Preoperative neutrophil-to-lymphocyte ratio as a prognostic predictor after curative-intent surgery for hepatocellular carcinoma: experience from a developing country

Prognostic value of neutrophil-to-lymphocyte ratio in patients with hepatocellular carcinoma receiving curative therapies: a systematic review and meta-analysis

BACKGROUND

Hepatocellular carcinoma (HCC) is one of the leading causes of cancer-related mortality worldwide. The prognostic significance of the neutrophil-to-lymphocyte ratio (NLR) in HCC patients has been extensively studied; however, the prognostic value of NLR in HCC patients undergoing curative treatment remains unclear.

OBJECTIVE

This systematic review and meta-analysis aimed to comprehensively evaluate the precise significance of preoperative and postoperative NLR in predicting the prognosis of HCC patients receiving curative treatment.

METHODS

We conducted a comprehensive search of the PubMed, Cochrane Library, Embase, and Web of Science databases from inception to August 2024. Studies that included univariate and multivariate analyses evaluating the association between NLR and survival outcomes in HCC patients undergoing resection, transplantation, or ablation were included. The prognostic value of NLR in HCC patients receiving curative treatment was analyzed by calculating pooled hazard ratios (HRs) and corresponding 95% confidence intervals (CIs).

RESULTS

A total of 43 studies involving 9,952 patients were included. Meta-analysis revealed that higher NLR was significantly associated with worse overall survival (OS) (HR = 1.55, 95% CI = 1.39-1.75, P < 0.001), recurrence-free survival (RFS) (HR = 1.77, 95% CI = 1.49-2.10, P < 0.001), and disease-free survival (DFS) (HR = 1.42, 95% CI = 1.25-1.63, P < 0.001) in HCC patients undergoing curative treatment. Subgroup analysis demonstrated a significant association between NLR and poor OS, independent of geographic region, type of survival analysis, preoperative or postoperative measurement, treatment modality, or NLR cutoff value. Publication bias and sensitivity analyses confirmed the robustness of these findings.

CONCLUSION

Elevated NLR is significantly associated with poorer OS, RFS, and DFS in HCC patients receiving curative treatment. Future research should focus on validating the optimal NLR threshold and exploring its predictive ability in different clinical settings.

Should lymphadenectomy be recommended in radical surgery of intrahepatic cholangiocarcinoma patients? A retrospective study

PURPOSE

Intrahepatic cholangiocarcinoma (ICC) is an extremely deadly cancer with high recurrence incidence, particularly in patients with lymph node metastasis (LNM). The necessity of lymphadenectomy including lymph node biology (LNB) and dissection (LND) during ICC radical surgery remains debate.

METHODS

We retrospectively analyzed the patients diagnosed with ICC and underwent radical surgery at the Cancer Hospital of the Chinese Academy of Medical Sciences from 2012 to 2023.

RESULTS

A total of 308 ICC patients were involved in this study. pLNM+ group had poorer OS (P < 0.0001) and poorer DFS (P < 0.0001) compared with pLNM- group. Compared to the LN- group, LN+ group exhibited worse OS (P = 0.038) and worse DFS (P = 0.003). After PSM and IPTW, compared with LN- group, LNB exhibited longer operation time (IPTW: P = 0.0024) and longer hospitalization days (IPTW: P = 0.0112) with no significant differences in complications, DFS, and OS. Compared with LN- group, LND group had no better DFS and OS, only more complications (IPTW: P = 0.0191), longer operation time (all P < 0.001), higher risk of bleeding (all P < 0.05), transfusion (IPTW: P = 0.014) and longer hospitalization days (IPTW: P = 0.0044). Compared with LNB group, LND had longer operation time (P = 0.0227), higher risk of bleeding (P = 0.017) and transfusion (P = 0.0321), and more postoperative complications (P = 0.0425), with no difference in DFS and OS.

CONCLUSION

Lymphadenectomy does not necessarily provide long-term survival or recurrence benefits. LND only achieves the effect of LNB while negatively affects postoperative recovery without survival benefit for ICC patients. LNB can be performed for accurate pathological staging while not all patients may require LND based on their specific circumstances.

Preoperative albumin-alkaline phosphatase ratio affects the prognosis of patients undergoing hepatocellular carcinoma surgery

BACKGROUND

The correlation between the preoperative albuminalkaline phosphatase ratio (AAPR) and the prognosis of hepatocellular carcinoma (HCC) patients after radical resection is still not comprehensive.

OBJECTIVE

This study aims to observe the correlation between preoperative AAPR and the prognosis of HCC patients after radical resection.

METHODS

We constructed a retrospective cohort study and included 656 HCC patients who underwent radical resection. The patients were grouped after determining an optimum AAPR cut-off value. We used the Cox proportional regression model to assess the correlation between preoperative AAPR and the prognosis of HCC patients after radical resection.

RESULTS

The optimal cut-off value of AAPR for assessing the prognosis of HCC patients after radical resection was 0.52 which was acquired by using X-tile software. Kaplan-Meier analysis curves showed that a low AAPR (⩽ 0.52) had a significantly lower rate of overall survival (OS) and recurrence-free survival (RFS) (P< 0.05). Multiple Cox proportional regression showed that an AAPR > 0.52 was a protective factor for OS (HR = 0.66, 95%CI 0.45-0.97, p= 0.036) and RFS (HR = 0.70, 95% CI 0.53-0.92, p= 0.011).

CONCLUSIONS

The preoperative AAPR level was related to the prognosis of HCC patients after radical resection and can be used as a routine preoperative test, which is important for early detection of high-risk patients and taking personalized adjuvant treatment.

Lung immune prognostic index‑based nomogram for recurrence of hepatocellular carcinoma after postoperative adjuvant TACE

BACKGROUND

Transarterial chemoembolization (TACE), one of the most commonly used postoperative adjuvant therapy for HCC, has achieved satisfactory outcomes. This study aimed to explore the prognostic value of lung immune prognostic index (LIPI) and develop a novel nomogram for recurrence-free survival (RFS) of HCC patients received postoperative adjuvant TACE (PA-TACE).

METHODS

The prognostic value of LIPI was evaluated by C-index, receiver operating characteristic (ROC) analysis, and Kaplan-Meier survival curve. An effective nomogram based on preoperative prognostic factors was established from multivariate analysis and validated in the validation cohort.

RESULTS

The ROC and survival analysis demonstrated that the LIPI exhibited better prediction performance of HCC recurrence than other inflammatory biomarkers. According to univariate and multivariate analysis, LIPI, followed by AFP, MVI and age, were significant independent predictors for HCC recurrence and were utilized to construct the nomogram. The C-indexes of the nomogram were 0.746 (95% CI 0.721-0.770) and 0.738 (95% CI 0.701-0.775) in the training and validation cohort, respectively. The AUCs for the 1-, 2-, and 3-year RFS were 0.799, 0.867 and 0.884 in the training cohort and 0.798, 0.779 and 0.770 in the validation cohort, respectively. The calibration curves presented good consistencies. Moreover, compared with the LIPI and other clinical staging system, the established nomogram presented better prognostic performance.

CONCLUSION

Preoperative LIPI might be a powerful predictor for RFS in HCC patients received PA-TACE. The LIPI-based nomogram could further effectively predict the risk of recurrence and help clinicians formulate personalized follow-up strategies and adjuvant therapy to improve patient outcomes.

Combination of Preoperative Circulating Tumor Cell Count and Neutrophil-Lymphocyte Ratio for Prognostic Prediction in Hepatocellular Carcinoma Patients after Curative Hepatectomy

Background

Both the preoperative neutrophil-lymphocyte ratio (NLR) and circulating tumor cell count (CTC) are associated with poor prognosis in hepatocellular carcinoma (HCC). The purpose of this study was to explore the prognostic value of these two indices (CTC-NLR) in HCC.

Methods

We retrospectively collected demographic and clinical data, including NLR and CTC, from 97 patients with HCC who underwent curative hepatectomy at our institution from March 2014 to May 2017. X-Tile software was used to confirm the optimal cut-off value of NLR and CTC for predicting overall survival (OS) in this study. OS were also analyzed using Kaplan-Meier and Cox regression methods. Based on preoperative CTC and NLR, patients were divided into three groups: CTC-NLR (0), CTC-NLR (1), and CTC-NLR (2). Relationships of CTC-NLR with clinicopathological factors and survival were evaluated.

Results

Preoperatively, CTC positively correlated with NLR. Patients with NLR and CTC higher than the cut-offs had shorter OS than patients with low NLR and CTC. Kaplan-Meier analysis, and log-rank tests revealed significantly lower OS among patients with CTC-NLR scores of 0, 1, and 2. Uni- and multivariate analyses showed that CTC-NLR (hazard ratio 2.050, P = 0.005), CTC (hazard ratio 2.285, P = 0.032), and NLR (hazard ratio 1.902, P = 0.048) were independent predictor of OS. A time-dependent ROC curve indicated that the prognostic efficacy of the CTC-NLR at 1 year (0.714) was better than that of NLR (0.687) and CTC (0.590); the prognostic efficacy of the CTC-NLR at 2 years (0.746) was better than that of NLR (0.711) and CTC (0.601); the prognostic efficacy of the CTC-NLR at 3 years (0.742) was better than that of NLR (0.694) and CTC (0.629).

Conclusions

HCC patients with higher NLR and CTC tend to show shorter OS. Preoperative CTC-NLR may be associated with poor survival and might be a reliable prognostic predictor in HCC after curative hepatectomy.

Usefulness of neutrophil-to-lymphocyte ratio (NLR) as a prognostic predictor after treatment of hepatocellular carcinoma." Review article

The neutrophil-to-lymphocyte ratio (NLR) is an inflammatory marker which has been investigated as a prognostic indicator in post-therapeutic recurrence and survival of patients with HCC. Our aim was to review all studies that assessed the prognostic value of pre-treatment NLR in predicting patient survival, cancer recurrence, and graft survival in patients undergoing various therapies for HCC. We searched the database of PubMed and Google Scholar to review all studies that have the word "NLR" and the word "HCC." We included all studies that assessed pre-treatment NLR as a prognostic factor in predicting outcomes in HCC patients. We excluded studies that assessed the correlation between post-treatment NLR or dynamic changes in NLR after treatment and HCC outcomes in an effort to minimize the confounding effect of each treatment on NLR. We reviewed 123 studies that studied the correlation between pre-treatment NLR and patient survival, 72 studies that evaluated the correlation between pre-treatment NLR and tumor recurrence, 21 studies that evaluated the correlation between NLR and tumor behavior, and 4 studies that assessed the correlation between NLR and graft survival. We found a remarkable heterogeneity between the methods of the studies, which is likely responsible for the differences in outcomes. The majority of the studies suggested a correlation between higher levels of pre-treatment NLR and poor outcomes. We concluded that NLR is a reliable and inexpensive biomarker and should be incorporated into other prognostic models to help determine outcomes following HCC treatment.

Liver transplantation for hepatocellular carcinoma: Improving eligibility without compromising outcomes

Background

In the context of liver transplantation for hepatocellular carcinoma (HCC), traditional transplant criteria appear restrictive. The objective of the current study was to determine risk factors for recurrence and improve transplant eligibility in patients with HCC.

Materials and methods

This was a retrospective study of patients who underwent living donor liver transplant (LDLT) for HCC (n = 219). Largest tumor diameter, tumor number, AFP and neutrophil to lymphocyte ratio were assessed. Multivariate analysis was performed to develop risk scores. The new model was compared with seven previously published transplant criteria using receiver operator curves.

Results

Largest tumor size >3.7 cm [HR:2.6, P = 0.02], and AFP > 600 ng/ml [HR:4.7, P = 0.001] were independent predictors of recurrence. Patients with risk scores of 0, 1–3, 4–6 and 7–9 had recurrence rate of 5.9%, 12.5%, 25% and 58.4% respectively. When compared with Milan criteria, Metro ticket 2.0, AFP model and Samsung criteria; transplant eligibility increased by 31.5%, 22.9%, 8.7%, and 7% respectively. Recurrence rate with the current model was 16/199 (8%) (P < 0.0001) and was comparable with other transplant criteria (6.9–9.1%). On ROC analysis, only Milan criteria (AUC = 0.7, P = 0.001) and the current model (AUC = 0.66, P = 0.01) showed significance for recurrence. All patients with high risk scores within Milan criteria had recurred at 3 years (P = 0.03).

Conclusions

Low AFP can be used to select patients for LDLT outside traditional criteria for HCC, with comparable recurrence rates.

•

There is an unmet need to expand transplant pool for hepatocellular carcinoma.

•

We developed a model, based on tumor size cutoff of 3.7 cm, any tumor number, and AFP cutoff of 600 ng/ml; and compared it with other transplant criteria.

•

There was considerable expansion in transplant pool with comparable outcomes.

Short- and Long-Term Outcomes After Hepatectomy in Elderly Patients with Hepatocellular Carcinoma: An Analysis of 229 Cases from a Developing Country

Background

The number of elderly patients with HCC who undergo liver resection is increasing. Because of the advanced age of the patients, increased postoperative morbidity and reduced overall survival are expected in this population. The study aim was to compare clinicopathologic and operative features, short- and long-term outcomes among hepatocellular carcinoma (HCC) patients from three age groups undergoing potentially curative liver resection in a developing country.

Methods

Prospectively collected data relating to 229 patients who underwent curative-intent liver resection from January 2009 until December 2018 were analyzed. The patients were divided into two age groups: G1 was below 70 years old (n=151) and G2 was 70 years old and older (n=78). Demographic, clinical, operative data, short- and long-term outcomes were compared between the two groups. Univariate and multivariate analyses of prognostic factors were performed.

Results

The mean overall morbidity rate of the patients was 31.1% (G1), and 46.2% (G2) by age group. Postoperative morbidity was significantly higher in the G2 group (p=0.03). There was no difference in major morbidity between the two groups (p=0.214). No significant difference in mortality rate and overall survival was found between the study groups (p=0.280, p=0.383). Both age ≥70 years (ie, G2 group) and liver cirrhosis were identified as prognostic factors for postoperative morbidity, and a Child-Pugh score B as a negative prognostic factor for overall survival. In subgroup analysis of patients with cirrhosis, age ≥70, diabetes mellitus and perioperative transfusion were identified as prognostic factors for postoperative morbidity.

Conclusion

The study confirmed the safety and feasibility of liver resection in elderly patients with HCC. However, appropriate patient selection among the elderly is mandatory in order to improve short- and long-term outcomes.

Liver resection versus transarterial chemoembolization for huge hepatocellular carcinoma: a propensity score matched analysis

To date, it is unclear which treatment modality, liver resection (LR) or transarterial chemoembolization (TACE) is the more appropriate for patients with huge (≥ 10 cm) hepatocellular carcinoma (HCC). The study aim was to compare, using propensity score matching, short- and long-term outcomes of patients with huge HCC who underwent potentially curative LR or TACE. Patients with huge HCC who had been managed at the Clinical Center by curative-intent LR or by palliative TACE between November 2001 and December 2018 were retrospectively identified. The morbidity and mortality rates and overall survival were compared between the groups before and after the propensity score matching. Independent predictors of long-term survival were determined by multivariate analysis. A total of 103 patients with huge HCC were included; 68 were assigned to the LR group and 35 to the TACE group. The overall morbidity rate was higher in the LR group than in the TACE group before matching (64.7% vs. 37.1%, p = 0.012), while there was no difference after matching (60% vs. 30%, p = 0.055). The major morbidity and 30-days mortality were similar between the groups before and after matching. The LR group was associated with longer overall survival than the TACE group before matching (p = 0.032) and after matching (p = 0.023). Total bilirubin and TACE treatment were independent prognostic factors associated with long-term survival. In patients with huge HCC, liver resection provides better long-term survival than TACE and should be considered as the initial treatment whenever possible.

The prognostic significance of inflammation-based scores in patients with ampullary carcinoma after pancreaticoduodenectomy

Background

Growing evidence indicates that the systemic inflammatory response plays an important role in cancer development and progression. Several inflammatory markers have been reported to be associated with clinical outcomes in patients with various types of cancer. This study was designed to evaluate the prognostic value of inflammatory indexes in patients with ampullary cancer (AC) who underwent pancreaticoduodenectomy (PD).

Methods

We retrospectively reviewed the data of 358 patients with AC who underwent PD between 2009 and 2018. R software was used to compare the area under the time-dependent receiver operating characteristic (ROC) curves (AUROCs) of the inflammation-based indexes, including the neutrophil-to-lymphocyte ratio (NLR), platelet-to-lymphocyte ratio (PLR), modified Glasgow Prognostic Score (mGPS), prognostic nutritional index (PNI) and prognostic index (PI), in terms of their predictive value for survival. The survival differences of these indexes were compared by the Kaplan-Meier method and univariate and multivariate analyses were performed to determine the prognostic factors of disease-free survival (DFS) and overall survival (OS).

Results

The estimated 1-, 2-, and 3-year OS and DFS rates were 83.9, 65.8, and 55.2% and 58.0, 42.8, and 37.8%, respectively, for the entire cohort. The survival differences were significant in terms of OS and DFS when patients were stratified by these inflammation-based indexes. The comparisons of the AUROCs of these inflammation-based indexes illustrated that NLR and PI displayed the highest prognostic value, compared to the other indexes. When NLR and PI were combined, NLR-PI showed even higher AUROC values and was identified as a significant prognostic factor for OS and DFS.

Conclusion

Specific inflammatory indexes, such as NLR, PLR and dNLR, were found to be able to predict the OS or DFS of patients. As a novel inflammatory index, the level of NLR-PI, which can be regarded as a more useful prognostic index, exhibited strong predictive power for predicting the prognosis of patients with AC after the PD procedure.

A comprehensive intervention on feasibility, efficacy, and safety between TAE combined with multi-applicator ablation therapy and TACE in the treatment of large hepatocellular carcinoma

BACKGROUND

Hepatocellular carcinoma (HCC) is one of the most common tumors in recent days with high mortality and low early diagnosis rate, resulting in the fourth leading cause of deaths globally. This study aimed to evaluate the feasibility, efficacy, and safety between transcatheter arterial embolization (TAE) therapy followed by multi-applicator ablation and transarterial chemoembolization (TACE) for the treatment of large HCC.

METHODS

An intervention study conducted at the Cancer Center of Sun Yat-sen University, Guangzhou, China, with whom had large HCC. A comparison between the two groups (intervention and control group) was evaluated at different time dimensions by repeated-measures analysis of variance, Mann-Whitney U rank-sum test, where Kaplan-Meier and log-rank test calculated for the overall survival (OS), tumor response (TR), and progression-free survival (PFS).

RESULTS

This study found the improved survival rate (SR) and PFS after 1-year treatment in the observation group (Group-I) by 56.4% and 12.8%, compared to 38.3% and 8.5% in the control group (Group-II). Likewise, 1- and 2-year OS rates (OSRs) in Group-I were 66.7% and 51.4%, wherein Group-II were 48.9% and 30.0%, respectively. The short-term efficacy of Group-I, such as complete response (CR), partial response (PR), stable disease (SD), progressive disease (PD) were 28.21%, 56.41%, 0, 15.38%, while in Group-II was 2.13%, 68.79%, 6.38% 22.70% respectively, which were significant. The short-term efficacy was more excellent in the Group-I than Group-II. The quality of life (QOL) was better in Group-I than that of Group-II.

CONCLUSIONS

TAE combined with multi-applicator ablation therapy is safer, effective with prolonged survival, and less severe adverse reactions compared to TACE therapy for the treatment of large HCC.

Prognostic Significance of Preoperative Gamma-Glutamyltransferase to Alkaline Phosphatase Ratio in Hepatocellular Carcinoma Patients with Curative Liver Resection: A Retrospective Cohort Study

Purpose

Gamma-glutamyltransferase (GGT) and alkaline phosphatase (ALP) were involved in the development and progression of cancers. This study aimed to evaluate the prognostic value of a preoperative GGT:ALP ratio (GAR) in hepatocellular carcinoma (HCC) patients with curative liver resection.

Patients and Methods

A total of 380 HCC patients underwent curative liver resection before December 2017 and from January to December 2018 were included and stratified into training set and validation set, respectively. Prediction accuracy was evaluated by the area under the receiver operating characteristic curve (AUC). Factors determined to be significant for overall survival (OS) and tumor-free survival (TFS) by using Cox regression analysis. The Kaplan–Meier method and Log rank test were utilized for survival analysis.

Results

The AUC of GAR was 0.70 (P < 0.001). An optimal cut-off value of 0.91 yielded a sensitivity of 78.1% and a specificity of 60.4% for GAR (P < 0.001), which stratified the HCC patients into high-risk (>0.91) and low-risk (≤ 0.91) groups. Time-dependent ROC revealed that the AUCs for 1-, 3-, and 5-year OS predictions for GAR were 0.60, 0.69 and 0.62, respectively. In addition, GAR was identified as an independent risk factor for OS and TFS both in training and validation cohort by univariate and multivariate Cox regression analysis, as well as a good prognostic indicator for patients with Barcelona Clinic Liver Cancer stage C or without vascular invasion. Notably, the AUC of the GAR for survival was better than several potential prognostic indices (P < 0.05).

Conclusion

We identified the GAR as a prognostic indicator in two independent cohorts of HCC patients with curative liver resection. The patients with decreased GAR score were significantly associated with better OS and TFS.

Neutrophil to lymphocyte ratio and albumin bilirubin grade in hepatocellular carcinoma: A systematic review

BACKGROUND

Hepatocellular carcinoma (HCC) is a frequent cause of cancer related death globally. Neutrophil to lymphocyte ratio (NLR) and albumin bilirubin (ALBI) grade are emerging prognostic indicators in HCC.

AIM

To study published literature of NLR and ALBI over the last five years, and to validate NLR and ALBI locally in our centre as indicators of HCC survival.

METHODS

A systematic review of the published literature on PubMed of NLR and ALBI in HCC over the last five years. The search followed the guidelines of the preferred reporting items for systematic reviews and meta-analyses. Additionally, we also investigated HCC cases between December 2013 and December 2018 in our centre.

RESULTS

There were 54 studies describing the relation between HCC and NLR and 95 studies describing the relation between HCC and ALBI grade over the last five years. Our local cohort of patients showed NLR to have a significant negative relationship to survival (P = 0.011). There was also significant inverse relationship between the size of the largest HCC nodule and survival (P = 0.009). Median survival with alpha fetoprotein (AFP) < 10 KU/L was 20 mo and with AFP > 10 KU/L was 5 mo. We found that AFP was inversely related to survival, this relationship was not statically significant (P = 0.132). Mean survival for ALBI grade 1 was 37.7 mo, ALBI grade 2 was 13.4 months and ALBI grade 3 was 4.5 mo. ALBI grades performed better than Child Turcotte Pugh score in detecting death from HCC.

CONCLUSION

NLR and ALBI grade in HCC predict survival better than the conventional alpha fetoprotein. ALBI grade performs better than Child Turcotte Pugh score. These markers are done as part of routine clinical care and in cases of normal alpha fetoprotein, these markers could give a better understanding of the patient disease progression. NLR and ALBI grade could have a role in modified easier to learn staging and prognostic systems for HCC.

Clinical efficacy of atorvastatin calcium combined with aspirin in patients with acute ischemic stroke and effect on neutrophils, lymphocytes and IL-33

Clinical efficacy of atorvastatin calcium combined with aspirin in patients with acute ischemic stroke (AIS) and its effect on neutrophils to lymphocytes ratio (NLR) and interleukin-33 (IL-33) were investigated. In total, 108 patients with AIS in Luoyang Central Hospital Affiliated to Zhengzhou University from April 2016 to October 2017 were selected. There were 56 cases treated with atorvastatin calcium combined with aspirin as the observation group, and 52 cases were treated with aspirin alone as the control group. The clinical effect was observed. The NLR and IL-33 levels were measured by routine blood test and enzyme linked immunosorbent assay (ELISA) before and after treatment. The scores of the National Institutes of Health Stroke scale (NIHSS) and the occurrence of complications were collected before and after treatment in the two groups. Modified Rankin Scale (MRS) was used to evaluate the curative effect. Score ≤2 points is effective in the treatment. Pearson's analysis was used to analyze the correlation between NLR, IL-33 and NIHSS score. The total hospitalization time and 1 year survival rate were compared. The total effective rate of treatment in the observation group was higher than that in the control group (P<0.05). There was no difference in NLR and IL-33 levels between the two groups before treatment (P>0.05). After treatment, the NLR in the observation group was significantly lower than that in the control group (P<0.05). After treatment, the NIHSS score, the total number of complications and the total hospitalization time in the observation group were significantly lower than those in the control group (P<0.05). Pearson's analysis showed a positive correlation between NLR and NIHSS score (r=0.681, P<0.001), and a negative correlation between IL-33 and NIHSS score (r=-0.708, P<0.001). In conclusion, atorvastatin calcium combined with aspirin has a better effective rate in the treatment of acute ischemic stroke than aspirin alone. The combination can better reduce the NLR, increase the expression level of IL-33 in serum, reduce the occurrence of complications and hospitalization time, and increase the survival rate of patients.

Acute rejection after liver transplantation is less common, but predicts better prognosis in HBV-related hepatocellular carcinoma patients

BACKGROUND

With a novel finding of significantly lower incidence of acute rejection (AR) in patients with hepatocellular carcinoma (HCC) after liver transplantation, compared with those with benign end-stage liver disease (BESLD), in a large national cohort, we analyzed the correlations among the perioperative immuno-inflammation status, postoperative AR, and prognosis in HCC and BESLD patients with same etiology of hepatitis B virus (HBV), who underwent liver transplantation.

METHODS

Patients who underwent liver transplantation due to HBV-related HCC or BESLD and experienced AR between September 2008 and April 2017 were analyzed retrospectively and followed up until April 2018. HCC patients with AR were matched with those without AR according to tumor stage and immunosuppressant concentration, at a 1:3 ratio. Preoperative immuno-inflammation status and prognosis of patients in both groups were compared.

RESULTS

The overall incidences of AR in patients with HCC and BESLD were 8.60% and 10.61%, respectively. The postoperative 28-day incidence of AR was significantly lower in HCC compared with BESLD patients (3.23% vs 7.08%, p = 0.031). Compared with BESLD patients, the rejection activity index and perioperative CD₄/CD₈ ratio were significantly lower (p = 0.047 and p < 0.001, respectively), while platelet/lymphocyte ratio was significantly higher in HCC patients (p = 0.041). Later tumor stage in HCC patients was associated with higher systemic immuno-inflammation index, neutrophil/lymphocyte ratio, monocyte/lymphocyte ratio, platelet/lymphocyte ratio, aspartate aminotransferase/lymphocyte ratio, C-reactive protein/albumin ratio and fibrinogen level, and lower CD₄/CD₈ ratio before transplantation. In HCC patients with AR, the percentage of regulatory T cells (CD₄⁺/CD₂₅⁺) and the level of IL-10 significantly decreased (p = 0.0023, < 0.0001, respectively), while Th1/Th2 ratio, levels of IFN-γ and IL-2 markedly increased before transplantation (p = 0.0018, 0.0059, 0.0416, respectively). Preoperative monocyte/lymphocyte ratio was an independent risk factor for overall and recurrence-free survival after liver transplantation in HCC patients (p = 0.025, < 0.001, respectively). The 1-, 3-, and 5-year survival rates were 76%, 71% and 53% in the AR group, and 67%, 37% and 25% in the non-AR group (p = 0.042).

CONCLUSION

Preoperative tumor-related immunosuppression may persist after liver transplantation in HCC patients, and reduce the incidence of AR. AR after liver transplantation may indicate a better prognosis in HCC patients.

Prognostic Value of Albumin-to-Alkaline Phosphatase Ratio in Hepatocellular Carcinoma Patients Treated with Liver Transplantation

Background: The albumin-to-alkaline phosphatase ratio (AAPR) is a newly developed index which was used to predict prognosis of HCC patients. However, its prognostic role in HCC patients undergoing liver transplantation (LT) remains unclear. This study aimed to investigate the correlation between AAPR and prognosis of these patients. Methods: A total of 210 patients who underwent LT from January 2003 to January 2014 were retrospectively analyzed (149 for discovery and 61 for validation). Univariate and multivariate analyses were performed to determine the discriminative ability of the AAPR in predicting long-term survival. The area under the receiver operating characteristic (AUC) was calculated to compare the accuracy of different factors. Results: Patients with high AAPR level were associated with less ascites rate (30.6% versus 53.2%, P=0.033) as well as more frequencies of Child-Pugh class A (73.6% versus 35.1%, P=0.001). Univariate and multivariate analyses suggested the AAPR was independent prognostic factor in predicting overall survival (HR: 0.585, 95% CI: 0.363-0.941, P=0.027). Validation cohort confirmed prognostic value of AAPR. Subgroup analysis demonstrated that reduced AAPR level was associated with worse prognosis in HCC patients categorized in Child-Pugh class A (P=0.029). The AUCs of the AAPR were 0.710 and 0.744 in predicting 3-year and 5-year survival outcomes, respectively. Conclusions: The study showed in two independent cohorts of HCC patients treated by LT that elevated AAPR was associated with better OS. As a low-cost routine laboratory test, it should be considered as biomarker in the clinical management of HCC.

Prognostic Value Of The Preoperative Neutrophil To Lymphocyte Ratio In Patients With Sinonasal Squamous Cell Carcinoma

Objective

This study explored the effectiveness of a new inflammatory prognostic system, using preoperative neutrophil to lymphocyte ratio (NLR) to predict the postoperative survival rate of patients with sinonasal squamous cell carcinoma (SSCC).

Methods

Patients diagnosed with SSCC who undergone surgically treated without neoadjuvant therapy were included in the study between May 2008 and October 2017. Preoperative NLR is defined as: preoperative neutrophil/postoperative lymphocyte ratio. The prognostic value was uncovered by univariate and multivariate Cox hazards analysis.

Results

A total of 147 patients were included in this study. Through the multivariate analysis, pathological T stage (hazard ratio [HR] 1.719, confidence interval [CI] 1.277–3.642, p<0.001), pathological N stage (HR 1.344, 95% CI 1.015–2.776, p<0.001), and preoperative NLR (HR 1.579, 95% CI 1.217–3.092, p=0.002) were independent risk factor for overall survival (OS). Pathological T stage (HR 1.835, 95% CI 1.141–3.132, <0.001), pathological N stage (HR 1.281, 95% CI 1.169–2.476, p<0.001), and preoperative NLR (HR 1.688, 95% CI 1.162–3.363, p p<0.001) were also independently associated with disease-free survival (DFS). Pathological T stage (HR p<0.001, 95% CI 1.537–3.021, p<0.001), pathological N stage (HR1.571, 95% CI 1.157–2.258, p<0.001), and preoperative NLR (HR 1.509, 95% CI 1.153–3.104, p=0.001) were independent risk factors for disease-specific survival (DSS).

Conclusion

The preoperative NLR is considered to be a useful predictor of postoperative survival in SSCC patients.

Prognostic Significance of Pre-surgical Combined Platelet Count and Neutrophil-Lymphocyte Ratio for Patients With Hepatocellular Carcinoma

BACKGROUND/AIM

Recent studies have investigated a novel inflammation-based prognostic system using the combination of platelet count and neutrophil-lymphocyte ratio (COP-NLR). As platelet count decreases with liver damage, we hypothesized that COP-NLR could indicate both inflammation and hepatic reserve in patients with hepatocellular carcinoma (HCC). This study was conducted to clarify the prognostic significance of preoperative COP-NLR in patients with HCC.

PATIENTS AND METHODS

We enrolled 176 patients with histologically-proven HCC who underwent initial curative hepatectomy. Patients were assigned one point each for low platelet count (<15×104/μl) or for high NLR (≥2.0), for hepatic-COP-NLR scores (h-COP-NLR) of 0, 1 or 2.

RESULTS

Five-year overall survival (OS) and recurrence-free survival (RFS) rates were 74.5±9%, and 62.2%±9.3% for score 0, 63.6±5.4% and 50.3%±5.6% for score 1, and 45.2±8.8% and 40.6±8.7% for score 2, respectively, and significantly differed (OS: p=0.01; RFS: p=0.03). In multivariate analysis, h-COP-NLR was an independent risk factor for tumor recurrence (HR=1.39, p=0.03) and death (HR=1.71, p=0.02).

CONCLUSION

h-COP-NLR was an independent predictor for prognosis of HCC patients after hepatic resection.

Expression and significance of ETFDH in hepatocellular carcinoma

The ETFDH (electron transfer flavoprotein dehydrogenase) gene mutations are reported to be a major cause of riboflavin-responsive multiple acyl-coenzyme A dehydrogenation deficiency (MADD). However, the role of ETFDH in the prognosis of hepatocellular carcinoma (HCC) remains unclear. The aim of this study was to investigate the expression of ETFDH in HCC. Immunohistochemical staining of the 207 HCC tissue microarray showed that expression of ETFDH was significantly decreased in HCC compared with the matching noncancerous hepatic tissues (P < 0.001). Moreover, ETFDH expression levels were found to be correlated with AFP levels (P = 0.011). Intriguingly, ETFDH expression levels were significantly lower in poorly differentiated or undifferentiated HCCs as compared to the well or moderately differentiated cases (P =  0.001). Kaplan-Meier analysis revealed that low tumor expression of ETFDH was associated with a poorer overall survival in patients with HCC (P =  0.024). Furthermore, multivariate analysis showed that ETFDH (P =  0.047) was an independent predictor of overall survival. Our findings may shed new light on the identification of new prognostic marker for HCC.

Elevated Controlling Nutritional Status (CONUT) Score is Associated with Poor Long-term Survival in Patients with Low-grade Soft-tissue Sarcomas Treated with Surgical Resection

BACKGROUND

Several studies have examined the Controlling Nutritional Status (CONUT) score, which is a screening tool for nutritional status and an effective biomarker for patient survival after cancer treatment. However, its role in soft-tissue sarcoma (STS) remains unknown. Because of the lack of predictive markers for survival in patients with STS, we aimed to determine the CONUT score's association with survival.

QUESTIONS/PURPOSES

(1) Is there a relationship between the CONUT score and clinicopathologic characteristics such as tumor size, tumor location, pathological grade, and advanced stage based on the American Joint Committee on Cancer (AJCC) guidelines? (2) Is the CONUT score associated with disease-free survival (DFS) and overall survival (OS) in patients treated surgically for STS, even when compared with other systemic inflammatory response markers?

METHODS

Between 1999 and 2016, 769 patients underwent R0 resection for STS at our institution. Adequate medical records and available followup data were required for inclusion in this study. Exclusion criteria were synchronous inflammatory diseases, unplanned excision, and neoadjuvant therapy. There were 658 patients (86%) who fulfilled all criteria. The minimum followup time was 24 months (median, 103 months; range, 61-147 months). The median age of the patients was 43 years (range, 5-85 years), and 265 patients (40%) were women. All patients had Stage I to IV tumors according to the 8 edition of the AJCC staging system. The grade classification was determined to be G1 in 130 patients (20%), G2 in 304 (46%), and G3 in 201 (31%). The CONUT score was calculated based on the serum albumin concentration, total peripheral lymphocyte count, and total cholesterol concentration. The score ranged from 0 to 12, with higher scores indicating worse nutritional status. The patients were classified into two groups according to a receiver operating characteristic curve analysis: the high (≥ 2) and low (0 or 1) CONUT score groups. There were 435 patients in the low CONUT score group and 223 in the high CONUT score group. We tested for an association between the CONUT scores and gender, age, tumor diameter, tumor depth, tumor grade, and AJCC stage using the chi-square and Fisher's exact methods. We also compared the strength of the association between postoperative survival and the CONUT scores, neutrophil-to-lymphocyte ratio (NLR), and platelet-to-lymphocyte ratio (PLR) using multivariate Cox proportional hazard model analyses.

RESULTS

High CONUT scores were associated with large tumor size (odds ratio [OR], 1.47; 95% CI, 1.06-2.04; p = 0.020), deep tumor location (OR, 1.66; 95% CI, 1.17-2.36; p = 0.004), high tumor grade (OR, 2.54; 95% CI, 1.56-4.14; p = 0.001), and advanced AJCC stage (OR, 1.86; 95% CI, 1.14-3.02; p < 0.001). The low CONUT score group exhibited a higher 5-year OS rate and longer OS than the high CONUT score group (82% versus 65%; odds ratio, 2.45; 95% CI, 1.27-4.72; p < 0.001; 81 versus 64 months, Z = -2.56; p < 0.001). A multivariate analysis indicated that an elevated CONUT score was an independent predictor of OS (hazard ratio [HR], 1.86; 95% CI, 1.47-4.14; p < 0.001) and DFS (HR, 1.63; 95% CI, 1.26-2.11; p < 0.001), but the NLR and PLR were not. In an individual subgroup analysis, the CONUT scores were associated with OS and DFS in the tumor diameter (< 5 or ≥ 5 cm) subgroup, tumor depth (superficial or deep) subgroup, tumor grade (G1 and G2) subgroup, and AJCC stage (I/II or III/IV) subgroup, but not in the G3 subgroup (p = 0.051 and p = 0.065).

CONCLUSION

High CONUT scores were independently associated with aggressive tumor behavior and unfavorable survival for patients with low-grade, but not high-grade, resected STS. If these findings can be substantiated in larger studies, the CONUT score might be useful for predicting survival and help to develop new treatment strategies for nutrition interventions.

LEVEL OF EVIDENCE

Level III, therapeutic study.

Construction and comprehensive analysis of a ceRNA network to reveal potential prognostic biomarkers for hepatocellular carcinoma

Background

Long noncoding RNAs (lncRNAs) can act as microRNA (miRNA) sponges to regulate protein-coding gene expression; therefore, lncRNAs are considered a major part of the competitive endogenous RNA (ceRNA) network and have attracted growing attention. The present study explored the regulatory mechanisms and functional roles of lncRNAs as ceRNAs in hepatocellular carcinoma (HCC) and their potential impact on HCC patient prognosis.

Methods

In this study, we systematically studied the expression profiles and prognostic value of lncRNA, miRNA, and mRNA from a total of 838 HCC patients from five HCC cohorts (TCGA, GSE54236, GSE76427, GSE64041 and GSE14520). The TCGA, GSE54236 and GSE76427 HCC cohorts were utilized to establish a prognosis-related network of dysregulated ceRNAs by bioinformatics methods. The GSE64041 and GSE14520 HCC cohorts were utilized to verify the expression of candidate genes.

Results

In total, 721 lncRNAs, 73 miRNAs, and 1563 mRNAs were aberrantly expressed in HCC samples. A ceRNA network including 26 lncRNAs, four miRNAs, and six mRNAs specific to HCC was established. The survival analysis showed that four lncRNAs (MYCNOS, DLX6-AS1, LINC00221, and CRNDE) and two mRNAs (CCNB1 and SHCBP1) were prognostic biomarkers for patients with HCC in both the TCGA and GEO databases.

Conclusion

The proposed ceRNA network may help elucidate the regulatory mechanism by which lncRNAs function as ceRNAs and contribute to the pathogenesis of HCC. Importantly, the candidate lncRNAs, miRNAs, and mRNAs involved in the ceRNA network can be further evaluated as potential therapeutic targets and prognostic biomarkers for HCC.

Electronic supplementary material

The online version of this article (10.1186/s12935-019-0817-y) contains supplementary material, which is available to authorized users.

The prognostic and predictive value of the combination of the neutrophil-to-lymphocyte ratio and the platelet-to-lymphocyte ratio in patients with hepatocellular carcinoma who receive transarterial chemoembolization therapy

Purpose

This study was designed to evaluate the prognostic value of the combination of neutrophil-to-lymphocyte ratio (NLR) and platelet-to-lymphocyte ratio (PLR) (neutrophil/platelet-to-lymphocyte ratio [NLR–PLR]) in patients with hepatocellular carcinoma (HCC) who receive transarterial chemoembolization (TACE) therapy.

Patients and methods

Data from 216 patients who were diagnosed with HCC after TACE therapy were retrospectively collected. R software was used to analyze the time-dependent receiver operating characteristic (ROC) curves and to compare the area under the ROC curves (AUROCs).

Results

The long-term survival rates were significantly higher for patients with lower values than those with higher values of NLR, PLR, and NLR–PLR. The mean overall survival decreased gradually with increases in the NLR–PLR score (P<0.0001). The AUROC values of the NLR–PLR score were consistently higher than those of NLR and PLR.

Conclusion

This study showed that the NLR–PLR score might be a useful predictor for patients with HCC who receive TACE therapy.

Utility and Limitation of Preoperative Neutrophil Lymphocyte Ratio as a Prognostic Factor in Hepatocellular Carcinoma

Background

The neutrophil lymphocyte ratio (NLR) has been proposed to be a surrogate marker of inflammation and immunological status and to have prognostic value in various malignancies. This study was conducted to clarify the prognostic significance of preoperative NLR in hepatocellular carcinoma (HCC).

Methods

We enrolled 135 patients with histologically-proven HCC who underwent initial curative hepatectomy. Based on the median NLR values, patients were divided into: NLR ≥ 2.0 (NLR-high, n = 69) and NLR < 2.0 (NLR-low, n = 66).

Results

In univariate analysis, the 5-year overall survival (OS) rates were 59.8 % ± 6.7% and 75.6% ± 6.5% (P = 0.028) in the NLR-high and NLR-low groups, respectively. Furthermore, the 5-year disease specific survival rates were 68.6% ± 6.7%, and 81.2 ± 6.4% (P = 0.048) in the NLR-high and NLR-low groups, respectively.

Conclusion

Our results showed that high NLR was an independent predictor for OS in hepatectomy-treated HCC, suggesting that NLR may be a novel prognostic biomarker for HCC. On the other hand, NLR also has a limitation to predict postoperative prognosis of HCC patients by itself.

Perspectives: Neutrophil-to-lymphocyte Ratio as a Potential Biomarker in Immune Checkpoint Inhibitor for Non-Small-Cell Lung Cancer

There is a rising need for optimal biomarkers to better tailor treatments for patients with cancer in the era of immunotherapy. In addition to programmed death-ligand 1 (PD-L1) and tumor mutation burden (TMB), neutrophil-to-lymphocyte (NLR) is regaining interest as a biomarker in immunotherapy for its availability, accessibility, and reproducibility. High NLR, according to different thresholds, is consistently reported to correlate with poor prognosis in different treatments in several cancers. Yet, most data come from retrospective analysis, and proof of mechanism and principle evaluations are limited. Prospective studies or adequately sized retrospective analyses of prospectively collected data are required to best assess its role in clinical practice. Moreover, effective myeloid or neutrophil modulators in tumor microenvironment can potentially contribute as a new therapeutic strategy. This perspective will summarize our current knowledge and will discuss where we stand now and propose future directions.

Preoperative albumin-to-globulin ratio as a significant prognostic indicator in urologic cancers: a meta-analysis

Background

Emerging studies reported that preoperative albumin-to-globulin ratio (AGR) correlated with tumor progression and prognosis in several types of cancer. The aim of this study was to systematically explore the association between preoperative AGR and clinical outcomes in cancers of the urinary system.

Methods

Relevant articles were searched in PubMed, Embase and Web of Science by two independent investigators from inception to June 1, 2018. Eligible studies were selected based on predetermined selection criteria. Summarized HRs or ORs and 95% CIs were calculated for prognosis and clinicopathologic features with the fixed-effects or random-effects models.

Results

Eight cohort studies comprising 2,668 patients were included for analysis. The pooled results showed that a low AGR significantly correlated with poor OS (HR: 0.38, 95% CI: 0.27-0.48, P<0.001), worse cancer-specific survival (CSS) (HR: 0.36, 95% CI: 0.22-0.50, P<0.001) and inferior event-free survival (EFS) (HR: 0.36, 95% CI: 0.25-0.48, P<0.001) in urologic cancers. In addition, patients in low and high AGR groups showed significant differences in lymphovascular invasion (P<0.001), pT status (P<0.001) and pN status (P<0.001).

Conclusion

Preoperative AGR might be a valuable, cheap and reproducible prognostic bio-marker in urologic cancers following surgical resection.