Prognostic and predictive value of neutrophil-to-lymphocyte ratio with adjuvant immunotherapy in stage III non-small-cell lung cancer

Impact of neutrophil-to-lymphocyte ratio on survival outcomes among cirrhotic and non-cirrhotic patients with advanced hepatocellular carcinoma under atezolizumab-bevacizumab combination therapy

Background

The efficacy of atezolizumab-bevacizumab in patients with hepatocellular carcinoma (HCC) has not been studied separately in cirrhotic and non-cirrhotic patients. Our aim was to evaluate the efficacy of atezolizumab-bevacizumab in these patients, in relation to baseline values of the neutrophil-to-lymphocyte ratio (NLR).

Methods

We divided 57 atezolizumab-bevacizumab-treated HCC patients according to baseline NLR (>3: NLR-H, ≤3: NLR-L) and studied overall survival (OS) and progression-free survival (PFS) in 4 groups: group A, non-cirrhotic/NLR-L; group B, non-cirrhotic/NLR-H; group C, cirrhotic/NLR-L; and group D, cirrhotic/NLR-H.

Results

The 4 groups were comparable except for etiology, ALBI grade, macrovascular invasion, Barcelona Clinic Liver Cancer stage and prior therapy. Median OS and PFS were 30, 10, 12 and 5 months, and 14, 4, 8 and 2 months, for groups A, B, C, D, respectively (P<0.001). By Cox regression, cirrhotic/NLR-H patients showed significantly worse OS and PFS. Cirrhotic/NLR-L patients had better OS (12 vs. 5 months, P=0.002) and PFS (8 vs. 2 months, P=0.028) compared to cirrhotic/NLR-H. NLR was significantly correlated with OS (P=0.015). Non-cirrhotic/NLR-L patients had better OS (30 vs. 10 months, P=0.006) and PFS (15 vs. 4 months, P=0.01) compared to non-cirrhotic/NLR-H patients. Prior therapy was significantly correlated with better OS (30 vs. 8 months, P<0.001) and PFS (24 vs. 4 months, P<0.001) in non-cirrhotic patients.

Conclusions

Cirrhotic/NLR-H HCC patients presented the worst survival. NLR is an independent risk factor for worse survival in cirrhotic patients. Prior therapy is the only factor significantly correlated with OS and PFS in non-cirrhotic patients.

The association of neutrophil-to-lymphocyte ratio with post-chemotherapy pulmonary infection in lung cancer patients

Background

Lung cancer patients are particularly vulnerable to pulmonary infections following chemotherapy, which can lead to suboptimal treatment outcomes and increased mortality rates. The neutrophil-to-lymphocyte ratio (NLR), an established inflammatory marker, has been extensively studied; however, its diagnostic value in identifying post-chemotherapy pulmonary infection (PCPI) in lung cancer patients remains unclear. This study aims to evaluate the independent diagnostic effectiveness of NLR in detecting PCPI among lung cancer patients.

Methods

A retrospective analysis was performed on clinical data from 638 lung cancer patients who underwent chemotherapy at the Central Hospital of Shaoyang between January 2020 and December 2023. After excluding cases with incomplete data, 502 patients were included in the final analysis. Due to the low incidence of PCPI within this cohort (19.52%), the Synthetic Minority Over-sampling Technique (SMOTE) was utilized to achieve data balance. Both the balanced and unbalanced datasets were subsequently analyzed and validated using multivariable regression analysis, restricted cubic spline (RCS) analysis, subgroup analysis, and sensitivity analysis.

Results

The findings demonstrated that NLR serves as an independent risk factor for PCPI in patients with lung cancer, irrespective of dataset balance [balanced dataset: odds ratio (OR) = 1.12, 95% confidence interval (CI): 1.08-1.16; unbalanced dataset: OR = 1.08, 95% CI: 1.03-1.13]. Furthermore, in the balanced dataset, after adjusting for all covariates (Model 4), quartile analysis of NLR revealed a significant increase in the risk of PCPI with higher NLR levels (fourth quartile group OR = 5.64, 95% CI: 3.17-10.01, p < 0.001). The RCS analysis corroborated the nonlinear association between NLR and PCPI. Subgroup analysis revealed that within the chemotherapy regimen subgroups, the association between NLR and PCPI was significantly higher in patients receiving platinum-based chemotherapy (PBC) compared to those receiving non-platinum-based chemotherapy (NPBC) (p for interaction = 0.001). Sensitivity analyses further affirmed the robustness of the model outcomes.

Conclusion

The analysis in this study indicates that NLR has the potential to be a predictor of PCPI for lung cancer patients. Although these preliminary research findings demonstrate diagnostic promise, its clinical applicability still needs to be verified through multicenter prospective studies to provide reliable evidence for decision-making.

Impact of Prophylactic Use of PEG-rhG-CSF on First-Line Immunochemotherapy in Advanced NSCLC: A Cohort Study

Introduction

This study aimed to assess the impact of prophylactic use of PEG-rhG-CSF on first-line immunochemotherapy in advanced NSCLC.

Methods

A cohort of patients with advanced NSCLC who received first-line immunochemotherapy at Shengjing Hospital of China Medical University between January 2019 and July 2024 was selected for this study. Patients were divided into the following two groups: a treatment group that received prophylactic PEG-rhG-CSF (≥1 cycle) 48 hours after immunochemotherapy and a control group that did not receive PEG-rhG-CSF. The primary end points were progression-free survival (PFS), overall survival (OS), overall response rate, and safety. A propensity score-matched analysis was performed to reduce potential confounders.

Results

A total of 220 patients were enrolled, with 87 in the treatment group and 133 in the control group. Median PFS was 10.5 months in both the treatment and control groups (p = 0.86), and median OS was 33.9 months in the treatment group versus not reached in the control group (p = 0.71). The overall response rate was 64.4% in the treatment group and 58.6% in the control group (p = 0.40). After propensity score-matched analysis (each group included 78 patients), median PFS was 12.6 months in the treatment group versus 10.5 months in the control group (p = 0.99), and median OS remained 30.3 months in the treatment group versus not reached in the control group (p = 0.85). The treatment group had a reduced incidence of chemotherapy interruptions, any grade of leukopenia, any grade of neutropenia, and grades 3 to 5 neutropenia, without an increase in immune-related adverse events.

Conclusions

The prophylactic use of PEG-rhG-CSF in patients with advanced NSCLC undergoing first-line immunochemotherapy did not compromise efficacy and safety. It reduced chemotherapy interruptions and neutropenia, without increasing immune-related adverse events, thus supporting safe and uninterrupted treatment.

Clinical Significance of the Peripheral Blood Neutrophil-to-Lymphocyte Ratio in Predicting Chemotherapy Outcomes for Small Cell Lung Cancer

Objective

This study aims to assess the clinical significance of the peripheral blood neutrophil-to-lymphocyte ratio (NLR) in predicting chemotherapy outcomes for patients with small cell lung cancer (SCLC).

Methods

A cohort of 44 patients diagnosed with SCLC between January 2021 to June 2022 at Fuyang People's Hospital was selected for analysis. All patients in this group received a first-line platinum-based doublet chemotherapy regimen. In parallel, a control group consisting of 44 healthy individuals undergoing routine physical examinations at the same hospital was also selected. Fasting venous blood samples were collected in the morning within one week before the initiation of chemotherapy, and a complete blood cell count was performed to calculate the NLR.

Results

The NLR in the plasma of patients with SCLC was significantly elevated compared to that of healthy individuals (P < 0.01). After two cycles of chemotherapy, there were no statistically significant differences in plasma NLR in SCLC patients compared to pre-chemotherapy levels (P > 0.05). However, in the subgroup of patients with a partial response (PR) to treatment, the NLR decreased to 2.625 (95% CI: 1.900, 3.625), down from a pre-chemotherapy level of 3.430 (2.688, 4.800) (Z = -3.127, P = 0.002). Conversely, in patients whose disease progressed (PD) following chemotherapy, the NLR increased to 3.880 (95% CI: 2.953, 5.223) from a pre-chemotherapy level of 2.060 (1.915, 2.968) (Z = -2.521, P = 0.012).

Conclusion

The dynamic variations in the peripheral blood NLR before and after chemotherapy in patients with SCLC are strongly associated with the efficacy of first-line chemotherapy regimens. These changes in NLR levels may serve as a crucial indicator for predicting the effectiveness of first-line chemotherapy in patients with SCLC.

Prognostic significance of the hemoglobin, albumin, lymphocyte, platelet (HALP) score after hepatectomy for colorectal liver metastases

PURPOSE

Inflammatory, nutritional, and immune biomarkers are associated with the prognosis of patients with various tumors. Recently, a comprehensive predictive biomarker, the hemoglobin, albumin, lymphocyte, and platelet (HALP) score, was introduced to predict clinical outcomes. We investigated the prognostic impact of preoperative HALP scores in patients who underwent hepatectomy for colorectal liver metastasis (CRLM).

METHOD

The subjects of this study were 209 patients who underwent hepatectomy for CRLM between February, 2005 and September, 2023. The HALP score was defined as (albumin [mg/dL] × hemoglobin [g/L] × lymphocyte [count/L]) / platelet [count/L]. The cutoff value was calculated according to the receiver operating characteristic curve based on 3-year survival.

RESULTS

The cutoff value of the HALP score was 35, and a low HALP score was confirmed in 107 patients (51%). Multivariate analysis of disease-free survival identified lymph node metastasis (HR 1.53, p = 0.03), extrahepatic lesions (HR 2.48, p < 0.01), and a low HALP score (HR 2.0, p < 0.01) as independently poor prognostic factors. Multivariate analysis of overall survival identified extrahepatic lesions (HR 2.98, p < 0.01), a high CEA (HR 1.78, p = 0.02), and a low HALP score (HR 1.92, p = 0.02) as independently poor prognostic factors.

CONCLUSIONS

The HALP score is a useful prognostic factor for patients undergoing hepatectomy for CRLM.

Durvalumab Following Chemoradiotherapy for Stage III Non-small Cell Lung Cancer: Differences in Survival Based on Age and Post-Progression Systemic Therapy

BACKGROUND

Concurrent chemoradiotherapy (cCRT) followed by 1 year of the immune checkpoint inhibitor (ICI) durvalumab is standard of care for patients with unresectable stage III nonsmall cell lung cancer (NSCLC).

OBJECTIVES

The purpose of this study was to evaluate survival outcomes of (1) cCRT followed by durvalumab in patients older versus younger than 75 years of age and (2) post-progression treatment with ICI alone versus chemotherapy alone versus combined ICI and chemotherapy.

PATIENTS AND METHODS

Patients with unresectable stage III NSCLC treated between January 2018 and July 2023 with cCRT followed by durvalumab were identified retrospectively. Progression-free survival (PFS) and overall survival (OS) from ICI start were analyzed in three cohorts aged < 65, 65-74, and ≥ 75 years. Multivariable Cox proportional hazard regression modelling of factors associated with OS was undertaken. Logistic regression analysis identified risk factors of early durvalumab discontinuation for toxicity. Time from first salvage drug treatment to death (OS-2) was described.

RESULTS

A total of 472 patients were analyzed: the proportions aged < 65, 65-74, and ≥ 75 years were 34.3%, 42.8%, and 22.9%, respectively. Odds of early durvalumab discontinuation was 2.2-fold greater in the oldest (versus youngest) cohort. Age associated differences in median PFS (26.7 months, 20.3 months, and 14.2 months; p < 0.001) and OS (60.8 months, 44.4 months, and 27.6 months; p < 0.001) were observed. On multivariable analysis, factors associated with shorter OS were age ≥ 75 years (versus < 65), performance status 2/3 (versus 0/1), stage IIIC (versus IIIA), neutrophil to lymphocyte ratio (per 7.43 unit increase), Charlson comorbidity index (per 1 unit increase), tumoral PD-L1 expression < 1% (versus ≥ 50%, 1-49%, or unknown), and squamous histology (versus non-squamous). Of 264 patients with disease progression, 48.5% received subsequent drug therapy. Median OS-2 was longer with ICI alone (9.9 months) or ICI-chemotherapy (11.8 months) than platinum doublet chemotherapy (6.7 months.) For recurrences < 6 months from the last durvalumab infusion, OS-2 were similar across treatment groups.

CONCLUSIONS

In the studied cohort, OS was significantly shorter for patients ≥ 75 years of age treated with cCRT followed by durvalumab compared to those < 65 years. Post-progression systemic therapy was associated with modest efficacy, underscoring the need for new therapies.

The preoperative hemoglobin, albumin, lymphocyte, and platelet score (HALP) as a prognostic indicator in patients with non-small cell lung cancer

Background

The Hemoglobin, Albumin, Lymphocyte, and Platelet score (HALP) is an inflammatory nutrition-related biomarker based on hemoglobin and albumin levels, as well as the lymphocyte and platelet load index, which has been reported to be associated with the prognosis of various types of tumors. This study aims to investigate the prognostic value of HALP in patients with non-small cell lung cancer (NSCLC).

Methods

A total of 2,428 patients with NSCLC were enrolled in the INSCOC study. Time-patient survival trends were validated using Kaplan-Meier curves and log-rank tests. The Restricted Cubic Spline function was used to analyze the relationship between the HALP index and overall survival (OS). The Cox regression model was used for univariate and multivariate analyses.

Results

The study included 2,053 patients with detailed biological information and follow-up data, consisting of 1,346 men (65.6%) and 707 women (34.4%). Within this cohort, 138 patients (6.7%) had stage I disease, 282 (13.7%) had stage II, 477 (23.2%) had stage III, and 1,156 (56.3%) had stage IV. A total of 536 patients (26.1%) underwent surgery, 1,494 (72.8%) received chemotherapy, and 271 (13.2%) received radiotherapy. The 1-, 2-, 3-, and 5-year survival rates for patients with NSCLC were 68.6, 48.6, 37.4, and 30.9%, respectively. The optimal cut-off for HALP was determined to be 29.71, with a sensitivity of 53.1% and specificity of 62.9%, leading to the categorization of patients into low (<29.71) (n = 963) and high (≥29.71) (n = 1,090) HALP groups. Patients with a high HALP demonstrated a significantly higher 5-year overall survival (OS) rate compared to those with a low HALP (38% vs. 23%, p < 0.001). Multivariable Cox proportional hazards regression analysis identified that low HALP was an independent risk factor for the survival of patients with non-small cell lung cancer.

Conclusion

The HALP index can be used as an independent prognostic factor for patients with NSCLC, offering clinicians a reference to identify high-risk patient with poor long-term prognoses and improve individualized treatment.

Derived neutrophil-to-lymphocyte ratio has the potential to predict safety and outcomes of durvalumab after chemoradiation in non-small cell lung cancer

The usefulness of the derived neutrophil-to-lymphocyte ratio (dNLR) and its dynamics before/after durvalumab consolidation therapy to predict safety or efficacy remains unclear. We retrospectively reviewed patients with locally advanced non-small cell lung cancer treated with durvalumab consolidation therapy after chemoradiotherapy (D group) or chemoradiotherapy alone (non-D group) at multiple institutions. We investigated the association between dNLR, or its dynamics, and pneumonitis, checkpoint inhibitor-related pneumonitis (CIP), irAEs, and efficacy. Ninety-eight and fifty-six patients were enrolled in the D and non-D groups, respectively. The dNLR at baseline was significantly lower in patients who experienced irAEs or CIP than in those who did not. The low dNLR group, 28 days following durvalumab consolidation therapy (dNLR28 ≤ 3), demonstrated longer progression-free survival (PFS) and overall survival (OS) than the high dNLR group (dNLR28 > 3) (PFS, hazard ratio [HR] 0.44, 95% confidence interval [CI] 0.22-0.88, p = 0.020; OS, HR 0.39, 95% CI 0.16-0.94, p = 0.037). Among patients with high dNLR at baseline (dNLR > 3), the dNLR28 ≤ 3 group showed longer PFS than the dNLR28 > 3 group (p = 0.010). The dNLR is a predictive factor for irAEs and CIP in patients receiving durvalumab consolidation therapy. The dNLR at 28 days after durvalumab consolidation therapy and its dynamics predict favorable outcomes.

Incorporating the inflammation-related parameters enhances the performance of the nomogram for predicting local control in lung cancer patients treated with stereotactic body radiation therapy

PURPOSE

The study aims to investigate whether including the inflammation-related parameters would enhance the accuracy of a nomogram for local control (LC) prediction in lung cancer patients undergoing stereotactic body radiation therapy (SBRT).

METHODS

158 primary or metastatic lung cancer patients treated with SBRT were retrospectively analyzed. The clinical, dosimetric and inflammation-related parameters were collected for the Cox regression analysis. The ACPB model was constructed by employing the clinical and dosimetric factors. And the ACPBLN model was established by adding the inflammation-related factors to the ACPB model. The two models were compared in terms of ROC, Akaike Information Criterion (AIC), C-index, time-dependent AUC, continuous net reclassification index (NRI), integrated discrimination improvement (IDI), calibration plots and decision curve analysis (DCA).

RESULTS

Multivariate Cox regression analysis revealed that six prognostic factors were independently associated with LC, including age, clinical stage, planning target volume (PTV) volume, BED of the prescribed dose (BEDPD), the lymphocyte count and neutrocyte count. The ACPBLN model performed better in AIC, bootstrap-corrected C-index, time-dependent AUC, NRI and IDI than the ACPB model. The calibration plots showed good consistency between the probabilities and observed values in the two models. The DCA curves showed that the ACPBLN nomogram had higher overall net benefit than the ACPB model across a majority of threshold probabilities.

CONCLUSION

The inflammation-related parameters were associated with LC for lung cancer patients treated with SBRT. The inclusion of the inflammation-related parameters improved the predictive performance of the nomogram for LC prediction.

[Correlation Analysis between Neutrophil-to-lymphocyte Ratio and the Risk of Malnutrition in Stage IV Primary Lung Cancer]

BACKGROUND

Malnutrition is commonly associated with poor prognosis in patients with malignant tumors. The neutrophil-to-lymphocyte ratio (NLR) is an indicator of inflammation in the body and predicts the risk of malnutrition in a variety of diseases; however, its association with malnutrition in lung cancer patients is unclear. The aim of this study is to clarify the association between NLR and nutritional status in stage IV primary lung cancer and to further determine the optimal NLR cut-off that best predicts the risk of malnutrition.

METHODS

A retrospective analysis of 209 patients admitted to the Department of Medical Oncology, Tianjin Medical University General Hospital with a primary diagnosis of stage IV lung cancer from May 2019 to February 2021 was performed, and the nutritional risk screening 2002 (NRS 2002) was used to examine their nutritional status. Patient demographic information, pathology, Karnofsky performance status (KPS) score, body mass index (BMI), comorbidities and clinical biochemical indicators were also included. The correlation between NLR and NRS 2002 was investigated. Receiver operating characteristic (ROC) curve was used to determine the best NLR cut-off predi cting malnutrition risk. Multivariable Logistic regression was used to assess the association between NLR and malnutrition risk.

RESULTS

The rate of patients with stage IV primary lung cancer at nutritional risk was 36.36% (76/209). A significant positive correlation was observed between NLR values and NRS 2002 risk score (r=0.765, P<0.001). The ROC curve analysis indicated that an NLR of 3.94 was the optimal cut-off for predicting malnutrition risk (area under the curve=0.747, 95%CI: 0.678-0.815, P<0.001), which showed a sensitivity of 55%, a specificity of 86%, a positive predictive value of 68%, and a negative predictive value of 77%. Patients in the NLR>3.94 group had a significantly higher risk of malnutrition compared to those in the NLR≤3.94 group (69.49% vs 23.33%, P<0.001). Furthermore, NLR was identified as a risk factor for malnutrition in stage IV primary lung cancer patients.

CONCLUSIONS

NLR is associated with the risk of malnutrition in stage IV primary lung cancer, and NLR can be used as one of the indicators for screening nutritional risk in patients with stage IV primary lung cancer.

Machine Learning-assisted immunophenotyping of peripheral blood identifies innate immune cells as best predictor of response to induction chemo-immunotherapy in head and neck squamous cell carcinoma - knowledge obtained from the CheckRad-CD8 trial

PURPOSE

Individual prediction of treatment response is crucial for personalized treatment in multimodal approaches against head-and-neck squamous cell carcinoma (HNSCC). So far, no reliable predictive parameters for treatment schemes containing immunotherapy have been identified. This study aims to predict treatment response to induction chemo-immunotherapy based on the peripheral blood immune status in patients with locally advanced HNSCC.

METHODS

The peripheral blood immune phenotype was assessed in whole blood samples in patients treated in the phase II CheckRad-CD8 trial as part of the pre-planned translational research program. Blood samples were analyzed by multicolor flow cytometry before (T1) and after (T2) induction chemo-immunotherapy with cisplatin/docetaxel/durvalumab/tremelimumab. Machine Learning techniques were used to predict pathological complete response (pCR) after induction therapy.

RESULTS

The tested classifier methods (LDA, SVM, LR, RF, DT, and XGBoost) allowed a distinct prediction of pCR. Highest accuracy was achieved with a low number of features represented as principal components. Immune parameters obtained from the absolute difference (lT2-T1l) allowed the best prediction of pCR. In general, less than 30 parameters and at most 10 principal components were needed for highly accurate predictions. Across several datasets, cells of the innate immune system such as polymorphonuclear cells, monocytes, and plasmacytoid dendritic cells are most prominent.

CONCLUSIONS

Our analyses imply that alterations of the innate immune cell distribution in the peripheral blood following induction chemo-immuno-therapy is highly predictive for pCR in HNSCC.

Neutrophil to lymphocyte ratio may predict efficacy of anti-PD-1 inhibitors in advanced EGFR-mutant non-small cell lung cancer: retrospective cohort study

This study aimed to investigate the associations between the clinical characteristics and effectiveness of anti-PD-1 inhibitors in patients with EGFR-sensitive mutations, aiming to identify the potential subgroup of patients who might benefit from anti-PD-1 inhibitor treatment. Patients with advanced non-small cell lung cancer (NSCLC) harboring epidermal growth factor receptor (EGFR)-sensitive mutations who received subsequent anti-PD-1 inhibitors in combination with chemotherapy/antiangiogenic agents or alone after progression to tyrosine kinase inhibitors (TKIs) were screened. Clinical characteristics, including hematological parameters, were investigated for potential correlations with clinical outcomes. Subgroup and multivariate analyses were used for further confirmation of the relationship. Kaplan-Meier curves and Cox survival regression models using the log-rank test were used for progression-free survival (PFS) and overall survival (OS) assessments between the groups. Multiple regression analysis was performed using the standard regression coefficient values. The Wilcoxon test was used for the analysis of the variation in NLR. P ≤ 0.05 was considered to indicate statistical significance. This study was a retrospective study. Twenty-two patients met the inclusion criteria and were included in the study. The median PFS was 3.05 months (95% CI, 2.9-10.2 months). The median OS was 7.30 months (95% CI, 5.2-18.1 months). PFS in low neutrophil to lymphocyte ratio (NLR ≤ 4) was significantly longer than high NLR (NLR > 4, 5.7 months versus 2.0 months, HR, 0.35, 95% CI, 0.08-0.63, P = 0.0083). The OS in the low NLR group was also significantly better than that in the high NLR group (OS, 21.3 months versus 5.0 months, HR, 0.33; 95% CI, 0.09-0.74; P = 0.0163). In the multivariate analysis, NLR was the only significant factor for OS benefits (β = 3.535, 95% CI, 1.175-10.636, P = 0.025). Further investigation revealed that front-line TKIs exposure may contribute to the elevation or decrease of NLR, and finally lead to different efficacy outcomes by anti-PD-1 inhibitors. The findings suggest that a portion of advanced NSCLC patients with low NLR characteristics (NLR ≤ 4), even those harboring EGFR-sensitive mutations, could benefit from anti-PD-1 inhibitors as further line treatment after progression to EGFR-TKIs.

Immunotherapy-related biomarkers: Confirmations and uncertainties

Immunotherapy profoundly changed oncology treatment, becoming one of the main therapeutical strategies. Remarkable improvement has been achieved in survival outcomes, but the percentage of patients who benefit from immunotherapy is still limited. Only one-third of patients receiving immune checkpoint inhibitors (ICIs) achieve long-term response. Several patients are not responsive to treatment or relapse after an initial response. To date, programmed death-ligand 1, microsatellite instability, and tumor mutational burden are the three biomarkers validated to predict the ICIs response, but a single variable seems still insufficient in the patient's selection. Considering the substantial and increasing use of these drugs, the identification of new predictive biomarkers of ICI response is of paramount importance. We summarize the state of the art and the clinical use of immune biomarkers in oncology, highlighting the strength and weaknesses of currently approved biomarkers, describing the emerging tissues and circulating biomarkers, and outlining future perspectives.

Exploration of a novel prognostic model based on nomogram in non-small cell lung cancer patients with distant organ metastasis: implications for immunotherapy

Background

Evidence for the effects of immunotherapy in non-small cell lung cancer (NSCLC) patients with distant organ metastasis is insufficient, and the predictive efficacy of established markers in tissue and blood is elusive. Our study aimed to determine the prognostic factors and develop a survival prognosis model for these patients.

Methods

A total of 100 advanced NSCLC patients with distant organ metastases, who received single or combination immune checkpoint inhibitors (ICIs) in Xijing Hospital between June 2018 and June 2021, were enrolled for retrospective analysis. The major clinicopathological parameters were collected, and associated survival outcomes were followed up by telephone or inpatient follow-up for nearly 3 years to assess prognoses. The survival prognosis model was established based on univariate and multivariate Cox regression analyses to determine the candidate prognostic factors.

Results

From the start of immunotherapy to the last follow-up, 77 patients progressed and 42 patients died, with a median follow-up of 18 months [95% confidence interval (CI): 15-19.9]. The median progression-free survival (PFS) and overall survival (OS) were 8 months (95% CI: 5.6-10.4) and 21 months (95% CI: 8.9-33.1), respectively. Multivariate Cox proportional hazards analysis showed Eastern Cooperative Oncology Group performance status (ECOG PS), body mass index (BMI), age-adjusted Charlson comorbidity index (ACCI), lactate dehydrogenase (LDH), and absolute neutrophil count (ANC) were correlated significantly with OS. Based on these five predictive factors, a nomogram and corresponding dynamic web page were constructed with a concordance index (C-index) of 0.81 and a 95% CI of 0.778-0.842. Additionally, the calibration plot and time-receiver operating characteristic (ROC) curve validated the precision of the model at 6-, 12-, and 18-month area under the curves (AUCs) reached 0.934, 0.829, and 0.846, respectively. According to the critical point of the model, patients were further divided into a high-risk total point score (TPS) >258, middle-risk (204< TPS ≤258), and low-risk group (TPS ≤204), and significant OS differences were observed among the three subgroups (median OS: 4.8 vs. 13.0 vs. 32.9 months).

Conclusions

A feasible and practical model based on clinical characteristics has been developed to predict the prognosis of NSCLC patients with distant organ metastasis undergoing immunotherapy.

The Role of Neutrophil-to-Lymphocyte Ratio in Advanced EGFR-Mutant NSCLC Patients Treated with First-Line Osimertinib

Purpose

Although serum neutrophil-to-lymphocyte ratio (NLR) is correlated with the outcome of various cancer types, its role in treatment-naïve, advanced, epidermal growth factor receptor (EGFR)-mutant non-small cell lung cancer (NSCLC) patients treated with osimertinib remains uncertain. We have the intention to use this biomarker to evaluate the outcomes in NSCLC.

Patients and Methods

Advanced EGFR-mutant NSCLC patients receiving osimertinib as the first-line treatment were included. We evaluated the prognostic role of baseline NLR and explored its association with patients' characteristics. A high NLR was defined as pretreatment serum NLR ≥ 5.

Results

A total of 112 eligible patients were included. The objective response rate was 83.7%. The median progression-free survival (PFS) and overall survival (OS) were 20.5 months (95% CI 14.5-26.5) and 47.3 months (95% CI 36.7-58.2), respectively. A high NLR predicted an inferior PFS (HR 1.90 [95% CI 1.02-3.51], P = 0.042) and OS (HR 3.85 [95% CI 1.39-10.66], P = 0.009). Patients with stage IVB disease were more likely to have a high baseline NLR than those with stage IIIB-IVA (33.9% vs 15.1%, P = 0.029). Other patients' characteristics did not correlate with the baseline NLR significantly. Patients with a high NLR had significantly more metastatic organs than those with a low NLR (2.5 ± 1.3 vs 1.8 ± 0.9, P = 0.012), particularly brain, liver, and bone metastasis. There was no significant association between NLR and intrathoracic metastasis.

Conclusion

Baseline serum NLR could act as an important prognostic marker for EGFR-mutant NSCLC patients receiving first-line osimertinib. A high NLR was associated with higher metastatic burden, more extrathoracic metastases, and therefore, a worse outcome.

Five years after PACIFIC: update on multimodal treatment efficacy based on real-world reports

INTRODUCTION

The growing body of real-life data on maintenance treatment with durvalumab suggests that immunological markers of the cancer host interplay may have significant effects on the efficacy of multimodal therapy in patients with unresectable stage III NSCLC.

AREAS COVERED

We summarize real-world clinical data regarding this new tri-modal approach and report on potential biomarker landscape.

EXPERT OPINION

The obvious question posed in this context of a very heterogeneous inoperable stage III NSCLC disease is: How can we augment an ability to predict checkpoint inhibition success or failure? Which tools and biomarkers, which clinical metadata and genetic background are relevant and feasible? No single biomarker will ever fully dominate the unresectable stage III NSCLC space, so we advocate multilevel and multivariate analysis of biomarkers. In this particular opinion piece, we explore the impact of PD-L1 expression on tumor cells, neutrophil-to-lymphocyte ratio, EGFR and STK11 mutational status, interferon-gamma signature, and tumor-infiltrating lymphocytes among others.

Immune Checkpoint Inhibitors for Solid Tumors in the Adjuvant Setting: Current Progress, Future Directions, and Role in Transplant Oncology

The rationale for administering immune checkpoint inhibitors (ICIs) in the adjuvant setting is to eradicate micro-metastases and, ultimately, prolong survival. Thus far, clinical trials have demonstrated that 1-year adjuvant courses of ICIs reduce the risk of recurrence in melanoma, urothelial cancer, renal cell carcinoma, non-small cell lung cancer, and esophageal and gastroesophageal junction cancers. Overall survival benefit has been shown in melanoma while survival data are still not mature in other malignancies. Emerging data also show the feasibility of utilizing ICIs in the peri-transplant setting for hepatobiliary malignancies. While ICIs are generally well-tolerated, the development of chronic immune-related adverse events, typically endocrinopathies or neurotoxicities, as well as delayed immune-related adverse events, warrants further scrutiny regarding the optimal duration of adjuvant therapy and requires a thorough risk-benefit determination. The advent of blood-based, dynamic biomarkers such as circulating tumor DNA (ctDNA) can help detect minimal residual disease and identify the subset of patients who would likely benefit from adjuvant treatment. In addition, the characterization of tumor-infiltrating lymphocytes, neutrophil-to-lymphocyte ratio, and ctDNA-adjusted blood tumor mutation burden (bTMB) has also shown promise in predicting response to immunotherapy. Until additional, prospective studies delineate the magnitude of overall survival benefit and validate the use of predictive biomarkers, a tailored, patient-centered approach to adjuvant ICIs that includes extensive patient counseling on potentially irreversible adverse effects should be routinely incorporated into clinical practice.

Estimation of the physiologic ability and surgical stress scoring system as a useful predictor of postoperative recurrence in patients with stage II colorectal cancer: a multicenter study

PURPOSE

We determined the usefulness of the estimation of physiologic ability and surgical stress (E-PASS), initially reported as a predictive factor for postoperative morbidity and mortality, as a prognostic indicator in stage II colorectal cancer (CRC).

METHODS

Overall, 739 patients who underwent proctocolectomy for CRC at Tottori University Hospital and affiliated hospitals and histologically diagnosed with stage II CRC were included in the current study.

RESULTS

A receiver operating characteristic (ROC) analysis of the five-year recurrence-free survival indicated that the comprehensive risk score (CRS) of E-PASS predicted postoperative recurrence. A multivariate analysis revealed that the presence of preoperative perforation, T4, v ≥ 2, and CRS^High (≥ 0.2267) were independent predictors of postoperative recurrence. Patients were assigned a score using these factors, as follows: the presence of perforation = 1, the absence of preoperative perforation = 0, T4 = 1, T3 = 0, v2/3 = 1, v0/1 = 0, CRS^High = 1, and CRS^Low = 0 (total score: 0-4). Accordingly, the respective 5-year relapse-free survival rates were 91.0%, 83.6%, 70.3%, and 52.0% among those with scores of 0, 1, 2, and both 3 and 4 (P < 0.001).

CONCLUSIONS

The CRS predicts postoperative recurrence in patients with stage II CRC.

Radiomics signature based on CECT for non-invasive prediction of response to anti-PD-1 therapy in patients with hepatocellular carcinoma

PURPOSE

This study aimed to develop a radiomics signature (RS) based on contrast-enhanced computed tomography (CECT) and evaluate its potential predictive value in hepatocellular carcinoma (HCC) patients receiving anti-PD-1 therapy.

METHOD

CECT scans of 76 HCC patients who received anti-PD-1 therapy were obtained in this study (training group = 53 and validation group = 23). The least absolute shrinkage and selection operator (LASSO) regression was applied to select radiomics features of primary and metastatic lesions and establish a RS to predict lesion-level response. Then, a nomogram combined the mean RS (MRS) and clinical variables with patient-level response as the end point.

RESULTS

In the lesion-level analysis, the area under the curves (AUCs) of RS in the training and validation groups were 0.751 (95% CI, 0.668-0.835) and 0.734 (95% CI, 0.604-0.864), respectively. In the patient-level analysis, the AUCs of the nomogram in the training and validation groups were 0.897 (95% CI, 0.798-0.996) and 0.889 (95% CI, 0.748-1.000), respectively. The nomogram stratified patients into low- and high-risk groups, which showed a significant difference in progression-free survival (PFS) (p<0.05).

CONCLUSIONS

The RS is a noninvasive biomarker for predicting anti-PD-1 therapy response in patients with HCC. The nomogram may be of clinical use for identifying high-risk patients and formulating individualised treatments.

Efficacy and safety of alectinib in ALK-positive non-small cell lung cancer and blood markers for prognosis and efficacy: a retrospective cohort study

Background

Alectinib is a second generation of ALK-tyrosine kinase inhibitors (ALK-TKIs), which has attracted much attention in the treatment of ALK-positive non-small cell lung cancer (NSCLC). At present, there are few reports on the efficacy and safety of alectinib in Chinese population. Moreover, biomarkers reflecting prognosis and efficacy are exceedingly needed. This study assessed the efficacy of alectinib in patients with ALK-positive NSCLC and analyzed the prognostic factors.

Methods

Patients with ALK-positive NSCLC who were confirmed by histopathology or cytology at the Affiliated Cancer Hospital of Nanjing Medical University between October 2018 and October 2021 were enrolled. All patients were treated with alectinib. The clinical characteristics and circulating tumor biomarkers before and after treatment were collected. Kaplan-Meier test was used to calculate the progression-free survival (PFS). Univariate and multivariate Cox regression analyses were used to explore the influencing factors on PFS. Incidence of adverse events was observed.

Results

Twenty patients progressed after first-line treatment (n=59) with alectinib, and 21 patients progressed following second-line treatment (n=36) with alectinib. The median PFS of first-line treatment patients was not achieved, and the median PFS of patients undergoing second-line treatment was 15.0 months [95% confidence interval (CI): 0.00-32.23]. The most common adverse reactions were liver dysfunction (37.50%), anemia (37.50%), and constipation (20.83%). The incidence of grade III and above adverse reactions was 6.25%. Univariate analysis showed that neutrophil-to-lymphocyte ratio [NLR; hazard ratio (HR) =0.424, P=0.005] carcinoembryonic antigen (CEA; HR =0.482, P=0.029), lactate dehydrogenase (LDH; HR =0.327, P<0.001), carbohydrate antigen (CA)199 (HR =0.313, P=0.002), and circulating cell free DNA (cfDNA; HR =0.229, P=0.008) concentration levels were associated with PFS, and multivariate analysis showed that NLR (HR =3.058, P=0.034) was independent prognostic factor. After three months of treatment, CEA, CA199, NLR, and LDH, could further predict the prognosis of alectinib treatment.

Conclusions

The efficacy and safety of alectinib as a first-line or second-line treatment for ALK-positive NSCLC in keeping with published prospective studies. CEA, CA199, NLR, and LDH within the normal range after three months of treatment were associated with good prognosis. Detection of serum tumor markers can indicate therapeutic success in patients treated with alectinib.

Prognostic Hematologic Biomarkers Following Immune Checkpoint Inhibition in Metastatic Uveal Melanoma

Background: There is no standardized treatment for metastatic uveal melanoma (MUM) but immune checkpoint inhibitors (ICI) are increasingly used. While ICI has transformed the survival of metastatic cutaneous melanoma, MUM patients do not equally benefit. Factors known to affect ICI response include the hematologic markers, lactate dehydrogenase (LDH) and neutrophil:lymphocyte ratio (NLR). We evaluated the prognostic value of LDH and NLR at the start of ICI and on treatment in MUM. Methods: MUM patients were treated between August 2006 and May 2022 with combination ipilimumab/nivolumab or ipilimumab/nivolumab/pembrolizumab single-agent therapy. Univariable (UVA) and multivariable (MVA) analyses were used to assess the prognostic value of predefined baseline factors on progression-free (PFS) and overall survival (OS). Results: In forty-six patients with MUM treated with ICI, elevated baseline and on-treatment LDH was prognostic for OS (start of ICI, HR (95% CI): 3.6 (1.9−7.0), p < 0.01; on-treatment, HR (95% CI): 3.7 (1.6−8.8), p < 0.01) and PFS (start of ICI, (HR (95% CI): 2.8 (1.5−5.4), p < 0.0001); on-treatment LDH (HR (95% CI): 2.2 (1.1−4.3), p < 0.01). On-treatment NLR was prognostic for PFS (HR (95% CI): 1.9 (1.0−3.9), p < 0.01). On-treatment LDH remained an important contributor to survival on MVA (OS: HR (95% CI): 1.001 (1.00−1.002), p < 0.05); PFS: HR (95% CI): 1.001 (1.00−1.002), p < 0.01). Conclusions: This study demonstrates that LDH and NLR could be useful in the prognostication of MUM patients treated with ICI. Additional studies are needed to confirm the importance of these and other prognostic biomarkers.

MDACT: A New Principle of Adjunctive Cancer Treatment Using Combinations of Multiple Repurposed Drugs, with an Example Regimen

In part one of this two-part paper, we present eight principles that we believe must be considered for more effective treatment of the currently incurable cancers. These are addressed by multidrug adjunctive cancer treatment (MDACT), which uses multiple repurposed non-oncology drugs, not primarily to kill malignant cells, but rather to reduce the malignant cells' growth drives. Previous multidrug regimens have used MDACT principles, e.g., the CUSP9v3 glioblastoma treatment. MDACT is an amalgam of (1) the principle that to be effective in stopping a chain of events leading to an undesired outcome, one must break more than one link; (2) the principle of Palmer et al. of achieving fractional cancer cell killing via multiple drugs with independent mechanisms of action; (3) the principle of shaping versus decisive operations, both being required for successful cancer treatment; (4) an idea adapted from Chow et al., of using multiple cytotoxic medicines at low doses; (5) the idea behind CUSP9v3, using many non-oncology CNS-penetrant drugs from general medical practice, repurposed to block tumor survival paths; (6) the concept from chess that every move creates weaknesses and strengths; (7) the principle of mass-by adding force to a given effort, the chances of achieving the goal increase; and (8) the principle of blocking parallel signaling pathways. Part two gives an example MDACT regimen, gMDACT, which uses six repurposed drugs-celecoxib, dapsone, disulfiram, itraconazole, pyrimethamine, and telmisartan-to interfere with growth-driving elements common to cholangiocarcinoma, colon adenocarcinoma, glioblastoma, and non-small-cell lung cancer. gMDACT is another example of-not a replacement for-previous multidrug regimens already in clinical use, such as CUSP9v3. MDACT regimens are designed as adjuvants to be used with cytotoxic drugs.

The role of biomarkers in personalized immunotherapy

BACKGROUND

Immune checkpoint inhibitors have revolutionized cancer therapeutic paradigm and substantially improved the survival of patients with advanced malignancies. However, a significant limitation is the wide variability in clinical response.

MAIN TEXT

Several biomarkers have been evaluated in prior and ongoing clinical trials to investigate their prognostic and predictive role of patient response, nonetheless, most have not been comprehensively incorporated into clinical practice. We reviewed published data regarding biomarkers that have been approved by the United States Food and Drug Administration as well as experimental tissue and peripheral blood biomarkers currently under investigation. We further discuss the role of current biomarkers to predict response and response to immune checkpoint inhibitors and the promise of combination biomarker strategies. Finally, we discuss ideal biomarker characteristics, and novel platforms for clinical trial design including enrichment and stratification strategies, all of which are exciting and dynamic to advance the field of precision immuno-oncology.

CONCLUSION

Incorporation and standardization of strategies to guide selection of combination biomarker approaches will facilitate expansion of the clinical benefit of immune checkpoint inhibitor therapy to appropriate subsets of cancer patients.

The preoperative hemoglobin, albumin, lymphocyte, and platelet score is a prognostic factor for non-small cell lung cancer patients undergoing adjuvant chemotherapy: a retrospective study

Background

Developing a simple, reliable and low-cost biomarkers is crucial to predict the prognosis of non-small cell lung cancer (NSCLC) patients receiving adjuvant chemotherapy. The score combining hemoglobin and albumin levels and lymphocyte and platelet counts (HALP score) is reportedly related to the prognosis of multiple types of tumors. However, few studies have focused on its prognostic value in patients with NSCLC. Our study aimed to investigate the prognostic role of the HALP score and develop a valuable prognostic model for patients with NSCLC undergoing adjuvant chemotherapy.

Methods

A total of 362 individuals with NSCLC undergoing adjuvant chemotherapy between 2013 and 2015 were included. The HALP score was computed according to the following formula: hemoglobin (g/L) × albumin (g/L) × lymphocytes (g/L)/platelets (g/L). Furthermore, demographic characteristic, including age, sex, smoking status, and drinking history, were collected from case report forms at admission. The main outcomes were overall survival (OS) and disease-free survival (DFS), which were assessed using Kaplan-Meier analysis with log-rank test. Furthermore, Cox regression analysis was employed to assess the prognostic role of HALP in NSCLC.

Results

We found the significant associations of clinicopathological features, including sex, pathological stage, tumor size, and lymph node metastasis (LNMets) in univariate Cox regression analysis. In multivariate analysis, NSCLC patients with a high HALP score were significantly associated with lower OS [hazard ratio (HR): 0.707; 95% confidence interval (CI): 0.503-0.995] and DFS (HR: 0.671; 95% CI: 0.491-0.916). The Kaplan-Meier analysis showed that a low HALP score predicted poorer OS (P=0.02) and DFS (P<0.01) outcomes. Furthermore, we performed stratification analysis by tumor node metastasis (TNM) stage, and the result indicated a low HALP score predicted poor OS (P=0.01) and DFS (P=0.04) outcomes in stage III-IV NSCLC patients.

Conclusions

Our study demonstrated that the HALP score might be a suitable prognostic index for NSCLC patients undergoing adjuvant chemotherapy. Combining demographic and clinicopathological features with the HALP score may help clinicians predict survival and treatment outcomes.