Document Type : Original Article(s)


Department of Radiation Oncology, Action Cancer Hospital, New Delhi, India



Background: Inflammation, when associated with cancer, has been shown to correlate with a worse prognosis. Neutrophil-lymphocyte ratio (NLR), platelet-lymphocyte ratio (PLR), and monocyte-lymphocyte ratio (MLR) serve as markers of inflammation. This study aims to investigate the influence of pretreatment NLR, PLR, and MLR on treatment outcomes and their correlation with sarcopenia in patients with locally advanced head and neck squamous cell carcinoma (LA-HNSCC) undergoing definitive chemoradiotherapy.
Method: In this retrospective study, 240 LA-HNSCC patients who received a radiotherapy dose of 70 Gy/35 fractions over 7 weeks in conjunction with chemotherapy were enrolled. Pretreatment NLR, PLR, and MLR were determined. Sarcopenia was evaluated by measuring skeletal muscle mass at the C3 level using radiotherapy planning computed tomography scans. The impact of NLR, PLR, and MLR on complete response rate and disease-free survival was calculated. The median follow-up duration for patients was 26 months.
Results: Inflammatory markers were notably higher in elderly patients, females, and those with laryngeal primary tumours. Patients achieving a complete response exhibited lower values than those who did not. Patients with significant sarcopenia demonstrated elevated mean values of inflammatory markers. Patients with NLR<3, PLR<145, and MLR<0.4 experienced more favorable outcomes regarding complete response rate and disease-free survival.
Conclusion: Inflammatory markers such as NLR, PLR, and MLR are independent prognostic factors in HNSCC patients. Elevated values are associated with sarcopenia and inferior treatment outcomes, indicative of more aggressive tumour behavior. These markers are straightforward to calculate and should be routinely employed for early prognosis assessment.


Deep Shankar Pruthi (PubMed)


Main Subjects

How to cite this article:

Pruthi DS, Nagpal P, Pandey M, Yadav A. Impact of pretreatment inflammatory markers in locally advanced head and neck cancer treated with concurrent chemoradiotherapy. Middle East J Cancer. 2024;15(3):226-33. doi:10.30476/mejc.2023.99132.1929.

  1. Bray F, Ferlay J, Soerjomataram I, Siegel RL, Torre LA, Jemal A. Global cancer statistics 2018: GLOBOCAN estimates of incidence and mortality worldwide for 36 cancers in 185 countries. CA Cancer J Clin. 2018;68(6):394-424. doi: 10.3322/caac.21492. Erratum in: CA Cancer J Clin. 2020;70(4):313.
  2. Forastiere AA, Zhang Q, Weber RS, Maor MH, Goepfert H, Pajak TF, et al. Long-term results of RTOG 91-11: a comparison of three nonsurgical treatment strategies to preserve the larynx in patients with locally advanced larynx cancer. J Clin Oncol. 2013;31(7):845-52. doi: 10.1200/JCO.2012.43.6097.
  3. Lacas B, Carmel A, Landais C, Wong SJ, Licitra L, Tobias JS, et al. Meta-analysis of chemotherapy in head and neck cancer (MACH-NC): An update on 107 randomized trials and 19,805 patients, on behalf of MACH-NC Group. Radiother Oncol. 2021;156:281-93. doi: 10.1016/j.radonc.2021.01.013.
  4. Magnes T, Wagner S, Kiem D, Weiss L, Rinnerthaler G, Greil R, et al. Prognostic and predictive factors in advanced head and neck squamous cell carcinoma. Int J Mol Sci. 2021;22(9):4981. doi: 10.3390/ijms22094981.
  5. Leoncini E, Vukovic V, Cadoni G, Pastorino R, Arzani D, Bosetti C, et al. Clinical features and prognostic factors in patients with head and neck cancer: Results from a multicentric study. Cancer Epidemiol. 2015;39(3):367-74. doi: 10.1016/j.canep.2015.02.004.
  6. Ang KK, Harris J, Wheeler R, Weber R, Rosenthal DI, Nguyen-Tân PF, et al. Human papillomavirus and survival of patients with oropharyngeal cancer. N Engl J Med. 2010;363(1):24-35. doi: 10.1056/NEJMoa0912217.
  7. Habbous S, Harland LT, La Delfa A, Fadhel E, Xu W, Liu FF, et al. Comorbidity and prognosis in head and neck cancers: Differences by subsite, stage, and human papillomavirus status. Head Neck. 2014;36(6):802-10. doi: 10.1002/hed.23360.
  8. Coussens LM, Werb Z. Inflammation and cancer. 2002;420(6917):860-7. doi:10.1038/nature01322.
  9. Balkwill F, Mantovani A. Inflammation and cancer: back to Virchow? 2001;357(9255):539-45. doi:10.1016/S0140-6736(00)04046-0.
  10. Hanahan D, Weinberg RA. Hallmarks of cancer: the next generation. 2011;144(5):646-74. doi:10.1016/j.cell.2011.02.013.
  11. Diakos CI, Charles KA, McMillan DC, Clarke SJ. Cancer-related inflammation and treatment effectiveness. Lancet Oncol. 2014;15(11):e493-e503. doi:10.1016/S1470-2045(14)70263-3.
  12. Kim MR, Kim AS, Choi HI, Jung JH, Park JY, Ko HJ. Inflammatory markers for predicting overall survival in gastric cancer patients: A systematic review and meta-analysis. PLoS One. 2020;15(7):e0236445.. doi:10.1371/journal.pone.0236445.
  13. Lugano R, Ramachandran M, Dimberg A. Tumor angiogenesis: causes, consequences, challenges and opportunities. Cell Mol Life Sci. 2020;77(9):1745-70. doi:10.1007/s00018-019-03351-7.
  14. Conteduca V, Crabb SJ, Jones RJ, Caffo O, Elliott T, Scarpi E, et al. Persistent neutrophil to lymphocyte ratio >3 during treatment with Enzalutamide and clinical outcome in patients with castration-resistant prostate cancer. PLoS One. 2016;11(7):e0158952. doi: 10.1371/journal.pone.0158952.
  15. Kim TW, Lee JH, Shim KH, Choo SH, Choi JB, Ahn HS, et al. Prognostic significance of preoperative and follow-up neutrophil-to-lymphocyte ratio and platelet-to-lymphocyte ratio in patients with non-metastatic clear cell renal cell carcinoma. Investig Clin Urol. 2019;60(1):14-20. doi: 10.4111/icu.2019.60.1.14.
  16. Choi JH, Suh YS, Choi Y, Han J, Kim TH, Park SH, et al. Comprehensive analysis of the neutrophil-to-lymphocyte ratio for preoperative prognostic prediction nomogram in gastric cancer. World J Surg. 2018;42(8):2530-41. doi: 10.1007/s00268-018-4510-4.
  17. Ng SP, Bahig H, Jethanandani A, Sturgis EM, Johnson FM, Elgohari B, et al. Prognostic significance of pre-treatment neutrophil-to-lymphocyte ratio (NLR) in patients with oropharyngeal cancer treated with radiotherapy. Br J Cancer. 2021;124(3):628-33. doi: 10.1038/s41416-020-01106-x.
  18. Nagpal P, Pruthi DS, Pandey M, Yadav A, Singh H. Impact of sarcopenia in locally advanced head and neck cancer treated with chemoradiation: An Indian tertiary care hospital experience. Oral Oncol. 2021;121:105483. doi:10.1016/j.oraloncology.2021.105483.
  19. Swartz JE, Pothen AJ, Wegner I, Smid EJ, Swart KM, de Bree R, et al. Feasibility of using head and neck CT imaging to assess skeletal muscle mass in head and neck cancer patients. Oral Oncol. 2016;62:28-33. doi: 10.1016/j.oraloncology.2016.09.006.
  20. Cho Y, Kim JW, Yoon HI, Lee CG, Keum KC, Lee IJ. The prognostic significance of neutrophil-to-lymphocyte ratio in head and neck cancer patients treated with radiotherapy. J Clin Med. 2018;7(12):512. doi:10.3390/jcm7120512
  21. Haddad CR, Guo L, Clarke S, Guminski A, Back M, Eade T. Neutrophil-to-lymphocyte ratio in head and neck cancer. J Med Imaging Radiat Oncol. 2015;59(4):514-9. doi:10.1111/1754-9485.12305.
  22. Ma SJ, Yu H, Khan M, Gill J, Santhosh S, Chatterjee U, et al. Evaluation of optimal threshold of neutrophil-lymphocyte ratio and its association with survival outcomes among patients with head and neck cancer. JAMA Netw Open. 2022;5(4):e227567. doi: 10.1001/jamanetworkopen.2022.7567.
  23. Malik A, Mishra A, Mair M, Chakrabarti S, Garg A, Singhvi H, et al. Role of neutrophil-to-lymphocyte ratio and platelet-to-lymphocyte ratio as prognostic markers in oral cavity cancers. Indian J Med Paediatr Oncol. 2019;40(1):94-100. doi: 10.4103/ijmpo.ijmpo_5_18.
  24. Ni J, Zhang L. Cancer cachexia: definition, staging, and emerging treatments. Cancer Manag Res. 2020;12:5597-605. doi: 10.2147/CMAR.S261585.
  25. Huang SH, Waldron JN, Milosevic M, Shen X, Ringash J, Su J, et al. Prognostic value of pretreatment circulating neutrophils, monocytes, and lymphocytes in oropharyngeal cancer stratified by human papillomavirus status. 2015;121(4):545-55. doi: 10.1002/cncr.29100.
  26. Al-Sahaf S, Hendawi NB, Ollington B, Bolt R, Ottewell PD, Hunter KD, et al. Increased abundance of tumour-associated neutrophils in HPV-negative compared to HPV-positive oropharyngeal squamous cell carcinoma is mediated by IL-1R signaling. Front Oral Health. 2021;2:604565. doi: 10.3389/froh.2021.604565.