Pre-treatment neutrophil-lymphocyte ratio is associated with overall mortality in localized non-small cell lung cancer treated with stereotactic body radiotherapy

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.

Prognostic utility of blood inflammation biomarkers before and after treatment on the survival of patients with locally advanced non-small cell lung cancer undergoing stereotactic body radiotherapy

BACKGROUND AND OBJECTIVE

The neutrophil-lymphocyte ratio (NLR) and platelet-lymphocyte ratio (PLR) were significant and succinct indicators of systemic inflammation. We assessed the influence of stereotactic body radiotherapy (SBRT) on NLR and PLR in patients with locally advanced non-small cell lung cancer (LA-NSCLC).

METHODS

We reviewed the medical data of patients with LA-NSCLC who underwent SBRT between 1 January 2013 and 31 December 2018. NLR and PLR values recorded at pre- and post-SBRT were examined. We assessed the correlation between pre/post-SBRT NLR and PLR and survival outcomes. The decision tree evaluation was conducted using Chi-square automatic detection.

RESULTS

In total, 213 patients were included in the study with a median follow-up duration of 40.00 (ranging from 5.28 to 100.70) months. Upon dichotomization by a median, we identified that post-SBRT NLR > 5.5 and post-SBRT PLR > 382.0 were negatively associated with shorter overall survival (OS). In the multivariate assessment, post-SBRT PLR > 382.0 was the only factor. Based on post-SBRT PLR, tumor locations, and tumor stage, we categorized patients into low, medium, or high-risk groups.

CONCLUSIONS

Post-SBRT PLR > 382.0 correlated with survival in patients undergoing SBRT. The decision tree model might play a role in future risk stratification to guide the clinical practice of individualized SBRT for LA-NSCLC.

Developing a clinical-radiomic prediction model for 3-year cancer-specific survival in lung cancer patients treated with stereotactic body radiation therapy

PURPOSE

The study aims to develop and validate a combined model for predicting 3-year cancer-specific survival (CSS) in lung cancer patients treated with stereotactic body radiation therapy (SBRT) by integrating clinical and radiomic parameters.

METHODS

Clinical data and pre-treatment CT images were collected from 102 patients treated with lung SBRT. Multivariate logistic regression and the least absolute shrinkage and selection operator were used to determine the clinical and radiomic factors associated with 3-year CSS. Three prediction models were developed using clinical factors, radiomic factors, and a combination of both. The performance of the models was assessed using receiver operating characteristic curve and calibration curve. A nomogram was also created to visualize the 3-year CSS prediction.

RESULTS

With a 36-month follow-up, 40 patients (39.2%) died of lung cancer and 62 patients (60.8%) survived. Three clinical factors, including gender, clinical stage, and lymphocyte ratio, along with three radiomic features, were found to be independent factors correlated with 3-year CSS. The area under the curve values for the clinical, radiomic, and combined model were 0.839 (95% CI 0.735-0.914), 0.886 (95% CI 0.790-0.948), and 0.914 (95% CI 0.825-0.966) in the training cohort, and 0.757 (95% CI 0.580-0.887), 0.818 (95% CI 0.648-0.929), and 0.843 (95% CI 0.677-0.944) in the validation cohort, respectively. Additionally, the calibration curve demonstrated good calibration performance and the nomogram created from the combined model showed potential for clinical utility.

CONCLUSION

A clinical-radiomic model was developed to predict the 3-year CSS for lung cancer patients treated with SBRT.

Neutrophil to lymphocyte ratio (NTLR) predicts local control and overall survival after stereotactic body radiotherapy (SBRT) in metastatic sarcoma

The neutrophil to lymphocyte ratio (NTLR) and absolute lymphocyte count (ALC) recovery are prognostic across many cancers. We investigated whether NLTR predicts SBRT success or survival in a metastatic sarcoma cohort treated with SBRT from 2014 and 2020 (N = 42). Wilcox Signed Rank Test and Friedman Test compare NTLR changes with local failure vs. local control (N = 138 lesions). Cox analyses identified factors associated with overall survival. If local control was successful, NLTR change was not significant (p = 0.30). However, NLTR significantly changed in patients with local failure (p = 0.027). The multivariable Cox model demonstrated higher NLTR before SBRT was associated with worse overall survival (p = 0.002). The optimal NTLR cut point was 5 (Youden index: 0.418). One-year overall survival in SBRT metastatic sarcoma cohort was 47.6% (CI 34.3%-66.1%). Patients with an NTLR above 5 had a one-year overall survival of 37.7% (21.4%-66.3%); patients with an NTLR below 5 had a significantly improved overall survival of 63% (43.3%-91.6%, p = 0.014). Since NTLR at the time of SBRT was significantly associated with local control success and overall survival in metastatic sarcoma treated with SBRT, future efforts to reduce tumor inhibitory microenvironment factors and improve lymphocyte recovery should be investigated.

Neutrophil to Lymphocyte Ratio (NTLR) Predicts Local Control Failure and Overall Survival after Stereotactic Body Radiotherapy (SBRT) In Metastatic Sarcoma

The neutrophil to lymphocyte ratio (NTLR) and absolute lymphocyte count (ALC) recovery are prognostic across many cancers. We investigated whether NLTR predicts SBRT success or survival in a metastatic sarcoma cohort treated with SBRT from 2014 and 2020 (N = 42). Wilcox Signed Rank Test and Friedman Test compare NTLR changes with local failure vs. local control (N = 138 lesions). Cox analyses identified factors associated with overall survival. If local control was successful, NLTR change was not significant (p = 0.30). However, NLTR significantly changed in patients local failure (p = 0.027). The multivariable Cox model demonstrated higher NLTR before SBRT was associated with worse overall survival (p = 0.002). The optimal NTLR cut point was 5 (Youden index: 0.418). One-year overall survival in SBRT metastatic sarcoma cohort was 47.6% (CI 34.3%-66.1%). Patients with an NTLR above 5 had a one-year overall survival of 37.7% (21.4%-66.3%); patients with an NTLR below 5 had a significantly improved overall survival of 63% (43.3%-91.6%, p = 0.014). Since NTLR at the time of SBRT was significantly associated with local control success and overall survival in metastatic sarcoma treated with SBRT, future efforts to reduce tumor inhibitory microenvironment factors and improved lymphocyte recovery should be investigated.

Association of neutrophil-lymphocyte ratio with survival in peripheral early-stage non-small cell lung cancer after stereotactic body radiation therapy

BACKGROUND

The role of neutrophil-lymphocyte ratio (NLR) as a predictor for survival in single fraction SBRT-treated non-small cell lung cancer (NSCLC) patients remains unclear. We performed an observational cohort study to determine the role of pretreatment NLR in predicting survival of early-stage NSCLC patients after single fraction SBRT.

METHODS

A single-institution database of peripheral early-stage NSCLC patients treated with SBRT from February 2007 to May 2022 was queried. Optimal threshold of neutrophil-lymphocyte ratio (NLR) was defined based on maximally selected rank statistics. Cox multivariable analysis (MVA), Kaplan-Meier, and propensity score matching were performed to evaluate outcomes.

RESULTS

A total of 286 patients were included for analysis with median follow up of 19.7 months. On Cox multivariate analysis, as a continuous variable, NLR was shown to be an independent predictor of OS (adjusted hazards ratio [aHR] 1.06, 95% CI 1.02-1.10, p = 0.005) and PFS (aHR 1.05, 95% CI 1.01-1.09, p = 0.013). In addition, NLR was associated with DF (aHR 1.11, 95% CI 1.05-1.18, p < 0.001). Maximally selected rank statistics determined 3.28 as the cutoff point of high NLR versus low NLR. These findings were confirmed upon propensity matching.

CONCLUSIONS

Pretreatment NLR is an independent predictor for survival outcomes of peripheral early-stage NSCLC patients after single fraction SBRT.

Prognostic markers including immune and inflammatory factors predict outcomes in patients receiving postoperative radiation therapy for cholangiocarcinoma

PURPOSE

This study aimed to analyze treatment outcomes and prognostic markers, including immune and inflammatory factors, of postoperative radiation therapy (RT) administered to patients with cholangiocarcinoma (CCA).

METHODS

We retrospectively included 59 patients with CCA who underwent surgery and postoperative RT with curative intent from 2004 to 2019. Patients received external irradiation (50 Gy in 25 fractions) using three-dimensional RT. We analyzed prognostic factors of inflammation, such as pre-RT platelet count, hemoglobin, lymphocyte count ratio (LCR) of the leukocyte count, platelet-to-lymphocyte ratio (PLR), and neutrophil-to-lymphocyte ratio (NLR).

RESULTS

Tumor stages were distributed as follows: I (n = 8), II (n = 25), III (n = 15), and IVA (n = 11). The median follow-up was 24 months. Two-year overall survival (OS), cause-specific survival (CSS), progression-free survival (PFS), and locoregional control (LRC) rates were 59.5%, 62.0%, 40.1%, and 66.7%, respectively. Univariate analysis revealed that lower LCR was significantly associated with shorter PFS (p = 0.0446). There was no significant difference between the median baseline values of PLR and NLR; and age ≥75, positive regional lymph node metastases (N+), and chemotherapy after RT were significantly associated with poor OS. Multivariate analysis revealed a significant association of N+ with worse OS, PFS, and CSS and that lower LCR was significantly associated with better PFS (p = 0.0234). Among late toxicity events, two patients (3.38%) were suspected with therapy-related liver toxicity.

CONCLUSIONS

Lower LCR before RT was a better prognostic factor for postoperative RT of patients with CCA.

Predicting if Lung Cancer Will Relapse-The Role of Neutrophil/Lymphocyte Ratio

OBJECTIVE/BACKGROUND

Baseline neutrophil/lymphocyte ratio (NLR), a surrogate marker for systemic inflammation and immunosuppression, is a well-studied prognostic marker in non-small cell lung cancer (NSCLC). This study tests if interim NLR is prognostic in NSCLC patients in remission.

METHODS

This single-center, retrospective cohort study analyzed 131 NSCLC patients treated from 2010 to 2015 who achieved complete remission. NLR was calculated at baseline and from the first available blood sample during remission. Kaplan-Meier estimates of overall survival (OS) and time to recurrence were compared using the log-rank test for trend. Multivariable analysis was conducted using the Cox proportional hazards model.

RESULTS

Of the 131 cases, 63 had subsequently recurred at the last follow-up. The mean age was 64 ± 10 years. Patients with stage I (35%), II (24%), and III (41%) were included. Histology were adenocarcinoma (60%), squamous cell (33%), and unspecified (7%). The majority of patients were smokers. For the univariate analysis interim NLR was binned into tertiles, NLR < 2, 2-4.08, and > 4.08. Of those with an interim NLR > 4.08, prognosis and recurrence risk were higher. In the multivariable analysis, remission NLR was strongly prognostic for OS ( p < .001) as did patient's age ( p = .002), but not stage, race, sex, and baseline NLR.

CONCLUSIONS

Our study found that interim NLR, obtained in remission, was strongly prognostic for OS and recurrence.

Derived Neutrophil-Lymphocyte Ratio and C-Reactive Protein as Prognostic Factors for Early-Stage Non-Small Cell Lung Cancer Treated with Stereotactic Body Radiation Therapy

Objectives: To explore the relationship between peripheral blood inflammation parameters and overall survival (OS) and progression-free survival (PFS) of early-stage non-small cell lung cancer patients who underwent stereotactic body radiotherapy (SBRT). Patients and methods: In this study, eligible patients treated with SBRT from 2013 to 2018, and both serum complete blood count and blood biochemical results were available prior to (within 60 days) radiotherapy were included. Results: A review of hospital registries identified 148 patients, and the 5-year OS and PFS of the entire cohort were 69.8% and 65.6%, respectively, with the median follow-up time was 52.8 months. Multivariable analysis showed that derived neutrophil-lymphocyte ratio (dNLR) ≥1.4 and C-reactive protein (CRP) ≥2.9 were statistically and independently associated with worse OS (HR = 4.62, 95% CI 1.89-11.27, p = 0.001; HR = 2.92, 95% CI 1.49-5.70, p = 0.002, respectively). The 5-year OS for patients with dNLR below and equal to or above the 1.4 were 85.3% and 62.9% (p = 0.002), respectively, and 76.7% for the low CRP group versus 58.5% for the high CRP group (p = 0.030). Higher serum level of post-treatment CRP also independent parameters for inferior PFS (HR = 4.83, 95% CI 1.28-18.25, p = 0.020). Conclusions: Our results demonstrate that dNLR and CRP are associated with the outcomes of early-stage NSCLC patients treated with SBRT, which may assist in selecting optimal nursing care and therapeutic scheme for every individual.

Prognostic role of modified Glasgow Prognostic score in elderly non-small cell lung cancer patients treated with anti-PD-1 antibodies

BACKGROUND

This study aimed to investigate whether the immunosenescence-related score is a critical prognostic predictor of anti-programmed cell death protein 1 (PD-1) axis inhibitors in elderly patients with advanced non-small cell lung cancer (NSCLC).

METHODS

We reviewed 51 patients with advanced NSCLC aged ≥75 years, who were treated with nivolumab or pembrolizumab at the National Cancer Center Hospital between December 2015 and April 2019. Factors such as modified Glasgow prognostic score (mGPS), Neutrophil-to-lymphocyte ratio (NLR), and Charlson comorbidity index (CCI) were used to assess immunosenescence.

RESULTS

The objective response rate (ORR) and disease control rate (DCR) of all patients were 25.4% (95% confidence interval [CI]: 14.3-39.6) and 52.9% (95% CI: 38.5-67.1), respectively. High mGPS (score of 2) was associated with low DCR compared to low mGPS (score of 0-1) (26.0% vs. 54.0%, p = 0.03). However, none of these scores were significantly related to the ORR. High mGPS was significantly linked to shorter median progression-free survival (mPFS) (4.2 mos. vs. 12.7 mos, p < 0.01), and median overall survival (mOS) (4.8 mos. vs. 28.1 mos, p = 0.03). However, neither CCI nor NLR was associated with prognosis. Multivariate regression analysis identified high mGPS as a significant prognostic factor for mOS (hazard ratio, HR: 0.31 [95% CI: 0.13-0.71], p < 0.01).

CONCLUSIONS

High mGPS scores significantly impaired DCR, mPFS, and mOS in patients with advanced NSCLC treated with anti-PD-1 antibodies.

Combined Radiomics-Clinical Model to Predict Radiotherapy Response in Inoperable Stage III and IV Non-Small-Cell Lung Cancer

Purpose: Radiotherapy is a promising treatment option for lung cancer, but patients' responses vary. The purpose of the study was to investigate the potential of radiomics and clinical signature for predicting the radiotherapy sensitivity and overall survival of inoperable stage III and IV non-small-cell lung cancer (NSCLC) patients. Materials: This retrospective study collected 104 inoperable stage III and IV NSCLC patients at the Yunnan Cancer Hospital from October 2016 to September 2020. They were divided into radiation-sensitive and non-sensitive groups. We used analysis of variance (ANOVA) to select features and support vector machine (SVM) to build the radiomic model. Furthermore, the logistic regression method was used to screen out clinically relevant predictive factors and construct the combined model of radiomics-clinical features. Finally, survival was estimated using the Kaplan-Meier method. Results: There were 40 patients in the radiation-sensitive group and 64 in the non-sensitive group. These patients were divided into training set (73 cases) and testing set (31 cases) according to the ratio of 7:3. Nine radiomics features and one clinical feature were significantly associated with radiotherapy sensitivity. Both the radiomics model and combined model have good predictive performance (the areas under the curve (AUC) values of the testing set were 0.864 (95% confidence interval [CI]: 0.683-0.996) and 0.868 (95% CI: 0.689-1.000), respectively). Only platelet level status was associated with overall survival. Conclusion: The combined model constructed based on radiomics and clinical features can effectively identify the radiation-sensitive population and provide valuable clinical information. Patients with higher platelet levels may have a poor prognosis.

Neutrophil‑to‑lymphocyte ratio as a prognostic predictor for patients with cancer treated with stereotactic body radiation therapy: A meta‑analysis

Stereotactic body radiation therapy (SBRT) is effective for the treatment of cancer. Neutrophil-to-lymphocyte ratio (NLR) is a common prognostic factor in predicting survival of patients with cancer. Previous studies have reported that NLR may be able to predict survival of patients with cancer treated with SBRT; however, the results are inconsistent. Therefore, the present study performed a meta-analysis to pool the data of prognostic prediction using NLR for patients with cancer who underwent SBRT. PubMed, Google Scholar, Embase and The Cochrane Library were used to search for articles published before October 2020. Pooled hazard radios (HRs) with 95% confidence intervals (CIs) were used to evaluate the association of NLR levels with patient outcome following SBRT. The primary endpoint was overall survival (OS). Subgroup analyses were used to detect sources of heterogeneity. Publication bias was assessed by Egger's test and Begg's test. A total of nine studies involving 1,010 participants were included in the present meta-analysis. Univariate and multivariate analyses revealed that elevated NLR predicted a worse outcome for OS (HR, 1.35; 95% CI, 1.22-1.49; P<0.001 and HR, 1.29; 95% CI, 1.16-1.44; P<0.001, respectively), regardless of pre- and post-treatment groups. Subgroup analysis demonstrated that the prospective group showed more significant heterogeneity (I²=57.7%; P=0.124) than the retrospective group (I²=0%) and overall (I²=47.5%). In conclusion, both pre- and post-SBRT elevated NLRs were revealed to be independently associated with poor survival in patients with cancer who received SBRT.

Pretreatment neutrophil-to-lymphocyte ratio and cigarette smoking as prognostic factors in patients with advanced NSCLC treated with osimertinib

Background

The remarkable efficacy of osimertinib in non‒small cell lung cancer (NSCLC) with acquired T790M mutation has been widely documented in clinical trials and real-world practice. However, some patients show primary resistance to this drug. Even patients who initially show a favorable response have inconsistent clinical outcomes later. Therefore, the aim of this study was to identify additional clinical predictive factors for osimertinib efficacy.

Methods

A prospective cohort of patients with acquired T790M positive stage IV lung adenocarcinoma treated with osimertinib salvage therapy in Hallym University Medical Center were analyzed.

Results

Sixty-one eligible patients were analyzed, including 38 (62%) women and 39 (64%) who never smoked. Their mean age was 63.3 years. The median follow-up after treatment with epidermal growth factor receptor (EGFR) tyrosine kinase inhibitors (TKIs) was 36.0 months (interquartile range, 24.7–50.2 months). The majority (n=45, 74%) of patients were deceased. Based on univariate analysis, low baseline neutrophil-to-lymphocyte ratios (NLR), age ≥50 years, never-smoking history, stage IVA at osimertinib initiation, and prolonged response to previous TKIs (≥10 months) were associated with a significantly longer progression-free survival (PFS). Multivariate analysis showed that never-smoking status (hazard ratio [HR], 0.54; 95% confidence interval [CI], 0.30–0.98; p=0.041) and a baseline NLR less than or equal to 3.5 (HR, 0.23; 95% CI, 0.12–0.45; p<0.001) were independently associated with a prolonged PFS with osimertinib.

Conclusion

Smoking history and high NLR were independent negative predictors of osimertinib PFS in patients with advanced NSCLC developing EGFR T790M resistance after the initial EGFR-TKI treatment.

Prognostic impact of immune inflammation biomarkers in predicting survival and radiosensitivity in patients with non-small-cell lung cancer treated with chemoradiotherapy

INTRODUCTION

The purpose of this retrospective study was to investigate the prognostic impact of neutrophil-to-lymphocyte ratio (NLR), platelet-to-lymphocyte ratio (PLR), derived NLR (dNLR) and systemic immune-inflammation index (SII) in predicting outcomes for patients with locally advanced non-small-cell lung cancer (NSCLC). The secondary endpoint was to evaluate the radiosensitivity in terms of response rate.

METHODS

Newly diagnosed locally advanced NSCLC patients were enrolled. Immune inflammation biomarkers were calculated from baseline blood samples. Patients were stratified in two groups based on optimal cut-off values for each biomarker. The associations between biomarkers and overall survival (OS), progression-free survival (PFS), local regional recurrence-free survival (LRRFS), and also response to radiotherapy were analysed.

RESULTS

A total of 392 patients were included. Five-year OS, PFS and LRRFS rates were 14.6%, 12.1%, and 13.4% respectively. Optimal cut-off values for NLR, PLR, dNLR and SII were 3.07, 166, 2.02 and 817 respectively. Low NLR (HR 1.73, 95% CI 1.34-2.24, P < 0.001), low PLR (HR 1.37, 95% CI 1.06-1.76, P = 0.013), low dNLR (HR 1.66, 95% CI 1.29-2.13, P < 0.001) and low SII (HR 1.63, 95% CI 1.18-2.04, P < 0.001) were independent prognostic factors for OS. Low NLR, PLR, dNLR and SII were also significant prognostic factors for PFS and LRRFS. Low NLR, low dNLR and low SII groups had better radiosensitivity than compared with high NLR, high dNLR and high SII groups (P = 0.001, P = 0.001 and P = 0.012).

CONCLUSION

NLR, PLR, dNLR and SII were independently associated with improved OS, PFS and LRRFS. Low NLR, dNLR and SII groups had better radiosensitivity. Immune inflammation biomarkers are promising prognostic predictors which can be obtained easily and inexpensively.

The Combination of Radiotherapy With Immunotherapy and Potential Predictive Biomarkers for Treatment of Non-Small Cell Lung Cancer Patients

Radiotherapy is an effective local treatment modality of NSCLC. Its capabilities of eliminating tumor cells by inducing double strand DNA (dsDNA) damage and modulating anti-tumor immune response in irradiated and nonirradiated sites have been elucidated. The novel ICIs therapy has brought hope to patients resistant to traditional treatment methods, including radiotherapy. The integration of radiotherapy with immunotherapy has shown improved efficacy to control tumor progression and prolong survival in NSCLC. In this context, biomarkers that help choose the most effective treatment modality for individuals and avoid unnecessary toxicities caused by ineffective treatment are urgently needed. This article summarized the effects of radiation in the tumor immune microenvironment and the mechanisms involved. Outcomes of multiple clinical trials investigating immuno-radiotherapy were also discussed here. Furthermore, we outlined the emerging biomarkers for the efficacy of PD-1/PD-L1 blockades and radiation therapy and discussed their predictive value in NSCLC.

Neutrophil-Lymphocyte Ratio and Absolute Lymphocyte Count as Prognostic Markers in Patients Treated with Curative-intent Radiotherapy for Non-small Cell Lung Cancer

AIMS

The neutrophil-lymphocyte ratio (NLR) and the absolute lymphocyte count (ALC) have been proposed as prognostic markers in non-small cell lung cancer (NSCLC). The objective of this study was to examine the association of NLR/ALC before and after curative-intent radiotherapy for NSCLC on disease recurrence and overall survival.

MATERIALS AND METHODS

A retrospective study of consecutive patients who underwent curative-intent radiotherapy for NSCLC across nine sites in the UK from 1 October 2014 to 1 October 2016. A multivariate analysis was carried out to assess the ability of pre-treatment NLR/ALC, post-treatment NLR/ALC and change in NLR/ALC, adjusted for confounding factors using the Cox proportional hazards model, to predict disease recurrence and overall survival within 2 years of treatment.

RESULTS

In total, 425 patients were identified with complete blood parameter values. None of the NLR/ALC parameters were independent predictors of disease recurrence. Higher pre-NLR, post-NLR and change in NLR plus lower post-ALC were all independent predictors of worse survival. Receiver operator curve analysis found a pre-NLR > 2.5 (odds ratio 1.71, 95% confidence interval 1.06-2.79, P < 0.05), a post-NLR > 5.5 (odds ratio 2.36, 95% confidence interval 1.49-3.76, P < 0.001), a change in NLR >3.6 (odds ratio 2.41, 95% confidence interval 1.5-3.91, P < 0.001) and a post-ALC < 0.8 (odds ratio 2.86, 95% confidence interval 1.76-4.69, P < 0.001) optimally predicted poor overall survival on both univariate and multivariate analysis when adjusted for confounding factors. Median overall survival for the high-versus low-risk groups were: pre-NLR 770 versus 1009 days (P = 0.34), post-NLR 596 versus 1287 days (P ≤ 0.001), change in NLR 553 versus 1214 days (P ≤ 0.001) and post-ALC 594 versus 1287 days (P ≤ 0.001).

CONCLUSION

NLR and ALC, surrogate markers for systemic inflammation, have prognostic value in NSCLC patients treated with curative-intent radiotherapy. These simple and readily available parameters may have a future role in risk stratification post-treatment to inform the intensity of surveillance protocols.

Stereotactic body radiation therapy (SBRT) of adrenal gland metastases in oligometastatic and oligoprogressive disease

Background

Stereotactic body radiation therapy (SBRT) as a form of noninvasive treatment that is becoming increasingly used to manage cancers with adrenal gland metastases. There is a paucity of data on safety and efficacy of this modality. The aim of the study was to evaluate the safety and efficacy of adrenal gland SBRT in oligometastatic and oligoprogressive disease.

Materials and methods

In this retrospective study, we performed a single-institution analysis of 26 adrenal lesions from 23 patients with oligometastatic or oligoprogressive disease treated from 2013 to 2019 with the goal of achieving durable local control. Palliative cases were excluded. Radiation dosimetry data was collected. Kaplan Meier product estimator and Cox proportional hazards regression analysis were used for statistical analysis.

Results

The median dose was 36 Gy in 3 fractions (range: 24-50 Gy and 3-6 fractions) with a median biologically effective dose (BED10) of 72 (range: 40-100). 1-year local control rate was 80% and median local control was not achieved due to a low number of failures. 1- and 2-year overall survival rates were 66% and 32%. Toxicity was mild with only one case of grade 2 nausea and no grade 3-5 toxicity. Higher neutrophil to lymphocyte ratio was associated with worse overall survival and a trend toward worse progression-free survival. In addition, worse performance status and lower BED10 were associated with worse survival. No such association could be shown for primary tumor location, histology, size or stage.

Conclusion

Adrenal SBRT for oligometastatic or oligoprogressive disease is a safe and effective form of treatment.

Prognostic utility of pretreatment neutrophil-lymphocyte ratio in survival outcomes in localized non-small cell lung cancer patients treated with stereotactic body radiotherapy: Selection of an ideal clinical cutoff point

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Neutrophil-lymphocyte ratio is a promising prognostic marker for several cancers.

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NLR is not useful as a marker of lung cancer survival in localized lung cancer.

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NLR has potential as a marker of competing mortality risk in localized lung cancer.

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NLR cutoff of 4.0 is proposed as a clinically useful cutoff point.

Background and purpose

Neutrophil-lymphocyte ratio (NLR) has been associated with overall survival (OS) in non-small cell lung cancer (NSCLC). We aimed to assess the utility of NLR as a predictor of lung cancer-specific survival (LCS) and identify an optimal, pretreatment cutoff point in patients with localized NSCLC treated with stereotactic body radiotherapy (SBRT) within the Veterans Affairs’ (VA) national database.

Materials and methods

In the VA database, we identified patients with biopsy-proven, clinical stage I NSCLC treated with SBRT between 2006 and 2015. Cutoff points for NLR were calculated using Contal/O’Quigley’s and Cox Wald methods. Primary outcomes of OS, LCS, and non-lung cancer survival (NCS) were evaluated in Cox and Fine-Gray models.

Results

In 389 patients, optimal NLR cutoff was identified as 4.0. In multivariable models, NLR > 4.0 was associated with decreased OS (HR 1.44, p = 0.01) and NCS (HR 1.68, p = 0.01) but not with LCS (HR 1.32, p = 0.09). In a subset analysis of 229 patients with pulmonary function tests, NLR > 4.0 remained associated with worse OS (HR 1.51, p = 0.02) and NCS (HR 2.18, p = 0.01) while the association with LCS decreased further (HR 1.22, p = 0.39).

Conclusion

NLR was associated with worse OS in patients with localized NSCLC treated with SBRT; however, NLR was only associated with NCS and not with LCS. Pretreatment NLR, with a cutoff of 4.0, offers potential as a marker of competing mortality risk which can aid in risk stratification in this typically frail and comorbid population. Further studies are needed to validate pretreatment NLR as a clinical tool in this setting.

Clinical Outcomes and Prognostic Factors of Salvage Stereotactic Body Radiotherapy for Post-Surgical Thoracic Oligo-Recurrence/Metastasis of Non-Small-Cell Lung Cancer

Purpose

The study aimed to assess the efficacy and safety of stereotactic body radiotherapy (SBRT) using CyberKnife (CK) in patients with postoperative thoracic oligo-recurrence/metastasis of non-small-cell lung cancer (NLCLC), and to analyze the prognostic factors affecting overall survival after SBRT.

Patients and Methods

A total of 44 patients with postoperative thoracic oligo-recurrence/metastatic of NLCLC treated with SBRT were reviewed. Thoracic oligo-recurrence/was defined as 1–3 loco-regional confined to lung lobe, hilar/mediastinal lymph nodes, bronchial stump, or chest wall. Primary endpoints included local control (LC), overall survival (OS), progression-free survival (PFS) and toxicity. Prognostic factors that affected these patients were analyzed by the univariate and multivariate analysis by Kaplan–Meier methods and Cox regression models, respectively.

Results

The median follow-up time after salvage SBRT was 48.5 months. Measuring from the date of salvage SBRT, the median OS of the 44 patients was 52.60 (95% CI: 29.59–75.60) months. 1-,3-and 5-year OS rates were 97.7%, 65.3% and 47.7%, respectively. The 1-,3-year and 5-year LC rates were 97.7%, 85.1% and 80.1%, respectively. At 1, 3 and 5 years, the PFS rates were 77.1%, 28.8% and 5.3%, respectively. Multivariate analysis demonstrated that pre-SBRT neutrophil-to-lymphocyte ratio (NLR) and Charlson comorbidity index (CCI) were independent prognostic factors (p < 0.05). The treatment-related side-effects were well tolerated. No patients developed grade 3 or greater pulmonary toxicity.

Conclusion

SBRT is a promising salvage therapeutic option for postoperative thoracic oligo-recurrence/metastasis of non-small-cell lung cancer with acceptable toxicity. Low pre-SBRT neutrophil-to-lymphocyte ratio (NLR) and low Charlson comorbidity index (CCI) were associated with a better prognosis and longer survival and might be considered as reliable and independent prognostic factors in these patients treated with SBRT.

Association of Pre- and Posttreatment Neutrophil-Lymphocyte Ratio With Recurrence and Mortality in Locally Advanced Non-Small Cell Lung Cancer

Objectives

Neutrophil–lymphocyte ratio (NLR) has been associated with mortality in non-small cell lung cancer (NSCLC), but its association with recurrence in locally advanced NSCLC (LA-NSCLC), specifically, is less established. We hypothesized pre- and posttreatment NLR would be associated with recurrence and mortality.

Methods

We studied the association of pretreatment NLR (pre-NLR) and posttreatment NLR at 1 (post-NLR₁) and 3 months (post-NLR₃) with outcomes in patients with LA-NSCLC treated with chemoradiation. Pre-NLR was dichotomized by 5, an a priori cutoff previously shown to be prognostic in LA-NSCLC. Post-NLR₁ and post-NLR₃ were dichotomized by their medians.

Results

We identified 135 patients treated with chemoradiation for LA-NSCLC between 2007 and 2016. Median follow-up for living patients was 61.1 months. On multivariable analysis, pre-NLR ≥ 5 was associated with worse overall survival (HR = 1.82; 95% CI 1.15 – 2.88; p = 0.011), but not with any recurrence, locoregional recurrence, or distant recurrence. Post-NLR₁ ≥ 6.3 was not associated with recurrence or survival. Post-NLR₃ ≥ 6.6 was associated with worse overall survival (HR = 3.27; 95% CI 2.01– 5.31; p < 0.001), any recurrence (HR = 2.50; 95% CI 1.53 – 4.08; p < 0.001), locoregional recurrence (HR = 2.50; 95% CI 1.40 – 4.46; p = 0.002), and distant recurrence (HR = 2.53; 95% CI 1.49 – 4.30; p < 0.001).

Conclusion

Pretreatment NLR is associated with worse overall survival and posttreatment NLR is associated with worse survival and recurrence. These findings should be validated independently and prospectively studied.

The Prognostic Role of Pretreatment Neutrophil to Lymphocyte Ratio (NLR) in Malignant Adrenal Lesions Treated With Stereotactic Body Radiation Therapy (SBRT)

OBJECTIVE

The objective of this study was to evaluate a single institution's experience with stereotactic body radiotherapy (SBRT) in treating malignant adrenal lesions, as well as the prognostic value of systemic inflammation biomarkers.

MATERIALS AND METHODS

From November 2007 to February 2018, 27 patients with malignant adrenal lesions received 31 SBRT treatments. Outcomes, measured from the date of SBRT, included overall survival (OS), local control (LC), and freedom from progression. Cox proportional hazard model was utilized to identify potential prognostic factors. Tumor response was assessed with PET Response Evaluation Criteria In Solid Tumors (PERCIST)/Response Evaluation Criteria in Solid Tumors (RECIST) criteria. Acute toxicity was evaluated with the National Cancer Institute Common Terminology Criteria for Adverse Events, version 4.03 criteria.

RESULTS

Median follow-up for all patients was 8 months. The complete response, partial response, stable disease, and progressive disease rates were 59%, 9%, 32%, and 0%, respectively. One-year LC, OS, and freedom from progression were 77.7%, 38.0%, and 10.0%, respectively. There was a trend toward significance upon multivariate analysis for pretreatment neutrophil to lymphocyte ratio >4.1 to predict inferior OS (adjusted hazard ratio=3.29, P=0.09, 1-year OS: 11% vs. 80%). There were 3 cases (10%) complicated by grade 2 acute toxicity, including nausea and fatigue. There was 1 grade 5 toxicity, as 1 case was complicated by a fatal gastric ulcer occurring 3 months after SBRT to the left adrenal gland (112.5 BED10).

CONCLUSIONS

These results support the limited existing literature, demonstrating that SBRT provides adequate LC for adrenal lesions with minimal toxicity. Pretreatment neutrophil to lymphocyte ratio may serve as a prognostic factor in these patients.

Tumor immune microenvironment in cancer patients with leukocytosis

Tumor-related leukocytosis (TRL) is correlated with poor survival in various types of cancers, but the microenvironment of TRL-associated human tumors has not been fully elucidated. Here, we aimed to characterize the immune microenvironment of cancer patients with TRL. The transcriptional signatures of tumor tissues obtained from cervical cancer patients with (TRL^pos) and without TRL (TRL^neg) were compared. As a surrogate for TRL diagnosis, a leukocytosis signature (LS) score was derived using genes differentially expressed between TRL^pos and TRL^neg tumors. The immunological profiles of patients in the TCGA database with high (LS^high) or low LS scores were compared. TRL^pos tumors were transcriptionally distinct from TRL^neg tumors, exhibiting up-regulation of radioresistance and down-regulation of adaptive immune response-related genes. In the TCGA cervical cancer cohort (n = 303), patients with high LS had inferior survival rates compared to those with low LS (P = 0.023). LS^high tumors were enriched in radioresistance, wound healing, and myeloid-derived suppressor cell (MDSC) signatures and had a higher infiltration of M2 macrophages and a lower infiltration of M1 macrophages and lymphocytes. LS^high tumors also expressed higher levels of CXCR2 chemokines, CSF2, and CSF3. In the pan-cancer cohort (n = 9984), LS^high tumors also exhibited poor survival, signatures of a suppressive immune microenvironment, and higher expression of CXCR2 chemokines. Our data provide evidence for a suppressive immune microenvironment in patients with TRL and suggest promising targets, such as the CXCR2 axis, for its therapeutic intervention.

Combination of PD-L1 expression and NLR as prognostic marker in patients with surgically resected non-small cell lung cancer

Background: In recent years, great improvement has been made in immunotherapies for non-small cell lung cancer (NSCLC). Current data have suggested that Programmed cell death ligand 1 (PD-L1) expression might not be an ideal marker for patient selection in isolation. Evidence has been increasing that alternative markers, such as neutrophil-to-lymphocyte ratio (NLR), a biomarker of systemic inflammation response (SIR) previously associated with outcomes in a variety of cancers including NSCLC, might be a predictor for patient selection and the response to therapy. No reports have examined the prognostic value of combination of PD-L1 expression and inflammatory markers such as NLR in NSCLC. This retrospective study explores the relationship between NLR and PD-L1 expression in NSCLC as well as the prognostic value of combination of PD-L1 expression and NLR.

Method: We evaluated tumor PD-L1 expression in 235 surgically resected NSCLC cases by immunohistochemical analysis. Carcinoma cells showing membranous staining for PD-L1 were considered PD-L1-positive cells (Figure 1). Cases with ≥1% tumor membrane staining were considered PD-L1-positive. The association of clinicopathological characteristics with PD-L1 expression was assessed by univariate and multivariate analyses. Moreover, univariate and multivariate analyses were performed to evaluate the predictive impact of PD-L1 expression and other factors on disease-free survival (DFS) and overall survival (OS).

Result: PD-L1 protein expression was elevated in 34.0% of patients at cut-off value of 1%. Univariate analyses showed that PD-L1 expression was significantly higher in men (χ² =5.226, P=0.030), heavy smokers (χ² =18.650, P<0.001), and patients with squamous cell carcinoma (χ² =4.036, P=0.045). No correlations were noted between PD-L1 expression and age, EGFR mutation status or clinical stage. No significant correlations between PD-L1 protein expression and NLR were found. Multivariate logistic regression revealed that smoking index ≥400 was independent predictor of PD-L1 expression (odds ratio [OR], 3.375; P < 0.001). The results of univariate survival analyses showed that clinical stage (log-rank χ² =7.876, P=0.019) was associated with DFS. Smoking index (log-rank χ² =4.832, P=0.028), clinical stage (log-rank χ² =7.582, P=0.023) and adjuvant treatment (log-rank χ² =5.440, P=0.020) were significantly associated with OS. Neither PD-L1 expression nor NLR was found to be associated with DFS or OS. Of interest, when patients were divided in two groups according to combined PD-L1/NLR: patients with PD-L1+/ high NLR as Group 1, other patients as Group 2, Group 1 had significantly shorter DFS as well as OS than Group 2 (DFS: log-rank χ² =5.231, P=0.022, Figure 2A; OS: log-rank χ² =4.742, P=0.029, Figure 2B). In the multivariate analysis, Cox proportional hazards regression models showed that, PD-L1+/ high NLR was associated with a significantly shorter DFS and OS (hazard ratio [HR], 1.394, P=0.040; HR, 1.442, P=0.042, respectively). Stratified analysis showed that the prognostic value of combined PD-L1/NLR can only be observed in cases without epidermal growth factor receptor (EGFR) mutations (DFS: log-rank χ² =5.593, P=0.018, Figure 2C, OS: log-rank χ² =9.323, P=0.002, Figure 2D). In EGFR mutation subgroup, combination of PD-L1 expression and NLR has no relationship with DFS or OS.

Conclusion: We found that combination of PD-L1 expression and NLR may be a promising prognostic indicator, and may also be a good marker for tumor recurrence, especially in the patients with wild-type EGFR.