Predictive value of neutrophil-to-lymphocyte, lymphocyte-to-monocyte, and platelet-to-lymphocyte ratios in adult and pediatric acute lymphoblastic leukemia patients

Mariam K Youssef; Rania A Radwan; Sara M Makkeyah; Sara I Taha

doi:10.4103/ejh.ejh_19_22

ORIGINAL ARTICLE

Year : 2022 | Volume : 47 | Issue : 4 | Page : 239-248

Predictive value of neutrophil-to-lymphocyte, lymphocyte-to-monocyte, and platelet-to-lymphocyte ratios in adult and pediatric acute lymphoblastic leukemia patients

Mariam K Youssef MD, PhD ¹, Rania A Radwan², Sara M Makkeyah³, Sara I Taha⁴
¹ Department of Clinical Pathology/Hematology, Faculty of Medicine, Ain Shams University, Cairo, Egypt
² Department of Hematology and Bone Marrow Transplantation, Faculty of Medicine, Ain Shams University, Cairo, Egypt
³ Department of Pediatrics/Hematology, Faculty of Medicine, Ain Shams University, Cairo, Egypt
⁴ Department of Clinical Pathology/Immunology, Faculty of Medicine, Ain Shams University, Cairo, Egypt

Date of Submission	07-Apr-2022
Date of Acceptance	19-Apr-2022
Date of Web Publication	09-Mar-2023

Correspondence Address:
Mariam K Youssef
Department of Clinical Pathology/Hematology, Faculty of Medicine, Ain Shams University, Abassia, Cairo 11566
Egypt

Source of Support: None, Conflict of Interest: None

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DOI: 10.4103/ejh.ejh_19_22

Abstract

Background Methods used for prognostication of acute lymphoblastic leukemia (ALL) are expensive; discovering low-cost prognostic factors is challenging. Objectives This study aimed to explore the prognostic role of baseline neutrophil-to-lymphocyte (NLR), lymphocyte-to-monocyte (LMR), and platelet-to-lymphocyte (PLR) ratios in predicting the response to end of induction chemotherapy in ALL patients. Patients and methods We included 44 adult patients and 47 pediatric patients who were newly diagnosed with ALL. All participants were subjected to a full history taking and a thorough medical examination. Laboratory investigations included complete blood count (CBC) with differential count analysis, with calculation of NLR, LMR, and PLR; bone marrow examination; conventional cytogenetic analysis; and immunophenotyping. Patients were followed until the end of the induction phase, and their response to treatment was assessed. Results Among the adult patients, 63.6% showed complete remission at the end of induction; their baseline CBC showed significantly lower NLR (P=0.001) and higher LMR (P=0.013). On the other hand, 66% of the pediatric patients showed good response to induction chemotherapy; their baseline CBC showed significantly lower NLR (P<0.001), greater LMR (P=0.0134), and lower PLR (P=0.017). NLR more than or equal to 1, LMR less than or equal to 2.846, and PLR more than or equal to 39.1 were able to discriminate adult patients who will respond to induction chemotherapy, similarly NLR more than or equal to 1, LMR less than or equal to 3.286, and PLR more than or equal to 10 among pediatric patients. Conclusion Our research discovered that the rise in NLR and PLR, together with the decline of LMR at ALL diagnosis, could predict future resistance to the routinely used induction protocols, and the need for intensification regimens.

Keywords: acute lymphoblastic leukemia, induction chemotherapy, lymphocyte-to-monocyte, neutrophil-to-lymphocyte, platelet-to-lymphocyte

How to cite this article:
Youssef MK, Radwan RA, Makkeyah SM, Taha SI. Predictive value of neutrophil-to-lymphocyte, lymphocyte-to-monocyte, and platelet-to-lymphocyte ratios in adult and pediatric acute lymphoblastic leukemia patients. Egypt J Haematol 2022;47:239-48

How to cite this URL:
Youssef MK, Radwan RA, Makkeyah SM, Taha SI. Predictive value of neutrophil-to-lymphocyte, lymphocyte-to-monocyte, and platelet-to-lymphocyte ratios in adult and pediatric acute lymphoblastic leukemia patients. Egypt J Haematol [serial online] 2022 [cited 2023 Jun 5];47:239-48. Available from: http://www.ehj.eg.net/text.asp?2022/47/4/239/371330

Introduction

Acute lymphoblastic leukemia (ALL) is a cancer that manifests itself as clonal proliferation and expansion of lymphoblastic cells. The disease can start in different lymphoid cell lineages, resulting in B or T cell lineage ALL, as well as mixed lineage (adult) ALL. Biological and clinical features of ALL are markedly heterogeneous, with substantial differences in patient outcomes. The recent years have noticed increasing interest in ALL prognosis. Variable aspects of ALL have been investigated for their prognostic value. These aspects not only help to categorize patients according to the risk of relapse posttreatment, but also can be predictive of the initial response to induction chemotherapy [1]. Although promising, many of the prognostication approaches are expensive and difficult to get, especially in locations with limited resources. As a result, finding prognostic indicators that are both inexpensive and easy to understand is always a challenge. Complete blood count (CBC) is an easy, time and cost effective, widely available test, important in the diagnosis and monitoring of a variety of medical conditions [2]. New applications of CBC, focusing on the proportion between the different types of blood cells, are being studied in many medical disorders, such as infections [3], inflammatory diseases [4], surgical emergencies [5], postoperative complications [6], and cardiovascular events [7]. Moreover, owing to the growing importance of the immune and inflammatory cells constituting the tumor microenvironment, several studies have reported the significance of the proportions between the different blood cells, as a prognostic factor in a variety of solid tumors, such as gastric [8], breast [9], head and neck [10], hepatic [11], lung [12], esophageal cancers [13], and melanoma [14]. However, there has not been a lot of publicity about the prognostic role of CBC-derived ratios in the context of acute leukemia. Hence, the present study aimed to explore the prognostic role of baseline neutrophil-to-lymphocyte (NLR), lymphocyte-to-monocyte (LMR), and platelet-to-lymphocyte (PLR) ratios in predicting postinduction treatment response in adult and pediatric Egyptian patients with ALL.

Patients and methods

Study settings and patients

This cross-sectional study included a convenience sample of newly diagnosed ALL patients, who attended the Hematology Unit of Ain Shams University Hospitals during the period from May to July, 2021. The diagnosis and classification of acute leukemia were based on the 2016 revision of the WHO Classification of Tumors of Haematopoeitic and Lymphoid Tissues [15]. At the time of hospital admission, all participants were subjected to a full history taking and a thorough medical examination, focusing on the presence of pallor, purpura, and extramedullary disease. The current study protocol was approved by the Research Ethics Committee of Ain Shams University Faculty of Medicine (FWA 00017585) on the basis of ethical considerations. All procedures were explained to all participants, and their informed consent was obtained before any of them could participate in the study. This study adheres to the Declaration of Helsinki.

Laboratory investigations

(1) A dose of 2 ml of venous blood samples was aseptically collected on ethylenediaminetetraacetic acid dipotassium salt vacutainer tubes (final concentration of 1.5 mg/ml) from each patient for performing CBC with differential count analysis, using the Sysmex XT-1800i autoanalyzer (Sysmex, Hyogo, Japan), with reviewing of Leishman’s stained peripheral blood smears. The ratios between neutrophil and lymphocyte, lymphocyte and monocyte, and platelet and lymphocyte counts were calculated.

(2) About 3 ml bone marrow aspirate blood was obtained from each patient and was divided as follows:
- (a) The first 0.5–1 ml aspirate specimen was used for preparing smears stained with Leishman and myeloperoxidase stains.
- (b) One milliliter aspirate specimen was obtained on lithium heparin for conventional cytogenetic analysis using Giemsa banding.
- (c) A specimen of 1 1/2 ml was obtained on a ethylenediaminetetraacetic acid dipotassium salt tube for performing IPT using a Coulter Epics XL flow cytometer (Coulter Electronics, Hialeah, Florida, USA) utilizing the usual panel for acute leukemia including common progenitor markers (CD34, HLADR), myeloid lineage markers (CD13, CD33, CD14, CD15, CD61, myeloperoxidase), B cell lymphoid lineage markers (CD10, CD19, CD20, CD79a, and CD79b), and T cell lymphoid lineage markers (CD2, CD3, CD5, CD7, and TCRab, TCRdg).

Induction chemotherapy protocol and response assessment

(1) St Jude Children’s Research Hospital Total Therapy XV protocol was used to stratify and treat pediatric ALL patients younger than 16 years old. At day 42, flow cytometric assessment of minimal residual disease, using lineage-specific panels for B and T-ALL, was done. Poor response to end of induction chemotherapy was determined by positive minimal residual disease at day 42, defined when blast cells exceed 0.01% of all marrow nucleated cells.

(2) Patients, whose ages were 16–20 years old received induction chemotherapy with CALGB protocol, composed of (cyclophosphamide+doxorubicin+ vincristine+prednisone+L-asparaginase). Patients whose ages were between 21 and 50 years received induction chemotherapy with hyper-CVAD protocol; cycle A composed of: (cyclophosphamide+vincristine+doxorubicin+dexamethasone), alternating with cycle B, composed of (methotrexate+cytarabine). Patients who were above 50 years old received Linker Regimen composed of (doxorubicin+vincristine+ prednisone+L-asparaginase). Remission was determined by the disappearance of leukemia evidence at day 28 postinduction chemotherapy, which is assessed by the absence of central nervous system (CNS) or testicular illness, as well as bone marrow testing that reveals normal cellularity and less than 5% blast cells.

Statistical analysis

Data analysis was done using IBM SPSS statistics (V. 26.0, 2019; IBM Corp., Chicago, Illinois, USA). Quantitative nonparametric data were expressed as median and percentiles, while categorized data were expressed as number and percentage. Wilcoxon rank-sum test was used to compare two independent groups for nonparametric data. Spearman’s Rank correlation test was used in nonparametric data, to investigate the relation between two variables, and the χ² test was used in classified data, to investigate the relation between two variables or the comparison between two independent groups. At 0.05, the likelihood of error was regarded significant; at 0.01 and 0.001, it was considered extremely significant. Diagnostic validity test and receiver-operating characteristic (ROC) curve were constructed to show the predictive performance of CBC-derived ratios.

Results

Baseline characteristics of acute lymphoblastic leukemia patients

The study included 44 newly diagnosed ALL adult patients, whose ages ranged from 16 to 57 years, and 47 newly diagnosed ALL pediatric patients, whose ages ranged from 3 to 15 years. [Table 1] shows the baseline characteristic features of the included patients. At diagnosis, adult ALL patients had a significantly higher serum uric acid levels (P=0.017), greater absolute monocyte counts (P=0.001), less platelet counts (P=0.001), and less PLR (P=0.017) than pediatric patients. The rate of remission in response to end of induction chemotherapy did not differ significantly between adult and pediatric ALL patients (P>0.05).

Table 1: Baseline characteristic features of the included study cohort

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Comparison of the characteristic features of adult acute lymphoblastic leukemia patients according to their postinduction treatment response

According to the response to end of induction chemotherapy, adult ALL patients were subdivided into two groups; remittent 28/44 (63.6%) and resistant 16/44 (36.4%) ([Table 2]). The baseline CBC of the remittent group of patients showed a significantly lower absolute neutrophil counts (P=0.001), lower absolute monocyte counts (P=0.019), lower platelet counts (P=0.003), lower NLR (P=0.001), and greater LMR (P=0.013). While all the remittent group had normal cytogenetic analysis, 25% of the resistant group had the t(9;22); the variability in cytogenetic analysis between both groups was statistically significant (P=0.006). The PLR, age, ALL phenotype, and the incidence of CNS infiltration, did not significantly differ between both groups (P>0.05).

Table 2: Comparison of the characteristic features of adult acute lymphoblastic leukemia patients according to their postinduction treatment response

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Comparison of the characteristic features of pediatric acute lymphoblastic leukemia patients according to their postinduction treatment response

According to the response to induction phase, pediatric ALL patients were subdivided into two groups: good 31/44 (66%) and poor 16/44 (34%) responders ([Table 3]). The CBC of the good responders showed a significantly lower absolute neutrophil counts (P=0.017), lower platelet counts (P=0.035), lower NLR (P<0.001), higher LMR (P=0.0134), and lower PLR (P=0.017). While all the good responders had normal cytogenetic analysis, 18.8% of the poor responders had the t(9;22); the variability in cytogenetic analysis between both groups was statistically significant (P=0.013). Also, the incidence of CNS infiltration was significantly elevated in those who were poor responders (P=0.044). The age and ALL phenotype did not significantly differ between both groups (P>0.05).

Table 3: Comparison of the characteristic features of pediatric acute lymphoblastic leukemia patients according to their postinduction treatment response

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Relation of complete blood count-derived ratios to the common prognostic factors in adult acute lymphoblastic leukemia

A lower PLR was significantly associated with higher total leukocytic count (TLC) at adult ALL diagnosis (P<0.001). Also, higher NLR (P=0.007) and lower LMR (P=0.013) were significantly related to the presence of t(9;22) at adult ALL diagnosis. No significant associations were found between CBC ratios and the presenting age at ALL diagnosis, as well as the ALL phenotype (P>0.05) ([Table 4]).

Table 4: Relation of complete blood count-derived ratios to the common prognostic factors in adult acute lymphoblastic leukemia

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Relation of complete blood count-derived ratios to the common prognostic factors in pediatric acute lymphoblastic leukemia

Higher NLR was significantly associated with a rise in the median age at presentation of pediatric ALL (P=0.012). Also, higher NLR (P=0.01) and lower PLR (P<0.001) were significantly associated with higher TLC at ALL diagnosis. In addition, higher NLR (P=0.007) was significantly related to the presence of t(9;22) at pediatric ALL diagnosis. No significant association was found between CBC ratios and the ALL phenotype (P>0.05) ([Table 5]).

Table 5: Relation of complete blood count-derived ratios to the common prognostic factors in pediatric acute lymphoblastic leukemia

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Evaluation of the performance of the different complete blood count-derived ratios in predicting the response to end of induction chemotherapy in acute lymphoblastic leukemia patients

[Table 6] and [Table 7] demonstrate diagnostic validity tests that were performed to assess the overall prognostic performance of CBC-derived ratios in adult and pediatric ALL patients, respectively. At adult ALL diagnosis, ROC curve analysis showed that NLR more than or equal to 1 [area under the curve (AUC): 0.789, 95% confidence interval (CI): 0.596–0.983], LMR less than or equal to 2.846 (AUC: 0.750, 95% CI: 0.534–0.966), and PLR more than or equal to 39.1 (AUC: 0.681, 95% CI: 0.433–0.930) were able to discriminate patients who will respond to end of induction chemotherapy from those who won’t. Also, by drawing a multi-ROC curve, the combination of NLR more than or equal to 1 with PLR more than or equal to 2, improved the overall predictive performance (AUC: 0.921, 95% CI: 0.824–1.020) ([Figure 1]).

Table 6: Diagnostic validity assessing the overall predictive performance of complete blood count-derived ratios in adult acute lymphoblastic leukemia

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Table 7: Diagnostic validity assessing the overall predictive performance of complete blood count-derived ratios in pediatric acute lymphoblastic leukemia

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Figure 1: ROC curve analysis showing the performance of NLR, LMR, and PLR for the prediction of postinduction treatment response in adult patients. AUC, area under the curve; CI, confidence interval; LMR, lymphocyte-to-monocyte ratio; NLR, neutrophil-to-lymphocyte ratio; PLR, platelet-to-lymphocyte ratio; ROC, receiver-operating characteristic.

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Similarly, at pediatric ALL diagnosis, ROC curve analysis showed that NLR more than or equal to 1 (AUC: 0.785, 95% CI: 0.589–0.981), LMR less than or equal to 3.286 (AUC: 0.707, 95% CI: 0.470–0.944), and PLR more than or equal to 10 (AUC: 0.511, 95% CI: 0.260–0.843) were able to discriminate patients who will respond to end of induction chemotherapy from those who won’t. Also, by drawing a multi-ROC curve, the combination of NLR more than or equal to 1 with PLR more than or equal to 2, improved the overall test predictive performance (AUC: 0.843, 95% CI: 0.684–1.002) ([Figure 2]).

Figure 2: ROC curve analysis showing the performance of NLR, LMR, and PLR for the prediction of postinduction treatment response in pediatric patients. AUC, area under the curve; CI, confidence interval; LMR, lymphocyte-to-monocyte ratio; NLR, neutrophil-to-lymphocyte ratio; PLR, platelet-to-lymphocyte ratio; ROC, receiver-operating characteristic.

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Discussion

The current study aimed at analyzing the value of baseline CBC-derived parameters, namely NLR, LMR, and PLR, in predicting the response to end of induction chemotherapy in adult and pediatric newly diagnosed ALL patients.

In our study, while NLR and LMR did not significantly differ between adult and pediatric patients, PLR was significantly more elevated in the pediatric group (P=0.017). This could be attributed to lower platelet counts in the older age groups. Adult ALL patients who achieved complete remission at the end of induction chemotherapy, had a significantly decreased NLR (P<0.001), and a significantly greater LMR (P=0.013), as compared with those who failed to achieve complete remission, while PLR did not significantly differ between both groups. Similarly, pediatric ALL patients who were good responders to induction chemotherapy, had a significantly lower NLR (P=0.001), and a significantly elevated LMR (P=0.014), in addition to a significantly lower PLR (P=0.017), as compared with those who were poor responders.

Multiple pretreatment variables have been linked to the prognosis of ALL; however, with the advance in diagnosis and treatment strategies, only a few risk variables have been identified, the most common of which are age, the initial white blood cell (WBC) level, karyotyping, and immunophenotyping [1]. In ALL, age is a significant prognostic risk factor. The remission rate has been steadily decreasing, from 95% in youngsters to 40–60% in individuals over 60 years old [1]. Moreover, infants less than 1 year old and children more than or equal to 10 years old have considerably lower remission rates than those 1–9 years of age [16]. Also, adults below the age of 30 years have a higher remission rate than those between the ages of 30 and 59 years, and so have a better prognosis than those above the age of 60 years. The differences in disease prognosis in the different age groups have been attributed to the difference in disease biology as well as in tolerance to treatment protocols [1]. A high WBC level at diagnosis is also a poor risk factor, where patients having a WBC count more than or equal to 50 × 10⁹/l show inferior outcomes [16]. Patients with T-cell phenotype have been supposed to have a more aggressive disease course than those with the pre-B phenotype; however, nowadays, both groups can have comparable outcomes with appropriate intensification protocols used in the treatment of T-ALL patients [16]. Recurrent cytogenetic aberrations related to bad prognosis include Philadelphia chromosome-positive ALL, 11q23 rearrangements, and hypodiploidy [16]. Although controversial, other factors have been found to have an adverse impact on the remission rate of ALL; these include male sex, morphological features, low platelet count, and extensive organ involvement [1].

On studying the relation between CBC-derived ratios and the most commonly used prognostic factors in ALL, we found a significant elevation of NLR with elevation in the median age of pediatric patients (P=0.012). High NLR was significantly related to higher WBC count at diagnosis of pediatric ALL patients (P=0.01). Also, owning to the fact that a higher WBC count at ALL presentation is usually accompanied by low platelet counts, PLR was significantly decreased in adult (P<0.001) and pediatric patients (P<0.001), who presented with high initial WBC counts. Higher NLR was significantly related to the presence of t(9;22) in adult (P=0.007) and pediatric patients (P=0.013). Also, the presence of t(9;22) in adult patients was significantly associated with lower LMR (P=0.013). CNS infiltration with malignant lymphoblasts in pediatric patients was significantly associated with higher NLR (P=0.02), lower LMR (P=0.04), and higher PLR (P=0.04).

It has been noted that tumor behavior, both biologically and clinically, could be dramatically affected by malignant cells’ interactions with host immune cells in the tumor microenvironment [17]. Lymphocytes are a major marker of tumor-infiltrating lymphocytes that reflect the host antitumor immune response [18]. Monocytes can be considered as a surrogate marker of tumor-associated macrophages within the tumor microenvironment, where they produce many cytokines that enhance carcinogenesis, angiogenesis, and distant spread [19]. Immunosuppression in certain cancers has been linked to neutrophils, which are a mirror of the systemic inflammatory response to malignancy [20]. In addition, platelet stimulation by systemic inflammation results in platelet aggregation and degranulation, with the release of platelet-derived proangiogenic mediators, which promote tumor proliferation [21]. In context with these facts, it would be theoretical to combine NLR, LMR, and PLR to better reflect the course and prognosis of malignant tumors.

The prognostic impact of CBC-derived ratios has been reported in many hematolymphoid malignancies. In diffuse large B cell lymphoma (DLBCL), Mu et al. [22] showed that a high NLR was a significant predictor of poor overall survival (OS) and progression-free survival (PFS). In addition, the authors found that high pretreatment NLR was associated with many prognostic factors in DLBCL such as old age, advanced Ann Arbor staging, the presence of B symptoms, higher rate of bone marrow involvement, and higher level of lactate dehydrogenase. In contrast, Azuma et al. [23] could not find a prognostic significance for NLR in DLBCL. The authors attributed that to the decrease in the number of tumor-infiltrating lymphocytes in lymphoid malignancies, which are associated with better disease course, and hence, NLR might not accurately reflect the outcome. Lee and Luque-Fernandez [24] discovered that a high LMR at diagnosis of follicular lymphoma was linked to a longer PFS, while a high NLR at recurrence was linked to a shorter PFS. Similarly, Kumagai et al. [25] found that a low LMR was associated with inferior PFS in follicular lymphoma. Haydaroglu Sahin [26] assessed the value of absolute monocyte count, NLR, and PLR in mantle cell lymphoma. According to the authors, absolute monocyte count 0.58 × 10⁹/l, NLR 2.4, and PLR 120.8 were revealed as predictive markers of poor PFS. Chiarenza et al. [27] reported that NLR was lower in healthy controls than in chronic lymphocytic leukemia patients, where NLR was higher in untreated than treated patients, and was not associated with genetic aberrations, or with serum prognostic indicators, such as CD38 and CD49d. Zeng et al. [28] demonstrated poor OS and PFS with high pretreatment NLR in multiple myeloma patients. Furthermore, NLR was associated with IPSS, isotype of light chain, and treatment response. Similarly, Mu et al. [29] discovered a link between elevated NLR and the mortality risk in patients with multiple myeloma. A study by Dogan and Demircioglu [30], considering the predictive value of NLR in Hodgkin’s lymphoma, found that a cutoff value of 4.23 for NLR was used to predict the outcome. In addition, Gu et al. [31] found that low LMR was associated with poorer OS and PFS in Hodgkin’s lymphoma patients. Also, Romano et al. [32] found that NLR was an independent predictor of PFS in Hodgkin’s lymphoma patients, and to build a new predictive method in Hodgkin’s lymphoma, researchers combined PET-2 scan, NLR, and LMR data. In patients with T-lymphoblastic lymphoma, LMR 2.8, NLR 3.3, and PLR 200 were observed to be related with a shorter PFS and OS [33]. The authors offered a score model that included LMR, NLR, and PLR, which they said was far more accurate than the International Prognostic Index score.

There is limited evidence for the predictive value of CBC ratios in myeloproliferative neoplasms. Lucijanic et al. [34] studied the prognostic role of NLR and PLR in primary myelofibrosis. The authors reported that NLR and PLR were lower in healthy individuals than in patients with primary myelofibrosis, where a greater NLR was linked to Janus kinase 2 mutations, wild-type calreticulin, advanced age, elevated TLC and hemoglobin levels, and bigger spleen. In addition, NLR at the time of diagnosis of essential thrombocythemia was found by Zhou et al. [35] to be a predictor of future thrombotic risk.

Meanwhile, the role of CBC-derived ratios has been evaluated in many mature hematological neoplasms; there is limited evidence supporting their value in acute leukemias. Two studies evaluated their prognostic significance in acute myeloid leukemia (AML) patients. Mushtaq et al. [36] investigated the relationship between NLR and treatment response and survival in AML patients who relapsed or were refractory. The authors found that NLR more than or equal to 3 was associated with shorter OS. Another study by Zhang et al. [37] found that de novo non-M3 AML patients with NLR less than 2 had longer OS and DFS. However, the role of CBC-derived ratios has not been explored yet in ALL.

To the best of our knowledge, this is the first study conducted to explore the value of CBC-derived parameters in predicting the response to end of induction chemotherapy in ALL.

The relatively short follow-up duration of the study, together with the little study population and the absence of sufficient cytogenetic and prognostic information in each age group, has been the major limitations for this study. Studies for extended duration of follow-up on larger ALL cohorts, with inclusion of more prognostic factors to explore the independent predictors of treatment response in multivariate analyses, are still required. Also, owing to the fact that while the period following the maintenance phase is related mainly to the behavior of the disease, the time to achieve complete remission following the induction phase depends mainly on the general condition of patients and the treatment tolerance; hence, studies for extended duration of follow-up are still required to study the effect of the disease behavior on CBC ratios, and explore the predictive value of the different ratios on posttreatment OS and PFS in ALL patients.

Conclusions

High NLR and PLR, together with low LMR at ALL diagnosis, could predict resistance to the routinely used induction chemotherapy protocols, and hence could suggest the need for intensification regimens from the start. Calculating LMR, NLR, and PLR from a complete blood picture routinely performed at ALL diagnosis is easy, cheap, rapid, and widely available, which can guide treatment protocols early to improve patients’ prognosis and response to treatment.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

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