Clinical Significance of Platelet Count in Patients with Renal Cell Carcinoma

The role of platelets in the regulation of tumor growth and metastasis: the mechanisms and targeted therapy

Platelets are a class of pluripotent cells that, in addition to hemostasis and maintaining vascular endothelial integrity, are also involved in tumor growth and distant metastasis. The tumor microenvironment is a complex and comprehensive system composed of tumor cells and their surrounding immune and inflammatory cells, tumor-related fibroblasts, nearby interstitial tissues, microvessels, and various cytokines and chemokines. As an important member of the tumor microenvironment, platelets can promote tumor invasion and metastasis through various mechanisms. Understanding the role of platelets in tumor metastasis is important for diagnosing the risk of metastasis and prolonging survival. In this study, we more fully elucidate the underlying mechanisms by which platelets promote tumor growth and metastasis by modulating processes, such as immune escape, angiogenesis, tumor cell homing, and tumor cell exudation, and further summarize the effects of platelet-tumor cell interactions in the tumor microenvironment and possible tumor treatment strategies based on platelet studies. Our summary will more comprehensively and clearly demonstrate the role of platelets in tumor metastasis, so as to help clinical judgment of the potential risk of metastasis in cancer patients, with a view to improving the prognosis of patients.

Expression of RSUME is associated with poor prognosis in clear cell Renal Carcinoma: involvement of ROS related metabolism

INTRODUCTION

RSUME (RWD domain-containing protein SUMO Enhancer), RWD domain containing 3 (RWDD3) gene product, is upregulated by hypoxia and expressed in organs prone to develop von Hippel-Lindau (VHL) syndrome tumors.

MATERIALS AND METHODS

We evaluated RSUME prognostic value in clear cell renal cell carcinoma (ccRCC) based mainly on the dataset (KIRC) from patients in The Cancer Genome Atlas (TCGA). Wilcoxon signed-rank test and one-way analysis of variance (ANOVA) followed by Tukey's test were used to evaluate relationships between clinicopathological features and RSUME expression and univariate and multivariate Cox regression analysis methods were used to evaluate prognostic factors. The biological function of RSUME was assessed by gene set enrichment analysis (GSEA). For validation, total amount of ROS was detected in ccRCC cell lines using dichlorofluorescin diacetate.

RESULTS

RSUME is highly expressed in tumor tissues compared with normal tissues (P = .006, P = .039, P = .002, P = .036, P < .001) and associates with tumor T (P = .018) and tumor M (P = .036) advanced stages and higher extent cysts (P = .005). RSUME expression appears to be an independent risk factor for overall survival (OS) (P = .002) and disease-specific survival (DSS) (P = .026) in ccRCC patients. GSEA showed enrichment of relevant glycerophospholipid- and ROS-related pathways in RSUME high-expression phenotype. ROS diminished levels in RSUME-silenced ccRCC cell lines validated RSUME relevance in ROS-related pathways.

CONCLUSION

RSUME high expression may predict poor prognosis in ccRCC and impact through its action on metabolism and ROS related pathways.

Pre-treatment systemic immune-inflammation index as a non-invasive biomarker for predicting clinical outcomes in patients with renal cell carcinoma: a meta-analysis of 20 studies

INTRODUCTION

To systematically assess the predictive significance of systemic immune-inflammation index (SII) in renal cell carcinoma (RCC).

METHODS

Relevant studies published before November 2022 were retrieved from public databases. Hazard ratio (HR), standardised mean difference (SMD) and relative risk (RR) were calculated to estimate associations of SII with prognosis, treatment responses and clinicopathological features.

RESULTS

Twenty studies involving 6887 patients were eligible. The meta-analysis results revealed a high SII level was associated with worse overall survival (HR: 1.45, p < 0.001), progression-free survival (HR: 1.63, p = 0.001), cancer-specific survival (HR: 1.86, p < 0.001), lower overall response rate (RR: 0.62, p = 0.003), disease control rate (RR: 0.69, p = 0.002), larger tumour size (SMD: 0.39, p = 0.001), poorer IMDC risk (RR: 7.09, p < 0.001), higher Fuhrman grade (RR: 1.54, p = 0.004), tumour stage (RR: 1.67, p = 0.045), the presence of distant metastasis (brain: RR, 2.04, p = 0.001; bone: RR, 1.33, p = 0.024) and tumour necrosis (RR: 1.57, p = 0.031). Subgroup analysis showed SII predicted OS and PFS for non-Asian, but CSS for both Asian and non-Asian populations.

CONCLUSION

Pre-treatment SII may be a promising predictor of clinical outcomes for RCC patients.

Platelet detection as a new liquid biopsy tool for human cancers

Cancer is still a leading cause of death worldwide and liquid biopsy is a powerful tool that can be applied to different stages of cancer screening and treatment. However, as the second most abundant cell type in the bloodstream, platelets are isolated through well-established and fast methods in clinic but their value as a BioSource of cancer biomarkers is relatively recent. Many studies demonstrated the bidirectional interaction between cancer cells and platelets. Platelets transfer various proteins (e.g., growth factors, cytokine, chemokines) and RNAs (e.g., mRNA, lncRNA, miRNA, circRNA) into the tumor cells and microenvironment, leading the stimulation of tumor growth and metastasis. In turn, the platelet clinical characteristics (e.g., count and volume) and contents (e.g., RNA and protein) are altered by the interactions with cancer cells and this enables the early cancer detection using these features of platelets. In addition, platelet-derived microparticles also demonstrate the prediction power of being cancer biomarkers. In this review, we focus on the clinical applications of platelet detection using the platelet count, mean platelet volume, platelet RNA and protein profiles for human cancers and discuss the gap in bringing these implementations into the clinic.

Ticagrelor prevents tumor metastasis via inhibiting cell proliferation and promoting platelet apoptosis

Tumor cells can activate platelets, which in turn facilitate tumor cell survival and dissemination. Platelets inhibition or blocking platelet-tumor cell interactions has become a strategy to suppress tumor progression. In this study, we investigated the effect of ticagrelor, a new antiplatelet drug, on tumor cell proliferation and metastasis. Our results show that ticagrelor not only inhibits the proliferation, migration, and invasion of B16F10 and Lewis lung carcinoma cells but also induces platelet apoptosis. In addition, we find that apoptosis of the platelet cells is dose dependent. Further, the result of in-vivo experiments proved that ticagrelor treatment decreased the tumor metastasis. The results of this study demonstrate that ticagrelor may be a potential anti-tumor agent for tumor metastasis.

A Hypercoagulable Hematological Metastasis Breast Cancer Model

BACKGROUND

The hypercoagulable status, which forms a vicious cycle with hematogenous metastasis, is a common systemic alteration in cancers. As modeling is a key approach in research, a model which is suitable for studying how the hypercoagulable status promotes hematogenous metastasis in breast cancer is urgently needed.

METHODS

Based on the tumor-bearing period (TBP) and postoperative incubation period (PIP), 4T1-breast cancer models were constructed to evaluate coagulation and tumor burden to generate multiple linear regression-based lung metastasis prediction formula. Platelets and 4T1 cells were cocultured for 30 min or 24 h in vitro to evaluate the early and late phases of their crosstalk, and then the physical characteristics (concentration and size) and procoagulant activity of the coculture supernatants were assayed.

RESULTS

The multiple linear regression model was constructed as log10 (photon number) = 0.147 TBP + 0.14 PIP + 3.303 (TBP ≤ 25 and PIP ≤ 17) to predict lung metastasis. Coculture of platelets and 4T1 cells contributed to the release of extracellular vesicles (EVs) and the development of the hypercoagulable status.

CONCLUSIONS

In vivo and in vitro hypercoagulable status models were developed to explore the mechanism of hypercoagulable status which is characterized by platelet activation and promotes hematogenous metastasis in breast cancer.

The predictive role of thrombocytosis in benign, borderline and malignant ovarian tumors

Ovarian cancer is a lethal gynecological malignancy. Although CA-125 is commonly measured in women with adnexal mass, it is estimated that it only has a positive predictive value (PPV) of 69% and a negative predictive value (NPV) of 88% for the detection of ovarian cancer. The aim of this study was to investigate the diagnostic significance and predictive impact of thrombocytosis in women with suspected or confirmed ovarian cancer. This was a retrospective study of women who had surgery for adnexal mass over a 48-month period between September 2014 and September 2018 at Swansea Gynecological Oncology Center in Wales, UK. A total of 294 women who underwent surgery for high-risk pelvic mass or biopsy-confirmed ovarian cancer were identified. 206 women (70%) had final histology confirming ovarian cancer, 54 women (18%) had benign tumors while 34 women (12%) had borderline tumors. 90/206 women (43.7%) with ovarian cancer had thrombocytosis prior to primary surgery or neoadjuvant chemotherapy compared to 8/54 (14.8%) for benign tumors and 4/34 (11.8%) for borderline tumors. Thrombocytosis was observed in 23.2%, 40%, 45.1%, and 65.1% of Stages I, II, III, and IV ovarian cancer, respectively. Thrombocytosis was a stronger predictor of ovarian malignancy in younger women of less than 60 years (p = .041). Overall, the positive likelihood ratio of platelet count in the detection of ovarian cancer was 2.61 while the negative likelihood ratio was 0.72, with a diagnostic odds ratio of 3.625. Thrombocytosis was strongly associated with advanced stage ovarian cancer (Stage III/IV) (p = .002). Interestingly, 4/8 (50%) women with thrombocytosis in the benign ovarian tumor group were diagnosed with ovarian fibroma/fibrothecoma, which often mimics advanced ovarian cancer at presentation. Predictive markers for borderline tumors continue to remain a challenge. We believe that there is a role for platelet count in primary care algorithm for women with suspected ovarian cancer. We suspect that platelets play a role in the metastasis of ovarian cancer.

Personalized Indicator Thrombocytosis Shows Connection to Staging and Indicates Shorter Survival in Colorectal Cancer Patients with or without Type 2 Diabetes

Background: Pre- and postoperative thrombocytosis was reported to have significant effect on patient survival. However, the definition of thrombocytosis throughout the literature is not unified. Methods: A retrospective longitudinal observational study has been conducted with the inclusion of 150 colorectal cancer (CRC) patients and 100 control subjects. A new measure of platelet changes at an individual level, named personalized indicator thrombocytosis (PIT) was defined, including 4 anemia adjusted variants. Results: In concordance with the literature, PIT values of control subjects showed a slow decrease in platelet counts, while PIT values of CRC patients were significantly higher (p < 0.0001). More advanced staging (p < 0.0001) and both local (p ≤ 0.0094) and distant (p ≤ 0.0440) metastasis are associated with higher PIT values. Higher PIT values suggested shorter survival times (p < 0.0001). Compared to conventional, a PIT-based definition resulted in approximately 3-times more patients with thrombocytosis. 28% and 77% of the deceased patients had conventional- and PIT-based thrombocytosis, respectively. Conclusions: Compared to conventional thrombocytosis, as an individual metric, PIT values may indicate the condition of patients more precisely. Possible future applications of PIT may include its usage in therapy decision and early cancer detection; therefore, further investigations are recommended.

Robotic assisted laparoscopic excision of a renal schwannoma from a community hospital: A case report

Renal schwannomas are an extremely rare renal tumor with possibility for malignant conversion. Although reports are scant, most reports have been presented from academic institutions. We report on a case of a renal schwannoma that was removed via robotic assisted laparoscopic nephrectomy in a community-based specialty practice under the suspicion of a renal malignancy.

Cancer and Thrombotic Risk: The Platelet Paradigm

Hematologic malignancies and solid tumors increase the risk of venous and arterial thrombosis and contribute greatly to patient morbidity and mortality. Thrombosis occurs when the intricate balance of circulating antithrombotic and prothrombotic blood elements are disrupted. In recent years, the interplay between paraneoplastic cells and platelets has become apparent, with a change in platelet phenotype causing dysregulated platelet activity. This review discusses mechanism of thrombosis in cancer, evidence for using drug therapy, and exciting research efforts to understand and hopefully control aberrant thrombotic events in patients with cancer.

The Potential Role of Senescence As a Modulator of Platelets and Tumorigenesis

In addition to thrombus formation, alterations in platelet function are frequently observed in cancer patients. Importantly, both thrombus and tumor formation are influenced by age, although the mechanisms through which physiological aging modulates these processes remain poorly understood. In this context, the potential effects of senescent cells on platelet function represent pathophysiological mechanisms that deserve further exploration. Cellular senescence has traditionally been viewed as a barrier to tumorigenesis. However, far from being passive bystanders, senescent cells are metabolically active and able to secrete a variety of soluble and insoluble factors. This feature, known as the senescence-associated secretory phenotype (SASP), may provide senescent cells with the capacity to modify the tissue environment and, paradoxically, promote proliferation and neoplastic transformation of neighboring cells. In fact, the SASP-dependent ability of senescent cells to enhance tumorigenesis has been confirmed in cellular systems involving epithelial cells and fibroblasts, leaving open the question as to whether similar interactions can be extended to other cellular contexts. In this review, we discuss the diverse functions of platelets in tumorigenesis and suggest the possibility that senescent cells might also influence tumorigenesis through their ability to modulate the functional status of platelets through the SASP.

Predictive and Prognostic Value of Preoperative Thrombocytosis in Upper Tract Urothelial Carcinoma

PURPOSE

The purpose of this study was to evaluate the predictive and prognostic role of preoperative thrombocytosis (TC) in upper tract urothelial carcinoma (UTUC) after radical nephroureterectomy (RNU) in a large multi-institutional cohort of patients.

METHODS

Records of 2492 patients undergoing RNU for non-metastatic UTUC between 1990 and 2008 were retrospectively analyzed. Preoperative TC was defined as a platelet count > 400 × 10⁹/L, irrespective of gender type. Logistic regression analyses were performed to evaluate its association with pathologic features. Cox proportional hazards regression was used for estimation of recurrence-free survival, cancer-specific survival, and overall survival.

RESULTS

Preoperative TC was found in 309 (12.4%) patients and was associated with advanced tumor stage and grade, lymph node metastasis, lymphovascular invasion, tumor architecture, necrosis, and concomitant carcinoma in situ (P-values ≤ .027). Preoperative TC independently predicted ≥ pT2 (P < .001), non-organ-confined (P < .001), and lymph node-positive (P < .001) disease in a preoperative model that adjusted for the effects of age, gender, location, multifocality, and tumor architecture. Within a median follow-up of 45 months, recurrence occurred in 663 (26.6%) patients with 545 (21.9%) dying of UTUC. In univariable Cox proportional hazard regression analysis, TC was significantly associated with recurrence-free survival (hazard ratio [HR], 1.32; P = .015) and overall survival (HR, 1.4; P < .001), but not cancer-specific survival (HR, 1.17; P = .2). In both pre- and postoperative multivariable models, when adjusted for the effects of standard clinicopathologic features, TC did not retain its association with survival outcomes.

CONCLUSIONS

Preoperative TC is associated with adverse clinicopathologic features and predicts worse pathology at RNU. Among other serum biomarkers, TC could benefit preoperative risk stratification and help guide treatment decisions.

Impact of preoperative thrombocytosis on prognosis after surgical treatment in pathological T1 and T2 renal cell carcinoma: results of a multi-institutional comprehensive study

Background

The prognostic significance of preoperative thrombocytosis (TC) in renal cell carcinoma (RCC) is not without some debate. The aim of the present multi-institutional study was to determine the association of preoperative TC with the clinicopathological features and prognosis of localized RCC patients who underwent surgery in a large cohort.

Methods

A study involving 8 institutions, and 4,376 patients with pT1 and pT2 RCC from the Korean renal cell carcinoma (KORCC) database, was conducted. TC was defined as a platelet count ≥400,000/μL. Patients were divided into 2 groups based on the presence of preoperative TC. Clinicopathological variables and survival rates were compared between the 2 groups.

Results

Out of the 4,376 patients in the study, 106 (2.4%) had preoperative TC. Compared to patients without TC, these patients had a lower body mass index. Additionally, these patients had more advanced stage tumors with a higher Fuhrman grade, and higher incidence of symptoms at the time of diagnosis. Kaplan-Meier curves revealed that patients with TC had a significantly lower rate of recurrence-free survival (RFS). Furthermore, a lower rate of overall survival (OS) was exhibited amongst patients with TC. Multivariate analysis revealed that TC was an independent prognostic factor in terms of the RFS and OS.

Conclusions

TC appeared to be an important prognostic determinant in localized RCC. Furthermore, preoperative platelet count may be clinically useful for risk stratification of patients with surgically treated localized RCC.

Basic Parameters of Blood Count as Prognostic Factors for Renal Cell Carcinoma

Background. Renal cell carcinoma is the most common type of kidney cancer. Taking account of morbidity and mortality increase, it is evident that searching for independent prognostic factors is needed. Aim of the Study. The aim of the study was to analyze routinely performed blood parameters as potential prognostic factors for kidney cancer. Material and Methods. We have retrospectively reviewed the records of 230 patients treated for renal cell carcinoma in the years 2000–2006. Preoperative blood parameters, postoperative histopathological results, and staging and grading were performed. To estimate the risk of tumor recurrence and cancer specific mortality (CSM) within five years of follow-up, uni- and multivariate Cox and regression analyses were used. To assess the quality of classifiers and to search for the optimal cut-off point, the ROC curve was used. Results. T stage of the tumor metastasis is the most important risk factor for early recurrence and cancer specific mortality (p < 0.001). The preoperative platelet count (PLT) above 351 × 10³/uL (95.3%; 55.1%) and AUC of 77% are negative prognostic factors and correlate with increased cancer specific mortality (CSM) during the five-year follow-up (p < 0.001). Increased risk of local recurrence was observed for PLT above 243.5 × 10³/ul (59%; 88%) and AUC of 80% (p = 0.001). The opposite was observed in the mean platelets volume (MPV) for cancer specific mortality (CSM). The cut-off point for the MPV was 10.1 fl (75.4%; 55.1%) and for the AUC is of 68.1% (p = 0.047). Conclusions. Many analyzed parameters in univariate regressions reached statistical significance and could be considered as potential prognostic factors for ccRCC. In multivariate analysis, only T stage, platelet count (PLT), and mean platelet volume (MPV) correlated with CSM or recurrent ccRCC.

Gemcitabine-induced thrombocytosis as a potential predictive factor in non-small cell lung cancer: analysis of 318 patients

INTRODUCTION

In spite of the progress in the treatment of non-small-cell lung cancer (NSCLC), the majority of patients with advanced disease still receive chemotherapy. Gemcitabine alone or combined with a platinum compound is a valid option. Thrombocytosis is a recognized prognostic factor in lung cancer and an adverse event that may occur during gemcitabine infusion.

METHODS

We retrospectively evaluated all patients with NSCLC treated with first-line gemcitabine-based chemotherapy in two Italian hospitals. We assessed the onset of thrombocytosis within the third cycle of therapy and the relation between thrombocytosis and survival.

RESULTS

We included 318 patients. Thrombocytosis occurred in 156 patients (49.1%). Median progression-free survival (PFS) was 5.6 months (95% CI, 4.7-6.9 months) in patients who developed thrombocytosis versus 6 months (95% CI, 5.1-7.2 months) in patients without thrombocytosis (p = 0.21). Median overall survival (OS) was 11.2 months (95% CI, 9.8-13.4 months) in patients with thrombocytosis versus 12 months (95% CI, 10.1-14.4 months) in patients without thrombocytosis (p = 0.25). We observed no difference in terms of PFS or OS according to age, sex, stage, chemotherapy (single-agent versus combination chemotherapy) and thrombocytosis.

CONCLUSIONS

Thrombocytosis is neither a prognostic nor a predictive factor for PFS or OS in patients with advanced NSCLC treated with first-line gemcitabine-based chemotherapy.

Clinical significance of preoperative thrombocytosis in patients who underwent radical nephrectomy for nonmetastatic renal cell carcinoma

Purpose

The aim of this study was to examine the association of preoperative thrombocytosis with the prognosis of patients with nonmetastatic renal cell carcinoma (RCC).

Materials and Methods

We conducted a retrospective analysis of 187 patients who underwent a radical nephrectomy for nonmetastatic RCC between July 1997 and June 2009. Thrombocytosis was defined as a platelet count≥400,000 µL, and patients were divided into 2 groups according to presence of preoperative thrombocytosis, and the cancer-specific survival rates and overall survival rates of the 2 groups after radical nephrectomy were compared.

Results

The mean age of the patients was 56.0±11.7 years and the mean follow-up period was 59.3±42.1 months; there were 20 patients with preoperative thrombocytosis. Thirty patients developed metastases and 9 patients died during the follow-up period. In Kaplan-Meier analysis using a univariate log-rank test, both cancer-specific survival rate (p=0.013) and overall survival rate (p=0.012) showed significant association with preoperative thrombocytosis. Controlling for pathological TNM stage, Fuhrman grade and tumor diameter, the Cox proportional hazards model for cancer-specific survival rates showed that preoperative thrombocytosis was an independent prognostic factor (p=0.025).

Conclusions

Preoperative thrombocytosis was associated with poorer prognosis in patients with nonmetastatic RCC. Thus, preoperative platelet count may be clinically useful for risk stratification of patients undergoing surgery for nonmetastatic RCC.

Platelets are versatile cells: New discoveries in hemostasis, thrombosis, immune responses, tumor metastasis and beyond

Platelets are small anucleate blood cells generated from megakaryocytes in the bone marrow and cleared in the reticuloendothelial system. At the site of vascular injury, platelet adhesion, activation and aggregation constitute the first wave of hemostasis. Blood coagulation, which is initiated by the intrinsic or extrinsic coagulation cascades, is the second wave of hemostasis. Activated platelets can also provide negatively-charged surfaces that harbor coagulation factors and markedly potentiate cell-based thrombin generation. Recently, deposition of plasma fibronectin, and likely other plasma proteins, onto the injured vessel wall has been identified as a new "protein wave of hemostasis" that may occur even earlier than the first wave of hemostasis, platelet accumulation. Although no experimental evidence currently exists, it is conceivable that platelets may also contribute to this protein wave of hemostasis by releasing their granule fibronectin and other proteins that may facilitate fibronectin self- and non-self-assembly on the vessel wall. Thus, platelets may contribute to all three waves of hemostasis and are central players in this critical physiological process to prevent bleeding. Low platelet counts in blood caused by enhanced platelet clearance and/or impaired platelet production are usually associated with hemorrhage. Auto- and allo-immune thrombocytopenias such as idiopathic thrombocytopenic purpura and fetal and neonatal alloimmune thrombocytopenia may cause life-threatening bleeding such as intracranial hemorrhage. When triggered under pathological conditions such as rupture of an atherosclerotic plaque, excessive platelet activation and aggregation may result in thrombosis and vessel occlusion. This may lead to myocardial infarction or ischemic stroke, the major causes of mortality and morbidity worldwide. Platelets are also involved in deep vein thrombosis and thromboembolism, another leading cause of mortality. Although fibrinogen has been documented for more than half a century as essential for platelet aggregation, recent studies demonstrated that fibrinogen-independent platelet aggregation occurs in both gene deficient animals and human patients under physiological and pathological conditions (non-anti-coagulated blood). This indicates that other unidentified platelet ligands may play important roles in thrombosis and might be novel antithrombotic targets. In addition to their critical roles in hemostasis and thrombosis, emerging evidence indicates that platelets are versatile cells involved in many other pathophysiological processes such as innate and adaptive immune responses, atherosclerosis, angiogenesis, lymphatic vessel development, liver regeneration and tumor metastasis. This review summarizes the current knowledge of platelet biology, highlights recent advances in the understanding of platelet production and clearance, molecular and cellular events of thrombosis and hemostasis, and introduces the emerging roles of platelets in the immune system, vascular biology and tumorigenesis. The clinical implications of these basic science and translational research findings will also be discussed.

Preoperative thrombocytosis and poor prognostic factors in endometrial cancer

This study aimed to evaluate the prevalence of preoperative thrombocytosis and its prognostic significance in Thai patients with endometrial cancer. We retrospectively reviewed the medical records of 238 cases who had undergone surgical staging procedures between January 2005 and December 2008. Associations between clinicopathological variables and preoperative platelet counts were analyzed using Pearson's chi square or two- tailed Fisher's exact tests. Survival analysis was performed with Kaplan-Meier estimates. Univariate and Cox- regression models were used to evaluate the prognostic impact of various factors including platelet count in terms of disease-free survival and overall survival. The mean preoperative platelet count was 315,437/μL (SD 100,167/ μL). Patients who had advanced stage, adnexal involvement, lymph node metastasis, and positive peritoneal cytology had significantly higher mean preoperative platelet counts when compared with those who had not. We found thrombocytosis (platelet count greater than 400,000/μL) in 18.1% of our patients with endometrial cancer. These had significant higher rates of advanced stage, cervical involvement, adnexal involvement, positive peritoneal cytology, and lymph node involvement than patients with a normal pretreatment platelet count. The 5-year disease-free survival and overall survival were significantly lower in patients who had thrombocytosis compared with those who had not (67.4% vs. 85.1%, p=0.001 and 86.0% vs. 94.9%, p=0.034, respectively). Thrombocytosis was shown to be a prognostic factor in the univariate but not the multivariate analysis. In conclusion, presence of thrombocytosis is not uncommon in endometrial cancer and may reflect unfavorable prognostic factors but its prognostic impact on survival needs to be clarified in further studies.

The prothrombotic activity of cancer cells in the circulation

The hemostatic system is often subverted in patients with cancer, resulting in life-threatening venous thrombotic events. Despite the multifactorial and complex etiology of cancer-associated thrombosis, changes in the expression and activity of cancer-derived tissue factor (TF) - the principle initiator of the coagulation cascade - are considered key to malignant hypercoagulopathy and to the pathophysiology of thrombosis. However, many of the molecular and cellular mechanisms coupling the hemostatic degeneration to malignancy remain largely uncharacterized. In this review we discuss some of the tumor-intrinsic and tumor-extrinsic mechanisms that may contribute to the prothrombotic state of cancer, and we bring into focus the potential for circulating tumor cells (CTCs) in advancing our understanding of the field. We also summarize the current status of anti-coagulant therapy for the treatment of thrombosis in patients with cancer.

The association of platelet count with clinicopathological significance and prognosis in renal cell carcinoma: a systematic review and meta-analysis

OBJECTIVE

Elevated platelet count (PC), a measure of systemic inflammatory response, is inconsistently reported to be associated with poor prognosis in patients with renal cell carcinoma (RCC). We conducted a systematic review and meta-analysis to clarify the significance of PC in RCC prognosis.

METHODS

PubMed, Embase, and Web of Science databases were searched to identify eligible studies to evaluate the associations of PC with patient survival and clinicopathological features of RCC.

RESULTS

We analyzed 25 studies including 11,458 patients in the meta-analysis and categorized the included articles into three groups based on RCC stage. An elevated PC level was associated with poor overall survival (OS, hazard ratio [HR] 2.24, 95% confidence interval [CI] 1.87-2.67, P<0.001) and cancer-specific survival (CSS, HR 2.59, 95% CI 1.92-3.48, P<0.001) when all stages were examined together; with poor CSS (HR 5.09, 95% CI 2.41-10.73, P<0.001) and recurrence-free survival (HR 6.68, 95% CI 3.35-13.34, P<0.001) for localized RCC; with poor OS (HR 2.00, 95% CI 1.75-2.28, P<0.001) for metastatic RCC; and with poor OS (HR 2.05, 95% CI 1.04-4.03, P = 0.038), CSS (HR 3.38, 95% CI 1.86-6.15, P<0.001), and PFS (HR 2.97, 95% CI 1.47-6.00, P = 0.002) for clear cell RCC. Furthermore, an elevated PC level was significantly associated with TNM stage (OR 3.11, 95% CI 1.59-6.06, P = 0.001), pathological T stage (OR 3.13, 95% CI 2.60-3.77, P<0.001), lymph node metastasis (OR 4.01, 95% CI 2.99-5.37, P<0.001), distant metastasis (OR 3.85, 95% CI 2.46-6.04, P<0.001), Fuhrman grade (OR 3.70, 95% CI 3.00-4.56, P<0.001), tumor size (OR 4.69, 95% CI 2.78-7.91, P<0.001) and Eastern Cooperative Oncology Group score (OR 5.50, 95% CI 3.26-9.28, P<0.001).

CONCLUSION

An elevated PC level implied poor prognosis in patients with RCC and could serve as a readily available biomarker for managing this disease.

Pretreatment platelet count improves the prognostic performance of the TNM staging system and aids in planning therapeutic regimens for nasopharyngeal carcinoma: a single-institutional study of 2,626 patients

INTRODUCTION

Thrombocytosis has been identified as an unfavorable prognostic factor in several types of cancer. This study aimed to evaluate the prognostic value of pretreatment platelet count in association with the TNM staging system and therapeutic regimens in patients with nasopharyngeal carcinoma (NPC).

METHODS

A total of 2,626 patients with NPC were retrospectively analyzed. Platelet count >300 × 10(9)/L was defined as thrombocytosis. Matched-pair analysis was performed between patients receiving chemoradiotherapy and radiotherapy.

RESULTS

Multivariate analysis showed that platelet count was an independent unfavorable prognostic factor for overall survival (OS) [hazard ratio (HR) = 1.810, 95% confidence interval (CI) = 1.531-2.140, P < 0.001] and distant metastasis-free survival (DMFS) (HR = 1.873, 95% CI = 1.475-2.379, P < 0.001) in the entire patient cohort. Further subgroup analysis revealed that increased platelet count was an independent unfavorable prognostic factor for OS and DMFS in patients with NPC stratified by early and advanced T category, N category, or TNM classification (all P ≤ 0.001). Receiver operating characteristic (ROC) curves verified that the predictive value of TNM classification for OS was improved when combined with pretreatment platelet count (P = 0.030). Matched-pair analysis showed that chemoradiotherapy significantly improved OS only in advanced-stage NPC with thrombocytosis (HR = 0.416, 95% CI = 0.226-0.765, P = 0.005).

CONCLUSIONS

Pretreatment platelet count, when combined with TNM classification, is a useful indicator for metastasis and survival in patients with NPC. It may improve the predictive value of the TNM classification and help to identify patients likely to benefit from more aggressive therapeutic regimens.

Involvement of platelets in extrahepatic metastasis of hepatocellular carcinoma

AIM

Recently, a relationship between platelets and cancer metastasis has been reported. The aim of this study is to elucidate the risk factors for extrahepatic metastasis (EHM), with emphasis on association with platelets in patients, with hepatocellular carcinoma (HCC).

METHODS

We examined risk factors for EHM in 1613 consecutive, newly diagnosed HCC patients by logistic regression analysis (case-control study). We also examined the factors by Cox proportional hazard model in a retrospective cohort fashion in 803 patients who received non-curative treatment for HCC.

RESULTS

In the case-control study, multivariate analysis revealed that high platelet counts (odds ratio [OR] = 4.84; 95% confidence interval [CI] = 1.29-29.54; P = 0.01), high tumor number and the presence of macroscopic vascular invasion were significantly associated with EHM. In the cohort study, EHM was diagnosed in 71 patients during the study period (mean observation time = 23.3 months). On multivariate analysis, high tumor number, high des-γ-carboxyprothrombin (DCP) and Child-Pugh class A were significantly correlated with EHM, and the patients with high platelet counts tended to develop EHM (OR = 1.73; 95% CI = 0.99-3.14; P = 0.055).

CONCLUSION

HCC patients with high platelet counts, as well as large numbers of tumors, high serum DCP and Child-Pugh class A, are at risk for EHM.

Effects of cancer on platelets

The main function of circulating platelets is to stop bleeding upon vascular injury by the formation of a hemostatic plug. The presence of cancer results in numerical and functional abnormalities of platelets. Thrombocytosis is commonly observed in cancer patients and is associated with decreased survival. Conversely, thrombocytopenia has been shown to have antimetastatic effects in experimental models. Tumor cells also can induce changes in the platelet activation status, both in direct and indirect manners. Direct tumor cell-induced platelet aggregation enables the formation of a cloak of aggregated platelets around circulating tumor cells (CTCs) that shields them from attacks by the immune system and facilitates metastasis to distant sites. Cancer also can induce platelet activation in various indirect ways. Tumor cells shed small extracellular vesicles that expose the transmembrane protein tissue factor (TF)--the initiator of the extrinsic coagulation cascade. The abundant presence of TF in the circulation of cancer patients can result in local generation of thrombin, the most potent platelet activator. Another pathway of indirect platelet activation is by increased formation of neutrophil extracellular traps in the presence of tumor-secreted granulocyte colony-stimulating factor (G-CSF). Last, tumor cells may regulate the selective secretion of angiogenic proteins from platelet granules, which enables the tumor to stimulate and stabilize the immature neovasculature in the tumor environment. Since there is little doubt that the cancer-induced platelet alterations are beneficial to tumor growth and dissemination, it could be worthwhile to intervene in the underlying mechanisms for anticancer purposes. Antiplatelet and anticoagulant agents that inhibit platelet activation and thrombin generation can potentially slow cancer progression, although the clinical evidence thus far is not unequivocal.

Associations between lifestyles and neutrophil-lymphocyte and platelet-lymphocyte ratios in colorectal cancer

AIMS

To explore the etiology of the neutrophil-lymphocyte ratio (NLR) and platelet-lymphocyte ratio (PLR) abnormalities in colorectal cancer.

METHODS

In total, 230 patients with histopathologically confirmed colorectal cancer from August 2009 to August 2011 were recruited to our study. The associations between lifestyles (smoking, alcohol and pickled food consumption) and pretreatment NLR and PLR were estimated using the Kruskal-Wallis tests and linear regression model.

RESULTS

The Kruskal-Wallis test showed a significant association between pickled food intake and pretreatment NLR but not PLR (P = 0.002, 0.057, respectively). Pairwise comparisons showed that, compared with those with a moderately frequent (2-3 times/week) and an infrequent (≤ once a week) intake of pickled food, high frequency (≥ four times/week) consumption of pickled food had a higher pretreatment NLR (P = 0.01, 0.007, respectively). Multivariate linear regression analysis showed pretreatment NLR increased significantly in high frequency (≥ four times/week) consumption of pickled food (P < 0.0001). No association between other lifestyle factors and pretreatment PLR was found.

CONCLUSIONS

A higher frequency intake of pickled food possibly contributes to higher NLR, which may reflect a systemic inflammatory response in colorectal cancer.

Platelet CLEC-2 and podoplanin in cancer metastasis

It has long been recognised that the function of platelets in health and disease span far beyond their roles in haemostasis and thrombosis. The observation that tumour cells induce platelet aggregation was followed by extensive experimental evidence linking platelets to cancer progression. Aggregated platelets coat tumour cells during their transit through the bloodstream and mediate adherence to vascular endothelium, protection from shear stresses, evasion from immune molecules, and release of an array of bioactive molecules that facilitate tumour cell extravasation and growth at metastatic sites. The sialyated membrane glycoprotein podoplanin is found on the leading edge of tumour cells and is thought to influence their migratory and invasive properties. Podoplanin elicits powerful platelet aggregation and is the endogenous ligand for the platelet C-type lectin receptor, CLEC-2, which itself regulates podoplanin signalling. Here, the bidirectional relationship between CLEC-2 and podoplanin is described and considered in the context of tumour growth and metastasis.

Impact of preoperative thrombocytosis on the survival of patients with primary colorectal cancer

BACKGROUND

Although thrombocytosis has been reported in patients with various types of cancer, the association between thrombocytosis and the clinicopathological features of patients with colorectal cancer (CRC) has not been fully investigated. We evaluated the clinical features associated with thrombocytosis in CRC.

MATERIALS AND METHODS

The medical records of 636 consecutive CRC patients undergoing surgery in our department between January 2002 and July 2008 were retrospectively reviewed. The correlation between the clinicopathological variables and the preoperative platelet count was analyzed by univariate and multivariate analyses. The impact of thrombocytosis on the prognosis of these patients was assessed, in comparison with the other clinicopathological variables.

RESULTS

Platelet count showed significant correlation with gender, age, venous involvement, tumor size, depth of invasion, regional lymph node metastasis, distant metastasis in univariate analysis, and tumor size and depth of invasion were independent factors in multivariate analysis. The cancer-specific survival (CSS) of CRC patients with thrombocytosis was significantly shorter than that for those without thrombocytosis (P < 0.001), specifically in patients with stage III CRC (P < 0.001). Multivariate analysis indicated that thrombocytosis was an independent prognostic factor of CSS (hazard ratio = 2.96, 95% confidence interval [CI] = 1.72-5.00). Moreover, within stage II CRC, the univariate analysis revealed that disease-free survival (DFS) was associated with preoperative thrombocytosis, but not the other clinicopathological variables.

CONCLUSIONS

Preoperative thrombocytosis is not only an independent indicator of poor CSS in CRC patients but also an independent predictor of poor DFS in patients with stage II CRC.

Increased platelet count is an indicator of metastasis in patients with nasopharyngeal carcinoma

This study aims to evaluate the impact of pretreatment thrombocytosis on survival in patients with nasopharyngeal carcinoma (NPC). The data of 1,582 patients with NPC, who underwent definitive treatment between 2003 and 2004, were retrospectively reviewed. The correlation between the clinicopathological variables and the platelet count was analyzed. The prognostic significance of thrombocytosis, together with various clinicopathological factors, was evaluated by univariate and multivariate analyses. Platelet count showed significant correlation with gender, clinical stage, and T stage in univariate analysis. There was poorer 5-year disease-specific survival (DSS) in the patients with thrombocytosis than in those without thrombocytosis (70 vs. 78 %; p = 0.001) and poorer metastases-free survival (MFS) (81 vs. 88 %; p = 0.006). Univariate and multivariate analyses showed that thrombocytosis was an independent prognostic factor for MFS and DSS. Thrombocytosis is a useful predictor of metastasis and poor prognosis in patients with NPC.

Does preoperative platelet count and thrombocytosis play a prognostic role in patients undergoing nephrectomy for renal cell carcinoma? Results of a comprehensive retrospective series

PURPOSE

To evaluate the still controversially discussed prognostic role of preoperative platelet level (PPL) and thrombocytosis (TC) in patients who undergo surgery for renal cell carcinoma (RCC) based on the largest patient series reported to date.

METHODS

A total of 3,139 patients, who underwent radical or nephron-sparing nephrectomy at four centres, were subdivided based on a threshold for preoperative platelets of 400 × 10(9) cells/L. Univariate and multivariable Cox regression analyses were applied to determine the prognostic influence of PPL and TC on cancer-specific survival (CSS) for patients with localized and metastatic disease at presentation.

RESULTS

Group 1 (PPL ≤ 400/nl) and Group 2 (PPL > 400/nl) included 2,862 (91 %) and 277 patients (9 %), respectively. With a median follow-up (FU) of 69.5 months (IQR: 35-105), CSS of all patients after 5 years was 84.6 % in Group 1 versus 53.4 % in Group 2 (p < 0.001). At multivariable analysis, TC (HR:1.337; p = 0.007) and continuous PPL (HR:1.001; p = 0.002) independently predicted a decreased survival. However, integration of these parameters into multivariable models for the entire study group and for patients with localized tumours did only result in marginal improvement of the model quality (0.66 and 1.04 %, respectively). Interestingly, neither TC (p = 0.257) nor PPL (p = 0.132) significantly influenced survival in M1 patients.

CONCLUSIONS

Preoperative TC turned out an independent predictor for decreased CSS in patients undergoing surgery for localized RCC. However, significant improvement of multivariable models comprising standard clinical and pathological parameters by the inclusion of TC is not achieved. In metastatic disease, TC did not reveal an independent influence on CSS.

Pretreatment thrombocytosis: a prognostic marker for oral squamous cell carcinoma?

PURPOSE

Thrombocytosis associated with poorer prognoses seems to be a frequent preoperative finding in different kind of cancers. The aim of the present study was to evaluate whether thrombocytosis can be used as a prognostic marker for oral squamous cell carcinoma (SCC).

METHODS

Altogether, 288 patients with oral SCC were considered, as well as all platelet counts between 1 and 5 days prior to surgical treatment, recurrence rate, and lymph node metastasis. The minimum follow-up time was 12 months.

RESULTS

The mean preoperative thrombocyte score of the patients who received surgery was 259.55 ± 83.8 Tsd/μl; 273 out of 288 patients were in the normal thrombocyte range, and 12 had a thrombocytosis. From 51 patients with recurrence, three were in the thrombocytosis group, and 45 patients with recurrence were in the normal thrombocyte range.

CONCLUSION

The present results do not confirm that thrombocytosis can be seen as marker for poor tumor prognosis.

A new prognostic model for cancer-specific survival after radical cystectomy including pretreatment thrombocytosis and standard pathological risk factors

Study Type - Prognosis (cohort series) Level of Evidence 2a What's known on the subject? and What does the study add? Preoperative thrombocytosis has been identified as a predictor of poor outcome in various cancer types. However, the prognostic role of platelet count in patients with invasive bladder cancer undergoing radical cystectomy is unknown. The present study demonstrates that preoperative thrombocytosis is an independent risk factor for decreased cancer-specific survival after radical treatment of invasive bladder cancer. We developed a new prognostic scoring model for cancer-specific outcomes after radical cystectomy including platelet count and established pathological risk factors. Consideration of platelet count in the final model increased its predictive accuracy significantly. Thrombocytosis may be a useful parameter to include within established international bladder cancer nomograms.

OBJECTIVE

•  To investigate the oncological significance of preoperative thrombocytosis in patients with invasive bladder cancer undergoing radical cystectomy, as it has been reported as a marker for aggressive tumour biology in a variety of solid tumours.

PATIENTS AND METHODS

•  The series comprised 258 patients undergoing radical cystectomy between 1999 and 2010 in whom different clinical and histopathological parameters were assessed. •  Elevated platelet count was defined as >450 × 10(9) /L. •  Based on regression estimates of significant parameters in multivariable analysis a new weighted scoring model was developed to predict cancer-specific outcomes.

RESULTS

•  The median follow-up was 30 months (6-116). •  Of the 258 patients, 26 (10.1%) had elevated and 232 (89.9%) had normal platelet count. The 3-year cancer-specific survival in patients with normal and elevated platelet count was 61.5% and 32.7%, respectively (P < 0.001). •  In multivariable analysis, cancer-specific survival was significantly lower in patients with locally advanced disease (≥pT3a) (relative risk 2.91, 1.54-5.65; P= 0.001), positive soft tissue surgical margins (4.03, 1.99-7.92; P= 0.001) and thrombocytosis (2.68, 1.26-5.14; P= 0.011). •  The 3-year cancer-specific survival in patients with a score 0 (low risk), 1-2 (intermediate risk) and 3-5 (high risk) was 81.0%, 54.8% and 8.2%, respectively (P < 0.001). •  Consideration of preoperative platelet count in the final model increased its predictive accuracy by 1.8% with a concordance index of 0.745 (P= 0.040).

CONCLUSIONS

•  The presence of thrombocytosis at radical cystectomy portends unfavourable prognosis. •  We constructed a simple weighted prognostic model for cancer-specific outcomes after radical cystectomy based on pretreatment platelet count and established pathological risk factors. •  These data warrant external validation and may allow for tailored monitoring and selection of appropriate patients for neoadjuvant and adjuvant trials.

Subclavian vein thrombosis: an unusual presentation of renal cell carcinoma

Subclavian vein thrombosis is an uncommon clinical condition which is often associated with venous catheterization or secondary to excessive effort. We present a 54-year-old female with subclavian vein thrombosis as a first presentation of renal cell carcinoma. Although this is an unusual presentation, malignancy should be considered in the differential diagnosis. Hypercoagulability as part of a paraneoplastic syndrome was considered a possible etiology. In patients with otherwise unexplained subclavian vein thrombosis, full systemic examination and radiological evaluation of the abdomen, retroperitoneum and pelvis should be pursued. A review of the literature relevant to this unusual case is provided.

Contribution of platelets to tumour metastasis

Extensive experimental evidence shows that platelets support tumour metastasis. The activation of platelets and the coagulation system have a crucial role in the progression of cancer. Within the circulatory system, platelets guard tumour cells from immune elimination and promote their arrest at the endothelium, supporting the establishment of secondary lesions. These contributions of platelets to tumour cell survival and spread suggest platelets as a new avenue for therapy.

Incidence of anemia, leukocytosis, and thrombocytosis in patients with solid tumors in China

Despite the fact that malignancies are associated with hematological abnormalities, some clinical studies have been unable to detect such a relation. The aim of our study was to detect the prevalence of pretreatment hematologic abnormalities in patients with common solid tumors and to determine if such a profile could be used for prognostic evaluations. We identified all patients in Cancer Center of Sun Yat-sen University who were diagnosed as solid tumors (breast carcinoma, hepatocellular carcinoma, nasopharyngeal carcinoma, esophageal carcinoma, gastric cancer, cervical carcinoma, endometrial cancer, renal cell carcinoma, and non-small cell lung cancer) between January 2000 and August 2009. All subjects were investigated regarding levels of white blood cells, platelets, and hemoglobin concentration. We identified 3,180 patients with solid tumors and 285 patients with benign diseases for the final analysis. The percentages of leukocytosis, anemia, and thrombocytosis in patients with solid tumors ranged from 4.0% to 25.6%, 3.3% to 29.2%, and 2.1% to 9.7%, respectively. The multivariate Cox analysis revealed that anemia was an independent prognostic factor in patients with breast cancer (P = 0.006), hepatocellular carcinoma (P = 0.002), nasopharyngeal carcinoma (P = 0.008), and esophageal carcinoma (P = 0.001). Leukocytosis was an independent prognostic factor in patients with cervical cancer (P = 0.007). The incidence of hematological abnormalities in Chinese patients with solid tumors was relatively lower than that of the counterparts in the Western countries. A pretreatment anemia or leukocytosis can serve as a useful marker to predict outcome of patients in some of the solid tumors.

Role of systemic inflammatory response in predicting survival in patients with primary operable cancer

Disease progression in cancer is dependent on the complex interaction between the tumor and the host inflammatory response. There is substantial evidence in advanced cancer that host factors, such as weight loss, poor performance status and the host systemic inflammatory response, are linked, and the latter is an important tumor-stage-independent predictor of outcome. Indeed, the systemic inflammatory response, as evidenced by an elevated level of C-reactive protein, is now included in the definition of cancer cachexia. This review examines the role of the systemic inflammatory response in predicting survival in patients with primary operable cancer. Approximately 80 studies have evaluated the role of the systemic inflammatory response using biochemical or hematological markers, such as elevated C-reactive protein levels, hypoalbuminemia or increased white cell, neutrophil and platelet counts. Combinations of such factors have been used to derive simple inflammation-based prognostic scores, such as the Glasgow Prognostic Score, the neutrophil:lymphocyte ratio and the platelet:lymphocyte ratio. This review demonstrates that there is now good evidence that preoperative measures of the systemic inflammatory response predict cancer survival, independent of tumor stage, in primary operable cancer. The evidence is particularly robust in colorectal (including liver metastases), gastro-esophageal and renal cancers. As described in this article, measurement of the systemic inflammatory response is simple, reliable and can be clinically incorporated into current staging algorithms. This will provide the clinician with a better prediction of outcome, and therefore better treatment allocation in patients with primary operable cancer. Furthermore, systemic inflammation-based markers and prognostic scores not only identify patients at risk, but also provide well-defined therapeutic targets for future clinical trials.

Impact of clinical variables on predicting disease-free survival of patients with surgically resected renal cell carcinoma

OBJECTIVE

To determine the value of particular clinical variables for the preoperative prognostic Cindolo formula (PPCF) to predict disease-free survival (DFS) of patients with surgically treated renal cell carcinoma (RCC).

PATIENTS AND METHODS

In all, 771 consecutive patients (T1-4NxM0) who had radical or partial nephrectomy were reviewed retrospectively. For each patient with RCC, PPCF was constructed according to clinical size and clinical presentation. On the basis of PPCF, patients were divided into Cindolo good prognosis (CGP) and Cindolo poor prognosis (CPP) groups. We also analysed further clinical variables (Eastern Cooperative Oncology Group score, American Society of Anesthesiologists score, body mass index, hepatic dysfunction, night sweat, fever, value of blood platelets, leukocytes, haemoglobin level, gender, age and location). DFS was estimated using the Kaplan-Meier method. Univariable and multivariable Cox proportional hazard regression models were fitted to determine associations between the PPCF, measured clinical features, and DFS.

RESULTS

Four of the variables emerged as statistically significant for DFS from the univariable analysis (P < 0.001), i.e. clinical presentation, clinical tumour size, haemoglobin level and blood platelet count. In the multivariable analysis, only clinical tumour size and blood platelet count remained significant for DFS. By contrast, clinical presentation, used in the PPCF, had no significant influence. According to the PPCF we developed the preoperative Amissah Prognosis Score (PAPS) calculated as (0.19 x clinical size) + (0.492 x platelet count (<or=400/nL = 0, >400/nL = 1) with a threshold between the two resulting prognosis groups at 1.76. The multivariable hazard ratio (95% confidence interval, CI) for the PAPS was 2.98 (2.15-4.12) (P < 0.001) compared to a hazard ratio for the PPCF of 1.36 (0.99-1.87) (P = 0.061). Furthermore, the predictive ability was greater when using the PAPS (area under the curve 0.721; 95% CI, 0.680-0.763; P <or= 0.001) than the PPCF (0.690; 0.647-0.734; P <or= 0.001).

CONCLUSIONS

Using preoperative prognostic models is reasonable to provide patients with pertinent information about their prognosis, and for tailoring the treatment to each patient's needs. Applying the PPCF allows a prediction of the outcome of patients with surgically treated RCC on the basis of preoperatively available variables. However, clinical presentation, included in this model, had no significant influence on DFS in the present patients. By contrast, using the PAPS resulted in an improvement in the predictive value and in a greater discrimination between patients subdivided into a good and a poor prognosis group and hence is suitable for preoperative risk assignment.