Prognostic value of platelet count and lymphocyte to monocyte ratio combination in stage IV non-small cell lung cancer with malignant pleural effusion

Impact of systemic immune-inflammation index and its evaluation of optimal threshold in patients with limited-stage small cell lung cancer: a retrospective study based on 572 cases

Background

Given the role of inflammation in cancer progression, the systemic immune-inflammation index (SII, defined as platelet × neutrophil/lymphocyte) has been suggested as an emerging prognostic marker in several solid malignant neoplasms. However, there are few studies on the prognostic value of SII in patients with limited-stage small cell lung cancer (LS-SCLC), and the optimal threshold of SII remains unclear in this population. This study calculated the optimal threshold of SII by a reasonable method and explored its association with survival outcomes.

Methods

This retrospective study reviewed clinical data of 572 patients with LS-SCLC. The threshold for SII was determined using an outcome-based method by maximizing the log-rank test statistic and the survival differences. Continuous time-dependent receiver operating characteristic curves (time-dependent ROC curves) were used to clarify the predictive ability of SII.

Results

The thresholds of SII for overall survival (OS) and progression-free survival (PFS) were both 760.6, based on which patients were divided into low [292 cases (51.0%)] and high [280 cases (49.0%)] SII groups. The area under the time-dependent ROC curves of SII in 12-, 24-, and 36-months were 0.727, 0.708, and 0.680, respectively. The overall median OS and PFS were 26.0 months [95% confidence interval (CI): 23.8-28.2] and 13.0 months (95% CI: 11.3-14.7), respectively. Significantly improved OS [35.0 (95% CI: 30.0-40.0) vs. 19.0 months (95% CI: 17.1-20.9), P<0.001] and PFS [20.0 (95% CI: 17.3-22.7) vs. 11.0 months (95% CI: 9.9-12.1), P<0.001] was seen in the low SII group than that in the high SII group. In the multivariable survival analysis, SII remained an independent prognostic factor for OS [hazard ratio (HR): 1.699; 95% CI: 1.374-2.100; P=0.001] and PFS (HR: 1.482; 95% CI: 1.214-1.809; P<0.001).

Conclusions

Our study demonstrates that elevated SII is an independent adverse prognostic factor for LS-SCLC.

[Predictive Value of Prognostic Nutritional Index in Prognosis and Spontaneous Pleurodesis of Patients with Advanced Non-small Cell Lung Cancer and Malignant Pleural Effusion]

BACKGROUND

A prognostic nutritional index (PNI) developed by nutritional status and inflammation are closely associated with poor prognosis in malignant tumors. However, the predictive impact of PNI in patients with malignant pleural effusion (MPE) remains inconclusive. The study aimed to determine the predictive value of PNI in prognosis and spontaneous pleurodesis among patients with MPE.

METHODS

The patients diagnosed with advanced non-small cell lung cancer (NSCLC) with MPE in West China Hospital between January 2015 and December 2022 were reviewed and allocated randomly to development set(60%) and validation set(40%). After collecting clinical data, peripheral blood inflammation indices and calculating systemic inflammation indices, the effects of PNI on prognosis and spontaneous pleurodesis have been evaluated by Cox proportional hazards models, Kaplan-Meier method and Nelson-Aalen cumulative risk curve.

RESULTS

In total, 261 patients diagnosed NSCLC with MPE were selected (development set: n=157; validation set: n=104), of whom 58.2% were aged <65 years, 53.6% were male and 95.8% were diagnosed with adenocarcinoma. The dichotomous cut-off value for PNI was 44.1, respectively. Compared with lower PNI (PNI<44.1) cases, patients with higher PNI (PNI≥44.1) showed significantly longer overall survival (36.5 vs 24.3 mon, P=0.02) and higher incidence of spontaneous pleurodesis (P=0.009). According to the multivariate Cox analysis, higher PNI was associated with good prognosis and successful spontaneous pleurodesis (P<0.05). According to the results of Cox regression analysis, the PNI-prognosis and PNI-spontaneous pleurodesis models are determined, the receiver operating characteristic (ROC) curves are drawn, and the area under the curves (AUC) value of development set are 0.694 (95%CI: 0.620-0.776) and 0.673 (95%CI: 0.590-0.737).

CONCLUSIONS

PNI is a reliable biomarker of prognosis and spontaneous pleurodesis in patients with MPE. Attention to the patient's nutritional status and inflammation may improve the prognosis and efficacy of pleural effusion.

Prognostic Value of the Noble and Underwood Score in Patients with Non-Small Cell Lung Cancer Undergoing Surgical Resection

Background: This retrospective study aimed to evaluate the clinical utility of the Noble and Underwood (NUn) score as a prognostic marker for overall survival (OS) in patients with stage I to IIIA non-small cell lung cancer (NSCLC). The NUn score is a novel composite marker that integrates C-reactive protein (CRP), serum albumin (ALB) levels, and white blood cell (WBC) count to provide a comprehensive assessment of systemic inflammation and nutritional status. Methods: We included patients with stage I to IIIA NSCLC and assessed the NUn score, calculated using CRP, ALB levels, and WBC count. Hazard ratios for OS were determined using Cox regression analysis. The predictive performance of the models was evaluated through metrics such as area under the curve (AUC), concordance index (C-index), integrated AUC (iAUC), integrated discrimination improvement (IDI), continuous net reclassification index (cNRI), and decision curve analysis (DCA). Results: The median age of the patients was 69 years, and 63.1% of patients were men. The cohort included 152 (63.1%) patients with stage I disease, 54 (22.4%) with stage II disease, and 35 (14.5%) with stage IIIA disease. In the multivariate Cox regression analysis, the NUn score, age, American Society of Anesthesiologists Physical Status, tumor-node-metastasis (TNM) stage, and pleural invasion emerged as independent prognostic factors for OS, forming the NUn model. The C-index and iAUC of the NUn model (0.832 and 0.802, respectively) outperformed those of the baseline model based solely on TNM stage. The NUn model also demonstrated superior discriminative capacity compared with the baseline model using metrics such as AUC, IDI, cNRI, and DCA at 3 and 5 years after surgery. Calibration of the nomogram based on the NUn model showed good accuracy. Conclusions: These findings underscore the prognostic significance of the NUn score in predicting OS among patients with stage I to IIIA NSCLC by integrating markers of inflammation and nutritional status. The NUn model, which integrates the NUn score with other clinical variables, exhibited superior discriminative ability compared with TNM stage alone. These findings highlight the potential of the NUn score as a valuable tool in personalized care for patients with NSCLC. Further external validation with independent cohorts is necessary to confirm the model's applicability to other populations.

Clinical significance of postoperative thrombocytosis after vats lobectomy for NSCLC

OBJECTIVES

Thrombocytosis is a clinical condition generally associated with poor prognosis in patients with cancer. Thrombocytosis may be present after lung cancer resection, but the clinical significance of thrombocytosis remains unclear. Herein, we evaluated whether postoperative thrombocytosis was a negative prognostic factor in patients undergoing thoracoscopic lobectomy for lung cancer.

METHODS

It was a retrospective monocentric study including consecutive patients undergoing thoracoscopic lobectomy for lung cancer from January 2020 to January 2023. The outcome of patients with postoperative thrombocytosis (defined as platelet count ≥ 450 × 10^9/L at 24 h after the surgery and confirmed at postoperative day 7) was compared with a control group. Postoperative morbidity, mortality, and survival were compared between the two groups to define whether thrombocytosis negatively affected outcomes.

RESULTS

Our study population included 183 patients; of these, 22 (12%) presented postoperative thrombocytosis: 9 (5%) mild thrombocytosis (451-700 × 10^9/L), 10 (5%) moderate thrombocytosis (701-900 × 10^9/L), and 3 (2%) severe thrombocytosis (901-1000 × 10^9/L). No significant differences were found regarding postoperative morbidity (p = 0.92), mortality (p = 0.53), overall survival (p = 0.45), and disease-free survival (p = 0.60) between the two study groups. Thrombocytosis was associated with higher rate of atelectasis (36% vs. 6%, p < 0.001) and residual pleural effusion (31% vs. 8%, p = 0.0008). Thrombocytosis group was administered low-dose acetylsalicylic acid for 10 days and no thrombotic events were observed. In all cases the platelet count returned to be within normal value at postoperative day 30.

CONCLUSIONS

Postoperative thrombocytosis seems to be a transient condition due to an inflammatory state and it does not affect the surgical outcome and survival after thoracoscopic lobectomy.

The potential of high-order features of routine blood test in predicting the prognosis of non-small cell lung cancer

BACKGROUND

Numerous studies have demonstrated that the high-order features (HOFs) of blood test data can be used to predict the prognosis of patients with different types of cancer. Although the majority of blood HOFs can be divided into inflammatory or nutritional markers, there are still numerous that have not been classified correctly, with the same feature being named differently. It is an urgent need to reclassify the blood HOFs and comprehensively assess their potential for cancer prognosis.

METHODS

Initially, a review of existing literature was conducted to identify the high-order features (HOFs) and classify them based on their calculation method. Subsequently, a cohort of patients diagnosed with non-small cell lung cancer (NSCLC) was established, and their clinical information prior to treatment was collected, including low-order features (LOFs) obtained from routine blood tests. The HOFs were then computed and their associations with clinical features were examined. Using the LOF and HOF data sets, a deep learning algorithm called DeepSurv was utilized to predict the prognostic risk values. The effectiveness of each data set's prediction was evaluated using the decision curve analysis (DCA). Finally, a prognostic model in the form of a nomogram was developed, and its accuracy was assessed using the calibration curve.

RESULTS

From 1210 documents, over 160 blood HOFs were obtained, arranged into 110, and divided into three distinct categories: 76 proportional features, 6 composition features, and 28 scoring features. Correlation analysis did not reveal a strong association between blood features and clinical features; however, the risk value predicted by the DeepSurv LOF- and HOF-models is significantly linked to the stage. Results from DCA showed that the HOF model was superior to the LOF model in terms of prediction, and that the risk value predicted by the blood data model could be employed as a complementary factor to enhance the prognosis of patients. A nomograph was created with a C-index value of 0.74, which is capable of providing a reasonably accurate prediction of 1-year and 3-year overall survival for patients.

CONCLUSIONS

This research initially explored the categorization and nomenclature of blood HOF, and proved its potential in lung cancer prognosis.

A Novel Clinical Prognostic Model for Breast Cancer Patients with Malignant Pleural Effusion: Avoiding Chemotherapy in Low-Risk Groups?

Purpose

Malignant pleural effusion (MPE) is a severe complication in patients with advanced cancer that is associated with a poor prognosis. Breast cancer is the second leading cause of MPE after lung cancer. We therefore aim to describe clinical characteristics of the patients with MPE combined with breast cancer and construct a machine learning-based model for predicting the prognosis of such patients.

Methods

This study is a retrospective and observational study. Least absolute shrinkage and selection operator (LASSO) and univariate Cox regression analyses were applied to identify eight key clinical variables, and a nomogram model was established. Model performance was evaluated by receiver operating characteristic (ROC) curve, calibration curve, and decision curve analyses.

Results

196 patients with both MPE and breast cancer (143 in the training group and 53 in the ex-ternal validation group) were analyzed in this study. The median overall survival in two cohorts was 16.20 months and 11.37 months. Based on the ROC curves for 3-, 6-, and 12-month survival, the areas under the curves were 0.824, 0.824, and 0.818 in the training set and 0.777, 0.790, and 0.715 in the validation set, respectively. In the follow-up analysis, both systemic and intrapleural chemotherapy significantly increased survival in the high-risk group compared to the low-risk group.

Conclusion

Collectively, MPE confers a poor prognosis in breast cancer patients. We have developed a first-ever survival prediction model for breast cancer patients with newly diagnosed MPE and validated the model using an independent cohort.

Investigation of poor predictive factors in extensive stage small cell lung cancer under etoposide-platinum-atezolizumab treatment

BACKGROUND

The phase III trial IMpower133 showed that platinum and etoposide plus atezolizumab was associated with improved overall survival (OS) and progression free-survival (PFS) when compared to the placebo group in treatment-naïve extensive stage (ES) small cell lung cancer (SCLC). Due to superiority in clinical outcomes, combination immunotherapy plus chemotherapy have become mainstay treatment modalities as first-line treatment in ES-SCLC. Nevertheless, real-world data are still lacking and the search for potential biomarkers is essential. This study aimed to evaluate potential predictive biomarkers applicable in ES-SCLC under combination therapy.

METHODS

Patients with ES-SCLC under etoposide-platinum-atezolizumab enrolled from seven university hospitals affiliated to the Catholic University of Korea were evaluated. Pretreatment clinical parameters were evaluated for association with OS and PFS. Adverse events (AEs) during induction and maintenance phases were also evaluated. p-values below 0.05 were considered statistically significant.

RESULTS

A total of 41 patients were evaluated. Six-month survival was 68.6%. As best response to treatment, 26 (63.4%) showed partial response, nine (22.0%) showed stable disease, and four (9.8%) showed progressive disease. During the induction phase, grade I-II AEs occurred in 22 (53.7%) patients, and grade III-IV AEs occurred in 26 (63.4%) patients. During the maintenance phase, nine out of 25 (36.0%) patients experienced any grade AEs. In multivariate analysis for OS, lactate dehydrogenase (LDH), c-reactive protein (CRP), and forced vital capacity (%) were significant factors. In multivariate analysis for PFS, sex, and LDH were significant.

CONCLUSION

In ES-SCLC under etoposide-platinum-atezolizumab, pretreatment CRP, LDH and FVC (%) were independent predictive factors.

Use of Platelet Parameters in the Differential Diagnosis of Lung Adenocarcinoma-Associated Malignant Pleural Effusion and Tuberculous Pleural Effusion

Background

Both malignant pleural effusion (MPE) and tuberculous pleural effusion (TPE) are common etiologies of pleural effusion; the present study was conducted to establish the diagnostic value of platelet parameters in the differential diagnosis of MPE and TPE.

Methods

This retrospective study enrolled patients with lung adenocarcinoma-associated MPE and TPE. Platelet parameter data, including platelet count (PLT), mean platelet volume (MPV), plateletcrit (PCT), platelet distribution width (PDW), and platelet-larger cell ratio (P-LCR), were collected. Principal component analysis and multiple logistic regression modelling were carried out to assess the diagnostic value of these platelet parameters.

Results

The MPE group and the TPE group enrolled 270 and 433 patients, respectively. Demographic characteristics of patients were more female and higher age in the MPE group. MPV, PDW, and P-LCR were significantly higher in MPE patients, while PLT and PCT were significantly higher in TPE patients. Principal component analysis generated two principal components (PCs) based on above platelet parameters. After adjusting for confounding factors including gender and age, multiple logistic regression showed positive association between PC1 and MPE.

Conclusion

Platelet parameters were potential biomarkers in distinguishing lung adenocarcinoma-associated MPE from TPE. A patient with lower PLT and PCT and higher MPV, PDW, and P-LCR was more likely to be diagnosed as the former. Principal component analysis and multiple logistic regression performed well in improving multicollinearity, adjusting confounding factors, and identifying important risk factors for MPE.

Systemic Immune Activation and Responses of Irradiation to Different Metastatic Sites Combined With Immunotherapy in Advanced Non-Small Cell Lung Cancer

Purpose

Considering the limited data, we aimed to identify the greatest immune activation irradiated site of common metastases and response to immune checkpoint inhibitors simultaneously in non-small cell lung cancer (NSCLC).

Methods

A total of 136 patients with advanced NSCLC who had received radiation to a primary or metastatic solid tumor were enrolled. We recorded blood cell counts in three time periods, before, during, and after radiotherapy (RT), and derived some blood index ratios including monocyte-to-lymphocyte ratio (MLR), neutrophil-to-lymphocyte ratio (NLR), platelet-to-lymphocyte ratio (PLR), and systemic immune-inflammation index (SII). The delta-IBs were calculated as medio-IBs ÷ pre-IBs − 1. We analyzed the changes before and during RT using Spearman rank correlation test, Kruskal–Wallis rank sum test, and logistic regression analyzing their correlation with efficacy.

Results

The medians of delta-MLR and delta-PLR were both the lowest while the median of delta-L was the highest in brain. Therapeutic effect evaluation showed that the objective response rate (ORR) of 48.65% (18/37) in the brain irradiation group was the highest, compared with 17.07% (7/41) in bone and 41.94% (13/31) in lung.

Conclusions

In this study, results suggested that irradiation to brain has the best immune activation effect and patient outcome compared with other organs in NSCLC, and when the earlier-line ICIs were combined with RT, a better patient outcome was reached. Prospective studies are also necessary to provide more convincing evidence and standards for clinical irradiation metastases selection.

Prognostic significance of thrombocytosis in lung cancer: a systematic review and meta-analysis

A potential relationship between poor prognosis and thrombocytosis has been suggested by previous studies in lung cancer, but the conclusions continued to be controversial. Here, we performed a meta-analysis to explore the prognostic impact of thrombocytosis in lung cancer. The Cochrane Library, EMBASE and PubMed databases were comprehensively and systematically retrieved from establishment to May 5, 2020. Pooled hazard ratios (HRs) with 95% confidence intervals (CIs) were applied to evaluate overall effects. Heterogeneity was assessed using I² statistics and Cochran's Q test. Sensitivity and subgroup analyses were performed to analyze the sources of heterogeneity. Publication bias was examined using the Egger's test and pooled HR was regulated using the trim-and-fill approach when publication bias was observed. A total of 37 studies including 14,833 patients were enrolled in the meta-analysis. Thrombocytosis was significantly correlated to poor overall survival (HR 1.033; 95% CI 1.017-1.050), disease-free survival (HR 1.568; 95% CI 1.276-1.928), and progression-free survival (HR 1.653; 95% CI 1.069-2.556). Although publication bias was identified, rectification for this bias using the trim-and-fill approach did not change the combined HR substantially. In conclusion, this meta-analysis result suggested that thrombocytosis is a predictor of poor prognosis in lung cancer.

Pleural Neutrophil-to-Lymphocyte Ratio May Be Associated With Early Disease Progression in Stage IV Non-small Cell Lung Cancer

BACKGROUND/AIM

While blood neutrophil-to-lymphocyte ratio (NLR) has been associated with poor prognosis in NSCLC, however few studies have focused on pleural fluid white blood cell differential count. We conducted a retrospective multicenter cohort study to evaluate the predictive value of pleural NLR in non-small cell lung cancer (NSCLC) patients with malignant pleural effusion (MPE).

PATIENTS AND METHODS

From the multicenter lung cancer cohort, 134 epidermal growth factor receptor (EGFR) wild-type patients with NSCLC were selected for evaluation. Receiver operating characteristic (ROC) curve analysis was performed for pretreatment pleural NLR to determine the cut-off value for predicting disease progression within 100 days after the diagnosis.

RESULTS

The low-pleural NLR group showed significantly longer overall survival (OS) and progression free survival (PFS) compared to the high-pleural NLR group. After stratification using quartile cut-off values of pleural NLR, the correlation between risk of disease progression and pleural NLR was shown to be dose-dependent. The multivariate analysis on PFS showed that high-pleural NLR (p=0.004) was an independent predictor for shorter PFS with HR of 1.036 (1.011-1.061).

CONCLUSION

Increased pleural NLR is predictive of early disease progression in EGFR mutation wild-type NSCLC patients with MPE.

Clinical significance of C-Reactive Protein to Lymphocyte Count Ratio as a prognostic factor for Survival in Non-small Cell Lung Cancer Patients undergoing Curative Surgical Resection

Purpose: We assessed the clinical feasibility of C-reactive protein to lymphocyte ratio (CLR) as a determinant of survival in patients with non-small cell lung cancer (NSCLC) undergoing curative surgical resection. Methods: A retrospective study was conducted on patients with stage I and II NSCLC undergoing curative resection. Demographic and clinical variables, including CLR, were collected and analyzed. The Cox proportional hazards model was used to calculate hazard ratios for overall survival (OS) and cancer-specific survival (CSS). The Mann-Whitney U test was used to compare differences between two independent groups. Results: The median age of the patients was 69.0 years, and male patients comprised 63.9% of all patients. A total of 164 (75.9%) patients were categorized as having stage I disease and 52 (24.1%) as having stage II disease. Using the multivariate Cox model, age (hazard ratio [HR] 1.08, p<0.001), lymphatic invasion (HR 3.12, p=0.004), stage (HR 5.10, p<0.001), and CLR (HR 1.01, p=0.003) were significant determinants of OS. In addition, age (HR 1.11, p=0.002), lymphatic invasion (HR 3.16, p=0.010), stage (HR 6.89, p<0.001), and CLR (HR 1.05, p=0.002) were significant determinants of CSS. Conclusions: Our findings show that CLR could be a determinant of survival in NSCLC patients undergoing curative surgical resection.

Predictability of early changes in derived neutrophil-to-lymphocyte ratio and neutrophil-to-lymphocyte ratio in patients with advanced non-small cell lung cancer treated with immune checkpoint inhibitors

Background

As association between systemic inflammation and disease progression has been suggested, early changes in neutrophil-to-lymphocyte ratio (NLR) and derived NLR (dNLR) may have accurate predictability for prognosis in non-small cell lung cancer (NSCLC) treated with ICI therapy.

Methods

Complete blood count (CBC) was measured immediately before the first and second cycles of ICI therapy in patients with advanced NSCLC. Differences in NLR and dNLR were measured. When the increase in NLR was ≥1, the patient was classified into the increased NLR group. Similarly, when the increase in dNLR was ≥1, the patient was classified into the increased dNLR group; otherwise, they were classified into the non-increased NLR or dNLR group.

Results

A total of 89 patients was selected for evaluation. Median progression-free survival (PFS) was significantly shorter in the increased NLR group than in the non-increased NLR group (2.6 vs. 9.5 months, P<0.001). The increased dNLR group showed significantly shorter median PFS than the non-increased dNLR group (4.2 vs. 9.2 months, P=0.001). Association with PFS was analyzed using the Cox regression model. In model 1, increase ≥1 in NLR showed significant association (HR =3.085, 95% CI, 1.657–5.742, P<0.001). In model 2, increase ≥1 in dNLR showed significant association (HR =2.826, 95% CI, 1.436–5.561, P=0.003).

Conclusions

Early changes in dNLR were shown to have prognostic value in patients undergoing immunotherapy. It can be an accurate and a comprehensive biomarker for predicting ICI response.

Prognostic Value of Pretreatment Lymphocyte-to-Monocyte Ratio in Lung Cancer: A Systematic Review and Meta-Analysis

BACKGROUND

The overall prognosis of lung cancer remains unfavorable and novel prognostic biomarkers of lung cancer are needed warranted. Accumulating evidence indicate that systemic inflammation plays a vital role in lung cancer. The lymphocyte-to-monocyte ratio (LMR) is biomarker that reflects the level of systemic inflammation.

OBJECTIVE

To perform a comprehensive meta-analysis exploring the correlation of pretreatment LMR with the overall survival (OS) and progression-free survival (PFS) of lung cancer patients.

METHODS

We conducted searches of the PubMed, Embase, Cochrane Library, and Web of Science databases to May 2020 to identify relevant studies and calculated combined hazard ratios (HRs) to evaluate the association between pretreatment LMR and survival time in patients with lung cancer.

RESULTS

A total of 23 studies comprising 8361 lung cancer patients were included. Among the patients, 5702 (68%) were males, 4548 were current smokers and 2212 were diagnosed with squamous carcinoma. The pooled analysis revealed that decreased pretreatment LMR was significantly correlated with reduced of PFS (HR = 1.49, 95% CI: 1.34-1.67, p < 0.01) and reduced OS (HR = 1.61, 95% CI: 1.45-1.79, p < 0.01) among lung cancer patients. Furthermore, in the subgroup analyses according to histologic type, a lower level of pretreatment LMR seemed to be unrelated to the poorer OS of small cell lung cancer (SCLC) patients (HR = 1.21, 95%CI: 0.87-1.67, P = 0.25).

CONCLUSIONS

Decreased pretreatment LMR in peripheral blood was associated with shorter OS and PFS in lung cancer patients, suggesting its potential prognostic value.

Impact of Combined Chronic Obstructive Pulmonary Disease Status and Systemic Inflammation on Outcome of Advanced NSCLC: Multicenter Retrospective Cohort Study

Background

In patients with non-small cell lung cancer (NSCLC), both chronic obstructive pulmonary disease (COPD) and systemic inflammatory biomarkers, such as neutrophil-lymphocyte ratio (NLR) and platelet-lymphocyte ratio (PLR), have significant association with prognosis. NLR and PLR also predict mortality in patients with COPD alone. A combination of the two parameters may be helpful in a more individualized approach for predicting prognosis in NSCLC.

Methods

Medical records of patients with stage IIIB and IV NSCLC from January 2012 to January 2018 in seven university hospitals were reviewed. Patients were categorized into four subgroups based on pulmonary function test results and cutoffs for NLR or PLR.

Results

A total of 277 patients were evaluated and categorized into non-COPD and COPD groups; 194 patients were in the non-COPD group and 83 patients were in the COPD group. The non-COPD group showed significantly longer overall survival (OS) compared with the COPD group (P = 0.019). Median survival was significantly different between high/low PLR groups (P < 0.001), between high/low NLR groups (P = 0.001), and between high/low c-reactive protein (CRP) groups (P < 0.001). PLR, NLR and CRP showed significant correlations with each other. PLR showed a significant negative linear correlation with FVC (absolute) (r = −0.149, P = 0.015), FVC (%) (r = −0.192, P = 0.002), DLCO (absolute) (r = −0.271, P < 0.001), DLCO (%) (r = −0.139, P = 0.032), and NLR (r = 0.718, P < 0.001). In the multivariate analysis, the high PLR, COPD sub-group showed significantly higher risk for mortality (HR 2.066 (1.175–3.633), P = 0.012) compared with the low-PLR non-COPD group. However, COPD-NLR subtype was not an independent predictor for OS.

Conclusion

A combination of COPD status and PLR may be a cost-effective and readily available prognostic marker in patients with advanced NSCLC.

Potential predictive value of change in inflammatory cytokines levels subsequent to initiation of immune checkpoint inhibitor in patients with advanced non-small cell lung cancer

For a definite indication for immunotherapy, finding appropriate biomarkers that are predictive of treatment responses is necessary. Inflammatory cytokines which play critical roles in immunity against infectious sources or cancer cells are suggested to activate immune cells after initiation of immune checkpoint inhibitors (ICI). Through activation of immune cells such as T cells, natural killer cells, macrophages, or tumor infiltrating dendritic cells, inflammatory cytokines usually increase after programmed death (PD)-1/PD-L1 axis blockade. There have been several studies evaluating the predictive value of early changes in inflammatory cytokines in non-small cell lung cancer (NSCLC) patients undergoing immunotherapy. In this mini-review, we went through recent articles on potential blood level values of inflammatory cytokines in NSCLC patients receiving ICI and their early change around commencement of ICIs in predicting response to treatment and disease progression. The studies evaluated cytokines including interleukin (IL)-2, 6, 8, interferon (IFN)-γ, and tumor necrosis factor (TNF)-α for predictability for responses to ICI. A combination cytokine panel can help predict the response and prognosis of patients with NSCLC who are receiving ICI treatment. Furthermore, a more individualized ICI treatment will be available if responses and change in tumor burden can be predicted. However, most of the studies on cytokines in NSCLC patients receiving ICIs had a small number of patients, and the heterogeneous measurement time points. Nevertheless, cytokines such as IL-8 and IFN- γ have considerable potential predictive value for immunotherapy response, which is worthy of further studies. To utilize blood cytokines levels as biomarkers for immunotherapy, a larger study with uniform measurement protocol is necessary.

Effects of reduced platelet count on the prognosis for patients with non-small cell lung cancer treated with EGFR-TKI: a retrospective study

BACKGROUND

Progressive lung cancer is associated with abnormal coagulation. Platelets play a vital part in evading immune surveillance and angiogenesis in the case of tumor metastasis. The study aimed to analyze the predictive and prognostic effects of platelet count on non-small cell lung cancer (NSCLC) patients treated with epidermal growth factor receptor tyrosine kinase inhibitors (EGFR-TKIs).

METHODS

This study retrospectively analyzed the prognostic effects of platelets on 52 NSCLC patients with epidermal growth factor receptor (EGFR) mutant following EGFR-TKI treatment. Related data, together with the progression-free survival (PFS) and overall survival (OS) were collected before and after 2 cycles of treatments (60 days).

RESULTS

The anti-EGFR treatment markedly reduced the platelet count in 33 (63.5%) patients after 2 cycles of treatment. Multivariate Cox analysis revealed that, the decreased platelet count was closely correlated with the longer OS (HR = 0.293; 95%CI: 0.107-0.799; p = 0.017). Besides, the median OS was 326 days in the decreased platelet count group and 241 days in the increased platelet count group (HR = 0.311; 95%CI: 0.118-0.818; P = 0.018), as obtained from the independent baseline platelet levels and other clinical features.

CONCLUSIONS

The platelet count may predict the prognosis for EGFR-TKI treatment without additional costs. Besides, changes in platelet count may serve as a meaningful parameter to establish the prognostic model for NSCLC patients receiving anti-EGFR targeted therapy.

Integration of platelet features in blood and platelet rich plasma for detection of lung cancer

OBJECTIVES

To determine whether the integration platelet features in blood and platelet rich plasma can establish a model to diagnose lung cancer and colon cancer, even differentiate lung malignancy from lung benign diseases.

METHODS

245 individuals including 159 lung cancer and 86 normal participants were divided into the training cohort and testing cohort randomly. Then, 32 colon cancers, 37 lung cancers, and 21 benign patients were enrolled into validate cohort. The whole blood and corresponding platelet rich plasma (PRP) samples from all participants were prospectively collected, and the platelet features were determined. The features which are statistically significant at the univariate analysis in the training cohort and reported significant features were entered the diagnostic model. A receiver operator characteristic (ROC) curve was drawn to evaluate the accuracy of the model in each cohort.

RESULTS

In the training cohort, multiple platelet features were significantly different in lung cancer patients, including MPV in whole blood, MPV, and platelet count in PRP and platelet recovery rate (PRR). For the training cohort, the diagnostic model for lung cancer performed well (AUC = 0.92). The probability distribution of lung cancers and controls in testing cohort were also separated well by the diagnostic model (AUC = 0.79). The diagnostic model for colon cancer also performed well (AUC = 0.79). The model also has a potential value in differentiating the lung malignancy from the benign (AUC = 0.69).

CONCLUSION

The PRR was first raised and used in the detection of lung cancer. This study identified a diagnostic model based on PRR and other platelet features in whole blood and PRP samples with the potential to distinguish patients with lung cancer or colon cancer from healthy controls. The model could also be used to distinguish between lung cancer from the benign disease.

Malignant pleural effusion survival prognostication in an Asian population

BACKGROUND AND OBJECTIVE

LENT and PROMISE scores prognosticate survival in patients with MPE. Prognostication guides the selection of interventions and management. However, the predictive value of these scores and their refinements (modified-LENT) in Asians remain unclear. We aim to evaluate the performance of LENT, modified-LENT and clinical PROMISE scores; identify predictors of survival; and develop an alternative prognostication tool should current scores lack accuracy.

METHODS

Retrospective medical record review of an Asian pleuroscopy database from 2011 to 2018 of patients with MPE was conducted. The prognostic capability of current available scores were evaluated using C-statistics. Demographic and clinical variables as predictors of survival were assessed, and an alternative model was developed using logistic regression.

RESULTS

In 130 patients, the C-statistics for modified-LENT was not significantly different from LENT (0.59 (95% CI: 0.52-0.67) vs 0.56 (95% CI: 0.49-0.63); P = 0.403). In 57 patients, the PROMISE C-statistics was 0.72 (95% CI: 0.53-0.91). In our alternative prognostication model (n = 147), Sex, Eastern Cooperative Oncology Group status, Leukocyte count, EGFR mutation, Chemotherapy and primary Tumour type (SELECT) were predictors of 90-day mortality (C-statistic = 0.87 (95% CI: 0.79-0.95)). SELECT sensitivity, specificity, positive and negative predictive values, and positive and negative likelihood ratios using a predicted probability of 90-day mortality cut-off point of 10% were 0.91, 0.68, 0.34, 0.98, 2.83 and 0.13, respectively.

CONCLUSION

The LENT, modified-LENT and PROMISE scores have poor accuracy of survival prognostication in Asian patients with MPE undergoing pleuroscopy. The proposed SELECT prognostication model is accurate at identifying patients with high probability of survival at 90 days.

The combination of platelet count and lymphocyte to monocyte ratio is a prognostic factor in patients with resected breast cancer

Many inflammation indicators have been reported to be related with patient outcomes in various cancers. Previous studies have evaluated the combination of platelet (PLT) and lymphocyte to monocyte ratio (COP-LMR) as a systemic inflammatory marker for prognostication in lung cancer, yet its prognostic role among breast cancer patients remains unclear.In the present study, a total of 409 breast cancer patients with surgical resection were retrospectively investigated. The receiver operating characteristic (ROC) curve was used to choose the optimal cut-off value of PLT and lymphocyte to monocyte ratio (LMR). Patients were classified into 3 groups according to the score of COP-LMR, and its relationship with various clinicopathological factors and breast cancer prognosis were further evaluated.The ROC curve analysis showed that COP-LMR had a higher area under the ROC curve for the prediction of 5-year disease-free survival and overall survival than PLT or LMR alone. Multivariable analysis showed that an elevated COP-LMR was an independent predictor of poor disease-free survival (P = .032) and overall survival (P = .005). Subgroup analysis revealed that COP-LMR was still significantly associated with prognosis in both luminal A and luminal B subtypes.Preoperative COP-LMR is a potential prognostic factor in breast cancer patients who underwent surgery.

Controlling Nutritional Status (CONUT) score is a prognostic factor in patients with resected breast cancer

The present study aimed to determine the correlation between controlling nutritional status (CONUT) and prognosis in resected breast cancer patients. Totally, 861 breast cancer patients with surgical resection in West China Hospital of Sichuan University between 2007 and 2010 were included. The relationship between CONUT and various clinicopathological factors as well as prognosis was evaluated. The results showed that the optimal cutoff value for CONUT to predict the 5-year survival was 3 and CONUT had a higher area under the ROC curve (AUC) for 5-year disease free survival (DFS) and overall survival (OS) prediction compared with the neutrophil lymphocyte ratio (NLR) and prognostic nutritional index (PNI). High CONUT was significantly correlated with older age, lymph node involvement, advanced T-stage, and surgery type. In the multivariate analysis, CONUT-high patients had worse DFS and OS, when compared with CONUT-low patients. In conclusion, preoperative CONUT is a useful marker for predicting long term outcomes in breast cancer patients after curative resection.

Tumour cell PD-L1 expression is prognostic in patients with malignant pleural effusion: the impact of C-reactive protein and immune-checkpoint inhibition

Malignant pleural effusion (MPE) confers dismal prognosis and has limited treatment options. While immune-checkpoint inhibition (ICI) proved clinical efficacy in a variety of malignancies, data on the prognostic role of PD-L1 in MPE is scarce. We retrospectively studied PD-L1 tumour proportion score and Ki-67 index in pleural biopsies or cytologies from 123 patients (69 lung cancer, 25 mesothelioma, and 29 extrathoracic primary malignancies). Additionally, the impact of C-reactive protein (CRP) and platelet count was also analysed. Median overall survival (OS) after MPE diagnosis was 9 months. Patients with PD-L1 positive tumours (≥1%) had significantly shorter OS than patients with negative PD-L1 status (p = 0.031). CRP and Ki-67 index were also prognostic and remained independent prognosticators after multivariate analysis. Interestingly, Ki-67 index and CRP influenced the prognostic power of PD-L1. Finally, patients receiving ICI tended to have a longer median OS and CRP - but not PD-L1 - was a significant prognosticator in this subgroup. In summary, histological and circulating biomarkers should also be taken into account as potential biomarkers in ICI therapy and they may have an impact on the prognostic power of PD-L1. Our findings might help personalizing immune-checkpoint inhibition for patients with MPE and warrant further prospective validation.

High Systemic Immune-Inflammation Index (SII) Represents an Unfavorable Prognostic Factor for Small Cell Lung Cancer Treated with Etoposide and Platinum-Based Chemotherapy

PURPOSE

Systemic immune-inflammation index (SII) has been demonstrated to be closely associated with prognosis of a series of solid tumors. However, its role in small cell lung cancer (SCLC) remains poorly understood. The present study aims to evaluate the prognostic significance of pretreatment SII in SCLC treated with etoposide and platinum-based chemotherapy.

METHODS

Sixty hundred and fifty-three newly diagnosed SCLC patients were enrolled. The optimal cut-off values for SII and LDH (lactate dehydrogenase) were obtained by a receiver operating characteristic (ROC) curve analysis. Overall survival (OS) was assessed by univariate and multivariate analyses.

RESULTS

The optimal cut-off values of pretreatment SII and LDH were 748.51 × 10⁹/L and 188.5 U/L, respectively. High pretreatment SII was significantly associated with advanced tumor stage (limited disease, LD vs. extensive disease, ED; 26.3% vs 46.5%; p < 0.001). On univariate analysis, age < 65 years, female, non-smoker, limited disease, SII < 748.51 × 10⁹/L, LDH < 188.5 U/L, distant metastasis numbers < 2, chemotherapy + radiotherapy, and chemotherapy + surgery were closely correlated with a prolonged OS (p < 0.05). The median OS for patients in high SII group was 12.0 months, compared with that of 17.0 months for patients in low SII group. Multivariate analysis showed smoking history (p = 0.014), tumor stage (p < 0.001), pretreatment SII (p < 0.001), LDH (p = 0.002), distant metastasis numbers (p = 0.006), and chemotherapy + radiotherapy (p < 0.001) were independent prognostic factors of OS. Furthermore, SII remained prognostic significance for SCLC stratified by variable subgroups analysis.

CONCLUSION

Pretreatment SII represents a powerful prognostic biomarker for SCLC patients treated with etoposide and platinum-based chemotherapy. It is significant for treatment strategy making in clinics.

Prognostic Value of Pretreatment Lymphocyte-to-Monocyte Ratio in Non-Small Cell Lung Cancer: A Meta-Analysis

Past evidence has shown that lymphocyte-to-monocyte ratio (LMR) could be considered as a potential prognostic factor in non-small cell lung cancer (NSCLC). We conducted the current meta-analysis based on published studies to elucidate the prognostic value of pretreatment LMR on survival outcomes in NSCLC. Comprehensive searches of available electronic databases were implemented to identify potentially related studies that focused on the role of pretreatment LMR in predicting the prognosis of NSCLC patients. The hazard ratios (HRs) with 95% confidence intervals (CIs) were combined to assess the association of pretreatment LMR with overall survival (OS) and progression-free survival (PFS). A total of 20 articles including 8,304 patients were analyzed. Compared with patients with higher LMR, patients with lower LMR had poorer OS (HR = 1.63, 95% CI: 1.44-1.85, p < 0.001) and PFS (HR = 1.49, 95% CI: 1.25-1.77, p < 0.001). The subgroup analysis outcomes were similar to the overall analysis. Pretreatment LMR may be a useful prognostic marker in patients with NSCLC. However, more well-designed studies are warranted to confirm our findings.

High systemic immune-inflammation index represents an unfavorable prognosis of malignant pleural mesothelioma

Background: Malignant pleural mesothelioma (MPM) represents a fatal disease with high aggressiveness, and limited biomarkers have yet been identified for MPM. The present study aims to explore potential serum prognostic factors of MPM.

Materials and methods: A retrospective analysis of 97 pathologically diagnosed MPM was performed. The optimal cutoff value of pretreatment systemic immune–inflammation index (SII) was determined by receiver operating characteristic curve. Kaplan–Meier curves and Cox regression analysis were performed to assess the potential prognostic roles of parameters.

Results: A total of 59.8% (n=58) patients are male, with a median age of 56.0 years (range 18–77). The optimal cutoff value of SII was 988.6×10⁹/L. High and low SII were found in 44 (45.4%) and 53 (54.6%) patients, respectively. Median survival time for total 97 cases was 18.5 months. The median overall survival for patients with low and high SII was 47.0 and 13.0 months, respectively. The 1-, 2- and 3-year survival rates for patients with low SII were 85.8%, 57.8% and 52.0% compared to that of 53.9%, 23.6% and 13.8% in patients with high SII. On univariate analysis, Eastern Cooperative Oncology Group performance status (ECOG PS)<2 points, low SII and adjuvant treatment (P<0.05) were found to be closely correlated with a better prognosis of MPM. Only ECOG PS (P=0.036) and SII (P=0.009) held statistical significance on multivariate analysis.

Conclusion: Pretreatment SII is easy to access to, and it represents an efficiency and noninvasive biomarker of MPM. High SII represents an unfavorable independent prognostic factor of MPM, and this needs to be validated in further studies.

Elevated pretreatment platelet-to-lymphocyte ratio is associated with poor survival in stage IV non-small cell lung cancer with malignant pleural effusion

A higher platelet-to-lymphocyte ratio (PLR) has a clinical correlation with shorter survival in non-small cell lung cancer (NSCLC). The present study evaluated the association between the PLR and survival in patients with advanced NSCLC with malignant pleural effusion (MPE). Between January 2012 and July 2016, 237 patients with stage IV NSCLC were selected for evaluation. Receiver operating characteristic analysis was used to determine a cutoff for the PLR. Clinicopathological characteristics were compared between the high and low PLR groups, and the role of PLR as a predictive/prognostic maker was investigated. Among the 237 patients, 122 were assigned to the low PLR group and the other 115 to the high PLR group. According to multivariate analysis, male sex, not receiving active anticancer treatment, low hemoglobin level, low albumin level, high C-reactive protein level, and high PLR were identified as significant risk factors for shorter overall survival (OS) (p = 0.010, <0.001, 0.011, 0.004, 0.003, and <0.001, respectively). In the subgroup multivariate analysis of driver mutation-negative NSCLC, high Eastern Cooperative Oncology Group score, not receiving active anticancer treatment, low hemoglobin level, high C-reactive protein level, and high PLR were identified as significant risk factors for shorter OS (p = 0.047, <0.001, = 0.036, = 0.003, and <0.001, respectively). A high pretreatment PLR is independently associated with poor survival in stage IV NSCLC with MPE and in a subgroup of epidermal growth factor receptor and anaplastic lymphoma kinase wild-type NSCLC.

Making cold malignant pleural effusions hot: driving novel immunotherapies

Malignant pleural effusions, arising from either primary mesotheliomas or secondary malignancies, heralds advanced disease and poor prognosis. Current treatments, including therapeutic thoracentesis and tube thoracostomy, are largely palliative. The immunosuppressive environment within the pleural cavity includes myeloid derived suppressor cells, T-regulatory cells, and dysfunctional T cells. The advent of effective immunotherapy with checkpoint inhibitors and adoptive cell therapies for lung cancer and other malignancies suggests a renewed examination of local and systemic therapies for this malady. Prior strategies reporting remarkable success, including instillation of the cytokine interleukin-2, perhaps coupled with checkpoint inhibitors, should be further evaluated in the modern era.

Combination of peripheral neutrophil-to-lymphocyte ratio and platelet-to-lymphocyte ratio is predictive of pathological complete response after neoadjuvant chemotherapy in breast cancer patients

The immune system seems to play a fundamental role in breast cancer responsiveness to chemotherapy. We investigated two peripheral indicators of immunity/inflammation, i.e. neutrophil to lymphocyte ratio (NLR) and platelet to lymphocyte ratio (PLR), in order to reveal a possible relationship with pathological complete response (pCR) in patients with early or locally advanced breast cancer treated with neoadjuvant chemotherapy (NACT). We retrospectively analyzed 373 consecutive patients affected by breast cancer and candidates to NACT. The complete blood cell count before starting NACT was evaluated to calculate NLR and PLR. ROC curve analysis determined threshold values of 2.42 and 104.47 as best cut-off values for NLR and PLR, respectively. The relationships between NLR/PLR and pCR, along with other clinical-pathological characteristics, were evaluated by Pearson's χ 2 or Fisher's exact test as appropriate. Univariate and multivariate analyses were performed using a logistic regression model. NLR and PLR were not significantly associated with pCR if analyzed separately. However, when combining NLR and PLR, patients with a NLR^low/PLR^low profile achieved a significantly higher rate of pCR compared to those with NLR^high and/or PLR^high (OR 2.29, 95% CI 1.22-4.27, p 0.009). Importantly, the predictive value of NLR^low/PLR^low was independent from common prognostic factors such as grading, Ki67, and molecular subtypes. The combination of NLR and PLR may reflect patients' immunogenic phenotype. Low levels of both NLR and PLR may thus indicate a status of immune system activation that may predict pCR in breast cancer patients treated with NACT.