Increased neutrophil-lymphocyte ratio predicts recurrence in patients with well-differentiated pancreatic neuroendocrine neoplasm based on the 2017 World Health Organization classification

Value of markers of systemic inflammation for the prediction of postoperative progression in patients with pancreatic neuroendocrine tumors

Background

Non-invasive prognostic predictors for rare pancreatic neuroendocrine tumors (PNETs) are lacking. We aimed to approach the prognostic value of preoperative systemic inflammatory markers in patients with PNETs.

Methods

The clinical data of 174 patients with PNETs undergoing surgical treatment were retrospectively analyzed to explore the correlation of neutrophil to lymphocyte ratio (NLR), platelet to lymphocyte ratio (PLR), lymphocyte to monocyte ratio (LMR), and platelet to white blood cell ratio (PWR) with clinicopathological parameters and the progression of tumor after the operation. The optimal cutoff values for predictors and the area under the curve (AUC) of the receiver operating characteristic (ROC) were estimated. Univariate and multivariate Cox proportional hazards models were used to assess the relation between NLR, LMR, PLR, and progression-free survival (PFS), examined by the Kaplan-Meier and log-rank tests.

Results

The scores of the NLR (P = 0.039) and PLR (P = 0.011) in the progression group were significantly higher than those in the progression-free group, and the LMR was significantly lower than those in the progression-free group (P = 0.001). The best cutoff values of NLR, LMR, and PLR before operation were 2.28, 4.36, and 120.91. The proportions of tumor progression in the high NLR group (P = 0.007) and high PLR group (P = 0.013) obviously increased, and the proportion of tumor development in the low LMR group was higher than that in the high LMR group (P < 0.001). The K-M survival curve showed that the progression-free survival rate was lower in the high NLR group (P = 0.004), the low LMR group (P < 0.001), and the high PLR group (P = 0.018). The results of the multivariate Cox proportional hazards model suggested that preoperative LMR (HR = 3.128, 95% CI: 1.107~8.836, P = 0.031) was an independent predictor of PFS.

Conclusion

The markers of systemic inflammation, especially LMR, can predict the postoperative progression of PNETs.

Prediction of the lymphatic, microvascular, and perineural invasion of pancreatic neuroendocrine tumors using preoperative magnetic resonance imaging

BACKGROUND

Significant correlation between lymphatic, microvascular, and perineural invasion (LMPI) and the prognosis of pancreatic neuroendocrine tumors (PENTs) was confirmed by previous studies. There was no previous study reported the relationship between magnetic resonance imaging (MRI) parameters and LMPI.

AIM

To determine the feasibility of using preoperative MRI of the pancreas to predict LMPI in patients with non-functioning PENTs (NFPNETs).

METHODS

A total of 61 patients with NFPNETs who underwent MRI scans and lymphadenectomy from May 2011 to June 2018 were included in this retrospective study. The patients were divided into group 1 (n = 34, LMPI negative) and group 2 (n = 27, LMPI positive). The clinical characteristics and qualitative MRI features were collected. In order to predict LMPI status in NF-PNETs, a multivariate logistic regression model was constructed. Diagnostic performance was evaluated by calculating the receiver operator characteristic (ROC) curve with area under ROC, sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV) and accuracy.

RESULTS

There were significant differences in the lymph node metastasis stage, tumor grade, neuron-specific enolase levels, tumor margin, main pancreatic ductal dilatation, common bile duct dilatation, enhancement pattern, vascular and adjacent tissue involvement, synchronous liver metastases, the long axis of the largest lymph node, the short axis of the largest lymph node, number of the lymph nodes with short axis > 5 or 10 mm, and tumor volume between two groups (P < 0.05). Multivariate analysis showed that tumor margin (odds ratio = 11.523, P < 0.001) was a predictive factor for LMPI of NF-PNETs. The area under the receiver value for the predictive performance of combined predictive factors was 0.855. The sensitivity, specificity, PPV, NPV and accuracy of the model were 48.1% (14/27), 97.1% (33/34), 97.1% (13/14), 70.2% (33/47) and 0.754, respectively.

CONCLUSION

Using preoperative MRI, ill-defined tumor margins can effectively predict LMPI in patients with NF-PNETs.

Effects of Dexmedetomidine on Systemic Inflammation and Postoperative Complications in Laparoscopic Pancreaticoduodenectomy: A Double-blind Randomized Controlled Trial

BACKGROUND

Laparoscopic pancreaticoduodenectomy (LPD) may induce intense inflammatory response which might be related to the patient's outcomes. Clinical dexmedetomidine (DEX) has been widely used for opioid-sparing anesthesia and satisfactory sedation. The objective of this study was to investigate the influence of DEX on inflammatory response and postoperative complications in LPD.

METHODS

Ninety-nine patients undergoing LPD were randomly assigned to two groups: normal saline (NS) and DEX. The primary outcome was the neutrophil-to-lymphocyte ratio (NLR) differences postoperatively within 48 h. Secondary outcomes were postoperative complications, the length of postoperative hospital stay and the incidence of ICU admission. Other outcomes included anesthetics consumption and intraoperative vital signs.

RESULTS

NLR at postoperative day 2 to baseline ratio decreased significantly in the DEX group (P = 0.032). Less major complications were observed in the DEX group such as pancreatic fistula, delayed gastric emptying and intra-abdominal infection (NS vs. DEX, 21.7% vs. 13.6%, P = 0.315; 10.9% vs. 2.3%, P = 0.226; 17.4% vs. 11.4%, P = 0.416, respectively) though there were no statistical differences. Three patients were transferred to the ICU after surgery in the NS group, while there was none in the DEX group (P = 0.242). The median postoperative hospital stay between groups were similar (P = 0.313). Both intraoperative propofol and opioids were less in the DEX group (P < 0.05).

CONCLUSIONS

Intraoperative DEX reduced the early postoperative inflammatory response in LPD. It also reduced the use of narcotics that may related to reduced major complications, which need additional research further.

The survival analysis of rifampicin/multidrug-resistant tuberculosis patients based on the levels of inflammatory biomarkers: a retrospective cohort study

Purpose

The development of tuberculosis and inflammatory status are closely related. The aim of this study was to investigate the prognostic value of inflammatory biomarkers in patients with rifampicin/multidrug-resistant tuberculosis (RR/MDR-TB).

Patients and methods

This study recruited 504 patients with RR/MDR-TB from Wuhan Jinyintan Hospital. A total of 348 RR/MDR patients from January 2017 to December 2019 were defined as training set, the rest of patients as validation set. The patients were divided into three-risk degrees according to the levels of inflammatory biomarkers (median, 85th percentile). Kaplan-Meier curve and log-rank test were used to assess survival differences among the groups. Cox proportion risk regression was used to identify risk factors for RR/MDR-TB mortality.

Results

In training set, cox proportion risk regression analysis showed that high age (≥60 years) [OR (95%CI):1.053(1.03188-1.077)], smoking [OR (95%CI):2.206(1.191-4.085)], and bronchiectasia [OR (95%CI):2.867(1.548-5.311)] were prognostic factors for RR/MDR-TB patients. In addition, lower survival rates were observed in high CAR group [OR (95%CI):1.464(1.275-1.681)], high CPR group[OR (95%CI):1.268(1.101-1.459)], high CLR group[OR (95%CI):1.004(1.002-1.005)], high NLR group[OR (95%CI):1.103(1.069-1.139)], high PLR group[OR (95%CI):1.003(1.002-1.004)], and high MLR group[OR (95%CI):3.471(2.188-5.508)].Furthermore, AUCs of age, smoking, bronchiectasia, CAR, CPR, CLR, NLR, PLR, and MLR for predicting mortality in RR/MDR-TB patients were 0.697(95%CI:0.618-0.775), 0.603(95%CI:0.512-0.695), 0.629(95%CI:0.538-0.721), 0.748(95%CI:0.675-0.821, P<0.05), 0.754(95%CI:0.683-0.824, P<0.05), 0.759(95%CI:0.689-0.828, P<0.05), 0.789(95%CI:0.731-0.846, P<0.05), 0.740(95%CI:0.669-0.812, P<0.05), and 0.752(95%CI:0.685-0.819, P<0.05), respectively. Importantly, the AUC of predicting mortality of combination of six inflammatory biomarkers [0.823 (95%CI:0.769-0.876)] is higher than any single inflammatory biomarkers. Additionally, the similar results are also obtained in the validation set.

Conclusion

Inflammatory biomarkers could predict the survival status of RR/MDR-TB patients. Therefore, more attention should be paid to the level of inflammatory biomarkers in clinical practice.

Elevated serum neutrophil-lymphocyte ratio is associated with worse long-term survival in patients with HBV-related intrahepatic cholangiocarcinoma undergoing resection

BACKGROUND

This study aimed to examine the influence of serum inflammatory marker levels on long-term outcomes after liver resection in patients with intrahepatic cholangiocarcinoma (ICC).

METHODS

Data from 1189 consecutive ICC patients who underwent liver resection were reviewed. The serum neutrophil-lymphocyte ratio (NLR), platelet-lymphocyte ratio (PLR), and prognostic nutritional index (PNI) were measured before surgery. Overall survival (OS) and tumour recurrence were analysed using the Kaplan-Meier method and compared using the log-rank test. Independent risk factors for OS and tumour recurrence were analysed using the Cox hazard regression model.

RESULTS

We identified elevated serum NLR (≥ 2.15) as an independent risk factor for both OS and tumour recurrence (hazard ratio [HR]: 1.327, 95% confidence interval [CI]: 1.105-1.593; HR: 1.274, 95% CI: 1.074-1.510) among the three inflammatory markers assessed. Elevated NLR was associated with higher carbohydrate antigen 19-9 (CA19-9) and carcinoembryonic antigen (CEA) levels, larger tumour size, multiple tumours, lymph node metastasis, vascular invasion, and more advanced tumour node metastasis (TNM) stage (III/IV). Subgroup analysis showed that elevated NLR was an independent risk factor for OS and tumour recurrence in patients with hepatitis B virus (HBV) infection compared with patients without HBV infection (HR: 1.347, 95% CI: 1.073-1.690; HR: 1.386, 95% CI: 1.112-1.726).

CONCLUSIONS

Elevated serum NLR was associated with worse prognosis among ICC patients who underwent liver resection, especially in patients with HBV infection.

Neutrophil to lymphocyte ratio as a prognosis biomarker of PRRT in NET patients

PURPOSE

Peptide Receptor Radionuclide Therapy (PRRT) with 177Lu-DOTATATE is a palliative therapeutic option for advanced Neuroendocrine Tumors (NETs). Prognostic factors can predict long-term outcomes and determine response to therapy. Among those already explored, biomarkers from full blood count, including neutrophil to lymphocyte ratio (NLR) and platelet to lymphocyte ratio (PLR) has shown value for other solid tumors and for NETs patients submitted to other forms of therapy. However, its relation to PRRT response and patients' prognosis is still to be determined.

METHODS

Medical records from 96 patients submitted to PRRT between 2010 and 2017 were reviewed, median NLR and PLR were calculated from baseline flood blood count and dichotomized as high or low. Progression-free survival (PFS) and Overall Survival (OS) were calculated.

RESULTS

NLR and PLR median values were 1.8 and 123, respectively. Patients with low NLR had a significantly longer OS (estimated median of 77.5 months, 95% CI: 27.3-127.7) when compared to patients with high NLR (estimated median of 47.7 months, 95% CI: 34.7-60.8); p = 0.04. Patients with low NLR had a trend toward a longer median PFS when compared to patients with high NLR [estimated medians of 77 months (95% CI: 27.3-127.7), and 47.7 months, (95% CI: 34.7-60.7)], respectively, p = 0.08.

CONCLUSION

Patients with advanced-stage NET with NLR higher than 1.8 have worse long term clinical outcomes after PPRT. Larger studies are needed to validate the optimal cutoff for this biomarker.

The Predicting Role of the Neutrophil-to-Lymphocyte Ratio for the Tumor Grade and Prognosis in Pancreatic Neuroendocrine Tumors

This study aims to investigate the prognostic role of the neutrophil-to-lymphocyte ratio (NLR) in pancreatic neuroendocrine tumors (PNETs) using meta-analysis. This study evaluates the correlation between the NLR and the prognosis in PNETs from nine eligible studies. In addition, a subgroup analysis based on the tumor grade, treatment, and evaluation criteria, was conducted. The estimated rate of a high NLR was 0.253 (95% confidence interval (CI) 0.198–0.317). The rate of high NLRs was significantly lower in patients with lower tumor grades (G1) than those with higher tumor grades (G2 or G3). In addition, the mean value of the NLR was significantly lower in lower tumor grades than in higher tumor grades. High NLRs were significantly correlated with worse overall and recurrence-free survivals (hazard ratio (HR) 2.180, 95% CI 1.499–3.169 and HR 2.462, 95% CI 1.677–3.615, respectively). In a subgroup analysis, the prognostic implications of the NLR were found in both higher and lower criteria of a high NLR. Taken together, our results show that the NLR could be useful for predicting the tumor grade and the prognosis in PNETs.

What is the impact of zinc deficiency for pancreatectomies in patients with pancreatic ductal adenocarcinoma?

BACKGROUND

and purpose: Zinc is an essential element for human health and plays an important role in metabolic, immunological and other biological processes. The present study was conducted to investigate the association between zinc deficiency (ZD) and the perioperative clinical course in patients with pancreatic ductal adenocarcinoma (PDAC).

METHODS

Of 216 patients with PDAC who underwent elective pancreatectomy between 2013 and 2017 at our institution, 206 patients with sufficient clinical data were retrospectively reviewed. The perioperative variables were compared and the risk factors associated with infectious complications were identified.

RESULTS

ZD was preoperatively present in 36 (17.5%) of 206 patients with PDAC. In the patients of the ZD group, a higher proportion of males, higher preoperative modified Glasgow prognostic scores, a higher neutrophil-to-lymphocyte ratio, and a higher occurrence of postoperative infectious complications after pancreatectomy were observed, compared to the non-ZD group. By a univariate analysis, three risk factors were significantly associated with infectious complications after pancreatectomy: ZD (vs non-ZD: p = 0.002), serum albumin <3.5 g/dl (vs ≥ 3.5 g/dl: p = 0.005), and the procedure of pancreaticoduodenectomy (vs others: p = 0.013). By multivariate logistic regression analysis, the occurrence of infectious complications was significantly associated with ZD (OR 3.430, 95%CI 1.570 to 7.490, p = 0.002) and the procedure of pancreaticoduodenectomy (OR 2.030, 95%CI 1.090 to 3.770, p = 0.025).

CONCLUSIONS

The current study newly demonstrated that ZD could serve as a preoperative predictor of infectious complications after pancreatectomies in the patients with PDAC.

Evaluation of the Significance of Lymphatic, Microvascular and Perineural Invasion in Patients With Pancreatic Neuroendocrine Neoplasms

BACKGROUND

Some prognostic factors for pancreatic neuroendocrine neoplasms (PanNENs) have been reported; however, the significance of lymphatic, microvascular, and perineural invasion remains unclear. We aimed to clarify the role of these factors in PanNEN recurrence.

PATIENTS AND METHODS

We analyzed 138 patients who underwent curative pancreatectomy and were pathologically diagnosed with PanNEN. We evaluated the association between clinicopathological factors and the recurrence of PanNENs.

RESULTS

The numbers of patients with lymphatic, microvascular, and perineural invasion were 34 (25%), 43 (31%) and 17 (12%), respectively. Twenty-four patients (17%) had recurrences, and the 3, 5, and 10-year recurrence-free survival (RFS) rates were 88%, 84%, and 76%, respectively. The recurrence sites (with duplication) were mainly the liver (twenty-two patients), followed by the lymph nodes (seven patients), and bone (two patients). In multivariate analyses, grade 2-3 and the presence of microvascular invasion were significant risk factors for RFS (hazard ratio=7.5 and 7.9, respectively). When examining outcomes according to these factors, the 5-year RFS rates of patients with risk scores of 0, 1, and 2 were 100%, 91%, and 32%, respectively (p<0.001). Even in patients with grade 1 (n=97) or limited resection (enucleation, splenic-preserving distal pancreatectomy, central pancreatectomy, and duodenum-preserving pancreatic head resection, n=62), the presence of microvascular invasion was a significant risk factor for RFS (hazard ratio=13.4 and 18.0, respectively).

CONCLUSION

The presence of microvascular invasion is an independent risk factor for recurrence in patients with PanNEN.