Neutrophil/Lymphocyte Ratio Can Upstage Bladder Cancer Patients Prior to Surgery

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SAN FRANCISCO—Prior to radical cystectomy for bladder cancer, preoperative neutrophil/lymphocyte ratio (NLR) can identify patients at risk for having non-organ-confined disease and who may benefit from neoadjuvant chemotherapy, University of Wisconsin investigators reported at the American College of Surgeons 97th Clinical Congress.

Their research, reported by Aaron Potretzke, MD, a surgical resident, earned the “Best Scientific Poster” award at the meeting.

“As urologists, we are limited in their ability to predict the final pathologic stage of bladder tumors,” Dr. Potretzke said. “This is evidenced by the fact that 50% of radical cystectomy cases are upstaged, and, more importantly, 43% are upstaged from previously organ-confined disease to non-organ-confined disease, which has a tremendous impact on prognosis and outcomes.”

Good clinical predictors of upstaging are also lacking, despite some correlation with hydronephrosis, tumor multifocality, lymphovascular invasion and carcinoma in situ.

Patients with non-organ-confined disease could benefit from neoadjuvant chemotherapy, which has proven overall and cancer-specific survival benefits for T3 bladder cancer. There is, therefore, great value in identifying these patients prior to surgery, he said.

“NLR has been shown to be an important predictor in gastric, colon, ovarian, pancreatic, and lymphatic cancer, so the purpose of our study was to evaluate NLR as a predictor of upstaging in bladder cancer,” Dr. Potretzke said.

The NLR is an indication of the immune system's capacity to fight off malignancy and metastasis, he explained.

The study included 76 patients who underwent radical cystectomy for urothelial cell cancer and were assessed for NLR within 100 days of surgery, were clinical stage T2 or higher, and had normal white blood cell counts preoperatively. Postoperative pathology categorized patients as upstaged, no change in stage or downstaged.

Upstaging of patients

Pathologists upstaged 42 patients (55.2%), downstaged 17 (22.4%), and kept the same stage in 17 (22.4%), he reported.

Patients who were upstaged had statistically significantly higher NLR ratios at baseline versus patients whose stage remained unchanged and those who were downstaged: 4.09, 2.78 and 2.36, respectively.

More importantly, he said, a significant difference in NLR was observed between non-organ-confined and organ-confined groups: 4,17 versus 2.60.

The researchers also created a receiver operating characteristic (ROC) curve to further define the utility of the NLR, compared to a well-validated nomogram for upstaging (Karakiewicz et al). “We found our simple assay was more predictive and useful, with an area under the curve of 0.718 versus 0.663,” he reported.

“Finally, we determined that 22 patients would have been upstaged based on their preoperative NLR,” Dr. Potretzke said. “We would have at least counseled these patients as to the benefits of neoadjuvant chemotherapy, which could have had a real clinical impact.”

The investigators will be implementing NLR in their clinic, and will further assess its utility in a clinical trial in which patients with high NLR will be randomly assigned to neoadjuvant chemotherapy or immediate cystectomy, he said.

Barbara Bass, MD, of Methodist Hospital in Houston, who moderated the Best Scientific Poster session, said this research “has the potential to become a clinically practice-changing.”



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