple tumors. Sarcopenia was assessed using the psoas muscle index. Preoperative inflammatory markers were used by calculating the prognostic nutritional index, albumin-globulin ratio (AGR), neutrophil-to-lymphocyte ratio (NLR), and platelet-to-lymphocyte ratio. Cox regression analysis was performed to determine the prognostic factors for overall survival.

RESULTS

Of 151 patients, sarcopenia occurred in 84 (55.6 %). Sarcopenia was significantly associated with male sex, older age, body mass index (<25 kg/m2), and a higher NLR. In the multivariate analysis, AGR <1.25 (hazard ratio [HR], 2.504; 95% confidence interval [CI]: 1.325-4.820; p < 0.05); alpha-fetoprotein levels ≥25 ng/mL (HR, 1.891; 95% CI: 1.016-3.480; p = 0.04); and sarcopenia (HR, 1.908; 95% CI: 1.009-3.776; p < 0.05) were independent predictors of overall survival. The sarcopenia and low AGR groups had significantly worse overall survival than either the non-sarcopenia and high AGR or sarcopenia and low AGR groups.

CONCLUSION

Sarcopenia and AGR are independent prognostic factors in patients with advanced HCC. Thus, sarcopenia may achieve a better prognostic value when combined with AGR.

Combination of sarcopenia and systemic inflammation-based markers for predicting the prognosis of patients undergoing pancreaticoduodenectomy for pancreatic cancer

BACKGROUND

This study aimed to evaluate the effects of sarcopenia and inflammation on the prognosis of patients with pancreatic cancer after pancreaticoduodenectomy.

METHODS

Eighty patients who had undergone pancreaticoduodenectomy for pancreatic cancer between July 2010 and December 2023 were included in this study. The psoas muscle index was used to assess sarcopenia. The C-reactive protein-to-albumin ratio, prognostic nutritional index, neutrophil-to-lymphocyte ratio, and platelet-to-lymphocyte ratio were used to calculate the preoperative inflammatory marker levels. The prognostic factors for overall survival were determined using Cox regression analysis.

RESULTS

Twenty-four patients were diagnosed with sarcopenia. Sarcopenia showed a significant association with advanced tumor stage. Univariate analysis revealed a significant reduction in overall survival in patients with a prognostic nutritional index of <45, C-reactive protein-to-albumin ratio of ≥0.047, cancer antigen 19-9 levels of ≥130 U/mL, sarcopenia, lymph node metastasis, and vascular invasion. Multivariate analysis revealed that a C-reactive protein-to-albumin ratio of ≥0.047 (hazards ratio, 3.383; 95% confidence interval: 1.384-8.689; p< 0.001), cancer antigen 19-9 levels of ≥130 U/mL (hazards ratio, 2.720; 95% confidence interval: 1.291-6.060; p = 0.008), sarcopenia (hazards ratio, 3.256; 95% confidence interval: 1.535-7.072; p = 0.002) and vascular invasion (hazards ratio, 2.092; 95% confidence interval: 1.057-4.170; p = 0.034) were independent predictors of overall survival. Overall survival in the sarcopenia and high C-reactive protein-to-albumin ratio groups was significantly poorer than that in the non-sarcopenia and low C-reactive protein-to-albumin ratio and sarcopenia or high C-reactive protein-to-albumin ratio groups.

CONCLUSION

Sarcopenia and a high C-reactive protein-to-albumin ratio are independent prognostic factors in patients with pancreatic cancer after pancreaticoduodenectomy. Thus, sarcopenia may have a better prognostic value when combined with the C-reactive protein-to-albumin ratio.

Immunotherapy Using Activated Natural Killer Cells Improves Postoperative Neutrophil-to-Lymphocyte Ratio and Long-Term Prognosis of Living Donor Liver Transplant Recipients With Hepatocellular Carcinoma

OBJECTIVE

Preoperative neutrophil-to-lymphocyte ratio (NLR) is a well-known prognostic indicator in various malignancies; however, the impact of postoperative NLR on living donor liver transplant (LDLT) recipients is unknown. Immunotherapy with donor liver-derived activated natural killer (NK) cells may improve postoperative NLR by coactivating immune cells or suppressing activated neutrophils. This study aims to clarify the clinical significance of postoperative NLR in recipients after LDLT with HCC and assess whether immunotherapy improves postoperative NLR.

METHODS

We conducted a retrospective study of LDLT recipients between 2001 and 2022 to evaluate the clinical significance of postoperative NLR. Furthermore, the correlation between postoperative NLR and the activation marker of infused NK cells was also evaluated. The postoperative NLR was examined 4 weeks after LDLT.

RESULTS

The postoperative high NLR group (N = 78) had preoperative lower NLR and higher model for end-stage liver disease and a higher rate of postoperative infection within 30 days after LDLT than the postoperative low NLR group (N = 41). Postoperative high NLR (hazard ratio [HR], 2.62; 95% confidence interval [CI], 1.01-6.79; P = .047) and nontreatment of immunotherapy (HR, 3.10; 95% CI, 1.33-7.22; P < .01) were independent risk factors for poor overall survival in multivariate analysis. Furthermore, the activation marker of infused NK cells is inversely correlated with decreased postoperative NLR.

CONCLUSIONS

The higher level of postoperative NLR was independently associated with poor prognosis in patients after LDLT with HCC. Immunotherapy using activated NK cells may improve postoperative NLR and long-term prognosis.

Living donor liver transplantation for Barcelona clinic liver cancer (BCLC) intermediate-stage hepatocellular carcinoma

Background

Barcelona clinic liver cancer (BCLC) stage B (intermediate stage) hepatocellular carcinoma (HCC) is highly heterogeneous; thus, identifying the most effective treatment for individual patients represents a significant clinical challenge. However, transarterial chemoembolization (TACE) is the only recommended treatment option. Therefore, we aimed to investigate the patient characteristics and outcomes of living donor liver transplantation (LDLT) for BCLC stage B HCC.

Methods

A total of 516 patients with BCLC stage B HCC who underwent LDLT (n=104) or did not undergo LDLT (non-LDLT; n=412) between 2004 to 2018 were analyzed by propensity score matching (PSM; 1:4) analysis. Factors influencing overall survival (OS) and recurrence were analyzed using Cox's proportional hazards models.

Results

Patients treated with LDLT achieved better OS than the non-LDLT group, including liver- and non-liver related survival (all P<0.001). Multivariate Cox regression analysis showed age >60 years (P=0.006), a neutrophil-lymphocyte ratio (NLR) >4 (P=0.016) and >3 locoregional therapies (LRT) before LDLT (P<0.001) were independent risk factors for HCC recurrence. In addition, age >60 years (P<0.001) and >3 LRT before LDLT (P=0.001) were independent risk factors for OS. Using a combination of age, NLR, and LRT before liver transplantation (LT), the patients can be divided into low-risk (none of risk), intermediate-risk (one of risk), and high risk (more than two of risk) groups. There were significant differences in the cumulative HCC recurrence (P<0.001) and mortality (P<0.001) rates among the three groups.

Conclusions

LDLT may represent a valuable therapeutic option for selected patients with BCLC stage B HCC.

Pulmonary neuroendocrine tumors: study of 266 cases focusing on clinicopathological characteristics, immunophenotype, and prognosis

OBJECTIVE

Pulmonary neuroendocrine tumors (PNETs) consist of small-cell lung cancer (SCLC), large-cell neuroendocrine carcinoma (LCNEC), typical carcinoid (TC), and atypical carcinoid (AC). We aimed to analyze the immunophenotypic, metastatic, and prognostic risk factors for PNETs.

MATERIALS AND METHODS

A total of 266 patients with PNETs were enrolled, including 219 patients with SCLC, 18 patients with LCNEC, 11 patients with TC, and 18 patients with AC. Clinicopathological characteristics and immunophenotypes were compared among the subtypes of PNETs. Risk factors for metastasis, progression-free survival (PFS), and overall survival (OS) were analyzed.

RESULTS

Thyroid transcription factor-1 (TTF-1) and the Ki-67 index were significantly different among subtypes of PNETs (all P < 0.05). Smoking (OR, 2.633; P = 0.031), high pretreatment carcinoembryonic antigen (CEA > 5 ng/ml: OR, 3.084; P = 0.014), and poorly differentiated pathotypes (P = 0.001) were independent risk factors for lymph-node metastasis. Smoking (OR, 2.071; P = 0.027) and high pretreatment CEA (OR, 2.260; P = 0.007) were independent risk factors for distant metastasis. Results of the multivariate Cox regression model showed pretreatment CEA (HR, 1.674; P = 0.008) and lymphocyte-monocyte ratio (LMR) (HR = 0.478, P = 0.007) were significantly associated with PFS; BMI (P = 0.031), lymph-node metastasis (HR = 4.534, P = 0.001), poorly differentiated pathotypes (P = 0.015), platelet-lymphocyte ratio (PLR) (HR = 2.305, P = 0.004), and LMR (HR = 0.524, P = 0.045) were significantly associated with OS.

CONCLUSIONS

PNETs are a group of highly heterogeneous tumors with different clinical manifestations, pathological features, and prognoses. Knowing clinicopathological characteristics and immunophenotypes of PNETs is significant for diagnosis. Pretreatment PLR, LMR, and CEA have certain value in the prognosis of PNETs.

Usefulness of neutrophil-to-lymphocyte ratio (NLR) as a prognostic predictor after treatment of hepatocellular carcinoma." Review article

The neutrophil-to-lymphocyte ratio (NLR) is an inflammatory marker which has been investigated as a prognostic indicator in post-therapeutic recurrence and survival of patients with HCC. Our aim was to review all studies that assessed the prognostic value of pre-treatment NLR in predicting patient survival, cancer recurrence, and graft survival in patients undergoing various therapies for HCC. We searched the database of PubMed and Google Scholar to review all studies that have the word "NLR" and the word "HCC." We included all studies that assessed pre-treatment NLR as a prognostic factor in predicting outcomes in HCC patients. We excluded studies that assessed the correlation between post-treatment NLR or dynamic changes in NLR after treatment and HCC outcomes in an effort to minimize the confounding effect of each treatment on NLR. We reviewed 123 studies that studied the correlation between pre-treatment NLR and patient survival, 72 studies that evaluated the correlation between pre-treatment NLR and tumor recurrence, 21 studies that evaluated the correlation between NLR and tumor behavior, and 4 studies that assessed the correlation between NLR and graft survival. We found a remarkable heterogeneity between the methods of the studies, which is likely responsible for the differences in outcomes. The majority of the studies suggested a correlation between higher levels of pre-treatment NLR and poor outcomes. We concluded that NLR is a reliable and inexpensive biomarker and should be incorporated into other prognostic models to help determine outcomes following HCC treatment.

Preoperative Albumin-to-Globulin Ratio Predicts Prognosis in Hepatocellular Carcinoma: A Cohort Study Including Non-Hepatitis Virus-Infected Patients

INTRODUCTION

We evaluated the prognostic significance of the preoperative albumin-to-globulin ratio (AGR) in patients with hepatocellular carcinoma (HCC) with various liver etiologies.

METHODS

We retrospectively analyzed 157 patients with HCC between July 2010 and February 2021. The relationship between clinicopathological variables was investigated using univariate and multivariate analyses. Statistical significance was set at p < 0.05.

RESULTS

The mean overall survival (OS) was 24.5 months. The 1-, 3-, and 5-year OS rates were 90.4%, 81.2%, and 68.7%, respectively. Patients were classified into 2 groups: AGR <1.16 (low-AGR group; n = 43) and AGR ≥1.16 (high-AGR group; n = 114). In univariate analysis, OS was significantly reduced in patients with a low AGR (AGR <1.16), an alpha-fetoprotein level ≥25 ng/mL, a tumor size ≥3.5 cm, microvascular invasion, and poor tumor differentiation. In multivariate analysis, a low AGR (hazard ratio [95% confidence interval]) (2.394 [1.092-5.213]; p = 0.030) and microvascular invasion (2.268 [1.019-5.169]; p = 0.045) were independent predictors of OS.

DISCUSSION/CONCLUSION

A low AGR was significantly associated with poor OS in patients with HCC, regardless of liver etiology. This may assist in treatment stratification and better management of patients with HCC.

Tailored Prediction Model of Survival after Liver Transplantation for Hepatocellular Carcinoma

This study aimed to create a tailored prediction model of hepatocellular carcinoma (HCC)-specific survival after transplantation based on pre-transplant parameters. Data collected from June 2006 to July 2018 were used as a derivation dataset and analyzed to create an HCC-specific survival prediction model by combining significant risk factors. Separate data were collected from January 2014 to June 2018 for validation. The prediction model was validated internally and externally. The data were divided into three groups based on risk scores derived from the hazard ratio. A combination of patient demographic, laboratory, radiological data, and tumor-specific characteristics that showed a good prediction of HCC-specific death at a specific time (t) were chosen. Internal and external validations with Uno’s C-index were 0.79 and 0.75 (95% confidence interval (CI) 0.65–0.86), respectively. The predicted survival after liver transplantation for HCC (SALT) at a time “t” was calculated using the formula: [1 − (HCC-specific death(t’))] × 100. The 5-year HCC-specific death and recurrence rates in the low-risk group were 2% and 5%; the intermediate-risk group was 12% and 14%, and in the high-risk group were 71% and 82%. Our HCC-specific survival predictor named “SALT calculator” could provide accurate information about expected survival tailored for patients undergoing transplantation for HCC.

Re-evaluating Blood Markers as Predictors of Outcome in Multivisceral and Intestinal Transplantation

BACKGROUND

Multivisceral transplant (MVTx) and isolated intestinal transplant (ITx) are complex surgical procedures. The subsequent proinflammatory state in the immediate postoperative period makes interpretation of blood markers difficult.

METHOD

We aimed to establish the course of various blood markers after MVTx/ITx, and to evaluate their use as diagnostic markers of complications. This was a single center prospective cohort. We analyzed blood markers collected preoperatively, on alternate days for the first postoperative week, and then weekly for 4 weeks. This study was in compliance with The Declaration of Helsinki.

RESULTS

Over a 16-month period (July 2017-October 2018), 20 subjects aged 2 to 67 years with a median age of 24.5 years received MVTx/ITx. Twelve recipients (60%) had an infection. Neutrophil lymphocyte count ratio (NLCR) was higher than established upper limits of normal, regardless of infection status. NLCR and white blood cell count were useful to identify infected MVTx/ITx recipients, with P values <.05 for 2 and 1 of 7 time points post transplant, respectively. Higher preoperative eosinophil% predicted future acute cellular rejection (P value .023).

CONCLUSIONS

This is the first study to extensively track the course of blood markers post MVTx/ITx and identified NLCR and white blood cell count as potential diagnostic blood markers of infection.

Analysis of prognostic factors in patients receiving transarterial radioembolization for unresectable hepatocellular carcinoma

AIM

This study aimed to analyze the prognostic factors of patients receiving transarterial radioembolization for unresectable hepatocellular carcinoma.

MATERIAL AND METHOD

Eighty-six (73 M and 13F; mean age: 64.3 ± 9.8 years) patients who received transarterial radioembolization for unresectable hepatocellular carcinoma were included. Relationship between serum alpha-fetoprotein and international normalization ratio level, albumin-bilirubin grade, neutrophil-lymphocyte ratio, presence of portal venous thrombosis and extrahepatic metastases, the dimension of index lesion and OS were analyzed.

RESULTS

Neutrophil lymphocyte ratio was ≤ 5 in 76 (88%) and >5 in 10 (12%) of patients. Sixty-two (72%) patients died during a mean of 25.6± 9.7 months follow-up. Mean OS for all patients was calculated as 12.9 ± 14.6 months. In univariate analysis, albumin-bilirubin grade (22.3 ± 3.8 vs. 11.6 ± 4.2; P = 0.03), neutrophil-lymphocyte ratio (21.8 ± 3.6 vs. 7.3 ± 2.6; P =0.04), presence of extrahepatic metastases (30.1 ± 5.4 vs. 7.4 ± 2.0; P = 0.001) and portal venous thrombosis (26.5± 4.8 vs. 10.5 ± 2.1; P = 0.01) had significant effect on OS. In multivariate analysis, serum international normalization ratio (P = 0.005) and alpha-fetoprotein level (P = 0.004), albumin-bilirubin grade (P = 0.05), neutrophil-lymphocyte ratio (P = 0.007), Child-Pugh score (0.006) and presence of ascites (P = 0.005) were significantly correlated with OS.

CONCLUSION

Patients with low basal albumin-bilirubin grade and neutrophil-lymphocyte ratio survive longer after transarterial radioembolization for unresectable hepatocellular carcinoma. Presence of extrahepatic metastases and portal venous thrombosis seems to have a prognostic value.

Advances in resection and transplantation for hepatocellular carcinoma

It would be impossible to summarise all of the significant developments in the surgical management of hepatocellular carcinoma (HCC), even just over the past year, in a manuscript of this scope. Thus, we have selected topics for discussion that are the subject of current controversy and have attempted to present balanced points of view. Hepatic resection and transplantation are both mature modalities, and for the most part technical advances and improvements in candidate selection are incremental. The ability to readily cure hepatitis C stands out as the most impactful development in the field over recent years, especially in Western countries where hepatitis C has long been the chief aetiology underlying HCC and a predictor of poor outcomes after surgery, but its full implications remain to be clarified. The rising incidence of non-alcoholic steatohepatitis-related HCC and what it means with regard to surgical HCC management is an area of great current interest. With advancing technology, non-surgical locoregional treatments are gaining increasing application as potentially curative therapies. In addition, the advances in molecular and genomic assessment of HCC hold promise for personalising treatment and prognostication. The possible role of immunotherapy as an adjuvant to resection is being aggressively investigated. While liver surgery maintains an important role, the care of patients with HCC is more and more a team effort and needs to take place in the context of a well-integrated interdisciplinary programme to achieve the best outcomes for patients.

Exploring the prognostic value of the neutrophil-to-lymphocyte ratio in cancer

In cancer patients, a high pre-treatment neutrophil-to-lymphocyte ratio (NLR) is associated with poorer survival outcomes. Significant variation in the magnitude of this association has been observed between studies, but sources of this variation are poorly understood. Here, we explore differences in the prognostic potential of NLR between patient subgroups stratified by demographic and clinical characteristics using a retrospective cohort of 5,363 patients treated at Moffitt Cancer Center (Tampa, FL). We identify patients for whom NLR has maximum prognostic potential via adjusted hazard ratios (HRs) calculated using multivariable Cox proportional hazards models and area under the curve analysis. NLR demonstrates stronger associations (HRs > 2) with survival among African-American patients, patients receiving radiation therapy, stage IV patients, and melanoma patients when compared with the overall study population (HR = 1.58). Sensitivity and specificity of NLR as a prognostic marker are also higher in these patient subgroups, and increase further with combinations of multiple "high-risk" demographic or clinical characteristics. In summary, NLR may have greater prognostic value in patients with certain demographic and clinical features. Future prospective studies could validate this hypothesis, after further characterization of populations in which NLR has maximum prognostic potential and the identification of meaningful thresholds for risk stratification.

C-reactive protein is an independent predictor for hepatocellular carcinoma recurrence after liver transplantation

BACKGROUND

Serum C-reactive protein (CRP) is a prognostic factor for overall survival (OS) and recurrence of hepatocellular carcinoma (HCC) in patients treated with resection or non-surgical treatment. Here, we investigated the association of elevated CRP (≥1 vs. <1 mg/dL) with (i) recurrence of HCC and (ii) OS after liver transplantation (LT).

METHODS

Adult HCC patients undergoing orthotopic deceased donor LT at the Medical University of Vienna between 1997 and 2014 were retrospectively analysed.

RESULTS

Among 216 patients included, 132 (61.1%) were transplanted within the Milan criteria and forty-two patients (19.4%) had microvascular invasion on explant histology. Seventy patients (32.4%) showed elevated CRP (≥ 1 mg/dL). On multivariate analysis, a CRP ≥ 1 mg/dL was an independent risk factor for HCC recurrence with a 5-year recurrence rate of 27.4% vs. 16.4% (HR 2.33; 95% CI 1.13-4.83; p = 0.022). OS was similar in patients with normal vs. elevated CRP levels.

CONCLUSIONS

Elevated serum CRP is associated with HCC recurrence after LT and may be a marker for more aggressive tumor biology. Future studies should evaluate whether patients with elevated pre-transplant CRP levels benefit from closer monitoring for HCC recurrence.

Serum biomarkers and risk of hepatocellular carcinoma recurrence after liver transplantation

Liver transplantation (LT) is the only potentially curative treatment for selected patients with cirrhosis and hepatocellular carcinoma (HCC) who are not candidates for resection. When the Milan criteria are strictly applied, 75% to 85%of 3- to 4-year actuarial survival rates are achieved, but up to 20% of the patients experience HCC recurrence after transplantation. The Milan criteria are based on the preoperative tumor macromorphology, tumor size and number on computed tomography or magnetic resonance imaging that neither correlate well with posttransplant histological study of the liver explant nor accurately predict HCC recurrence after LT, since they do not include objective measures of tumor biology. Preoperative biological markers, including alpha-fetoprotein, des-gamma-carboxiprothrombin or neutrophil-to-lymphocyte ratio and platelet-to-lymphocyte ratio, can predict the risk for HCC recurrence after transplantation. These biomarkers have been proposed as surrogate markers of tumor differentiation and vascular invasion, with varied risk magnitudes depending on the defined cutoffs. Different studies have shown that the combination of one or several biomarkers integrated into prognostic models predict the risk of HCC recurrence after LT more accurately than Milan criteria alone. In this review, we focus on the potential utility of these serum biological markers to improve the performance of Milan criteria to identify patients at high risk of tumoral recurrence after LT.

Selecting patients with hepatocellular carcinoma for liver transplantation: incorporating tumor biology criteria

Liver transplantation (LT) is the optimal therapeutic option for patients with liver cirrhosis and hepatocellular carcinoma (HCC). Due to universal donor shortage, only the patients with limited tumor burden (under the so-called Milan criteria) are considered as potential candidates for LT in most institutions. It is expected that in the near future, more liver grafts will be available for patients with HCC due to the implementation of new direct antivirals against hepatitis C, leaving a prone scenario to consider expanding Milan criteria. A moderate expansion of Milan criteria could be implemented without increasing the risk of tumor recurrence if patients with favorable biological behavior are carefully selected. Incorporating information regarding tumor biology in the decision-making algorithm would result in a more rational use of LT in patients with HCC. In the present review, surrogate markers of tumor biology are critically evaluated as potential tools to be combined with existing radiological criteria. In addition, the current state of liquid biopsy is discussed, as this cutting-edge technology may reshape the management of HCC in the upcoming years.

Diagnostic value of alpha-fetoprotein combined with neutrophil-to-lymphocyte ratio for hepatocellular carcinoma

BACKGROUND

To investigate the diagnostic performance of alpha-fetoprotein (AFP) and neutrophil-to-lymphocyte ratio (NLR) as well as their combinations with other markers.

METHODS

Serum aspartate aminotransferase (AST), alanine aminotransferase (ALT), AFP and levels as well as the numbers of neutrophils and lymphocytes of all enrolled patients were collected. The NLR was calculated by dividing the number of neutrophils by the number of lymphocytes. Receiver operating characteristic (ROC) curve analysis was conducted to determine the ability of each marker and combination of markers to distinguish HCC and liver disease patients.

RESULTS

In total, 545 patients were included in this study. The area under the ROC curve (AUC) values for AFP, ALT, AST, and NLR were 0.775 (0.738-0.810), 0.504 (0.461-0.547), 0.660 (0.618-0.699), and 0.738 (0.699-0.774) with optimal cut-off values of 24.6 ng/mL, 111 IU/mL, 27 IU/mL, and 2.979, respectively. Of the four biomarkers, AFP and NLR showed comparable specificity (0.881 and 0.858) and sensitivity (0.561 and 0.539). The combination of AFP and NLR showed the highest AUC (0.769) with a significantly higher sensitivity (0.767) and a lower specificity (0.773) compared to AFP or NLR alone, and it had the highest sum of sensitivity and specificity (1.54) among all combinations. In patients with AFP < 20 ng/mL, the NLR showed the highest AUC and combination with other markers did not improve the diagnostic accuracy.

CONCLUSIONS

Our data indicate that the combination of AFP and NLR offers better diagnostic performance than either marker alone for differentiating HCC from liver disease, which may benefit clinical screening.

Profiling Neutrophil-to-Lymphocyte Ratio Changes in Response to Nucleoside Analog Therapy for Chronic Hepatitis B Infection

BACKGROUND/AIM

The neutrophil-lymphocyte ratio (NLR) has gained attention as an index of inflammation in patients with chronic hepatitis B virus (HBV); however, changes with nucleoside analog therapy require investigation.

PATIENTS AND METHODS

We carried out a retrospective study identifying monoinfected HBV patients initiated on therapy with NLR follow-up over 1 year. Biochemistries recorded at treatment initiation and 1 year included alanine aminotransferase (ALT), Model for End Stage Liver Disease (MELD) score, and NLR.

RESULTS

A total of 67 patients were initiated on therapy and had baseline characteristics including e-antigen (eAg) (50, 74.6%) and cirrhosis (19, 28.4%). On subgroup analysis among those with HBV-associated cirrhosis, the NLR decreased over 1 year (3.08±0.39 vs. 1.77±0.18, p<0.001) as did MELD and ALT. Among the non-cirrhotic cohort, there was no difference in NLR (1.99±0.89 vs. 2.14±1.03, p=0.134) despite a decrease in ALT.

CONCLUSION

Nucleoside analog therapy in HBV cirrhosis is associated with a decrease in NLR over 1 year that tracks with changes of established indices of inflammation/global hepatic function.

Systemic inflammation response index (SIRI) predicts prognosis in hepatocellular carcinoma patients

The systemic inflammation response index (SIRI) is a useful tool for predicting prognosis in some types of cancer. In this retrospective study, we evaluated the efficacy of SIRI in predicting overall survival in hepatocellular carcinoma (HCC) patients following local or systemic therapy. A cutoff value of 1.05 was identified for SIRI using ROC analysis in a training patient cohort. In the validation cohort, survival analysis revealed that median overall survival was longer in HCC patients with SIRI scores < 1.05 than in those with scores ≥ 1.05. Cox analysis of the validation cohort demonstrated that SIRI was associated with overall survival and was more predictive of overall survival that the AFP level or Child-Pugh score. However, SIRI and Barcelona Clinic Liver Cancer (BCLC) stage were equally effective for predicting survival. In addition, HCC patients with BCLC stage C had higher SIRI scores and poorer overall survival. SIRI also correlated with liver function parameters. Thus SIRI may be a convenient, low cost and reliable tumor marker for predicting prognosis in HCC patients.

Systemic immune-inflammation index in germ-cell tumours

Background:

We evaluated systemic immune-inflammation index (SII) and its association with patient outcome in germ-cell tumours (GCTs).

Methods:

Two independent cohorts of patients were analysed; the discovery set (n=171) from a single institution and the validation set (n=181) previously included in a study evaluating PD-L1 in GCTs. The SII was calculated using platelet (P), neutrophil (N) and lymphocyte (L) counts before chemotherapy and correlated with survival using regression analyses and Kaplan–Meier method.

Results:

In the discovery cohort, the SII was associated with poor risk clinical features. Patients with low SII had significantly longer progression-free survival (HR=0.22, 95% CI 0.12–0.41, P<0.001) and overall survival (OS) (HR=0.16, 95% CI 0.08–0.32, P<0.001) compared to high SII. This index was independent of International Germ Cell Cancer Collaborative Group criteria in multivariable Cox regression analysis for OS and was validated in an independent cohort. When combining PD-L1 expression on tumour infiltrating lymphocytes (TILs) and SII, we identified three distinctive prognostic groups.

Conclusions:

High SII was associated with poor outcome in GCTs. Combination of PD-L1 positive TILs and SII could further refine prognosis in GCTs.

A novel combined systemic inflammation-based score can predict survival of intermediate-to-advanced hepatocellular carcinoma patients undergoing transarterial chemoembolization

BACKGROUND

There is currently limited information regarding the prognostic ability of the dNLR-PNI (the combination of the derived neutrophil-to-lymphocyte ratio [dNLR] and prognostic nutritional index [PNI]) for hepatocellular carcinoma (HCC). This study aimed to assess the predictive ability of the dNLR-PNI in patients with intermediate-to-advanced HCC after transarterial chemoembolization (TACE).

METHODS

A total of 761 HCC patients were enrolled in the study. The dNLR-PNI was retrospectively calculated in these patients, as follows: patients with both an elevated dNLR and a decreased PNI, as determined using the cutoffs obtained from receiver operating characteristic curve analysis, were allocated a score of 2, while patients showing one or neither of these alterations were allocated a score of 1 or 0, respectively.

RESULTS

During the follow-up period, 562 patients died. Multivariate analysis suggested that elevated total bilirubin, Barcelona Clinic Liver Cancer C stage, repeated TACE, and dNLR-PNI were independently associated with unsatisfactory overall survival. The median survival times of patients with a dNLR-PNI of 0, 1, and 2 were 31.0 (95% confidence interval [CI] 22.5-39.5), 16.0 (95% CI 12.2-19.7) and 6.0 (95% CI 4.8-7.2) months, respectively (P < 0.001).

CONCLUSIONS

The dNLR-PNI can predict the survival outcomes of intermediate-to-advanced HCC patients undergoing TACE, and should be further evaluated as a prognostic marker for who are to undergo TACE treatment.

Pretreatment neutrophil-lymphocyte ratio: useful prognostic biomarker in hepatocellular carcinoma

Hepatocellular carcinoma (HCC) is the most common liver malignancy and the third most common cause of cancer-related deaths. Liver resection (LR) and liver transplantation (LT) are the only curative modalities for HCC. Despite recent advances and the adoption of the Milan and University of California, San Francisco, criteria, HCC recurrence after LR and LT remains a challenge. Several markers and prognostic scores have been proposed to predict tumor aggressiveness and supplement radiological data; among them, neutrophil–lymphocyte ratio (NLR) has recently gained significant interest. An elevated NLR is thought to predispose to HCC recurrence by creating a protumorigenic microenvironment through both relative neutrophilia and lymphocytopenia. In the present review, we attempted to summarize the published work on the role of pretreatment NLR as a prognostic marker for HCC following LR and LT. A total of 13 LT and 18 LR studies were included from 2008 to 2015. Pretransplant NLR was most often predictive of HCC recurrence, recurrence-free survival, and overall survival. NLR was, however, more variably and less clearly associated with worse outcomes following LR.

Neutrophil-to-lymphocyte and aspartate-to-alanine aminotransferase ratios predict hepatocellular carcinoma prognosis after transarterial embolization

The neutrophil-to-lymphocyte ratio (NLR) reflects the systematic inflammatory status, and the aspartate aminotransferase-to-alanine aminotransferase ratio (AAR) is a biomarker of liver fibrosis and cirrhosis. These values can be conveniently obtained from routine blood tests; however, their combined clinical utility has not been extensively studied in patients with hepatocellular carcinoma (HCC) undergoing transarterial chemoembolization (TACE). This study aimed to investigate the prognostic value of NLR-AAR in patients with unresectable HCC undergoing TACE. Data for 760 patients with newly diagnosed HCC were retrospectively evaluated. The NLR-AAR was calculated as follows: patients in whom both the NLR and AAR were elevated according to the receiver operating characteristic (ROC) curve analysis were assigned a score of 2; patients showing an elevation in one or neither of these indicators were assigned a score of 1 or 0, respectively. Univariate and multivariate analyses were performed to identify the clinicopathological variables associated with overall survival. An ROC curve was also generated and the area under the curve (AUC) was calculated to evaluate the discriminatory ability of each index at 1, 3, and 5 years of follow-up, as well as overall. The NLR-AAR consistently had a greater AUC value at 1 year (0.669), 3 years (0.667), and 5 years (0.671) post-TACE compared with either NLR or AAR alone. The median survival times of patients with a NLR-AAR of 0, 1, and 2 were 31.0 (95% confidence interval [CI] 24.0-38.0), 15.0 (95% CI 11.2-18.8), and 5.0 (95% CI 4.0-5.9) months, respectively (P < .001). Multivariate analysis showed that the NLR-AAR, elevated total bilirubin level, and vascular invasion were independently associated with overall survival. NLR and AAR, when combined to produce an inflammation-based index and fibrosis score, is an independent marker of poor prognosis in patients with HCC receiving TACE.

Peripheral blood neutrophil count as a prognostic factor for patients with hepatocellular carcinoma treated with sorafenib

Sorafenib is currently the only efficient molecular targeted therapy for hepatocellular carcinoma (HCC), although its effect is relatively moderate and variable between individuals. The present study aimed to evaluate the significance of peripheral blood neutrophils in the prognosis of HCC patients treated with sorafenib. A total of 464 patients with HCC were treated with sorafenib at Zhongshan Hospital (Shanghai, China) between January 1st, 2008 and December 31st, 2012, among which 120 patients were enrolled in the study. The optimal cutoff point for low vs. high neutrophil count (3.65×109) was obtained from a receiver operating characteristic curve. Overall survival (OS) was compared between the patients with low and high peripheral neutrophil counts. Univariate and multivariate analyses were used to explore the prognostic factors associated with OS in the patients treated with sorafenib. A nomogram model was also performed to predict the OS times of these patients. The median OS time was 9.0 months (95% confidence interval, 5.9-12.1 months) in the whole group of patients, with 1-, 2- and 3-year OS rates of 36, 24 and 16%, respectively. Using a cutoff level of 3.65×109 neutrophils/l, the median OS time was longer in the group of patients with a low peripheral neutrophil count than in those with a high peripheral neutrophil count (11.5 vs. 5.0 months, respectively; P<0.001). The multivariate analysis showed that peripheral neutrophil count, α-fetoprotein level and tumor size were independent prognostic factors for OS. In addition, using the nomogram model for the prediction of OS, the Harrell's c-index was 0.79. Therefore, it was concluded that a lower peripheral blood neutrophil count was associated with a better prognosis following treatment with sorafenib therapy.

Neutrophil-lymphocyte Ratio Plus Prognostic Nutritional Index Predicts the Outcomes of Patients with Unresectable Hepatocellular Carcinoma After Transarterial Chemoembolization

For many malignancies, inflammation-based scores correlate with survival. The neutrophil-to-lymphocyte ratio (NLR) and prognostic nutritional index (PNI) are immunonutritional indices associated with postoperative outcomes in patients with hepatocellular carcinoma (HCC). We evaluated whether a combined preoperative NLR and PNI score was prognostically superior to either index alone in 793 patients with unresectable HCC after transarterial chemoembolization. Patient demographic, clinical, and pathological data were also collected and analysed. A receiver-operating characteristic (ROC) analysis was used to classify patients as follows: NLR-PNI 0 group (NLR ≤ 2.2 and PNI > 46), NLR-PNI 1 group (NLR > 2.2 or PNI ≤ 46) and NLR-PNI 2 group (NLR > 2.2 and PNI ≤ 46). Regarding 1-, 3-, and 5-year survival, the NLR-PNI score had superior discriminative abilities (i.e., higher area under the ROC curve), compared with either the NLR or PNI alone, and patients in the NLR-PNI 0, 1, and 2 groups had median survival times of 33 (95% confidence interval: 22.8-43.2), 14 (10.9-17.1), and 6 (9.9-14.1) months, respectively. In multivariate analyses, the Barcelona Clinic Liver Cancer, total bilirubin, vascular invasion, and NLR-PNI score adversely affected overall survival. In conclusion, the NLR-PNI score can improve the accuracy of prognoses for patients with unresectable HCC.

Neutrophil-to-lymphocyte ratio predicts survival in European patients with hepatocellular carcinoma administered sorafenib

Neutrophil-to-lymphocyte ratio (NLR) is considered a prognostic factor in patients with hepatocellular carcinoma (HCC). Our aim is to investigate the prognostic significance of NLR in patients with HCC treated with sorafenib.

Results

Median follow-up time was 7 months. Patients were mostly in the intermediate (27.3%) or advanced (72.7%) BCLC stages, 38.6% had vascular invasion and 27.5% extrahepatic disease. A large proportion (38.9%) had been previously treated with TACE. Liver function was preserved: 65.8% were classed as Child A. Median overall survival was 7.7 months (95% CI: 5.8-9.6). In univariate analysis, vascular invasion (P = 0.004), ECOG-PS ≥ 1 (P < 0.001), high bilirubin (P < 0.001), clinical ascites (P = 0.036), BCLC stage (P = 0.004), no previous TACE (P = 0.041) and NRL ≥ 2.3 (P = 0.005) were predictors of poor survival. Skin toxicity (P = 0.039) or hypertension (P = 0.033) during treatment were related to better survival. In multivariate analysis NLR ≥ 2.3 [HR 1.72 (95% CI: 1.03-2.71)], hyperbilirubinemia [HR 3.42 (95% CI: 1.87-6.25)] and ECOG-PS ≥ 1 [HR 1.97 (95% CI: 1.19-3.26)] were found as independent indicators of poor overall survival. Dermatologic adverse effects were an indicator of good overall survival [HR 0.59 (95% CI: 0.38-0.92)].

Material and Methods

One hundred and fifty-four consecutive HCC patients treated with sorafenib in four different Spanish hospitals between August 2005 and October 2013 were analysed. Clinical, laboratory, and tumour features were obtained. Survival was calculated from the moment sorafenib treatment was initiated. Log-rank and Cox regression were used to analyse the ability of NLR to predict survival.

Conclusions

NLR is an independent prognostic indicator for overall survival in HCC patients treated with sorafenib.

Association between some inflammatory markers and primary ovarian insufficiency

OBJECTIVE

This study investigated the discriminative values of neutrophil-to-lymphocyte ratio (NLR), serum amyloid A protein (SAA), and C-reactive protein (CRP) in cases of primary ovarian insufficiency (POI).

METHODS

A total of 84 women were included in this comparative cross-sectional study. The study group consisted of 43 women diagnosed as having POI, and the control group consisted of 41 women with normal fertility. After obtaining a written informed consent form from all participants, we retrieved clinical and demographic data and laboratory findings from the participants and the hospital database. The following variables were analyzed: age, body mass index, smoking, family history, comorbidities, sonographic findings, complete blood count, baseline hormone levels, CRP, and SAA.

RESULTS

NLR was significantly lower in the study group than in the control group (mean [SD], 1.3 [0.7] vs 2.0 [0.7]; P < 0.001). The mean SAA level was 151.6 ng/mL (range, 48.5-12,554.7 ng/mL) in the study group and 147.8 ng/mL (range, 29.8-3,760.4 ng/mL) in the control group (P > 0.05). There was no significant difference in serum CRP levels between two groups (P > 0.05). Receiver operating characteristic analysis revealed that NLR, but not SAA and CRP, was a significantly discriminative parameter for POI (area under the curve, 0.829; P < 0.001). Multivariate logistic regression analysis showed that a family history of POI, smoking, and NLR of 1.5 or less were independent risk factors for POI.

CONCLUSIONS

SAA and CRP do not seem to be valuable discriminative markers for POI, whereas NLR may be a significant promising marker before presentation or in the early stages of POI and may be useful for developing appropriate fertility treatment options.

Liver transplantation for hepatocellular carcinoma beyond the Milan criteria: A review

Liver transplantation (LT) has been accepted as an effective therapy for hepatocellular carcinoma (HCC). The Milan criteria (MC) are widely used across the world to select LT candidates in HCC patients. However, the MC may be too strict because a substantial subset of patients who have HCC exceed the MC and who would benefit from LT may be unnecessarily excluded from the waiting list. In recent years, many extended criteria beyond the MC were raised, which were proved to be able to yield similar outcomes compared with those patients meeting the MC. Because the simple use of tumor size and number was insufficient to indicate HCC biological features and to predict the risk of tumor recurrence, some biological markers such as Alpha-fetoprotein, Des-Gamma-carboxy prothrombin and the neutrophil-to-lymphocyte ratio were useful in selecting LT candidates in HCC patients beyond the MC. For patients with advanced HCC, downstaging therapy is an effective way to reduce the tumor stage to fulfill the MC by using liver-directed therapy such as transarterial chemoembolization, radiofrequency ablation and percutaneous ethanol injection. This article reviews the recent advances in LT for HCC beyond the MC.

Neutrophil-Lymphocyte Ratio Is Significantly Decreased in Preemptive Renal Transplant Patients

AIM

Cardiovascular diseases and infections are the leading two causes of morbidity and mortality in end-stage renal disease (ESRD) patients. Kidney transplantation is the preferred method for renal replacement owing to better survival. There are reports of irreversibly damaged immune system in dialysis patients, which did not return to normal even after kidney transplantation. The neutrophil-lymphocyte ratio (NLR) is an easily applicable method for evaluation of inflammation. We hypothesized that preemptive kidney transplantation can improve inflammatory state compared with nonpreemptive recipients. To test our hypothesis, we retrospectively investigated pretransplant and posttransplant NLR and C-reactive protein (CRP) levels of ESRD patients and compared them with values in healthy controls.

MATERIALS AND METHODS

We retrospectively analyzed NLR, CRP, and other hematologic parameters of ESRD patients who were transplanted between January 2005 and January 2014 on the day of transplantation and at the end of first year. We grouped the patients as preemptive and nonpreemptive ones. We excluded patients with coronary artery disease, obesity, hypotension, hyperthyroidism, uncontrolled diabetes mellitus, hematologic or solid organ cancers, and active documented infection at any evaluation period.

RESULTS

We included 137 ESRD patient and 34 healthy control individual in our study. Of the 137 ESRD patients, 52 (38%) were transplanted preemptively. Of the patients, 85 were already on either hemodialysis or peritoneal dialysis therapy at the time of transplantation. The white blood cell count value of the patient and control group (7246.72 ± 1460.26 and 76661.76 ± 1286.29, respectively; P = .43), NLR of the control group was significantly lower than patient group (1.98 ± 0.94 and 3.47 ± 2.33, respectively; P = .007). The NLR of the preemptive group was decreased substantially at the end of first year posttransplantation, the NLR of the preemptive group was significantly lower than the nonpreemptive group (3.08 ± 1.32 and 3.71 ± 2.33; P = .01).

CONCLUSIONS

We showed that all ESRD patients had an increased inflammation rate according to CRP and NLR when compared with healthy controls. We also found that improvement of inflammatory state in preemptive patients is significantly better than nonpreemptive patients at the end of first year evaluation.

A Novel and Validated Inflammation-Based Score (IBS) Predicts Survival in Patients With Hepatocellular Carcinoma Following Curative Surgical Resection: A STROBE-Compliant Article

As chronic inflammation is involved in the pathogenesis and progression of hepatocellular carcinoma (HCC), we investigated the prognostic accuracy of a cluster of inflammatory scores, including the Glasgow Prognostic Score, modified Glasgow Prognostic Score, platelet to lymphocyte ratio, Prognostic Nutritional Index, Prognostic Index, and a novel Inflammation-Based Score (IBS) integrated preoperative and postoperative neutrophil to lymphocyte ratio in 2 independent cohorts. Further, we aimed to formulate an effective prognostic nomogram for HCC after hepatectomy.Prognostic value of inflammatory scores and Barcelona Clinic Liver Cancer (BCLC) stage were studied in a training cohort of 772 patients with HCC underwent hepatectomy. Independent predictors of survival identified in multivariate analysis were validated in an independent set of 349 patients with an overall similar clinical feature.In both training and validation cohorts, IBS, microscopic vascular invasion, and BCLC stage emerged as independent factors of overall survival (OS) and recurrence-free survival (RFS). The predictive capacity of the IBS in both OS and RFS appeared superior to that of the other inflammatory scores in terms of C-index. Additionally, the formulated nomogram comprised IBS resulted in more accurate prognostic prediction compared with BCLC stage alone.IBS is a novel and validated prognostic indicator of HCC after curative resection, and a robust HCC nomogram including IBS was developed to predict survival for patients after hepatectomy.

Prediction of hepatocellular carcinoma biological behavior in patient selection for liver transplantation

Morphological criteria have always been considered the benchmark for selecting hepatocellular carcinoma (HCC) patients for liver transplantation (LT). These criteria, which are often inappropriate to express the tumor’s biological behavior and aggressiveness, offer only a static view of the disease burden and are frequently unable to correctly stratify the tumor recurrence risk after LT. Alpha-fetoprotein (AFP) and its progression as well as AFP-mRNA, AFP-L3%, des-γ-carboxyprothrombin, inflammatory markers and other serological tests appear to be correlated with post-transplant outcomes. Several other markers for patient selection including functional imaging studies such as ¹⁸F-FDG-PET imaging, histological evaluation of tumor grade, tissue-specific biomarkers, and molecular signatures have been outlined in the literature. HCC growth rate and response to pre-transplant therapies can further contribute to the transplant evaluation process of HCC patients. While AFP, its progression, and HCC response to pre-transplant therapy have already been used as a part of an integrated prognostic model for selecting patients, the utility of other markers in the transplant setting is still under investigation. This article intends to review the data in the literature concerning predictors that could be included in an integrated LT selection model and to evaluate the importance of biological aggressiveness in the evaluation process of these patients.

Elevated Preoperative Neutrophil-Lymphocyte Ratio Is Associated with Poor Prognosis in Hepatocellular Carcinoma Patients Treated with Liver Transplantation: A Meta-Analysis

This study aims to investigate the prognostic value of neutrophil to lymphocyte ratio (NLR) in hepatocellular carcinoma (HCC) patients treated with liver transplantation (LT) through meta-analysis. Relevant articles were sought in PubMed, Embase, and Wangfang databases up to July 2015. A total of 1687 patients from 10 studies were included in this meta-analysis. Meta-analysis results showed that elevated NLR was significantly associated with poorer overall survival (OS) (HR = 2.71, 95% CI: 1.91-3.83) and poorer disease-free survival (DFS) (HR = 3.61, 95% CI: 2.23-5.84) in HCC patients treated with LT. Moreover, subgroup analysis showed the significant association between elevated preoperative NLR and poor prognosis was not altered by cutoff values of NLR or types of LT. Therefore, elevated preoperative NLR is associated with poor prognosis in HCC patients treated with LT. Preoperative NLR should be used to predict the prognosis of HCC after LT in our clinical work.

Aspartate aminotransferase-lymphocyte ratio index and systemic immune-inflammation index predict overall survival in HBV-related hepatocellular carcinoma patients after transcatheter arterial chemoembolization

It has been suggested that lymphocytes play central roles in host antitumor immune responses and control cancer outcome. We reviewed the clinical parameters of 189 hepatocellular carcinoma (HCC) patients and investigated the prognostic significance of lymphocyte-related scores in HCC patients following transcatheter arterial chemoembolization (TACE). Survival analysis revealed that an elevated aspartate aminotransferase-lymphocyte ratio index (ALRI) > 57 and a systemic immune-inflammation index (SII) > 300 were negatively associated with overall survival in HBV-related HCC (HR = 2.181, P = 0.003 and HR = 2.453, P = 0.003; respectively). Spearman chi-square analysis showed that ALRI had a specificity of 82.4% and that SII index had a sensitivity of 71.9% for HCC overall survival. ALRI and SII had negative predictive values of 74.6% and 80%, respectively for HCC overall survival. Additionally, Barcelona Clinic Liver Cancer (BCLC) stage C patients had significantly higher ALRI and SII scores (both P < 0.0001) and poorer overall survival (HR = 3.618, P < 0.001). Additionally, HCC patients with portal vein tumor thrombosis (PVTT) had higher ALRI and SII scores (P < 0.0001 and P = 0.0059, respectively). In conclusion, as noninvasive, low cost, easily assessable and reproducible parameters, elevated ALRI and SII should be used as negative predictive factors for overall survival in HBV-related HCC in clinical practice.

Glutamate dehydrogenase and alkaline phosphatase as very early predictors of hepatocellular carcinoma recurrence after liver transplantation

BACKGROUND

Although long-term survival rates for patients undergoing liver transplant (LT) for hepatocellular carcinoma (HCC) are good, the relatively high rate of tumor recurrence after LT necessitates the identification of biological parameters that supplement morphological predictors of recurrence.

METHOD

From chart review we identified 175 patients who received liver transplantation due to HCC at our center between January 2000 and December 2013. We documented demographic and clinical data, as well as clinicopathological characteristics of the tumors, with a focus on liver values at the time of LT.

RESULTS

HCC recurred in 23% of LT patients. Most recurrences (59%) occurred within 12 months after LT; hardly any recurrence was detected later than 3 years after LT. Recurrence was positively correlated with tumor size, tumor stage and alpha-fetoprotein level (AFP), and it was most likely with certain causes of liver disease. Interestingly, tumor recurrence was independently predicted by serum levels of glutamate dehydrogenase (GLDH) and alkaline phosphatase (AP) at the time of LT.

CONCLUSIONS

Because all HCC recurrence occurs within 36 months after LT, HCC detected more than 3 years after LT may be considered de novo. Liver values, with GLDH and AP being the most preponderant, serve as easy-to-assess biomarkers which contribute to predict the risk of tumor recurrence.

High pretreatment neutrophil-lymphocyte ratio predicts recurrence and poor prognosis for combined small cell lung cancer

BACKGROUNDS

Compared to pure small cell lung cancer (SCLC), combined small cell lung cancer (C-SCLC) has its own characteristics. High neutrophil to lymphocyte ratio (NLR) and platelet-lymphocyte ratio (PLR) have been shown to be related to poor prognosis in several types of tumors. The aim of this study was to explore the prognosis value of NLR and PLR in patients with C-SCLC.

METHODS

A total of 112 patients diagnosed with C-SCLC between January 2000 and March 2009 were enrolled in the study. The clinicopathological parameters, laboratory analyses, and survival time were collected and analyzed. The correlation between NLR, PLR, and clinicopathological characters was analyzed. Univariate and multivariate analyses were performed to investigate the prognostic significance of these parameters for C-SCLC.

RESULTS

The pretreatment NLR was elevated in 37.5 % patients (NLR ≥ 4.15; n = 42; H-NLR). NLR was significantly related to disease stage (p = 0.033) and tumor recurrence (p = 0.014). The median overall survival (OS) and progression-free survival (PFS) were significantly worse in the H-NLR group (OS: 22.0 months vs 11.7 months, p = 0.001; PFS: 11.1 vs 6.0 months, p < 0.001). However, PLR at diagnosis was not associated with OS or PFS. Multivariate analyses indicated elevated NLR (HR = 1.6; p = 0.001), disease stage (HR = 1.6; p = 0.001), and performance status (HR = 1.8; p = 0.015) as independent prognostic factors.

CONCLUSIONS

High pretreatment NLR (≥4.15) is a potential useful indicator for C-SCLC recurrence and predicts a poor long-term prognosis for C-SCLC, which should be considered in defining the prognosis with other well-known prognosticators in C-SCLC patients.

Preoperative neutrophil-to-lymphocyte ratio for prognostication of patients with distal bile duct carcinomas undergoing surgery

BACKGROUND

Surgical resection continues to be the current standard treatment for distal bile duct carcinoma (DBC), as no effective alternative treatment exists. However, even after resection, the long-term prognosis is poor. Simple biomarkers that can predict response or toxicity, and which are applicable to all community oncology settings worldwide, have not been identified. Differential white-cell counts, such as the neutrophil-to-lymphocyte ratio (NLR), as markers of inflammation, may be simple and readily available biomarkers. This study aimed to determine whether the NLR can be used as a predictor of surgical outcome in patients with DBC.

MATERIALS AND METHODS

We enrolled 91 DBC patients who had undergone pancreatoduodenectomy (PD) at a single institution between April 2000 and December 2013. Blood was sampled on admission for determination of NLR. An NLR of ≥5 was selected as the cut-off value for validation.

RESULTS

Seventeen patients had an NLR of ≥5 (Group 1; 18.7%), while 74 had an NLR of <5 (Group 2; 81.3%). The 1-, 3- and 5-year survival rates for Group 1 patients were 75.9, 34.5 and 34.5%, respectively, while those for Group 2 patients were 94.8, 55.2 and 46.6%, respectively (p = 0.02). There were no significant inter-group differences in clinicolaboratory background factors such as the mean operation time, bleeding volume, tumor size, CRP, neutrophil count and lactate dehydrogenase (LDH) level. On the other hand, there were significant inter-group differences for albumin level (p = 0.011), lymphocyte count (p = 0.001) and NLR (p < 0.001). Multivariate analyses were performed for factors such as gender, age, maximum tumor diameter, drainage method, operation time, bleeding volume, pathology, albumin, CRP, neutrophil count, lymphocyte count, LDH and NLR. The results revealed that NLR (odds ratio, 2.032; 95% CI, 0.999-4.134; p = 0.040) was associated with postoperative overall survival.

CONCLUSIONS

An NLR of ≥5 predicts a poor outcome in patients undergoing PD for DBC. NLR is an independent indicator of overall survival for such patients.

Preoperative neutrophil-to-lymphocyte ratio is a predictor of recurrence following thermal ablation for recurrent hepatocellular carcinoma: a retrospective analysis

PURPOSE

The aim of this study is to determine the predictive value of preoperative blood neutrophil-to-lymphocyte ratio (NLR) for recurrence in recurrent hepatocellular carcinoma (RHCC) patients following thermal ablation.

MATERIAL AND METHODS

This retrospective study enrolled 506 RHCC patients who underwent thermal ablation from April 2006 to April 2014. The clinicopathological parameters including NLR were evaluated to identify predictors of recurrence rate after thermal ablation. A Cox multiple regression analysis was performed to determine the parameters that predicted recurrence in RHCC patients. The best cutoff value of NLR was determined with time-dependent receiver operating characteristic (ROC) curve analysis. The recurrence-free survival (RFS) rate was determined in patients with high and low NLR.

RESULTS

The multivariate Cox proportional hazard model analysis showed that NLR was a prognostic factor in recurrence-free survival. NLR ≥ 2.14 was evaluated (AUROC = 0.824; P<0.001), and 183 of 506 patients (36.2%) had a NLR of more than 2.14. During the follow-up period (12-96 months), the 1-, and 3- year recurrence rates were 20.7% and 31.6% in low NLR group, respectively. These recurrence rates were significantly less than those in the high NLR group (57.9% and 82.5%, respectively) (P<0.001). A recurrence-free survival analyses demonstrated that the RFS in the low NLR group (67.2%) was significantly higher than that in the high NLR group (13.1%) (P<0.001).

CONCLUSION

Our results show that preoperative NLR is a predictor for re-recurrence after thermal ablation in RHCC patients. Additionally, patients with NLR <2.14 have a lower recurrence rate, which may improve the clinical management of RHCC patients.

Neutrophil-lymphocyte ratio is useful for the prognosis of patients with hepatocellular carcinoma

There is increasing evidence that neutrophil-lymphocyte ratio (NLR) may play a role in predicting recurrence in patients with hepatitis B virus-related hepatocellular carcinoma (HCC) after liver transplantation. In the original study by Yan et al, it was aimed to determine whether an elevated NLR is associated with tumor recurrence. Total tumor size (> 9 cm) and macro-vascular invasion were found to be more significant than NLR according to the multivariate logistic regression analysis. Therefore, substantive significance should be emphasized rather than NLR because total tumor size and macro-vascular invasion are easier and more expressive than NLR in assessing HCC recurrence. NLR and platelet-lymphocyte ratio (PLR) are markers which are easy to obtain and can be used as inflammation indicators. Moreover, assessment of both NLR and PLR may add some value as a good predictor of risk for post-liver transplantation HCC recurrence. However, while the study was constructed on whole blood analysis, further details about the features and performance characteristics of the whole-blood analyzer, and preanalytical/analytical variables should also be mentioned.

Inflammatory markers as selection criteria of hepatocellular carcinoma in living-donor liver transplantation

AIM: To investigate that inflammatory markers can predict accurately the prognosis of hepatocelluar carcinoma (HCC) patients in living-donor liver transplantation (LDLT).

METHODS: From October 2000 to November 2011, 224 patients who underwent living donor liver transplantation for HCC at our institution were enrolled in this study. We analyzed disease-free survival (DFS) and overall survival (OS) after LT in patients with HCC and designed a new score model using pretransplant neutrophil-lymphocyte ratio (NLR) and C-reactive protein (CRP).

RESULTS: The DFS and OS in patients with an NLR level ≥ 6.0 or CRP level ≥ 1.0 were significantly worse than those of patients with an NLR level < 6.0 or CRP level < 1.0 (P = 0.049, P = 0.003 for NLR and P = 0.010, P < 0.001 for CRP, respectively). Using a new score model using the pretransplant NLR and CRP, we can differentiate HCC patients beyond the Milan criteria with a good prognosis from those with a poor prognosis.

CONCLUSION: Combined with the Milan criteria, new score model using NLR and CRP represent new selection criteria for LDLT candidates with HCC, especially beyond the Milan criteria.

Inflammation based regulation of cancer cachexia

Cancer cachexia, consisting of significant skeletal muscle wasting independent of nutritional intake, is a major concern for patients with solid tumors that affects surgical, therapeutic, and quality of life outcomes. This review summarizes the clinical implications, background of inflammatory cytokines, and the origin and sources of procachectic factors including TNF-α, IL-6, IL-1, INF-γ, and PIF. Molecular mechanisms and pathways are described to elucidate the link between the immune response caused by the presence of the tumor and the final result of skeletal muscle wasting.