Prognostic value of the neutrophil‑lymphocyte, platelet‑lymphocyte and monocyte‑lymphocyte ratio in breast cancer patients

  • Authors:
    • Joanna Huszno
    • Zofia Kolosza
  • View Affiliations

  • Published online on: October 8, 2019     https://doi.org/10.3892/ol.2019.10966
  • Pages: 6275-6283
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Abstract

The aim of the present study was to assess the blood the neutrophil‑lymphocyte ratio (NLR), platelet‑lymphocyte ratio (PLR) and monocyte‑lymphocyte ratio (MLR) as prognostic factors in breast cancer (BC) patients. A retrospective analysis of 436 BC patients who were treated at COI (Gliwice, Poland) between January 2005 and June 2018 was performed. The prognostic value [overall survival (OS)] of the pre‑treatment PLR, NLR and MLR was assessed by univariate and multivariate analysis. The 5‑year OS was lower in the NLR >2.65 compared with that in the NLR≤2.65 group (82.5 vs. 89.6%; P=0.053), and significantly lower in the subgroup of triple‑negative breast cancer (TNBC; 70.3 vs. 89.3%; P=0.034) and in patients whose tumors had an estrogen receptor‑negative [ER(‑)] status (66.6 vs. 83.6%; P=0.018). The 5‑year OS was lower in patients with PLR >190.9 compared with that in the PLR≤190.9 group (78.7 vs. 89.4%; P=0.020). A poor OS rate associated with an elevated PLR was also observed in the subgroups with TNBC (68.2 vs. 88.5%; P=0.032) and with ER(‑) status tumors (57.7 vs. 83.6%, P=0.002). An elevated MLR (>0.28) was not associated with OS time (P=0.830). Multivariate analysis revealed that the NLR and PLR were insignificant negative prognostic factors, except for the subgroup of patients with ER(‑) tumors, where an elevated NLR [hazard ratio (HR)=2.40; 95% confidence interval (CI): 1.20‑4.80; P=0.013] and a higher PLR (HR=2.51; 95%CI: 1.23‑5.14; P=0.012) were independent prognostic factors for poor OS together with lymph node metastasis ((HR=5.47; 95%CI: 2.46‑12.15; P=0.0001 and HR=4.82; 95% CI: 2.15‑10.78; P=0.0001), respectively. The present results revealed that an elevated NLR (>2.65) and PLR (>190.9) are associated with poor OS in BC patients. In the ER(‑) subgroup of patients, an elevated NLR and PLR were significant independent prognostic factors. However, the MLR did not affect OS.

Introduction

Breast cancer (BC) is a common malignancy in women. In the Silesian region of Poland, the BC-associated morbidity was reported to be 21% of cancer cases in females in the year 2013. Cancer-associated mortality has been reported in 15% of BC patients. Traditional prognostic factors in BC patients are metastases in lymph/axillary nodes, tumor size, tumor grade (histologic or nuclear), vessel infiltration, the estrogen receptor (ER) and progesterone receptor (PR) status, and HER2 overexpression (1).

Inflammation impacts each step of tumorigenesis, including tumor initiation, promotion and metastatic progression (2). Biomarkers including the neutrophil, lymphocyte and platelet count, as well as the neutrophil-lymphocyte ratio (NLR), platelet-lymphocyte ratio (PLR) and monocyte-lymphocyte ratio (MLR) are indices of inflammation (3). They have been reported to be prognostic factors in several types of solid tumor. The NLR is defined as neutrophil count divided by lymphocyte count. The prognostic value of the NLR has been confirmed in patients with colorectal cancer (4), hepatocellular carcinoma (5), BC (6), bladder cancer (7), lung cancer (8), pancreatic cancer (9), prostate cancer (10) and renal cell cancer (RCC) (1113). The PLR is defined as the platelet count divided by the lymphocyte count. The prognostic value of PLR has been studied in patients with various cancer types (14), including gastric cancer (15), colorectal cancer (16), hepatocellular carcinoma (17), ovarian cancer (18), non-small cell lung cancer (19), pancreatic cancer (20), prostate cancer and RCC (2124).

The LMR is the determined by dividing the lymphocyte count by the monocyte count in the blood. In turn, the MLR is the monocyte count divided by the lymphocyte count in the blood. The prognostic value of the LMR or MLR has been reported in patients with pulmonary squamous cell carcinoma (lung cancer) (25), hepatocellular carcinoma (26), colorectal cancer (27), endometrial cancer (28), pancreatic cancer (29), gastric cancer (30) and ovarian cancer (31). An elevated pre-treatment LMR was reported as a significant positive prognostic factor for patients with locally advanced BC. According to univariate and multivariate Cox regression analyses, elevated LMR levels (≥4.25) were significantly associated with a favorable prognosis regarding disease-free survival (DFS) (32). In line with this, a low pre-operative LMR was reported to be a poor prognostic factor for BC patients (33). A prognostic role of the NLR in BC patients has been determined by certain studies (6,34). A higher pre-treatment peripheral NLR was identified as a significant and independent poor prognostic factor for BC and TNBC (34). Certain meta-analyses have reported that the PLR may be a prognostic factor in BC patients. Zhu et al (35), have demonstrated that a high PLR was associated with worse overall survival (OS) and DFS in BC patients.

The aim of the present study was to evaluate the prognostic value of the PLR, NLR and the MLR in BC patients.

Patients and methods

Patients

The medical records and laboratory results of 436 BC patients who were diagnosed and treated at the MSC Memorial Cancer Centre and Institute of Oncology, Gliwice Branch (Gliwice, Poland) from January 2005 to June 2018 were reviewed. The median age of the patients was 52.5 years (range, 25.2–78.3 years). All of the patients were women and had a good overall performance status (ZUBROD 0–1) (normal activity or symptomatic and ambulatory, cares for self) (36). All patients provided written informed consent regarding the use of their biological material for clinical research (all were routine laboratory analyses). The blood cell parameters were determined at the baseline, before first treatment. Treatment strategies are showed in Table I. In retrospective analysis, patients with PLR (>190.9) (P=0.026) and NLR (>2.65) (P=0.025) significantly more often had received chemotherapy regiments with taxanes. Similarly, patients with elevated PLR (P=0.0001) and NLR (P=0.042) more frequently had no surgery. In contrary, women with lower PLR (P=0.006), NLR (P=0.015) or MLR (P=0.012) were more frequently treated with hormonotherapy. In our study, there was reported no association between radiotherapy and PLR (P=0.359), NLR (P=0.981) or MLR (P=0.225).

Table I.

Treatment strategy.

Table I.

Treatment strategy.

NLR, n (%)PLR, n (%)MLR, n (%)



TreatmentAll groups (n=436)NLR≤2.65 (n=346)NLR>2.65 (n=90)P-valuePLR ≤190.9 (n=382)PLR >190.9 (n=54)P-valueMLR ≤0.28 (n=275)MLR>0.28 (n=159)P-value
Chemotherapy 0.0498 0.088 0.627
  No45 (10)41 (12)4 (4) 43 (11)2 (4) 30 (11)15 (9)
  Yes391 (90)305 (88)86 (96) 339 (89)52 (96) 245 (89)144 (91)
Chemotherapy regimen
  Total n for all chemotherapy patients39130586 33952 245144
  AC FAC302 (77)241 (79)61 (71)0.025265 (78)37 (71)0.026193 (79)108 (75)0.441
  AC + taxanes80 (20)56 (18)24 (28) 66 (19)14 (27) 47 (19)33 (23)
  CMF8 (2)8 (3)0 8 (2)0 5 (2)2 (1)
  Other1 (0)01 (1) 01 (2) 01 (1)
Local treatment 0.042 0.0001 0.153
  Mastectomy278 (64)224 (65)54 (60) 246 (64)32 (59) 177 (64)99 (62)
  Breast conservation surgery130 (30)105 (30)25 (28) 119 (31)11 (20) 85 (31)45 (28)
  Without surgery28 (6)17 (5)11 (12) 17 (4)11 (20) 13 (5)15 (9)
Hormonotherapy 0.015 0.006 0.012
  No149 (34)108 (31)41 (46) 121 (32)28 (52) 82 (30)67 (42)
  Yes287 (66)238 (69)49 (54) 261 (68)26 (48) 193 (70)92 (58)
Radiotherapy 0.981 0.359 0.225
  No111 (25)88 (25)23 (26) 100 (26)11 (20) 75 (27)35 (22)
  Yes325 (75)258 (75)67 (74) 282 (74)43 (80) 200 (73)124 (78)

[i] Data are presented as n (%). AC, Adriamycin (or doxorubicin; 60 mg/m2) and Cyclophosphamide (600 mg/m2) treatment; FAC, Fluorouracil (500 mg/m2), Adriamycin (or doxorubicin; 50 mg/m2) and Cyclophosphamide (500 mg/m2) treatment; CMF, Cyclophosphamide (100 mg/m2), Methotrexate (40 mg/m2) and Fluorouracil (600 mg/m2) treatment.

Patients underwent clinical follow-up examinations every three months in the first two years, then every six months until the fifth year after diagnosis and every year thereafter. The inclusion criteria were as follows: BC confirmed by microscopic examination, performance status of ZUBROD 0–1, an age of >18 years, and renal and liver function as well as bone marrow parameters within the normal ranges. The data, including the age at diagnosis, menopausal status, treatment strategy, disease stage according to the Tumor-Nodes-Metastasis classification, tumor histology, estrogen (ER) and progesterone (PR) status, as well as the presence of HER2 overexpression and contralateral BC, were gathered from hospital records and pathology reports. The analysis of the patients' medical records was performed according to national law regulations. The clinicopathological characteristics of the patients are presented in Table II.

Table II.

Patient clinicopathological characteristics.

Table II.

Patient clinicopathological characteristics.

NLRPLRMLR



CharacteristicAll groups (n=436)NLR≤2.65 (n=346)NLR>2.65 (n=90)P-valuePLR ≤190.9 (n=382)PLR >190.9 (n=54)P-valueMLR ≤0.28 (n=275)MLR>0.28 (n=159)P-value
Age, median (Q1-Q3)52.5 (44.2–60.8)53.5 (45.0–61.0)47.7 (41.3–59.5)0.02153.4 (44.9–61.1)47.7 (42.6–57.0)0.02253.5 (45.0–60.7)50.8 (43.1–61.7)0.002
Menopausal status 0.021 0.035 0.209
  Pre-224 (51%)168 (49%)56 (62%) 189 (49%)35 (65%) 135 (49%)88 (55%)
  Post212 (49%)178 (51%)34 (38%) 193 (51%)19 (35%) 140 (51%)71 (45%)
Tumor size 0.187 0.146 0.186
  T1-T2333 (76%)269 (78%)64 (71%) 296 (77%)37 (69%) 216 (79%)116 (73%)
  T3-T4103 (24%)77 (22%)26 (29%) 86 (23%)17 (31%) 59 (21%)43 (27%)
Lymph node status 0.803 0.564 0.345
  Negative242 (56%)191 (55%)51 (57%) 214 (56%)28 (52%) 148 (54%)93 (58%)
  Positive194 (44%)155 (45%)39 (43%) 168 (44%)26 (48%) 127 (46%)66 (42%)
Tumor grade 0.062 0.020 0.783
  G1-G2265 (61%)218 (63%)47 (52%) 240 (63%)25 (46%) 168 (61%)95 (60%)
  G3171 (39%)128 (37%)43 (48%) 142 (37%)29 (54%) 107 (39%)64 (40%)
Estrogen receptor 0.008 0.005 0.031
  ER(−)152 (35%)110 (32%)42 (47%) 124 (32%)28 (52%) 86 (31%)66 (42%)
  ER(+)284 (65%)236 (68%)48 (53%) 258 (68%)26 (48%) 189 (69%)93 (58%)
Molecular subtype 0.242 0.028 0.580
  Luminal171 (39%)142 (41%)29 (32%) 157 (41%)14 (26%) 112 (41%)58 (36%)
  HER2 positive179 (41%)140 (40%)39 (43%) 156 (41%)23 (43%) 112 (41%)66 (42%)
  Triple negative86 (20%)64 (18%)22 (24%) 69 (18%)17 (31%) 51 (19%)35 (22%)
WBC (109 cells/l)6.38 (5.45–7.69)6.18 (5.27–7.30)7.64 (6.16–8.97)0.00016.49 (5.49–7.70)5.70 (5.11–6.73)0.0176.22 (5.30–7.45)6.67 (5.65–8.27)0.002
Neutrophil count (109 cells/l)3.72 (2.96–4.62)3.42 (2.79–4.16)5.30 (4.22–6.52)0.00013.69 (2.96–4.61)3.78 (2.96–4.76)0.3143.41 (2.80–4.31)4.07 (3.37–5.35)0.0001
Lymphocyte (109 cells/l)1.92 (1.60–2.28)2.01 (1.69–2.41)1.51 (1.31–1.82)0.00011.99 (1.68–2.36)1.42 (1.11–1.65)0.00012.08 (1.72–2.45)1.69 (1.47–1.95)0.0001
Monocyte (109 cells/l)0.50 (0.40–0.60)0.49 (0.39–0.58)0.54 (0.42–0.66)0.0230.50 (0.41–0.60)0.42 (0.35–0.55)0.0130.45 (0.36–0.52)0.59 (0.50–0.71)0.0001
Platelet (109 cells/l)252.0 (217.0–292.0)250.0 (215.0–290.0)260.5 (223.0–295.0)0.199248.0 (213.0–281.0)317.5 (272.0–367.0)0.0001249.0 (215.0–288.0)260.0 (221.0–295.0)0.123

[i] Data are presented as either n (%) or the median (Q1-Q3), as indicated. NLR, neutrophil to lymphocyte ratio; PLR, platelet to lymphocyte ratio; MLR, monocyte to lymphocyte ratio; T, tumor size; G, tumor grade; ER, estrogen receptor; HER2, human epidermal growth factor receptor 2.

The prognostic value (regarding OS) of various laboratory parameters, including the PLR, NLR and MLR, was assessed based on univariate and multivariate analysis. The cut-off values were determined using receiver operating characteristic curves. Based on the cut-off values determined, the NLR was considered as ‘elevated’ at >2.65, the MLR value was ‘elevated’ at >0.28 and the PLR was considered ‘elevated’ at >190.9.

Statystical analysis

Statistical analysis was performed using Dell Statistica v.13 software. The frequency of the appearance of side effects was denoted. Qualitative features were presented as the percentage of their occurrence and evaluated with Fisher's test and the Chi-squared test with Yates correction. Continuous data were expressed as the median (first quartile-third quartile) and the significance of differences was identified using the Mann-Whitney U-test. Survival curves were obtained using the Kaplan-Meier method and the log-rank test was performed to determine the significance of differences in survival between subgroups. The relative risk of death was estimated as hazard ratios (HRs) using the Cox proportional hazard regression. NLR and PLR were re-evaluated in multivariate analyses adjusted significant BC prognostic factors. P<0.05 was considered to indicate a statistically significant difference.

Results

Follow-up

The median duration of follow-up was 71 months (range, 3–156 months). The 5- and 10-year OS rates were 88.1 and 80.2%, respectively.

Patients characteristics according to NLR

Patients with an NLR of >2.65 were more frequently of younger age (median 47.7 vs. 53.5 years, P=0.021) and more frequently had a negative ER(−) status (47 vs. 32%, P=0.008) in comparison with the NLR ≤2.65 subgroup. There was no difference between the NLR >2.65 and ≤2.65 groups with regard to tumor size (78 vs. 71%; P=0.187), negative lymph node status (57 vs. 55%; P=0.803) and BC subtype (P=0.242; Table II).

Prognostic value of an elevated NLR

The 5-year OS in the NLR >2.65 subgroup was lower compared with that in the NLR ≤2.65 subgroup (82.5 vs. 89.6%; P=0.053; Fig. 1A), particularly in those patients with triple-negative breast cancer (TNBC; 70.3 vs. 89.3%; P=0.034; Fig. 1B), in patients with ER(−) status tumors (66.6 vs. 83.6%; P=0.018; Fig. 1C) or with a higher tumor grade of G3 (77.4 vs. 89.0%; P=0.020; Fig. 1D). Similar but insignificant association was observed in subgroups with lymph node metastases (74.3 vs. 82.6%; P=0.118; Fig. 1E) and HER2 overexpression (80.8 vs. 87.8%; P=0.167; Fig. 1F).

Patients characteristics according to PLR

Patients with a high PLR (>190.9) more frequently had a higher histological tumor grade of G3 (54 vs. 37%; P=0.020), an ER(−) status (52 vs. 32%; P=0.005) and TNBC (31 vs. 18%; P=0.028) in comparison with those with a low PLR (Table II).

Prognostic value of an elevated PLR

The 5-year OS was lower in patients with a PLR of >190.9 compared with that in patients with a PLR of ≤190.9 (78.7 vs. 89.4%; P=0.020; Fig. 2A). A PLR of >190.9 was also associated with a worse OS rate in the subgroups with TNBC (68.2 vs. 88.5%; P=0.032; Fig. 2B), ER(−) status tumors (57.7 vs. 83.6%; P=0.002; Fig. 2C) or tumors with a higher histological grade of G3 (70.4 vs. 89.2%; P=0.002; Fig. 2D), lymph node metastases (70.0 vs. 83.8%; P=0.085; Fig. 2E), tumors with HER2 overexpression (73.7 vs. 88.2%; P=0.061; Fig. 2F) and the non-Luminal BC subtype (43.6 vs. 74.8%; P=0.018) and the presence of BRCA mutation (61.4 vs. 81.6%; P=0.058).

Patients characteristics according to MLR

Patients with an elevated MLR (>0.28) more frequently had an ER(−) status (42 vs. 31%; P=0.031) compared with those with a lower MLR. There was no difference between the high and low MLR groups regarding the tumor size (73 vs. 76%; P=0.186), the presence of lymph node metastases (58 vs. 56%; P=0.345) and the frequency of a histological tumor grade G3 (40 vs. 39%; P=0.783; Table II).

Prognostic value of an elevated MLR

In the cohort of the present study, an ‘elevated’ MLR (>0.28) was not associated with OS time (P=0.830; Fig. 3A), also not in the subgroups with TNBC (P=0.219; Fig. 3B), ER(−) (P=0.453; Fig. 3C), G3 (P=0.995; Fig. 2D) and HER2 overexpression (P=0.474; Fig. 3F). However, a worse OS rate was observed in patients with lymph node metastases and an ‘elevated’ MLR (77.5 vs. 85.6%; P=0.058; Fig. 2E).

Univariate and multivariate analysis

Univariate Cox regression analyses of OS showed prognostic significance for factors such as patient's age [hazard ratio (HR)=1.03; 95% confidence interval (CI): 1.00–1.05; P=0.018], tumor size (T3-4 vs. T1-2, HR=2.75; 95% CI: 1.69–4.48; P=0.0001), the presence of lymph node metastases (N+ vs. N0, (HR=3.74; 95% CI: 2.17–6.46; P=0.0001), estrogen receptor status (ER(+) vs. ER(−), HR=0.51; 95% CI: 0.32–0.83; P=0.007) and PLR (PLR>190.9 vs. ≤190.9, HR=2.02; 95% CI: 1.12–3.65; P=0.020). Factors such as menopausal status, tumor grade, HER2 overexpression, NLR and MLR were not statistically significant (Table III).

Table III.

Univariate and multivariate analysis in all breast cancer patients.

Table III.

Univariate and multivariate analysis in all breast cancer patients.

Univariate analysisNLR Multivariate analysisPLR Multivariate analysis



VariableHR (95%CI)P-valueHR (95%CI)P-valueHR (95%CI)P-value
Age1.03 (1.00–1.05)0.0181.03 (1.01–1.06)0.0051.03 (1.01–1.06)0.006
Status postmenopausal vs. pre1.36 (0.83–2.22)0.218
T3-T4 vs. T1-T22.75 (1.69–4.48)0.00011.97 (1.17–3.31)0.0101.97 (1.17–3.30)0.010
N+ vs. N03.74 (2.17–6.46)0.00013.65 (2.09–6.37)0.00013.56 (2.03–6.23)0.0001
G3 vs. G1-G21.27 (0.77–2.09)0.344
ER(+) vs. ER(−)0.51 (0.32–0.83)0.0070.53 (0.32–0.89)0.0160.54 (0.32–0.91)0.021
HER2 positive vs. HER2 negative1.56 (0.97–2.54)0.069
NLR>2.65 vs. NLR≤2.651.70 (1.00–2.90)0.0501.58 (0.92–2.72)0.100
PLR >190.9 vs. PLR ≤190.92.02 (1.12–3.65)0.020 1.55 (0.83–2.88)0.170
MLR>0.28 vs. MLR ≤0.280.94 (0.56–1.58)0.829

[i] NLR, neutrophil to lymphocyte ratio; PLR, platelet to lymphocyte ratio; HR, hazard ratio; CI, confidence interval; T, tumor size; N, node; G, tumor grade; ER, estrogen receptor; HER2, human epidermal growth factor receptor 2; MLR, monocyte to lymphocyte ratio.

Multivariate analysis revealed that the NLR and PLR are insignificant negative prognostic factors in all BC patients (Table III). Negative prognostic factors were: Patients age, tumor size and lymph node metastases. In contrary, positive prognostic factor was positive steroid receptor status (ER+). However, analysis of the subgroup of patients with ER(−) tumors indicated that a higher NLR (HR=2.40; 95% CI: 1.20–4.80; P=0.013) and a higher PLR (HR=2.51; 95% CI: 1.23–5.14; P=0.012) were independent prognostic factors for a lower OS together with metastatic lymph nodes (HR=5.47; 95% CI: 2.46–12.15; P=0.0001 and HR=4.82; 95% CI: 2.15–10.78; P=0.0001, respectively; Table IV).

Table IV.

Multivariate analysis of the subgroup of patients with ER negative and grade G3 tumors.

Table IV.

Multivariate analysis of the subgroup of patients with ER negative and grade G3 tumors.

NLR Multivariate analysisPLR Multivariate analysis


Patient groupHR (95%CI)P-valueHR (95%CI)P-value
Patients with ER negative
  N+ vs. N05.47 (2.46–12.15)0.00014.82 (2.15–10.78)0.0001
  NLR >2.65 vs. ≤2.652.40 (1.20–4.80)0.013
  PLR >190.9 vs. ≤190.92.51 (1.23–5.14)0.012
Patients with tumor grade G3
  T3-T4 vs. T1-T21.99 (0.88–4.49)0.098
  N+ vs. N04.04 (1.73–9.40)0.0013.53 (1.51–8.25)0.004
  ER(+) vs. ER(−)0.28 (0.12–0.68)0.0050.37 (0.15–0.94)0.036
  NLR >2.65 vs. ≤2.652.14 (0.97–4.68)0.058
  PLR >190.9 vs. ≤190.92.61 (1.15–5.89)0.021

[i] NLR, neutrophil to lymphocyte ratio; PLR, platelet to lymphocyte ratio; HR, hazard ratio; CI, confidence interval; T, tumor size; N, node; ER, estrogen receptor.

Discussion

In this retrospective study, we reported the prognostic value of the NLR, PLR and MLR in BC patients. The influence of the NLR, MLR and PLR on the survival time (OS or DFS) of BC patients has been investigated in numerous studies (6,34,35).

In the present study, no association between an elevated MLR (>0.28) and the OS time was identified (P=0.830), also not in the subgroups with TNBC (P=0.219) and ER(−) status (P=0.453). An elevated pre-treatment (prior to neoadjuvant chemotherapy) peripheral blood LMR was reported to be a significantly favorable prognostic factor for patients with locally advanced BC. Univariate and multivariate analysis confirmed that a higher LMR (≥4.25) was significantly associated with favorable DFS (P = 0.009 and P = 0.011, respectively). In addition, univariate analysis revealed an increased probability of DFS in patients with a higher lymphocyte count (≥1.5×109/l). However, a lower monocyte count (<0.4×109/l) was associated with a significantly better prognosis regarding DFS (P = 0.010) (32). The pre-operative LMR (prior to neoadjuvant chemotherapy) as a prognostic factor in BC patients was also analyzed in a meta-analysis by Hu et al (33), revealing that a low LMR was significantly associated with a worse prognosis regarding OS (HR=0.65; 95% CI: 0.47–0.90; P=0.009) and DFS (HR=0.60; 95% CI: 0.49–0.74; P<0.001). Subgroup analyses indicated that a low LMR had a negative impact on the prognosis regarding OS in Asian populations with triple-negative BC without metastases. However, no association between a low LMR and clinicopathological factors was identified (33). Our data did not confirmed above mentioned results. In our study MLR was not prognostic factor according to OS, also in subgroup analysis. However, we did not analyze DFS.

In the present study, a higher NLR was associated with a lower 5-year OS rate, particularly in the subgroup of TNBC (P=0.034), in patients with ER(−) status tumors (P=0.018) and in patients with G3 (P=0.020). Similar but insignificant association was observed in subgroups with lymph node metastases (P=0.118) and HER2 overexpression (P=0.167). In a previous study, Chen et al (6) suggested that a higher NLR may be a prognostic factor regarding OS with an HR of 2.28 (95% CI: 1.08–4.80; Pheterogeneity<0.001), particularly in Caucasian populations (HR=4.53; 95% CI: 3.11–6.60; Pheterogeneity=0.096). An elevated NLR was also associated with a high risk regarding DFS (HR=1.38; 95% CI=1.09–1.74; Pheterogeneity=0.050) (36). In an analysis conducted by Jia et al (34), a higher pre-treatment level of NLR (before neo-adjuvant chemotherapy) was identified as a significant and independent poor prognostic factor for BC patients, particularly in the TNBC subgroup. The higher NLR was a better prognostic factor in comparison to a lower LMR. Univariate analysis indicated that a lower NLR (≤2.0) and a higher LMR (>4.8) were significantly associated with a better DFS in TNBC patients (P=0.007 and 0.011, respectively). By contrast, in other molecular BC subtypes (luminal subtype: ER+ and/or PR+ and HER2-; HER2-positive subtype: HER2+), no significant association between the NLR or the LMR with survival (DFS or OS) was identified (34). Our study support the results of previous dates. We confirm NLR to be negative prognostic factor, especially for subgroups with TNBC, ER negative status or G3 tumors. In study conducted by Li et al (37) NLR in healthy people was positively associated with age. There was reported the highest NLR in the eldest age group. In contrary, the youngest age group had the lowest NLR. NLR was also slightly positively associated with blood pressure, and BMI (P<0.001). In our group, patients with an NLR of >2.65 were more frequently of younger age (median 47.7 vs. 53.5 years, P=0.021).

Another hematological parameter examined as a prognostic factor in BC patients is the PLR. In the present study, a lower 5-year OS in patients with PLR>190.9 in comparison with those with PLR≤190.9 was observed, particularly in the subgroup with TNBC (P=0.032) and in those patients with ER(−) status tumors (P=0.002) and in those patients with G3 (P=0.002). A meta-analysis conducted by Zhu et al (35), revealed that the PLR is an unfavorable prognostic factor in BC patients. In that study, a higher PLR was associated with a worse OS (HR=1.55; 95% CI: 1.07–2.25; P=0.022) and DFS (HR=1.73; 95% CI: 1.3–2.3; P<0.001) in BC patients. An elevated PLR was associated with worse OS in Asian populations and with poor DFS in Asian as well as non-Asian subgroups. In addition, PLR was identified as a significant prognostic factor for OS (HR=1.78; 95% CI=1.06–2.99; P=0.03) and DFS in patients who receive chemotherapy (HR=2.6; 95% CI=1.47–4.61; P=0.001). Furthermore, the study reported an association between PLR and the presence of HER-2 overexpression (odds ratio=1.48; 95% CI: 1.2–1.83; P<0.001) (35). Results of our study confirm the role of elevated PLR as a negative prognostic factor in BC patients, particularly in the subgroups with TNBC, ER(−) status tumors or tumors with a higher histological grade of G, lymph node metastases, tumors with HER2 overexpression and the non-Luminal BC subtype and the presence of BRCA mutation.

An elevated pre-treatment NLR (>2.65) (insignificantly) and PLR (>190.9) (significantly) was associated with a worse prognosis regarding OS in BC patients. In univariate analysis higher NLR and PLR were significantly negative prognostic factors for subgroups such as: TNBC, ER(−) and with a higher tumor grade of G3. However, the MLR did not affect OS. In multivariate analyses in the ER(−) subgroup of patients, an elevated NLR and PLR were significant independent prognostic factors.

Acknowledgements

The authors would like to thank Dr. Jolanta Mrochem-Kwarciak (Analytics and Clinical Biochemistry Department) for the laboratory assistance.

Funding

No funding was received.

Availability of data and materials

All data generated or analyzed during the present study are included in this published article.

Authors' contributions

JH analyzed and interpreted the patients' data and was a major contributor in writing the manuscript. ZK performed the statistical analyses, and analyzed and interpreted the data.

Ethics approval and consent to participate

At the time of venous blood collection for genetic diagnostic testing, all patients provided written informed consent. The present study analyzed the results of these genetic diagnostic tests retrospectively.

Patient consent for publication

Not applicable.

Competing interests

The authors declare that they have no competing interests.

References

1 

Bundred NJ: Prognostic and predictive factors in breast cancer. Cancer Treat Rev. 27:137–142. 2001. View Article : Google Scholar : PubMed/NCBI

2 

Grivennikov SI, Greten FR and Karin M: Immunity, inflammation and cancer. Cell. 140:883–899. 2010. View Article : Google Scholar : PubMed/NCBI

3 

Hutterer GC, Stoeckigt C, Stojakovic T, Jesche J, Eberhard K, Pummer K, Zigeuner R and Pichler M: Low preoperative lymphocyte-monocyte ratio (LMR) represents a potentially poor prognostic factor in nonmetastatic clear cell renal cell carcinoma. UrolOncol. 32:1041–1048. 2014.

4 

Li MX, Liu XM, Zhang XF, Zhang JF, Wang WL, Zhu Y, Dong J, Cheng JW, Liu ZW, Ma L and Lv Y: Prognostic role of neutrophil-to-lymphocyte ratio in colorectal cancer: A systematic review and meta-analysis. Int J Cancer. 134:2403–2413. 2014. View Article : Google Scholar : PubMed/NCBI

5 

Xiao WK, Chen D, Li SQ, Fu SJ, Peng BG and Liang LJ: Prognostic significance of neutrophil-lymphocyte ratio in hepatocellular carcinoma: A meta-analysis. BMC Cancer. 14:1172014. View Article : Google Scholar : PubMed/NCBI

6 

Chen J, Deng Q, Pan Y, He B, Ying H, Sun H, Liu X and Wang S: Prognostic value of neutrophil-to-lymphocyte ratio in breast cancer. FEBS Open Bio. 5:502–507. 2015. View Article : Google Scholar : PubMed/NCBI

7 

Tang X, Du P and Yang Y: The clinical use of neutrophil-to-lymphocyte ratio in bladder cancer patients: A systematic review and meta-analysis. Int J Clin Oncol. 22:817–825. 2017. View Article : Google Scholar : PubMed/NCBI

8 

Akinci Ozyurek B, Sahin Ozdemirel T, Buyukyaylaci Ozden S, Erdogan Y, Kaplan B and Kaplan T: Prognostic value of the neutrophil to lymphocyte ratio (NLR) in lung cancer cases. Asian Pac J Cancer Prev. 18:1417–1421. 2017.PubMed/NCBI

9 

Asaoka T, Miyamoto A, Maeda S, Tsujie M, Hama N, Yamamoto K, Miyake M, Haraguchi N, Nishikawa K, Hirao M, et al: Prognostic impact of preoperative NLR and CA19-9 in pancreatic cancer. Pancreatology. 16:434–440. 2016. View Article : Google Scholar : PubMed/NCBI

10 

Cao J, Zhu X, Zhao X, Li XF and Xu R: Neutrophil-to-lymphocyte ratio predicts PSA response and prognosis in prostate cancer: A systematic review and meta-analysis. PLoS One. 11:e01587702016. View Article : Google Scholar : PubMed/NCBI

11 

Semeniuk-Wojtaś A, Lubas A, Stec R, Syryło T, Niemczyk S and Szczylik C: Neutrophil-to-lymphocyte ratio, platelet-to-lymphocyte ratio and C-reactive protein as new and simple prognostic factors in patients with metastatic renal cell cancer treated with tyrosine kinase inhibitors: A systemic review and meta-analysis. Clin Genitourin Cancer. 16:e685–e693. 2018. View Article : Google Scholar : PubMed/NCBI

12 

Hu K, Lou L, Ye J and Zhang S: Prognostic role of the neutrophil-lymphocyte ratio in renal cell carcinoma: A meta-analysis. BMJ Open. 5:e0064042015. View Article : Google Scholar : PubMed/NCBI

13 

Park YH, Ku JH, Kwak C and Kim HH: Post-treatment neutrophil-to-lymphocyte ratio in predicting prognosis in patients with metastatic clear cell renal cell carcinoma receiving sunitinib as first line therapy. Springerplus. 3:2432014. View Article : Google Scholar : PubMed/NCBI

14 

Zhou X, Du Y, Huang Z, Xu J, Qiu T, Wang J, Wang T, Zhu W and Liu P: Prognostic value of PLR in various cancers: A meta-analysis. PLoS One. 9:e1011192014. View Article : Google Scholar : PubMed/NCBI

15 

Xu Z and Xu W, Cheng H, Shen W, Ying J, Cheng F and Xu W: The prognostic role of the platelet-lymphocytes ratio in gastric cancer: A meta-analysis. PLoS One. 11:e01637192016. View Article : Google Scholar : PubMed/NCBI

16 

Tan D, Fu Y, Su Q and Wang H: Prognostic role of platelet-lymphocyte ratio in colorectal cancer: A systematic review and meta-analysis. Medicine (Baltimore). 95:e38372016. View Article : Google Scholar : PubMed/NCBI

17 

Zhao Y, Si G, Zhu F, Hui J, Cai S, Huang C, Cheng S, Fathy AH, Xiang Y and Li J: Prognostic role of platelet to lymphocyte ratio in hepatocellular carcinoma: A systematic review and meta-analysis. Oncotarget. 8:22854–22862. 2017. View Article : Google Scholar : PubMed/NCBI

18 

Raungkaewmanee S, Tangjitgamol S, Manusirivithaya S, Srijaipracharoen S and Thavaramara T: Platelet to lymphocyte ratio as a prognostic factor for epithelial ovarian cancer. J Gynecol Oncol. 23:265–273. 2012. View Article : Google Scholar : PubMed/NCBI

19 

Yi F, Gu Y, Chen S, Liu Y, Yin W, Zhang Y and Cao B: Impact of the pretreatment or posttreatment NLR and PLR on the response of first line chemotherapy and the outcomes in patients with advanced non-small cell lung cancer. Zhongguo Fei Ai Za Zhi. 21:481–492. 2018.(In Chinese). PubMed/NCBI

20 

Zhou Y, Cheng S, Fathy AH, Qian H and Zhao Y: Prognostic value of platelet-to-lymphocyte ratio in pancreatic cancer: A comprehensive meta-analysis of 17 cohort studies. Onco Targets Ther. 5:1899–1908. 2018. View Article : Google Scholar

21 

Wang J, Liu Y, Zhang N, Li X, Xin P, Bi J and Kong Ch: Prognostic role of pretreatment platelet to lymphocyte ratio in urologic cancer. Oncotarget. 8:70874–70882. 2017.PubMed/NCBI

22 

Sciarra A, Gentilucci A, Salciccia S, Pierella F, Del Bianco F, Gentile V, Silvestri I and Cattarino S: Prognostic value of inflammation in prostate cancer progression and response to therapeutic: A critical review. J Inflamm (Lond). 13:352016. View Article : Google Scholar : PubMed/NCBI

23 

Gunduz S, Mutlu H, Tural D, Yıldız Ö, Uysal M, Coskun HS and Bozcuk H: Platelet to lymphocyte ratio as a new prognostic for patients with metastatic renal cell cancer. Asia Pac J Clin Oncol. 11:288–292. 2015. View Article : Google Scholar : PubMed/NCBI

24 

Park TJ, Cho YH, Chung HS, Hwang EC, Jung SH, Hwang JE, Bae WK, Kim JW, Heo SH, Hur YH, et al: Prognostic significance of platelet-lymphocyte ratio in patients receiving first-line tyrosine kinase inhibitors for metastatic renal cell cancer. Springerplus. 5:18892016. View Article : Google Scholar : PubMed/NCBI

25 

Minami S, Ihara S and Komuta K: Pretreatment lymphocyte to monocyte ratio as a prognostic marker for advanced pulmonary squamous cell carcinoma treated with chemotherapy. J Clin Med Res. 10:657–664. 2018. View Article : Google Scholar : PubMed/NCBI

26 

Yang YT, Jiang JH, Yang HJ, Wu ZJ, Xiao ZM and Xiang BD: The lymphocyte-to-monocyte ratio is a superior predictor of overall survival compared to established biomarkers in HCC patients undergoing liver resection. Sci Rep. 8:25352018. View Article : Google Scholar : PubMed/NCBI

27 

Wu Q, Hu T, Zheng E, Deng X and Wang Z: Prognostic role of the lymphocyte-to-monocyte ratio in colorectal cancer: An up-to-date meta-analysis. Medicine (Baltimore). 96:e70512017. View Article : Google Scholar : PubMed/NCBI

28 

Kimyon Cömert G, Türkmen O, Kar İ, Sınacı S, Yılmaz Ergani S, Karalök A, Başaran D and Turan T: Independent predictors of survival in endometrium cancer: Platelet-to-lymphocyte ratio and platelet/neutrophil/monocyte-to-lymphocyte ratio. J Turk Ger Gynecol Assoc. 19:78–86. 2018. View Article : Google Scholar : PubMed/NCBI

29 

Li W, Tao L, Zhang L and Xiu D: Prognostic role of lymphocyte to monocyte ratio for patients with pancreatic cancer: A systematic review and meta-analysis. Onco Targets Ther. 10:3391–3397. 2017. View Article : Google Scholar : PubMed/NCBI

30 

Ma JY and Liu Q: Clinicopathological and prognostic significance of lymphocyte to monocyte ratio in patients with gastric cancer: A meta-analysis. Int J Surg. 50:67–71. 2018. View Article : Google Scholar : PubMed/NCBI

31 

Xiang J, Zhou L, Li X, Bao W, Chen T, Xi X, He Y and Wan X: Preoperative monocyte-to-lymphocyte ratio in peripheral blood predicts stages, metastasis, and histological grades in patients with ovarian cancer. Transl Oncol. 10:33–39. 2017. View Article : Google Scholar : PubMed/NCBI

32 

Ni XJ, Zhang XL, Ou-Yang QW, Qian GW, Wang L, Chen S, Jiang YZ, Zuo WJ, Wu J, Hu X, et al: An elevated peripheral blood lymphocyte-to-monocyte ratio predicts favorable response and prognosis in locally advanced breast cancer following neoadjuvant chemotherapy. PLoS One. 9:e1118862014. View Article : Google Scholar : PubMed/NCBI

33 

Hu RJ, Liu Q, Ma JY, Zhou J and Liu G: Preoperative lymphocyte-to-monocyte ratio predicts breast cancer outcome: A meta-analysis. Clin Chim Acta. 84:1–6. 2018. View Article : Google Scholar

34 

Jia W, Wu J, Jia H, Yang Y, Zhang X, Chen K and Su F: The peripheral blood neutrophil-to-lymphocyte ratio is superior to the lymphocyte-to-monocyte ratio for predicting the long-term survival of triple-negative breast cancer patients. PLoS One. 10:e01430612015. View Article : Google Scholar : PubMed/NCBI

35 

Zhu Y, Si W, Sun Q, Qin B, Zhao W and Yang J: Platelet-lymphocyte ratio acts as an indicator of poor prognosis in patients with breast cancer. Oncotarget. 8:1023–1030. 2017.PubMed/NCBI

36 

West HJ and Jin JO: Performance status in patients with cancer. JAMA Oncol. 1:9982015. View Article : Google Scholar : PubMed/NCBI

37 

Li J, Chen Q, Luo X, Hong J, Pan K, Lin X, Liu X, Zhou L, Wang H, Xu Y, et al: Neutrophil-to-lymphocyte ratio positively correlates to age in healthy population. J Clin Lab Anal. 29:437–443. 2015. View Article : Google Scholar : PubMed/NCBI

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December 2019
Volume 18 Issue 6

Print ISSN: 1792-1074
Online ISSN:1792-1082

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APA
Huszno, J., & Huszno, J. (2019). Prognostic value of the neutrophil‑lymphocyte, platelet‑lymphocyte and monocyte‑lymphocyte ratio in breast cancer patients. Oncology Letters, 18, 6275-6283. https://doi.org/10.3892/ol.2019.10966
MLA
Huszno, J., Kolosza, Z."Prognostic value of the neutrophil‑lymphocyte, platelet‑lymphocyte and monocyte‑lymphocyte ratio in breast cancer patients". Oncology Letters 18.6 (2019): 6275-6283.
Chicago
Huszno, J., Kolosza, Z."Prognostic value of the neutrophil‑lymphocyte, platelet‑lymphocyte and monocyte‑lymphocyte ratio in breast cancer patients". Oncology Letters 18, no. 6 (2019): 6275-6283. https://doi.org/10.3892/ol.2019.10966