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Prognostic utility of baseline neutrophil-to-lymphocyte ratio in patients receiving immune checkpoint inhibitors: a review and meta-analysis

Authors Sacdalan DB, Lucero JA, Sacdalan DL

Received 5 October 2017

Accepted for publication 5 December 2017

Published 23 February 2018 Volume 2018:11 Pages 955—965


Checked for plagiarism Yes

Review by Single-blind

Peer reviewer comments 2

Editor who approved publication: Dr Tohru Yamada

Danielle Benedict Sacdalan,1 Josephine Anne Lucero,2 Dennis Lee Sacdalan1

1Section of Medical Oncology, Department of Medicine, University of the Philippines Manila and Philippine General Hospital, Manila, Philippines; 2Department of Medicine, University of the Philippines Manila and Philippine General Hospital, Manila, Philippines

Introduction: Systemic inflammation is associated with prognosis in solid tumors. The neutrophil-to-lymphocyte ratio (NLR) is a marker for the general immune response to various stress stimuli. Studies have shown correlation of NLR to outcomes in immune checkpoint blockade, peripheral neutrophil count to intratumor neutrophil population, and NLR to intratumoral levels of myeloid-derived suppressor cells. Studies have shown elevated peripheral blood regulator T cells accompanied by elevated NLR are associated with poor outcomes further highlighting the importance of inflammation in the prognosis of cancer patients.
Methods: We performed a meta-analysis of published articles on the utility of baseline NLR in predicting outcomes in patients treated with immune checkpoint inhibitors (ICIs) using Review Manager, version 5.3. Seven studies on the prognostic utility of NLR in ICI treatment were included in this analysis. For outcomes of interest, the hazard ratios (HRs) were computed. Subgroup analyses were planned based on type of malignancy and type of immune checkpoint inhibitor.
Results/discussion: A high NLR resulted in worse overall survival (OS) (HR, 1.92; 95% CI, 1.29–2.87; p=0.001) and progression-free survival (PFS; HR, 1.66; 95% CI, 1.38–2.01; p<0.00001) across types of malignancies studied (melanoma, non-small-cell lung cancer, and genitourinary cancer). Subgroup analysis across different types of malignancies treated with ICI showed similar results for OS and PFS. The single study on genitourinary cancers also showed worse OS and PFS (OS: HR, 1.82; 95% CI, 1.29–2.87; p=0.001 and PFS: HR, 1.83; 95% CI, 0.97–3.44; p=0.06). A high NLR also showed worse OS and PFS across all ICIs (ipilimumab, nivolumab, and unspecified or pooled pembrolizumab and nivolumab; OS: HR, 1.92; 95% CI, 1.29–2.87; p=0.001 and PFS: HR, 1.66; 95% CI, 1.38–2.01; p<0.00001). Subgroup analysis by type of ICI showed similar results.
Conclusion: A high NLR is associated with poorer outcomes across studies. This shows that NLR has the potential as a readily available prognostic indicator for patients receiving ICI based on available studies. Studies utilizing more stringent design may serve to better determine the utility of this tool.

Keywords: neutrophil-to-lymphocyte ratio, immunotherapy, biomarkers, inflammation

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