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Investigation of CRP and NLR as potential biomarkers for redefining biological borderline resectable pancreatic cancer

  • Authors:
    • Keishi Kawasaki
    • Hidehiro Tajima
    • Teppei Tatsuoka
    • Musashi Takada
    • Soya Meguro
    • Hirotaka Ishido
    • Hideyuki Yoshitomi
  • View Affiliations / Copyright

    Affiliations: Department of Surgery, Dokkyo Medical University Saitama Medical Center, Koshigaya, Saitama 343‑8555, Japan
    Copyright: © Kawasaki et al. This is an open access article distributed under the terms of Creative Commons Attribution License.
  • Article Number: 428
    |
    Published online on: July 28, 2026
       https://doi.org/10.3892/ol.2026.15783
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Abstract

Anatomically resectable pancreatic cancer with markedly elevated carbohydrate antigen 19‑9 (CA19‑9) levels has recently been recognized as a biologically borderline resectable (BR‑B) disease due its poor prognosis. The present study evaluated whether C‑reactive protein (CRP) levels and the neutrophil‑to‑lymphocyte ratio (NLR) could further refine preoperative prognostic stratification. Data from 154 patients with resectable (R) and BR‑B pancreatic cancer who underwent resection with curative intent between March 2014 and June 2024 were retrospectively analyzed. Based on the 2017 International Consensus Criteria, BR‑B was defined as resectable pancreatic cancer with a serum CA19‑9 level >500 U/ml. Prognostic factors were assessed using Cox proportional hazards regression analysis. Among the 154 patients, 128 were classified as R and 26 as BR‑B. Multivariate analysis identified a CA19‑9 level ≥500 U/ml (P<0.001), CRP level ≥0.3 mg/dl (P=0.003) and NLR ≥3.13 (P=0.008) as independent predictors of poor overall survival. Survival progressively worsened with an increasing number of elevated biomarkers. Patients with no elevated biomarker levels experienced the most favorable outcomes. The CRP level and NLR were independent prognostic biomarkers for pancreatic cancer. However, their integration with CA19‑9 levels enables more refined preoperative prognostic stratification and may help guide individualized treatment strategies, including the selection of patients for neoadjuvant chemotherapy or upfront surgery.
View Figures

Figure 1

Comparison of survival between R and
BR-B pancreatic cancer. (A) DFS and (B) OS curves comparing R
(n=128) and BR-B (n=26) groups. Patients with BR-B disease
exhibited significantly worse DFS and OS than those with R disease
(both P<0.001). BR-B, biologically borderline resectable; DFS,
disease-free survival; OS, overall survival; R, resectable.

Figure 2

Survival according to the BR-B/CRP
classification. Kaplan-Meier curves of (A) DFS and (B) OS among
three groups: BR-B with high CRP (n=3), R with low CRP (n=89) and
others (n=49). The BR-B + high CRP group showed significantly
poorer DFS and OS than both the others group and the R + low CRP
group, whereas the R + low CRP group showed significantly better
DFS and OS than both other groups (all P<0.0167 after Bonferroni
correction). Only patients with available CRP measurements were
included in this analysis (n=141). BR-B, biologically borderline
resectable; CRP, C-reactive protein; DFS, disease-free survival;
OS, overall survival; R, resectable.

Figure 3

Survival according to the BR-B/NLR
classification. Kaplan-Meier curves of (A) DFS and (B) OS comparing
the BR-B with high NLR (n=10), R with low NLR (n=76) and others
(n=42) groups. The BR-B + high NLR group exhibited significantly
worse DFS and OS than both the others group and the R + low NLR
group, whereas the R + low NLR group had significantly better DFS
and OS than both other groups (all P<0.0167 after Bonferroni
correction). Only patients with available NLR measurements were
included in this analysis (n=128). BR-B, biologically borderline
resectable; DFS, disease-free survival; NLR,
neutrophil-to-lymphocyte ratio; OS, overall survival; R,
resectable.

Figure 4

Survival according to the number of
elevated biomarkers (CA19-9, CRP and NLR). Kaplan-Meier curves for
(A) DFS and (B) OS in patient groups stratified according to the
number of high-risk biomarkers (high CA19-9, high CRP and high
NLR): 0 factors (n=55), 1 factor (n=44), 2 factors (n=15) and 3
factors (n=2). The 0 factors group exhibited the most favorable
survival, whereas the 3 factors group exhibited the poorest
outcomes. Significant differences were observed between the 0
factors group and 1 factor group for both DFS (P=0.0037) and OS
(P<0.001), and between the 2 factors group and 3 factors group
for DFS (P=0.0076). Only patients with complete CA19-9, CRP and NLR
data were included in this analysis (n=116). CA19-9, carbohydrate
antigen 19-9; CRP, C-reactive protein; DFS, disease-free survival;
NLR, neutrophil-to-lymphocyte ratio; OS, overall survival.

Figure 5

DFS according to treatment strategy in
patients without high-risk biomarkers. Kaplan-Meier curves of DFS
comparing the NAC group (n=23) and the upfront surgery group (n=32)
of patients with 0 high-risk biomarkers. The NAC group exhibited
significantly poorer DFS than the upfront surgery group (P=0.0139).
DFS, disease-free survival; NAC, neoadjuvant chemotherapy.
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Copy and paste a formatted citation
Spandidos Publications style
Kawasaki K, Tajima H, Tatsuoka T, Takada M, Meguro S, Ishido H and Yoshitomi H: Investigation of CRP and NLR as potential biomarkers for redefining biological borderline resectable pancreatic cancer. Oncol Lett 32: 428, 2026.
APA
Kawasaki, K., Tajima, H., Tatsuoka, T., Takada, M., Meguro, S., Ishido, H., & Yoshitomi, H. (2026). Investigation of CRP and NLR as potential biomarkers for redefining biological borderline resectable pancreatic cancer. Oncology Letters, 32, 428. https://doi.org/10.3892/ol.2026.15783
MLA
Kawasaki, K., Tajima, H., Tatsuoka, T., Takada, M., Meguro, S., Ishido, H., Yoshitomi, H."Investigation of CRP and NLR as potential biomarkers for redefining biological borderline resectable pancreatic cancer". Oncology Letters 32.4 (2026): 428.
Chicago
Kawasaki, K., Tajima, H., Tatsuoka, T., Takada, M., Meguro, S., Ishido, H., Yoshitomi, H."Investigation of CRP and NLR as potential biomarkers for redefining biological borderline resectable pancreatic cancer". Oncology Letters 32, no. 4 (2026): 428. https://doi.org/10.3892/ol.2026.15783
Copy and paste a formatted citation
x
Spandidos Publications style
Kawasaki K, Tajima H, Tatsuoka T, Takada M, Meguro S, Ishido H and Yoshitomi H: Investigation of CRP and NLR as potential biomarkers for redefining biological borderline resectable pancreatic cancer. Oncol Lett 32: 428, 2026.
APA
Kawasaki, K., Tajima, H., Tatsuoka, T., Takada, M., Meguro, S., Ishido, H., & Yoshitomi, H. (2026). Investigation of CRP and NLR as potential biomarkers for redefining biological borderline resectable pancreatic cancer. Oncology Letters, 32, 428. https://doi.org/10.3892/ol.2026.15783
MLA
Kawasaki, K., Tajima, H., Tatsuoka, T., Takada, M., Meguro, S., Ishido, H., Yoshitomi, H."Investigation of CRP and NLR as potential biomarkers for redefining biological borderline resectable pancreatic cancer". Oncology Letters 32.4 (2026): 428.
Chicago
Kawasaki, K., Tajima, H., Tatsuoka, T., Takada, M., Meguro, S., Ishido, H., Yoshitomi, H."Investigation of CRP and NLR as potential biomarkers for redefining biological borderline resectable pancreatic cancer". Oncology Letters 32, no. 4 (2026): 428. https://doi.org/10.3892/ol.2026.15783
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