Neoadjuvant chemoradiotherapy of rectal carcinoma : Baseline hematologic parameters influencing outcomes

Construction and Evaluation of Nomogram for Hematological Indicators to Predict Pathological Response after Neoadjuvant Chemoradiotherapy in Locally Advanced Rectal Cancer

OBJECTIVE

A retrospective study was conducted by developing prediction models to evaluate the association between hematological indexes, their changes during neoadjuvant chemoradiotherapy (NCRT), and tumor pathological response in patients with locally advanced rectal cancer.

METHODS

The clinical data of 202 patients who received NCRT and radical surgery in Sichuan Cancer Hospital were retrospectively analyzed. Univariate and logistic multivariate regression analyses were used to identify hematological indexes with predictive significance. The independent risk factors were imported into the R software, and a nomogram prediction model was developed. The bootstrap method and ROC curve were used to evaluate the discriminative degree of the model.

RESULTS

Univariate analysis demonstrated age, tumor diameter, preoperative T, distance from tumor to the anal verge, CEA before NCRT, preoperative CEA, lymphocyte changes, platelet changes, and pathology of rectal cancer after NCRT were associated. Multivariate analysis demonstrated that age, tumor distance from the anus, preoperative CEA, lymphocyte changes, and platelet changes were independent risk factors. The independent risk factors were imported into the R software to construct a nomogram model. The area under the ROC was 0.76, and the slope of the calibration curve of the nomogram was close to 1.

CONCLUSION

A low preoperative CEA level, a young age, a high tumor from the anal verge, the maintenance of circulating lymphocyte level, and a decreased platelet level after NCRT are important factors for favorable outcomes after NCRT. Developing a nomogram prediction model with good discrimination and consistency can provide some guidance for predicting pathological responses after NCRT.

Neutrophil-to-lymphocyte ratio predict survival of patients with rectal cancer receiving neo-adjuvant chemoradiation followed by radical resection: a meta-analysis

BACKGROUND

Neutrophil-to-lymphocyte ratio is suggested as a prognostic and predictive factor for patients with rectal cancer. The purpose of the current meta-analysis is to evaluate the relationship between neutrophil-lymphocyte ratio (NLR) and the outcome of patients, with rectal cancer receiving chemoradiation and surgery.

METHODS

A systematic review on two databases and a selection of studies were done. Thereafter, two meta-analyses were performed, evaluating the relationship of baseline NLR with overall survival (OS) and disease-free survival (DFS).

RESULTS

Thirty-one retrospective studies were selected. Twenty-six studies have documented a significant relationship of NLR to OS (HR 2.05, CI 1.66-2.53), whereas 23 studies have reported a weaker but significant relationship of NLR to DFS (HR 1.78, CI 1.49-2.12). Among the moderator variables, a possible effect for age and sex on the relationship of NLR with DFS is suggested.

CONCLUSIONS

Baseline NLR >3 is a simple and reproducible prognostic factor, with a more consistent effect in the elderly. It could be a reliable variable to support clinicians in defining personalized treatment strategies, even though a standardization of the cutoff and a better characterization among microsatellite unstable rectal tumors are necessary.

Prognostic role of platelet-to-lymphocyte ratio, neutrophil-to-lymphocyte, and lymphocyte-to-monocyte ratio in operated rectal cancer patients: systematic review and meta-analysis

BACKGROUND

Inflammation plays an important role in tumor growth. Novel serum blood biomarkers, including neutrophil-to-lymphocyte ratio (NLR), platelet-to-lymphocyte ratio (PLR), and lymphocyte-to-monocyte ratio (LMR), have been proposed as useful prognostic indexes in cancer patients. However, their role in rectal cancer is controversial.

METHODS

A comprehensive literature review was conducted including MEDLINE/Pubmed, EMBASE, SCOPUS, and the Cochrane Database of Systematic Reviews through May 2022. The systematic review and meta-analysis were conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) guidelines. Quality was appraised with the Methodological Index for Non-Randomized Studies (MINORS) tool. Aim of the study was to summarize available literature on PLR, NLR, and LMR in patients with rectal cancer undergoing resection.

RESULTS

Forty-seven observational studies (14,205 patients) were included; there were 42 retrospective and 5 prospective cohort studies with an average MINORS score of 14.6 (range: 12-18). Worse overall survival was associated with high NLR (HR 1.81; 95%CI 1.52-2.15; p < 0.001), high PLR (HR 1.24; 95%CI 1.06-1.46; p = 0.009), and low LMR (HR 0.67; 95%CI 0.49-0.91; p = 0.01). High NLR and low LMR were also associated with disease-free-survival (HR 1.68; 95%CI 1.35-2.08; p < 0.001 and HR 0.71; 95%CI 0.58-0.87; p < 0.001, respectively).

CONCLUSIONS

NLR, PLR, and LMR are independent clinical predictors for overall survival in patients with rectal cancer treated with curative surgery. NLR and LMR are also good predictors for disease free survival. These biomarkers, which are readily available, appear optimal prognostic indexes and may help clinicians predict the prognosis of rectal cancer and develop individualized treatment strategies.

Predicting Factors of Complete Pathological Response in Locally Advanced Rectal Cancer

Background: Current treatment of choice for locally advanced rectal cancer is neoadjuvant chemoradiotherapy (neo-CRT) followed by surgical resection and adjuvant chemotherapy. Some patients may experience complete pathological response (cPR) after the neoadjuvant treatment. However, the predicting factors are still debated. Methods: In this registry-based retrospective cohort study, 258 patients with locally advanced rectal cancer were included. Patients were categorized into two groups with or without cPR. Logistic regression analysis was recruited to investigate the odds ratio for all independent variables, and those with significant results were included in multivariate regression analysis. Results: Achievement of cPR was 21.3%. The odds ratio of cPR was significantly lower when the tumor distance from the anal verge was>10 centimeters (OR=0.24, P=0.040). Also, the odds of cPR with N1 involvement in comparison with N0 involvement decreased for 0.41 (P=0.043). It was also true for patients with N2 involvement in comparison with N0 involvement (OR=0.31, P=0.031). Higher odds ratio of cPR was observed in patients who underwent surgery in>12 weeks after neo-CRT (OR=2.9, P=0.022). Furthermore, the odds of cPR decreased for 0.9 with increasing in carcinoembryonic antigen (CEA) level (P=0.044). Conclusion: Patients with rectal cancer in clinical stage II or lower, without the involvement of the lymphatic system at diagnosis, and with tumors located in the lower parts of the rectum, with lower levels of CEA, and longer duration between neo-CRT and surgery were more likely to achieve cPR after neo-CRT. With the current knowledge, the "wait and watch policy" is still debated and needs to be defined more precisely by upcoming studies.

Meta-Analysis on the Neutrophil-Lymphocyte Ratio in Rectal Cancer Treated With Preoperative Chemoradiotherapy: Prognostic Value of Pre- and Post-Chemoradiotherapy Neutrophil-Lymphocyte Ratio

Background

To evaluate the prognostic value of neutrophil-lymphocyte ratio (NLR) in rectal cancer patients treated with preoperative chemoradiotherapy (CRT) and curative surgery.

Methods

A comprehensive search of the EMBASE and PubMed databases was performed to screen studies that compared treatment outcomes according to the pre-CRT and/or post-CRT NLR in patients receiving preoperative CRT and curative surgery for locally advanced rectal cancer. Hazard ratios (HRs) for disease-free survival (DFS) and/or overall survival (OS) were extracted, and a random-effects model was used for pooled analysis.

Results

Totally, 22 retrospective studies comprising 6316 patients were included. Preoperative CRT was administered with concurrent chemotherapy (mostly fluoropyrimidine-based regimens). The elevated pre-CRT NLR was significantly associated with an increased risk of recurrence (HR, 1.54; 95% confidence interval [CI], 1.31-1.81) and death (HR, 2.14; 95% CI, 1.61-2.84). Post-CRT NLR was reported in only 3 of 22 studies, and the correlation was not statistically significant for recurrence (HR, 1.44; 95% CI, 0.86-2.41) or death (HR, 2.38; 95% CI, 0.94-6.07).

Conclusions

Elevated pre-CRT NRL, but not post-CRT NRL, is associated with inferior DFS and OS. Further studies are needed to confirm the prognostic value of NLR in rectal cancer patients receiving preoperative CRT.

Small heterodimer partner as a predictor of neoadjuvant radiochemotherapy response and survival in patients with rectal cancer: A preliminary study

Small heterodimer partner (SHP) plays an essential role in the regulation of innate immune and inflammatory responses. The aim of the present study was to identify whether SHP levels are associated with cancer immunology and treatment outcomes in rectal cancer. SHP expression was analyzed via gene set enrichment analysis and the OncoLnc database. In addition, immunohistochemistry and reverse transcription-quantitative PCR analyses were performed on the tissues of patients with locally advanced rectal cancer, and the associations of SHP expression with the clinicopathological and hematological features or treatment response to preoperative radiochemotherapy (pRCT) were analyzed retrospectively. Furthermore, the present study investigated whether SHP expression correlated with immune infiltration levels and immune checkpoint molecules in rectal cancer. The results revealed that low SHP mRNA expression was significantly associated with an inflammatory response and poor prognosis. The nuclear expression of SHP was associated with clinical N stage, neutrophil count, lymphocyte count, neutrophil-lymphocyte ratio and complete pathologic response following pRCT. The low nuclear expression of SHP was associated with poor overall and distant metastasis-free survival (DMFS). In multivariate analysis, the low nuclear expression of SHP was identified as a significant independent prognostic factor for DMFS and a marginally significant prognostic factor for overall survival in rectal cancer. Furthermore, patients with low SHP expression exhibited higher neutrophil and CD8⁺ T cell infiltration levels and higher PD-L1 expression in rectal adenocarcinoma. These results indicate that SHP may act as an anti-inflammatory mediator via the regulation of systemic and local immune responses in rectal cancer. Moreover, SHP might be useful a potential marker or therapeutic target in rectal cancer.

Prognostic and predictive value of neutrophil-to-lymphocyte ratio after curative rectal cancer resection: A systematic review and meta-analysis

BACKGROUND

Neutrophil-to-lymphocyte ratio (NLR) has been shown to be associated with poor prognosis in numerous solid malignancies. Here, we quantify the prognostic value of NLR in rectal cancer patients undergoing curative-intent surgery, and compare it with platelet-to-lymphocyte ratio (PLR) and lymphocyte-to-monocyte ratio (LMR).

METHODS

A comprehensive search of several electronic databases was performed through January 2021, to identify studies evaluating the prognostic impact of pretreatment NLR in patients undergoing curative rectal cancer resection. The endpoints were overall survival (OS), disease-free survival (DFS), and clinicopathologic parameters. The pooled hazard ratio (HR) or odds ratio with 95% confidence interval (CI) were calculated.

RESULTS

Thirty-one studies comprising 7553 patients were assessed. All studies evaluated NLR; thirteen and six evaluated PLR and LMR, respectively. High NLR was associated with worse OS (HR 1.92, 95% CI 1.60-2.30, P < 0.001) and DFS (HR 1.83, 95% CI 1.51-2.22, P < 0.001), and the results were consistent in all subgroup analyses by treatment modality, tumor stage, study location, and NLR cut-off value, except for the subgroups limited to cohorts with cut-off value ≥ 4. The size of effect of NLR on OS and DFS was greater than that of PLR, and similar to that of LMR. Finally, high NLR was associated with lower rate of pathologic complete response.

CONCLUSIONS

In the setting of curative rectal cancer resection, pretreatment NLR correlates with tumor response to neoadjuvant therapy, and along with LMR, is a robust predictor of poorer prognosis. These biomarkers may thus help risk-stratify patients for individualized treatments and enhanced surveillance.

Prognostic significance of BIRC7/Livin, Bcl-2, p53, Annexin V, PD-L1, DARC, MSH2 and PMS2 in colorectal cancer treated with FOLFOX chemotherapy with or without aspirin

Evasion of apoptosis is associated with treatment resistance and metastasis in colorectal cancer (CRC). Various cellular processes are associated with evasion of apoptosis. These include overexpression of pro-apoptotic proteins (including p53 and PD-L1), anti-apoptotic proteins (BIRC7/Livin and Bcl-2), chemokine receptors (including DARC), and dysregulation of DNA mismatch repair proteins (including MSH2 and PMS2). The aim of this study was to determine the effect of folinic acid, 5-FU and oxaliplatin (FOLFOX) as a single agent and aspirin plus FOLFOX in various combinations on the aforementioned proteins in human CRC, SW480 cell line and rat models of N-Methyl-N-Nitrosourea (NMU)-induced CRC. In addition, effects of the NMU-induced CRC and chemotherapeutic regimens on haematological and biochemical parameters in the rat models were studied. Immunohistochemistry, immunofluorescence and immunoblot techniques were used to study the expression pattern of the related proteins in the human CRC cells pre- and post-treatment. Double contrast barium enema, post-mortem examination and histological analyses were used to confirm tumour growth and the effect of the treatment in vivo in rat models. Notably, we found in human mucinous CRC, a significant increase in expression of the BIRC7/Livin post-FOLFOX treatment compared with pre-treatment (p = 0.0001). This increase provides new insights into the prognostic role of BIRC7/Livin in evasion of apoptosis and facilitation of treatment resistance, local recurrence and metastasis particularly among mucinous CRCs post-FOLFOX chemotherapy. These poor prognostic features in the CRC may be further compounded by the significant suppression of DARC, PD-L1, PMS2 and overexpression of MSH2 and anti-apoptotic Bcl-2 and p53 proteins observed in our study (p < 0.05). Importantly, we found a significant reduction in expression of BIRC7/Livin and reactivation of DARC and PD-L1 with a surge in Annexin V expression in rat models of CRC cells post-treatment with a sequential dose of aspirin plus FOLFOX compared with other treatments in vivo (p <0.05). The mechanistic rational of these effects underscores the importance of expanded concept of possible aspirin combination therapy with FOLFOX sequentially in future CRC management. Validation of our findings through randomized clinical trials of aspirin plus FOLFOX sequentially in patients with CRC is therefore warranted.

Predicting pathological response to chemoradiotherapy for rectal cancer: a systematic review

Introduction: Pathological complete response (pCR) rates of approximately 20% following neoadjuvant long-course chemoradiotherapy for rectal cancer have given rise to non-operative or watch-and-wait (W&W) management. To improve outcomes there has been significant research into predictors of response. The goal is to optimize selection for W&W, avoid chemoradiotherapy in those who won't benefit and improve treatment to maximize the clinical complete response (cCR) rate and the number of patients who can be considered for W&W.Areas covered: A systematic review of articles published 2008-2018 and indexed in PubMed, Embase or Medline was performed to identify predictors of pathological response (including pCR and recognized tumor regression grades) to fluoropyrimidine-based chemoradiotherapy in patients who underwent total mesorectal excision for rectal cancer. Evidence for clinical, biomarker and radiological predictors is discussed as well as potential future directions.Expert opinion: Our current ability to predict the response to chemoradiotherapy for rectal cancer is very limited. cCR of 40% has been achieved with total neoadjuvant therapy. If neoadjuvant treatment for rectal cancer continues to improve it is possible that the treatment for rectal cancer may eventually parallel that of anal squamous cell carcinoma, with surgery reserved for the minority of patients who don't respond to chemoradiotherapy.

Clinical predictors of response to chemoradiotherapy for rectal cancer as an aid to organ preservation

AIM

Clinical predictors of pathological response to chemoradiotherapy for rectal cancer can influence patient management including selection for organ preservation. This study aimed to identify clinical predictors at a tertiary referral hospital.

METHODS

A retrospective review of clinical records was undertaken after identifying all patients with stage 1-3 rectal cancer treated with long course chemoradiotherapy and total mesorectal excision from 2013 to 2018. Clinicopathological factors were recorded and multivariate analysis performed to identify predictors of pathological complete response (pCR) and good response (AJCC TRG 0-1).

RESULTS

A total of 470 patients with rectal cancer were identified of which 164 met the inclusion criteria for the study. The pCR rate was 14.6% and good response (TRG 0-1) rate 43.7%. On univariate analysis, lower T stage, older age, node negative status, anterior tumour position and shorter tumour length on magnetic resonance imaging (MRI) were associated with good response (TRG 0-1). On univariate analysis cN stage, carcinoembryonic antigen <5 and shorter tumour length on MRI were associated with pCR. On binary logistic regression shorter length on MRI and lower clinical nodal stage were predictive of pCR and lower body mass index, anterior tumour position and higher haemoglobin were predictive of good response (TRG 0-1).

CONCLUSION

Anterior tumour position is newly identified as an independent predictor of good response (TRG 0-1) to nCRT for rectal cancer and this should be explored in future studies. Higher haemoglobin and lower body mass index were also independent predictors of good response (TRG 0-1) and optimisation of these factors should be considered when using neoadjuvant chemoradiotherapy for rectal cancer.

The Time Between Chemoradiation and Surgery for Rectal Carcinoma Negatively Influences Mesorectal Excision Quality

Total mesorectal excision quality (TMEq) is a prognostic factor associated with local recurrence in rectal adenocarcinoma. Neoadjuvant chemoradiotherapy (NCRT) reduces the risk of tumor recurrence, but may compromise TMEq. The time between NCRT and surgery (TTS) and how it influences TMEq and tumor control were evaluated. In prospective registry, 236 patients after NCRT and TME were analyzed. NCRT involved radiotherapy with 45 Gy to the pelvis, plus tumor boost dose 5.4 Gy with concurrent 5-fluorouracil infusion. NCRT was followed by TME after 9 weeks on average (median 9.4 ± SD 2.5). TMEq was parametrically analyzed by standard three-grade system. With median follow-up of 47.5 months, 3-year overall survival (OS) was 83.8%, disease-free survival (DFS) was 77.7%, and 6.4% was the rate of local recurrence (LR). TTS was not associated with OS, DFS, or LR. TMEq was found to be associated with LR in univariate analysis, but not in multivariate, where pathological tumor stage and resection margins remained dominant predictors. TMEq was negatively influenced by inferior location of the tumor, longer TTS, higher tumor and nodal stage, presence of tumor perforation, perineural invasion, and close/positive resection margins. Nonetheless, TTS remained a strong predictor of TMEq in multivariate analyses. TTS was proven to be an independent predictor of TMEq. With longer TTS, fewer complete TME with intact mesorectal plane were observed. However, TTS was not associated with survival deterioration or tumor recurrence. These were negatively influenced by other factors interfering with TMEq, especially by pathological tumor stage and resection margins.

A meta-analysis of the impact of neutrophil-to-lymphocyte ratio on treatment outcomes after radiotherapy for solid tumors

BACKGROUND

To evaluate the impact of neutrophil-to-lymphocyte ratios (NLR) as a prognostic factor in predicting treatment outcomes after radiotherapy (RT) for solid tumors.

METHODS

PubMed and Embase databases were used to search for articles published by February 2019 based on the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guideline. Hazard ratios (HR) with 95% confidence intervals (CI) were used to evaluate the association between NLR levels and treatment outcomes after RT. The primary endpoint was overall survival (OS) rates. Secondary endpoints included progression-free survival, disease-free survival, and disease-specific survival rates.

RESULTS

Thirty-eight datasets with a total of 7065 patients were included in the meta-analysis. Patients with high pretreatment NLR demonstrated significantly worse OS with a pooled HR of 1.90 (95% CI 1.66-2.17, P < .001). In patients receiving RT alone, the pooled HR for OS was 1.71 (95% CI 1.44-2.04, P < .001) with no between-study heterogeneity (I = 0%, P = .46).

CONCLUSION

Elevated pretreatment NLR is associated with poorer survival in cancer patients undergoing RT. Elevated pretreatment NLR prior to RT initiation may be a useful biomarker to predict treatment outcomes and select a subgroup of patients in need of a more aggressive treatment approach.

Prognostic impact of persistent lower neutrophil-to-lymphocyte ratio during preoperative chemoradiotherapy in locally advanced rectal cancer patients: A propensity score matching analysis

Purpose

This study investigated the significance of change in neutrophil-to-lymphocyte ratio (NLR) during preoperative chemoradiotherapy (preop-CRT) in patients with non-metastatic rectal cancer using a propensity score matching method (PSM).

Methods

Patients who underwent surgery after completion of preop-CRT for non-metastatic rectal cancers from Jan 2004 to Dec 2013 were retrospectively enrolled. NLRs were obtained before commencement of CRT (pre-NLR) and between completion of CRT and surgery (post-NLR). Using Cox regression hazards models, the association of NLRs with survival after PSM was examined.

Results

A total of 131 patients were grouped as follows: group A, pre-NLR < 3 & post-NLR < 3 (n = 47); group B, pre-NLR < 3 & post-NLR ≥ 3 (n = 45); group C, pre-NLR ≥ 3 & post-NLR < 3 (n = 5); group D, pre-NLR ≥ 3 & post-NLR ≥ 3 (n = 34). There was no difference in disease-free survival (DFS) or overall survival (OS) rate according to group. When dichotomized into group A versus groups B-D, DFS was higher in group A (84.7%) than groups B-D (67.5%, p = 0.021). After PSM (n = 94), multivariable analysis identified persistent lower NLR as an independent favorable prognosticator of DFS (HR 0.37, 95% CI 0.15–0.92, p = 0.033).

Conclusions

Persistent non-inflammatory state measured by NLR may be an indicator of decreased risk of recurrence in patients with locally advanced rectal cancer treated with preop-CRT.

Preoperative Serum Platelet-Lymphocyte Ratio as a Prognostic Factor in Cholangiocarcinoma Patients after Radical Resection: A Retrospective Analysis of 119 Patients

Aims

Although prognostic markers are important to establish therapeutic strategies in patients for conducting radical resection of cholangiocarcinoma (CCA), there is still a lack of simple, valid, and repeatable markers in clinical settings. We aim to evaluate the prognostic value of the preoperative serum platelet-lymphocyte ratio (PLR) in CCA patients who underwent radical resection.

Methods

We retrospectively analyzed CCA patients who underwent radical resection surgery in our institution from January 2011 to June 2016. Baseline PLR and other clinical pathological data were measured when patients were diagnosed initially. The prognostic value of PLR in overall survival (OS) and progression-free survival (PFS) were analyzed with the Cox proportional hazard model and the Kaplan–Meier method.

Results

This study retrospectively analyzed 119 patients who underwent radical resection of CCA. During a median follow-up time of 11.0 months, there were 99.2% recurrences and 42.9% who died, and the median OS and PFS were 9.4 months and 7.4 months, respectively. Multivariate Cox analysis identified that elevated levels of PLR (PLR > 157.25) as a significant factor predicted poorer OS (P = 0.018, HR: 2.160, 95% CI: 1.139-4.096) and PFS (P = 0.005, HR: 1.930, 95% CI: 1.220-3.053). In subgroup analysis, PLR also effectively predicted OS (P = 0.016, HR: 2.515, 95% CI: 1.143-5.532) and PFS (P = 0.042, HR: 1.908, 95% CI: 0.982-3.713) in CCA patients with positive lymphatic metastasis and/or positive surgical margin who required adjuvant therapy.

Conclusions

The preoperative serum PLR is an independent prognostic factor for OS and PFS in CCA patients after radical resection, including patients requiring adjuvant therapy.

Repeating of local therapy of distant metastases increases overall survival in patients with synchronous metastasized rectal cancer-a monocentric analysis

PURPOSE

The aim was to evaluate the outcome of treatment-naive patients with synchronous metastatic rectal cancer after chemotherapy with FOLFOXIRI followed by local therapeutic procedures of all tumor lesions as complete as possible.

METHODS

We reviewed data of 30 patients with synchronous distant metastatic rectal cancer who underwent chemotherapy with FOLFOXIRI and subsequent local therapy in our institution.

RESULTS

Median follow-up was 28 months (range: 8; 74). Cumulative overall survival (OS) and progression-free survival (PFS) was 93.3, 76.9, 55.6% and 46.2, 29.7, 29.7% after 1, 2, 4 years. Non-response to chemotherapy with FOLFOXIRI was associated with a highly significant decreased OS (p < 0.0001). The consistent use of local ablative procedures led to a statistically significant increase in OS (p < 0.0001), but not in PFS (p = 0.635). Patients with ≤ 4 distant metastases showed a better OS (p = 0.033).

CONCLUSIONS

Response to intensified first-line chemotherapy with FOLFOXIRI, treatment of the primary rectal tumor, and repeated thorough local ablative procedures in patients with synchronous metastasized rectal cancer may lead to long-term survival, even in a subset of patients with unresectable disease at initial diagnosis.

Baseline neutrophil-lymphocyte ratio and platelet-lymphocyte ratio in rectal cancer patients following neoadjuvant chemoradiotherapy

PURPOSE

There is uncertainty over the effect of systemic inflammatory response on oncologic outcomes in patients who underwent neoadjuvant chemoradiotherapy and surgery for rectal cancer. We investigated the association between neutrophil-lymphocyte ratio (NLR) and platelet-lymphocyte ratio (PLR) as markers of systemic inflammation and tumor response and prognosis after treatment.

METHODS

A total of 176 patients who underwent neoadjuvant chemoradiotherapy and curative surgery for rectal cancer were analyzed retrospectively. Pretreatment hematologic parameters and the main clinical factors for patients and tumors were investigated with respect to their relationship with tumor regression and survival.

RESULTS

In the receiver operating characteristic analysis, NLR 2.0 and PLR 133.4 had the highest sensitivity and specificity in predicting tumor response. NLR <2.0 and PLR <133.4 were significantly correlated with good tumor response (odds ratio [OR] 2.490, 95% confidence interval [CI] 1.264-4.904, p = .008; OR 3.009, 95% CI 1.477-6.127, p < .001). Patients with NLR <2.0 had significantly better 5-year disease-free survival rate and overall survival rate compared to patients with NLR ⩾2.0 in multivariate analysis (86.8% vs 70.7%, p = .014; 92.4% vs 71.9%, p = .027).

CONCLUSIONS

Elevated NLR and PLR levels can be considered as predictors of poor pathologic response, and NLR can be considered a prognosticator in patients who underwent neoadjuvant chemoradiotherapy for locally advanced rectal cancer.

Predictive impact of the inflammation-based indices in colorectal cancer patients with adjuvant chemotherapy

Increasing evidences reported that cancer-triggered inflammation was associated with survival prognosis from colorectal cancer (CRC). However, the comprehensive effects of inflammatory-based coNLR-PLR that combines neutrophil-to-lymphocyte ratio (NLR) and platelet-to-lymphocyte ratio (PLR) rarely remain to be determined during chemotherapy. We retrospectively analyzed clinical data and baseline laboratory parameters from 153 colorectal cancer patients who underwent palliative adjuvant chemotherapy between January 2009 to January 2012. Receiver operating characteristic (ROC) curves and linear regression analyzed the predictive ability of NLR, and PLR for calculating the score of coNLR-PLR. Overall survival (OS) and recurrence-free survival (RFS) rates were estimated using the Kaplan-Meier method and analyzed by the Cox proportional hazards model in univariate and multivariate analysis. The optimal cut-off value of NLR and PLR was 2.24 and 186 by the ROC analysis. Kaplan-Meier method showed that patients with high coNLR-PLR score was associated with poorer OS and RFS (all P < .05). In univariate and multivariate analysis, it obtained that the coNLR-PLR severed as a strong independent prognostic factor for OS and RFS (all P < .05). These results highlight that coNLR-PLR index severed as a strong predictor of prognosis biomarker in CRC patients receiving adjuvant chemotherapy. Furthermore, its assessment could contribute to accurately predicting prognosis after chemotherapy in clinical practice.

[Inflammatory and immune biomarkers of radiation response]

In radiotherapy, the treatment is adapted to each individual to protect healthy tissues but delivers most of time a standard dose according to the tumor histology and site. The only biomarkers studied to individualize the treatment are the HPV status with radiation dose de-escalation strategies, and tumor hypoxia with dose escalation to hypoxic subvolumes using FMISO- or FAZA-PET imaging. In the last decades, evidence has grown about the contribution of the immune system to radiation tumor response. Many preclinical studies have identified some of the mechanisms involved. In this context, we have realised a systematic review to highlight potential inflammatory and immune biomarkers of radiotherapy response. Some are inside the tumor microenvironment, as lymphocyte infiltration or PD-L1 expression, others are circulating biomarkers, including different types of hematological cells, cytokines and chemokines.

The value of neutrophil-to-lymphocyte ratio for response and prognostic effect of neoadjuvant chemotherapy in solid tumors: A systematic review and meta-analysis

Introduction: The neutrophil-to-lymphocyte ratio (NLR) has been found to be an indicator of poor prognosis in many tumour types. However, little is known about the relationship between the NLR and patients with tumours who receive neoadjuvant chemotherapy (NAC) in terms of response rate and prognostic ability. We thus performed this meta-analysis to further investigate this relationship. Methods: An electronic systematic literature search for articles published before September 2017 was performed to explore the association between the pretreatment NLR and outcome in patients treated with NAC. Data were extracted by the reported odds ratios (ORs) and hazard ratios (HRs) with their 95% confidence intervals (CIs) for the response rate and the survival outcome, respectively. The results were pooled using the random-effect or fixed-effect model. Results: Thirty-three studies were eventually included in our study, and all were published no earlier than 2011. An NLR that was higher than the cut-off was associated with a lower pathological complete response (pCR) rate in patients with cancer (OR = 1.72, 95% CI, 1.26-2.33). A lower NLR was associated with better overall survival (OS) (HR = 1.58, 95% CI, 1.34-1.86), cancer-specific survival (CSS) (HR = 2.22, 95% CI, 1.32-3.74), disease-free survival (DFS) (HR = 1.32, 95% CI, 1.10-1.59) and recurrence-free survival (RFS) (HR = 1.90, 95% CI, 1.50-2.40). Conclusion: Overall, an NLR lower than the cut-off value indicated a greater chance for pCR and may predict good survival outcomes after NAC for patients with solid tumours. The use of the NLR for risk stratification before NAC should be further demonstrated by future large-scale prospective studies.

The role of the systemic inflammatory response in predicting outcomes in patients with operable cancer: Systematic review and meta-analysis

Cancer remains a leading causes of death worldwide and an elevated systemic inflammatory response (SIR) is associated with reduced survival in patients with operable cancer. This review aims to examine the evidence for the role of systemic inflammation based prognostic scores in patients with operable cancers. A wide-ranging literature review using targeted medical subject headings for human studies in English was carried out in the MEDLINE, EMBASE, and CDSR databases until the end of 2016. The SIR has independent prognostic value, across tumour types and geographical locations. In particular neutrophil lymphocyte ratio (NLR) (n = 158), platelet lymphocyte ratio (PLR) (n = 68), lymphocyte monocyte ratio (LMR) (n = 21) and Glasgow Prognostic Score/ modified Glasgow Prognostic Score (GPS/mGPS) (n = 60) were consistently validated. On meta-analysis there was a significant relationship between elevated NLR and overall survival (OS) (p < 0.00001)/ cancer specific survival (CSS) (p < 0.00001), between elevated LMR and OS (p < 0.00001)/CSS (p < 0.00001), and elevated PLR and OS (p < 0.00001)/CSS (p = 0.005). There was also a significant relationship between elevated GPS/mGPS and OS (p < 0.00001)/CSS (p < 0.00001). These results consolidate the prognostic value of the NLR, PLR, LMR and GPS/mGPS in patients with resectable cancers. This is particularly true for the NLR/GPS/mGPS which should form part of the routine preoperative and postoperative workup.