title: Preoperative platelet-to-lymphocyte ratio improves the performance of the international consensus guidelines in predicting malignant pancreatic cystic neoplasms.
abstract: BACKGROUND
  To determine if neutrophil-to-lymphocyte ratio (NLR) and platelet-to-lymphocyte ratio (PLR) were predictive of malignancy in pancreatic cystic neoplasms (PCN) and if these improved the performance of the international consensus guidelines (ICG) in the initial triage of these patients.
  
  
  METHODS
  318 patients with surgically-treated suspected PCN were retrospectively reviewed. Malignant neoplasms were defined as neoplasms harbouring invasive carcinoma. The optimal cut-off for NLR and PLR were determined by plotting the receiver operating characteristics (ROC) curves of NLR/PLR in predicting malignant PCN and utilizing the Youden index.
  
  
  RESULTS
  The optimal NLR and PLR cut-offs were determined to be 3.33 and 205, respectively. Univariate analyses demonstrated that symptomatic PCNs, age, obstructive jaundice, presence of solid component, dilatation of main pancreatic duct ≥10 mm, high NLR and high PLR were predictive of a malignant PCN. Multivariate analyses demonstrated that obstructive jaundice, presence of solid component, MPD ≥10 mm and high PLR but not NLR were independent predictors of a malignant PCN. A high PLR significantly predicted invasive carcinoma in patients classified within the ICG(HR) group. Comparison between the ROC curves of the ICG versus ICG plus high PLR in predicting malignant PCN demonstrated a significant improvement in the accuracy of the ICG when PLR was included [AUC 0.784 (95% CI: 0.740-0.829) vs AUC 0.822 (95% CI: 0.772-0.872) (p = 0.0032)].
  
  
  CONCLUSIONS
  High PLR is an independent predictor of malignancy in PCN. The addition of PLR as a criterion to the ICG improved the accuracy of these guidelines in detecting invasive neoplasms.
authors.affiliation: Department of Hepatopancreatobiliary and Transplantation Surgery, Singapore General Hospital, Singapore; Duke-NUS Graduate Medical School, Singapore. Electronic address: bsgkp@hotmail.com.
authors.forename: Brian K P
authors.initials: BK
authors.lastname: Goh
authors.affiliation: Department of Hepatopancreatobiliary and Transplantation Surgery, Singapore General Hospital, Singapore.
authors.forename: Jin-Yao
authors.initials: JY
authors.lastname: Teo
authors.affiliation: Duke-NUS Graduate Medical School, Singapore.
authors.forename: John C
authors.initials: JC
authors.lastname: Allen
authors.affiliation: Department of Gastroenterology and Hepatology, Singapore General Hospital, Singapore.
authors.forename: Damien M Y
authors.initials: DM
authors.lastname: Tan
authors.affiliation: Department of Hepatopancreatobiliary and Transplantation Surgery, Singapore General Hospital, Singapore.
authors.forename: Chung-Yip
authors.initials: CY
authors.lastname: Chan
authors.affiliation: Department of Hepatopancreatobiliary and Transplantation Surgery, Singapore General Hospital, Singapore.
authors.forename: Ser-Yee
authors.initials: SY
authors.lastname: Lee
authors.affiliation: Division of Medical Oncology, National Cancer Centre, Singapore.
authors.forename: David W M
authors.initials: DW
authors.lastname: Tai
authors.affiliation: Department of Diagnostic Imaging, National Cancer Centre, Singapore.
authors.forename: Choon-Hua
authors.initials: CH
authors.lastname: Thng
authors.affiliation: Department of Hepatopancreatobiliary and Transplantation Surgery, Singapore General Hospital, Singapore.
authors.forename: Peng-Chung
authors.initials: PC
authors.lastname: Cheow
authors.affiliation: Department of Hepatopancreatobiliary and Transplantation Surgery, Singapore General Hospital, Singapore; Duke-NUS Graduate Medical School, Singapore.
authors.forename: Pierce K H
authors.initials: PK
authors.lastname: Chow
authors.affiliation: Department of Hepatopancreatobiliary and Transplantation Surgery, Singapore General Hospital, Singapore; Duke-NUS Graduate Medical School, Singapore.
authors.forename: London L P J
authors.initials: LL
authors.lastname: Ooi
authors.affiliation: Department of Hepatopancreatobiliary and Transplantation Surgery, Singapore General Hospital, Singapore.
authors.forename: Alexander Y F
authors.initials: AY
authors.lastname: Chung
mesh_terms: D000293:Adolescent; D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D032921:Consensus; D005260:Female; D017408:Guidelines as Topic; D006801:Humans; D041781:Jaundice, Obstructive / Q000150:complications; D018655:Lymphocyte Count; D008297:Male; D008875:Middle Aged; D009361:Neoplasm Invasiveness / Q000473:pathology; D018297:Neoplasms, Cystic, Mucinous, and Serous / Q000097:blood* / Q000175:diagnosis* / Q000601:surgery; D009504:Neutrophils; D010190:Pancreatic Neoplasms / Q000097:blood* / Q000175:diagnosis* / Q000601:surgery; D010976:Platelet Count; D011237:Predictive Value of Tests; D011379:Prognosis; D012189:Retrospective Studies; D014218:Triage / Q000379:methods; D055815:Young Adult
keywords: Consensus guidelines; Intraductal papillary mucinous neoplasms; Neutrophil-lymphocyte-ratio; Pancreatic cystic neoplasms; Platelet-lymphocyte-ratio