Predictive Role of the Neutrophil-to-Lymphocyte Ratio in Patients with Advanced Hepatocellular Carcinoma Receiving Sorafenib

We read the recently published article entitled ‘The Blood Neutrophil-to-lymphocyte Ratio Predicts Survival in Patients with Advanced Hepatocellular Carcinoma Receiving Sorafenib’ by Zheng et al. (2013), with interest. In the mentioned article authors aimed to determine the prognostic significance of the blood neutrophil-to-lymphocyte ratio (NLR) in patients with advanced hepatocellular carcinoma (HCC) who received sorafenib monotherapy. At the end of the article, the authors concluded that elevated NLR is associated with worse overall survival (OS) and time to progression (TTP) for the patients with advanced HCC receiving sorafenib monotherapy. We would like to thank the authors for their contribution. NLR is a readily available and inexpensive laboratory marker which is used to measure systemic inflammation. In previous researches, it was shown that renal and/ or hepatic failure, acute coronary syndromes, valvular heart diseases, diabetes mellitus, metabolic syndrome, essential hypertension, thyroid functional abnormalities, inflammatory diseases and many drugs may potentially affect the NLR (Balta et al., 2013; Karaman et al., 2013; Stotz et al., 2013). Thus, it would be more relevant if Zheng et al. had mentioned these NLR-affecting factors while evaluating the prognostic significance of the NLR in patients with advanced HCC receiving sorafenib. And also, as a limitation of study, it would be more objective if a large number of patients were included in the research. We believe that the findings of Zheng et al. (2013) will lead to further studies concerning predicting role of NLR in patients with HCC. Besides NLR, age, sex, tumor size, tumor number, capsule state, cell differentiation, location of tumor, presence of major blood vessel invasion, functional status of the liver (synthetic function), existence of portal hypertension/cirrhosis, TNM stage are previously described prognostic factors of hepatocellular carcinoma (Qin and Tang, 2002; Mulcahy, 2005; Song et al., 2011). Thus, it should be clearly kept in mind that NLR itself alone without other prognostic variables may not secure true information about the prognosis advanced HCC. Finally we concluded that, in terms of NLR’s predictive role in HCC, NLR should be evaluated with other prognostic variables as mentioned above. LETTER to the EDITOR