Clinical Significance of Pre-treated Neutrophil-Lymphocyte Ratio in the Management of Urothelial Carcinoma: A Systemic Review and Meta-Analysis

Monitoring trends in the absolute lymphocyte count and the neutrophil-to-lymphocyte ratio in patients with breast cancer receiving eribulin

BACKGROUND

Studies have shown that the absolute lymphocyte count (ALC) and the neutrophil-to-lymphocyte ratio (NLR) are related to the outcomes in patients with breast cancer receiving specific chemotherapies. However, the reports have focussed on the initial blood test and there is a lack of evidence or data to support that dynamic changes of ALC or NLR are associated with the patients' survival outcomes.

METHODS

We retrospectively reviewed electronic medical records from patients with breast cancer treated with eribulin from 2015 to 2019 at our institution. Blood test data were available prior to starting eribulin (baseline), and at 1, 3 and 6 months after initiating eribulin. We classified the patients into ALC and NLR high and low groups using the following cut-offs: 1000/µl for ALC and 3 for NLR. We defined ALC and NLR trends as increasing or decreasing compared with the initial data. We assessed the associations between the ALC and NLR with progression-free survival and overall survival.

RESULTS

There were 136 patients with breast cancer treated with eribulin. Of these patients, 60 had complete blood tests and follow-up data. Neither a high ALC nor a low baseline NLR was associated with the survival outcome. One month after initiating eribulin treatment, a high ALC and a low NLR were significantly associated with longer progression-free survival (p = 0.044 for each). Three months after initiating eribulin, a high ALC was significantly associated with better overall survival (p = 0.006). A high NLR at 3 or 6 months after initiating eribulin was associated with worse overall survival (p = 0.017 and p = 0.001, respectively). The ALC and NLR trends across times were not associated with survivals.

CONCLUSION

We showed that 1, 3 and 6 months after initiating eribulin, a high ALC and a low NLR may be related to the patients' survival outcomes. The ALC and NLR trends were not associated with survival. Accordingly, we believe patients who maintain a high ALC and a low NLR may have better clinical outcomes after initiating eribulin.

Definitions, End Points, and Clinical Trial Designs for Bladder Cancer: Recommendations From the Society for Immunotherapy of Cancer and the International Bladder Cancer Group

PURPOSE

There is a significant unmet need for new and efficacious therapies in urothelial cancer (UC). To provide recommendations on appropriate clinical trial designs across disease settings in UC, the Society for Immunotherapy of Cancer (SITC) and the International Bladder Cancer Group (IBCG) convened a multidisciplinary, international consensus panel.

METHODS

Through open communication and scientific debate in small- and whole-group settings, surveying, and responses to clinical questionnaires, the consensus panel developed recommendations on optimal definitions of the disease state, end points, trial design, evaluations, sample size calculations, and pathology considerations for definitive studies in low- and intermediate-risk nonmuscle-invasive bladder cancer (NMIBC), high-risk NMIBC, muscle-invasive bladder cancer in the neoadjuvant and adjuvant settings, and metastatic UC. The expert panel also solicited input on the recommendations through presentations and public discussion during an open session at the 2021 Bladder Cancer Advocacy Network (BCAN) Think Tank (held virtually).

RESULTS

The consensus panel developed a set of stage-specific bladder cancer clinical trial design recommendations, which are summarized in the table that accompanies this text.

CONCLUSION

These recommendations developed by the SITC-IBCG Bladder Cancer Clinical Trial Design consensus panel will encourage uniformity among studies and facilitate drug development in this disease.

Study of pre-operative neutrophil-lymphocyte ratio in urothelial carcinoma

OBJECTIVES

Neutrophil-lymphocyte ratio (NLR), as an indicator of heightened systemic inflammatory response, predicts increased disease burden and poor oncological outcomes in urothelial carcinoma (UC). The study was undertaken with an aim to evaluate the association of NLR with clinicopathological variables and survival outcomes.

METHODS

A total of 80 patients of UC were enrolled in the current retrospective study. Pre-operative NLR (within one month prior to the procedure), patient age, sex, tumour grade, pathological stage, recurrence free survival (RFS), progression free survival (PFS) and cancer specific survival (CSS) were recorded. We chose a cut-off value of 2.7 for NLR and patients were divide into two groups (NLR <2.7 and ≥2.7).

RESULTS

NLR ≥2.7 was significantly associated with advanced tumour stage (p=0.001), but not with tumour grade (p=0.116). Progression (p=0.032) and death rates (p=0.026) were high in patients with NLR ≥2.7. Mean RFS (p=0.03), PFS (p=0.04) and CSS (p=0.04) were reduced in patients with NLR ≥2.7. On univariate analysis, NLR ≥2.7 predicted worse RFS (HR=2.928, p=0.007), PFS (HR=3.180, p=0.006) and CSS (HR=3.109, p=0.016). However, it was not an independent predictor of outcomes on multivariate analysis.

CONCLUSIONS

Tumour stage and grade are the only independent predictors of RFS, PFS and CSS. High NLR at a cut-off value of ≥2.7 is associated with advanced pathological stage, but does not have an independent predictive value for RFS, PFS and CSS.

Prognostic value of pretreatment serum albumin−globulin ratio in urothelial carcinoma: A systematic review and meta-analysis

Objective

To evaluate whether pretreatment albumin−globulin ratio (AGR) can be used as a biomarker for predicting the prognosis of patients with urothelial carcinoma (UC).

Methods

We systematically searched PubMed, Web of Science, China National Knowledge Infrastructure (CNKI), Google Scholar and Cochrane Library; the search time was up to May 2022. Stata 16.0 was used for data processing and statistical analysis.

Results

We identified 12 studies with 5,727 patients from 317 unique citations during the meta-analysis. Our results suggested that a low AGR before treatment was significantly associated with poor overall survival (OS) [hazard ratio (HR) = 1.99, 95% confidence interval (CI) = 1.45-2.75, P < 0.001], cancer-specific survival (CSS) [HR=2.01, 95% CI = 1.50-2.69, P < 0.001] and recurrence-free survival (RFS) [HR=1.39, 95% CI = 1.12-1.72, P = 0.002]. Furthermore, we defined different subgroups according to ethnicity, cancer type, cut-off value, sample size and stage. Similar prognostic outcomes for OS and CSS were observed in most subgroups. However, for subgroup of stage, the low pretreatment AGR only predicted the poor survival of patients with non-metastatic UC.

Conclusion

Our meta-analysis revealed that the AGR before treatment could be used as a predictive biomarker to indicate the prognosis of UC patients during clinical practice, especially in patients with non-metastatic UC.

Do changes in inflammatory markers predict hepatocellular carcinoma recurrence and survival after liver transplantation?

Backgrounds/Aims

The role of inflammation in malignant cell proliferation has been well described. High values of platelet-to-lymphocyte ratio (PLR) and neutrophil-to-lymphocyte ratio (NLR) as markers of systemic inflammation have shown associations with unfavorable long-term outcomes. The purpose of this study was to determine values of NLR and PLR evaluated prior to and after surgery and their associations with mortality and recurrence rates of liver transplant patients with hepatocellular carcinoma (HCC).

Methods

A total of 105 patients with HCC who underwent orthotopic liver transplantation (OLT) were retrospectively reviewed. NLR and PLR values were obtained from complete blood counts prior to and after surgery. Overall survival (OS) and recurrence-free survival (RFS) in relation with delta NLR and PLR were estimated.

Results

Serum alpha-fetoprotein levels > 100 ng/mL (p = 0.014) and lymphovascular emboli in the specimen (p = 0.048) were identified to be significant predictors of RFS. Child-Pugh score (p = 0.016) was found to be an independent factor associated with poorer OS. An increasing delta PLR was associated with worse RFS, although it showed no significant association with OS.

Conclusions

The analysis of PLR as a continuous variable may predict recurrence outcomes in patients undergoing OLT for HCC. It is more representative than isolated values.

Prognostic and Predictive Factors in Advanced Urothelial Carcinoma Treated with Immune Checkpoint Inhibitors: A Review of the Current Evidence

In recent years, the treatment landscape of urothelial carcinoma has significantly changed due to the introduction of immune checkpoint inhibitors (ICIs), which are the standard of care for second-line treatment and first-line platinum-ineligible patients with advanced disease. Despite the overall survival improvement, only a minority of patients benefit from this immunotherapy. Therefore, there is an unmet need to identify prognostic and predictive biomarkers or models to select patients who will benefit from ICIs, especially in view of novel therapeutic agents. This review describes the prognostic and predictive role, and clinical readiness, of clinical and tumour factors, including new molecular classes, tumour mutational burden, mutational signatures, circulating tumour DNA, programmed death-ligand 1, inflammatory indices and clinical characteristics for patients with urothelial cancer treated with ICIs. A classification of these factors according to the levels of evidence and grades of recommendation currently indicates both a prognostic and predictive value for ctDNA and a prognostic relevance only for concomitant medications and patients' characteristics.

Pyuria as a Predictive Marker of Bacillus Calmette-Guérin Unresponsiveness in Non-Muscle Invasive Bladder Cancer

This study aims to investigate the clinical role of preoperative pyuria for predicting bacillus Calmette-Guérin (BCG) unresponsiveness in non-muscle invasive bladder cancer (NMIBC). We performed a logistic regression analysis on 453 patients with NMIBC who were treated with BCG immunotherapy after a transurethral resection of bladder tumours, to evaluate predictive factors of BCG unresponsiveness. We also analysed univariate and multivariable survival data to estimate the prognostic impact of pyuria. Of the total study population, 37.6% (170/453) of patients had BCG unresponsiveness. A multivariable logistic regression analysis revealed that a history of upper urinary tract cancer (odds ratio (OR): 1.86, 95% confidence interval (CI): 1.04-3.32, p-value = 0.035) and the presence of pyuria (OR: 1.51, 95% CI: 1.01-2.27, p = 0.047) and tumour multiplicity (OR: 1.80, 95% CI: 1.18-2.75, p-value < 0.001) were significant predictors of BCG unresponsiveness. A Cox proportional hazards analysis model showed that pyuria was a significant prognostic factor for progression-free survival (hazard ratio: 4.51, 95% CI: 1.22-16.66, p = 0.024). A history of upper urinary tract cancer and the presence of pyuria and tumour multiplicity are predictive markers of BCG unresponsiveness. For patients with NMIBC who have preoperative pyuria, treatment using BCG should be considered cautiously.

Prognostic role of neutrophil-to-lymphocyte ratio (NLR) in urological tumors: an umbrella review of evidence from systematic reviews and meta-analyses

BACKGROUND

Neutrophil-to-lymphocyte ratio (NLR) has been studied as a biomarker for cancer prognosis, predicting survival in many tumors. The aim of this umbrella review was to combine the results from all systematic reviews and meta-analyses related to the prognostic role of the NLR in patients with urological tumors.

METHODS

A PubMed, Scopus, Embase and Cochrane search was undergone from inception through September 2020 for systematic reviews and meta-analyses investigating the prognostic value of NLR in urological tumors, subdivided into prostate cancer, renal cell carcinoma, urothelial bladder and upper tract carcinomas PROSPERO (CRD42020216310).

RESULTS

The results have shown, with a high level of evidence, that an elevated NLR predicts worse overall survival (OS), progression-free survival (PFS) and relapse-free survival (RFS) in prostate cancer, worse OS, PFS and RFS in renal cell carcinoma, worse OS, PFS, RFS and cancer-specific survival (CSS) in muscle invasive bladder cancer, worse PFS and RFS in non-muscle invasive bladder cancer, and worse OS, PFS, RFS and CSS in urothelial upper tract carcinoma.

CONCLUSION

NLR has a significant prognostic value in urological tumors and should be included in prognostic scores of these cancers.

Clinical Value of Postoperative Neutrophil-to-Lymphocyte Ratio Change as a Detection Marker of Bladder Cancer Recurrence

Purpose

This study investigated the clinical significance of postoperative neutrophil-to-lymphocyte ratio (NLR) changes in bladder cancer recurrence.

Patients and Methods

For evaluating the predictive value of postoperative dynamic change of NLR, a retrospective cohort study was performed to analyze 213 patients with bladder cancer who underwent surgical treatment from January 2013 to December 2019 at the Affiliated Tumor Hospital of Guangxi Medical University. Baseline characteristics and recurrence-free survival (RFS) were statistically compared, and a multivariate analysis was used to identify prognostic factors.

Results

Compared with preoperative NLR levels, postoperative decreased NLR in 130 patients and postoperative increased NLR in 83 patients were detected. The 1-, 3- and 5-year RFS rates were 88.0%, 75.4% and 75.4% in the decreased postoperative NLR group, respectively, and 51.2%, 25.8% and 16.1% in the increased postoperative NLR group, respectively (P < 0.05). Kaplan–Meier curves showed that the cumulative DFS rate in the increased group was significantly lower than that in the decreased group (P < 0.05). The preoperative NLR showed significant difference with postoperative NLR in the total cohort, high-grade non-muscle-invasive bladder cancer (HG-NMIBC) and muscle-invasive bladder cancer (MIBC) group, while there was no significant difference between postoperative NLR and NLR of recurrence or last follow-up. Multivariate analysis suggested that postoperative-preoperative NLR was an independent predictor for RFS (HR=6.206, 95% CI: 3.826–10.067, P < 0.001) in the total cohort, RFS (HR=9.373, 95% CI: 2.724–32.245, P < 0.001) in the LG-NMIBC group, RFS rates (HR=6.873, 95% CI: 2.486–18.999, P < 0.001) in the HG-NMIBC group and RFS rates (HR=6.109, 95% CI: 2.847–13.109, P < 0.001) in the MIBC group.

Conclusion

The dynamic change of postoperative NLR is a potential marker for the early detection of bladder cancer recurrence. Patients with increased NLR after surgery tend to have higher risk of recurrence.

Dynamic perioperative variation of neutrophil-to-lymphocyte ratio as an independent prognosis factor following lobectomy for NSCLC

Inflammation plays a key role in malignant tumor progression. The neutrophil-to-lymphocyte ratio (NLR) is a marker of systemic inflammation and, as such, high isolated pretreatment NLR has been shown to be associated with worse long-term outcomes. The aim of the present study is to evaluate the prognostic value of pre- and post-operative NLR in relation to mortality and recurrence rates in patients undergoing lung lobectomy for NSCLC. A single-center retrospective analysis of 534 lobectomies was performed between 2009 and 2018. NLR was measured in two opportunities: 1 month prior to surgery and 1-4 months after. Primary outcomes were overall survival (OS) and recurrence-free survival (RFS). Secondary outcomes were variables associated with mortality and recurrence. The study sample included 264 lobectomies. Independent predictors of OS were ASA 3/4 (p = 0.041) and open surgical approach (p = 0.042). Adjuvant chemotherapy (p = 0.002) and pathological N 1/2-stage (p = 0.0015) were associated with RFS. Delta NLR correlated with OS (p = 0.042) and RFS (p < 0.001). Patients were divided into three delta NLR categories: delta NLR < 0, delta NLR 0-0.5 and delta NLR > 0.5. Increasing delta NLR was significantly associated with worse OS (p < 0.001) and RFS (p < 0.001). Dynamic behaviour of NLR assessed through delta NLR is a useful tool that potentially allows predicting mortality and recurrence outcomes in patients undergoing lung lobectomy for NSCLC and may be more informative than static baseline values.

The Significance of Neutrophil-to-Lymphocyte Ratio and Combined Chemoradiotherapy in Patients Undergoing Bladder Preservation Therapy for Muscle-Invasive Bladder Cancer

Background

Bladder-sparing treatment has been developed with the aim of preserving bladder function. However, considerable controversy remains regarding the effectiveness of organ preservation strategies. Accordingly, we investigated factors influencing the prognosis of muscle-invasive bladder cancer (MIBC) patients who received bladder-sparing treatment.

Materials and Methods

In the study, we retrospectively reviewed 193 patients who were newly diagnosed with MIBC and received bladder-sparing treatment from 2006 to 2013 in our hospital.

Results

The 5-year overall survival, progression-free survival (PFS) and bladder-preservation survival rates after diagnosis were 64.7%, 52.1%, and 64%, respectively. The presence of hydronephrosis, advanced stage and not achieving complete response were associated with a marked reduction in PFS. Treatment with an adequate dose of combined chemoradiotherapy (CCRT) (chemotherapy ≥2 cycles combined with radiotherapy dose ≥56Gy) significantly improved the complete response (CR), 5-year bladder-preservation survival, and PFS rates, particularly for patients with good performance status. The 5-year bladder-preservation survival rates for CR and non-CR patients were 75%, and 21%, respectively. Furthermore, higher pre-treatment neutrophil-to-lymphocyte ratio (NLR) (≥3) and lower hemoglobin (≤12) were significantly associated with lower CR rate, increased risk of loco-regional recurrence and reduced bladder-preservation survival rate. Multivariable Cox regression analysis based on different co-variables showed that pretreatment NLR was an independent prognostic factor for PFS when MIBC patients were stratified by clinical stage and the doses of CCRT.

Conclusion

In MIBC patients with bladder-sparing treatment, adequate doses of CCRT and low NLR were found to be correlated with better PFS. We suggest the use of NLR as a clinical biomarker for the prognosis of MIBC and guidance of treatment decisions.

Neutrophil to lymphocyte ratio and cancer prognosis: an umbrella review of systematic reviews and meta-analyses of observational studies

BACKGROUND

Although neutrophils have been linked to the progression of cancer, uncertainty exists around their association with cancer outcomes, depending on the site, outcome and treatments considered. We aimed to evaluate the strength and validity of evidence on the association between either the neutrophil to lymphocyte ratio (NLR) or tumour-associated neutrophils (TAN) and cancer prognosis.

METHODS

We searched MEDLINE, Embase and Cochrane Database of Systematic Reviews from inception to 29 May 2020 for systematic reviews and meta-analyses of observational studies on neutrophil counts (here NLR or TAN) and specific cancer outcomes related to disease progression or survival. The available evidence was graded as strong, highly suggestive, suggestive, weak or uncertain through the application of pre-set GRADE criteria.

RESULTS

A total of 204 meta-analyses from 86 studies investigating the association between either NLR or TAN and cancer outcomes met the criteria for inclusion. All but one meta-analyses found a hazard ratio (HR) which increased risk (HR > 1). We did not find sufficient meta-analyses to evaluate TAN and cancer outcomes (N = 9). When assessed for magnitude of effect, significance and bias related to heterogeneity and small study effects, 18 (9%) associations between NLR and outcomes in composite cancer endpoints (combined analysis), cancers treated with immunotherapy and some site specific cancers (urinary, nasopharyngeal, gastric, breast, endometrial, soft tissue sarcoma and hepatocellular cancers) were supported by strong evidence.

CONCLUSION

In total, 60 (29%) meta-analyses presented strong or highly suggestive evidence. Although the NLR and TAN hold clinical promise in their association with poor cancer prognosis, further research is required to provide robust evidence, assess causality and test clinical utility.

TRIAL REGISTRATION

PROSPERO CRD42017069131 .

Inflammatory indexes are not associated with sarcopenia in Chinese community-dwelling older people: a cross-sectional study

Background

Inflammatory indexes (platelet-to-lymphocyte ratio [PLR], neutrophil-to-lymphocyte ratio [NLR], and lymphocyte-to-monocyte ratio [LMR]) are recently supposed to be the biomarkers of sarcopenia. We aimed to validate the association between these inflammatory indexes and sarcopenia in Chinese community-dwelling older people.

Methods

We consecutively recruited community-dwelling older adults aged 60 years or older. The neutrophil, lymphocyte, monocyte, and platelet counts, and C-reactive protein (CRP) were tested using standard methods. Sarcopenia was defined according to different criteria: the Asian Working Group for Sarcopenia (AWGS), the updated version of AWGS (AWGS 2019), the European Working Group on Sarcopenia in Older People (EWGSOP), the updated version of EWGSOP (EWGSOP2), the International Working Group on Sarcopenia (IWGS), and the Foundation for the National Institutes of Health Sarcopenia Project (FNIH). Multiple logistic regression analysis was performed.

Results

We included 384 participants. A total of 61 participants (15.9%) were diagnosed with sarcopenia according to the AWGS criteria. There was no significant difference in PLR, NLR, LMR, and CRP between the sarcopenia group and the non-sarcopenia group regardless of the diagnostic criteria. No significant association between PLR, NLR, LMR, and AWGS-defined sarcopenia was found (PLR per 1- standard deviation [SD]: adjusted odds ratio [OR] 1.09, 95% confidence interval [CI] 0.82 to 1.45; NLR per 1-SD: adjusted OR 0.96, 95% CI 0.71 to 1.30; LMR per 1-SD: adjusted OR 1.01, 95% CI 0.74 to 1.38). Similar results were found when sarcopenia was defined by different criteria and when PLR, NLR, LMR were treated as categorical variables.

Conclusions

Our study did not support the utility of the inflammatory indexes (NLR, PLR, and LMR) as the biomarkers of sarcopenia in Chinese community-dwelling older people. However, considering the inflammatory indexes can be simply calculated from a routine blood test, further studies in different populations remain warranted.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12877-020-01857-5.

A Retrospective Cohort Study on Pretreated Neutrophil-to-Lymphocyte Ratio and Prognosis of Small Cell Lung Cancer: Evidence of Effect Modification by Chemotherapy Regimen

Purpose

Neutrophil-to-lymphocyte ratio (NLR) has been suggested as an independent risk factor for progression-free survival (PFS) and overall survival (OS) in small cell lung cancer (SCLC). However, it is still unknown whether there is a linear relationship between the NLR and the risk of death in SCLC. The objective of this study is to provide further results.

Patients and Methods

A retrospective cohort study was performed among a total of 251 participants with SCLC. Smooth curve fitting and piecewise Cox regression model were used to determine the linear relationship between NLR and mortality risk. A multivariable Cox regression model was used to estimate the effects of NLR on OS. Interaction and stratified analyses were conducted according to covariates.

Results

The analysis indicated no significant nonlinear relationship or threshold effect between NLR and hazard of death. Multivariate analysis revealed that every unit increase in NLR was associated with a 10% increase in mortality risk. High NLR (>3.5) at baseline was associated with poor OS (hazard ratio [HR]=1.97, P=0.009). The difference in median OS duration between the high and low NLR groups was statistically significant (9.1 months vs 14.6 months, P=0.0067). Furthermore, interaction analysis identified the chemotherapy regimen to play an interactive role in the association between NLR and hazard of death.

Conclusion

NLR was identified as an independent risk factor for OS in SCLC and the linear correlation was observed between them. Administration of etoposide plus cisplatin (EP) regimen in patients with low NLR resulted in better long-term outcome than that of etoposide plus carboplatin (EC) regimen, while administration of the EC regimen conferred longer OS than that of the EP regimen in patients with high NLR.