Neutrophil to lymphocyte ratio as an indicator of the malignant behaviour of hepatocellular carcinoma

C-Reactive Protein-Albumin Ratio (CAR): A More Promising Inflammation-Based Prognostic Marker for Patients Undergoing Curative Hepatectomy for Hepatocellular Carcinoma

Background

Systemic inflammatory response is a hallmark of cancer and plays a significant role in the development and progression of various malignant tumors. This research aimed to estimate the prognostic function of the C-reactive protein-albumin ratio (CAR) in patients undergoing hepatectomy for hepatocellular carcinoma (HCC) and compare it with other inflammation-based prognostic scores, including the neutrophil-lymphocyte ratio, platelet-lymphocyte ratio, monocyte-lymphocyte ratio, systemic immune inflammation index, prognostic index, Glasgow prognostic score, and modified Glasgow prognostic score.

Methods

Retrospective analysis was conducted on data from 1039 HCC cases who underwent curative liver resection. The prognostic performance of CAR was compared with other scores using the area under the time-dependent receiver operating characteristic (t-ROC) curve. Multivariable Cox regression analyses were performed to confirm independent predictors for disease-free survival (DFS) and overall survival (OS).

Results

The area under the t-ROC curve for CAR in the evaluation of DFS and OS was significantly greater than that of other scores and alpha-fetoprotein (AFP). Patients were stratified based on the optimal cut-off value of CAR, and the data revealed that both DFS and OS were remarkably worse in the high-CAR set compared to the low-CAR set. Multivariable Cox analysis demonstrated that CAR was an independent prognostic parameters for assessing DFS and OS. Regardless of AFP levels, all patients were subsequently divided into significantly different subgroups of DFS and OS based on CAR risk stratification. Similar results were observed when applying CAR risk stratification to other scoring systems. CAR also showed good clinical applicability in patients with different clinical features.

Conclusion

CAR is a more effective inflammation-based prognostic marker than other scores and AFP in predicting DFS as well as OS among patients with HCC after curative hepatectomy.

Prognostic implications of alpha-fetoprotein and C-reactive protein elevation in hepatocellular carcinoma following resection (PACE): a large cohort study of 2770 patients

BACKGROUND

Routine clinical staging for hepatocellular carcinoma (HCC) incorporates liver function, general health, and tumor morphology. Further refinement of prognostic assessments and treatment decisions may benefit from the inclusion of tumor biological marker alpha-fetoprotein (AFP) and systemic inflammation indicator C-reactive protein (CRP).

METHODS

Data from a multicenter cohort of 2770 HCC patients undergoing hepatectomy were analyzed. We developed the PACE risk score (Prognostic implications of AFP and CRP Elevation) after initially assessing preoperative AFP and CRP's prognostic value. Subgroup analyzes were performed in BCLC cohorts A and B using multivariable Cox analysis to evaluate the prognostic stratification ability of the PACE risk score and its complementary utility for BCLC staging.

RESULTS

Preoperative AFP ≥ 400ng/mL and CRP ≥ 10 mg/L emerged as independent predictors of poorer prognosis in HCC patients who underwent hepatectomy, leading to the creation of the PACE risk score. PACE risk score stratified patients into low, intermediate, and high-risk groups with cumulative 5-year overall (OS) and recurrence-free survival (RFS) rates of 59.6%/44.9%, 43.9%/38.4%, and 20.6%/18.0% respectively (all P < 0.001). Increased PACE risk scores correlated significantly with early recurrence and extrahepatic metastases frequency (all P < 0.001). The multivariable analysis identified intermediate and high-risk PACE scores as independently correlating with poor postoperative OS and RFS. Furthermore, the PACE risk score proficiently stratified the prognosis of BCLC stages A and B patients, with multivariable analyses demonstrating it as an independent prognostic determinant for both stages.

CONCLUSION

The PACE risk score serves as an effective tool for postoperative risk stratification, potentially supplementing the BCLC staging system.

The Immunomodulatory Effect of Various Anaesthetic Practices in Patients Undergoing Gastric or Colon Cancer Surgery: A Systematic Review and Meta-Analysis of Randomized Clinical Trials

BACKGROUND

Gastric and colorectal carcinomas are associated with increased mortality and an increasing incidence worldwide, while surgical resection remains the primary approach for managing these conditions. Emerging evidence suggests that the immunosuppression induced by the chosen anaesthesia approach, during the perioperative period, can have a significant impact on the immune system and consequently the prognosis of these patients.

AIM

This systematic review aims to comprehensively summarize the existing literature on the effects of different anaesthesia techniques on immune system responses, focusing on cellular immunity in patients undergoing the surgical removal of gastric or colorectal carcinomas. There is no meta-analysis investigating anaesthesia's impact on immune responses in gastric and colorectal cancer surgery. Anaesthesia is a key perioperative factor, yet its significance in this area has not been thoroughly investigated. The clinical question of how the anaesthetic technique choice affects the immune system and prognosis remains unresolved.

METHODS

Major electronic databases were searched up to February 2023 to May 2023 for relevant randomized controlled trials (RCTs). The study protocol has been registered with Prospero (CRD42023441383).

RESULTS

Six RCTs met the selection criteria. Among these, three RCTs investigated the effects of volatile-based anaesthesia versus total intravenous anaesthesia (TIVA), while the other three RCTs compared general anaesthesia alone to the combination of general anaesthesia with epidural anaesthesia. According to our analysis, there were no significant differences between TIVA and volatile-based anaesthesia, in terms of primary and secondary endpoints. The combination of general anaesthesia with epidural analgesia had a positive impact on NK cell counts (SMD 0.61, 95% CI 0.28 to 0.94, I2 0.0% at 24 and 72 h after the operation), as well as on CD4+ cells (SMD 0.59, CI 95% 0.26 to 0.93, I2 0.0%). However, the CD3+ cell count, CD4+/CD8+ ratio, neutrophil-to-lymphocyte ratio (NLR), IL-6 and TNF-α levels remained unaffected.

CONCLUSIONS

The combination of epidural analgesia and general anaesthesia can potentially improve, postoperatively, the NK cell count and CD4+ cell levels in gastric or colon surgery patients. However, the specific impact of TIVA or volatile-based anaesthesia remains uncertain. To gain a better understanding of the immunomodulatory effects of anaesthesia, in this particular group of cancer patients, further well-designed trials are required.

Advanced development of biomarkers for immunotherapy in hepatocellular carcinoma

Hepatocellular carcinoma (HCC) is the most common liver cancer and one of the leading causes of cancer-related deaths in the world. Mono-immunotherapy and combination therapy with immune checkpoint inhibitors (ICIs) and multitargeted tyrosine kinase inhibitors (TKIs) or anti-vascular endothelial growth factor (anti-VEGF) inhibitors have become new standard therapies in advanced HCC (aHCC). However, the clinical benefit of these treatments is still limited. Thus, proper biomarkers which can predict treatment response to immunotherapy to maximize clinical benefit while sparing unnecessary toxicity are urgently needed. Contrary to other malignancies, up until now, no acknowledged biomarkers are available to predict resistance or response to immunotherapy for HCC patients. Furthermore, biomarkers, which are established in other cancer types, such as programmed death ligand 1 (PD-L1) expression and tumor mutational burden (TMB), have no stable predictive effect in HCC. Thus, plenty of research focusing on biomarkers for HCC is under exploration. In this review, we summarize the predictive and prognostic biomarkers as well as the potential predictive mechanism in order to guide future research direction for biomarker exploration and clinical treatment options in HCC.

Fashionable, but What is Their Real Clinical Usefulness? NLR, LMR, and PLR as a Promising Indicator in Colorectal Cancer Prognosis: A Systematic Review

The link between inflammation and cancer is still an attractive subject of many studies because systemic inflammatory response has been proven to play a pivotal role in cancer progression and metastasis. The strongest relationship between chronic inflammation and cancer development is observed in colorectal cancer (CRC). The evaluation of ratios derived from the routinely performed inflammatory biomarkers shows limited performances and limited clinical utility when individually used as prognostic factors for patients with CRC. In this review, we would like to summarize the latest knowledge about the diagnostic utility of systemic inflammatory ratios: neutrophil/lymphocyte (NLR), lymphocyte/monocyte (LMR), and platelet/lymphocyte (PLR) in CRC. We focused on the papers that assessed the diagnostic utility of blood cell parameters on the basis of the area under the ROC curve published in the recent 6 years. Identification of biomarkers that are significantly associated with prognostic in cancer would help the selection of patients with a high risk of poor outcomes.

The causal relationship between white blood cell counts and hepatocellular carcinoma: a Mendelian randomization study

BACKGROUND

Most of hepatocellular carcinoma (HCC) arises on the background of chronic inflammation. The presence of infiltrating inflammatory cells is associated with tumour initiation, progression and clinical response to treatment. The influence of white blood cell (WBC) subtype counts on HCC progression remains unclear.

METHODS

In this study, we performed a Mendelian randomization (MR) study with the validation of two datasets. The summary data for WBC counts were extracted from a recent large GWAS of individuals of European ancestry. The GWAS data related to HCC were obtained from the UK Biobank (UKB). Univariable and multivariable MR analyses were used to identify risk factors genetically associated with HCC risks.

RESULTS

In the discovery dataset, multivariable MR analysis revealed that sum basophil neutrophil counts had an independent causal effect on the occurrence of HCC, with the sum basophil neutrophil counts as follows: (OR = 0.437, P = 0.003, CI 0.252-0.757). Similarly, in the validation dataset, total basophil neutrophil counts were also been identified as an independent risk factor for HCC. The sum basophil neutrophil counts were as follows: (OR = 0.574, P = 0.021, CI 0.358-0.920).

CONCLUSION

In the European population, genetically predicted lower total basophil neutrophil counts might be an independent risk factor for HCC.

Neutrophil to Lymphocyte Ratio and Platelet to Lymphocyte Ratio in Hepatocellular Carcinoma Treated with Stereotactic Body Radiotherapy

PURPOSE

To investigate the prognostic value of the neutrophil to lymphocyte ratio (NLR) and platelet to lymphocyte ratio (PLR) in patients with hepatocellular carcinoma (HCC) treated with stereotactic body radiotherapy (SBRT).

METHODS

The medical records of HCC patients treated with SBRT between 2008 and 2019 were reviewed retrospectively. The NLR and PLR were calculated from the serum complete blood count before and after SBRT, and the prognostic values of the NLR and PLR for the treatment outcomes were evaluated.

RESULTS

Thirty-nine patients with 49 HCC lesions were included. After a median follow-up of 26.8 months (range, 8.4-80.0 months), three-year local control, overall survival (OS), and progression-free survival (PFS) rate were 97.4%, 78.3%, and 35.2%, respectively. Both NLR and PLR increased significantly after SBRT and decreased slowly to the pre-SBRT value at 6 months. Univariable analysis showed that gross tumor volume (GTV) >14 cc, post-SBRT PLR >90, and PLR change >30 were associated with a poorer OS (p=0.002, p=0.011, and p=0.001, respectively), and the PLR change was significant in multivariable analysis (hazard ratio [HR], 10.09; 95% CI, 1.15-88.40; p=0.037). For PFS, GTV >14 cc, post-SBRT NLR >2.5 and post-SBRT PLR >90 were predictive of a poorer PFS in univariable analysis (p=0.011, p=0.004 and p=0.041, respectively) and only post-SBRT NLR >2.5 remained significant in multivariable analysis (HR, 2.44; 95% CI, 1.03-5.76; p=0.042, respectively).

CONCLUSIONS

The NLR and PLR increased transiently after SBRT, and the post-SBRT NLR and PLR were associated with the clinical outcomes of HCC patients.

Neutrophils as potential therapeutic targets in hepatocellular carcinoma

The success of atezolizumab plus bevacizumab treatment contributed to a shift in systemic therapies for hepatocellular carcinoma (HCC) towards combinations that include cancer immunotherapeutic agents. Thus far, the principal focus of cancer immunotherapy has been on interrupting immune checkpoints that suppress antitumour lymphocytes. As well as lymphocytes, the HCC environment includes numerous other immune cell types, among which neutrophils are emerging as an important contributor to the pathogenesis of HCC. A growing body of evidence supports neutrophils as key mediators of the immunosuppressive environment in which some cancers develop, as well as drivers of tumour progression. If neutrophils have a similar role in HCC, approaches that target or manipulate neutrophils might have therapeutic benefits, potentially including sensitization of tumours to conventional immunotherapy. Several neutrophil-directed therapies for patients with HCC (and other cancers) are now entering clinical trials. This Review outlines the evidence in support of neutrophils as drivers of HCC and details their mechanistic roles in development, progression and metastasis, highlighting the reasons that neutrophils are well worth investigating despite the challenges associated with studying them. Neutrophil-modulating anticancer therapies entering clinical trials are also summarized.

A nomogram for predicting the risk of postoperative recurrence of hepatitis B virus-related hepatocellular carcinoma in patients with high preoperative serum glutamyl transpeptidase

BACKGROUND

Recurrence is a major risk factor affecting the postoperative survival of patients with hepatocellular carcinoma (HCC), especially those with high preoperative serum γ-glutamyl transpeptidase (GGT) levels. This study had the aim of developing a personalized predictive tool to accurately determine the risk of postoperative recurrence of hepatitis B-virus (HBV)-related HCC in patients with high preoperative serum GGT levels.

METHODS

Patients who underwent curative liver resection of HBV-related HCC and had high preoperative GGT levels were consecutively enrolled between 2008 and 2011. Prognostic indicators for recurrence were determined using Cox regression analysis. A nomogram was then developed and assessed by integrating the independent risk factors into the model.

RESULTS

A total of 603 eligible patients were included. The final nomogram for predicting HCC recurrence in patients with high preoperative GGT levels consisted of five independent prognostic factors: α-fetoprotein (AFP), HBV-DNA, satellite nodules, microvascular invasion, and tumor grade. The C-index of the nomogram for predicting recurrence was 0.759, and validation showed high accuracy and discriminatory.

CONCLUSIONS

The predictive nomogram developed and validated in this study performs well in predicting postoperative recurrence of HBV-related HCC in patients with high preoperative GGT levels. It can provide personalized assessments to inform the development of surveillance strategies and allows patients with a high risk of recurrence to be selected for further adjuvant treatment.

Prognostic Nomogram for Patients with Hepatitis E Virus-related Acute Liver Failure: A Multicenter Study in China

BACKGROUND AND AIMS

Timely and effective assessment scoring systems for predicting the mortality of patients with hepatitis E virus-related acute liver failure (HEV-ALF) are urgently needed. The present study aimed to establish an effective nomogram for predicting the mortality of HEV-ALF patients.

METHODS

The nomogram was based on a cross-sectional set of 404 HEV-ALF patients who were identified and enrolled from a cohort of 650 patients with liver failure. To compare the performance with that of the model for end-stage liver disease (MELD) scoring and CLIF-Consortium-acute-on-chronic liver failure score (CLIF-C-ACLFs) models, we assessed the predictive accuracy of the nomogram using the concordance index (C-index), and its discriminative ability using time-dependent receiver operating characteristics (td-ROC) analysis, respectively.

RESULTS

Multivariate logistic regression analysis of the development set carried out to predict mortality revealed that γ-glutamyl transpeptidase, albumin, total bilirubin, urea nitrogen, creatinine, international normalized ratio, and neutrophil-to-lymphocyte ratio were independent factors, all of which were incorporated into the new nomogram to predict the mortality of HEV-ALF patients. The area under the curve of this nomogram for mortality prediction was 0.671 (95% confidence interval: 0.602-0.740), which was higher than that of the MELD and CLIF-C-ACLFs models. Moreover, the td-ROC and decision curves analysis showed that both discriminative ability and threshold probabilities of the nomogram were superior to those of the MELD and CLIF-C-ACLFs models. A similar trend was observed in the validation set.

CONCLUSIONS

The novel nomogram is an accurate and efficient mortality prediction method for HEV-ALF patients.

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.

Neutrophil-lymphocyte ratio and the risk of hepatocellular carcinoma in patients with hepatitis B-caused cirrhosis

AIM

The neutrophil-to-lymphocyte ratio (NLR) has been reported as a prognostic marker of hepatocellular carcinoma (HCC); however, the relationship between NLR and risk of HCC occurrence has yet to be systematically elucidated. We aimed to investigate the association between NLR and HCC risk in patients with hepatitis B-caused cirrhosis (HBC) undergoing antiviral therapy.

METHODS

A total of 1599 patients with HBC receiving entecavir or tenofovir at three tertiary hospitals between June 2014 and November 2017 were included. Cox proportional hazards regression was used to identify the association between NLR and risk of HCC occurrence by adjusting for potential risk factors. The cumulative incidence of HCC was evaluated using Kaplan-Meier analysis.

RESULTS

At study enrollment, the median NLR was 2.0 (interquartile range, 1.4-3.0). The 3-year cumulative probabilities of HCC were 4.8, 8.4, 13.2, and 18.0% across the NLR quartiles, respectively (P < 0.001). Compared with the lowest quartile, higher NLR correlated with an increased HCC occurrence [NLR 1.4-2.0: adjusted hazard ratio (aHR), 1.18 (95% confidence interval (CI), 1.11-1.25); NLR 2.0-3.0: aHR, 2.09 (95% CI, 1.19-3.66); NLR > 3.0: aHR, 2.80 (95% CI, 1.59-4.95); P for trend = 0.001] in the fully adjusted models. In the subgroup analysis, elevated NLR was associated with increased HCC risk, regardless of stratification criteria.

CONCLUSION

Elevated NLR is an independent risk factor for HCC occurrence in patients with HBC undergoing antiviral therapy.

The Prognostic Value of the Albumin to Gamma-Glutamyltransferase Ratio in Patients with Hepatocellular Carcinoma Undergoing Radiofrequency Ablation

Albumin to gamma-glutamyltransferase ratio (AGR) is a newly developed biomarker for the prediction of patients' prognosis in solid tumors. The purpose of the study was to establish a novel AGR-based nomogram to predict tumor prognosis in patients with early-stage HCC undergoing radiofrequency ablation (RFA). 394 hepatocellular carcinoma (HCC) patients who had received RFA as initial treatment were classified into the training cohort and validation cohort. Independent prognostic factors were identified by univariate and multivariate analyses. The value of AGR was evaluated by the concordance index (C-index), receiver operating characteristic (ROC) curves, and likelihood ratio tests (LAT). Logistic regression and nomogram were performed to establish the pretreatment scoring model based on the clinical variables. As a result, AGR = 0.63 was identified as the best cutoff value to predict overall survival (OS) in the training cohort. According to the results of multivariate analysis, AGR was an independent indicator for OS and recurrence-free survival (RFS). In both training cohort and validation cohort, the high-AGR group showed better RFS and OS than the low-AGR group. What is more, the C-index, area under the ROC curves, and LAT χ 2 values suggested that AGR outperformed the Child-Pugh (CP) grade and albumin-bilirubin (ALBI) grade in terms of predicting OS. The AGR, AKP, and tumor size were used to establish the OS nomogram. Besides, the results of Hosmer-Lemeshow test and calibration curve analysis displayed that both nomograms in the training and validation cohorts performed well in terms of calibration. Therefore, the AGR-based nomogram can predict the postoperative prognosis of early HCC patients undergoing RFA.

Neutrophil Lymphocyte Ratio to Albumin Ratio and White Blood Cell to Hemoglobin Ratio as Prognostic Markers for Hepatocellular Carcinoma Patients Who Underwent Curative Hepatectomy

Purpose

Inflammation factors affect the prognosis of hepatocellular carcinoma (HCC). However, it is not clear if the preoperative neutrophil lymphocyte ratio to albumin ratio (NLRAR) and white blood cell to hemoglobin ratio (WHR) affect the prognosis of HCC post curative hepatectomy. We assessed the prognostic values of NLRAR and WHR in patients suffering from HCC who underwent curative resection.

Materials and Methods

A total of 169 eligible HCC cases were reviewed. The optimal cut-off values for NLRAR and WHR were selected using the X-tile software. The overall survival (OS) rate was assessed following the Kaplan–Meier analysis method. The Log rank test and Cox proportional hazard regression model were also used to analyze the data. The prognostic values of NLRAR and WHR were calculated by analyzing the area under the receiver operating characteristic curve (AUC). The decision curve analysis (DCA) was performed for clinical benefits.

Results

The OS rate recorded for the high NLRAR group was poorer than the OS rate recorded for the low NLRAR group. Similar trends were observed for WHR. The NLRAR and WHR were the independent predictors of OS. The results were based on the multivariate Cox analyses method. Results obtained by analyzing the subgroups revealed that NLRAR and WHR could be used for the prognosis of HCC in tumor stage I-patients. The NLRAR–WHR scoring system (NWS) could be used to classify HCC patients into two cohorts with different prognoses. This scoring system was more efficient than NLRAR or WHR in predicting OS.

Conclusion

The preoperative NLRAR and WHR are effective prognostic indicators for HCC in patients who underwent curative hepatectomy.

Cellular based immunotherapy for primary liver cancer

Primary liver cancer (PLC) is a common malignancy with high morbidity and mortality. Poor prognosis and easy recurrence on PLC patients calls for optimizations of the current conventional treatments and the exploration of novel therapeutic strategies. For most malignancies, including PLC, immune cells play crucial roles in regulating tumor microenvironments and specifically recognizing tumor cells. Therefore, cellular based immunotherapy has its instinctive advantages in PLC therapy as a novel therapeutic strategy. From the active and passive immune perspectives, we introduced the cellular based immunotherapies for PLC in this review, covering both the lymphoid and myeloid cells. Then we briefly review the combined cellular immunotherapeutic approaches and the existing obstacles for PLC treatment.

Development and validation of prognostic nomograms for single large and huge hepatocellular carcinoma after curative resection

AIM

The prediction model of postoperative survival for single large and huge hepatocellular carcinoma (SLH-HCC, diameter > 5.0 cm) without portal vein tumour thrombus has not been well established. This study aimed to develop novel nomograms to predict postoperative recurrence and survival of these patients.

METHODS

Data from 2469 patients with SLH-HCC who underwent curative resection from January 2005 to December 2015 in China were retrospectively collected. Specifically, nomograms of recurrence-free survival (RFS) and overall survival (OS) using data from a training cohort were developed with the Cox regression model (n = 1012). The modes were verified in an internal validation cohort (n = 338) and an external cohort comprising four tertiary institutions (n = 1119).

RESULTS

The nomograms of RFS and OS based on tumour clinicopathologic features (diameter, differentiation, microvascular invasion, α-fetoprotein), operative factors (preoperative transcatheter arterial chemoembolisation therapy, scope of liver resection and intraoperative blood transfusion), underlying liver function (albumin-bilirubin grade) and systemic inflammatory or immune status (neutrophil-to-lymphocyte ratio) achieved high C-indexes of 0.85 (95% confidence interval [CI], 0.79-0.91) and 0.86 (95% CI, 0.79-0.93) in the training cohort, respectively, which were significantly higher than those of the five conventional HCC staging systems (0.62-0.73 for RFS, 0.63-0.75 for OS). The nomograms were validated in the internal cohort (0.83 for RFS, 0.84 for OS) and external cohort (0.87 for RFS, 0.88 for OS) and had well-fitted calibration curves. Our nomograms accurately stratified patients with SLH-HCC into low-, intermediate- and high-risk groups of postsurgical recurrence and mortality.

CONCLUSIONS

The two nomograms achieved optimal prediction for postsurgical recurrence and OS for patients with SLH-HCC after curative resection.

Prognostic value of the NLR combined with CIP2A in the serum of patients with colorectal cancer

Objective

This study aimed to investigate the prognostic value of CIP2A (cancerous inhibitor of protein phosphatase 2A) and the NLR (neutrophil–lymphocyte ratio) in the serum of patients with CRC (colorectal cancer) after resection.

Methods

The clinicopathological data of 61 patients who underwent resection between January 2012 and December 2013 were collected. The NLR and CIP2A were divided into low score groups (0) and high score groups (1) with 2.03 and 6.07 as the optimal cut-off value according to the receiver operating characteristic (ROC) curve analysis. To identify the COCN (combination of CIP2A and the NLR) score, we added CIP2A and NLR points together and categorized CRC patients into three groups. Kaplan–Meier curves were used to identify the overall survival (OS) rates of the different groups. Finally, a ROC curve was plotted to evaluate the prognostic efficacy of COCN.

Results

The CIP2A was associated with location (P = 0.046) and CEA (P = 0.037) in patients with CRC. Kaplan–Meier survival curves showed that the 5-year OS of patients with low level of serum CIP2A was better than that of high level. The 5-year OS of the patients in the low NLR group was better than that of those in the high NLR group. The COCN score was associated with CEA (P < 0.001) and CA19-9 (P = 0.001). The 5-year OS of the patients in the COCN 0 group was highest, followed by that of those in the COCN 1 and COCN 2 groups. Age, N stage and M stage were factors associated with 5-year OS according to the univariate and multivariate analyses (P < 0.05). The area under the curve (AUC) for COCN was largest, indicating that COCN has better prognostic power than CIP2A or the NLR alone.

Conclusion

COCN could be used as a better prognostic biomarker for CRC than the NLR or CIP2A alone.

Sarcomatoid hepatocellular carcinoma is distinct from ordinary hepatocellular carcinoma: Clinicopathologic, transcriptomic and immunologic analyses

Sarcomatoid hepatocellular carcinoma (SHCC), which was a rare histological subtype of hepatocellular carcinoma (HCC), is currently subclassified as poorly differentiated HCC because of insufficient evidence to define SHCC as a subtype of HCC. We aimed to assess the feasibility of classifying SHCC as a histological subtype of HCC by comprehensively identifying novel and distinct characteristics of SHCC compared to ordinary HCC (OHCC). Fifteen SHCCs (1.4%) defined as HCC with at least a 10% sarcomatous component, 15 randomly disease-stage-matched OHCCs and 163 consecutive OHCCs were extracted from 1106 HCCs in the Pathology Database (1997-2019) of our hospital. SHCC patients showed poor prognosis, and the tumors could be histologically subclassified into the pleomorphic, spindle and giant cell types according to the subtype of carcinomas with sarcomatoid or undifferentiated morphology in other organs. The transcriptomic analysis revealed distinct characteristics of SHCC featuring the upregulation of genes associated with epithelial-to-mesenchymal transition and inflammatory responses. The fluorescent multiplex immunohistochemistry results revealed prominent programmed death-ligand 1 (PD-L1) expression on sarcomatoid tumor cells and higher infiltration of CD4⁺ and CD8⁺ T cells in SHCCs compared to OHCCs. The density of CD8⁺ T cells in the nonsarcomatous component of SHCCs was also higher than that in OHCCs. In conclusion, the comprehensive analyses in our study demonstrated that SHCC is distinct from OHCC in terms of clinicopathologic, transcriptomic and immunologic characteristics. Therefore, it is reasonable to consider SHCC as a histological subtype of HCC.

Defining the Risk of Early Recurrence Following Curative-Intent Resection for Distal Cholangiocarcinoma

BACKGROUND

Although multidisciplinary treatments including the use of adjuvant therapy (AT) have been adopted for biliary tract cancers, patients with distal cholangiocarcinoma (DCC) can still experience recurrence. We sought to characterize the incidence and predictors of early recurrence (ER) that occurred within 12 months following surgery for DCC.

PATIENTS AND METHODS

Patients who underwent resection for DCC between 2000 and 2015 were identified from the US multi-institutional database. Cox regression analysis was used to identify clinicopathological factors to develop an ER risk score, and the predictive model was validated in an external dataset.

RESULTS

Among 245 patients included in the analysis, 67 patients (27.3%) developed ER. No difference was noted in ER rates between patients who did and did not receive AT (28.7% vs. 25.0%, p = 0.55). Multivariable analysis revealed that neutrophil-to-lymphocyte ratio (NLR), peak total bilirubin (T-Bil), major vascular resection (MVR), lymphovascular invasion, and R1 surgical margin status were associated with a higher ER risk. A DIstal Cholangiocarcinoma Early Recurrence Score was developed according to each factor available prior to surgery [NLR > 9.0 (2 points); peak T-bil > 1.5 mg/dL (1 points); MVR (2 points)]. Cumulative ER rates incrementally increased among patients who were low (0 points; 10.6%), intermediate (1-2 points; 26.8%), or high (3-5 points; 57.6%) risk (p < 0.001) in the training dataset, as well as in the validation dataset [low (0 points); 3.4%, intermediate (1-2 points); 32.7%, or high risk (3-5 points); 55.6% (p < 0.001)].

CONCLUSIONS

Among patients undergoing resection for DCC, 1 in 4 patients experienced an ER. Alternative treatment strategies such as neoadjuvant chemotherapy may be considered especially among individuals deemed to be at high risk for ER.

Prognostic value of the preoperative lymphocyte-to-monocyte ratio for survival after lung cancer surgery

Background

The aim of this study was to assess the effect of the lymphocyte-to-monocyte ratio (LMR), neutrophil-to-lymphocyte ratio and platelet-to-lymphocyte ratio on overall survival and disease-free survival in patients with lung cancer treated with radical surgery.

Methods

We performed a retrospective review of patients with lung cancer who prospectively underwent radical resection between 2004 and 2012. Blood samples were taken as part of the preoperative workup. The inflammatory markers studied were absolute values of lymphocytes, monocytes, neutrophils and platelets, with subsequent calculation of ratios. Median follow-up was 52 months.

Results

Two hundred and sixty-eight patients underwent surgery, of whom 218 (81.3%) were men. Mean age was 62.9 ± 8.7 years. A lymphocyte-to-monocyte ratio ≥ 2.5 was independently associated with longer disease-free survival (hazard ratio [HR] 0.476 (0.307–0.738), p = 0.001) and longer overall survival (HR, 0.546; 95% CI: 0.352–0.846; p = 0.007), in models adjusted for age, sex, stage, and type of resection. No other systemic inflammatory marker showed a significant association.

Conclusion

Preoperative LMR is an independent prognostic factor of overall survival and recurrence-free survival in patients with surgically-resected early stage lung cancer.

Multi-institutional validation of novel models for predicting the prognosis of patients with huge hepatocellular carcinoma

The population of patients with huge hepatocellular carcinoma (H-HCC diameter > 10.0 cm) is an odd group that is not well adjudicated in the current staging systems, whose prognosis after curative resection varies. We aimed to develop novel models to predict the long-term outcomes of patients with H-HCC without portal vein tumor thrombus after hepatectomy. There were 1076 H-HCC patients enrolled who underwent curative liver resection in five institutions in China. In total, 670 patients were recruited from our center and randomly divided into the training cohort (n = 502) and internal validation (n = 168) cohorts. Additionally, 406 patients selected from other four centers as the external validation cohort. Novel models were constructed based on independent preoperative and postoperative predictors of postsurgical recurrence (PSR) and postsurgical mortality (PSM) determined in multivariable cox regression analysis. The predictive accuracy and discriminative ability of the model were measured using Harrell's concordance index (C index) and calibration curve and compared with five conventional HCC staging systems. PSR model and PSM model were constructed based on tumor number, microscopic vascular invasion, tumor differentiation, preoperative alpha-fetoprotein level, albumin-bilirubin grade, liver segment invasion, neutrophil-to-lymphocyte ratio or platelet-to-neutrophil ratio, and surgical margin or intraoperative blood transfusion. The C-indexes were 0.84 (95% CI, 0.78-0.90) and 0.85 (95% CI, 0.78-0.91) for the PSR and PSM models, respectively, which were substantially higher than those of the five conventional HCC staging systems (0.63-0.75 for PSR; 0.66-0.77 for PSM). The two novel models achieved more accurate prognostic predictions of PSR and PSM for H-HCC patients after curative liver resection.

Neutrophil-to-lymphocyte ratio correlates with prognosis and response to chemotherapy in patients with non-M3 de novo acute myeloid leukemia

Background

Neutrophil-to-lymphocyte (NLR) ratio can predict survival outcome and assess response to chemotherapy in several tumors. However, the values of NLR in acute myeloid leukemia (AML) remains unknown.

Methods

A retrospective review of 181 patients with de novo AML excluding acute promyelocytic leukemia (M3) was conducted in our institute. We categorized the patients into two groups by defining NLR =2.0 as the cut-off point. NLR was calculated by the ratio of the number of neutrophils to lymphocytes in the peripheral blood (PB). The baseline clinicopathologic parameters were compared using Chi-squared test or Kruskal-Wallis H test. Kaplan-Meier analysis was used to assess survival, and overall survival (OS) and disease-free survival (DFS) were analyzed using the Cox regression with log-rank tests.

Results

We found AML patients with low NLR (<2.0) had longer OS and DFS than those with high NLR (≥2.0). NLR, absolute neutrophil count (ANC), and absolute lymphocyte count (ALC) were significantly associated with OS and DFS in all AML patients. NLR, ANC, and ALC were associated with OS and DFS only in those case with myeloblasts over 50% in bone marrow (BM). Furthermore, the median NLR was dramatically increased in low NLR group when patients achieved complete remission (CR).

Conclusions

Pretreatment NLR as a marker can predict the prognosis and NLR can assess the response to chemotherapy in patients with non-M3 AML, especially in those cases with myeloblasts over 50% in BM.

Clinical Significance of Preoperative Albumin-Bilirubin Grade in Pancreatic Cancer

BACKGROUND

No study has clarified the clinical significance of albumin-bilirubin (ALBI) grade in a large cohort of pancreatic cancer patients.

METHODS

A total of 1006 consecutive patients diagnosed with pancreatic cancer and deemed eligible for surgical resection were analyzed. The ALBI score was calculated as: ALBI score = (log₁₀ bilirubin [µmol/L] × 0.66) + (albumin [g/L]  × - 0.0852). ALBI grade was assigned as grade 1, 2a, 2b, and 3. ALBI grade 1 was assigned to the ALBI low group (N = 566), and grades 2a, 2b, and 3 to the ALBI high group (N = 440).

RESULTS

The primary lesion could not be resected in 129 patients. Among all patients, overall survival (OS) was significantly worse in the ALBI high group than in the ALBI low group (P = 0.024). Overall, 877 patients underwent pancreatectomy. In these patients, the ALBI high group was associated with high CA19-9 level (P < 0.001), lower morbidity rate (P < 0.001), and pancreatic head tumor (P = 0.001). Patients' OS after resection was significantly worse in the ALBI high group than in the ALBI low group (P < 0.001). Cox proportional hazard analysis revealed ALBI grade as an independent predictor for prognosis (hazard ratio, 1.33; P = 0.015). Even in the CA19-9 negative patients, OS was significantly worse in the ALBI high group than in the ALBI low group (P = 0.046).

CONCLUSIONS

The ALBI grade is a clinically useful predictor for prognosis in pancreatic cancer patients.

Predictive value of preoperative and postoperative peripheral lymphocyte difference in hepatitis B virus-related hepatocellular cancer patients: Based on the analysis of dynamic nomogram

BACKGROUND

Inflammation plays an important role in the progression and prognosis of hepatocellular carcinoma (HCC). Our aim is to explore the prognostic value of preoperative and postoperative peripheral lymphocyte differences and to develop a dynamic prognosis nomogram in hepatitis B virus-related HCC patients.

METHODS

Important indicators related to overall survival (OS) are screened out by Cox proportional hazard models. The receiver operating characteristic curves, decision curve analysis curves, net reclassification improvement, and integrated discrimination improvement were used to evaluate the performance of the model.

RESULTS

Lymphocyte (L) difference was an independent risk factor. It was further verified that the performance of the nomogram was significantly improved after the L difference was incorporated into the nomogram. The nomogram generated had the area under curves of 0.779, 0.775, and 0.793 at 3, 5, and 7 years after surgery, respectively. Our nomogram models showed significantly better performance in predicting the HCC prognosis compared to other models. And online webserver and scoring system table was built based on the proposed nomogram for convenient clinical use.

CONCLUSIONS

It is newly found that L difference is an effective predictor of OS, and the nomogram based on this indicator can accurately predict the prognosis of HCC patients.

A-G Score Associated With Outcomes in Solitary Hepatocellular Carcinoma Patients After Hepatectomy

Aim: The study aimed to investigate the clinical significance of preoperative alpha-fetoprotein (AFP) and gamma-glutamyl transferase (GGT) (A-G score) on hepatocellular carcinoma (HCC) patients.

Methods: A total of 474 solitary HCC patients were included. Survival analysis was evaluated by Kaplan-Meier method. Prognostic factors were analyzed in a multivariate model. The comparison of the predictive value of AFP, GGT, and A-G score was performed by receiver operating characteristic curve (ROC) analysis and decision curve analysis (DCA).

Results: Of the 474 patients, 137(28.9%), 241(50.8%), and 96(20.3%) patients were assigned to A-G score 0, 1, and 2, respectively. In multivariate analysis, A-G score, tumor size, microvascular invasion, tumor differentiation, satellite lesion, and state of HBV infection were independently predictive factors for RFS of solitary HCC patients. The A-G score could significantly stratify solitary HCC patients with a distinguished prognosis. The 1-, 3-, and 5-year RFS and OS among patients with A-G score 1 was better than that of patients with A-G score 2 and worse than that of patients with A-G score 0(all p < 0.05). Based on the result from the ROC analysis and DCA analysis, the A-G score appeared to be superior to either AFP or GGT alone in the prediction of prognosis of solitary HCC patients. In the subgroup analysis, the A-G score could accurately predict the prognosis of solitary HCC patients without MVI or with liver cirrhosis.

Conclusions: Preoperative A-G score could effectively and simply predict prognosis of solitary HCC patients after hepatectomy, especially for those with non-MVI solitary HCC or those with liver cirrhosis.

Novel Models Predict Postsurgical Recurrence and Overall Survival for Patients with Hepatitis B Virus-Related Solitary Hepatocellular Carcinoma ≤10 cm and Without Portal Venous Tumor Thrombus

BACKGROUND

The predictive model of postsurgical recurrence for solitary early hepatocellular carcinoma (SE-HCC) is not well established. The aim of this study was to develop a novel model for prediction of postsurgical recurrence and survival for patients with hepatitis B virus (HBV)-related SE-HCC ≤10 cm.

PATIENTS AND METHODS

Data from 1,081 patients with HBV-related SE-HCC ≤10 cm who underwent curative liver resection from 2003 to 2016 in our center were collected retrospectively and randomly divided into the derivation cohort (n = 811) and the internal validation cohort (n = 270). Eight hundred twenty-three patients selected from another four tertiary hospitals served as the external validation cohort. Postsurgical recurrence-free survival (RFS) and overall survival (OS) predictive nomograms were generated. The discriminatory accuracies of the nomograms were compared with six conventional hepatocellular carcinoma (HCC) staging systems.

RESULTS

Tumor size, differentiation, microscopic vascular invasion, preoperative α-fetoprotein, neutrophil-to-lymphocyte ratio, albumin-to-bilirubin ratio, and blood transfusion were identified as the risk factors associated with RFS and OS. RFS and OS predictive nomograms based on these seven variables were generated. The C-index was 0.83 (95% confidence interval [CI], 0.79-0.87) for the RFS-nomogram and 0.87 (95% CI, 0.83-0.91) for the OS-nomogram. Calibration curves showed good agreement between actual observation and nomogram prediction. Both C-indices of the two nomograms were substantially higher than those of the six conventional HCC staging systems (0.54-0.74 for RFS; 0.58-0.76 for OS) and those of HCC nomograms reported in literature.

CONCLUSION

The novel nomograms were shown to be accurate at predicting postoperative recurrence and OS for patients with HBV-related SE-HCC ≤10 cm after curative liver resection.

IMPLICATIONS FOR PRACTICE

This multicenter study proposed recurrence or mortality predictive nomograms for patients with hepatitis B virus-related solitary early hepatocellular carcinoma ≤10 cm after curative liver resection. A close postsurgical surveillance protocol and adjuvant therapy should be considered for patients at high risk of recurrence.

Predictors of outcome after liver transplantation for hepatocellular carcinoma (HCC) beyond Milan criteria

The Milan criteria have been the cornerstone of selection policies for patients with hepatocellular carcinoma (HCC) awaiting liver transplantation (LT) globally for over two decades. Many groups have proposed the transplantation of patients with larger and more numerous tumors achieving comparable results. Many of these use radiologic morphometric criteria as surrogates for explant pathology to predict outcomes. Several other indices have been developed both within and beyond Milan incorporating biological indices as well as dynamic markers of response to pre-transplant locoregional treatments and waiting time. These have allowed for successful expansion of transplant selection criteria without compromising outcomes with limited organ supplies. In this review we will discuss the predictors of outcome in patients beyond Milan criteria.

Perioperative blood transfusion has distinct postsurgical oncologic impact on patients with different stage of hepatocellular carcinoma

Background

The influence of perioperative blood transfusion (PBT) on postsurgical survival of patients with different stage of hepatocellular carcinoma (HCC) is not well clarified. This study aimed to evaluate the impact of PBT on survival outcomes of different stage of HCC patients.

Methods

Consecutive patients who underwent liver resection for HCC between January 2009 and November 2015 were identified from an HCC prospective database in authors’ center. The survival outcomes were compared between patients receiving PBT and those without PBT before and after propensity score matching (PSM) in different stage subsets. Cox regression analysis was performed to verify the impact of PBT on outcomes of HCC.

Results

Among 1255 patients included, 804 (64.1%) were Barcelona Clinic Liver Cancer (BCLC) stage 0-A, and 347 (27.6%) received PBT. Before PSM, patients with PBT had worse disease free survival (DFS) and overall survival (OS) compared with those without PBT in both BCLC 0-A subset and BCLC B-C subset (all P < 0.05). After PSM, 288 pairs of patients (with and without PBT) were created. In the subset of BCLC 0-A, the median DFS of patients with PBT was shorter than those without PBT (12.0 months vs. 36.0 months, P = 0.001) Similar result was observed for OS (36.0 months vs. 96.0 months, P = 0.001). In the subset of BCLC B-C, both DFS and OS were comparable between patients with PBT and those without PBT. Cox regression analysis showed that PBT involved an increasing risk of DFS (HR = 1.607; P < 0.001) and OS (HR = 1.756; P < 0.001) for this subset. However, PBT had no impact on DFS (P = 0.126) or OS (P = 0.139) for those with stage B-C HCC.

Conclusions

PBT negatively influenced oncologic outcomes of patient with BCLC stage 0-A HCC, but not those with stage B-C after curative resection.

Early risk warning system for distant metastasis of hepatitis B virus-associated hepatocellular carcinoma with portal vein tumor thrombus

Portal vein tumor thrombus (PVTT) promotes distant metastasis of hepatocellular carcinoma (HCC), which increases the mortality of patients with HCC and PVTT. The aim of the present study was to develop an early risk warning system for distant metastasis of hepatitis B virus (HBV)-associated primary HCC (HBV-HCC) with PVTT. Data from 346 patients (263 and 83 in the modeling and validation cohorts, respectively) who had received primary diagnoses of HBV-HCC and PVTT between January 2012 and June 2015 at Beijing Ditan Hospital (Beijing, China) were retrospectively examined. In the modeling cohort, univariate and multivariate logistic regression analyses were conducted to determine the factors that were significantly associated with distant metastasis. Furthermore, an early risk warning model for distant metastasis was proposed and validated through receiver operating characteristic curve analysis in the validation cohort. The results revealed that neutrophil to lymphocyte ratios of ≥2.31, red blood cell counts of ≥4.07×10¹² cells/l, C-reactive protein levels of ≥7.02 mg/l, aspartate aminotransferase levels of ≥118.5 U/l and tumor thrombus site (at branch) were significantly positively associated with distant metastasis of HBV-HCC with PVTT (P<0.05; odds ratio >1.000). A formula for predicting distant metastasis was obtained with an accuracy of ~70%. The results of the present study may allow for the early prediction of distant metastasis and facilitate the administration of appropriate treatment to improve the outcomes and prognosis of patients with intermediate to advanced HCC.

A novel prognostic nomogram based on microvascular invasion and hematological biomarkers to predict survival outcome for hepatocellular carcinoma patients

PURPOSE

This study aimed to develop and validate a nomogram for overall survival (OS) prediction in which combine clinical characteristics and hematological biomarkers in patients with hepatocellular carcinoma (HCC).

METHODS

We performed a retrospective analysis of 807 HCC patients. All the clinical data of these patients were collected through electronic medical record (EMR). The independent predictive variables were identified by cox regression analysis. We tested the accuracy of the nomograms by discrimination and calibration, and then plotted decision curves to assess the benefits of nomogram-assisted decisions in a clinical context, and compared with the TNM staging systems and microvascular invasion (MVI) on HCC prognosis.

RESULTS

The primary cohort consisted of 545 patients with clinicopathologically diagnosed with HCC from 2008 to 2013, while 262 patients from 2014 to 2016 in external validation cohort. Variables included in the nomograms were TNM Stage, microvascular invasion (MVI), alpha fetoprotein (AFP), platelet to lymphocyte ratio (PLR) and prothrombin time (PT). The C-index of nomogram was 0.768, which was superior than the C-index of TNM Stage (0.660, P < 0.001) and MVI(0.664, P < 0.001) alone in the primary cohort. In the validation cohort, the models had a C-index of 0.845, and were also statistically higher when compared to C-index values for TNM Stage (0.687, P < 0.001) and MVI(0.684, P < 0.001). Calibration curves showed adequate calibration of predicted and reported OS prediction throughout the range of HCC outcomes. Decision curve analysis demonstrated that the nomogram was clinically useful than the TNM Stage and MVI alone. Moreover, patients were divided into three distinct risk groups for OS by the nomogram: low risk group, middle risk group and a high risk group, respectively.

CONCLUSION

The nomogram presents more accurate and useful prognostic power, which could be used to predict OS for patients with HCC.

The Preoperative Prognostic Nutritional Index in Hepatocellular Carcinoma After Curative Hepatectomy: A Retrospective Cohort Study and Meta-Analysis

OBJECTIVE

Conflicting results existed about the role of prognostic nutritional index (PNI) for hepatocellular carcinoma (HCC) patients who received curative hepatectomy. The aim of this study is to identify the predictive capacity of PNI for survival after hepatectomy.

METHODS

Preoperative PNI, neutrophil-to-lymphocyte ratio (NLR), tumor feature and clinical information of 187 patients with HCC from Sir Run Run Shaw hospital were evaluated. We also conducted a meta-analysis of seven cohort studies.

RESULTS

Our study showed that HCC patients with a low PNI of <45 had a poor recurrence-free survival (RFS) rate (hazard ratio [HR] 1.762, 95% confidence interval [CI] 1.066-2.911, p = 0.027, respectively). The 5-year OS and RFS rates of the high PNI (≥45) vs low PNI (<45) were 76.7% vs 50.1% (p = 0.001) and 47.0% vs 28.9% (p = 0.001), respectively. In HCC TNM I patients (n = 144), a low PNI remained an independent prognostic factor of OS and RFS (HR 2.305, 95% CI 1.008-5.268, p = 0.048; HR 2.122, 95% CI 1.149-3.920, p = 0.016). The 5-year OS and RFS rates of the high PNI vs low PNI were 81.3% vs 62.4% (p = 0.041) and 53.4% vs 45.6% (p = 0.013), respectively. In the pooled analysis, the data showed that a low PNI was significantly associated with poor OS and RFS (HR 2.27, 95% CI 1.03-4.07, p < 0.001 and HR 1.68, 95% CI 1.45-1.94, p < 0.001, respectively).

CONCLUSIONS

The preoperative PNI was an independent prognostic factor for OS and RFS rates in HCC patients who received hepatectomy.

Analysis of Clinical Characteristics and Poor Prognostic Predictors in Patients With an Initial Diagnosis of Autoimmune Encephalitis

Purpose: We aimed to retrospectively analyze the clinical features, laboratory and imaging results, and predictors of poor prognosis for patients with an initial diagnosis of autoimmune encephalitis (AE) at the Affiliated Hospital of Zunyi Medical University. Methods: Fifty patients with an initial diagnosis of AE who were admitted to our hospital from May 2014 to May 2018 were enrolled retrospectively. Clinical characteristics and experimental test data, including the neutrophil-to-lymphocyte ratio (NLR), were collected from medical records within 24 h of admission. Independent prognostic factors were determined by multivariate logistic regression analysis. A good or poor prognosis for patients was defined based on the modified Rankin Scale (mRS). The correlation between the immunotherapy latency and prognostic mRS score was determined using the Spearman rank correlation test. Results: Univariate analysis indicated that increased NLR (P = 0.001), decreased lymphocyte counts (P = 0.001), low serum albumin (P = 0.017), consciousness disorders (P = 0.001), epileptic seizures (P = 0.007), extrapyramidal symptoms (P = 0.042), abnormal electroencephalogram (EEG) findings (P = 0.001), abnormal brain magnetic resonance imaging (MRI) findings (P = 0.003), and pulmonary infection complications (P = 0.000) were associated with the poor prognosis of AE. Multivariate logistic regression analysis showed that NLR (odds ratio [OR] 2.169, 95% confidence interval [CI] 1.029-4.570; P < 0.05) was an independent risk factor for predicting the poor prognosis of AE. NLR > 4.45 was suggested as the cut-off threshold for predicting the adverse outcomes of AE. In addition, we revealed that there was a positive correlation between immunotherapy latency and mRS score (r_s = 0.535, P < 0.05). Conclusions: NLR may have predictive value for the poor outcomes of AE. Early initiation of immunotherapy is associated with a good prognosis.

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.

Underlying liver disease and advanced stage liver cancer are associated with elevated neutrophil-lymphocyte ratio

Background/Aims

Inflammation-based scores, such as the neutrophil-to-lymphocyte ratio (NLR), have been associated with prognosis in hepatocellular carcinoma (HCC); but variable cut-off values and potential lack of specificity have limited the utility of NLR. This study evaluates NLR in a large cohort of HCC patients.

Methods

We retrospectively reviewed 789 HCC cases (1993–2017) for demographics, tumor characteristics, treatment, and survival. NLR was stratified into NLR ≥1.5 and NLR ≥3 and analyzed for correlation with American Joint Committee on Cancer (AJCC) and Barcelona Clinic Liver Cancer (BCLC) stages. In 235 patients who underwent liver resection, survival and recurrence were evaluated by NLR.

Results

In 789 HCC cases, mean NLR was increased with advanced AJCC and BCLC stages. Hepatitis C patients were less likely to have NLR ≥1.5 and ≥3. Non-alcoholic steatohepatitis patients were more likely to have NLR ≥3. Patients with tumor size >5 cm, rupture, or macrovascular invasion were more likely to have NLR ≥3. In patients treated with resection, NLR ≥3 predicted early recurrence (odds ratio [OR] 4.14, P<0.01) and overall recurrence (OR 4.05, P<0.01). Mean NLR was 4.30 in those with recurrence and 2.75 in those without recurrence. Patients with NLR ≥3 showed significantly worse survival compared to those with NLR <3 (P<0.01 by log-rank test).

Conclusions

Elevated NLR is associated with advanced cancer stage and aggressive tumor characteristics, such as large size, rupture, and invasion. NLR ≥3 was associated with early and overall recurrence after resection but varied with etiology. NLR may be a useful biomarker in predicting recurrence for HCC patients undergoing curative resection, but further studies are required to elucidate the effect of disease etiology.

Prognostic markers affecting the early recurrence of hepatocellular carcinoma with liver cirrhosis after curative resection

Background:

Early recurrence is associated with poor prognosis after curative resection for hepatocellular carcinoma. Thus, we studied which factors, including this inflammation-based scoring system, affect disease recurrence in single hepatocellular carcinoma patients with liver cirrhosis.

Methods:

A total of 430 consecutive hepatocellular carcinoma patients were enrolled in our institution between January 2002 and December 2015. Survival rate, univariate, and multivariate analyses were performed to identify the variables associated with recurrence and early recurrence especially.

Results:

The overall survival rate was significantly lower in the early recurrence group than in the non-early recurrence group ( P<0.001). According to the multivariate analysis, protein induced by vitamin K absence or antagonist (PIVKA) greater than 200 ( P=0.035), neutrophil-to-lymphocyte ratio greater than 2.0 ( P<0.001), elevated Glasgow prognostic score ( P=0.003), tumor size greater than 5 cm ( P=0.002), and the presence of lymphovascular invasion ( P=0.002) were significantly different among the groups and affected the early recurrence of hepatocellular carcinoma. The patients were categorized into five levels of risk for early recurrence according to the number of independent risk factors, and patients with no risk factors were set as the reference group.

Conclusion:

Neutrophil-to-lymphocyte ratio, Glasgow prognostic score, and serum level of PIVKA offer significant prognostic information associated with early recurrence following single lesion hepatocellular carcinoma patients with liver cirrhosis after curative resection.

Hepatocellular carcinoma in a rapidly growing community: Epidemiology, clinico-pathology and predictors of extrahepatic metastasis

BACKGROUND AND STUDY AIMS

Hepatocellular carcinoma (HCC) with extrahepatic metastasis has been studied, however, data from the Middle East remain scarce. In this study, we assess epidemiology of HCC in Qatar, and identify predictors of the metastatic behaviour.

PATIENTS AND METHODS

All newly-diagnosed HCC patients on top of liver cirrhosis between 2011 and 2015 were included in the study.

RESULTS

A total of 180 patients met our inclusion criteria. The mean age was 58.8 ± 10.5 years with a mean follow-up of 1.0 ± 1.1 years. There were 150 male patients and HCV was the most common cause of liver cirrhosis 108 (60%), and 22 (12.2%) patients were classified as Child-Pugh class C. The overall survival of 51.1%, and 47 (26%) had at least one extrahepatic metastasis at the time of diagnosis. Single site metastasis was diagnosed in 10 patients, whereas 37 patients had multiple sites metastases. We compared patients who had metastases with patients who did not have metastasis at the time of diagnosis of HCC regarding several variables, and analysis revealed that tumour diameter larger than 5 cm (OR = 6.10, 95% CI = 1.85-20.12) (p = 0.003), and bilobar liver involvement (OR = 5.49, 95% CI = 1.10-27.30) (p = 0.037) were independent predictors of metastatic behaviour of HCC.

CONCLUSION

The incidence of HCC is rising in our population, extrahepatic metastasis is no longer rare and tumours larger than 5 cm and bilobar involvement are determinants of the extrahepatic metastasis.

Utility and Limitation of Preoperative Neutrophil Lymphocyte Ratio as a Prognostic Factor in Hepatocellular Carcinoma

Background

The neutrophil lymphocyte ratio (NLR) has been proposed to be a surrogate marker of inflammation and immunological status and to have prognostic value in various malignancies. This study was conducted to clarify the prognostic significance of preoperative NLR in hepatocellular carcinoma (HCC).

Methods

We enrolled 135 patients with histologically-proven HCC who underwent initial curative hepatectomy. Based on the median NLR values, patients were divided into: NLR ≥ 2.0 (NLR-high, n = 69) and NLR < 2.0 (NLR-low, n = 66).

Results

In univariate analysis, the 5-year overall survival (OS) rates were 59.8 % ± 6.7% and 75.6% ± 6.5% (P = 0.028) in the NLR-high and NLR-low groups, respectively. Furthermore, the 5-year disease specific survival rates were 68.6% ± 6.7%, and 81.2 ± 6.4% (P = 0.048) in the NLR-high and NLR-low groups, respectively.

Conclusion

Our results showed that high NLR was an independent predictor for OS in hepatectomy-treated HCC, suggesting that NLR may be a novel prognostic biomarker for HCC. On the other hand, NLR also has a limitation to predict postoperative prognosis of HCC patients by itself.

Prognostic significance of neutrophil/prealbumin ratio for intrahepatic cholangiocarcinoma undergoing curative resection

BACKGROUND

This study aimed to clarify the prognostic significance of neutrophil/prealbumin ratio index (NPRI) for overall survival (OS) and recurrence free survival (RFS) of ICC after curative surgery.

METHODS

Two-hundred and seventy-six ICC patients who underwent curative resection from December 2006 to April 2017 were recruited and analyzed retrospectively. The correlations between clinicopathological features and NPRI were analyzed. OS and RFS were calculated using Kaplan-Meier curve, and cox univariate and multivariate analyses were used to identify the prognostic factors.

RESULTS

The optimal cut-off value of NPRI determined by ROC curve was 1.74 and the patients were divided into high-value and low-value groups. High-value NPRI was associated with higher risk of postoperative complications (p = 0.035) and longer hospitalization (p = 0.004).Univariate and multivariate cox analyses demonstrated that NPRI was an independent predictor for OS (p = 0.015) and RFS (p = 0.004) in ICC after curative resection. Furthermore, NPRI was also a significant predictor for OS and RFS in different subgroups of ICC, including CA19-9<35U/mL, single tumor, no vascular invasion, no local invasion and AJCC stages I + II.

CONCLUSIONS

NPRI was an independent prognostic predictor for ICC after curative resection. It would have high clinical values due to its convenience.

Nomograms based on inflammatory biomarkers for predicting tumor grade and micro-vascular invasion in stage I/II hepatocellular carcinoma

Background: Increasing evidences reveal that inflammation plays a critical role in tumorigenesis and progression. We aimed to develop the nomograms based on inflammatory biomarkers to predict micro-vascular invasion (MVI) and tumor grade in stage I/II hepatocellular carcinoma (HCC).Methods: A retrospective cohort of 627 patients with stage I/II HCC between January 2007 and December 2014 was included in the study. Logistic regression was performed to identify the independent risk factors of tumor grade and MVI. The significant predictors including neutrophil-to-lymphocyte ratio (NLR), derived neutrophil-to-lymphocyte ratio (dNLR), lymphocyte-to-monocyte ratio (LMR), tumor volume age, and tumor size were subsequently incorporated to build the nomograms. The prediction accuracies of the nomograms were evaluated using the area under the receiver operating characteristic (ROC) curve.Results: The independent risk factors for tumor grade were NLR, dNLR, and tumor volume (P<0.001, P=0.001, and P<0.001, respectively), which were assembled into tumor grade nomogram. MVI nomogram was developed by dNLR, LMR, age, and tumor size (P<0.001, P<0.001, P<0.001, and P=0.001, respectively) which were the independent predictors for MVI. The area under the ROC curve of nomograms for predicting tumor grade and MVI were 0.727 (95% confidence intervals [CI]: 0.690-0.761) and 0.839 (95% CI: 0.808-0.867), respectively. Patients who had a nomogram score of less than 100 and 79 were considered to have high possibility of moderate grade and have low risks of MVI presence, respectively.Conclusion: We successfully developed nomograms predicting tumor grade and MVI based on inflammatory biomarkers with high accuracy, leading to a rational therapeutic choice for stage I/II HCC.

Prognostic role of inflammatory biomarkers in HIV-infected patients with a first diagnosis of hepatocellular carcinoma: A single-center study

OBJECTIVES

To assess hepatocellular carcinoma (HCC) survival and to investigate the prognostic role of immunonutritional biomarkers, as neutrophil to lymphocyte ratio (NLR), platelet to lymphocyte ratio (PLR) and prognostic nutritional index (PNI), in a cohort of human immunodeficiency virus (HIV)-infected patients.

METHODS

All HIV-positive patients diagnosed with HCC at our Department from January 2000 to December 2013 were included. The outcomes were overall survival (OS), recurrence-free survival (RFS), and liver-related death (LRD). To examine the role of inflammatory biomarkers on the outcomes, univariate and multivariable Cox regression models were used. Receiver operating characteristic (ROC) curves were implemented to evaluate the prediction role of NLR, PLR, and PNI.

RESULTS

A total of 40 patients (90% males) with a mean age of 48.3 years (SD = 5.6) were recruited. NLR ≥ 2.9 was associated with all causes mortality, as well as, PLR ≥ 126. NLR and PLR were predictors of OS, RFS, and LRD, while PNI did not emerge as a prognostic marker. According to the multivariate analysis, no HCC treatment was the only risk factor associated with risk of death. The areas under the ROC curves were 68.3 (95% confidence interval [CI], 54.5-82.1) for PLR and 66.3 (95% CI, 54.3-78.2) for NLR at 3 years; similar results were found at 5 years of follow-up.

CONCLUSIONS

Although, if examined singularly, NLR and PLR are prognostic factors for HCC recurrence and survival in HIV-infected patients, at the multivariate analysis, "no HCC treatment" remains the only independent risk factor associated with fatal outcome.

The prognostic significance of serum HBeAg on the recurrence and long-term survival after hepatectomy for hepatocellular carcinoma: A propensity score matching analysis

The effects of serum hepatitis B e antigen (HBeAg) on the prognosis of hepatocellular carcinoma (HCC) patients after hepatectomy remain controversial. Our aim was to explore the prognostic significance of serum HBeAg on the prognosis of patients with HCC using a propensity matching model. Between January 2009 and March 2015, 953 patients with HCC who underwent hepatectomy in West China Hospital were analysed. Propensity matching analysis was applied, and survival analysis was performed using the Kaplan-Meier method. Risk factors were identified by the Cox proportional hazards model. All patients with HCC were classified into an HBeAg(-) group (n = 775, 81.3%) or an HBeAg(+) group (n = 178, 18.7%). Patients with positive serum HBeAg had poorer recurrence-free survival and overall survival before and after propensity matching. Similar results were found in patients within the Milan criteria. For patients beyond the Milan criteria, the HBeAg(+) group had poor overall survival before and after propensity matching. In term of recurrence-free survival, there was no statistically significant impact after propensity matching (P = .055), although there was a trend for HBeAg(+) patient to have reduced recurrence-free survival. Positive serum HBeAg, positive HBV-DNA load, largest tumour size, multiple tumours, microvascular invasion and a high serum level of preoperative alpha-fetoprotein were risk factors for recurrence. Our propensity model confirmed that positive serum HBeAg had a negative impact on the recurrence and long-term survival irrespective of tumour stages. HBeAg seroconversion might be beneficial for reducing the rate of recurrence.

Neutrophil Lymphocyte Ratio and Transarterial Chemoembolization in Neuroendocrine Tumor Metastases

BACKGROUND

The neutrophil-to-lymphocyte ratio (NLR) has been shown to be predictive of outcomes in various cancers, including neuroendocrine tumors (NETs), and cancer-related treatments, including transarterial chemoembolization (TACE). We hypothesized that NLR could be predictive of response to TACE in patients with metastatic NET.

METHODS

We reviewed 262 patients who underwent TACE for metastatic NET at a single tertiary medical center from 2000 to 2016. NLR was calculated from blood work drawn 1 d before TACE, as well as 1 d, 1 wk, and 6 mo after treatment.

RESULTS

The median post-TACE overall survival (OS) of the entire cohort was 30.1 mo. Median OS of patients with a pre-TACE NLR ≤ 4 was 33.3 mo versus 21.1 mo for patients with a pre-TACE NLR >4 (P = 0.005). At 6 mo, the median OS for patients with post-TACE NLR > pre-TACE NLR was 21.4 mo versus 25.8 mo for patients with post-TACE NLR ≤ pre-TACE NLR (P = 0.007). On multivariate analysis, both pre-TACE NLR and 6-mo post-TACE NLR were independent predictors of survival. NLR values from 1-d and 1-wk post-TACE did not correlate with outcome.

CONCLUSIONS

An elevated NLR pre-TACE and an NLR that has not returned to its pre-TACE value several months after TACE correlate with outcomes in patients with NET and liver metastases. This value can easily be calculated from laboratory results routinely obtained as part of preprocedural and postprocedural care, potential treatment strategies.

Long-term outcomes and prognostic markers in gallbladder cancer

Cancer-related inflammation and systemic inflammatory markers have been widely recognized as an essential part in tumor multiplication, invasion, and metastasis of tumor cells. This study aimed to estimate and compare the prognostic value of various biomarkers on overall survival (OS) in patients with gallbladder cancer patients.We performed a retrospective study of 159 patients received different therapies in West China Hospital from 2009 to 2014. The preoperative biomarker data, including neutrophil-lymphocyte ratio (NLR), platelet-lymphocyte ratio (PLR), monocyte-lymphocyte ratio (MLR), lactate dehydrogenase, and alkaline phosphatase, as well as other clinical information, were obtained from electronic record. And the receiver operating characteristic curves were used to analyze the optimal cut-off values of them. Kaplan-Meier survival analysis and Cox proportional hazard model analysis were applied to evaluate the association between markers and OS.The optimal cut-off value was 4.39 for NLR, 181.85 for PLR, 0.30 for MLR, and 3.02 for carcinoembryonic antigen (CEA). Kaplan-Meier analysis and univariate Cox analysis both demonstrated the significant prognostic value of NLR, MLR, and CEA. However, PLR failed to be a significant predictor of OS. The multivariate Cox analysis showed that preoperative NLR and CEA were independent prognostic factors for OS.Advanced tumor/node/metastasis stage, enhanced pretherapeutic NLR, and CEA were significantly associated with worse OS of gallbladder cancer patients. Furthermore, NLR was a better prognostic factor than CEA in advanced T (T3-T4) stage patients, while CEA was better for early T (T1-T2) stage, early N (N0-N1) stage, and early M (M0) stage patients.

Non-linear association between long-term outcome and preoperative neutrophil-to-lymphocyte ratio in patients undergoing curative resection for gastric cancer: a retrospective analysis of 1335 cases in a tetrachotomous manner

Objective

Although the prognostic utility of the pretreatment neutrophil-to-lymphocyte ratio (NLR) has been widely reported for gastric cancer and several other malignancies, the optimal patient stratification methodologies for such analyses have yet to be established. We aimed to examine the predictive value of preoperative NLR in patients with operable gastric cancer, and to elucidate whether or not the relationship between long-term outcome and pretreatment NLR is monotonically linear.

Methods

Preoperative data from 1335 patients who underwent curative surgery for gastric cancer were retrospectively evaluated. Patients were divided into four groups (Q1-Q4) according to preoperative NLR (1.59, 2.11 and 2.96). Survival time was calculated applying the Cox proportional hazard model to both univariate and multivariate estimates.

Results

On univariate Cox regression analysis, preoperative NLR was significantly associated with overall survival (OS) and relapse-free survival (RFS). On subsequent multivariate analysis, preoperative NLR, as a tetrachotomous variable, was independently associated with OS and RFS (P = 0.028, 0.023, respectively). When comparing Q1 with Q3 or Q4 in multivariate analysis, there were no significant prognostic differences in OS (P = 0.23, 0.37, respectively) and RFS (P = 0.26, 0.46, respectively). The Q2 group showed significantly longer RFS than the Q1 group (hazard ratio 0.69, 95% confidence interval 0.48-0.99, P = 0.048).

Conclusions

Although preoperative NLR was significantly associated with long-term outcome in gastric cancer patients, the association was not linear.

The prognostic significance of preoperative neutrophil-lymphocyte ratio in patients with hepatocellular carcinoma receiving hepatectomy: A systematic review and meta-analysis

BACKGROUND AND AIMS

Numerous reports have indicated that preoperative Neutrophil-Lymphocyte ratio (NLR) was correlated with the prognosis of hepatocellular carcinoma who underwent hepatectomy. However, the results still remained controversial. Therefore, the present meta-analysis of 17 studies was performed to evaluate the prognostic value of preoperative NLR in HCC patients.

METHOD

Databases of PubMed, Embase, Cochrane Library and Web of Science were retrieved. Hazard Ratio (HR) or Odds Ratio (OR) with its 95% confidence intervals (CI) was used to evaluate the association between preoperative NLR and the prognosis or clinical features of HCC patients.

RESULT

A total of 17 studies eventually were included in this meta-analysis. Elevated preoperative NLR had a close relationship with the overall survival (OS) (HR 1.52; 95% CI 1.37-1.69), recurrence-free survival (RFS) (HR 1.64; 95% CI 1.44-1.87) and disease-free survival (DFS) (HR 1.50; 95% CI 1.35-1.67) of hepatocellular carcinoma. Additionally, preoperative NLR was also associated with tumor vascular invasion (OR 2.08; 95% CI 1.60-2.70), HBV (OR 0.68; 95% CI 0.51-0.90) and large tumor size (OR: 4.07; 95% CI 2.60-6.37).

CONCLUSION

The present meta-analysis indicated that preoperative NLR had significant association with the prognosis of hepatocellular carcinoma patients and may be an effectively prognostic indicator.

Model predicting the microvascular invasion and satellite lesions of hepatocellular carcinoma after hepatectomy

BACKGROUND

Microvascluar invasion and satellite lesion (MS), important unfavourable pathological factors, significantly contribute to tumour recurrence and impair the prognosis in hepatocellular carcinoma. We aimed to construct a model for the prediction of MS in order to plan treatment better.

METHODS

A total of 1135 consecutive patients with hepatocellular carcinoma who received radical hepatectomy at West China Hospital were randomly assigned to a training set and a validation set. Multivariate analysis was preformed to identify independent risk factors of MS in the training set, and a nomogram was then constructed based on the risk factors. The concordance index (C-index) and a calibration curve were used to assess the predictive performance of the model.

RESULTS

The occurrence rate of MS was about 36.5%. Based on the multivariate analysis, the following six variables were incorporated into the nomogram: age (hazard ratio (HR): 0.531), alpha fetoprotein (HR: 1.327), neutrophil-to-lymphocyte ratio (>2.8, HR: 1.732), international normalized ratio (>1.07, HR: 1.702), tumour size (HR: 1.116) and tumour number (HR: 1.842). The model showed satisfactory discrimination abilities, with a C-index of 0.721 for the training set and 0.704 for the validation set. The receiver operating characteristic curve confirmed the predictive power. Meanwhile, the calibration curve presented a goodness of fit between prediction of the model and actual observations.

CONCLUSIONS

The user-friendly model may be useful for prediction of the occurrence of MS and to plan treatment more rationally preoperatively.

The prognostic value of microvascular invasion in early-intermediate stage hepatocelluar carcinoma: a propensity score matching analysis

Background

Microvascular invasion (MVI) is well established as a negative prognostic factor for hepatocelluar carcinoma (HCC). However, its prognostic value in different subgroups of Barcelona Clinical Liver Cancer (BCLC) stages remains to be elucidated.

Methods

Four hundred fifty-eight MVI-negative and 204 MVI-positive patients who underwent hepatectomy were retrospectively analyzed. After propensity score matching (PSM) analysis, 187 pairs of matched patients were generated. Long-term survival was compared by the Kaplan–Meier method.

Results

Patients with MVI commonly had more advanced tumors. All the patients with MVI had significantly worse survival rate compared to the patients without MVI before and after PSM(p < 0.001). In the subgroup analysis, BCLC stage A HCC patients without MVI had better prognosis than those with MVI before and after PSM (p < 0.001 and p = 0.024). For BCLC stage B HCCs, long-term survival was significantly better for patients without MVI before PSM(p = 0.001). However, the overall survival (OS) rate was comparable between both groups after PSM (p = 0.682), although MVI-positive group had a higher rate of recurrence (p = 0.011).. Surgery type, satellite lesions, tumor size, and serum ALT level were statistically significant factors associated with survival in MVI-positive group. Tumor number, tumor size and neutrophil to lymphocyte ratio (NLR) were predictors of survival in MVI-negative group.

Conclusions

Its prognostic value in different subgroups of BCLC stages differed. MVI is an independent predictor of prognosis in patients with BCLC stage A. For BCLC stage B HCCs, MVI-positive group had poor prognosis through more advanced HCCs.

Prognostic nomograms for patients with resectable hepatocelluar carcinoma incorporating systemic inflammation and tumor characteristics

Background

The model to predict the prognosis of resectable hepatocelluar carcinoma (HCC) has not been determined.

Methods

Predictors were selected using Cox model. Nomograms were generated in the training set and validated in the validation set. The predictive ability of the nomogram was determined by concordance index and calibration curve.

Results

Independent factors for overall survival including alpha-fetoprotein level (hazard ratio (HR):1.292), tumor size (HR:1.092), tumor number (HR:1.472), microvascular invasion (HR:1.660), neutrophil to lymphocyte count ratio (NLR) (HR:1.428), major vascular invasion (HR:2.485) and satellite lesions(HR:1.392) were selected into the nomogram for survival. The c-index in the training set and validation set were 0.767 and 0.719, respectively, which were statistically higher than those of the four conventional staging systems.(Barcelona Clinic Liver Cancer: 0.644 and 0.609; the seventh American Joint Committee on Cancer: 0.678 and 0.674; Cancer of the Liver Italian Program: 0.692 and 0.648; Hong Kong Liver Cancer: 0.689 and 0.639, p < 0.001 for all). A nomogram for predicting 3- and 5-year recurrence free survival was generated with the c-index of 0.746 for the training set and 0.718 for the validation set, respectively.

Conclusions

We have generated nomograms predicting prognosis for HCC treated by hepatectomy with a higher predictive power.

The lymphocyte-to-monocyte ratio is a superior predictor of overall survival compared to established biomarkers in HCC patients undergoing liver resection

The aim of this study was to investigate the prognostic value of the lymphocyte-to-monocyte ratio (LMR) in patients undergoing hepatectomy and to compare it to established biomarkers including the neutrophil-to-lymphocyte ratio (NLR) and platelet-to-lymphocyte ratio (PLR). Medical records were retrospectively analyzed for 652 HCC patients undergoing hepatectomy at the Affiliated Tumor Hospital of Guangxi Medical University and the First People’s Hospital of Changde between April 2004 to April 2012. The correlation between the LMR and clinical variables were analyzed in Kaplan-Meier log-rank survival analysis and then multivariate Cox regression models trying to find relation with disease-free survival (DFS) and overall survival (OS). The area under the ROC curve (AUC) of the LMR(AUC:0.627) for predicting long-term survival was greater than that of the NLR(AUC:0.600) and the PLR(AUC:0.520).Multivariate analysis showed LMR to be an independent risk factor for OS (P = 0.002), and the NLR and PLR were not independently significant. Subgroup analysis also showed that LMR was significantly associated with poor DFS and OS in patients positive for HBsAg or with cirrhosis (both P < 0.001).Elevated preoperative LMR is an independently associated with poor OS and DFS in HCC patients following curative resection and appears to be superior to NLR and PLR.