Development of a Preoperative Nomogram Incorporating Biomarkers of Systemic Inflammatory Response to Predict Nonorgan-confined Urothelial Carcinoma of the Bladder at Radical Cystectomy

The Utility of Inflammatory Serum Markers in the Assessment of Perioperative Morbidity after Radical Cystectomy for Bladder Cancer

Background and Objectives: To date, sparse evidence exists about the impact of inflammatory serum markers in predicting perioperative complications after radical cystectomy (RC) for bladder cancer (BC). Here, we evaluated the role of the neutrophil-to-lymphocyte ratio (NLR), platelet-to-lymphocyte ratio (PLR), lymphocyte-to-monocyte ratio (LMR), systemic immune-inflammation index (SII), C-reactive protein (CRP), and plasma fibrinogen in predicting perioperative morbidity and unplanned 30-days readmission after RC for BC. Materials and methods: We relied on a collaborative database of 271 patients who underwent open RC for cT1-4a N0 M0 BC between January 2012 and December 2022. Univariable and multivariable binomial logistic regression analyses were performed to assess the odds ratio (OR) with 95% confidence intervals (CI) testing the ability of each serum marker to predict postoperative complications (any-grade and major complications), and 30-days unplanned readmission. Results: The median age at RC was 73 yr (IQR 67-79). A total of 182 (67.2%) patients were male and the median BMI was 25.2 (IQR 23.2-28.4). Overall, 172 (63.5%) patients had a Charlson Comorbidity Index (CCI) greater than 2 points and 98 (36.2%) were current smokers at the time of RC. Overall, 233 (86.0%) patients experienced at least one complication after RC. Of these, 171 (63.1%) patients had minor complications (Clavien-Dindo grade 1-2) while 100 (36.9%) experienced major complications (Clavien-Dindo grade ≥ 3). According to multivariable analysis, current smoking status, high plasma fibrinogen, and preoperative anemia were independently associated with major complications (OR 2.10, 95%CI 1.15-4.90, p = 0.02), (OR 1.51, 95%CI 1.26-1.98, p = 0.09), and (OR 1.35, 95%CI 1.17-2.57, p = 0.03), respectively. Overall, 56 (20.7%) patients experienced a 30-days unplanned readmission. According to univariable analysis, high preoperative CRP and hyperfibrinogenemia were significantly associated with an increased risk of unplanned readmission (OR 2.15, 95%CI 1.15-4.16, p = 0.02; OR 2.18, 95%CI 1.13-4.44, p = 0.02, respectively). Conclusions: In our study, the preoperative immune-inflammation signature described by NLR, PLR, LMR, SII, and CRP showed a low reliability in predicting perioperative course after RC. Preoperative anemia and hyperfibrinogenemia were independent predictors of major complications. Further studies are pending in order to draw definitive conclusions.

Impact of the preoperative modified glasgow prognostic score on disease outcome after radical cystectomy for urothelial carcinoma of the bladder

BACKGROUND

To investigate the predictive and prognostic value of the preoperative modified Glasgow Prognostic Score (mGPS) in patients with urothelial carcinoma of the bladder (UCB) treated with radical cystectomy (RC).

METHODS

We conducted a retrospective analysis of an established multicenter database consisting of 4,335 patients who were treated with RC +/- adjuvant chemotherapy for UCB between 1979 and 2012. The mGPS of each patient was calculated on the basis of preoperative serum C-reactive protein and albumin. Uni- and multivariable logistic and Cox regression analyses were performed. The discriminatory ability of the models was assessed by calculating the area under receiver operating characteristics curves (AUC) and concordance-indices (C-Index). The additional clinical net-benefit was assessed using the decision curve analysis (DCA).

RESULTS

A mGPS of 0, 1, and 2 was observed in 3,158 (72.8%), 1,020 (23.5%), and 157 (3.6%) patients, respectively. On multivariable logistic regression analyses, mGPS of 1 or 2 were associated with an increased risk of pT3/4 disease at RC (OR 1.25, p=0.004 and OR 2.58, p<0.001, respectively) and/or lymph node metastasis (OR 1.7, p<0.001 and OR 3.9, p<0.001, respectively). Addition of the mGPS to a predictive model based on preoperatively available variables improved its accuracy for prediction of lymph node metastasis (change of AUC +3.7%, p<0.001). On multivariable Cox regression analyses, mGPS of 1 or 2 remained associated with worse recurrence-free survival (HR 1.14, p=0.03 and HR 1.89 p<0.001, respectively), cancer-specific survival (HR 1.16, p=0.032 and HR 2.1, p<0.001, respectively) and overall survival (HR 1.5, p=0.007 and HR 1.92 p<0.001, respectively) compared to mGPS of 0. The additional discriminatory ability of the mGPS for prognosis of survival outcomes in separate models that included either established pre- or postoperative variables did not improve the C-Index by a prognostically relevant degree (change of C-Index <2% for all models). On DCA, the inclusion of the mGPS did not meaningfully improve the net-benefit for clinical decision-making regarding survival outcomes.

CONCLUSIONS

We confirmed that an elevated mGPS is an independent risk factor for non-organ confined disease and poor survival outcomes in patients with UCB undergoing RC. However, the mGPS showed little value in improving the discriminatory ability of predictive and prognostic models that relied on either pre- or postoperative clinicopathological variables. The discriminatory ability of this biomarker in the age of immunotherapy warrants further evaluation.

Prognostic value of preoperative albumin-to-fibrinogen ratio (AFR) in patients with bladder cancer treated with radical cystectomy

INTRODUCTION AND OBJECTIVES

To evaluate the prognostic role of albumin-to-fibrinogen ratio (AFR) for the prediction of oncological outcomes in a multi-institutional cohort of bladder cancer (BC) patients treated with radical cystectomy (RC).

MATERIALS AND METHODS

We retrospectively analyzed a multicenter cohort of patients treated with upfront RC for localized (cT1-4aN0M0) BC. Multivariable logistic regression analyses were performed to evaluate the ability of AFR to predict non-organ confined (NOC) disease and lymph-node involvement (LNI) at time of RC. Multivariable Cox' regression models were performed to evaluate the prognostic effect of AFR on Time-to-Progression (TTP), overall survival (OS), and cancer-specific survival (CSS).

RESULTS

A cut-off value to discriminate between low and high AFR was determined by calculating the receiver operating characteristic (ROC) curve. The area under the curve was 0.73 with an optimal cut-off at 9.53. Data were available for 246 patients (91 with low AFR, 155 with high AFR). Low AFR was associated with characteristics of tumor aggressiveness and independently predicted NOC (OR 2.11, P = 0.02) and LNI (OR 1.58, P = 0.04) at final pathological report. On multivariable Cox' regression analyses, preoperative low AFR was independently associated with worse TTP (HR 2.21, P = 0.02), OS (HR 2.24, P = 0.03), and CSS (HR 2.70, P = 0.01).

CONCLUSION

Preoperative low AFR is a prognostic biomarker for worse TTP, OS, CSS, and is independently associated with adverse tumor pathological features in BC patients undergoing RC. Our results suggest that especially patients with low AFR may be considered for neoadjuvant treatment.

Lymphocyte-to-Monocyte Ratio Is the Independent Prognostic Marker of Progression in Patients Undergoing BCG-Immunotherapy for Bladder Cancer

Introduction

Transurethral resection of bladder tumor with subsequent BCG immunotherapy is the current gold standard in the treatment of high risk and some medium-risk non-muscle invasive bladder cancer. Clinical factors like stage, grade, age and gender are well-know predictors of progression to muscle-invasive bladder cancer. In recent years novel hematological biomarkers were shown to be independent predictors of progression. This study aimed to evaluate which of these novel markers has the highest prognostic value of progression in patients with bladder cancer receiving BCG immunotherapy.

Materials and methods

We retrospectively analyzed the data of 125 patients with non-muscle invasive bladder cancer who received BCG immunotherapy. Of these, 61 progressed to muscle-invasive disease or had high-grade recurrence. These patients were compared with the group who did not progress (n = 64). Clinical data including stage, grade, age, gender, smoking status and observational time was collected. Besides, information on blood count analysis was obtained from ambulatory digital charts. On this basis neutrophil-to-lymphocyte ratio (NLR), platelet-to lymphocyte ratio (PLR) and lymphocyte-to-monocyte ratio (LMR) was counted and compared between groups.

Results

NLR, PLR and LMR were shown to be independent prognostic markers of progression in multivariable analysis. The model with stage, grade, age, gender, smoking status and LMR had the highest prognostic values of all models (area under curve [AUC] = 0.756). The cut-off point according to ROC curves for LMR was 3.25. Adding LMR to the baseline model including clinical variables significantly increased area under curve by 0.08 (p = 0.001). NLR and PLR did not increase areas under curve significantly to baseline model.

Conclusions

LMR outperformed NLR and PLR for prediction of progression in patients with non-muscle-invasive bladder cancer receiving BCG immunotherapy. LMR, as an easily obtainable biomarker, should be incorporated to the present risk stratification models.

Prognostic role of the systemic immune-inflammation index in upper tract urothelial carcinoma treated with radical nephroureterectomy: results from a large multicenter international collaboration

Purpose

To investigate the prognostic role of the preoperative systemic immune–inflammation index (SII) in patients with upper tract urothelial carcinoma (UTUC) treated with radical nephroureterectomy (RNU).

Materials and methods

We retrospectively analyzed our multi-institutional database to identify 2492 patients. SII was calculated as platelet count × neutrophil/lymphocyte count and evaluated at a cutoff of 485. Logistic regression analyses were performed to investigate the association of SII with muscle-invasive and non-organ-confined (NOC) disease. Cox regression analyses were performed to investigate the association of SII with recurrence-free, cancer-specific, and overall survival (RFS/CSS/OS).

Results

Overall, 986 (41.6%) patients had an SII > 485. On univariable logistic regression analyses, SII > 485 was associated with a higher risk of muscle-invasive (P = 0.004) and NOC (P = 0.03) disease at RNU. On multivariable logistic regression, SII remained independently associated with muscle-invasive disease (P = 0.01). On univariable Cox regression analyses, SII > 485 was associated with shorter RFS (P = 0.002), CSS (P = 0.002) and OS (P = 0.004). On multivariable Cox regression analyses SII remained independently associated with survival outcomes (all P < 0.05). Addition of SII to the multivariable models improved their discrimination of the models for predicting muscle-invasive disease (P = 0.02). However, all area under the curve and C-indexes increased by < 0.02 and it did not improve net benefit on decision curve analysis.

Conclusions

Preoperative altered SII is significantly associated with higher pathologic stages and worse survival outcomes in patients treated with RNU for UTUC. However, the SII appears to have relatively limited incremental additive value in clinical use. Further study of SII in prognosticating UTUC is warranted before routine use in clinical algorithms.

Supplementary Information

The online version of this article (10.1007/s00262-021-02884-w) contains supplementary material, which is available to authorized users.

Prognostic value of albumin to globulin ratio in non-muscle-invasive bladder cancer

Purpose

To investigate the prognostic value of preoperative serum albumin to globulin ratio (AGR) in patients with non-muscle-invasive bladder cancer (NMIBC) treated with transurethral resection of bladder tumor (TURB) with or without intravesical therapy (IVT).

Materials and methods

We retrospectively reviewed 1,096 consecutive patients with NMIBC. Levels of albumin and globulin were obtained before TURB and used to calculate the preoperative AGR level. Multivariable Cox regression analyses were performed to assess the prognostic effect of preoperative AGR on oncologic outcomes. Subgroup analyses were performed in patients based on the European Association of Urology (EAU) risk groups for NMIBC.

Results

Low AGR levels were observed in 389 (35.5%) patients. The median follow-up was 63.7 months (IQR 25.3–111). On multivariable Cox regression analysis, low AGR was associated with increased risk of progression to muscle-invasive BCa (MIBC) (HR 1.81, 95% CI 1.22–2.68, P = 0.003). The addition of AGR only minimally improved the discrimination ability of a base model that included established clinicopathologic features (C-index = 0.7354 vs. C-index = 0.7162). Low preoperative AGR was not significantly associated with the risk of disease recurrence (P = 0.31). In subgroup analyses based on patients’ EAU risk groups, low preoperative AGR was not associated with recurrence-free survival (RFS) (P = 0.59) or progression-free survival (PFS) (P = 0.22) in any of the risk groups. Additionally, in patients treated with Bacillus Calmette–Guerin (BCG) for intermediate- or high-risk NMIBC, low AGR failed to predict disease recurrence or progression.

Conclusion

Preoperative serum AGR levels independently predicted the risk of disease progression in patients with NMIBC. However, it was not found to be associated with either RFS or PFS in NMIBC patients based on their EAU risk group. This marker seems to have a limited role in NMIBC at the present time. However, further research is needed to investigate this marker in combination with other systemic inflammatory markers to help improve prediction in this heterogeneous group of patients.

Supplementary Information

The online version contains supplementary material available at 10.1007/s00345-020-03586-1.

Prediction of the Need for an Extended Lymphadenectomy at the Time of Radical Cystectomy in Patients with Bladder Cancer

BACKGROUND

A prospective randomized trial (LEA AUO AB 25/02) found no survival benefit in extended compared with limited pelvic lymph node dissection (PLND) templates in bladder cancer (BCa) patients treated with radical cystectomy (RC). However, the rate of lymph node invasion (LNI) in the standard and extended templates was lower than estimated.

OBJECTIVE

To assess the accuracy of preoperative clinical and pathological parameters to predict LNI and to develop a model to preoperatively select candidates for the extended PLND templates.

DESIGN, SETTING, AND PARTICIPANTS

A total of 903 BCa patients treated at a single institution were retrospectively identified. The primary outcome was to identify preoperatively the risk of LNI to tailor the type of PLND. The extended PLND templates consisted in the removal of pelvic lymph nodes together with the common iliac, presacral, para-aortocaval, interaortocaval, and paracaval sites up to the inferior mesenteric artery.

INTERVENTION

A total of 903 BCa patients were treated with RC and bilateral extended PLND templates.

OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS

Several models predicting LNI were evaluated using the area under the receiver operating characteristic curve (AUC), calibration plots and decision curve analyses. A nomogram predicting LNI in the extended pattern was developed and validated internally.

RESULTS AND LIMITATIONS

Overall, 55 patients (6.1%) had LNI in the extended PLND templates at RC. The median number of nodes removed was 19 (interquartile range: 13-26). A model including age, clinical T stage, clinical node stage, lymphovascular invasion, and presence of carcinoma in situ at the last transurethral resection before RC was developed. The AUC of this model is 73%. Using a cutoff of 3%, 108 extended PLNDs (12%) would be spared and only two LNIs (3%) would be missed. The main limitations of our model are the retrospective nature of the data, lack of external validation, and low rate of LNI.

CONCLUSIONS

This is the first proposed model to predict LNI in the extended PLND templates. This model might help urologists identify which patients might benefit from an extended PLND at the time of RC, reserving a standard PLND for all the others.

PATIENT SUMMARY

We developed the first nomogram to predict lymph node invasion (LNI) in the extended pelvic lymph node dissection templates in bladder cancer patients treated with radical cystectomy. The adoption of our model to identify candidates for the extended pelvic lymph node dissection templates could avoid up to 12% of these procedures at the cost of missing only 3% of patients with LNI.

Oncological impact of inflammatory biomarkers in elderly patients treated with radical cystectomy for urothelial bladder cancer

Objective

To evaluate the impact of preoperative markers of systemic inflammation on complications and oncological outcomes in patients aged ≥75 years treated with radical cystectomy (RC) for urothelial bladder cancer (UBC).

Patients and methods

The clinical data of 694 patients treated with open RC for UBC at our institution between January 2008 and December 2015 were retrospectively reviewed. Patients aged <75 years, with distant metastases, other-than-urothelial histological type, comorbidities that could affect the systemic inflammatory markers, and patients who received neoadjuvant chemotherapy were excluded. Multivariable regression models were built for the prediction of major postoperative surgical complications, disease recurrence, cancer-specific mortality (CSM), and overall mortality (OM).

Results

The median (interquartile range [IQR]) age at surgery was 79 (75–83) years. Major postoperative surgical complications were registered in 41.9% of the patients. The 5-year overall survival, cancer-specific survival and recurrence-free survival rates were 42.4% (95% confidence interval [CI] 34.7–49.9%), 70.3% (95% CI 62.3–76.9%), and 59.8% (95% CI 52.4–66.5), respectively. At multivariable analysis, higher levels of fibrinogen and a modified Glasgow Prognostic Score (mGPS) of 1 and 2 at baseline were independently associated with higher risk of major postoperative complications and of CSM. The inclusion of mGPS and fibrinogen to a standard multivariable model for recurrence and for CSM increased discrimination from 69.4% to 73.0% and from 71.3% to 73.9%, respectively. Preoperative neutrophil-to-lymphocyte ratio of >3 was independently associated with OM (hazard ratio 1.38, 95% CI 1.01–1.77; P = 0.01).

Conclusions

In a cohort of elderly patients with UBC treated with RC, fibrinogen and mGPS appeared to be the most relevant prognostic measurements and increased the accuracy of clinicopathological preoperative models to predict major postoperative complications, disease recurrence and mortality.

Abbreviations

ASA: American Society of Anesthesiologists; CCI: Charlson Comorbidity Index; CIS: carcinoma in situ; CRP: C-reactive protein; CSM: cancer-specific mortality; CSS: cancer-specific survival; ECOG PS: Eastern Cooperative Oncology Group Performance Status; HDL: high-density lipoprotein; (S)HR: (subdistribution) hazard ratio; LND: lymphadenectomy; LVI: lymphovascular invasion; mGPS: modified Glasgow Prognostic Score; NLR: neutrophil-to-lymphocyte ratio; NOC: non-organ-confined; OM: overall mortality; OR: odds ratio; OS: overall survival; RC: radical cystectomy; RNU: radical nephroureterectomy; UBC: urothelial bladder cancer; UTUC: upper urinary tract urothelial carcinoma

Role of Systemic Inflammatory Response Markers in Urothelial Carcinoma

Urothelial carcinoma (UC) can occur in various parts of the urinary tract and occurs in different stages and grades. The disease recurs frequently and is monitored through a series of invasive tests, such as cystoscopy or ureteroscopy, over the lifetime of an individual. Although many researchers have attempted to stratify the risks of UC, with the majority being based on cancer characteristics and host factors such as performance status, a risk classification system has yet to be fully developed. Cancer affects various parts of the body through the systemic immune response, including changes in hormones, the number and ratio of white blood cells and platelets, and C-reactive protein (CRP) or albumin levels under the influence of neuroendocrine metabolism, hematopoietic function, and protein and energy metabolism, respectively. Herein, we reviewed various systemic inflammatory response markers (SIRs) related to UC, including CRP, albumin-globulin ratio, albumin, Glasgow prognostic score (GPS), modified GPS, neutrophil-lymphocyte ratio, and platelet-lymphocyte ratio. Our aim was to summarize the role of various SIRs in the treatment of patients with UC.

Prognostic value of preoperative hematologic biomarkers in urothelial carcinoma of the bladder treated with radical cystectomy: a systematic review and meta-analysis

This systematic review and meta-analysis aimed to assess the prognostic value of preoperative hematologic biomarkers in patients with urothelial carcinoma of the bladder treated with radical cystectomy. PUBMED, Web of Science, Cochrane Library, and Scopus databases were searched in September 2019 according to the Preferred Reporting Items for Systematic Review and Meta-analysis statement. Studies were deemed eligible if they compared cancer-specific survival in patients with urothelial carcinoma of the bladder with and without pretreatment laboratoryabnormalities. Formal meta-analyses were performed for this outcome. The systematic review identified 36 studies with 23,632 patients, of these, 32 studies with 22,224 patients were eligible for the meta-analysis. Several preoperative hematologic biomarkers were significantly associated with cancer-specific survival as follows: neutrophil − lymphocyte ratio (pooled hazard ratio [HR]: 1.20, 95% confidence interval [CI]: 1.11–1.29), hemoglobin (pooled HR: 0.87, 95% CI 0.82–0.94), C-reactive protein (pooled HR: 1.44, 95% CI 1.26–1.66), De Ritis ratio (pooled HR: 2.18, 95% CI 1.37–3.48), white blood cell count (pooled HR: 1.05, 95% CI 1.02–1.07), and albumin-globulin ratio (pooled HR: 0.26, 95% CI 0.14–0.48). Several pretreatment laboratory abnormalities in patients with urothelial carcinoma of the bladder were associated with cancer-specific mortality. Therefore, it might be useful to incorporate such hematologic biomarkers into prognostic tools for urothelial carcinoma of the bladder. However, given the study limitations including heterogeneity and retrospective nature of the primary data, the conclusions should be interpreted with caution.

Risk stratification for bladder cancer: Biomarkers of inflammation and immune activation

OBJECTIVE

Recent development is reviewed in biomarkers of inflammation and immune activation in risk stratification of bladder cancer (BC).

METHODS

PubMed, Wiley Online Library, and Science Direct databases were reviewed in November 2019 for relevant studies limited to those published in English from 2008 to 2019. Articles were included if they contained references to BC, urological cancers, inflammation, immune activation, disease risk, disease progression, genomics, proteomics, and biomarkers.

RESULTS

Inflammatory biomarkers show promise in prognostication in BC, including neutrophil-to-lymphocyte ratio, C-reactive protein, selected cytokines and stress proteins. Most of the current evidence, however, stems from retrospective studies. None of these biomarkers are sufficient by themselves to be used for prognostication. Using a panel of different biomarkers, alongside clinical and pathological data, seems to improve risk stratification. More robust data is necessary, however, before these biomarkers will be suitable for use in routine practice.

CONCLUSION

Biomarkers of inflammation and immune system activation can assist in risk stratification of BC. Currently most of these biomarkers lack robust external validity. In the future these biomarkers likely will have an important role in augmenting the conventional clinical and pathological predictors of outcomes in BC.

Nomogram for predicting overall survival of patients with bladder cancer: A population-based study

OBJECTIVE

The aim of this study was to develop and validate a reliable nomogram to estimate overall survival in bladder cancer.

METHOD

Patients diagnosed with bladder cancer identified in the Surveillance, Epidemiology, and End Results database were randomly divided into training and validation cohorts. The powerful prognostic variables were examined using Cox regression analyses. A nomogram was developed on the prognostic factors.

RESULTS

The results suggested that age, sex, race, grade, histologic type, primary site, pathological stage, surgical treatment, and number of primary tumors, were the powerful prognostic factors. All these factors were integrated to construct the nomogram. The nomogram for predicting overall survival showed better discrimination power than the tumor-node-metastasis (TNM) stage system 8th edition.

CONCLUSION

The nomogram has the potential to provide an individualized prediction of overall survival in patients with bladder cancer.

Prognostic value of preoperative blood-based biomarkers in upper tract urothelial carcinoma treated with nephroureterectomy: A systematic review and meta-analysis

PURPOSE

This systematic review and meta-analysis assessed the prognostic value of preoperative blood-based biomarkers in patients with upper tract urothelial carcinoma (UTUC) treated with nephroureterectomy.

METHODS

PUBMED, Web of Science, Cochrane Library, and Scopus databases were searched in June 2019 according to the Preferred Reporting Items for Systematic Review and Meta-analysis statement. Studies were deemed eligible if they compared cancer-specific survival in UTUC patients with and without pretreatment laboratory abnormalities. Formal meta-analyses were performed for this outcome.

RESULTS

The review identified 54 studies with 23,118 patients, of these, 52 studies with 22,513 patients were eligible for the meta-analysis. Several preoperative blood-based biomarkers were significantly associated with cancer-specific survival as follows: neutrophil-lymphocyte ratio (pooled hazard ratio [HR]: 1.66, 95% confidence interval [CI]: 1.34-2.06), C-reactive protein (pooled HR: 1.17, 95% CI: 1.07-1.29), platelet-lymphocyte ratio (pooled HR: 1.68, 95% CI: 1.30-2.17), white blood cell (pooled HR: 1.58, 95% CI: 1.02-2.46), De Ritis ratio (pooled HR: 2.40, 95% CI: 1.92-2.99), fibrinogen (pooled HR: 2.23, 95% CI: 1.86-2.68), albumin-globulin ratio (pooled HR: 3.00, 95% CI: 1.87-4.84), hemoglobin (pooled HR: 1.51, 95% CI: 1.22-1.87), and estimate glomerular filtration rate (pooled HR: 1.52, 95% CI: 1.19-1.94). The Cochrane's Q test and I² test revealed significant heterogeneity for neutrophil-lymphocyte ratio, C-reactive protein, white blood cell, hemoglobin, and estimated glomerular filtration rate (P = 0.022; I² = 50.7%, P = 0.000; I² = 80.4%, P = 0.000; I² = 88.3%, P = 0.010; I² = 62.0%, P = 0.000; I² = 83.9%, respectively).

CONCLUSIONS

Several pretreatment laboratory abnormalities in patients with UTUC were associated with increased risks of cancer-specific mortality. Therefore, blood-based biomarkers may have the potential to serve as prognostic factors to assist patients and physicians in selecting appropriate treatment strategies for UTUC. However, considering the study limitations including heterogeneity and retrospective nature of the primary data, the conclusions should be interpreted with caution.

Prognostic Significance of the Lymphocyte-to-Monocyte Ratio in Bladder Cancer Undergoing Radical Cystectomy: A Meta-Analysis of 5638 Individuals

Introduction

A growing number of studies have explored the association between the pretreatment lymphocyte-to-monocyte ratio (LMR) and survival outcomes in various cancers. However, its prognostic significance on bladder cancer remains inconsistent. The aim of this meta-analysis was to evaluate the prognostic value of pretreatment LMR in bladder cancer.

Methods

The MEDLINE, EMBASE, Cochrane Library, and CNKI databases were comprehensively searched for relevant studies. A meta-analysis of overall survival (OS), recurrence-free survival (RFS), or cancer-specific survival (CSS) clinicopathological features was conducted.

Results

Nine studies containing 5,638 cancer patients were analyzed in this meta-analysis. Patients with high LMR tended to have favourable OS (HR: 0.63, 95% CI: 0.50-0.80, P < 0.001), RFS (HR: 0.59, 95% CI: 0.38-0.91, P = 0.017), and CSS (HR: 0.76, 95% CI: 0.70-0.83, P < 0.001). Moreover, low LMR was highly correlated with age (≥60), differentiation (low), T stage (III-IV), lymph node metastasis (yes), and concomitant Cis (yes).

Conclusion

Pretreatment LMR might be a useful predictor of survival outcomes in patients with bladder cancer.

Prognostic value of modified Glasgow Prognostic Score in non-muscle-invasive bladder cancer

PURPOSE

To investigate the prognostic value of preoperative modified Glasgow Prognostic Score (mGPS) in patients with non-muscle-invasive bladder cancer (NMIBC) treated with transurethral resection of bladder with or without intravesical therapy.

MATERIAL AND METHODS

We retrospectively reviewed our medical records to identify 1,096 consecutive patients with NMIBC treated with transurethral resection of bladder. The mGPS of each patient was calculated on the basis of preoperative serum C-reactive protein and albumin. Univariable and multivariable Cox regression analyses were performed to investigate the association of mGPS with recurrence-free survival (RFS) and progression-free survival (PFS).

RESULTS

The mGPS of 0, 1, and 2 was observed in 764 (69.7%), 299 (27.3%), and 33 (3.0%) patients, respectively. On univariable analysis, mGPS 2 was associated with worse RFS (Hazard Ratio [HR]: 1.60, 95%; CI: 1.01-2.54). However, on multivariable analyses, which adjusted for the effects of established clinicopathologic features, mGPS 2 did not maintain its independent association with RFS (HR: 1.41, 95% CI: 0.88-2.26). On multivariable analysis, mGPS 1 and 2 were both independently associated with worse PFS compared to mGPS 0 (HR: 2.06, 95% CI: 1.37-3.12 and HR: 3.31, 95% CI: 1.40-7.87, respectively). The inclusion of mGPS improved the discrimination of a standard prognostic model for PFS from 71.6% to 73.8%. In subgroup analyses, mGPS 1 was associated with PFS (HR 2.09, 95% CI: 1.24-3.52) on multivariable analysis in patients with the European Association of Urology high-risk group. Additionally, in patients treated with bacillus Calmette-Guérin, mGPS 2 was associated with disease PFS (HR10.1, 95% CI: 2.61-38.8).

CONCLUSIONS

The mGPS independently predicts PFS in patients with NMIBC. Inclusion of mGPS in prognostic models might help identify patients who are more likely to fail standard therapy and experience disease progression and, therefore, may benefit from intensified therapy such as radical cystectomy or inclusion in clinical trials of novel immunotherapeutics.

Role of systemic inflammatory response markers in urological malignancy

The systemic inflammatory response is associated with survival in patients with a variety of cancers. This inflammatory response is measured in the peripheral blood, and can be monitored using two categories of indices: concentration of specific serum proteins (albumin, C-reactive protein) and differential blood cell count (neutrophils, lymphocytes and platelets). Furthermore, combinations of these indices, such as the Glasgow Prognostic Score, which consists of the serum C-reactive protein and albumin level; the neutrophil-to-lymphocyte ratio; the platelet-to-lymphocyte ratio; and the prognostic nutritional index, which is based on peripheral blood lymphocyte count and serum albumin level, have also been evaluated and compared in cancer research. To date, there are hundreds of studies that have shown the prognostic value of systemic inflammatory response markers in patients with urological cancer. Most studies have evaluated the prognostic and predictive role of the pretreatment value of the markers, although some have focused on the role of the post-treatment value at specific points during the clinical course. The advantages of systemic inflammatory response markers are that they are easily measurable and inexpensive in the clinical setting. However, it is important to consider how clinicians use these markers in clinical practice. The present review provides a concise overview regarding systemic inflammatory markers in urological cancers, specifically C-reactive protein, Glasgow Prognostic Score/modified Glasgow Prognostic Score, neutrophil-to-lymphocyte ratio, platelet-to-lymphocyte ratio and prognostic nutritional index.

A systematic review and meta-analysis of the impact of lymphovascular invasion in bladder cancer transurethral resection specimens

The aim of the present review was to assess the prognostic impact of lymphovascular invasion (LVI) in transurethral resection (TUR) of bladder cancer (BCa) specimens on clinical outcomes. A systematic review and meta-analysis of the available literature from the past 10 years was performed using MEDLINE, EMBASE and Cochrane library in August 2017. The protocol for this systematic review was registered on PROSPERO (Central Registration Depository: CRD42018084876) and is available in full on the University of York website. Overall, 33 studies (including 6194 patients) evaluating the presence of LVI at TUR were retrieved. LVI was detected in 17.3% of TUR specimens. In 19 studies, including 2941 patients with ≤cT1 stage only, LVI was detected in 15% of specimens. In patients with ≤cT1 stage, LVI at TUR of the bladder tumour (TURBT) was a significant prognostic factor for disease recurrence (pooled hazard ratio [HR] 1.97, 95% CI: 1.47-2.62) and progression (pooled HR 2.95, 95% CI: 2.11-4.13), without heterogeneity (I² = 0.0%, P = 0.84 and I² = 0.0%, P = 0.93, respectively). For patients with cT1-2 disease, LVI was significantly associated with upstaging at time of radical cystectomy (pooled odds ratio 2.39, 95% CI: 1.45-3.96), with heterogeneity among studies (I² = 53.6%, P = 0.044). LVI at TURBT is a robust prognostic factor of disease recurrence and progression in non-muscle invasive BCa. Furthermore, LVI has a strong impact on upstaging in patients with organ-confined disease. The assessment of LVI should be standardized, reported, and considered for inclusion in the TNM classification system, helping clinicians in decision-making and patient counselling.