Diabetes mellitus and the neutrophil to lymphocyte ratio predict overall survival in non-viral hepatocellular carcinoma treated with transarterial chemoembolization

Which is the best TACE agent for patients with different NLR hepatocellular carcinomas? A systematic review and network meta-analysis

Background

Transarterial chemoembolization (TACE) is a common treatment for hepatocellular carcinoma (HCC), but the best therapeutic agent for TACE treatment has not been determined. The neutrophil/lymphocyte ratio (NLR) is a systemic immune system marker; however, the ability of the NLR to predict the prognosis of patients with HCC is unknown, and no studies have been conducted to determine the most appropriate TACE regimen for HCC patients with different NLRs.

Methods

The PubMed, Embase, Web of Science, and CNKI databases were searched through May 28, 2023. Comparisons of overall survival (OS) among cohort studies with different NLRs and different TACE treatment regimens were performed with a random effects model.

Findings

Thirty-five studies involving 9210 patients were included in this meta-analysis. The results showed that Group 3-4 (NLR<2.5) patients had a significantly longer OS than Group 1-2 (NLR 2.5-5.0). Among the patients, Group 1-3 (NLR 2.0-5.0) patients had the best survival after treatment with adriamycin (lnHR (95 % CI = 0.48 [0.31, 0.75] and lnHR (95 % CI = 0.41 [0.19, 0.91]). Among the Group 4 patients (NLR<2.0), the best outcome was obtained with platinum + adriamycin (lnHR (95 % CI = 0.59 [0.45, 0.78]), followed by adriamycin. A subgroup analysis of TACE combined with other treatments showed that adriamycin combined with sorafenib was the most effective and superior to the other treatment agents.

Interpretation

The NLR can be used to predict the prognosis of HCC patients treated with TACE; the higher the NLR is, the worse the prognosis. Adriamycin may be the best therapeutic agent for HCC patients treated with TACE.

MASLD-Related HCC-Update on Pathogenesis and Current Treatment Options

Hepatocellular carcinoma (HCC) is a common complication of chronic liver diseases and remains a relevant cause of cancer-related mortality worldwide. The global prevalence of metabolic dysfunction-associated steatotic liver disease (MASLD) as a risk factor for hepatocarcinogenesis is on the rise. Early detection of HCC has been crucial in improving the survival outcomes of patients with metabolic dysfunction-associated steatohepatitis (MASH), even in the absence of cirrhosis. Understanding how hepatocarcinogenesis develops in MASH is increasingly becoming a current research focus. Additive risk factors such as type 2 diabetes mellitus (T2DM), genetic polymorphisms, and intestinal microbiota may have specific impacts. Pathophysiological and epidemiological associations between MASH and HCC will be discussed in this review. We will additionally review the available tumor therapies concerning their efficacy in MASH-associated HCC treatment.

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.

The neutrophil-to-lymphocyte ratio is a predictive factor for the survival of patients with hepatocellular carcinoma undergoing transarterial chemoembolization

Background

Neutrophil-to-lymphocyte ratio (NLR) is considered as a prognostic predictor of hepatocellular carcinoma (HCC). However, its prognostic ability is still controversial. This study aimed to evaluate the prognostic value of NLR changes in HCC patients undergoing transarterial chemoembolization (TACE).

Methods

The patients who were newly diagnosed with HCC and treated with TACE in our center from July 2010 to December 2014 were enrolled in the study. The factors, including NLR, were recorded at baseline and three days and one month after TACE.

Results

A total of 380 consecutive patients were studied retrospectively. The median NLR values at baseline, 3 days and 1 month after TACE (2.4, 6.3 and 2.4 respectively), were used as the cut-off value for patient stratification. Compared with the patients in low NLR group, those with high NLR had a larger tumor size. For baseline measurement, the low NLR group showed improved overall survival (OS) compared with the high group (median OS, 27.1 vs. 15.6 months, P=0.004). There was no survival difference between the low and high NLR groups when measured at 3 days and at 1 month after TACE (P>0.05). Multivariate analysis showed that baseline NLR >2.4 was an independent prognostic predictor of poor OS. There was significant survival difference between the normal NLR group and the high or increased NLR group, with a median OS of 29.1 and 19.1 months, respectively (P=0.023).

Conclusions

The dynamic changes of baseline NLR are significantly associated with OS in HCC patients treated with TACE, and as a result patient selection and prognostic prediction may be refined.

Prognostic significance of inflammatory indices in hepatocellular carcinoma treated with transarterial chemoembolization: A systematic review and meta-analysis

Objectives

To investigate the association between inflammatory indices and clinical outcomes of hepatocellular carcinoma (HCC) patients treated with transarterial chemoembolization (TACE) by performing meta-analysis.

Methods

A systematic literature search for relevant studies published up to August 2019 was performed by using PubMed, Web of Science, EMBASE, China National Knowledge Internet (CNKI) and Wanfang databases. Pooled hazard ratios (HR) or odds ratio (OR) and 95% confidence intervals (95% CI) were calculated.

Results

A total of 5280 patients from 22 studies were finally enrolled in the meta-analysis. The results demonstrated that elevated preoperative NLR, PLR, and CRP was associated with poor OS in HCC patients treated by TACE (HR = 1.81, P<0.00001; HR = 1.56, P = 0.007; HR = 1.45, P<0.00001, respectively). In addition, high NLR was significantly correlated with the presence of tumor vascular invasion (OR = 1.49, P = 0.002). Elevated PLR tended to be correlated with higher incidence of tumor size>3 cm (OR = 2.42, P = 0.005).

Conclusions

Elevated preoperative NLR, PLR, and CRP are associated with poor prognosis in HCC patients treated with TACE. These inflammatory indices may be convenient, accessible, affordable and dependable biomarkers with prognostic potential for HCC patients treated by TACE.

Prognostic and clinicopathological significance of Gamma-Glutamyltransferase in patients with hepatocellular carcinoma: A PRISMA-compliant meta-analysis

BACKGROUND

Many studies explored the prognostic and clinicopathological significance of pretreatment serum Gamma-Glutamyltransferase (GGT) level in hepatocellular carcinoma (HCC). However, there are inconsistent results in the prognostic and clinicopathological significance of pretreatment serum GGT level in HCC. Thus, we conducted this meta-analysis to comprehensively assess the prognostic and clinicopathological significance of pretreatment serum GGT level in HCC patients.

METHODS

We systematically searched PubMed, EMBASE and Web of Science for relevant studies (up to June 14, 2018). The estimated hazard ratios (HRs) were used to assess the association between pretreatment serum GGT level and survival in HCC patients. The estimated odds ratios (ORs) were applied to evaluate the correlation between pretreatment serum GGT and clinicopathological features in HCC.

RESULTS

Our results showed that high pretreatment serum GGT level was significantly correlated with poor overall survival (OS) (HR = 1.70, 95% CI: 1.54-1.87; P < .01) and disease-free survival/relapse-free survival (DFS/RFS) (HR = 1.56, 95% CI: 1.42-1.71; P < .01). Additionally, our results also revealed that there was a close correlation between GGT level and several clinicopathological features in HCC patients, including vascular invasion, tumor size, tumor number and Alpha-fetoprotein (AFP) level.

CONCLUSIONS

This meta-analysis shows that high pretreatment serum GGT level is significantly correlated with poor survival and unfavorable clinicopathological features in HCC patients, suggesting that pretreatment serum GGT may be an economical and effective prognostic biomarker for HCC patients. However, more high-quality studies are still warranted to further validate our findings, considering there are several limitations in this meta-analysis.

The prognostic significance of pretreatment serum γ-glutamyltranspeptidase in primary liver cancer: a meta-analysis and systematic review

Aim: To assess the prognostic value of the pretreatment serum γ-glutamyltranspeptidase (GGT) level in patients with primary liver cancer (PLC). Methods: Relevant studies were systematically searched online on Web of Science, PubMed, and Embase databases published until 9 October 2018. The end points were overall survival (OS), recurrence-free survival (RFS), and disease-free survival (DFS). Meta-analysis was conducted using hazard ratio (HR), and its 95% confidence interval (CI) as effect measure. Results: A total of 33 eligible studies with 9238 patients with PLC were included in this meta-analysis. The synthesized analysis showed that that higher serum GGT level was significantly related to poorer OS (HR: 1.79, 95% CI: 1.66–1.93, P<0.01), RFS (HR: 1.60, 95% CI: 1.46–1.77, P<0.01), and DFS (HR: 1.52, 95% CI: 1.33–1.73, P<0.01) of patients with PLC. Subgroup analyses demonstrated that the negative prognostic impact of higher serum GGT level on OS and RFS was still of significance regardless of ethnicity, pathological type, sample size, cut-off value, first-line treatment, and analysis type. Conclusion: The pretreatment serum GGT might be a predictive factor of poor prognosis for PLC patients.

Neutrophil-to-lymphocyte ratio as prognostic indicator in gastrointestinal cancers: a systematic review and meta-analysis

An accurate, time efficient, and inexpensive prognostic indicator is needed to reduce cost and assist with clinical decision making for cancer management. The neutrophil-to-lymphocyte ratio (NLR), which is derived from common serum testing, has been explored in a variety of cancers. We sought to determine its prognostic value in gastrointestinal cancers and performed a meta-analysis of published studies using the Meta-analysis Of Observational Studies in Epidemiology guidelines. Included were randomized control trials and observational studies that analyzed humans with gastrointestinal cancers that included NLR and hazard ratios (HR) with overall survival (OS), disease-free survival (DFS), progression-free survival (PFS), and/or cancer-specific survival (CSS).

We analyzed 144 studies comprising 45,905 patients, two-thirds of which were published after 2014. The mean, median, and mode cutoffs for NLR reporting OS from multivariate models were 3.4, 3.0, 5.0 (±IQR 2.5-5.0), respectively. Overall, NLR greater than the cutoff was associated with a HR for OS of 1.63 (95% CI, 1.53-1.73; P < 0.001). This association was observed in all subgroups based on tumor site, stage, and geographic region. HR for elevated NLR for DFS, PFS, and CSS were 1.70 (95% CI, 1.52-1.91, P < 0.001), 1.64 (95% CI, 1.36-1.97, P < 0.001), and 1.83 (95% CI, 1.50-2.23, P < 0.001), respectively.

Available evidence suggests that NLR greater than the cutoff reduces OS, independent of geographic location, gastrointestinal cancer type, or stage of cancer. Furthermore, DFS, PFS, and CSS also have worse outcomes with elevated NLR.

The pretreatment neutrophil-lymphocyte ratio may predict prognosis of patients with liver cancer: A systematic review and meta-analysis

BACKGROUND

At present, several studies have reported that the pretreatment neutrophil-lymphocyte ratio (NLR) may be associated with the prognosis of liver cancer. Nevertheless, their conclusions remain controversial. Thus, we performed a meta-analysis of 54 studies to evaluate the prognostic value of NLR.

METHOD

Databases including PubMed, Embase, Cochrane Library, and Web of Science were searched to July 2017.

RESULT

A total of 54 studies including 12 979 patients were included in this meta-analysis. Elevated NLR had a close relationship with the overall survival (OS) (HR 1.52; 95% CI 1.39-1.67), recurrence-free survival (RFS) (HR 1.84; 95% CI 1.48-2.30), and disease-free survival (DFS) (HR 1.71; 95% CI 1.39-2.11) of liver cancer, respectively. In addition, elevated NLR was associated with the presence of tumor vascular invasion (OR 2.35; 95% CI 1.93-2.86), multiple tumors (OR 1.38; 95% CI 1.15-1.66), alpha-fetoprotein ≥ 400 ng/mL (OR 1.51; 95% CI 1.15-1.98), presence of HbsAg (+) (OR 0.68; 95% CI 0.51-0.90), and cirrhosis (OR: 0.59; 95% CI 0.44-0.80).

CONCLUSION

This meta-analysis indicated that elevated NLR may be an effective and noninvasive indicator for prognosis of patients with liver cancer.

Prognostic value of the neutrophil-to-lymphocyte ratio for hepatocellular carcinoma patients with portal/hepatic vein tumor thrombosis

AIM

To investigate whether the preoperative neutrophil-to-lymphocyte ratio (NLR) could predict the prognosis of hepatocellular carcinoma (HCC) patients with portal/hepatic vein tumor thrombosis (PVTT/HVTT) after hepatectomy.

METHODS

The study population included 81 HCC patients who underwent hepatectomy and were diagnosed with PVTT/HVTT based on pathological examination. The demographics, laboratory analyses, and histopathology data were analyzed.

RESULTS

Overall survival (OS) and disease-free survival (DFS) were determined in the patients with a high (> 2.9) and low (≤ 2.9) NLR. The median OS and DFS duration in the high NLR group were significantly shorter than those in the low NLR group (OS: 6.2 mo vs 15.7 mo, respectively, P = 0.007; DFS: 2.2 mo vs 3.7 mo, respectively, P = 0.039). An NLR > 2.9 was identified as an independent predictor of a poor prognosis of OS (P = 0.034, HR = 1.866; 95%CI: 1.048-3.322) in uni- and multivariate analyses. Moreover, there was a significantly positive correlation between the NLR and the Child-Pugh score (r = 0.276, P = 0.015) and the maximum diameter of the tumor (r = 0.435, P < 0.001). Additionally, the NLR could enhance the prognostic predictive power of the CLIP score for DFS in these patients.

CONCLUSION

The preoperative NLR is a prognostic predictor after hepatectomy for HCC patients with PVTT/HVTT. NLR > 2.9 indicates poorer OS and DFS.

Neutrophil-to-lymphocyte ratio for the prognostic assessment of hepatocellular carcinoma: A systematic review and meta-analysis of observational studies

BACKGROUND AND AIMS

Neutrophil to lymphocyte ratio (NLR) is an inflammatory-based marker. A systematic review and meta-analysis was performed to explore the prognostic role of NLR in patients with hepatocellular carcinoma (HCC).

RESULTS

Overall, 598 papers were identified, of which 90 papers including 20,475 HCC patients were finally included. Low baseline NLR was significantly associated with better overall survival (HR = 1.80, 95% CI: 1.59-2.04, p < 0.00001) and recurrence-free or disease-free survival (HR = 2.23, 95% CI: 1.80-2.76, p < 0.00001). Low post- treatment NLR was significantly associated with better overall survival (HR = 1.90, 95% CI: 1.22-2.94, p = 0.004). Decreased NLR was significantly associated with overall survival (HR = 2.23, 95%CI: 1.83-2.72, p < 0.00001) and recurrence-free or disease-free survival (HR = 2.23, 95% CI: 1.83-2.72, p < 0.00001). The findings from most of subgroup meta-analyses were consistent with those from the overall meta-analyses.

MATERIALS AND METHODS

All relevant literatures were identified via PubMed, EMBASE, and Cochrane library databases. Hazard ratio (HR) with 95% confidence interval (95%CI) was calculated. Subgroup meta-analyses were performed according to the treatment options, NLR cut-off value ranges, and regions.

CONCLUSIONS

NLR should be a major prognostic factor for HCC patients. NLR might be further incorporated into the prognostic model of HCC.

Influence of gastrointestinal factors on glucose metabolism in patients with cirrhosis

BACKGROUND AND AIM

The impaired glucose tolerance in cirrhosis is poorly understood. We evaluated the influence of gastrointestinal-mediated glucose disposal and incretin effect in patients with cirrhosis.

METHODS

Non-diabetic patients with Child-Pugh A or B cirrhosis (n = 10) and matched healthy controls (n = 10) underwent a 50-g oral glucose tolerance test (OGTT) and an isoglycemic intravenous glucose infusion. We presented data as median ± interquartile range and compared groups using non-parametric analysis of variance.

RESULTS

Patients with cirrhosis were glucose intolerant compared with healthy controls (4-h OGTTAUC : 609 ± 458 vs 180 ± 155 min × mmol/L; P = 0.005), insulin resistant (homeostatic model assessment for insulin resistance: 3.7 ± 4.9 vs 2.6 ± 1.4; P = 0.014) and had fasting hyperglucagonemia (8 ± 3 vs 3 ± 4 pmol/L; P = 0.027). Isoglycemia was achieved using 35 ± 12 g of intravenous glucose in patients with cirrhosis compared with 24 ± 10 g in healthy controls (P = 0.003). The gastrointestinal-mediated glucose disposal was markedly lower in patients with cirrhosis (30 ± 23 vs 52 ± 20%; P = 0.003). Despite higher levels of the incretin hormones glucagon-like peptide-1 and glucose-dependent insulinotropic peptide patients with cirrhosis had reduced incretin effect (35 ± 44 vs 55 ± 30%; P = 0.008).

CONCLUSION

Impaired gastrointestinal-mediated glucose disposal and reduced incretin effect may contribute to the glucose intolerance seen in patients with cirrhosis.

Prediction of chemotherapeutic efficacy using the ratio of neutrophils to lymphocytes in patients with unresectable or recurrent gastric cancer

In cancer patients, the balance between neutrophil (N) and lymphocyte (L) cell counts fluctuates with the tumor load. The objective of the present study was to determine the implications of the chemotherapy effect by the fluctuations of N/L ratio in patients with unresectable or recurrent gastric cancer. The study participants were identified from a prospective cohort of patients with unresectable or recurrent gastric cancer (n=135). The median N/L ratio was 3.23 (range: 0.76-20.45) prior to chemotherapy (pre-chemo-N/L ratio) and 2.55 (range: 1.17-13.45) following 2-4 weeks from when the chemotherapy was completed (post-chemo-N/L ratio), respectively. The median overall survival was 7.9 months. The results demonstrated that the N/L ratio of the post-chemotherapy was significantly reduced compared with the pre-chemotherapy group (P<0.001). The survival rate for the pre-chemo-N/L ratio ≥4.0 group was significantly reduced compared to the N/L <4.0 group (P=0.01). The difference of the pre-chemo-N/L ratio subtracted from the post-chemo-N/L ratio can inflect the chemotherapy effect, respectively. These results indicate that the N/L ratio may be used to predict the potential chemotherapy efficacy in unresectable or recurrent gastric cancer.

Portal vein tumor thrombus in advanced hepatocellular carcinoma: A case report

Portal vein tumor thrombus (PVTT) in hepatocellular carcinoma (HCC) is a common entity. However, the prognosis of patients with hepatocellular carcinoma (HCC) with portal vein tumor thrombus (PVTT) is extremely poor. The current study reports a case of HCC with PVTT, including a description of the gross surgical pathology and discussion of the relevance of assessing the growth of the tumor thrombus to the outcome of this disease. This case suggests that destruction of the primary tumor and PVTT must be considered according to the growth characteristics and modality of PVTT. It also indicates that transcatheter arterial embolization may be a suitable strategy for palliative treatment of patients with advanced HCC with PVTT.