The prognostic value of the systemic inflammatory score in patients with unresectable metastatic colorectal cancer

  • Authors:
    • Masatsune Shibutani
    • Kiyoshi Maeda
    • Hisashi Nagahara
    • Tatsunari Fukuoka
    • Shinji Matsutani
    • Kenjiro Kimura
    • Ryosuke Amano
    • Kosei Hirakawa
    • Masaichi Ohira
  • View Affiliations

  • Published online on: May 4, 2018     https://doi.org/10.3892/ol.2018.8628
  • Pages: 666-672
Metrics: HTML 0 views | PDF 0 views     Cited By (CrossRef): 0 citations

Abstract

Inflammation has been widely recognized as a contributor to cancer progression and several inflammatory markers have been reported as associated with the clinical outcomes in patients with various types of cancer. Recently, a novel inflammatory marker, the systemic inflammatory score (SIS), which is based on a combination of the lymphocyte‑to‑monocyte ratio (LMR) and the serum albumin concentration has been reported as a useful prognostic marker. The aim of the present study was to assess the prognostic value of the SIS in patients with unresectable metastatic colorectal cancer (mCRC). The retrospective cohort study included 160 patients who underwent combination chemotherapy for unresectable mCRC between January 2008 and December 2016. The SIS was used to classify the patients into three groups based on their LMR and the serum albumin concentration. Patients with high‑LMR and high serum albumin level were given a score of 0; patients with low‑LMR or low serum albumin level were given a score of 1; patients with low‑LMR and low serum albumin level were given a score of 2. There were significant differences in the overall survival among the three SIS groups and the SIS was an independent prognostic factor for the overall survival. Although the SIS was significantly associated with the overall survival rate even when using the original cut‑off values, the SIS according to the new cut‑off values had a more accurate prognostic value. The present study determined that the SIS was a useful biomarker for predicting the survival outcomes in patients with unresectable mCRC, although the optimum cut‑off value of the SIS according to the patients' background needs to be examined in further studies.

Introduction

Inflammation is known to contribute to cancer progression (1,2), and several inflammatory markers, such as the neutrophil-to-lymphocyte ratio (NLR), the lymphocyte-to-monocyte ratio (LMR) and the Glasgow prognostic score (GPS) have been reported to be associated with clinical outcomes in patients with various types of cancer, including colorectal cancer (38). Recently, a new inflammatory marker, the systemic inflammatory score (SIS), based on the combination of the LMR and the serum albumin concentration has been reported to be a useful prognostic marker in patients with clear-cell renal cell carcinoma, colorectal cancer and oral cavity squamous cell carcinoma (911).

However, there are only a few reports on the SIS, and the prognostic value of the SIS in patients with unresectable metastatic colorectal cancer (mCRC) remains unclear. In addition, the optimum cut-off value may change depending on the type of cancer and stage and merits further study.

This study aimed to evaluate the prognostic value of the SIS and to determine its optimum cut-off value in patients with unresectable mCRC who underwent chemotherapy.

Materials and methods

Patients

This retrospective cohort study included 160 patients who underwent combination chemotherapy for unresectable mCRC at the Department of Surgical Oncology of Osaka City University (Osaka, Japan) between January 2008 and December 2016.

Methods

Blood samples were collected within one week prior to the initiation of chemotherapy. We analyzed the differential white blood cell count using an XE-5000 hematology analyzer (Sysmex, Kobe, Japan) based on the manufacturer's protocol. The LMR was calculated by dividing the absolute number of circulating lymphocytes by the absolute number of circulating monocytes. We assessed the serum albumin concentrations by a chemiluminescent immunoassay (Wako, Osaka, Japan) according to the manufacturer's protocol. The SIS was defined according to the methods of a previous report (9), using the combination of the LMR and the serum albumin concentration: patients with LMR >4.44 and serum albumin level >4.0 g/dl were given a score of 0; patients with LMR ≤4.44 or serum albumin level ≤4.0 g/dl were given a score of 1; patients with LMR ≤4.4 and 4 serum albumin level ≤4.0 g/dl were given a score of 2. The location of the primary tumor was defined as follows. The oral side of the splenic flexure was termed ‘the right side’ and the anal side of splenic flexure was termed ‘the left side’. Furthermore, we defined synchronous and metachronous metastases as follows. Synchronous metastases were defined as metastatic lesions that were already confirmed at the time of the diagnosis of the primary lesion; metachronous metastases were defined as metastatic lesions that developed after the excision of the primary tumor, regardless of the period.

Ethical considerations

All patients were informed of the investigational nature of this study and provided their written informed consent for the retrospective analysis of their data. Full ethical approval was granted by the Ethics Committee of Osaka City University (approval no. 926).

Statistical analysis

The significance of the correlations between the SIS and the clinicopathological characteristics were analyzed using the Chi-squared test. Survival curves were constructed using the Kaplan-Meier method and were compared using the log-rank test. A multivariate analysis was performed using a Cox proportional hazards model. All of the statistical analyses were performed using the SPSS software program (version 19.0; IBM, Armonk, NY, USA). P<0.05 was considered to indicate a statistically significant difference.

Results

Patients' baseline characteristics

The characteristics of the 160 patients in the present study are summarized in Table I. The study population included 86 male patients and 74 female patients. The median age of the patients was 65 years (range: 18 to 89). According to the definition of the Eastern Cooperative Oncology Group performance status (PS), 140 patients were classified as having a PS of 0, 17 were classified as having a PS of 1, and 3 were classified as having a PS of 2. A total of 39 patients had primary tumors located on the right side, and 121 had primary tumors located on the left side. One hundred and seven patients had single-organ metastasis, and 53 multiple organs affected by metastases. All of the patients underwent combination chemotherapy with oxaliplatin, irinotecan plus 5-fluorouracil/leucovorin, or a prodrug of 5-fluorouracil as first-line chemotherapy. The regimens used for all of the patients in this study were considered to have the same efficacy (1214). Seventy-five patients received FOLFOX, 53 received CapeOX, 25 received FOLFIRI, and 7 SOX. A total of 103 patients underwent chemotherapy combined with molecular-targeted therapy. The median follow-up period for the surviving patients was 21.8 months (range: 1.2 to 94.0 months). A total of 113 patients died during the follow-up period.

Table I.

The patients' baseline characteristics.

Table I.

The patients' baseline characteristics.

CharacteristicsNo. of patients
Median age, years (range)65 (18–89)
Sex
  Male86
  Female74
Performance status
  0140
  117
  23
Location of primary tumor
  Right side39
  Left side121
Histological type
  Well, moderately143
  Poorly, mucinous17
RAS status
  Wild type64
  Mutant type54
  Unknown42
Detection of unresectable tumor
  Synchronous106
  Metachronous54
Number of organs affected by metastasis
  One organ107
  Multiple organs53
Peritoneal dissemination
  Negative125
  Positive35
First-line chemotherapy regimen
  FOLFOX75
  CapeOX53
  FOLFIRI25
  SOX7
Molecular-targeted therapy
  Bevacizumab85
  Cetuximab11
  Panitumumab7
  None57
Lymphocyte-to-monocyte ratio
  Median (range)4.53 (1.25–14.06)
Serum albumin concentration
  Median (range)3.9 (2.5–4.9)
Systemic inflammatory score
  046
  168
  246
Correlations between the SIS and clinicopathological factors

The correlations between the SIS and clinicopathological factors are shown in Table II. The SIS and clinicopathological factors did not differ to a statistically significant extent.

Table II.

The correlations between the SIS and the clinicopathological factors.

Table II.

The correlations between the SIS and the clinicopathological factors.

SIS

Clinicopathological factor0 (n=46)1 (n=68)2 (n=46)P-value
Age 0.385
  <65 years273124
  ≥65 years193722
Sex 0.718
  Male233924
  Female232922
Location of primary tumor 0.416
  Right side1318  8
  Left side335038
Performance status 0.630
  0425840
  ≥1  410  6
Histological type 0.335
  Well, moderately435842
  Poorly, mucinous  310  6
RAS status 0.310
  Wild type252217
  Mutant type162612
  Unknown  52017
Detection of unresectable tumor 0.119
  Synchronous294136
  Metachronous172710
Number of organs affected by metastasis 0.960
  One organ304631
  Multiple organs162215
Peritoneal dissemination 0.101
  Negative345041
  Positive1218  5
Molecular-targeted therapy 0.312
  Absent132420
  Present334426

[i] SIS, systemic inflammatory score.

Prognostic significance of the SIS according to the original cut-off values defined in the previous report

The median overall survival time was 31.6 months in those with a SIS of 0, 22.9 months in those with a SIS of 1, and 20.6 months in those with a SIS of 2. A log-rank test demonstrated significant differences in the overall survival among the three groups (P=0.0021). However, there were no significant differences in the overall survival between the patients with a SIS of 1 and those with a SIS of 2, although the overall survival rate tended to be worse in patients with a SIS of 2 than in those with a SIS of 1 (P=0.0810; Fig. 1).

Univariate and multivariate analyses of the risk factors for overall survival

In the univariate analysis, the PS, the location of the primary tumor, the RAS status and the SIS were associated with overall survival. Furthermore, a multivariate analysis demonstrated that gender, the location of the primary tumor and the SIS were independent prognostic factors for survival (Table III).

Table III.

Univariate and multivariate analyses of risk factors for overall survival.

Table III.

Univariate and multivariate analyses of risk factors for overall survival.

Univariate analysisMultivariate analysis


CharacteristicHazard ratio95% CIP-valueHazard ratio95% CIP-value
Age (years)
  <65Reference Reference
  ≥651.3180.908–1.9120.1461.3090.825–2.0770.254
Sex
  MaleReference Reference
  Female1.2560.868–1.8170.2271.7711.097–2.8590.019
Performance status
  0Reference Reference
  ≥11.8241.085–3.0650.0231.4480.664–3.1540.352
Location of primary tumor
  Left sideReference Reference
  Right side1.9821.273–3.0860.0022.1791.192–3.9840.011
Histological type
  Well, moderatelyReference Reference
  Poorly, mucinous0.6850.355–1.3210.2590.5520.257–1.1850.127
RAS status
  Wild typeReference Reference
  Mutant type1.6991.100–2.6250.0171.5330.957–2.4560.075
Detection of unresectable tumor
  SynchronousReference Reference
  Metachronous1.1070.740–1.6560.6211.1710.642–2.1330.607
The number of organs affected by metastasis
  1Reference Reference
  ≥21.1190.756–1.6560.5730.6500.360–1.1750.154
Peritoneal dissemination
  NegativeReference Reference
  Positive1.1450.726–1.8050.5601.7390.850–3.5590.130
Molecular targeted therapy
  PresentReference Reference
  Absent1.1160.764–1.6300.5710.9600.601–1.5340.866
SIS
  0Reference Reference
  11.5670.975–2.5160.0631.8731.075–3.2630.027
  22.3861.451–3.9210.0014.1382.163–7.916<0.001

[i] CI, confidence interval; SIS, systemic inflammatory score.

Setting new cut-off values for the LMR and the serum albumin concentration

A receiver operating characteristic (ROC) curve analysis was used to determine the optimal cut-off LMR and serum albumin level. We used the LMR and serum albumin level, continuous variables, as the test variable and the 24.4-month survival (median survival time: 24.4 months) as the state variable. The optimum cut-off values were selected based on the highest Youden index; the optimum cut-off LMR was 2.96 (sensitivity: 89.4%; specificity: 35.1%), while the optimum cut-off serum albumin level was 4.0 (sensitivity: 53.0%; specificity: 73.4%) (Fig. 2). The patients were classified into the high-LMR (n=120) and low-LMR (n=40) groups based on the new cut-off LMR. In the same way, the patients were classified into the high-ALB (n=60) and low-ALB (n=100) groups.

Prognostic value of the LMR and the serum albumin concentration

The patients in the low-LMR group had a significantly worse overall survival rate in comparison to the patients in the high-LMR group (P<0.0001; Fig. 3A). Similarly, the patients in the low-ALB group had significantly worse overall survival in comparison to the high-ALB group (P=0.0004; Fig. 3B).

Prognostic value of the SIS according to the new cut-off value derived in our data set

According to the new cut-off value (LMR: 2.96, serum albumin level: 4.0) as well as the original cut-off value, the SIS was significantly associated with the overall survival rates (P<0.0001; Fig. 4). Furthermore, there were significant differences between the each subgroup.

Discussion

The results obtained in this study suggested that the SIS was significantly associated with the survival outcomes and may be useful as a prognostic biomarker in patients with unresectable mCRC. To our knowledge, this is the first study to assess the prognostic value of the SIS in patients with unresectable mCRC.

Albumin is a protein synthesized in the liver. Under conditions of systemic inflammation, the ability to synthesize albumin decreases, resulting in hypoalbuminemia (15). Therefore, a low serum albumin concentration is associated with ongoing systemic inflammation. Due to the fact that continuous systemic inflammation promotes cancer progression (1,2), hypoalbuminemia is associated with a poor survival (16).

The LMR reflects the balance between the immune status of the host and the degree of tumor burden. Lymphocytes play a key role in anticancer immunity (1,17), and a decreasing number of lymphocytes has been reported to be associated with a poor prognosis (18,19). In contrast, monocytes contribute to cancer progression (1,20,21). Circulating monocytes differentiate into macrophages in the cancer microenvironment (22,23). Most macrophages in the cancer microenvironment have an M2-like phenotype and promote tumor growth, angiogenesis and metastasis (20,24). Thus an increasing number of monocytes has been reported to be associated with a poor prognosis (5,18,25). For these reasons, a low LMR is associated with a poor prognosis.

The serum albumin concentration and white blood cell count are inexpensive to measure and are routinely applied in clinical practice. The combination of these two inflammatory markers based on different mechanisms may enable a more accurate prognostic prediction.

Both the serum albumin concentration and the LMR, which are components of the SIS, are markers related to inflammation, but their severity is not always correlated with each other (11). Therefore, the combination of these two markers enables a more detailed stratification. The SIS can be used to classify patients into three risk subgroups, whereas most inflammatory markers reported as prognostic markers in previous reports are only able to divide patients into two groups. The GPS as well as the SIS can classify patients into three risk subgroups. However, according to the GPS, most patients (80–90%) are classified into the low-risk group (10,26,27), and the distribution of the GPS score is not well-balanced. In contrast, the distribution of the SIS score is relatively well-balanced. These results suggest that the SIS may have higher clinical utility than other inflammatory markers.

According to the original cut-off values defined in a previous report, the SIS was significantly associated with the survival. However, the optimum cut-off values derived in our dataset was different from those obtained in the previous report. As cancer progresses, the degree of inflammation caused by the response of the host to the cancer increases (3). In previous reports, the inflammatory markers tended to increase as the stage progressed (3,10,28). Furthermore, even at the same stage, the degree of inflammation may vary depending on the type of cancer. The optimum cut-off values of the inflammatory markers used in previous reports differed by type of cancer, even at the same stage (2931). Therefore, it is necessary to reset the optimum cut-off value of the serum albumin concentration and the LMR, which is most closely associated with the prognosis, depending on the characteristics of the target, such as the cancer type and stage. The optimum cut-off value of the SIS needs to be examined in further studies, which include a large unified population of cancer types, stages and treatments. The same may be true of the cut-off for the GPS.

The AUC of the ROC curve for the LMR and the serum albumin concentration were relatively low, despite both markers having been reported to be useful prognostic markers in many previous reports (5,6,16). We thought that the small number of cases was the reason for the low AUC. A large prospective study is therefore necessary to confirm the usefulness of the SIS as a prognostic marker.

In conclusion, the SIS is considered to be a useful biomarker for predicting the survival outcomes in patients with unresectable mCRC cancer who undergo chemotherapy, although the optimum cut-off value according to each patient's background needs to be examined in further studies. Patients with high SIS scores are expected to have a poor prognosis. Thus, an intensive chemotherapy regimen aiming at cytoreduction-as opposed to disease control-should be selected for patients with a high SIS score. The SIS may contribute to decisions regarding the choice of therapeutic strategies.

Acknowledgements

Not applicable.

Funding

No funding was received.

Availability of data and materials

The datasets used and/or analyzed during the current study are available from the corresponding author on reasonable request.

Authors' contributions

MS and KM designed the study, performed the statistical analysis and drafted the manuscript. HN, TF, SM, KK and RA collected the clinical data and critically revised the manuscript. KH and MO designed the study and critically reviewed the manuscript. All authors read and approved the final manuscript.

Ethics approval and consent to participate

All patients were informed of the investigational nature of this study and provided their written informed consent. Full ethical approval was granted by the ethics committee of Osaka City University (approval number 926).

Consent for publication

All patients provided written informed consent for the publication of their data.

Competing interests

The authors declare that they have no competing interests.

Glossary

Abbreviations

Abbreviations:

SIS

systemic inflammatory score

LMR

lymphocyte-to-monocyte ratio

mCRC

metastatic colorectal cancer

NLR

neutrophil-to-lymphocyte ratio

GPS

Glasgow prognostic score

PS

performance status

ROC curve

receiver operating characteristic curve

CI

confidence interval

References

1 

Mantovani A, Allavena P, Sica A and Balkwill F: Cancer-related inflammation. Nature. 454:436–444. 2008. View Article : Google Scholar : PubMed/NCBI

2 

Balkwill F and Mantovani A: Inflammation and cancer: Back to Virchow? Lancet. 357:539–545. 2001. View Article : Google Scholar : PubMed/NCBI

3 

Shibutani M, Maeda K, Nagahara H, Noda E, Ohtani H, Nishiguchi Y and Hirakawa K: A high preoperative neutrophil-to-lymphocyte ratio is associated with poor survival in patients with colorectal cancer. Anticancer Res. 33:3291–3294. 2013.PubMed/NCBI

4 

Absenger G, Szkandera J, Stotz M, Postlmayr U, Pichler M, Ress AL, Schaberl-Moser R, Loibner H, Samonigg H and Gerger A: Preoperative neutrophil-to-lymphocyte ratio predicts clinical outcome in patients with stage II and III colon cancer. Anticancer Res. 33:4591–4594. 2013.PubMed/NCBI

5 

Shibutani M, Maeda K, Nagahara H, Iseki Y, Ikeya T and Hirakawa K: Prognostic significance of the preoperative lymphocyte-to-monocyte ratio in patients with colorectal cancer. Oncol Lett. 13:1000–1006. 2017. View Article : Google Scholar : PubMed/NCBI

6 

Guo YH, Sun HF, Zhang YB, Liao ZJ, Zhao L, Cui J, Wu T, Lu JR, Nan KJ and Wang SH: The clinical use of the platelet/lymphocyte ratio and lymphocyte/monocyte ratio as prognostic predictors in colorectal cancer: A meta-analysis. Oncotarget. 8:20011–20024. 2017.PubMed/NCBI

7 

Liu Y, He X, Pan J, Chen S and Wang L: Prognostic role of Glasgow prognostic score in patients with colorectal cancer: Evidence from population studies. Sci Rep. 7:61442017. View Article : Google Scholar : PubMed/NCBI

8 

Kishiki T, Masaki T, Matsuoka H, Kobayashi T, Suzuki Y, Abe N, Mori T and Sugiyama M: Modified Glasgow prognostic score in patients with incurable stage IV colorectal cancer. Am J Surg. 206:234–240. 2013. View Article : Google Scholar : PubMed/NCBI

9 

Chang Y, An H, Xu L, Zhu Y, Yang Y, Lin Z and Xu J: Systemic inflammation score predicts postoperative prognosis of patients with clear-cell renal cell carcinoma. Br J Cancer. 113:626–633. 2015. View Article : Google Scholar : PubMed/NCBI

10 

Suzuki Y, Okabayashi K, Hasegawa H, Tsuruta M, Shigeta K, Kondo T and Kitagawa Y: Comparison of preoperative inflammation-based prognostic scores in patients with colorectal cancer. Ann Surg. 267:527–531. 2018.PubMed/NCBI

11 

Eltohami YI, Kao HK, Lao WW, Huang Y, Abdelrahman M, Liao CT, Yen TC and Chang KP: The prediction value of the systemic inflammation score for oral cavity squamous cell carcinoma. Otolaryngol Head Neck Surg. Jan 1–2018.(Epub ahead of print). View Article : Google Scholar : PubMed/NCBI

12 

Cassidy J, Clarke S, Díaz-Rubio E, Scheithauer W, Figer A, Wong R, Koski S, Lichinitser M, Yang TS, Rivera F, et al: Randomized phase III study of capecitabine plus oxaliplatin compared with fluorouracil/folinic acid plus oxaliplatin as first-line therapy for metastatic colorectal cancer. J Clin Oncol. 26:2006–2012. 2008. View Article : Google Scholar : PubMed/NCBI

13 

Tournigand C, André T, Achille E, Lledo G, Flesh M, Mery-Mignard D, Quinaux E, Couteau C, Buyse M, Ganem G, et al: FOLFIRI followed by FOLFOX6 or the reverse sequence in advanced colorectal cancer: A randomized GERCOR study. J Clin Oncol. 22:229–237. 2004. View Article : Google Scholar : PubMed/NCBI

14 

Yamada Y, Takahari D, Matsumoto H, Baba H, Nakamura M, Yoshida K, Yoshida M, Iwamoto S, Shimada K, Komatsu Y, et al: Leucovorin, fluorouracil, and oxaliplatin plus bevacizumab versus S-1 and oxaliplatin plus bevacizumab in patients with metastatic colorectal cancer (SOFT): An open-label, non-inferiority, randomised phase 3 trial. Lancet Oncol. 14:1278–1286. 2013. View Article : Google Scholar : PubMed/NCBI

15 

McMillan DC, Elahi MM, Sattar N, Angerson WJ, Johnstone J and McArdle CS: Measurement of the systemic inflammatory response predicts cancer-specific and non-cancer survival in patients with cancer. Nutr Cancer. 41:64–69. 2001. View Article : Google Scholar : PubMed/NCBI

16 

Nazha B, Moussaly E, Zaarour M, Weerasinghe C and Azab B: Hypoalbuminemia in colorectal cancer prognosis: Nutritional marker or inflammatory surrogate? World J Gastrointest Surg. 7:370–377. 2015. View Article : Google Scholar : PubMed/NCBI

17 

Dunn GP, Old LJ and Schreiber RD: The immunobiology of cancer immunosurveillance and immunoediting. Immunity. 21:137–148. 2004. View Article : Google Scholar : PubMed/NCBI

18 

Shibutani M, Maeda K, Nagahara H, Ohtani H, Sakurai K, Yamazoe S, Kimura K, Toyokawa T, Amano R, Tanaka H, et al: Prognostic significance of the lymphocyte-to-monocyte ratio in patients with metastatic colorectal cancer. World J Gastroenterol. 21:9966–9973. 2015. View Article : Google Scholar : PubMed/NCBI

19 

Cézé N, Thibault G, Goujon G, Viguier J, Watier H, Dorval E and Lecomte T: Pre-treatment lymphopenia as a prognostic biomarker in colorectal cancer patients receiving chemotherapy. Cancer Chemother Pharmacol. 68:1305–1313. 2011. View Article : Google Scholar : PubMed/NCBI

20 

Condeelis J and Pollard JW: Macrophages: Obligate partners for tumor cell migration, invasion, and metastasis. Cell. 124:263–266. 2006. View Article : Google Scholar : PubMed/NCBI

21 

Leek RD and Harris AL: Tumor-associated macrophages in breast cancer. J Mammary Gland Biol Neoplasia. 7:177–189. 2002. View Article : Google Scholar : PubMed/NCBI

22 

Qian BZ and Pollard JW: Macrophage diversity enhances tumor progression and metastasis. Cell. 141:39–51. 2010. View Article : Google Scholar : PubMed/NCBI

23 

Mantovani A, Bottazzi B, Colotta F, Sozzani S and Ruco L: The origin and function of tumor-associated macrophages. Immunol Today. 13:265–270. 1992. View Article : Google Scholar : PubMed/NCBI

24 

Pollard JW: Tumour-educated macrophages promote tumour progression and metastasis. Nat Rev Cancer. 4:71–78. 2004. View Article : Google Scholar : PubMed/NCBI

25 

Paik KY, Lee IK, Lee YS, Sung NY and Kwon TS: Clinical implications of systemic inflammatory response markers as independent prognostic factors in colorectal cancer patients. Cancer Res Treat. 46:65–73. 2014. View Article : Google Scholar : PubMed/NCBI

26 

Sugimoto K, Komiyama H, Kojima Y, Goto M, Tomiki Y and Sakamoto K: Glasgow prognostic score as a prognostic factor in patients undergoing curative surgery for colorectal cancer. Dig Surg. 29:503–509. 2012. View Article : Google Scholar : PubMed/NCBI

27 

Furukawa K, Shiba H, Haruki K, Fujiwara Y, Iida T, Mitsuyama Y, Ogawa M, Ishida Y, Misawa T and Yanaga K: The Glasgow prognostic score is valuable for colorectal cancer with both synchronous and metachronous unresectable liver metastases. Oncol Lett. 4:324–328. 2012. View Article : Google Scholar : PubMed/NCBI

28 

Jia J, Zheng X, Chen Y, Wang L, Lin L, Ye X, Chen Y, Chen D and Dettke M: Stage-dependent changes of preoperative neutrophil to lymphocyte ratio and platelet to lymphocyte ratio in colorectal cancer. Tumour Biol. 36:9319–9325. 2015. View Article : Google Scholar : PubMed/NCBI

29 

Shibutani M, Maeda K, Nagahara H, Ohtani H, Sakurai K, Yamazoe A, Kimura K, Toyokawa T, Amano R, Kubo N, et al: Significance of markers of systemic inflammation for predicting survival and chemotherapeutic outcomes and monitoring tumor progression in patients with unresectable metastatic colorectal cancer. Anticancer Res. 35:5037–5046. 2015.PubMed/NCBI

30 

Tanaka H, Muguruma K, Toyokawa T, Kubo N, Ohira M and Hirakawa K: Differential impact of the neutrophil-lymphocyte ratio on the survival of patients with stage IV gastric cancer. Dig Surg. 31:327–333. 2014. View Article : Google Scholar : PubMed/NCBI

31 

Cedrés S, Torrejon D, Martínez A, Martinez P, Navarro A, Zamora E, Mulet-Margalef N and Felip E: Neutrophil to lymphocyte ratio (NLR) as an indicator of poor prognosis in stage IV non-small cell lung cancer. Clin Transl Oncol. 14:864–869. 2012. View Article : Google Scholar : PubMed/NCBI

Related Articles

Journal Cover

July 2018
Volume 16 Issue 1

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

Sign up for eToc alerts

Recommend to Library

Copy and paste a formatted citation
APA
Shibutani, M., Maeda, K., Nagahara, H., Fukuoka, T., Matsutani, S., Kimura, K. ... Ohira, M. (2018). The prognostic value of the systemic inflammatory score in patients with unresectable metastatic colorectal cancer. Oncology Letters, 16, 666-672. https://doi.org/10.3892/ol.2018.8628
MLA
Shibutani, M., Maeda, K., Nagahara, H., Fukuoka, T., Matsutani, S., Kimura, K., Amano, R., Hirakawa, K., Ohira, M."The prognostic value of the systemic inflammatory score in patients with unresectable metastatic colorectal cancer". Oncology Letters 16.1 (2018): 666-672.
Chicago
Shibutani, M., Maeda, K., Nagahara, H., Fukuoka, T., Matsutani, S., Kimura, K., Amano, R., Hirakawa, K., Ohira, M."The prognostic value of the systemic inflammatory score in patients with unresectable metastatic colorectal cancer". Oncology Letters 16, no. 1 (2018): 666-672. https://doi.org/10.3892/ol.2018.8628