Impact of pretherapeutic neutrophil-to-lymphocyte ratio, serum albumin, body-mass index, and advanced lung cancer inflammation index on clinical outcome in sinonasal squamous cell carcinoma
Introduction
Sinonasal carcinomas include cancers of the nasal cavity and paranasal sinuses. These carcinomas comprise less than 1% of all cancers among men and less than 0.5% among women (Curado et al., 2007). Most sinonasal cancers have an epithelial histology, with squamous cell carcinomas being the most frequent, followed by adenocarcinomas (Franchi et al., 2011). Survival of patients with this rare and aggressive malignancy is low, with a 5-year survival rate of less than 40% (Kuo et al., 2017).
A common therapy modality for sinonasal squamous cell carcinoma (SNSCC) is surgical resection, showing excellent results in small tumors with clear resection margins (Robbins et al., 2011). However, in many patients SNSCC is detected at a rather advanced stage, which makes surgical resection more difficult, especially because of the close proximity to the orbit and skull base. In large tumors and in resections with positive margins, postoperative radiotherapy is employed. However, survival of these patients remains poor. In locally advanced cases (T4b) primary chemoradiotherapy is utilized, although the benefit of this therapeutic approach remains questionable (Porceddu et al., 2004).
Systemic inflammation is known to be an important factor during carcinogenesis in many cancer types; it enhances angiogenesis, response to treatment, and metastasis development (Mantovani, 2009). The role of inflammation in sinonasal cancer was investigated by Turri-Zanoni et al. (2017). They reported that high pretherapeutic values of neutrophil-to-lymphocyte ratio (NLR) and platelet-to-lymphocyte ratio (PLR) were associated with poor survival.
Pretherapeutic values of nutrition markers, namely body-mass index (BMI) and serum albumin (ALB), can also be used as survival predictors in malignant diseases. Gama et a.l (Gama et al., 2017) noted that high BMI prior to therapy is associated with better outcomes in head and neck cancer. Similar results were reported by Takenaka et al. (2015).
Pretreatment ALB was shown to be a significant prognosticator in head and neck squamous cell carcinoma Lim et al. (Lim et al., 2017). Head and neck cancer patients often present with a poor nutritional status and weight loss at the time of initial diagnosis (McRackan et al., 2008). Therefore, patients with a higher BMI might have greater nutritional reserves for enduring the side-effects of radio- and chemotherapy, including appetite loss, mucositis, and oral pain (Jafri et al., 2013).
Advanced lung cancer inflammation index (ALI) appears to be another useful tool for predicting patients outcome. It is calculated by multiplying the ALB value (g/l) and the BMI, and then dividing by the NLR. The importance of its predictive value has been shown with regard to lung cancer (Jafri et al., 2013). Feng et al. (2014) reported on the significant prognostic value of ALI in esophageal squamous cell carcinoma. Jank et al. (2019) noted that low pretherapeutic ALI was linked with significantly worse overall survival (OS) and disease-free survival (DFS) in patients with head and neck squamous cell carcinoma undergoing primary surgical resection with postoperative radiotherapy.
Generally, research into predictive markers in head and neck cancer focuses on tumors localized in the oral cavity, pharynx, or larynx. Studies investigating SNSCC are comparatively rare. Our study aimed to investigate the prognostic value of pretherapeutic inflammation and the nutritional markers NLR, ALB, BMI, and ALI in SNSCC patients.
Section snippets
Materials and methods
This retrospective study was conducted at a tertiary academic referral center (Department of Otorhinolaryngology and Head and Neck Surgery at the Medical University of Vienna, Austria). Eligibility criteria for inclusion in the study were presence of pathologically confirmed SNSCC, available pretherapeutic blood samples, and data on height and weight, prior to any kind of therapy.
Data on inpatient and outpatient activity for all patients fulfilling the inclusion criteria were extracted from the
Results
41 patients were treated for SNSCC in our center between 2002 and 2015. 26 patients (63.4%) were male. The mean age of our patient cohort was 60.6 years (range 35.5–84.7 years). A locally advanced tumor (T4) was observed in 23 patients (56.1%). Most of the patients had no lymph node metastases (33 patients — 80.5%). A single patient (2.4%) developed distant metastasis during radiotherapy. In our study, 51.2% patients (n = 21) underwent primary surgical resection and the remaining 48.8% received
Discussion
This retrospective study assessed the prognostic value of pretreatment markers including ALB, BMI, NLR and ALI in SNSCC. Patients with this rare form of cancer face poor survival rates. To date, aside from the TNM system, there are no routinely used prognostic indicators to assess prognosis for patients with SNSCC. Therefore, further markers are required in order to provide us with more information about this disease, which may help us to consult patients more effectively and to decide on the
Conclusion
In conclusion, there might be an association between low ALI and high NLR with worse OS in patients with SNSCC. However, our patient cohort was too small to observe an independent effect on patient outcome in association with these two variables. Serum ALB did not influence outcome. BMI showed the biggest potential as a prognostic marker in our study. Given the fact that these markers are inexpensive and easily obtainable during pretreatment evaluation, they could be conveniently used in
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