Med Oncol (2014) 31:264 DOI 10.1007/s12032-014-0264-5
ORIGINAL PAPER
Pre-treatment neutrophil-to-lymphocyte ratio affects survival in patients with advanced hepatocellular carcinoma treated with sorafenib Leonardo Gomes da Fonseca • Romulado Barroso-Sousa • Afonso da Silva Alves Bento • Bruna Paccola Blanco • Gabriel Luis Valente Tulio Eduardo Flesch Pfiffer • Paulo Marcelo Hoff • Jorge Sabbaga
•
Received: 3 September 2014 / Accepted: 20 September 2014 / Published online: 2 October 2014 Ó Springer Science+Business Media New York 2014
Abstract Sorafenib is the first systemic therapy to demonstrate survival benefit in advanced hepatocellular carcinoma (HCC) in randomized controlled trials with rigorous patient selection. Neutrophil-to-lymphocyte ratio (NLR) has been shown to be associated with poor survival in various solid tumors. Our aim is to evaluate the prognostic role of NLR in HCC patients treated with sorafenib. A total of 105 advanced HCC patients treated with sorafenib were retrospectively reviewed, and relevant data from the clinical records were collected. Univariate and multivariate analysis were carried out to identify factors associated with survival. The median age of the cohort was 59.7 years, and 84.8 % were Child–Pugh class A, and 86.7 % had ECOG performance status 0 or 1. Median duration of sorafenib treatment was 100 days. Median overall survival (OS) of the entire cohort was 8.03 months. Median OS was 5.23 months (95 % CI 2.96–7.50 months) and 10.05 months (95 % IC 2.52–18.47 months) for patients with NLR [ 3.5 and NLR B 3.5, respectively (p = 0.002). Alpha-fetoprotein [1,030 ng/mL and serum albumin B3.8 g/dL were also associated with worse prognosis (p = 0.006 and p = 0.042, respectively). The subgroup of patients with high alphafetoprotein, low albumin and NLR [ 3.5 had median OS of 1.7 months, whereas the subgroup with none of these parameters had median OS of 16.5 months (p \ 0.001). NLR affects survival in advanced HCC patients treated with sorafenib. Selecting HCC patients based on the laboratorial L. G. da Fonseca (&) R. Barroso-Sousa T. E. F. Pfiffer P. M. Hoff J. Sabbaga Cancer Institute of Sao Paulo State, University of Sao Paulo, Av. Dr. Arnaldo 251, Sa˜o Paulo, Sa˜o Paulo, Brazil e-mail: [email protected] A. S. A. Bento B. P. Blanco G. L. Valente School of Medicine, University of Sao Paulo, Sao Paulo, Brazil
features may improve the therapeutic effectiveness of sorafenib. Keywords Hepatocellular cancer Sorafenib tosylate Neutrophil count Lymphocyte count Prognosis
Introduction The search for markers that help to anticipate treatment benefit or the assessment of tumor prognosis is becoming increasingly challenged. This assumption is particularly important in the context of tumors treated with target agents, in which classical responses, like those seen with cytotoxic drugs, are not expected to occur. Hepatocellular carcinoma (HCC), the fifth most common malignancy worldwide, fits perfectly in this scenario [1]. Surgical resection and liver transplantation are the only curative options for this disease, but are just suitable for the 15 % of patients diagnosed with only locoregional tumors. In 50 % of cases, HCC is diagnosed at advanced stages, a condition for which few systemic therapies are available [2]. Sorafenib is an oral multitarget tyrosine kinase inhibitor directed to vascular endothelial growth factor receptor (VEGFR)-1, -2, -3, platelet-derived growth factor receptor (PDGFR)- b, c-KIT, RET, FLT-3 and RAF. This agent is the only systemic therapy that consistently produces survival benefit in advanced HCC and has received FDA approval for this indication based on the results of two placebo-controlled randomized trials [3, 4]. In the SHARP trial, sorafenib significantly prolonged overall survival (OS) from 7.9 to 10.7 months [3]. The Asia–Pacific trial, restricted to eastern population, also demonstrated improvement in median OS in favor of sorafenib (6.5 vs. 4.2 months) [4]. In both trials, however, the observed objective response rates were 2 and
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3.3 %, respectively, showing that patients have their disease course improved and their life prolonged without expressing any measurable sight. Because not all patients will present clinical and radiological improvement, prior recognition of those that will not benefit from this treatment would be very useful, in order to avoid futile costs and unnecessary exposure to adverse events. In this regard, the neutrophil-to-lymphocyte ratio (NLR), an easy and reproducible marker of systemic inflammation, has been evaluated as predictor of survival in various solid tumors [5–8]. Elevated NLR has already been shown to be associated with poor survival in patients with HCC treated with surgical resection, trans-arterial chemoembolization or liver transplantation [9–11]. The aim of this study is to evaluate the prognostic role of NLR and other clinical and laboratorial parameters in a ‘‘real-world’’ cohort of advanced HCC patients receiving sorafenib as single-agent first-line therapy.
Med Oncol (2014) 31:264
Treatment and assessment Sorafenib was administered orally, usually at starting dose of 400 mg twice daily. In patients with significant comorbidities, ECOG status performance 2 or with liver dysfunction (Child–Pugh B) sorafenib could be initiated at a reduced starting dose (400–600 mg daily) with subsequent dose escalation according to tolerance and physician’s judgment. During treatment, dose reductions could be done for the management of adverse events depending on their type and severity. Treatment was continued until evidence of disease progression, unacceptable adverse event or death. The follow-up generally consisted of regular physical examination, laboratory assessment every 4–6 weeks and image studies (computed tomography, ultrasonography or magnetic resonance) every 6–12 weeks. OS was defined as the time from start of sorafenib treatment to death. Statistical analyses
Materials and methods Patients and methods A database of 120 consecutive patients treated at Instituto do Cancer do Estado de Sa˜o Paulo, Universidade de Sa˜o Paulo, Brazil, from July 2009 and November 2013 was retrospectively evaluated after approval by the local ethics committee. Study population consisted of patients with diagnostic criteria for HCC based on radiological or histological findings, according to the American Association for the Study of the Liver [12]. All patients received sorafenib as initial systemic treatment. Relevant data from the clinical records were collected including age, gender, ECOG performance status, preexisting hepatopathy, Child–Pugh score, extrahepatic spread, vascular invasion, serum laboratory findings (alpha-fetoprotein, bilirubin, alkaline phosphatase and albumin), prior treatments for HCC, sorafenib treatment duration, dose reductions, toxicity and overall survival. Outcome data were last updated on January 28, 2014. Neutrophil-to-lymphocyte ratio was defined as the absolute neutrophil count divided by the absolute lymphocyte count measured on peripheral blood samples obtained in the period of 7 days before the start of sorafenib treatment. Patients were excluded from this analysis if they had demonstrable infection, chronic inflammatory disease, or if they were using steroids or granulocyte colony-stimulating factor. Patients were divided into a high NLR group ([3.5) and normal NLR group (B3.5) according to pre-treatment NLR, based on approximated value of the median NLR obtained in this analysis (3.48) and others studies threshold [5–11].
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Data were evaluated using SPSS software version 11.0 (SPSS Chicago, IL). Continuous variables were expressed as mean and ranges, and categorical variables were expressed as frequency, and compared using chi-square test. We analyzed pre-treatment clinical and laboratorial markers potentially associated with outcome. Potential predictive factors explored included ECOG performance status, Child– Pugh classification, the presence of vascular invasion and extrahepatic spread, the serum levels of alpha-fetoprotein and albumin and NLR. Kaplan–Meier curves comparing OS between groups were constructed, and log-rank testing was used for comparisons in univariate analysis. Variables were found to be significant if two-sided p value was \0.05 on multivariate testing using the Cox regression test.
Results Patients characteristics From the total of 120 consecutive patients treated, 15 patients were excluded for lack of sufficient data on clinical features or pre-treatment laboratory tests. Median age of the 105 patients included was 59.7 years (range 19–80.3). Most of the patients were male (71.4 %) and had ECOG performance status of 0 or 1 (86.7 %). Well preserved liver function (Child–Pugh class A) was found in 84.8 %, extrahepatic spread was found in 57.1 % and vascular invasion in 49.5 %. Hepatitis C, B and alcohol were preexisting conditions in 33.3, 20 and 27.6 % of patients, respectively. Detailed patient characteristics are shown in Table 1.
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Table 1 Baseline demographic and clinicopathologic characteristics of the patients Characteristic
n = 105 (%)
Median age (range)
59.7 years (19–80.3)
Table 2 Adverse events related to sorafenib treatment Adverse event Fatigue
Gender—[n (%)] Male
75 (71.4)
Female
30 (28.6)
ECOG performance status—[n (%)] 0 or 1 2 or 3 Child–Pugh class—[n (%)]
24 (13.3)
A
89 (84.8)
B
16 (15.2)
Coexisting liver disease—[n (%)] Hepatitis B
21 (20)
Hepatitis C
35 (33.3)
Alcohol
29 (27.6)
Other
20 (19)
Extrahepatic spread—[n (%)]
60 (57.1)
54 (51.4)
Grade 1/2
47 (44.7)
Grade 3/4
7 (6.7)
Diarrhea Grade 1/2 Grade 3/4
91 (86.7)
n (%)
Hand-foot reaction
45 (42.9) 36 (34.3) 9 (8.6) 42 (40)
Grade 1/2
35 (33.3)
Grade 3/4
7 (6.7)
Nauseas Grade 1/2 Grade 3/4 Vomiting Grade 1/2 Grade 3/4 Mucositis
15 (14.3) 15 (14.3) 0 (0) 13 (12.4) 12 (11.4) 1 (1) 9 (8.6)
Grade 1/2
8 (7.6)
Grade 3/4
1 (1)
Lung
14 (13.3)
Lymph nodes
14 (13.3)
Bone
17 (16.2)
Grade 1/2
9 (8.6)
52 (49.5)
Grade 3/4
0 (0)
Macroscopic vascular invasion—[n (%)] BCLC stage—[n (%)] B C Previous locoregional treatment—[n (%)]
24 (22.9) 81 (77.1) 53 (50.5)
Thrombocytopenia
9 (8.6)
Neutropenia
7 (6.7)
Grade 1/2
5 (4.8)
Grade 3/4
2 (1.9)
Anemia
4 (3.8)
Biochemical analysis
Grade 1/2
3 (2.9)
Albumin—(g/dL)
Grade 3/4
1 (1)
Median
3.85
Range
2.2–5.1
Total bilirubin—(mg/dL) Median
0.95
Range
0.24–26.38
Alpha-fetoprotein—(ng/mL) Median
1,030
Range
0.9–60,500
Alkaline phosphatase—(U/L) Median
156
Range
9.8–8,050
Neutrophil-to-lymphocyte ratio Median Range
3.48 0.64–20.0
BCLC Barcelona clinic liver cancer
patients (70.4 %), whereas 17 patients (16.2 %) discontinued for adverse events. There were no treatment-related deaths. Ninety-three patients (88.6 %) started with 800 mg/ daily and 12 (11.4 %) with reduced dose (600 or 400 mg/ daily). During treatment, 37 patients (35.2 %) required dose reductions for management of adverse events. Subsequent systemic therapies were provided for 29 patients (27.6 %). The most common adverse events related to sorafenib treatment were asthenia (51.4 %), diarrhea (42.8 %), handfoot skin reaction (40 %) and nauseas (14.3 %). Grades 3 or 4 toxicities were observed in 24 patients (22.9 %). Table 2 showed detailed side effects and grade related to sorafenib.
Treatment characteristics: safety and tolerability Treatment outcomes: NLR and survival The median duration of sorafenib treatment was 100 days (range 13–693). In the time of this analysis, 14 patients (13.3 %) were still receiving sorafenib. The main reason for drug discontinuation was disease progression in 74
Median follow-up was 11.4 months (range 0.47–27.1). Median survival of the entire cohort was 8.03 months (95 % CI 5.1–10.9).
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Fig. 1 Overall survival probability in months according to NLR ([3.5 vs. B3.5)
Table 3 Multivariate analysis of potential predictors for OS Variable
Multivariate p
HR (95 % confidence interval)
NLR [ 3.5
0.002
0.50 (0.32–0.78)
Albumin B3.8 g/dL
0.042
0.64 (0.41–0.98)
Alpha-fetoprotein B1,030 ng/mL
0.006
1.93 (1.20–3.08)
Extrahepatic spread
0.098
1.47 (0.93–2.335)
Vascular invasion
0.813
1.11 (0.71–1.75)
ECOG PS (0–1 vs. 2–3)
0.645
0.92 (0.46–1.8)
Child–Pugh (A vs. B)
0.002
0.55 (0.30–0.88)
NLR neutrophil–lymphocyte ratio, ECOG PS Eastern cooperative oncology group performance status
The median NLR was 3.48 (range 0.64–20.0). Fifty-one patients (48.6 %) had NLR [ 3.5 and 54 patients (51.4 %) had NLR B 3.5. Median OS of patients with NLR [ 3.5 was 5.23 months (95 % CI 2.96–7.50 months) and 10.05 months (95 % IC 2.52–18.47 months) for patients with NLR B 3.5. (p = 0.005—univariate analysis). (Fig. 1) NLR retained its significance as a prognostic marker on multivariate analysis in the entire cohort (Table 3). Treatment outcomes: other prognostic factors The median serum alpha-fetoprotein was 1,030 ng/mL. Fifty-two patients (49.5 %) had alpha-fetoprotein [1,030 ng/mL and 53 patients (50.5 %) had alpha-fetoprotein B1,030 ng/mL. Median OS of patients with alphafetoprotein [1,030 ng/mL was 5.23 months (95 % CI
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2.99–7.82 months) and 11.43 months (95 % IC 2.78–15.42 months) for patients with alpha-fetoprotein B1,030 ng/mL (p = 0.023—univariate analysis) (Fig. 2a). The median serum albumin was 3.8 ng/dL. Fifty-two patients (49.5 %) had serum albumin [3.8 ng/dL and 53 patients (50.5 %) had serum albumin B3.8 ng/dL. Median OS of patients with serum albumin B3.8 ng/dL was 3.86 months (95 % CI 0.98–5.25 months) and 10.70 months (95 % IC 6.56–14.67 months) for patients with serum albumin [ 3.8 ng/dL (p = 0.010—univariate analysis) (Fig. 2b). Multivariate analysis showed that, besides NLR, Child– Pugh B, pre-treatment alpha-fetoprotein[1,030 ng/mL and albumin B3.8 g/dL were also predictor of worse prognosis (p = 0.006 and p = 0.042, respectively). Extrahepatic spread, ECOG performance status (0–1 vs. 2–3) and vascular invasion were not associated with poorer survival in multivariate analysis (p = 0.098; p = 0.813 and p = 0.645; respectively) (Table 3). Considering three variables that showed association with poor survival (NLR [ 3.5, serum alpha-fetoprotein [1,030 ng/mL and serum albumin B3.8 ng/dL), we classified the patients according to the number of variables presented in four groups: (1) 24 patients (22.8 %) scored none variable, (2) 38 patients scored 1 variable (36.2 %), (3) 33 patients (31.4 %) scored 2 variables and (4) 10 patients (9.52 %) scored the 3 variables. The median OS was higher for patients with 0 variables and worse for patients that scored three variables (16.5 vs. 1.7 months; p \ 0.001). Table 4 shows the median OS and confidence interval and Fig. 3 shows the curves for each group.
Discussion In our cohort, we showed that high NLR affects survival in advanced HCC patients treated with sorafenib. Together with known worse prognostic factors, such as high alphafetoprotein and low serum albumin, NLR could distinguish HCC patients presenting poor survival with sorafenib treatment. Cancer patients may have local and systemic changes in inflammatory parameters, such as blood cell numbers, changes in erythrocyte sedimentation rate and elevation of acute-phase proteins similar to those observed in infection or inflammatory diseases. Data suggest that inflammation influences cancer progression, promoting cell proliferation, angiogenesis and response to therapies [13, 14]. The NLR is an easily reproducible marker of systemic inflammation, and increasing data have shown its value as a prognostic marker. A recent meta-analysis comprising 40,559 patients with solid tumors, including 1,667 patients with HCC, observed that high NLR is associated with adverse OS [5].
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Fig. 2 Overall survival probability in months according a serum alpha-fetoproteins (B1,030 ng/mL vs. [1,030 ng/mL) and b serum albumin (B3.8 ng/dL vs. [3.8 ng/dL)
Table 4 OS according to the number of variables scored Groups (n)
Median OS (months)
Median 95 % confidence interval
0 variables (n = 24)
16.50
(10.43–22.56)
1 variable (n = 38)
10.70
(8.52–12.88)
2 variables (n = 33)
3.96
(3.44–4.49)
3 variables (n = 10)
1.7
(0.35–3.04)
Overall (n = 105)
8.03
(5.13–10.93)
NLR neutrophil–lymphocyte ratio, ECOG PS Eastern cooperative oncology group performance status
The mechanisms that underline the role of NLR are still unknown, but some hypothesis can be raised regarding inflammatory response with tumor growth and invasion. A high NLR reflects both increasing in neutrophil response and decreasing in lymphocyte-depending immune reaction. Neutrophils have been shown to produce cytokines such as tumor necrosis factor and secrete VEGF, a pro-angiogenic circulating molecule, and intra-tumoral infiltration of neutrophils stimulate tumor invasion by producing hepatocyte growth factor [15]. In HCC, IL-17 seems to promote tumor growth and higher NLR is associated with up-regulation of IL-17 [16]. On the other hand, a relative lymphopenia may reflect deficient immune response to malignancy mediated by CD4? T-helper and cytotoxic CD8? cells. In colorectal cancer, tumor infiltration by lymphocyte is predictive of longer survival [17]. It is important to note that neither neutrophil count nor lymphopenia alone may reflect clinical outcome (data not shown), but interaction between these two immune cells counts was able to predict survival in HCC patients treated with sorafenib.
Fig. 3 Overall survival probability in months according to number of independent variables associated with worse OS (serum albumin, alpha-fetoprotein and NLR)
Identifying factors affecting clinical outcomes of HCC patients treated with sorafenib is an important task, since the desired delay in disease progression is rarely accomplished through tumor responses. Patients stay in treatment until progression without any clue if they are obtaining benefit from therapy or just the side effects. Indeed, there is only limited data on markers associated with antitumor treatment of patients with HCC. A retrospective analysis with sorafenib-treated patients indicated that elevated bilirubin and alpha-fetoprotein were significantly associated with worse OS [18]. Serum alpha-fetoprotein has been correlated with tumor burden and many
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published reports confirm that it carries prognostic value [18–20]. Liver function tests are important factors related to survival of patients with HCC. Low albumin may reflect nutrition deficiency or, more importantly, is a surrogate marker of altered liver function, a well recognized predictive and prognostic factor in HCC [18]. Using these markers, the identification of subgroups that could have little or no benefit from sorafenib can help clinical decision and expectations. Many investigators have worked to find biomarkers that predict survival to sorafenib. Serum concentrations of VEGF and phosphorylated ERK proved to be good predictors [21, 22]. These biomarkers are, however, expensive and not easily available in clinical practice. We have used markers that are routinely obtained when planning HCC treatment. A clear limitation of this study is its retrospective nature. Large prospective randomized trials are the ideal source for detecting laboratorial and clinical based biomarkers. However, data extracted from a cohort of clinically similar patients uniformly treated in single institutions also provide useful information regarding prognostic and predictive indicators. Prospective validation by further trials of NLR as a prognostic marker must be warranted. The intriguing and provocative finding of these data is that selecting HCC patients based on the laboratorial features others than the ones related to the liver function may improve the therapeutic effectiveness of sorafenib. Conflict of interest
None.
References 1. Parkin DM, Bray F, Ferlay J, et al. Global cancer statistics, 2002. CA Cancer J Clin. 2005;55(2):74–108. 2. Llovet JM, Fuster J, Bruix J. The Barcelona approach: diagnosis, staging, and treatment of hepatocellular carcinoma. Liver Transplant. 2004;10(2):S115–20. 3. Llovet JM, Ricci S, Mazzaferro V, et al. Sorafenib in advanced hepatocellular carcinoma. N Engl J Med. 2008;359(4):378–90. 4. Cheng AL, Kang YK, Chen Z, et al. Efficacy and safety of sorafenib in patients in the Asia–Pacific region with advanced hepatocellular carcinoma: a phase III randomized, double-blind, placebo-controlled trial. Lancet Oncol. 2009;10(1):25–34. 5. Templeton AJ, McNamara MG, Sˇeruga B, et al. Prognostic role of neutrophil-to-lymphocyte ratio in solid tumors: a systematic review and meta-analysis. J Natl Cancer Inst. 2014;106(6):dju124.
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6. Kishi Y, Kopetz S, Chun YS, et al. Blood neutrophil-to-lymphocyte ratio predicts survival in patients with colorectal liver metastases treated with systemic chemotherapy. Ann Surg Oncol. 2009;16(3):614–22. 7. An X, Ding PR, Li YH, et al. Elevated neutrophil to lymphocyte ratio predicts survival in advanced pancreatic cancer. Biomarkers. 2010;15(6):516–22. 8. 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(3–4):215–20. 9. 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(8):1757–62. 10. Limaye AR, Clark V, Soldevila-Pico C, et al. Neutrophil–lymphocyte ratio predicts overall and recurrence free survival after liver transplantation for hepatocellular carcinoma. Hepatol Res. 2013;43(7):757–64. 11. McNally ME, Martinez A, Khabiri H, et al. Inflammatory markers are associated with outcome in patients with unresectable hepatocellular carcinoma undergoing transarterial chemoembolization. Ann Surg Oncol. 2013;20(3):923–8. 12. Bruix J, Sherman M. Management of hepatocellular carcinoma: an update. Hepatology. 2011;53(3):1020–2. 13. Mantovani A, Allavena P, Sica A, et al. Cancer-related inflammation. Nature. 2008;454(7203):436–44. 14. Hanahan D, Weinberg RA. Hallmarks of cancer: the next generation. Cell. 2011;144(5):646–74. 15. Kuang DM, Zhao Q, Wu Y, et al. Peritumoral neutrophils link inflammatory response to disease progression by fostering angiogenesis in hepatocellular carcinoma. J Hepatol. 2011;54(5):948–55. 16. Motomura T, Shirabe K, Mano Y, et al. Neutrophil–lymphocyte ratio reflects hepatocellular carcinoma recurrence after liver transplantation via inflammatory microenvironment. J Hepatol. 2013;58(1):58–64. 17. Ohtani H. Focus on TILs: prognostic significance of tumor infiltrating lymphocytes in human colorectal cancer. Cancer Immun. 2007;21(7):4. 18. Baek KK, Kim JH, Uhm JE, et al. Prognostic factors in patients with advanced hepatocellular carcinoma treated with sorafenib: a retrospective comparison with previously known prognostic models. Oncology. 2011;80(3–4):167–74. 19. Johnson PJ. The role of serum alpha-fetoprotein estimation in the diagnosis and management of hepatocellular carcinoma. Clin Liver Dis. 2001;5(1):145–59. 20. Nomura F, Ohnishi K, Tanabe Y. Clinical features and prognosis of hepatocellular carcinoma with reference to serum alpha-fetoprotein levels: analysis of 606 patients. Cancer. 1989;64(8):1700–7. 21. Llovet JM, Pena CE, Lathia CD, et al. Plasma biomarkers as predictors of outcome in patients with advanced hepatocellular carcinoma. Clin Cancer Res. 2012;18(8):2290–300. 22. Zhang Z, Zhou X, Shen H, et al. Phosphorylated ERK is a potential predictor of sensitivity to sorafenib when treating hepatocellular carcinoma: evidence from an in vitro study. BMC Med. 2009;7:41.
ORIGINAL PAPER
Pre-treatment neutrophil-to-lymphocyte ratio affects survival in patients with advanced hepatocellular carcinoma treated with sorafenib Leonardo Gomes da Fonseca • Romulado Barroso-Sousa • Afonso da Silva Alves Bento • Bruna Paccola Blanco • Gabriel Luis Valente Tulio Eduardo Flesch Pfiffer • Paulo Marcelo Hoff • Jorge Sabbaga
•
Received: 3 September 2014 / Accepted: 20 September 2014 / Published online: 2 October 2014 Ó Springer Science+Business Media New York 2014
Abstract Sorafenib is the first systemic therapy to demonstrate survival benefit in advanced hepatocellular carcinoma (HCC) in randomized controlled trials with rigorous patient selection. Neutrophil-to-lymphocyte ratio (NLR) has been shown to be associated with poor survival in various solid tumors. Our aim is to evaluate the prognostic role of NLR in HCC patients treated with sorafenib. A total of 105 advanced HCC patients treated with sorafenib were retrospectively reviewed, and relevant data from the clinical records were collected. Univariate and multivariate analysis were carried out to identify factors associated with survival. The median age of the cohort was 59.7 years, and 84.8 % were Child–Pugh class A, and 86.7 % had ECOG performance status 0 or 1. Median duration of sorafenib treatment was 100 days. Median overall survival (OS) of the entire cohort was 8.03 months. Median OS was 5.23 months (95 % CI 2.96–7.50 months) and 10.05 months (95 % IC 2.52–18.47 months) for patients with NLR [ 3.5 and NLR B 3.5, respectively (p = 0.002). Alpha-fetoprotein [1,030 ng/mL and serum albumin B3.8 g/dL were also associated with worse prognosis (p = 0.006 and p = 0.042, respectively). The subgroup of patients with high alphafetoprotein, low albumin and NLR [ 3.5 had median OS of 1.7 months, whereas the subgroup with none of these parameters had median OS of 16.5 months (p \ 0.001). NLR affects survival in advanced HCC patients treated with sorafenib. Selecting HCC patients based on the laboratorial L. G. da Fonseca (&) R. Barroso-Sousa T. E. F. Pfiffer P. M. Hoff J. Sabbaga Cancer Institute of Sao Paulo State, University of Sao Paulo, Av. Dr. Arnaldo 251, Sa˜o Paulo, Sa˜o Paulo, Brazil e-mail: [email protected] A. S. A. Bento B. P. Blanco G. L. Valente School of Medicine, University of Sao Paulo, Sao Paulo, Brazil
features may improve the therapeutic effectiveness of sorafenib. Keywords Hepatocellular cancer Sorafenib tosylate Neutrophil count Lymphocyte count Prognosis
Introduction The search for markers that help to anticipate treatment benefit or the assessment of tumor prognosis is becoming increasingly challenged. This assumption is particularly important in the context of tumors treated with target agents, in which classical responses, like those seen with cytotoxic drugs, are not expected to occur. Hepatocellular carcinoma (HCC), the fifth most common malignancy worldwide, fits perfectly in this scenario [1]. Surgical resection and liver transplantation are the only curative options for this disease, but are just suitable for the 15 % of patients diagnosed with only locoregional tumors. In 50 % of cases, HCC is diagnosed at advanced stages, a condition for which few systemic therapies are available [2]. Sorafenib is an oral multitarget tyrosine kinase inhibitor directed to vascular endothelial growth factor receptor (VEGFR)-1, -2, -3, platelet-derived growth factor receptor (PDGFR)- b, c-KIT, RET, FLT-3 and RAF. This agent is the only systemic therapy that consistently produces survival benefit in advanced HCC and has received FDA approval for this indication based on the results of two placebo-controlled randomized trials [3, 4]. In the SHARP trial, sorafenib significantly prolonged overall survival (OS) from 7.9 to 10.7 months [3]. The Asia–Pacific trial, restricted to eastern population, also demonstrated improvement in median OS in favor of sorafenib (6.5 vs. 4.2 months) [4]. In both trials, however, the observed objective response rates were 2 and
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3.3 %, respectively, showing that patients have their disease course improved and their life prolonged without expressing any measurable sight. Because not all patients will present clinical and radiological improvement, prior recognition of those that will not benefit from this treatment would be very useful, in order to avoid futile costs and unnecessary exposure to adverse events. In this regard, the neutrophil-to-lymphocyte ratio (NLR), an easy and reproducible marker of systemic inflammation, has been evaluated as predictor of survival in various solid tumors [5–8]. Elevated NLR has already been shown to be associated with poor survival in patients with HCC treated with surgical resection, trans-arterial chemoembolization or liver transplantation [9–11]. The aim of this study is to evaluate the prognostic role of NLR and other clinical and laboratorial parameters in a ‘‘real-world’’ cohort of advanced HCC patients receiving sorafenib as single-agent first-line therapy.
Med Oncol (2014) 31:264
Treatment and assessment Sorafenib was administered orally, usually at starting dose of 400 mg twice daily. In patients with significant comorbidities, ECOG status performance 2 or with liver dysfunction (Child–Pugh B) sorafenib could be initiated at a reduced starting dose (400–600 mg daily) with subsequent dose escalation according to tolerance and physician’s judgment. During treatment, dose reductions could be done for the management of adverse events depending on their type and severity. Treatment was continued until evidence of disease progression, unacceptable adverse event or death. The follow-up generally consisted of regular physical examination, laboratory assessment every 4–6 weeks and image studies (computed tomography, ultrasonography or magnetic resonance) every 6–12 weeks. OS was defined as the time from start of sorafenib treatment to death. Statistical analyses
Materials and methods Patients and methods A database of 120 consecutive patients treated at Instituto do Cancer do Estado de Sa˜o Paulo, Universidade de Sa˜o Paulo, Brazil, from July 2009 and November 2013 was retrospectively evaluated after approval by the local ethics committee. Study population consisted of patients with diagnostic criteria for HCC based on radiological or histological findings, according to the American Association for the Study of the Liver [12]. All patients received sorafenib as initial systemic treatment. Relevant data from the clinical records were collected including age, gender, ECOG performance status, preexisting hepatopathy, Child–Pugh score, extrahepatic spread, vascular invasion, serum laboratory findings (alpha-fetoprotein, bilirubin, alkaline phosphatase and albumin), prior treatments for HCC, sorafenib treatment duration, dose reductions, toxicity and overall survival. Outcome data were last updated on January 28, 2014. Neutrophil-to-lymphocyte ratio was defined as the absolute neutrophil count divided by the absolute lymphocyte count measured on peripheral blood samples obtained in the period of 7 days before the start of sorafenib treatment. Patients were excluded from this analysis if they had demonstrable infection, chronic inflammatory disease, or if they were using steroids or granulocyte colony-stimulating factor. Patients were divided into a high NLR group ([3.5) and normal NLR group (B3.5) according to pre-treatment NLR, based on approximated value of the median NLR obtained in this analysis (3.48) and others studies threshold [5–11].
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Data were evaluated using SPSS software version 11.0 (SPSS Chicago, IL). Continuous variables were expressed as mean and ranges, and categorical variables were expressed as frequency, and compared using chi-square test. We analyzed pre-treatment clinical and laboratorial markers potentially associated with outcome. Potential predictive factors explored included ECOG performance status, Child– Pugh classification, the presence of vascular invasion and extrahepatic spread, the serum levels of alpha-fetoprotein and albumin and NLR. Kaplan–Meier curves comparing OS between groups were constructed, and log-rank testing was used for comparisons in univariate analysis. Variables were found to be significant if two-sided p value was \0.05 on multivariate testing using the Cox regression test.
Results Patients characteristics From the total of 120 consecutive patients treated, 15 patients were excluded for lack of sufficient data on clinical features or pre-treatment laboratory tests. Median age of the 105 patients included was 59.7 years (range 19–80.3). Most of the patients were male (71.4 %) and had ECOG performance status of 0 or 1 (86.7 %). Well preserved liver function (Child–Pugh class A) was found in 84.8 %, extrahepatic spread was found in 57.1 % and vascular invasion in 49.5 %. Hepatitis C, B and alcohol were preexisting conditions in 33.3, 20 and 27.6 % of patients, respectively. Detailed patient characteristics are shown in Table 1.
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Table 1 Baseline demographic and clinicopathologic characteristics of the patients Characteristic
n = 105 (%)
Median age (range)
59.7 years (19–80.3)
Table 2 Adverse events related to sorafenib treatment Adverse event Fatigue
Gender—[n (%)] Male
75 (71.4)
Female
30 (28.6)
ECOG performance status—[n (%)] 0 or 1 2 or 3 Child–Pugh class—[n (%)]
24 (13.3)
A
89 (84.8)
B
16 (15.2)
Coexisting liver disease—[n (%)] Hepatitis B
21 (20)
Hepatitis C
35 (33.3)
Alcohol
29 (27.6)
Other
20 (19)
Extrahepatic spread—[n (%)]
60 (57.1)
54 (51.4)
Grade 1/2
47 (44.7)
Grade 3/4
7 (6.7)
Diarrhea Grade 1/2 Grade 3/4
91 (86.7)
n (%)
Hand-foot reaction
45 (42.9) 36 (34.3) 9 (8.6) 42 (40)
Grade 1/2
35 (33.3)
Grade 3/4
7 (6.7)
Nauseas Grade 1/2 Grade 3/4 Vomiting Grade 1/2 Grade 3/4 Mucositis
15 (14.3) 15 (14.3) 0 (0) 13 (12.4) 12 (11.4) 1 (1) 9 (8.6)
Grade 1/2
8 (7.6)
Grade 3/4
1 (1)
Lung
14 (13.3)
Lymph nodes
14 (13.3)
Bone
17 (16.2)
Grade 1/2
9 (8.6)
52 (49.5)
Grade 3/4
0 (0)
Macroscopic vascular invasion—[n (%)] BCLC stage—[n (%)] B C Previous locoregional treatment—[n (%)]
24 (22.9) 81 (77.1) 53 (50.5)
Thrombocytopenia
9 (8.6)
Neutropenia
7 (6.7)
Grade 1/2
5 (4.8)
Grade 3/4
2 (1.9)
Anemia
4 (3.8)
Biochemical analysis
Grade 1/2
3 (2.9)
Albumin—(g/dL)
Grade 3/4
1 (1)
Median
3.85
Range
2.2–5.1
Total bilirubin—(mg/dL) Median
0.95
Range
0.24–26.38
Alpha-fetoprotein—(ng/mL) Median
1,030
Range
0.9–60,500
Alkaline phosphatase—(U/L) Median
156
Range
9.8–8,050
Neutrophil-to-lymphocyte ratio Median Range
3.48 0.64–20.0
BCLC Barcelona clinic liver cancer
patients (70.4 %), whereas 17 patients (16.2 %) discontinued for adverse events. There were no treatment-related deaths. Ninety-three patients (88.6 %) started with 800 mg/ daily and 12 (11.4 %) with reduced dose (600 or 400 mg/ daily). During treatment, 37 patients (35.2 %) required dose reductions for management of adverse events. Subsequent systemic therapies were provided for 29 patients (27.6 %). The most common adverse events related to sorafenib treatment were asthenia (51.4 %), diarrhea (42.8 %), handfoot skin reaction (40 %) and nauseas (14.3 %). Grades 3 or 4 toxicities were observed in 24 patients (22.9 %). Table 2 showed detailed side effects and grade related to sorafenib.
Treatment characteristics: safety and tolerability Treatment outcomes: NLR and survival The median duration of sorafenib treatment was 100 days (range 13–693). In the time of this analysis, 14 patients (13.3 %) were still receiving sorafenib. The main reason for drug discontinuation was disease progression in 74
Median follow-up was 11.4 months (range 0.47–27.1). Median survival of the entire cohort was 8.03 months (95 % CI 5.1–10.9).
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Fig. 1 Overall survival probability in months according to NLR ([3.5 vs. B3.5)
Table 3 Multivariate analysis of potential predictors for OS Variable
Multivariate p
HR (95 % confidence interval)
NLR [ 3.5
0.002
0.50 (0.32–0.78)
Albumin B3.8 g/dL
0.042
0.64 (0.41–0.98)
Alpha-fetoprotein B1,030 ng/mL
0.006
1.93 (1.20–3.08)
Extrahepatic spread
0.098
1.47 (0.93–2.335)
Vascular invasion
0.813
1.11 (0.71–1.75)
ECOG PS (0–1 vs. 2–3)
0.645
0.92 (0.46–1.8)
Child–Pugh (A vs. B)
0.002
0.55 (0.30–0.88)
NLR neutrophil–lymphocyte ratio, ECOG PS Eastern cooperative oncology group performance status
The median NLR was 3.48 (range 0.64–20.0). Fifty-one patients (48.6 %) had NLR [ 3.5 and 54 patients (51.4 %) had NLR B 3.5. Median OS of patients with NLR [ 3.5 was 5.23 months (95 % CI 2.96–7.50 months) and 10.05 months (95 % IC 2.52–18.47 months) for patients with NLR B 3.5. (p = 0.005—univariate analysis). (Fig. 1) NLR retained its significance as a prognostic marker on multivariate analysis in the entire cohort (Table 3). Treatment outcomes: other prognostic factors The median serum alpha-fetoprotein was 1,030 ng/mL. Fifty-two patients (49.5 %) had alpha-fetoprotein [1,030 ng/mL and 53 patients (50.5 %) had alpha-fetoprotein B1,030 ng/mL. Median OS of patients with alphafetoprotein [1,030 ng/mL was 5.23 months (95 % CI
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2.99–7.82 months) and 11.43 months (95 % IC 2.78–15.42 months) for patients with alpha-fetoprotein B1,030 ng/mL (p = 0.023—univariate analysis) (Fig. 2a). The median serum albumin was 3.8 ng/dL. Fifty-two patients (49.5 %) had serum albumin [3.8 ng/dL and 53 patients (50.5 %) had serum albumin B3.8 ng/dL. Median OS of patients with serum albumin B3.8 ng/dL was 3.86 months (95 % CI 0.98–5.25 months) and 10.70 months (95 % IC 6.56–14.67 months) for patients with serum albumin [ 3.8 ng/dL (p = 0.010—univariate analysis) (Fig. 2b). Multivariate analysis showed that, besides NLR, Child– Pugh B, pre-treatment alpha-fetoprotein[1,030 ng/mL and albumin B3.8 g/dL were also predictor of worse prognosis (p = 0.006 and p = 0.042, respectively). Extrahepatic spread, ECOG performance status (0–1 vs. 2–3) and vascular invasion were not associated with poorer survival in multivariate analysis (p = 0.098; p = 0.813 and p = 0.645; respectively) (Table 3). Considering three variables that showed association with poor survival (NLR [ 3.5, serum alpha-fetoprotein [1,030 ng/mL and serum albumin B3.8 ng/dL), we classified the patients according to the number of variables presented in four groups: (1) 24 patients (22.8 %) scored none variable, (2) 38 patients scored 1 variable (36.2 %), (3) 33 patients (31.4 %) scored 2 variables and (4) 10 patients (9.52 %) scored the 3 variables. The median OS was higher for patients with 0 variables and worse for patients that scored three variables (16.5 vs. 1.7 months; p \ 0.001). Table 4 shows the median OS and confidence interval and Fig. 3 shows the curves for each group.
Discussion In our cohort, we showed that high NLR affects survival in advanced HCC patients treated with sorafenib. Together with known worse prognostic factors, such as high alphafetoprotein and low serum albumin, NLR could distinguish HCC patients presenting poor survival with sorafenib treatment. Cancer patients may have local and systemic changes in inflammatory parameters, such as blood cell numbers, changes in erythrocyte sedimentation rate and elevation of acute-phase proteins similar to those observed in infection or inflammatory diseases. Data suggest that inflammation influences cancer progression, promoting cell proliferation, angiogenesis and response to therapies [13, 14]. The NLR is an easily reproducible marker of systemic inflammation, and increasing data have shown its value as a prognostic marker. A recent meta-analysis comprising 40,559 patients with solid tumors, including 1,667 patients with HCC, observed that high NLR is associated with adverse OS [5].
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Fig. 2 Overall survival probability in months according a serum alpha-fetoproteins (B1,030 ng/mL vs. [1,030 ng/mL) and b serum albumin (B3.8 ng/dL vs. [3.8 ng/dL)
Table 4 OS according to the number of variables scored Groups (n)
Median OS (months)
Median 95 % confidence interval
0 variables (n = 24)
16.50
(10.43–22.56)
1 variable (n = 38)
10.70
(8.52–12.88)
2 variables (n = 33)
3.96
(3.44–4.49)
3 variables (n = 10)
1.7
(0.35–3.04)
Overall (n = 105)
8.03
(5.13–10.93)
NLR neutrophil–lymphocyte ratio, ECOG PS Eastern cooperative oncology group performance status
The mechanisms that underline the role of NLR are still unknown, but some hypothesis can be raised regarding inflammatory response with tumor growth and invasion. A high NLR reflects both increasing in neutrophil response and decreasing in lymphocyte-depending immune reaction. Neutrophils have been shown to produce cytokines such as tumor necrosis factor and secrete VEGF, a pro-angiogenic circulating molecule, and intra-tumoral infiltration of neutrophils stimulate tumor invasion by producing hepatocyte growth factor [15]. In HCC, IL-17 seems to promote tumor growth and higher NLR is associated with up-regulation of IL-17 [16]. On the other hand, a relative lymphopenia may reflect deficient immune response to malignancy mediated by CD4? T-helper and cytotoxic CD8? cells. In colorectal cancer, tumor infiltration by lymphocyte is predictive of longer survival [17]. It is important to note that neither neutrophil count nor lymphopenia alone may reflect clinical outcome (data not shown), but interaction between these two immune cells counts was able to predict survival in HCC patients treated with sorafenib.
Fig. 3 Overall survival probability in months according to number of independent variables associated with worse OS (serum albumin, alpha-fetoprotein and NLR)
Identifying factors affecting clinical outcomes of HCC patients treated with sorafenib is an important task, since the desired delay in disease progression is rarely accomplished through tumor responses. Patients stay in treatment until progression without any clue if they are obtaining benefit from therapy or just the side effects. Indeed, there is only limited data on markers associated with antitumor treatment of patients with HCC. A retrospective analysis with sorafenib-treated patients indicated that elevated bilirubin and alpha-fetoprotein were significantly associated with worse OS [18]. Serum alpha-fetoprotein has been correlated with tumor burden and many
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published reports confirm that it carries prognostic value [18–20]. Liver function tests are important factors related to survival of patients with HCC. Low albumin may reflect nutrition deficiency or, more importantly, is a surrogate marker of altered liver function, a well recognized predictive and prognostic factor in HCC [18]. Using these markers, the identification of subgroups that could have little or no benefit from sorafenib can help clinical decision and expectations. Many investigators have worked to find biomarkers that predict survival to sorafenib. Serum concentrations of VEGF and phosphorylated ERK proved to be good predictors [21, 22]. These biomarkers are, however, expensive and not easily available in clinical practice. We have used markers that are routinely obtained when planning HCC treatment. A clear limitation of this study is its retrospective nature. Large prospective randomized trials are the ideal source for detecting laboratorial and clinical based biomarkers. However, data extracted from a cohort of clinically similar patients uniformly treated in single institutions also provide useful information regarding prognostic and predictive indicators. Prospective validation by further trials of NLR as a prognostic marker must be warranted. The intriguing and provocative finding of these data is that selecting HCC patients based on the laboratorial features others than the ones related to the liver function may improve the therapeutic effectiveness of sorafenib. Conflict of interest
None.
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