328 Research paper
Neutrophil/lymphocyte ratio, platelet/lymphocyte ratio, and mean platelet volume as potential biomarkers for early detection and monitoring of colorectal adenocarcinoma Serta Kilincalpa, Şahin Çobana, Hakan Akincia, Mevlüt Hamamcıa, Fatih Karaahmeta, Yusuf Coşkuna, Yusuf Üstüna, Zahide Şimşeka, Elife Erarslana and İlhami Yüksela,b Colorectal cancer (CRC) is the third most common cause of cancer-related death in Europe. The aim of the present study was to elucidate the efficiency of the neutrophil/ lymphocyte ratio (NLR), the platelet/lymphocyte ratio (PLR), and the mean platelet volume (MPV) as tools for the preoperative diagnosis of CRC and their usefulness in the follow-up of CRC. A total of 144 CRC patients, as diagnosed by colonoscopy, and 143 age-matched and sex-matched healthy participants were included in the study. Medical records were used to compare preoperative and postoperative data including hemoglobin levels, platelet counts, MPV, NLR, and PLR. NLR, PLR, and MPV were significantly higher in CRC patients preoperatively, compared with healthy participants. Receiver-operating characteristic curve analysis suggested 2.02 as the cutoff value for NLR [area under the curve (AUC): 0.921, sensitivity: 86%, specificity: 84%], 135 as the cutoff value for PLR, (AUC: 0.853, sensitivity: 70%, specificity: 90%) and 8.25 fl as the cutoff value for MPV (AUC: 0.717, sensitivity: 54%, specificity: 76%). Subgroup analysis showed that NLR, PLR, and MPV levels were also significantly higher in nonanemic
Introduction Colorectal cancer (CRC) is the third most common cause of cancer-related death in Europe, and with population ageing, the number of deaths from CRC is expected to rise (Ferlay et al., 2010). On average, the lifetime risk of developing colon cancer is about 5% (American Cancer Society Cancer Facts and Figures, 2011–2013). About 70% of cases arise in the colon and about 28% in the rectum. CRC-related death can be prevented through readily available screening. Unfortunately, only 39% of cancers are diagnosed at an early stage. When the disease is at an advanced stage with documented metastatic involvement of lymph nodes or other organs, the prognosis is especially dismal. The corresponding 5-year survival rate for patients with known distant metastasis is about 10% (American Cancer Society Cancer Facts and Figures, 2011–2013). CRC can remain clinically silent for years. When present, symptoms often develop insidiously over a period of months and years. The main symptoms suggesting CRC are rectal bleeding, abdominal pain, and a change in
CRC patients compared with the control group, which is of great theoretical and clinical value for the early detection of CRC. Surgical tumor resection resulted in a significant decrease in NLR, PLR, and MPV. Our results suggest that NLR, PLR, and MPV may be used as easily available additional biomarkers for CRC in screening the general population, as well as in postoperative follow-up. European Journal of Cancer Prevention 24:328–333 Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved. European Journal of Cancer Prevention 2015, 24:328–333 Keywords: biomarker, colorectal cancer, diagnose, mean platelet volume, neutrophil/lymphocyte ratio, platelet/lymphocyte ratio a Department of Gastroenterology, Dıskapı Yıldırım Beyazıt Educational and Research Hospital and bDepartment of Gastroenterology, Yıldırım Beyazıt University School of Medicine, Ankara, Turkey
Correspondence to Serta Kilincalp, MD, Department of Gastroenterology, Dıskapı Education and Research Hospital, Altındag, 06120, Ankara, Turkey Tel: + 90 312 596 30 85; fax: + 90 312 318 66 90; e-mail: [email protected] Received 8 April 2014 Accepted 5 September 2014
defecation habits. Total resection of all malignant tissue is the treatment of choice for most patients with CRC, and it is currently the only treatment option that offers a reasonable chance of cure. A primary goal following curative resection of CRC is to detect a possible curable tumor relapse or second primary tumors. Several tumor factors have been used in the diagnosis and follow-up of CRC, including carcinoembryonic antigen (CEA), carbohydrate antigen 19-9 (CA 19-9), α-fetoprotein, and tumorspecific growth factor (Hu et al., 2013). Nevertheless, their clinical usefulness remains controversial from diagnostic, prognostic, and surveillance points of view. Neutrophil count, lymphocyte count, platelet count, and the mean platelet volume (MPV) are parameters routinely determined by complete blood count (CBC) analyzers. Neutrophil/lymphocyte ratio (NLR) as well as platelet/lymphocyte ratio (PLR) can be determined by dividing the sum of neutrophil and platelet counts by the lymphocyte count. A complex interaction between the local characteristics of the tumor and the host inflammatory response has been shown to predict earlier tumor
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Copyright © 2015 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
DOI: 10.1097/CEJ.0000000000000092
NLR, PLR, and MPV as biomarkers for CRC Kilincalp et al. 329
relapse and mortality in operable CRCs (Walsh et al., 2005). NLR and PLR are markers of systemic inflammatory response and their elevation has been shown in some studies to be associated with progression of CRC (Walsh et al., 2005; Kurt et al., 2012). MPV is an indicator of the average thrombocyte volume, recognized as a hallmark of platelet production rate and stimulation. The association between increased MPV and the presence of many solid tumors such as hepatocellular carcinoma, pancreatic carcinoma, lung cancer, endometrial cancer, and gastric cancer has been widely reported (Karaman et al., 2011; Kurt et al., 2012; Ishizuka et al., 2013; Kılınçalp et al., 2013; Oge et al., 2013; Inagaki et al., 2014). However, the predictive value or usefulness of NLR, PLR, and MPV in the diagnosis and follow-up of CRC has not been investigated yet. The aim of the present study was to assess the utility of MPV, NLR, and PLR as tools for the preoperative diagnosis of CRC and in follow-up of CRC, and also to investigate whether there is an association of these markers with the disease stage.
Patients and methods The medical records of all patients with CRC at Diskapi Education and Research Hospital were examined. The period covered was from December 2010 to November 2013. The records of patients with CRC who had been diagnosed by colonoscopy for various indications and had undergone colorectal resection thereafter were retrospectively reviewed for demographic and clinical information. Patients with coexistent hematological disorders, renal disease, chronic infection, coronary artery or cerebrovascular disease, and other types of cancers were excluded from the study. Patients who had received preoperative chemoradiotherapy and those with postoperative infections including wound infections were also excluded. Only patients with histological confirmation of adenocarcinomas were included in the study. The staging of CRC was performed according to the tumor–nodes–metastases (TNM) classification, in accordance with the American Joint Committee on Cancer recommendations (Edge et al., 2010). In total, 144 CRC patients and 143 age-matched and sex-matched healthy participants, who were diagnosed as healthy by colonoscopy, were included in the study. Preoperative and postoperative data including hemoglobin (Hb) levels, platelet counts, MPV, NLR, and PLR were recorded. Anemia was defined by Hb less than 13 g/dl in men and less than 12 g/dl in women. Preoperative data were obtained from colonoscopic examination in the week before the operation. Postoperative data were obtained 2 weeks after the operation. NLR and PLR were directly calculated from the CBC. CBCs of ethylenediaminetetraacetic acid-treated blood were measured using Siemens Healthcare Diagnostic Item ADVIA 2120i (Siemens Healthcare, Malvern, Pennsylvania, USA), and
blood samples were analyzed within 1 h after veni puncture. Normal MPV in our laboratory was between 7.0 and 11.5 fl. Statistical analysis
SPSS software (SPSS 16.0, Chicago, Illinois, USA) was used for statistical analyses. Data were expressed as mean ± SD. An independent t-test was used to compare the parameters of preoperative CRC patients and controls. The χ2-test was used to compare the categorical variables. The paired sample test was used to compare the preoperative and postoperative variables. Receiveroperating characteristic (ROC) curve analysis was carried out to identify optimal cutoff values of NLR, PLR, and MPV. A P-value cutoff less than 0.05 was considered statistically significant.
Results A total of 144 patients with CRC and a control group of 143 healthy participants were enrolled in this study. The demographic characteristics, CBCs, tumor localization, and TNM staging of patients and controls are shown in Table 1. There was no statistical difference between the groups in age and sex. Independent of TNM stage, NLR, PLR, and MPV were significantly higher in preoperative CRC patients compared with healthy participants (6.13 vs. 1.50, P < 0.001; 230.5 vs. 106.5, P < 0.001; 8.41 vs. 7.82 fl, P < 0.001; Tables 1 and 2). ROC analysis suggested 2.02 as the cutoff value for NLR [area under the curve (AUC): 0.921, sensitivity: 86%, specificity: 84%], 135 as the cutoff value for PLR (AUC: 0.853, sensitivity: 70%, specificity: 90%), and 8.25 fl as the cutoff value of MPV (AUC: 0.717, sensitivity: 54%, Table 1
Demographic features of preoperative patients and
controls Variables Age (mean ± SD) (years) Sex (male/female) Tumor location [n (%)] Rectum Left colon Right colon TNM staging [n (%)] І ІІ ІІІ ІV Anemia [n (%)] Yes No Hb (mean ± SD) (g/dl) Platelets (mean ± SD) (109/l) MPV (mean ± SD) (fl) NLR (mean ± SD) PLR (mean ± SD)
CRC patients (N = 144)
Control group (N = 143)
P-value
61.3 ± 12.9
60.0 ± 12.7
0.40
98/46
97/45
0.93
100 (69.4) 44 (30.6) 11.6 ± 2.2 280.8 ± 106.1
14.2 ± 1.17 239.7 ± 50.7
< 0.001 < 0.001
8.41 ± 0.98 6.1 ± 5.8 230.5 ± 145.2
7.82 ± 0.49 1.5 ± 0.4 106.3 ± 23.6
< 0.001 < 0.001 < 0.001
47 (32.7) 59 (40.9) 38 (26.4) 24 43 46 31
(16) (30) (32) (21)
CRC, colorectal cancer; Hb, hemoglobin; MPV, mean platelet volume; NLR, neutrophil/lymphocyte ratio; PLR, platelet/lymphocyte ratio; TNM, tumor–nodes– metastases.
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330 European Journal of Cancer Prevention 2015, Vol 24 No 4
MPV, NLR, and PLR values of preoperative CRC patients according to TNM stages, as well as of controls
Table 2
MPV (fl) (mean ± SD)
NLR (mean ± SD)
Comparison of MPV, NLR, and PLR values of preoperative nonanemic CRC patients with those of controls
Table 3
Variable PLR (mean ± SD)
P-value*
211.1 ± 189.2 250.2 ± 173.4 210.5 ± 135.3 236.6 ± 122.9 106.3 ± 23.6
< 0.001 < 0.001 < 0.001 < 0.001
TNM staging of CRC patients (N = 144) І (n = 24) 8.27 ± 0.63 6.97 ± 6.4 ІІ (n = 43) 8.55 ± 1.04 6.96 ± 6.6 ІІІ (n = 46) 8.33 ± 0.81 6.59 ± 7.1 ІV (n = 31) 8.39 ± 0.73 5.14 ± 3.4 Control group 7.82 ± 0.49 1.5 ± 0.4 (N = 143)
CRC, colorectal cancer; MPV, mean platelet volume; NLR, neutrophil/lymphocyte ratio; PLR, platelet/lymphocyte ratio; TNM, tumor–nodes–metastases. *P-value represents the comparison of MPV, NLR, and PLR values of preoperative nonanemic CRC patients with those of controls.
Platelets (mean ± SD) (109/l) MPV (mean ± SD) (fl) NLR (mean ± SD) PLR (mean ± SD)
ROC curve
Control group
P-value
262.4 ± 79.3 8.23 ± 0.98 4.56 ± 5.6 157.4 ± 84.9
239.7 ± 50.7 7.82 ± 0.49 1.5 ± 0.4 106.3 ± 23.6
0.089 0.019 < 0.001 < 0.001
CRC, colorectal cancer; MPV, mean platelet volume; NLR, neutrophil/lymphocyte ratio; PLR, platelet/lymphocyte ratio.
Table 4 Comparison of preoperative and postoperative Hb levels, platelet levels, MPV, NLR, and PLR of CRC patients Variable Hb (mean ± SD) (g/dl) Platelets (mean ± SD) (109/l) MPV (mean ± SD) (fl) NLR (mean ± SD) PLR (mean ± SD)
Fig. 1
CRC (nonanemic)
Preoperative
Postoperative
P-value
11.6 ± 2.2 280.8 ± 106.1 8.41 ± 0.98 6.13 ± 5.8 230.5 ± 145.2
11.8 ± 1.7 231.7 ± 162.0 7.91 ± 0.62 2.38 ± 2.2 141.6 ± 106.9
0.214 < 0.001 < 0.001 < 0.001 < 0.001
CRC, colorectal cancer; Hb, hemoglobin; MPV, mean platelet volume; NLR, neutrophil/lymphocyte ratio; PLR, platelet/lymphocyte ratio.
1.0
Discussion
Sensitivity
0.8
0.6
0.4 Source of the curve Preoperative NLR Preoperative PLR Preoperative MPV Reference line
0.2
0.0 0.0
0.2
0.4 0.6 1−specificity
0.8
1.0
ROC curves of NLR, PLR, and MPV for preoperative patients and controls. AUC for NLR, PLR, and MPV are 0.921, 0.853, and 0.717, respectively. AUC, area under the curve; MPV, mean platelet volume; NLR, neutrophil/lymphocyte ratio; PLR, platelet/lymphocyte ratio; ROC, receiver-operating characteristic.
specificity: 76%; Fig. 1). In the patient group, 44 patients were nonanemic. Subgroup analysis showed that NLR, PLR, and MPV were significantly higher in nonanemic CRC patients compared with age-matched and sexmatched healthy participants (4.56 vs. 1.42, P < 0.001; 157.4 vs. 107.1, P < 0.001; 8.23 vs. 7.75 fl, P = 0.019; Table 3). Surgical tumor resection resulted in a significant decrease in NLR, PLR, and MPV (6.13 vs. 2.38, P < 0.001; 230.5 vs. 141.6, P < 0.001; 8.41 vs. 7.91 fl, P < 0.001; Table 4). We further investigated NLR, PLR, and MPV according to TNM stage. There was no statistically significant difference between NLR, PLR, and MPV, on one side, and TNM stages, on the other.
CRC is the second most common cancer among women and the third most common cancer among men worldwide. CRC is one of the major causes of mortality, with a 5-year survival rate of ∼ 50% (Boyle and Ferlay, 2005). Moreover, 25% of the patients show metastases of the liver and lungs at the time of presentation (Simmonds et al., 2006). When the disease is at an advanced stage with documented metastatic involvement, the prognosis is especially grim. Therefore, prompt diagnostic evaluation is vital when CRC is suspected. In the development and progression of cancer, inflammation is a crucial and essential process (Balkwill and Coussens, 2004). Persistence of the inflammatory process within the tumor leads to an increase in the proliferation of tumor cells, angiogenesis, and the inhibition of apoptosis. Several reports have suggested that markers of systemic inflammation including cytokines, C-reactive protein, Glasgow Prognostic Score, NLR, and PLR may provide useful information on the prognosis of CRC (Erlinger et al., 2004; Walsh et al., 2005; Roxburgh et al., 2009; Klampfer, 2011; Kurt et al., 2012). Thus, pathogenesis of CRC appears to be an inflammation-driven malignancy. Usually, cancer cells are a source of inflammatory cytokines and growth factors. Interleukin-6 (IL-6) is an inflammatory cytokine that can cause carcinogenesis through several signal pathways involved in carcinogenesis, as well as metastasis of a variety of malignancies, including CRC (Knüpfer and Preiss, 2010). It has been shown that CRC patients have higher levels of IL-6 compared with a healthy control group (Knüpfer and Preiss, 2010). IL-6 is released from leukocytes and is also able to activate the production of IL-6 by tumor cells through the IL-6 receptor (Weidle et al., 2010). In
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NLR, PLR, and MPV as biomarkers for CRC Kilincalp et al. 331
addition, it has been proven that IL-6 can stimulate the growth of colorectal carcinoma cells through a paracrine mechanism (Schneider et al., 2010). Besides their role in homeostasis, platelets take part in the pathophysiology of tumor angiogenesis. Platelets are known to be the major transporter of vascular endothelial growth factor, which is the target for antiangiogenic therapies (Sierko and Wojtukiewicz, 2004). Vascular endothelial growth factor accelerates the formation of blood vessels in the tumor and facilitates infiltration and spread to adjacent tissues, which in turn promotes the formation of metastases (Wang et al., 2014). Solid tumors such as renal, gastric, and colon malignancies produce IL-6, which induces the proliferation and differentiation of megakaryocyte progenitors through specific receptors (Belluco et al., 2000; Negrier et al., 2004; Ashizawa et al., 2005). This process causes platelet activation and aggregation. Platelet size has been shown to reflect changes in the level of platelet stimulation and the rate of platelet production (Threatte, 1993). As for MPV, it is an indicator of platelet volume. Increased MPV indicates the presence of a subpopulation of young, metabolically and enzymatically more active platelets taking part in the process of homeostasis (Mangalpally et al., 2010). We speculate that increased MPV in a patient group newly diagnosed with CRC may be a reflection of ongoing colonic inflammation, and it can be related to increased levels of cytokines, particularly IL-6. Moreover, our results also demonstrated that MPV significantly decreased after CRC operation, suggesting that surgical resection of colon cancer not only effectively alleviates the tumor burden, but also the CRC-related inflammatory process. Thus, we suggest that MPV could be used for monitoring CRC relapse after surgical resection regardless of TNM staging. NLR and PLR are two representative indices of systemic inflammation. It has been shown that a preoperative NLR of greater than 4 or 5 is associated with a poor outcome in gastric cancer, non-small-cell lung cancer, and ovarian cancer (Cho et al., 2009; Shimada et al., 2010; Yao et al., 2013). Increased PLR was also demonstrated as being an independent adverse prognostic factor for CRC (Walsh et al., 2005). Neutrophils and leukocytes play a crucial role in the host systemic inflammatory response. A nonspecific systemic inflammatory response due to a tumor leads to an increase in the levels of circulating neutrophils and an elevated NLR, all of which are clearly demonstrated in our study. Lymphocytes play a key role in cytotoxic cell death and the production of cytokines that inhibit proliferation and metastatic spread of tumor cells (Ferradini et al., 1991; Tsiatas et al., 2009). In contrast, neutrophils have a protumor effect by being the primary source of circulating angiogenesis-regulating chemokines, growth factors, and proteases (Spicer et al., 2012). Elevated neutrophil levels
may result in an increase in angiogenesis, which promotes development and progression of the neoplasm (Kusumanto et al., 2003). Therefore, NLR can be considered as the balance between protumor inflammatory status and antitumor immune status. At present, there is little information on the relevance of these prognostic markers to both diagnosis and monitoring of CRC. Our results demonstrate that newly diagnosed CRC patients have significantly higher NLR and PLR compared with the healthy control group, regardless of anemia. Moreover, we found that surgical tumor resection resulted in a significant decrease in NLR and PLR. However, no relationship was observed between NLR and PLR, on one side, and TNM stages, on the other. Screening and surveillance have a documented benefit in reducing the risk of CRC-related morbidity and mortality (Rex et al., 2009). Fecal occult blood testing (FOBT) is the most widely available screening modality for CRC. It typically involves a two-stage approach, with patients positive for the test being referred for colonoscopy. Multiple studies have provided information on the sensitivity and specificity of immunochemical FOBT for the detection of CRC, in which the sensitivity ranged from 47.1 to 69%, and the specificity from 81.8 to 100% (Morikawa et al., 2005). In contrast, the sensitivity of the guaiac test for detecting CRC has been reported to be as low as 37.1%, with a specificity of 86.7% (Allison et al., 1996). However, the immunochemical tests are more expensive than the guaiac-based tests, which limits their use. Colonoscopy is widely regarded as the reference standard for CRC screening. However, several factors contribute to the lack of compliance with colonoscopic screening, including inappropriate perception of risk, dietary restrictions, and the invasiveness of the procedure (Levin et al., 2008). When compared with previous studies, the diagnostic specificity and sensitivity of NLR at least 2.05 (sensitivity: 86%, specificity: 84%), PLR at least 130 (sensitivity: 70%, specificity: 90%), and MPV at least 8.25 fl (sensitivity: 54%, specificity: 76%) for detecting CRC are comparable to FOBT (Allison et al., 1996; Morikawa et al., 2005). Thus, independent of the presence of anemia, high NLR, PLR, and MPV may help to diagnose CRC earlier, especially when used with the other markers and diagnostic methods. Iron-deficiency anemia has been recognized as a feature of CRC. It is present in 57% of patients with CRC and is particularly suggestive of cecal tumors (Fjørtoft et al., 2013). There is broad consensus among physicians that individuals with unexplained iron-deficiency anemia should be considered for a colonoscopy to exclude colonic neoplasm. Although CRC is often associated with iron-deficiency anemia, its absence does not necessarily exclude the disease. Thus, patients without anemia might suffer a delay in the diagnosis of CRC. In our study 44 CRC patients did not have anemia at the time of diagnosis. There was a significant difference in NLR,
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332 European Journal of Cancer Prevention 2015, Vol 24 No 4
PLR, and MPV between nonanemic CRC patients and control participants, which may be of clinical value for early detection of CRC. Patients with resected CRCs are candidates for a followup program. This includes outpatient visits and clinical, hematological, radiological, and colonoscopic evaluation. However, failure in detection of asymptomatic recurrences is ∼50%, which is more likely to result in attempts at curative reoperation (Walker et al., 2014). A variety of serum tumor markers are commonly used in CRC detection, particularly CEA and CA 19-9. Previous studies have suggested that CEA and CA 19-9 do not show satisfactory sensitivity as screening markers for CRC (Yamashita and Watanabe, 2009). The use of CEA to monitor patients after CRC resection can have advantages (early detection of recurrences), as well as disadvantages (false-positive CEA rises). Because of the poor sensitivity, it is frequently used in combination with other tumor markers, particularly with CA 19-9. In CRC, the majority of preoperative CEA studies showed that it could be used as a prognostic indicator (Søreide et al., 2009). However, the sensitivity of CEA for early colon cancer detection is low. The CEA level is associated with tumor stage, and it was demonstrated that CEA levels are elevated when the tumor is at an advanced stage (Yi et al., 2013). It was also shown that an increase in CEA level implies a higher recurrence rate and worse prognosis (Wanebo et al., 1978). The overall reported incidences of high CA 19-9 levels in preoperative CRC patients range from 10.6 to 24.4% (Yu et al., 2013). In some previous studies, a high preoperative CA 19-9 level was shown to be independently associated with high pre-CEA, lymph node metastasis, large tumor size, and peritoneal seeding (Yang et al., 2004; Yu et al., 2013). However, the present data are insufficient to recommend CA 19-9 for staging, surveillance, or monitoring treatment of patients with CRC (Duffy et al., 2003). In the current study, we have demonstrated that NLR, PLR, and MPV decrease after colorectal resection, probably due to a decrease in the tumor burden. There are a few limitations to our study. First, our study has a single-center design and a retrospective nature of data acquisition. Second, the high NLR, PLR, and MPV that were observed in our study group of newly diagnosed CRC patients may be a reflection of a nonspecific inflammatory response due to CRC. Hence, any inflammatory or malignant process can lead to an increase in these parameters. In practice, these markers, if used alone, may have a low positive predictive value in screening an asymptomatic population. Therefore, prospective studies on a larger number of asymptomatic patients are needed to compare the performance of NLR, PLR, and MPV with that of other diagnostic and monitoring tests to confirm their diagnostic utility. Despite these limitations, we think our findings are still important in two respects. First, our results suggest that patients
with stage I and stage II disease have higher levels of these parameters than controls. Thus, independent of the presence of anemia, patients with high NLR, PLR, and MPV with suspicious symptoms and/or signs of CRC are candidates for early evaluation of CRC, which can prevent delay in the diagnosis of CRC. Second, a decrease in these potential markers after surgical resection indicates that they can be widely used in combination with other tumor markers such as CEA or CA 19-9 during the course of postoperative follow-up of patients with resected CRC, at low cost when compared with other modalities.
Acknowledgements Conflicts of interest
There are no conflicts of interest.
References Allison JE, Tekawa IS, Ransom LJ, Adrain AL (1996). A comparison of fecal occult-blood tests for colorectal-cancer screening. N Engl J Med 334:155–159. American Cancer Society Cancer Facts and Figures (2011-2013). Available at: http://www.cancer.org/. [Accessed 2 August 2014]. Ashizawa T, Okada R, Suzuki Y, Takagi M, Yamazaki T, Sumi T, et al. (2005). Clinical significance of interleukin-6 (IL-6) in the spread of gastric cancer: role of IL-6 as a prognostic factor. Gastric Cancer 8:124–131. Balkwill F, Coussens LM (2004). Cancer: an inflammatory link. Nature 431:405–6. Belluco C, Nitti D, Frantz M, Toppan P, Basso D, Plebani M, et al. (2000). Interleukin-6 blood level is associated with circulating carcinoembryonic antigen and prognosis in patients with colorectal cancer. Ann Surg Oncol 7:133–138. Boyle P, Ferlay J (2005). Mortality and survival in breast and colorectal cancer. Nat Clin Pract Oncol 2:424–425. Cho H, Hur HW, Kim SW, Kim SH, Kim JH, Kim YT, Lee K (2009). Pre-treatment neutrophil to lymphocyte ratio is elevated in epithelial ovarian cancer and predicts survival after treatment. Cancer Immunol Immunother 58:15–23. Duffy MJ, van Dalen A, Haglund C, Hansson L, Klapdor R, Lamerz R, et al. (2003). Clinical utility of biochemical markers in colorectal cancer: European Group on Tumour Markers (EGTM) guidelines. Eur J Cancer 39:718–727. Edge SB, Byrd DR, Compton CC, Fritz AG, Greene FL, Trotti A (2010). American joint committee on cancer staging manual. 7th ed. New York: Springer. Erlinger TP, Platz EA, Rifai N, Helzlsouer KJ (2004). C-reactive protein and the risk of incident colorectal cancer. JAMA 291:585–590. Ferlay J, Parkin DM, Steliarova-Foucher E (2010). Estimates of cancer incidence and mortality in Europe in 2008. Eur J Cancer 46:765–781. Ferradini L, Miescher S, Stoeck M, Busson P, Barras C, Cerf-Bensussan N, et al. (1991). Cytotoxic potential despite impaired activation pathways in T lymphocytes infiltrating nasopharyngeal carcinoma. Int J Cancer 47:362–370. Fjørtoft I, Furnes B, Hausken T, Storli KE, Eide GE, Søndenaa K (2013). Preoperative anaemia in colon cancer patients became normal after more than a year post-operatively but did not influence oncological outcome in the final analysis. Scand J Gastroenterol 48:663–671. Hu Y, Wang JL, Tao HT, Wu BS, Sun J, Cheng Y, et al. (2013). Expression and significance of TSGF, CEA and AFP in patients before and after radical surgery for colon cancer. Asian Pac J Cancer Prev 14:3877–3880. Inagaki N, Kibata K, Tamaki T, Shimizu T, Nomura S (2014). Prognostic impact of the mean platelet volume/platelet count ratio in terms of survival in advanced non-small cell lung cancer. Lung Cancer 83:97–101. Ishizuka M, Nagata H, Takagi K, Iwasaki Y, Kubota K (2013). Combination of platelet count and neutrophil to lymphocyte ratio is a useful predictor of postoperative survival in patients with colorectal cancer. Br J Cancer 109:401–407. Karaman K, Bostanci EB, Aksoy E, Kurt M, Celep B, Ulas M, et al. (2011). The predictive value of mean platelet volume in differential diagnosis of nonfunctional pancreatic neuroendocrine tumors from pancreatic adenocarcinomas. Eur J Intern Med 22:e95–e98. Kılınçalp S, Ekiz F, Başar O, Ayte MR, Coban S, Yilmaz B, et al. (2013). Mean platelet volume could be possible biomarker in early diagnosis and monitoring of gastric cancer. Platelets[Epub ahead of print]. Klampfer L (2011). Cytokines, inflammation and colon cancer. Curr Cancer Drug Targets 11:451–464.
Copyright © 2015 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
NLR, PLR, and MPV as biomarkers for CRC Kilincalp et al. 333
Knüpfer H, Preiss R (2010). Serum interleukin-6 levels in colorectal cancer patients – a summary of published results. Int J Colorectal Dis 25:135–140. Kurt M, Onal IK, Sayilir AY, Beyazit Y, Oztas E, Kekilli M, et al. (2012). The role of mean platelet volume in the diagnosis of hepatocellular carcinoma in patients with chronic liver disease. Hepatogastroenterology 59:1580–1582. Kusumanto YH, Dam WA, Hospers GA, Meijer C, Mulder NH (2003). Platelets and granulocytes, in particular the neutrophils, form important compartments for circulating vascular endothelial growth factor. Angiogenesis 6:283–287. Levin B, Lieberman DA, McFarland B, Andrews KS, Brooks D, Bond J, et al. American Cancer Society Colorectal Cancer Advisory Group; US MultiSociety Task Force; American College of Radiology Colon Cancer Committee (2008). Screening and surveillance for the early detection of colorectal cancer and adenomatous polyps, 2008: a joint guideline from the American Cancer Society, the US Multi-Society Task Force on Colorectal Cancer, and the American College of Radiology. Gastroenterology 134:1570–1595. Mangalpally KK, Siqueiros-Garcia A, Vaduganathan M, Dong JF, Kleiman NS, Guthikonda S (2010). Platelet activation patterns in platelet size sub-populations: differential responses to aspirin in vitro. J Thromb Thrombolysis 30:251–262. Morikawa T, Kato J, Yamaji Y, Wada R, Mitsushima T, Shiratori Y (2005). A comparison of the immunochemical fecal occult blood test and total colonoscopy in the asymptomatic population. Gastroenterology 129:422–428. Negrier S, Perol D, Menetrier-Caux C, Escudier B, Pallardy M, Ravaud A, et al. Groupe Francais d’Immunotherapie (2004). Interleukin-6, interleukin-10, and vascular endothelial growth factor in metastatic renal cell carcinoma: prognostic value of interleukin-6–from the Groupe Francais d’Immunotherapie. J Clin Oncol 22:2371–2378. Oge T, Yalcin OT, Ozalp SS, Isikci T (2013). Platelet volume as a parameter for platelet activation in patients with endometrial cancer. J Obstet Gynaecol 33:301–314. Rex DK, Johnson DA, Anderson JC, Schoenfeld PS, Burke CA, Inadomi JM. American College of Gastroenterology (2009). American College of Gastroenterology guidelines for colorectal cancer screening 2009 [corrected]. Am J Gastroenterol 104:739–750. Roxburgh CS, Crozier JE, Maxwell F, Foulis AK, Brown J, McKee RF, et al. (2009). Comparison of tumour-based (Petersen Index) and inflammation-based (Glasgow Prognostic Score) scoring systems in patients undergoing curative resection for colon cancer. Br J Cancer 100:701–706. Schneider MR, Hoeflich A, Fischer JR, Wolf E, Sordat B, Lahm H (2000). Interleukin-6 stimulates clonogenic growth of primary and metastatic human colon carcinoma cells. Cancer Lett 151:31–38. Shimada H, Takiguchi N, Kainuma O, Soda H, Ikeda A, Cho A, et al. (2010). High preoperative neutrophil–lymphocyte ratio predicts poor survival in patients with gastric cancer. Gastric Cancer 13:170–176. Sierko E, Wojtukiewicz MZ (2004). Platelets and angiogenesis in malignancy. Semin Thromb Hemost 30:95–108.
Simmonds PC, Primrose JN, Colquitt JL, Garden OJ, Poston GJ, Rees M (2006). Surgical resection of hepatic metastases from colorectal cancer: a systematic review of published studies. Br J Cancer 94:982–999. Søreide K, Nedrebø BS, Knapp JC, Glomsaker TB, Søreide JA, Kørner H (2009). Evolving molecular classification by genomic and proteomic biomarkers in colorectal cancer: potential implications for the surgical oncologist. Surg Oncol 18:31–50. Spicer JD, McDonald B, Cools-Lartigue JJ, Chow SC, Giannias B, Kubes P, Ferri LE (2012). Neutrophils promote liver metastasis via Mac-1-mediated interactions with circulating tumor cells. Cancer Res 72:3919–3927. Threatte GA (1993). Usefulness of the mean platelet volume. Clin Lab Med 13:937–950. Tsiatas ML, Gyftaki R, Liacos C, Politi E, Rodolakis A, Dimopoulos MA, Bamias A (2009). Study of T lymphocytes infiltrating peritoneal metastases in advanced ovarian cancer: associations with vascular endothelial growth factor levels and prognosis in patients receiving platinum-based chemotherapy. Int J Gynecol Cancer 19:1329–1334. Walker AS, Zwintscher NP, Johnson EK, Maykel JA, Stojadinovic A, Nissan A, et al. (2014). Future directions for monitoring treatment response in colorectal cancer. J Cancer 5:44–57. Walsh SR, Cook EJ, Goulder F, Justin TA, Keeling NJ (2005). Neutrophil–lymphocyte ratio as a prognostic factor in colorectal cancer. J Surg Oncol 91:181–184. Wanebo HJ, Rao B, Pinsky CM, Hoffman RG, Stearns M, Schwartz MK, Oettgen HF (1978). Preoperative carcinoembryonic antigen level as a prognostic indicator in colorectal cancer. N Engl J Med 299:448–451. Wang Y, Han G, Wang K, Liu G, Wang R, Xiao H, et al. (2014). Tumor-derived GM-CSF promotes inflammatory colon carcinogenesis via stimulating epithelial release of VEGF. Cancer Res 74:716–726. Weidle UH, Klostermann S, Eggle D, Krüger A (2010). Interleukin 6/interleukin 6 receptor interaction and its role as a therapeutic target for treatment of cachexia and cancer. Cancer Genomics Proteomics 7:287–302. Yamashita K, Watanabe M (2009). Clinical significance of tumor markers and an emerging perspective on colorectal cancer. Cancer Sci 100:195–199. Yang SH, Lin JK, Lai CR, Chen CC, Li AF, Liang WY, Jiang JK (2004). Risk factors for peritoneal dissemination of colorectal cancer. J Surg Oncol 87:167–173. Yao Y, Yuan D, Liu H, Gu X, Song Y (2013). Pretreatment neutrophil to lymphocyte ratio is associated with response to therapy and prognosis of advanced non-small cell lung cancer patients treated with first-line platinumbased chemotherapy. Cancer Immunol Immunother 62:471–479. Yi JH, Kim H, Jung M, Shin SJ, Choi JS, Choi GH, et al. (2013). Prognostic factors for disease-free survival after preoperative chemotherapy followed by curative resection in patients with colorectal cancer harboring hepatic metastasis: a single-institute, retrospective analysis in Asia. Oncology 85:283–239. Yu H, Son GM, Joh YG (2013). The clinical significance of preoperative serum levels of carbohydrate antigen 19-9 in colorectal cancer. J Korean Surg Soc 84:231–237.
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Neutrophil/lymphocyte ratio, platelet/lymphocyte ratio, and mean platelet volume as potential biomarkers for early detection and monitoring of colorectal adenocarcinoma Serta Kilincalpa, Şahin Çobana, Hakan Akincia, Mevlüt Hamamcıa, Fatih Karaahmeta, Yusuf Coşkuna, Yusuf Üstüna, Zahide Şimşeka, Elife Erarslana and İlhami Yüksela,b Colorectal cancer (CRC) is the third most common cause of cancer-related death in Europe. The aim of the present study was to elucidate the efficiency of the neutrophil/ lymphocyte ratio (NLR), the platelet/lymphocyte ratio (PLR), and the mean platelet volume (MPV) as tools for the preoperative diagnosis of CRC and their usefulness in the follow-up of CRC. A total of 144 CRC patients, as diagnosed by colonoscopy, and 143 age-matched and sex-matched healthy participants were included in the study. Medical records were used to compare preoperative and postoperative data including hemoglobin levels, platelet counts, MPV, NLR, and PLR. NLR, PLR, and MPV were significantly higher in CRC patients preoperatively, compared with healthy participants. Receiver-operating characteristic curve analysis suggested 2.02 as the cutoff value for NLR [area under the curve (AUC): 0.921, sensitivity: 86%, specificity: 84%], 135 as the cutoff value for PLR, (AUC: 0.853, sensitivity: 70%, specificity: 90%) and 8.25 fl as the cutoff value for MPV (AUC: 0.717, sensitivity: 54%, specificity: 76%). Subgroup analysis showed that NLR, PLR, and MPV levels were also significantly higher in nonanemic
Introduction Colorectal cancer (CRC) is the third most common cause of cancer-related death in Europe, and with population ageing, the number of deaths from CRC is expected to rise (Ferlay et al., 2010). On average, the lifetime risk of developing colon cancer is about 5% (American Cancer Society Cancer Facts and Figures, 2011–2013). About 70% of cases arise in the colon and about 28% in the rectum. CRC-related death can be prevented through readily available screening. Unfortunately, only 39% of cancers are diagnosed at an early stage. When the disease is at an advanced stage with documented metastatic involvement of lymph nodes or other organs, the prognosis is especially dismal. The corresponding 5-year survival rate for patients with known distant metastasis is about 10% (American Cancer Society Cancer Facts and Figures, 2011–2013). CRC can remain clinically silent for years. When present, symptoms often develop insidiously over a period of months and years. The main symptoms suggesting CRC are rectal bleeding, abdominal pain, and a change in
CRC patients compared with the control group, which is of great theoretical and clinical value for the early detection of CRC. Surgical tumor resection resulted in a significant decrease in NLR, PLR, and MPV. Our results suggest that NLR, PLR, and MPV may be used as easily available additional biomarkers for CRC in screening the general population, as well as in postoperative follow-up. European Journal of Cancer Prevention 24:328–333 Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved. European Journal of Cancer Prevention 2015, 24:328–333 Keywords: biomarker, colorectal cancer, diagnose, mean platelet volume, neutrophil/lymphocyte ratio, platelet/lymphocyte ratio a Department of Gastroenterology, Dıskapı Yıldırım Beyazıt Educational and Research Hospital and bDepartment of Gastroenterology, Yıldırım Beyazıt University School of Medicine, Ankara, Turkey
Correspondence to Serta Kilincalp, MD, Department of Gastroenterology, Dıskapı Education and Research Hospital, Altındag, 06120, Ankara, Turkey Tel: + 90 312 596 30 85; fax: + 90 312 318 66 90; e-mail: [email protected] Received 8 April 2014 Accepted 5 September 2014
defecation habits. Total resection of all malignant tissue is the treatment of choice for most patients with CRC, and it is currently the only treatment option that offers a reasonable chance of cure. A primary goal following curative resection of CRC is to detect a possible curable tumor relapse or second primary tumors. Several tumor factors have been used in the diagnosis and follow-up of CRC, including carcinoembryonic antigen (CEA), carbohydrate antigen 19-9 (CA 19-9), α-fetoprotein, and tumorspecific growth factor (Hu et al., 2013). Nevertheless, their clinical usefulness remains controversial from diagnostic, prognostic, and surveillance points of view. Neutrophil count, lymphocyte count, platelet count, and the mean platelet volume (MPV) are parameters routinely determined by complete blood count (CBC) analyzers. Neutrophil/lymphocyte ratio (NLR) as well as platelet/lymphocyte ratio (PLR) can be determined by dividing the sum of neutrophil and platelet counts by the lymphocyte count. A complex interaction between the local characteristics of the tumor and the host inflammatory response has been shown to predict earlier tumor
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DOI: 10.1097/CEJ.0000000000000092
NLR, PLR, and MPV as biomarkers for CRC Kilincalp et al. 329
relapse and mortality in operable CRCs (Walsh et al., 2005). NLR and PLR are markers of systemic inflammatory response and their elevation has been shown in some studies to be associated with progression of CRC (Walsh et al., 2005; Kurt et al., 2012). MPV is an indicator of the average thrombocyte volume, recognized as a hallmark of platelet production rate and stimulation. The association between increased MPV and the presence of many solid tumors such as hepatocellular carcinoma, pancreatic carcinoma, lung cancer, endometrial cancer, and gastric cancer has been widely reported (Karaman et al., 2011; Kurt et al., 2012; Ishizuka et al., 2013; Kılınçalp et al., 2013; Oge et al., 2013; Inagaki et al., 2014). However, the predictive value or usefulness of NLR, PLR, and MPV in the diagnosis and follow-up of CRC has not been investigated yet. The aim of the present study was to assess the utility of MPV, NLR, and PLR as tools for the preoperative diagnosis of CRC and in follow-up of CRC, and also to investigate whether there is an association of these markers with the disease stage.
Patients and methods The medical records of all patients with CRC at Diskapi Education and Research Hospital were examined. The period covered was from December 2010 to November 2013. The records of patients with CRC who had been diagnosed by colonoscopy for various indications and had undergone colorectal resection thereafter were retrospectively reviewed for demographic and clinical information. Patients with coexistent hematological disorders, renal disease, chronic infection, coronary artery or cerebrovascular disease, and other types of cancers were excluded from the study. Patients who had received preoperative chemoradiotherapy and those with postoperative infections including wound infections were also excluded. Only patients with histological confirmation of adenocarcinomas were included in the study. The staging of CRC was performed according to the tumor–nodes–metastases (TNM) classification, in accordance with the American Joint Committee on Cancer recommendations (Edge et al., 2010). In total, 144 CRC patients and 143 age-matched and sex-matched healthy participants, who were diagnosed as healthy by colonoscopy, were included in the study. Preoperative and postoperative data including hemoglobin (Hb) levels, platelet counts, MPV, NLR, and PLR were recorded. Anemia was defined by Hb less than 13 g/dl in men and less than 12 g/dl in women. Preoperative data were obtained from colonoscopic examination in the week before the operation. Postoperative data were obtained 2 weeks after the operation. NLR and PLR were directly calculated from the CBC. CBCs of ethylenediaminetetraacetic acid-treated blood were measured using Siemens Healthcare Diagnostic Item ADVIA 2120i (Siemens Healthcare, Malvern, Pennsylvania, USA), and
blood samples were analyzed within 1 h after veni puncture. Normal MPV in our laboratory was between 7.0 and 11.5 fl. Statistical analysis
SPSS software (SPSS 16.0, Chicago, Illinois, USA) was used for statistical analyses. Data were expressed as mean ± SD. An independent t-test was used to compare the parameters of preoperative CRC patients and controls. The χ2-test was used to compare the categorical variables. The paired sample test was used to compare the preoperative and postoperative variables. Receiveroperating characteristic (ROC) curve analysis was carried out to identify optimal cutoff values of NLR, PLR, and MPV. A P-value cutoff less than 0.05 was considered statistically significant.
Results A total of 144 patients with CRC and a control group of 143 healthy participants were enrolled in this study. The demographic characteristics, CBCs, tumor localization, and TNM staging of patients and controls are shown in Table 1. There was no statistical difference between the groups in age and sex. Independent of TNM stage, NLR, PLR, and MPV were significantly higher in preoperative CRC patients compared with healthy participants (6.13 vs. 1.50, P < 0.001; 230.5 vs. 106.5, P < 0.001; 8.41 vs. 7.82 fl, P < 0.001; Tables 1 and 2). ROC analysis suggested 2.02 as the cutoff value for NLR [area under the curve (AUC): 0.921, sensitivity: 86%, specificity: 84%], 135 as the cutoff value for PLR (AUC: 0.853, sensitivity: 70%, specificity: 90%), and 8.25 fl as the cutoff value of MPV (AUC: 0.717, sensitivity: 54%, Table 1
Demographic features of preoperative patients and
controls Variables Age (mean ± SD) (years) Sex (male/female) Tumor location [n (%)] Rectum Left colon Right colon TNM staging [n (%)] І ІІ ІІІ ІV Anemia [n (%)] Yes No Hb (mean ± SD) (g/dl) Platelets (mean ± SD) (109/l) MPV (mean ± SD) (fl) NLR (mean ± SD) PLR (mean ± SD)
CRC patients (N = 144)
Control group (N = 143)
P-value
61.3 ± 12.9
60.0 ± 12.7
0.40
98/46
97/45
0.93
100 (69.4) 44 (30.6) 11.6 ± 2.2 280.8 ± 106.1
14.2 ± 1.17 239.7 ± 50.7
< 0.001 < 0.001
8.41 ± 0.98 6.1 ± 5.8 230.5 ± 145.2
7.82 ± 0.49 1.5 ± 0.4 106.3 ± 23.6
< 0.001 < 0.001 < 0.001
47 (32.7) 59 (40.9) 38 (26.4) 24 43 46 31
(16) (30) (32) (21)
CRC, colorectal cancer; Hb, hemoglobin; MPV, mean platelet volume; NLR, neutrophil/lymphocyte ratio; PLR, platelet/lymphocyte ratio; TNM, tumor–nodes– metastases.
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330 European Journal of Cancer Prevention 2015, Vol 24 No 4
MPV, NLR, and PLR values of preoperative CRC patients according to TNM stages, as well as of controls
Table 2
MPV (fl) (mean ± SD)
NLR (mean ± SD)
Comparison of MPV, NLR, and PLR values of preoperative nonanemic CRC patients with those of controls
Table 3
Variable PLR (mean ± SD)
P-value*
211.1 ± 189.2 250.2 ± 173.4 210.5 ± 135.3 236.6 ± 122.9 106.3 ± 23.6
< 0.001 < 0.001 < 0.001 < 0.001
TNM staging of CRC patients (N = 144) І (n = 24) 8.27 ± 0.63 6.97 ± 6.4 ІІ (n = 43) 8.55 ± 1.04 6.96 ± 6.6 ІІІ (n = 46) 8.33 ± 0.81 6.59 ± 7.1 ІV (n = 31) 8.39 ± 0.73 5.14 ± 3.4 Control group 7.82 ± 0.49 1.5 ± 0.4 (N = 143)
CRC, colorectal cancer; MPV, mean platelet volume; NLR, neutrophil/lymphocyte ratio; PLR, platelet/lymphocyte ratio; TNM, tumor–nodes–metastases. *P-value represents the comparison of MPV, NLR, and PLR values of preoperative nonanemic CRC patients with those of controls.
Platelets (mean ± SD) (109/l) MPV (mean ± SD) (fl) NLR (mean ± SD) PLR (mean ± SD)
ROC curve
Control group
P-value
262.4 ± 79.3 8.23 ± 0.98 4.56 ± 5.6 157.4 ± 84.9
239.7 ± 50.7 7.82 ± 0.49 1.5 ± 0.4 106.3 ± 23.6
0.089 0.019 < 0.001 < 0.001
CRC, colorectal cancer; MPV, mean platelet volume; NLR, neutrophil/lymphocyte ratio; PLR, platelet/lymphocyte ratio.
Table 4 Comparison of preoperative and postoperative Hb levels, platelet levels, MPV, NLR, and PLR of CRC patients Variable Hb (mean ± SD) (g/dl) Platelets (mean ± SD) (109/l) MPV (mean ± SD) (fl) NLR (mean ± SD) PLR (mean ± SD)
Fig. 1
CRC (nonanemic)
Preoperative
Postoperative
P-value
11.6 ± 2.2 280.8 ± 106.1 8.41 ± 0.98 6.13 ± 5.8 230.5 ± 145.2
11.8 ± 1.7 231.7 ± 162.0 7.91 ± 0.62 2.38 ± 2.2 141.6 ± 106.9
0.214 < 0.001 < 0.001 < 0.001 < 0.001
CRC, colorectal cancer; Hb, hemoglobin; MPV, mean platelet volume; NLR, neutrophil/lymphocyte ratio; PLR, platelet/lymphocyte ratio.
1.0
Discussion
Sensitivity
0.8
0.6
0.4 Source of the curve Preoperative NLR Preoperative PLR Preoperative MPV Reference line
0.2
0.0 0.0
0.2
0.4 0.6 1−specificity
0.8
1.0
ROC curves of NLR, PLR, and MPV for preoperative patients and controls. AUC for NLR, PLR, and MPV are 0.921, 0.853, and 0.717, respectively. AUC, area under the curve; MPV, mean platelet volume; NLR, neutrophil/lymphocyte ratio; PLR, platelet/lymphocyte ratio; ROC, receiver-operating characteristic.
specificity: 76%; Fig. 1). In the patient group, 44 patients were nonanemic. Subgroup analysis showed that NLR, PLR, and MPV were significantly higher in nonanemic CRC patients compared with age-matched and sexmatched healthy participants (4.56 vs. 1.42, P < 0.001; 157.4 vs. 107.1, P < 0.001; 8.23 vs. 7.75 fl, P = 0.019; Table 3). Surgical tumor resection resulted in a significant decrease in NLR, PLR, and MPV (6.13 vs. 2.38, P < 0.001; 230.5 vs. 141.6, P < 0.001; 8.41 vs. 7.91 fl, P < 0.001; Table 4). We further investigated NLR, PLR, and MPV according to TNM stage. There was no statistically significant difference between NLR, PLR, and MPV, on one side, and TNM stages, on the other.
CRC is the second most common cancer among women and the third most common cancer among men worldwide. CRC is one of the major causes of mortality, with a 5-year survival rate of ∼ 50% (Boyle and Ferlay, 2005). Moreover, 25% of the patients show metastases of the liver and lungs at the time of presentation (Simmonds et al., 2006). When the disease is at an advanced stage with documented metastatic involvement, the prognosis is especially grim. Therefore, prompt diagnostic evaluation is vital when CRC is suspected. In the development and progression of cancer, inflammation is a crucial and essential process (Balkwill and Coussens, 2004). Persistence of the inflammatory process within the tumor leads to an increase in the proliferation of tumor cells, angiogenesis, and the inhibition of apoptosis. Several reports have suggested that markers of systemic inflammation including cytokines, C-reactive protein, Glasgow Prognostic Score, NLR, and PLR may provide useful information on the prognosis of CRC (Erlinger et al., 2004; Walsh et al., 2005; Roxburgh et al., 2009; Klampfer, 2011; Kurt et al., 2012). Thus, pathogenesis of CRC appears to be an inflammation-driven malignancy. Usually, cancer cells are a source of inflammatory cytokines and growth factors. Interleukin-6 (IL-6) is an inflammatory cytokine that can cause carcinogenesis through several signal pathways involved in carcinogenesis, as well as metastasis of a variety of malignancies, including CRC (Knüpfer and Preiss, 2010). It has been shown that CRC patients have higher levels of IL-6 compared with a healthy control group (Knüpfer and Preiss, 2010). IL-6 is released from leukocytes and is also able to activate the production of IL-6 by tumor cells through the IL-6 receptor (Weidle et al., 2010). In
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NLR, PLR, and MPV as biomarkers for CRC Kilincalp et al. 331
addition, it has been proven that IL-6 can stimulate the growth of colorectal carcinoma cells through a paracrine mechanism (Schneider et al., 2010). Besides their role in homeostasis, platelets take part in the pathophysiology of tumor angiogenesis. Platelets are known to be the major transporter of vascular endothelial growth factor, which is the target for antiangiogenic therapies (Sierko and Wojtukiewicz, 2004). Vascular endothelial growth factor accelerates the formation of blood vessels in the tumor and facilitates infiltration and spread to adjacent tissues, which in turn promotes the formation of metastases (Wang et al., 2014). Solid tumors such as renal, gastric, and colon malignancies produce IL-6, which induces the proliferation and differentiation of megakaryocyte progenitors through specific receptors (Belluco et al., 2000; Negrier et al., 2004; Ashizawa et al., 2005). This process causes platelet activation and aggregation. Platelet size has been shown to reflect changes in the level of platelet stimulation and the rate of platelet production (Threatte, 1993). As for MPV, it is an indicator of platelet volume. Increased MPV indicates the presence of a subpopulation of young, metabolically and enzymatically more active platelets taking part in the process of homeostasis (Mangalpally et al., 2010). We speculate that increased MPV in a patient group newly diagnosed with CRC may be a reflection of ongoing colonic inflammation, and it can be related to increased levels of cytokines, particularly IL-6. Moreover, our results also demonstrated that MPV significantly decreased after CRC operation, suggesting that surgical resection of colon cancer not only effectively alleviates the tumor burden, but also the CRC-related inflammatory process. Thus, we suggest that MPV could be used for monitoring CRC relapse after surgical resection regardless of TNM staging. NLR and PLR are two representative indices of systemic inflammation. It has been shown that a preoperative NLR of greater than 4 or 5 is associated with a poor outcome in gastric cancer, non-small-cell lung cancer, and ovarian cancer (Cho et al., 2009; Shimada et al., 2010; Yao et al., 2013). Increased PLR was also demonstrated as being an independent adverse prognostic factor for CRC (Walsh et al., 2005). Neutrophils and leukocytes play a crucial role in the host systemic inflammatory response. A nonspecific systemic inflammatory response due to a tumor leads to an increase in the levels of circulating neutrophils and an elevated NLR, all of which are clearly demonstrated in our study. Lymphocytes play a key role in cytotoxic cell death and the production of cytokines that inhibit proliferation and metastatic spread of tumor cells (Ferradini et al., 1991; Tsiatas et al., 2009). In contrast, neutrophils have a protumor effect by being the primary source of circulating angiogenesis-regulating chemokines, growth factors, and proteases (Spicer et al., 2012). Elevated neutrophil levels
may result in an increase in angiogenesis, which promotes development and progression of the neoplasm (Kusumanto et al., 2003). Therefore, NLR can be considered as the balance between protumor inflammatory status and antitumor immune status. At present, there is little information on the relevance of these prognostic markers to both diagnosis and monitoring of CRC. Our results demonstrate that newly diagnosed CRC patients have significantly higher NLR and PLR compared with the healthy control group, regardless of anemia. Moreover, we found that surgical tumor resection resulted in a significant decrease in NLR and PLR. However, no relationship was observed between NLR and PLR, on one side, and TNM stages, on the other. Screening and surveillance have a documented benefit in reducing the risk of CRC-related morbidity and mortality (Rex et al., 2009). Fecal occult blood testing (FOBT) is the most widely available screening modality for CRC. It typically involves a two-stage approach, with patients positive for the test being referred for colonoscopy. Multiple studies have provided information on the sensitivity and specificity of immunochemical FOBT for the detection of CRC, in which the sensitivity ranged from 47.1 to 69%, and the specificity from 81.8 to 100% (Morikawa et al., 2005). In contrast, the sensitivity of the guaiac test for detecting CRC has been reported to be as low as 37.1%, with a specificity of 86.7% (Allison et al., 1996). However, the immunochemical tests are more expensive than the guaiac-based tests, which limits their use. Colonoscopy is widely regarded as the reference standard for CRC screening. However, several factors contribute to the lack of compliance with colonoscopic screening, including inappropriate perception of risk, dietary restrictions, and the invasiveness of the procedure (Levin et al., 2008). When compared with previous studies, the diagnostic specificity and sensitivity of NLR at least 2.05 (sensitivity: 86%, specificity: 84%), PLR at least 130 (sensitivity: 70%, specificity: 90%), and MPV at least 8.25 fl (sensitivity: 54%, specificity: 76%) for detecting CRC are comparable to FOBT (Allison et al., 1996; Morikawa et al., 2005). Thus, independent of the presence of anemia, high NLR, PLR, and MPV may help to diagnose CRC earlier, especially when used with the other markers and diagnostic methods. Iron-deficiency anemia has been recognized as a feature of CRC. It is present in 57% of patients with CRC and is particularly suggestive of cecal tumors (Fjørtoft et al., 2013). There is broad consensus among physicians that individuals with unexplained iron-deficiency anemia should be considered for a colonoscopy to exclude colonic neoplasm. Although CRC is often associated with iron-deficiency anemia, its absence does not necessarily exclude the disease. Thus, patients without anemia might suffer a delay in the diagnosis of CRC. In our study 44 CRC patients did not have anemia at the time of diagnosis. There was a significant difference in NLR,
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332 European Journal of Cancer Prevention 2015, Vol 24 No 4
PLR, and MPV between nonanemic CRC patients and control participants, which may be of clinical value for early detection of CRC. Patients with resected CRCs are candidates for a followup program. This includes outpatient visits and clinical, hematological, radiological, and colonoscopic evaluation. However, failure in detection of asymptomatic recurrences is ∼50%, which is more likely to result in attempts at curative reoperation (Walker et al., 2014). A variety of serum tumor markers are commonly used in CRC detection, particularly CEA and CA 19-9. Previous studies have suggested that CEA and CA 19-9 do not show satisfactory sensitivity as screening markers for CRC (Yamashita and Watanabe, 2009). The use of CEA to monitor patients after CRC resection can have advantages (early detection of recurrences), as well as disadvantages (false-positive CEA rises). Because of the poor sensitivity, it is frequently used in combination with other tumor markers, particularly with CA 19-9. In CRC, the majority of preoperative CEA studies showed that it could be used as a prognostic indicator (Søreide et al., 2009). However, the sensitivity of CEA for early colon cancer detection is low. The CEA level is associated with tumor stage, and it was demonstrated that CEA levels are elevated when the tumor is at an advanced stage (Yi et al., 2013). It was also shown that an increase in CEA level implies a higher recurrence rate and worse prognosis (Wanebo et al., 1978). The overall reported incidences of high CA 19-9 levels in preoperative CRC patients range from 10.6 to 24.4% (Yu et al., 2013). In some previous studies, a high preoperative CA 19-9 level was shown to be independently associated with high pre-CEA, lymph node metastasis, large tumor size, and peritoneal seeding (Yang et al., 2004; Yu et al., 2013). However, the present data are insufficient to recommend CA 19-9 for staging, surveillance, or monitoring treatment of patients with CRC (Duffy et al., 2003). In the current study, we have demonstrated that NLR, PLR, and MPV decrease after colorectal resection, probably due to a decrease in the tumor burden. There are a few limitations to our study. First, our study has a single-center design and a retrospective nature of data acquisition. Second, the high NLR, PLR, and MPV that were observed in our study group of newly diagnosed CRC patients may be a reflection of a nonspecific inflammatory response due to CRC. Hence, any inflammatory or malignant process can lead to an increase in these parameters. In practice, these markers, if used alone, may have a low positive predictive value in screening an asymptomatic population. Therefore, prospective studies on a larger number of asymptomatic patients are needed to compare the performance of NLR, PLR, and MPV with that of other diagnostic and monitoring tests to confirm their diagnostic utility. Despite these limitations, we think our findings are still important in two respects. First, our results suggest that patients
with stage I and stage II disease have higher levels of these parameters than controls. Thus, independent of the presence of anemia, patients with high NLR, PLR, and MPV with suspicious symptoms and/or signs of CRC are candidates for early evaluation of CRC, which can prevent delay in the diagnosis of CRC. Second, a decrease in these potential markers after surgical resection indicates that they can be widely used in combination with other tumor markers such as CEA or CA 19-9 during the course of postoperative follow-up of patients with resected CRC, at low cost when compared with other modalities.
Acknowledgements Conflicts of interest
There are no conflicts of interest.
References Allison JE, Tekawa IS, Ransom LJ, Adrain AL (1996). A comparison of fecal occult-blood tests for colorectal-cancer screening. N Engl J Med 334:155–159. American Cancer Society Cancer Facts and Figures (2011-2013). Available at: http://www.cancer.org/. [Accessed 2 August 2014]. Ashizawa T, Okada R, Suzuki Y, Takagi M, Yamazaki T, Sumi T, et al. (2005). Clinical significance of interleukin-6 (IL-6) in the spread of gastric cancer: role of IL-6 as a prognostic factor. Gastric Cancer 8:124–131. Balkwill F, Coussens LM (2004). Cancer: an inflammatory link. Nature 431:405–6. Belluco C, Nitti D, Frantz M, Toppan P, Basso D, Plebani M, et al. (2000). Interleukin-6 blood level is associated with circulating carcinoembryonic antigen and prognosis in patients with colorectal cancer. Ann Surg Oncol 7:133–138. Boyle P, Ferlay J (2005). Mortality and survival in breast and colorectal cancer. Nat Clin Pract Oncol 2:424–425. Cho H, Hur HW, Kim SW, Kim SH, Kim JH, Kim YT, Lee K (2009). Pre-treatment neutrophil to lymphocyte ratio is elevated in epithelial ovarian cancer and predicts survival after treatment. Cancer Immunol Immunother 58:15–23. Duffy MJ, van Dalen A, Haglund C, Hansson L, Klapdor R, Lamerz R, et al. (2003). Clinical utility of biochemical markers in colorectal cancer: European Group on Tumour Markers (EGTM) guidelines. Eur J Cancer 39:718–727. Edge SB, Byrd DR, Compton CC, Fritz AG, Greene FL, Trotti A (2010). American joint committee on cancer staging manual. 7th ed. New York: Springer. Erlinger TP, Platz EA, Rifai N, Helzlsouer KJ (2004). C-reactive protein and the risk of incident colorectal cancer. JAMA 291:585–590. Ferlay J, Parkin DM, Steliarova-Foucher E (2010). Estimates of cancer incidence and mortality in Europe in 2008. Eur J Cancer 46:765–781. Ferradini L, Miescher S, Stoeck M, Busson P, Barras C, Cerf-Bensussan N, et al. (1991). Cytotoxic potential despite impaired activation pathways in T lymphocytes infiltrating nasopharyngeal carcinoma. Int J Cancer 47:362–370. Fjørtoft I, Furnes B, Hausken T, Storli KE, Eide GE, Søndenaa K (2013). Preoperative anaemia in colon cancer patients became normal after more than a year post-operatively but did not influence oncological outcome in the final analysis. Scand J Gastroenterol 48:663–671. Hu Y, Wang JL, Tao HT, Wu BS, Sun J, Cheng Y, et al. (2013). Expression and significance of TSGF, CEA and AFP in patients before and after radical surgery for colon cancer. Asian Pac J Cancer Prev 14:3877–3880. Inagaki N, Kibata K, Tamaki T, Shimizu T, Nomura S (2014). Prognostic impact of the mean platelet volume/platelet count ratio in terms of survival in advanced non-small cell lung cancer. Lung Cancer 83:97–101. Ishizuka M, Nagata H, Takagi K, Iwasaki Y, Kubota K (2013). Combination of platelet count and neutrophil to lymphocyte ratio is a useful predictor of postoperative survival in patients with colorectal cancer. Br J Cancer 109:401–407. Karaman K, Bostanci EB, Aksoy E, Kurt M, Celep B, Ulas M, et al. (2011). The predictive value of mean platelet volume in differential diagnosis of nonfunctional pancreatic neuroendocrine tumors from pancreatic adenocarcinomas. Eur J Intern Med 22:e95–e98. Kılınçalp S, Ekiz F, Başar O, Ayte MR, Coban S, Yilmaz B, et al. (2013). Mean platelet volume could be possible biomarker in early diagnosis and monitoring of gastric cancer. Platelets[Epub ahead of print]. Klampfer L (2011). Cytokines, inflammation and colon cancer. Curr Cancer Drug Targets 11:451–464.
Copyright © 2015 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
NLR, PLR, and MPV as biomarkers for CRC Kilincalp et al. 333
Knüpfer H, Preiss R (2010). Serum interleukin-6 levels in colorectal cancer patients – a summary of published results. Int J Colorectal Dis 25:135–140. Kurt M, Onal IK, Sayilir AY, Beyazit Y, Oztas E, Kekilli M, et al. (2012). The role of mean platelet volume in the diagnosis of hepatocellular carcinoma in patients with chronic liver disease. Hepatogastroenterology 59:1580–1582. Kusumanto YH, Dam WA, Hospers GA, Meijer C, Mulder NH (2003). Platelets and granulocytes, in particular the neutrophils, form important compartments for circulating vascular endothelial growth factor. Angiogenesis 6:283–287. Levin B, Lieberman DA, McFarland B, Andrews KS, Brooks D, Bond J, et al. American Cancer Society Colorectal Cancer Advisory Group; US MultiSociety Task Force; American College of Radiology Colon Cancer Committee (2008). Screening and surveillance for the early detection of colorectal cancer and adenomatous polyps, 2008: a joint guideline from the American Cancer Society, the US Multi-Society Task Force on Colorectal Cancer, and the American College of Radiology. Gastroenterology 134:1570–1595. Mangalpally KK, Siqueiros-Garcia A, Vaduganathan M, Dong JF, Kleiman NS, Guthikonda S (2010). Platelet activation patterns in platelet size sub-populations: differential responses to aspirin in vitro. J Thromb Thrombolysis 30:251–262. Morikawa T, Kato J, Yamaji Y, Wada R, Mitsushima T, Shiratori Y (2005). A comparison of the immunochemical fecal occult blood test and total colonoscopy in the asymptomatic population. Gastroenterology 129:422–428. Negrier S, Perol D, Menetrier-Caux C, Escudier B, Pallardy M, Ravaud A, et al. Groupe Francais d’Immunotherapie (2004). Interleukin-6, interleukin-10, and vascular endothelial growth factor in metastatic renal cell carcinoma: prognostic value of interleukin-6–from the Groupe Francais d’Immunotherapie. J Clin Oncol 22:2371–2378. Oge T, Yalcin OT, Ozalp SS, Isikci T (2013). Platelet volume as a parameter for platelet activation in patients with endometrial cancer. J Obstet Gynaecol 33:301–314. Rex DK, Johnson DA, Anderson JC, Schoenfeld PS, Burke CA, Inadomi JM. American College of Gastroenterology (2009). American College of Gastroenterology guidelines for colorectal cancer screening 2009 [corrected]. Am J Gastroenterol 104:739–750. Roxburgh CS, Crozier JE, Maxwell F, Foulis AK, Brown J, McKee RF, et al. (2009). Comparison of tumour-based (Petersen Index) and inflammation-based (Glasgow Prognostic Score) scoring systems in patients undergoing curative resection for colon cancer. Br J Cancer 100:701–706. Schneider MR, Hoeflich A, Fischer JR, Wolf E, Sordat B, Lahm H (2000). Interleukin-6 stimulates clonogenic growth of primary and metastatic human colon carcinoma cells. Cancer Lett 151:31–38. Shimada H, Takiguchi N, Kainuma O, Soda H, Ikeda A, Cho A, et al. (2010). High preoperative neutrophil–lymphocyte ratio predicts poor survival in patients with gastric cancer. Gastric Cancer 13:170–176. Sierko E, Wojtukiewicz MZ (2004). Platelets and angiogenesis in malignancy. Semin Thromb Hemost 30:95–108.
Simmonds PC, Primrose JN, Colquitt JL, Garden OJ, Poston GJ, Rees M (2006). Surgical resection of hepatic metastases from colorectal cancer: a systematic review of published studies. Br J Cancer 94:982–999. Søreide K, Nedrebø BS, Knapp JC, Glomsaker TB, Søreide JA, Kørner H (2009). Evolving molecular classification by genomic and proteomic biomarkers in colorectal cancer: potential implications for the surgical oncologist. Surg Oncol 18:31–50. Spicer JD, McDonald B, Cools-Lartigue JJ, Chow SC, Giannias B, Kubes P, Ferri LE (2012). Neutrophils promote liver metastasis via Mac-1-mediated interactions with circulating tumor cells. Cancer Res 72:3919–3927. Threatte GA (1993). Usefulness of the mean platelet volume. Clin Lab Med 13:937–950. Tsiatas ML, Gyftaki R, Liacos C, Politi E, Rodolakis A, Dimopoulos MA, Bamias A (2009). Study of T lymphocytes infiltrating peritoneal metastases in advanced ovarian cancer: associations with vascular endothelial growth factor levels and prognosis in patients receiving platinum-based chemotherapy. Int J Gynecol Cancer 19:1329–1334. Walker AS, Zwintscher NP, Johnson EK, Maykel JA, Stojadinovic A, Nissan A, et al. (2014). Future directions for monitoring treatment response in colorectal cancer. J Cancer 5:44–57. Walsh SR, Cook EJ, Goulder F, Justin TA, Keeling NJ (2005). Neutrophil–lymphocyte ratio as a prognostic factor in colorectal cancer. J Surg Oncol 91:181–184. Wanebo HJ, Rao B, Pinsky CM, Hoffman RG, Stearns M, Schwartz MK, Oettgen HF (1978). Preoperative carcinoembryonic antigen level as a prognostic indicator in colorectal cancer. N Engl J Med 299:448–451. Wang Y, Han G, Wang K, Liu G, Wang R, Xiao H, et al. (2014). Tumor-derived GM-CSF promotes inflammatory colon carcinogenesis via stimulating epithelial release of VEGF. Cancer Res 74:716–726. Weidle UH, Klostermann S, Eggle D, Krüger A (2010). Interleukin 6/interleukin 6 receptor interaction and its role as a therapeutic target for treatment of cachexia and cancer. Cancer Genomics Proteomics 7:287–302. Yamashita K, Watanabe M (2009). Clinical significance of tumor markers and an emerging perspective on colorectal cancer. Cancer Sci 100:195–199. Yang SH, Lin JK, Lai CR, Chen CC, Li AF, Liang WY, Jiang JK (2004). Risk factors for peritoneal dissemination of colorectal cancer. J Surg Oncol 87:167–173. Yao Y, Yuan D, Liu H, Gu X, Song Y (2013). Pretreatment neutrophil to lymphocyte ratio is associated with response to therapy and prognosis of advanced non-small cell lung cancer patients treated with first-line platinumbased chemotherapy. Cancer Immunol Immunother 62:471–479. Yi JH, Kim H, Jung M, Shin SJ, Choi JS, Choi GH, et al. (2013). Prognostic factors for disease-free survival after preoperative chemotherapy followed by curative resection in patients with colorectal cancer harboring hepatic metastasis: a single-institute, retrospective analysis in Asia. Oncology 85:283–239. Yu H, Son GM, Joh YG (2013). The clinical significance of preoperative serum levels of carbohydrate antigen 19-9 in colorectal cancer. J Korean Surg Soc 84:231–237.
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