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Available online at www.sciencedirect.com EJSO 34 (2008) 55 e 60 www.ejso.com Elevated preoperative neutrophil to

Available online at www.sciencedirect.com

Available online at www.sciencedirect.com EJSO 34 (2008) 55 e 60 www.ejso.com Elevated preoperative neutrophil to

EJSO 34 (2008) 55e60

online at www.sciencedirect.com EJSO 34 (2008) 55 e 60 www.ejso.com Elevated preoperative neutrophil to lymphocyte

Elevated preoperative neutrophil to lymphocyte ratio predicts survival following hepatic resection for colorectal liver metastases

K.J. Halazun, A. Aldoori, H.Z. Malik, A. Al-Mukhtar, K.R. Prasad, G.J. Toogood, J.P.A. Lodge *

HPB and Transplant Unit, St. James’s University Hospital, Leeds LS9 7TF, UK

Accepted 7 February 2007 Available online 19 April 2007


Background: The neutrophile lymphocyte ratio (NLR) provides an indicator of inflammatory status. An elevated NLR has been shown to be a prognostic indicator in primary colorectal malignancy. The aim of this study was to establish whether NLR predicts outcome in patients undergoing resection for colorectal liver metastasis. Design : Retrospective analysis of the white cell and differential counts for 440 patients undergoing liver resections for colorectal liver metastasis between January 1996 and January 2006. An NLR 5 was considered to be elevated. Results : Two hundred and eighty-nine males and 151 females were included. Seventy-eight patients (18%) had an elevated NLR, 55 of whom died, giving elevated NLR a positive predictive value (PPV) for death of 71%. Sixty of the 78 patients had recurrent disease giving raised NLR an PPV for recurrence of 78%. The 5-year survival for patients undergoing resection with high NLR was significantly worse than that for patients with normal NLR (22% vs. 43%, p < 0.0001). Univariate analysis of factors affecting survival revealed raised NLR, number of metastases > 8, tumour size > 5 cm and age > 70 significantly affected outcome. All factors except tumour size remained sig- nificant predictors of term survival on multivariate analysis (NLR:HR ¼ 2.261, CI ¼ 1.654 e3.129, p < 0.0001, metastases > 8:HR ¼ 1.611, CI ¼ 1.006 e 2.579, p ¼ 0.047, age > 70:HR ¼ 1.418, CI ¼ 1.049e 1.930, p ¼ 0.027). Elevated NLR was found to be the sole positive pre- dictor of recurrence on univariate analysis (HR ¼ 4.521, CI ¼ 2.475 e 8.257, p < 0.0001). Conclusion : Elevated NLR increases both risk of death and the risk of recurrence in patients who undergo surgery for CRLM. Preoperative NLR measurement may therefore provide a simple method of identifying patients with a poorer prognosis. 2007 Elsevier Ltd. All rights reserved.

Keywords: Colorectal liver metastases; Neutrophil to lymphocyte ratio; Prognosis


Liver resection is the primary mode of treatment for patients with CRLM, offering the only potential for disease eradication and therefore cure. Five-year survival approaches 45 e 50% in some centres, 1 e 6 however, cure from CRLM after surgery only occurs in 15 e 20% of patients. In addition, both intra- and extra-hepatic tumour recurrence rates remain high at around 60 e 65%. 7,8 The identification of patients more likely to have recurrence or poor outcome after surgery is therefore important and useful in guiding treatment.

* Corresponding author. Tel.: þ44 (0) 113 2064890; fax: þ44 (0) 113


E-mail address: peter.lodge@leedsth.nhs.uk (J.P.A. Lodge).

0748-7983/$ - see front matter 2007 Elsevier Ltd. All rights reserved.


Several studies have searched for prognostic indicators of outcome for CRLM patients. Potential prognostic indica- tors include primary tumour stage and grade, size, distribu- tion and number of liver metastases, extra-hepatic disease, resection margins and lymph node status. 4,9 e 13 Although these histological and surgical prognostic indicators are valuable, they have not been widely applied and little exists by way of a consensus for selecting patients who would benefit most from surgery and adjuvant chemotherapy. More recently, there has been growing interest in the host’s inflammatory response to tumour, and the systemic effects exerted by tumours in causing upregulation of the inflam- matory process, thereby increasing propensity to metasta- sise through the inhibition of apoptosis, promotion of angiogenesis and damage of DNA. 14 e 18


K.J. Halazun et al. / EJSO 34 (2008) 55e60

The most widely studied measure of inflammation is C-reactive protein (CRP), levels of which have been shown to independently predict survival in patients who undergo curative resection for colorectal cancer. 19,20 Recently, our group has identified CRP as a prognostic indictor in pa- tients undergoing surgery for CRLM. 21 A further marker of inflammation that is increasingly used to assess outcome in critically ill surgical patients is the neutrophil to lympho- cyte ratio (NLR). An elevated NLR has been shown to be an indictor of poor outcome in vascular and cardiovascular patients undergoing intervention. 22,23 Walsh et al. 24 have also shown an NLR 5 to be a marker of survival in colo- rectal cancer patients. We therefore hypothesise that an el- evated NLR may be used as a preoperative prognostic indictor of both outcome and recurrence in CRLM patients undergoing curative hepatic resection.

Patients and methods

Calculation of NLR

Patients undergoing resection for colorectal liver metasta- ses had neutrophil and lymphocyte counts measured preoper- atively as part of the routine work up. All white cell and differential counts were taken on the day before surgery with none of the patients showing clinical signs of sepsis. The NLR was calculated from the differential count by divid- ing the neutrophil measurement by the lymphocyte measure- ment. An NLR 5 was considered elevated. Patients were excluded if preoperative full blood counts were unavailable or the surgery was synchronous with primary colorectal resection.

Patient selection and surgical technique

The criteria for acceptance for surgery included fitness for major resection and lack of disseminated or irresectable extra-hepatic disease identified by CT or MRI scan. In all cases studied the colorectal primary had been previously resected and the patients had recovered fully from that pro- cedure. Intra-operative ultrasound was used as an adjunct to the preoperative radiological investigations. Resection was performed using the Cavi-Pulse Ultrasonic Surgical Aspira- tor (CUSA, Model 200T, Valley Lab., Boulder Colorado, USA). If necessary an intermittent Pringle manoeuvre was used with 15 min of ischaemia followed by 5 min of reperfusion. All patients undergoing liver resection accord- ing to our unit protocol were offered adjuvant therapy in the form of 5-FU/folinic acid, unless they had received adju- vant therapy following their colonic resection within the past 1 year. Patients were followed up at specialist clinics, with a minimum follow-up period of 11 months at the time of writing (range 11 e 97 months; median 24 months). No patients were lost to follow-up. An intensive policy of post-operative surveillance exists within this unit. Patients

have 3 monthly chest and abdominal computerised tomo- graphy (CT) performed during the 1st post-operative year, then 6 monthly during year 2. From years 3 e 5, a CT scan is performed yearly and finally at years 7 and 10 of follow-up. Tumour markers (CEA, CA19-9) and liver func- tion tests are performed during each clinic visit. The data examined included patient demographics; liver resection histology; pre-hepatectomy NLR; post-operative morbid- ity/mortality results as well as recurrence and survival figures.

Statistical methods

SPSS version 11 and Graph Pad Prism 4 for Mac were used to analyse the data. Chi-squared and Fisher’s Exact tests were used to analyse differences among groups of pa- tients with high or normal NLR. Kaplan-Meier survival curves were used to analyse patient outcome and disease free survival. A Cox regression analysis was then per- formed in a step-wise manner in order to perform a multi- variable analysis of clinico-pathological factors that impact both overall survival. Binary logistic regression analysis was used to investigate factors influencing recurrence. All confidence intervals are 95%.


A total of 440 patients were included in this study. Of these patients 289 (65%) were males and 151 (35%) females. The mean age of patient at time of surgery was 64 years (range 32 e 88 years; S.D. 10.7 years). All patients underwent liver resection. A total of 266 patients (61%) had

a ‘‘major’’ (three or more Couinaud’s segments) resection

performed. The in-hospital mortality rate was 2.5%, overall (long term) mortality was 42% and 52% of patients devel- oped recurrence.

Predictive value of NLR

The preoperative NLR was elevated ( 5) in 78 patients

(18%). Of these 55 patients have died, therefore giving elevated NLR a positive predictive value for death of 71%. Recurrence occurred in 60 of the 78 patients with

a high NLR, giving high NLR a positive predictive value for recurrence of 78%.

Elevated NLR effects survival and recurrence

There was no significant difference in demographic and clinico-pathological features between patients with normal and high NLR ( Table 1 ). There was a significant difference in long term survival between patients with

a normal NLR and those with a high NLR as shown in

Fig. 1 . Five-year survival for patients with a normal NLR was 43% compared to 22% for patients with a raised NLR (log rank test p < 0.0001). A marked difference also

K.J. Halazun et al. / EJSO 34 (2008) 55 e60


Table 1 Comparison of clinico-pathological and demographic features


Normal NLR ( <5) N ¼ 362

Elevated NLR ( 5) N ¼ 78


( p)

Age (mean) Male gender Neoadjuvant chemotherapy Synchronous disease Multiple (eight or more) metastases Major resections (>3 segments) Large metastases size (>50 mm) Positive margin

























existed between the two groups of patients with respect to disease free survival; patients with a high NLR having a 5 year disease free survival of 12% compared to 42% in patients with a normal NLR (log rank test p < 0.0001) (Fig. 2). Univariate analysis of factors affecting overall out- come (long term survival) revealed that tumour size > 5 cm, tumour number ( > 8), Age ( > 70) and elevated NLR ( 5) influenced overall survival (Table 2 ). Elevated NLR, age and tumour number remained significant on multi- variate analysis ( Table 3 ). Elevated NLR was found to be the sole predictor of recurrence on univariate analysis ( Table 4 ).

100 Normal NLR Elevated NLR 75 50 25 Log Rank Test: p < 0.0001 0
Normal NLR
Elevated NLR
Log Rank Test: p < 0.0001
% Survival

Disease Free Survival - Years

No. at Risk (% survival)








Normal NLR


259 (72%)

119 (56%)

70 (49%)

42 (43%)

24 (42%)

High NLR


39 (57%)

15 (26%)

11 (20%)

7 (14%)

5 (12%)

Figure 2. KaplaneMeier chart showing disease free survival in patients with normal and high NLR.


Inflammation, elevated NLR and malignancy

The first casual link between cancer and inflammation was described over one and a half centuries ago by Rudolf

100 Normal NLR Elevated NLR 75 50 25 Log Rank Test: p < 0.0001 0
Normal NLR
Elevated NLR
Log Rank Test: p < 0.0001
Survival Years
No. at Risk (% survival)
Normal NLR
322 (90%)
187 (79%)
117 (67%)
73 (57%)
36 (43%)
High NLR
54 (71%)
35 (53%)
21 (41%)
11 (25%)
9 (22%)
% Survival

Figure 1. KaplaneMeier chart comparing survival in both patient groups.

Table 2 Univariate analysis of factors affecting overall survival



Hazard ratio (CI)

Age <70 ( n ¼ 303) >70 ( n ¼ 137) Gender F ( n ¼ 151) M ( n ¼ 289) No. of tumours <8 ( n ¼ 388) >8 ( n ¼ 52)


1.381 (1.020e1.869)


1.110 (0.824e1.494)


1.535 (0.997e2.364)

Size of largest tumour <5 cm ( n ¼ 249)



cm ( n ¼ 174)


1.464 (1.039e1.962)

Timing of tumour Synchronous ( n ¼ 146) Metachronous ( n ¼ 153) No. of segments removed <3 ( n ¼ 174) >3 ( n ¼ 266) Preoperative NLR <5 ( n ¼ 362) 5 ( n ¼ 78) Resection margin ve ( n ¼ 269) +ve ( n ¼ 153)


1.023 (0.738e1.418)


1.156 (0.858e1.559)








K.J. Halazun et al. / EJSO 34 (2008) 55e60

Table 3 Multivariate analysis of factors affecting overall survival



Hazard ratio (CI)

Age > 70 Tumour no. > 8 NLR > 5 Tumour size > 5


1.418 (1.049e 1.930) 1.611 (1.006e 2.579) 2.275 (1.654e 3.129)







Virchow, when he observed that leucocytes existed in neo- plastic tissue. 14 It is only in the past decade, however, that the complexities of the tumour inflammatory microenviron- ment, and the host’s response to tumour induced inflamma- tory pathways are beginning to be understood, resulting in an improved ability to prevent and treat malignancy. Inflammation has been shown to play an important role in the pathogenesis and progression of colorectal carci- noma. Links have been established through the greatly in- creased risk of malignancy that exists in patients with inflammatory bowel disease, 25 as well as the approximate 50% decrease in colorectal cancer risk in patients who take regular NSAIDs and aspirin. 26 In addition, elevated markers of inflammation, especially elevated CRP, have been used as prognostic tools in patients undergoing cura- tive resection for primary colorectal tumours. 16 e 20 A fur- ther preoperative marker, an elevated neutrophil to lymphocyte ratio (NLR), has also been linked with poor prognosis in patients with primary colorectal carcinoma. 24 Despite the frequency of metastasis of primary colorectal tumours to the liver, few inflammatory marker have been linked with prognosis in patients with CRLM. Our study demonstrates that the preoperative inflammatory status of

Table 4 Univariate analysis of factors affecting recurrence



Hazard ratio (CI)

Age <70 ( n ¼ 303) >70 ( n ¼ 137) Gender F ( n ¼ 151) M ( n ¼ 289) No. of tumours <8 ( n ¼ 388) >8 ( n ¼ 52) Size of largest tumour <10 cm ( n ¼ 407) >10 cm ( n ¼ 33) Timing of tumour Synchronous ( n ¼ 146) Metachronous ( n ¼ 153) No. of segments removed <3 ( n ¼ 174) >3 ( n ¼ 266) Preoperative NLR <5 ( n ¼ 362) 5 ( n ¼ 78) Resection margin ve ( n ¼ 269) +ve ( n ¼ 153)


0.787 (0.523e 1.183)


1.199 (0.807e 1.783)


1.328 (0.734e 2.402)


1.421 (0.688e 2.934)


0.906 (0.568e 1.447)


1.262 (0.858e 1.856)









patients with CRLM, as evidenced by a raised NLR, is associated with poor overall and disease free survival, and an increased risk of recurrence. This is consistent with the above studies which associate CRP and high NLR with poor outcome in primary colorectal tumours, as well as a study from our unit which correlates high CRP levels with poor outcome in CRLM patients. 16 e 21,24 This is the first study to link elevated NLR and outcome after resection of CRLM:

this study implicates elevated NLR with increased recur- rence risk and reduced disease free survival. The association between elevated NLR and poor progno- sis is probably complex and largely unclear, however, several possible explanations exist. The host’s immune response to tumour is lymphocyte dependent. Several studies have demonstrated that patients with weaker lymphocytic infil- trates at tumour margins have a worse prognosis. 27 e 30 Okano et al. 30 found that patients with CRLM and weak lym- phocytic infiltration at the tumour margin did worse after liver resection than those with an adequate lymphocyte response to tumour. Patients with elevated NLR have a rela- tive lymphocytopaenia, and, as a result may exhibit a poorer lymphocyte mediated immune response to malignancy, thereby worsening their prognosis, and increasing the poten- tial for the tumour to recur. Alternatively, an elevated neutrophil count may aid in the development and progression of the neoplasm by pro- viding an adequate environment for it to grow. Circulating neutrophils have been shown to contain and secrete the vast majority of circulating VEGF, a pro-angiogenic factor that is thought to play an integral role in tumour development. 31 Increased angiogenic activity in GI tumours has been asso- ciated with poor outcomes, 32,33 The high circulating neu- trophil levels in patients with an elevated NLR may confer a survival advantage for metastatic colorectal

tumour cells, thus accounting for the poorer outcome and increased recurrence rates in these patients.

Clinical use of elevated NLR

The ability to successfully predict poor prognosis and increased risk of recurrence in CRLM patients using NLR is potentially valuable in directing both pre- and post- operative therapies to such patients in order to improve their outcome. No specific therapies for these patients exist at present, however, there has been ongoing research into the effects of anti-inflammatory agents on tumour progres- sion. Several studies have shown that the anti-angiogenic activity of COX-2 inhibitors, via the suppression of VEGF, inhibits and may even prevent the growth and pro- liferation of CRLM. 34 e 36 Such therapeutic strategies may prove most beneficial in patients with an elevated NLR in whom high levels of VEGF and other pro-angiogenic fac- tors could be inhibited both pre- and post-operatively. Other studies have used therapies directed at enhancing the host response to tumour in order to decrease the propensity of colorectal tumours to propagate and metastasise. 37,38 One

K.J. Halazun et al. / EJSO 34 (2008) 55 e60


such study by Oosterling et al. showed that the preoperative administration of GM-CSF in patients undergoing surgery for colorectal tumours enhances the immune activity of the liver by increasing the hepatic population of dendritic cells, and enhancing their interaction with CD8 þ T lym- phocytes. 38 The possibility of preoperatively treating patients with an elevated NLR with GM-CSF has not been explored, but may improve their immune response to tu- mour, and therefore decrease the risk of recurrence and im- prove their long term survival. The use of vaccines to enhance the lymphocyte response to tumour has also been shown to be effective in colorectal cancer, 39,40 and may again be an avenue for treatment of patients with a high NLR.


In summary, elevated preoperative NLR increases both risk of death and the risk of recurrence in patients who un- dergo surgery for colorectal liver metastases. Preoperative NLR measurement in such patients may provide a simple method of identifying patients with a poorer prognosis and aid in guiding treatment effectively. Although no spe- cific therapy for such patients exists at present, pre- and post-operative inflammatory and immune modulation may prove beneficial in improving their long term outcome.


The authors would like to acknowledge Mr. Anthony Kaye (Department of Haematology) for providing access to patients’ blood results.


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