title: Neutrophil-to-lymphocyte ratio predicts progression and recurrence of non-muscle-invasive bladder cancer.
abstract: OBJECTIVE
  Neutrophil-to-lymphocyte ratio (NLR) predicts advanced stage disease and decreased survival in patients undergoing radical cystectomy for urothelial carcinoma of the bladder. The predictive value of NLR in non-muscle-invasive bladder cancer (NMIBC) has not been well studied. We aimed to evaluate whether NLR predicted disease recurrence and progression in NMIBC.
  
  
  METHODS
  The medical records of 122 consecutive, newly diagnosed, patients with NMIBC treated with transurethral tumor resection, between the years 2003 and 2010, were reviewed. Patients with hematological malignancies (n = 4) and without preoperative NLR (n = 11) were excluded. Cutoff points for NLR were tested separately for recurrence and progression using the standardized cutoff-finder algorithm. Univariate and multivariate Cox regression analyses were used to evaluate the association between NLR and disease recurrence and progression.
  
  
  RESULTS
  The study cohort comprised 91 men and 16 women at a median age of 68 years. The median NLR was 2.85 (interquartile range: 2-3.9). In total, 68 patients (64%) had an NLR>2.41. Patients with NLR>2.41 were more often men (P = 0.02) and had T1 category tumors (P = 0.034). Analyzed as a continuous variable, higher NLR showed a weak positive association with high tumor grade (R = 0.21, P = 0.028). The median follow-up for patients without disease recurrence was 40 months (interquartile range: 23-51). The estimated 3-year progression-free survival rate in patients with an NLR>2.41 was 61%, compared with 84% in patients with an NLR≤2.41 (P = 0.004). On multivariate analysis, an NLR>2.41 (hazard ratio [HR] = 3.52; 95% CI: 1.33-9.33; P = 0.012) and high-risk tumors compared with low-intermediate-risk tumors (HR = 4.83; 95% CI: 1.31-17.77; P = 0.018), as defined by the European Organization for Research and Treatment of Cancer risk tables, were associated with disease progression. An NLR>2.43 (HR = 1.75; 95% CI: 1.05-2.92; P = 0.032) and treatment with intravesical instillations (HR = 0.49; 95% CI: 0.28-0.85; P = 0.011) were associated with disease recurrence on multivariate analysis.
  
  
  CONCLUSIONS
  NLR is an independent predictor of disease progression and recurrence in patients with NMIBC without hematological malignancies. Prospective studies are required to validate the role of NLR as a prognostic marker in NMIBC.
authors: Department of Urology, Rabin Medical Center, Petach Tikva, Israel; Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel. Electronic address: roymano78@gmail.com.
authors: Roy
authors: R
authors: Mano
authors: Department of Urology, Rabin Medical Center, Petach Tikva, Israel; Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel.
authors: Jack
authors: J
authors: Baniel
authors: Department of Urology, Rabin Medical Center, Petach Tikva, Israel; Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel.
authors: Ohad
authors: O
authors: Shoshany
authors: Department of Urology, Rabin Medical Center, Petach Tikva, Israel; Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel.
authors: David
authors: D
authors: Margel
authors: Department of Mathematics, Technion-Israel Institute of Technology, Haifa, Israel.
authors: Tomer
authors: T
authors: Bar-On
authors: Department of Urology, Bnai Zion Medical Center, Haifa, Israel; The Ruth and Bruce Rappaport Faculty of Medicine, Technion-Israel Institute of Technology, Haifa, Israel.
authors: Ofer
authors: O
authors: Nativ
authors: Department of Mathematics, Technion-Israel Institute of Technology, Haifa, Israel.
authors: Jacob
authors: J
authors: Rubinstein
authors: Department of Urology, Bnai Zion Medical Center, Haifa, Israel; The Ruth and Bruce Rappaport Faculty of Medicine, Technion-Israel Institute of Technology, Haifa, Israel.
authors: Sarel
authors: S
authors: Halachmi
mesh_terms: D000368:Aged; D015331:Cohort Studies; D018450:Disease Progression; D005260:Female; D006801:Humans; D008214:Lymphocytes / Q000276:immunology / Q000473:pathology*; D008297:Male; D008875:Middle Aged; D009364:Neoplasm Recurrence, Local / Q000276:immunology / Q000473:pathology; D009504:Neutrophils / Q000276:immunology / Q000473:pathology*; D011237:Predictive Value of Tests; D012189:Retrospective Studies; D016019:Survival Analysis; D001749:Urinary Bladder Neoplasms / Q000276:immunology / Q000473:pathology* / Q000601:surgery
keywords: Bladder tumor; Disease progression; Lymphocyte; Neutrophil; Recurrence