The American Journal of Surgery (2015) 209, 333-337
Clinical Science
Prognostic value of preoperative neutrophils to lymphocytes ratio in patients resected for gastric cancer Luigina Graziosi, M.D., Ph.D.a, Elisabetta Marino, M.D.a,*, Verena De Angelis, M.D.b, Alberto Rebonato, M.D., Ph.D.a, Emanuel Cavazzoni, M.D., Ph.D.a, Annibale Donini, M.D., Ph.D.a a
Dipartimento di Scienze Chirurgiche, Radiologiche e Odontostomatologiche, Nuova Facolta` di Medicina e Chirurgia, Sant’Andrea delle Fratte, Perugia 06132, Italy; bOncologia Medica, Ospedale Santa Maria della Misericordia, Sant’Andrea delle Fratte, Perugia 06132, Italy
KEYWORDS: Gastric cancer; Neutrophils to lymphocytes ratio
Abstract BACKGROUND: The neutrophil/lymphocyte ratio (NLR) in the peripheral blood is considered an easily assessable prognostic factor in cancer patients. We evaluated the predictive significance of the NLR in patients affected by gastric cancer that underwent gastric resection. METHODS: From July 2003 to March 2012, 156 patients who had undergone gastrectomy with curative intent for gastric adenocarcinoma were included. Data were retrieved from a prospective collected database. NLR was calculated from lymphocyte and neutrophil counts on routine blood tests taken before surgery. Survival analyses were generated according to the Kaplan–Meier method. Univariate and multivariate analyses were carried out by the Cox proportional hazard model. RESULTS: The median follow-up time for surviving patients was 38 months (range 1 to 108 months) and median preoperative NLR was 2.3 (range .47 to 19.73). Subjects were dichotomized at the N/L value of 2.3. Median survival of patients with NLR below the median was around 60 months compared with the 36 months of patients with an NLR above the median. A multivariate analysis established a significant and independent relationship between the NLR and the overall survival with a P value of less than .05. CONCLUSIONS: The results suggest that the elevated preoperative NLR predicts poor overall survival following resection for gastric adenocarcinoma. It may be used as a simple, reliable prognostic factor for risk stratification. Ó 2015 Elsevier Inc. All rights reserved.
Gastric cancer is the most common cause of cancer death in the world and its overall survival (OS) is still poor, as most patients arrive to medical attention with an advanced, inoperable disease. Even in those who undergo * Corresponding author. Tel./fax: 139-75-5786445. E-mail address: [email protected] Manuscript received February 8, 2014; revised manuscript May 21, 2014 0002-9610/$ - see front matter Ó 2015 Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.amjsurg.2014.06.014
potentially curative resection, 5-year survival is about 30% to 50%.1 After curative resection for gastric cancer, pathologic analysis of tumor-related factors guides prognosis and treatment. A variety of high-risk features, including tumor stage, resection margins, and nodal status, are considered important in determining cancer recurrence and survival.2–4 It is now increasingly recognized that the outcomes of patients with cancer are determined not only by tumor-related
334 factors but also by host-related factors, in particular systemic inflammatory response.5,6 Although preoperative tumor staging is useful to select the appropriate therapeutic strategy for patients with gastric cancer, clinical tumor staging alone cannot predict patients’ prognosis. Few studies demonstrated that host inflammatory response to cancer cells is associated with tumor progression.7 In advanced tumors, a high preoperative C-reactive protein level and/or high platelet count were frequently observed and were associated with poor patient prognosis.8 The preoperative neutrophil/lymphocyte ratio (NLR) also reflects patients’ inflammation status, clinical stage, and patients’ survival in colon cancer, lung cancer, and liver cancer.9–14 Increased numbers of neutrophils and/or decreased numbers of lymphocytes may suppress lymphokine-activated killer cells, thereby increasing the propensity to metastasis.15 However, only limited information on the clinical significance and prognostic significance of NLR in patients with gastric cancer has been reported.16 In this study, we measured the preoperative NLR in 156 patients with primary gastric cancer and we evaluated its clinical and prognostic impact.
Patients and Methods Patients Between 2003 and 2012, a total of 156 patients with primary gastric adenocarcinoma who underwent gastric resection at the Department of General and Emergency Surgery were investigated. Clinical–pathological characteristics of the patients are shown in Table 1. Patients with gastric cancer, who did not undergo a surgical curative approach, were excluded from the study, because they represent a small population (4 patients) and would not be statistically comparable. The patient population consisted of 92 men (58.9%) and 64 women (41.1%), with a median age of 74 years (range 39 to 91 years). We considered patients who underwent perioperative chemotherapy (neoadjuvant chemotherapy plus postoperative adjuvant chemotherapy) and adjuvant chemotherapy (only postoperative). Only 18 patients underwent neoadjuvant chemotherapy in our study, because an accepted protocol by the ethic committee is present in our center only since 2011. The total number of patients who received an adjuvant treatment is 70 (44%) including the perioperative group. All patients underwent either a total or subtotal gastrectomy with standard D2 lymphadenectomy. The resected specimens were pathologically classified according to the 13th edition (2nd English edition) of the Japanese classification of gastric carcinoma17 The distribution of cancer stages was as follows: stage I: 42 (27.0%); stage II: 29 (18.6%); stage III: 62 (39.7%); and stage IV: 23 (14.7%).
The American Journal of Surgery, Vol 209, No 2, February 2015 Table 1
Clinical–pathological characteristics of the patients
Patient characteristics Sex Female Male Age .75 %75 Lauren Diffuse Intestinal Other Stage IA IB IIA IIB IIIA IIIB IIIC IV Perioperative therapy Adjuvant therapy
N/L R 2.3
N/L, 2.3
Total
28 (17.94) 53 (33.98)
36 (23.08) 39 (25.00)
64 (41.02) 92 (58.98)
44 (28.20) 40 (25.64)
25 (16.03) 47 (30.13)
69 (44.23) 87 (55.77)
33 (21.15) 48 (30.77) 2 (1.28)
25 (16.02) 45 (28.85) 3 (1.92)
58 (37.18) 93 (59.62) 5 (3.20)
9 7 2 10 9 15 14 13 6
23 3 2 15 4 9 11 10 12
32 10 4 25 13 24 25 23 18
(5.77) (4.49) (1.28) (6.41) (5.77) (9.62) (8.97) (8.33) (7.4)
24 (29.6)
(14.74) (1.92) (1.28) (9.62) (2.56) (5.77) (7.05) (6.41) (16)
28 (37.3)
(20.51) (6.41) (2.56) (16.03) (8.33) (15.38) (16.03) (14.74) (11.5)
52 (33.3)
Data are expressed as number (percentage).
All patients were followed up regularly until December 2012 or until death every 6 months for the first 2 years from surgery and every year thereafter. Median follow-up period was of 23 months. Only 4 patients of our series were not treated with a surgical intervention, therefore a third group was not considered, because of a lack in statistical homogeneity.
Data collection Demographic details, operation type, histopathologic diagnosis, and survival data were collected by review of patients’ record, retrospectively. Only one venous blood sample was taken the day before surgery, and collected in ethylenediaminetetraacetic acidcontaining tube according to other studies present in the literature. The normal range of white blood cell (WBC) count was from 4,000 to 10,800 cells/mm3. Baseline NLR was calculated as neutrophil count divided by lymphocyte count. The patients were dichotomized at the median value of NLR. Nutritional status was evaluated at the time of admission, and in case of malnutrition, parenteral nutrition was administrated before the major surgery.
Blood sample analyses Peripheral blood was obtained at the time of diagnosis before surgery.
L. Graziosi et al.
Neutrophils to lymphocytes in gastric cancer following resection
The numbers of WBCs and platelets were determined with a hemocytometer. Absolute counts of particular cells were calculated by multiplying the percentage of particular cells by the number of WBCs. An NLR value of 2.34 was used as a median cutoff value, classifying high NLR (R2.34) and low NLR groups. For each stage, patients were dichotomized on the basis of a median NLR cutoff value and survival curves were analyzed. In addition, N0 and N1 patients were divided into subgroups on the basis of a median NLR cutoff value.
Statistical analysis NLR values were compared using the Mann–Whitney U test. Fisher’s exact probability test was used to determine the significance of differences between the 2 groups. Survival probabilities were calculated using the product limit method of Kaplan and Meier, considering overall deaths. Survival differences between groups were determined using the log-rank test. The influence of each significant predictor identified by univariate analysis was assessed by multivariate analysis using Cox’s proportional hazards model.
Results Based on the cutoff value of 2.34, 51.2% (n 5 80) of the 156 patients were classified in the high NLR group and 48.8% (n 5 76) in the low NLR group. Five-year OS of the high NLR group patients and low NLR group patients were 35% and 60%. respectively. Median disease-free survival of the high NLR group patients and low NLR group patients was 12 and 20 months, respectively. Recurrences were observed in 22 (27.5%) patients in the high NLR group and in 15 (19.7%) patients in the low NLR group. Patients with peritoneal metastasis (35.2% vs 15.8%) were most frequently in the high NLR group. Death occurred in 29 (18.5%) patients and 41 (38.2) patients of the low and high NLR group, respectively. To investigate whether a high NLR value reflected a poor prognosis for patients, a Kaplan–Meier analysis and a log-rank test were carried out for each stage of disease dichotomizing patients on the basis of a median NLR cut off. Five-year OS for stage IA in the high NLR group was 70% and in low was 90%; for stage IB, 5-year OS in the high NLR group was 73% and in the low was 100%; for stage II, 5-year OS in the high NLR group was 60% and in the low was 75%; for stage IIIB, 5-year OS in the high NLR group was 27% and in the low was 30%; for stage IIIC, 5year OS in the high NLR group was 15% and in the low
335
was 40%. In stage IV, all patients of both high and low NLR group died before 5 years of follow-up and no statistically significant difference of survival was seen in the 2 NLR groups. Kaplan–Meier survival curves were also performed by dividing patients with positive lymphonodes from patients without pathological nodes. Five-year OS for node-negative patients in the high NLR group was 60% and in the low was 90% with a P value of less than .05; for node-positive patients, 5-year OS in the high NLR group was 20% and in the low was 21%. The following factors were also correlated with poorer OS: American Joint committe on cancer stage IV (P , .001), mixed (P , .004) or diffuse type of Lauren classification (P , .007), and NLR (P , .029). These significant factors were entered into a multivariate Cox proportional regression model to test for independence. The NLR was still significant in the final multivariate model (hazards ratio 1.70, 95% confidence interval: 1.02 to 2.84; P , .043) and mixed-type Lauren classification (hazards ratio 4.78, 95% confidence interval: 1.35 to 16.93; P , .015).
Comments We set out to determine whether peripheral lymphocyte and neutrophil counts could predict the OS in patients with gastric cancer who underwent radical surgery. The results of this study show that a high peripheral lymphocyte and a high NLR are an independent favorable prognostic factor of disease-free survival and OS; the major impact of NLR on survival was seen in patients at early stages (stage I to II or N0 patients). At late stage, gastric cancer patients’ survival was influenced by lymphonodal involvement or T depth. In previous studies, the lymphocyte count was found to be an independent prognostic factor in pancreatic cancer,18 breast cancer,19 and lung cancer.20 The ability of tumors to invade and metastasize is dependent both on the intrinsic characteristics of the tumor and on the tumoral environment21 The abnormal phenotype of the tumor may stimulate an influx of inflammatory cells into tissues around the tumor and the tissue destruction and disruption caused by the physical neoplastic growth may trigger a more generalized and nonspecific inflammatory response.22 As a consequence of these inflammation processes, neutrophils increase and lymphocytes decrease with the following advancement of cancer. These findings are in agreement with our study, in which the neutrophil and lymphocyte count and the NLR correlated with cancer stage but in particular with early stages of disease. Various studies indicated that a decreased lymphocyte count in the peripheral blood is a predictor of a poor prognosis in cancer patients.23–25
336 These altered WBC count subsets have been linked with prognosis of cancer patients in many investigations. Bruckner et al26 suggested that a surgical pretreatment absolute neutrophil count of 6,000 cells/mm3 and lymphocyte count of 1,500 cells/mm3 were independent prognostic indicators of a good prognosis for patients with metastatic gastric cancer. Moreover, Elias et al27 investigated mononuclear cell percentages in patients with head and neck cancer, and they showed that high percentages of lymphocytes (.30%) and low monocyte percentages (,10%) are related to a better prognosis. Elevated NLR at the time of diagnosis accompanies low survival rates in ovarian cancer.28 In addition, an elevated NLR is also a potentially poor prognostic predictor after curative resection for hepatocellular carcinoma.14 Walsh et al11 demonstrated that for patients with colorectal cancers, preoperative NLR value greater than 5 was associated with a poor survival rate. Yamanaka et al16 found that in patients with NLR value less than 2.5, the median survival time was significantly higher than those with NLR of 2.5 in advanced gastric cancer (363 vs 239 days). Similarly, in this study, patients with an NLR value lower than 2.34 had significantly higher 5-year OS than those with an NLR value of 2.34 or above (35% vs 60%, P 5 .001). There are several possible explanations for the association between elevated NLR and poorer prognosis. One is that the high NLR reflects an enhanced neutrophil response to tumors. Circulating neutrophils have been shown to favor the angiogenesis and proangiogenetic factor secretion including vascular endothelial growth factor; therefore an elevated neutrophil count stimulates tumor angiogenesis and aids the progression of neoplasm.23 Another possible explanation is that patients with elevated NLR have a relative lymphocytopenia and as a result they have a poorer lymphocyte-mediated antitumor cellular immune response. Actually, some investigations revealed that increased neutrophils suppress the cytolytic activity of lymphocyte, natural killer cells, and activated T cells.24 Finally, there is now good consistent evidence that the presence of a systemic inflammatory response is associated with progressive nutritional and functional decline in the cancer patients and their subsequent poor outcome.5 According to several previous studies29 as well as our own results, an NLR may also serve as an additive prognostic factor for recurrence after potentially curative resection of cancer. It remains to be established what treatment might be given to patients at high risk, but patients with high preoperative NLR should be considered as candidates for more intensive multimodality and integrated treatment. We strongly believe that preoperative NLR might be used to screen patients more accurately in early stages, which generally undergo routine follow-up. NLR could be
The American Journal of Surgery, Vol 209, No 2, February 2015 used to select this group of patients who need a more aggressive follow-up and chemotherapic treatment. Therefore, our study could represent the basis for a prospective study.
References 1. Wang W, Li YF, Sun XW, et al. Prognosis of 980 patients with gastric cancer after surgical resection. Chin J Cancer 2010;29:923–30. 2. Siewert JR, Bo¨ttcher K, Stein HJ, et al. Relevant prognostic factors in gastric cancer: ten-year results of the German Gastric Cancer Study. Ann Surg 1998;228:449–61. 3. Seta¨la¨ LP, Kosma VM, Marin S, et al. Prognostic factors in gastric cancer: the value of vascular invasion, mitotic rate and lymphoplasmacytic infiltration. Br J Cancer 1996;74:766–72. 4. Wang SY, Yeh CN, Lee HL, et al. Clinical impact of positive surgical margin status on gastric cancer patients undergoing gastrectomy. Ann Surg Oncol 2009;16:2738–43. 5. McMillan DC. Systemic inflammation, nutritional status and survival in patients with cancer. Curr Opin Clin Nutr Metab Care 2009;12: 223–6. 6. Roxburgh CS, McMillan DC. Role of systemic inflammatory response in predicting survival in patients with primary operable cancer. Future Oncol 2010;6:149–63. 7. Mohri Y, Tanaka K, Ohi M, et al. Prognostic significance of host- and tumor-related factors in patients with gastric cancer. World J Surg 2010;34:285–90. 8. Wang CS, Sun CF. C-reactive protein and malignancy: clinicopathological association and therapeutic implication. Chang Gung Med J 2009;32:471–82. 9. Ietomi K. [A study on the role of granulocytes in carcinoma-bearing hostsdG/L ratio as a new host indicator (in Japanese). Nihon Gan Chiryo Gakkai Shi 1990;25:662–71. 10. Satomi A, Murakami S, Ishida K, et al. Significance of increased neutrophils in patients with advanced colorectal cancer. Acta Oncol 1995; 34:69–73. 11. Walsh SR, Cook EJ, Goulder F, et al. Neutrophil-lymphocyte ratio as a prognostic factor in colorectal cancer. J Surg Oncol 2005;91: 181–4. 12. Sarraf KM, Belcher E, Raevsky E, et al. Neutrophil/lymphocyte ratio and its association with survival after complete resection in non-small cell lung cancer. J Thorac Cardiovasc Surg 2009;137:425–8. 13. Halazun KJ, Aldoori A, Malik HZ, et al. Elevated preoperative neutrophil to lymphocyte ratio predicts survival following hepatic resection for colorectal liver metastases. Eur J Surg Oncol 2008;34:55–60. 14. Gomez D, Farid S, Malik HZ, et al. Preoperative neutrophil-tolymphocyte ratio as a prognostic predictor after curative resection for hepatocellular carcinoma. World J Surg 2008;32:1757–62. 15. Shau HY, Kim A. Suppression of lymphokine-activated killer induction by neutrophils. J Immunol 1988;141:4395–402. 16. Yamanaka T, Matsumoto S, Teramukai S, et al. The baseline ratio of neutrophils to lymphocytes is associated with patient prognosis in advanced gastric cancer. Oncology 2007;73:215–20. 17. Japanese Gastric Cancer Association. Japanese classification of gastric carcinomad2nd English edition. Gastric Cancer 1998;1:10–24. 18. Clark EJ, Connor S, Taylor MA, et al. Preoperative lymphocyte count as a prognostic factor in resected pancreatic ductal adenocarcinoma. HPB (Oxford) 2007;9:456–60. 19. Ownby HE, Roi LD, Isenberg RR, et al. Peripheral lymphocyte and eosinophil counts as indicators of prognosis in primary breast cancer. Cancer 1983;52:126–30. 20. Zhang J, Huang SH, Li H. Preoperative lymphocyte count is a favorable prognostic factor of disease-free survival in non-small-cell lung cancer. Med Oncol 2013;30:352. 21. Coussens LM, Werb Z. Inflammation and cancer. Nature 2002;420: 860–7.
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Neutrophils to lymphocytes in gastric cancer following resection
22. Nagtegaal ID, Marijnen CA, Kranenberg EK, et al. Local and distant recurrences in rectal cancer patients are predicted by the nonspecific immune response; specific response as only a systemic effectdA histopathological and immunohistochemical study. BMC Cancer 2001;1:7. 23. Shamamian P, Schwartz JD, Pocock BJ, et al. Activation of progelatinase A (MMP-2) by neutrophil elastase, cathepsin G, and proteinase-3: a role for inflammatory cells in tumor invasion and angiogenesis. J Cell Physiol 2001;189:197–206. 24. Petrie HT, Klassen LW, Kay HD. Inhibition of human cytotoxic T lymphocyte activity in vitro by autologous peripheral blood granulocytes. J Immunol 1985;134:230–4. 25. el-Hag A, Clark RA. Immunosuppression by activated human neutrophils. Dependence on the myeloperoxidase system. J Immunol 1987; 139:2406–13.
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26. Bruckner HW, Lavin PT, Plaxe SC, et al. Absolute granulocyte, lymphocyte, and monocyte counts. Useful determinants of prognosis for patients with metastatic cancer of the stomach. JAMA 1982;247: 1004–6. 27. Elias EG, Leuchten JM, Buda BS, et al. Prognostic value of initial mononucleated cell percentages in patients with epidermoid carcinoma of the head and neck. Am J Surg 1986;152:487–90. 28. Cho H, Hur HW, Kim SW, et al. Pretreatment neutrophil to lymphocyte ratio is elevated in epithelial ovarian cancer and predicts survival after treatment. Cancer Immunol Immunother 2009; 58:15–23. 29. Hirashima M, Higuchi S, Sakamoto K, et al. The ratio of neutrophils to lymphocytes and the phenotypes of neutrophils in patients with early gastric cancer. J Cancer Res Clin Oncol 1998;124:329–34.
Clinical Science
Prognostic value of preoperative neutrophils to lymphocytes ratio in patients resected for gastric cancer Luigina Graziosi, M.D., Ph.D.a, Elisabetta Marino, M.D.a,*, Verena De Angelis, M.D.b, Alberto Rebonato, M.D., Ph.D.a, Emanuel Cavazzoni, M.D., Ph.D.a, Annibale Donini, M.D., Ph.D.a a
Dipartimento di Scienze Chirurgiche, Radiologiche e Odontostomatologiche, Nuova Facolta` di Medicina e Chirurgia, Sant’Andrea delle Fratte, Perugia 06132, Italy; bOncologia Medica, Ospedale Santa Maria della Misericordia, Sant’Andrea delle Fratte, Perugia 06132, Italy
KEYWORDS: Gastric cancer; Neutrophils to lymphocytes ratio
Abstract BACKGROUND: The neutrophil/lymphocyte ratio (NLR) in the peripheral blood is considered an easily assessable prognostic factor in cancer patients. We evaluated the predictive significance of the NLR in patients affected by gastric cancer that underwent gastric resection. METHODS: From July 2003 to March 2012, 156 patients who had undergone gastrectomy with curative intent for gastric adenocarcinoma were included. Data were retrieved from a prospective collected database. NLR was calculated from lymphocyte and neutrophil counts on routine blood tests taken before surgery. Survival analyses were generated according to the Kaplan–Meier method. Univariate and multivariate analyses were carried out by the Cox proportional hazard model. RESULTS: The median follow-up time for surviving patients was 38 months (range 1 to 108 months) and median preoperative NLR was 2.3 (range .47 to 19.73). Subjects were dichotomized at the N/L value of 2.3. Median survival of patients with NLR below the median was around 60 months compared with the 36 months of patients with an NLR above the median. A multivariate analysis established a significant and independent relationship between the NLR and the overall survival with a P value of less than .05. CONCLUSIONS: The results suggest that the elevated preoperative NLR predicts poor overall survival following resection for gastric adenocarcinoma. It may be used as a simple, reliable prognostic factor for risk stratification. Ó 2015 Elsevier Inc. All rights reserved.
Gastric cancer is the most common cause of cancer death in the world and its overall survival (OS) is still poor, as most patients arrive to medical attention with an advanced, inoperable disease. Even in those who undergo * Corresponding author. Tel./fax: 139-75-5786445. E-mail address: [email protected] Manuscript received February 8, 2014; revised manuscript May 21, 2014 0002-9610/$ - see front matter Ó 2015 Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.amjsurg.2014.06.014
potentially curative resection, 5-year survival is about 30% to 50%.1 After curative resection for gastric cancer, pathologic analysis of tumor-related factors guides prognosis and treatment. A variety of high-risk features, including tumor stage, resection margins, and nodal status, are considered important in determining cancer recurrence and survival.2–4 It is now increasingly recognized that the outcomes of patients with cancer are determined not only by tumor-related
334 factors but also by host-related factors, in particular systemic inflammatory response.5,6 Although preoperative tumor staging is useful to select the appropriate therapeutic strategy for patients with gastric cancer, clinical tumor staging alone cannot predict patients’ prognosis. Few studies demonstrated that host inflammatory response to cancer cells is associated with tumor progression.7 In advanced tumors, a high preoperative C-reactive protein level and/or high platelet count were frequently observed and were associated with poor patient prognosis.8 The preoperative neutrophil/lymphocyte ratio (NLR) also reflects patients’ inflammation status, clinical stage, and patients’ survival in colon cancer, lung cancer, and liver cancer.9–14 Increased numbers of neutrophils and/or decreased numbers of lymphocytes may suppress lymphokine-activated killer cells, thereby increasing the propensity to metastasis.15 However, only limited information on the clinical significance and prognostic significance of NLR in patients with gastric cancer has been reported.16 In this study, we measured the preoperative NLR in 156 patients with primary gastric cancer and we evaluated its clinical and prognostic impact.
Patients and Methods Patients Between 2003 and 2012, a total of 156 patients with primary gastric adenocarcinoma who underwent gastric resection at the Department of General and Emergency Surgery were investigated. Clinical–pathological characteristics of the patients are shown in Table 1. Patients with gastric cancer, who did not undergo a surgical curative approach, were excluded from the study, because they represent a small population (4 patients) and would not be statistically comparable. The patient population consisted of 92 men (58.9%) and 64 women (41.1%), with a median age of 74 years (range 39 to 91 years). We considered patients who underwent perioperative chemotherapy (neoadjuvant chemotherapy plus postoperative adjuvant chemotherapy) and adjuvant chemotherapy (only postoperative). Only 18 patients underwent neoadjuvant chemotherapy in our study, because an accepted protocol by the ethic committee is present in our center only since 2011. The total number of patients who received an adjuvant treatment is 70 (44%) including the perioperative group. All patients underwent either a total or subtotal gastrectomy with standard D2 lymphadenectomy. The resected specimens were pathologically classified according to the 13th edition (2nd English edition) of the Japanese classification of gastric carcinoma17 The distribution of cancer stages was as follows: stage I: 42 (27.0%); stage II: 29 (18.6%); stage III: 62 (39.7%); and stage IV: 23 (14.7%).
The American Journal of Surgery, Vol 209, No 2, February 2015 Table 1
Clinical–pathological characteristics of the patients
Patient characteristics Sex Female Male Age .75 %75 Lauren Diffuse Intestinal Other Stage IA IB IIA IIB IIIA IIIB IIIC IV Perioperative therapy Adjuvant therapy
N/L R 2.3
N/L, 2.3
Total
28 (17.94) 53 (33.98)
36 (23.08) 39 (25.00)
64 (41.02) 92 (58.98)
44 (28.20) 40 (25.64)
25 (16.03) 47 (30.13)
69 (44.23) 87 (55.77)
33 (21.15) 48 (30.77) 2 (1.28)
25 (16.02) 45 (28.85) 3 (1.92)
58 (37.18) 93 (59.62) 5 (3.20)
9 7 2 10 9 15 14 13 6
23 3 2 15 4 9 11 10 12
32 10 4 25 13 24 25 23 18
(5.77) (4.49) (1.28) (6.41) (5.77) (9.62) (8.97) (8.33) (7.4)
24 (29.6)
(14.74) (1.92) (1.28) (9.62) (2.56) (5.77) (7.05) (6.41) (16)
28 (37.3)
(20.51) (6.41) (2.56) (16.03) (8.33) (15.38) (16.03) (14.74) (11.5)
52 (33.3)
Data are expressed as number (percentage).
All patients were followed up regularly until December 2012 or until death every 6 months for the first 2 years from surgery and every year thereafter. Median follow-up period was of 23 months. Only 4 patients of our series were not treated with a surgical intervention, therefore a third group was not considered, because of a lack in statistical homogeneity.
Data collection Demographic details, operation type, histopathologic diagnosis, and survival data were collected by review of patients’ record, retrospectively. Only one venous blood sample was taken the day before surgery, and collected in ethylenediaminetetraacetic acidcontaining tube according to other studies present in the literature. The normal range of white blood cell (WBC) count was from 4,000 to 10,800 cells/mm3. Baseline NLR was calculated as neutrophil count divided by lymphocyte count. The patients were dichotomized at the median value of NLR. Nutritional status was evaluated at the time of admission, and in case of malnutrition, parenteral nutrition was administrated before the major surgery.
Blood sample analyses Peripheral blood was obtained at the time of diagnosis before surgery.
L. Graziosi et al.
Neutrophils to lymphocytes in gastric cancer following resection
The numbers of WBCs and platelets were determined with a hemocytometer. Absolute counts of particular cells were calculated by multiplying the percentage of particular cells by the number of WBCs. An NLR value of 2.34 was used as a median cutoff value, classifying high NLR (R2.34) and low NLR groups. For each stage, patients were dichotomized on the basis of a median NLR cutoff value and survival curves were analyzed. In addition, N0 and N1 patients were divided into subgroups on the basis of a median NLR cutoff value.
Statistical analysis NLR values were compared using the Mann–Whitney U test. Fisher’s exact probability test was used to determine the significance of differences between the 2 groups. Survival probabilities were calculated using the product limit method of Kaplan and Meier, considering overall deaths. Survival differences between groups were determined using the log-rank test. The influence of each significant predictor identified by univariate analysis was assessed by multivariate analysis using Cox’s proportional hazards model.
Results Based on the cutoff value of 2.34, 51.2% (n 5 80) of the 156 patients were classified in the high NLR group and 48.8% (n 5 76) in the low NLR group. Five-year OS of the high NLR group patients and low NLR group patients were 35% and 60%. respectively. Median disease-free survival of the high NLR group patients and low NLR group patients was 12 and 20 months, respectively. Recurrences were observed in 22 (27.5%) patients in the high NLR group and in 15 (19.7%) patients in the low NLR group. Patients with peritoneal metastasis (35.2% vs 15.8%) were most frequently in the high NLR group. Death occurred in 29 (18.5%) patients and 41 (38.2) patients of the low and high NLR group, respectively. To investigate whether a high NLR value reflected a poor prognosis for patients, a Kaplan–Meier analysis and a log-rank test were carried out for each stage of disease dichotomizing patients on the basis of a median NLR cut off. Five-year OS for stage IA in the high NLR group was 70% and in low was 90%; for stage IB, 5-year OS in the high NLR group was 73% and in the low was 100%; for stage II, 5-year OS in the high NLR group was 60% and in the low was 75%; for stage IIIB, 5-year OS in the high NLR group was 27% and in the low was 30%; for stage IIIC, 5year OS in the high NLR group was 15% and in the low
335
was 40%. In stage IV, all patients of both high and low NLR group died before 5 years of follow-up and no statistically significant difference of survival was seen in the 2 NLR groups. Kaplan–Meier survival curves were also performed by dividing patients with positive lymphonodes from patients without pathological nodes. Five-year OS for node-negative patients in the high NLR group was 60% and in the low was 90% with a P value of less than .05; for node-positive patients, 5-year OS in the high NLR group was 20% and in the low was 21%. The following factors were also correlated with poorer OS: American Joint committe on cancer stage IV (P , .001), mixed (P , .004) or diffuse type of Lauren classification (P , .007), and NLR (P , .029). These significant factors were entered into a multivariate Cox proportional regression model to test for independence. The NLR was still significant in the final multivariate model (hazards ratio 1.70, 95% confidence interval: 1.02 to 2.84; P , .043) and mixed-type Lauren classification (hazards ratio 4.78, 95% confidence interval: 1.35 to 16.93; P , .015).
Comments We set out to determine whether peripheral lymphocyte and neutrophil counts could predict the OS in patients with gastric cancer who underwent radical surgery. The results of this study show that a high peripheral lymphocyte and a high NLR are an independent favorable prognostic factor of disease-free survival and OS; the major impact of NLR on survival was seen in patients at early stages (stage I to II or N0 patients). At late stage, gastric cancer patients’ survival was influenced by lymphonodal involvement or T depth. In previous studies, the lymphocyte count was found to be an independent prognostic factor in pancreatic cancer,18 breast cancer,19 and lung cancer.20 The ability of tumors to invade and metastasize is dependent both on the intrinsic characteristics of the tumor and on the tumoral environment21 The abnormal phenotype of the tumor may stimulate an influx of inflammatory cells into tissues around the tumor and the tissue destruction and disruption caused by the physical neoplastic growth may trigger a more generalized and nonspecific inflammatory response.22 As a consequence of these inflammation processes, neutrophils increase and lymphocytes decrease with the following advancement of cancer. These findings are in agreement with our study, in which the neutrophil and lymphocyte count and the NLR correlated with cancer stage but in particular with early stages of disease. Various studies indicated that a decreased lymphocyte count in the peripheral blood is a predictor of a poor prognosis in cancer patients.23–25
336 These altered WBC count subsets have been linked with prognosis of cancer patients in many investigations. Bruckner et al26 suggested that a surgical pretreatment absolute neutrophil count of 6,000 cells/mm3 and lymphocyte count of 1,500 cells/mm3 were independent prognostic indicators of a good prognosis for patients with metastatic gastric cancer. Moreover, Elias et al27 investigated mononuclear cell percentages in patients with head and neck cancer, and they showed that high percentages of lymphocytes (.30%) and low monocyte percentages (,10%) are related to a better prognosis. Elevated NLR at the time of diagnosis accompanies low survival rates in ovarian cancer.28 In addition, an elevated NLR is also a potentially poor prognostic predictor after curative resection for hepatocellular carcinoma.14 Walsh et al11 demonstrated that for patients with colorectal cancers, preoperative NLR value greater than 5 was associated with a poor survival rate. Yamanaka et al16 found that in patients with NLR value less than 2.5, the median survival time was significantly higher than those with NLR of 2.5 in advanced gastric cancer (363 vs 239 days). Similarly, in this study, patients with an NLR value lower than 2.34 had significantly higher 5-year OS than those with an NLR value of 2.34 or above (35% vs 60%, P 5 .001). There are several possible explanations for the association between elevated NLR and poorer prognosis. One is that the high NLR reflects an enhanced neutrophil response to tumors. Circulating neutrophils have been shown to favor the angiogenesis and proangiogenetic factor secretion including vascular endothelial growth factor; therefore an elevated neutrophil count stimulates tumor angiogenesis and aids the progression of neoplasm.23 Another possible explanation is that patients with elevated NLR have a relative lymphocytopenia and as a result they have a poorer lymphocyte-mediated antitumor cellular immune response. Actually, some investigations revealed that increased neutrophils suppress the cytolytic activity of lymphocyte, natural killer cells, and activated T cells.24 Finally, there is now good consistent evidence that the presence of a systemic inflammatory response is associated with progressive nutritional and functional decline in the cancer patients and their subsequent poor outcome.5 According to several previous studies29 as well as our own results, an NLR may also serve as an additive prognostic factor for recurrence after potentially curative resection of cancer. It remains to be established what treatment might be given to patients at high risk, but patients with high preoperative NLR should be considered as candidates for more intensive multimodality and integrated treatment. We strongly believe that preoperative NLR might be used to screen patients more accurately in early stages, which generally undergo routine follow-up. NLR could be
The American Journal of Surgery, Vol 209, No 2, February 2015 used to select this group of patients who need a more aggressive follow-up and chemotherapic treatment. Therefore, our study could represent the basis for a prospective study.
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