Neutrophil-lymphocyte ratio as a predictive biomarker for response to high dose interleukin-2 in patients with renal cell carcinoma
Kuzman et al. BMC Urology
Neutrophil-lymphocyte ratio as a predictive biomarker for response to high dose interleukin-2 in patients with renal cell carcinoma
James A. Kuzman 0
David D. Stenehjem 0 2
Joseph Merriman 0
Archana M. Agarwal 1
Shiven B. Patel 0
Andrew W. Hahn 0
Anitha Alex 0
Dan Albertson 0
David M. Gill 0
Neeraj Agarwal 0
0 University of Utah Huntsman Cancer Institute , Salt Lake City, UT , USA
1 Department of Pathology and ARUP Laboratories, University of Utah , Salt Lake City, UT , USA
2 Department of Pharmacotherapy, College of Pharmacy, University of Utah , Salt Lake City, UT , USA
Background: Immunotherapy with high-dose interleukin-2 (HD-IL2) results in long-term survival in some metastatic renal cell carcinoma (mRCC) patients but has significant acute toxicities. Biomarkers predicting response to therapy are needed to better select patients most likely to benefit. NLR (absolute neutrophil count (ANC)/absolute lymphocyte count (ALC)) is a prognostic and predicative biomarker in various malignancies. The goal was to determine whether NLR can predict response to HD-IL2 in this setting. Methods: Patients with clear cell mRCC treated with HD-IL2 were identified from an institutional database from 2003-2012. Baseline variables for the assessment of IMDC risk criteria, and neutrophil and lymphocyte count, were collected. Best response criteria were based on RECIST 1.0. Wilcoxon rank-sum test was used to evaluate the association of continuous baseline variables with disease control. NLR was stratified by ≤4 or >4. Progression free survival (PFS) and overall survival (OS) were estimated with the Kaplan-Meier method and Cox proportional hazard models assessed associations of NLR with survival. Results: In 71 eligible patients, median NLR in those with an objective response (n = 14, 20%) was 2.3 vs 3.4 in those without (n = 57, 80%, p = 0.02). NLR ≤4 was associated with improved progression free and overall survival. After adjustment for IMDC risk criteria, NLR remained a significant predictor of OS (ANC/ALC ≤4 vs >4, HR 0.41, 95% CI 1.09-5.46, p = 0.03; ANC/ALC continuous variable per unit change in NLR, HR 1.08, 95% CI 1.01-1.14, p = 0.03). Conclusions: In this discovery set, NLR predicts overall survival in patients treated with HD-IL2 in mRCC, and may allow better patient selection in this setting. Data needs validation in an independent cohort.
Renal cell carcinoma; Neutrophil lymphocyte ratio; High dose interleukin-2
The landscape of metastatic renal cell carcinoma (mRCC)
has significantly improved in the last decade as the biology
is better understood and novel treatments are developed.
Targeting various signal transduction molecules has been
shown to be effective in improving progression free and
overall survival. Despite these developments, the prognosis
remains relatively poor, and most die of their disease within
a few years of onset of metastatic disease. High dose
interleukin-2 (HD-IL2) is an approved therapy for select
patients with mRCC. It was one of the first immunotherapy
agents used that resulted in a durable response in a small
population of patients. However, the therapy is associated
with many acute and rare chronic toxicities and requires
experienced management of these acute toxicities in a
critical care setting. Clearly a subset of patients derives benefit
© The Author(s). 2017 Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0
International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and
reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to
the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver
(http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.
from HD-IL2, but at the current time there are no
predicative markers to help identify these patients.
Prognostic models have been used for about a decade to
help stratify patients with mRCC into different risk
categories [1, 2]. However, currently there is not a single
biomarker, which is used in the clinic to predict response to
therapy in patients with mRCC. Current prognostic
models include interval from diagnosis to treatment,
Karnofsky performance status, serum LDH, corrected serum
calcium, and serum hemoglobin. Later absolute neutrophil
count greater than upper limit of normal was found to be
an independent adverse prognostic factor . Recently
addition of NLR has been proposed to be used to help risk
stratify patients with metastatic prostate cancer .
Neutrophil-lymphocyte ratio has been shown to be a
prognostic marker for a wide variety of malignancies
including renal cell carcinoma. It was also previously shown
that increase in absolute lymphocyte number correlated
with objective response in patients undergoing therapy
with interleukin-2. Given that NLR is a crude measure of
immune function it may be useful in predicting response
with immune related treatments such as checkpoint
inhibition or HD-IL2.
This study investigates the role of using NLR as a
predicative marker of response to HD-IL2 in patients with
mRCC. We hypothesized that lower NLR would be
associated with better OR, PFS, and OS in patients treated
All sequential patients with clear cell mRCC treated with
HD-IL2 at the University of Utah Huntsman Cancer
Institute from 2003–2013 were identified. Any patient with
clear cell mRCC with good performance status, and intact
organ function was offered treatment with HDIL-2,
regardless of the prognostic risk category. These are also the
selection criteria currently recommended by the National
Comprehensive Cancer Network (NCCN) guidelines for
treatment with HDIL-2 . Patients were excluded if date
of last follow-up or death was not available or date of
HDIL2 administration was not recorded. Patient age, gender,
Karnofsky performance status, and absolute neutrophil and
lymphocyte values were collected prior to HD-IL2 therapy.
Clear cell histology was confirmed by pathology reports
and number and sites of metastasis prior to HD-IL2 was
recorded. Demographics, as well as clinical and laboratory
were collected. The Institutional Review Board of the
University of Utah approved the study design, and
informed consent was obtained from all patients.
followed by cycle two over 5–6 days. HD-IL2 dosing
comprised the standard regimen of 600,000 IU/kg IV
every 8 h for a total of 14 planned doses per cycle.
Restaging scans were done approximately 8 weeks after
the first course. Thereafter, restaging scans were done
every 12 weeks.
HD-IL2 response criteria
Best response criteria were based on RECIST 1.0. A PR was
defined as a >30% decrease in target lesion size. Progressive
disease was a >20% increase in target lesion size or new
lesion. CR indicated no imaging evidence of disease. Patients
not meeting criteria for PR or progressive disease (PD) were
considered to have stable disease (SD). Patients without
appropriate follow-up between radiographic imaging and
treatment, who were lost to follow-up or died before
determining response were classified as not evaluable (NE) and
grouped with PD for statistical analysis.
The absolute neutrophil and lymphocyte values
immediately prior to initiating HD-IL2 and within 30 days were
used to calculate the NLR ratio. The 75% quartile of
NLR values was used to stratify outcomes. The NLR was
also assessed as a continuous variable.
The primary objective was progression free survival (PFS)
and overall survival (OS) stratified by NLR patients with
mRCC treated with HD-IL2.
Descriptive statistics were used to summarize patient
and treatment characteristics. Kaplan-Meier method
with log-rank tests were used to assess PFS and OS
by HD-IL2 response. PFS was defined as the time
from first HD-IL2 initiation to disease progression,
death, or last follow-up. OS was defined as the time
from first HD-IL2 administration to death or last
follow-up. In the PFS analysis, censoring occurred at
the time of treatment discontinuation if treatment
was discontinued for any other reason than progression or
death. In both the PFS and OS analysis, censoring
occurred at the time of last follow-up in those who had
not progressed or were still alive at the end of the
designated study period. Cox proportional-hazards models
were created with IMDC prognostic risk criteria, gender,
and NLR ratio both as a continuous variable and with a
cut off of at the 75% quartile for PFS and OS. Significance
was set at less than 0.05 for the analysis.
HD-IL2 treatment protocol
One course of HD-IL2 consisted of two cycles – cycle
administered over 5–6 days, followed by one week off,
In 71 eligible patients ANC and ALC values were
obtained and 53 (75%) of the patients were male with a
Fig. 1 Histogram of the NLR at initiation of HD-IL2
median age at diagnosis of metastatic disease of
55 years. IMDC criteria was favorable for 9 (13%),
intermediate for 49 (69%), and poor for 13 (18%)
patients (Table 1). The median NLR was three and the
75% quartile was 4 (Fig. 1). There was a trend for
better objective response rate in patients with NLR < 4
though this was not significant (24% vs 10%, p = 0.32).
There was also a trend for higher complete response
rate in patients with NLR <4 vs ≥4 with CR rates of
18% vs 0% (p = 0.086), respectively (Tables 1 and 2).
NLR ≤4 (versus NLR >4) was associated with
significant improvement in both progression free and overall
Years of age, median (IQR)
Prior Therapy, n (%)
Previous systemic treatment
Number of metastatic disease sites, n (%)
IMDC risk factors, n (%)
survival (Figs. 2a and 1b). Median PFS was improved
by 4.7 months (8.0 vs. 3.3, p = 0.024), and median OS
was improved by 28.4 months (40.9 vs 12.5, p =
0.0003). The role of NLR to predict survival outcomes
after adjustment for IMDC risk criteria was also
investigated. NLR was significant predictor of PFS in
univariate analysis and OS by univariate and OS for
multivariate analysis after correction for IMDC
criteria and sex (Table 3).
This study shows that NLR could be used to help predict
response to HD-IL2. HD-IL2 is a very effective treatment
for a small population of patients with mRCC. Given its
several acute but rare chronic toxicities, a predictive
biomarker in this setting is expected to optimize selection of
patients, who are most likely to derive benefit from therapy.
Low NLR has been associated with a better prognosis for
many different types of malignancies. This is the first report
to suggest that low NLR may be “predictive” of improved
survival outcomes to HD-IL2 in the setting of mRCC.
It is clear that inflammation and immune response play a
pivotal role in neoplastic progression . Indeed novel
treatment strategies targeting the immune system, such as
immune check point inhibitors, have been shown to
improve outcomes and are approved for multiple
malignancies. One of simplest estimations of the balance of
inflammation and immune response is neutrophil/lymphocyte
ratio [6, 7].
NLR has been reported to be a predictive and
prognostic factor for localized renal cell carcinoma [8, 9]. In
a large meta-analysis of 15 cohorts including 3357
patients, NLR predicted poorer OS (hazard ratio = 1.82,
95% CI 1.51-2.19) . Additionally, high preoperative
NLR was associated with larger tumor size, higher
nuclear grade, histologic tumor necrosis, and sarcomatoid
differentiation . Recently, on treatment neutropenia
was shown to be an independent biomarker of favorable
outcome in mRCC, independent of treatment type .
NLR was also recently shown to predict response to
ipilimimab in melanoma patients. In a recent report, lower
NLR ratio predicted improved overall survival in
patients with metastatic melanoma .
Table 3 Univariate and Multivariate analysis results for PFS and OS
Unlike recently developed immunotherapeutic agents,
the mechanism of action of HD-IL2 is not fully understood.
Interleukin-2 is a recombinant protein that has a wide
range of effects on the immune system, including
promoting proliferation and differentiation of CD4(+) T cell into
specific effector T cell subsets, of CD8(+) T cells into
effector T cells, and in to memory cells, but also expansion
of immunosuppressive CD4(+)FOXP3 T regulatory cells in
certain situations .
Historically, HD-IL2 therapy has generally been shown
to have an objective response rate of approximately
1020%, including complete responses in ~10% of patients.
More recently, in a large cohort of patients with mRCC
(n = 391) treated with HDIL-2, a clinical benefit with
HDIL2 was seen in ~50% of patients. In addition to ~20%
patients who experienced objective responses (CR in 9%
and PR in 10%), an additional 32% experienced SD as the
best response to treatment. The survival outcomes were
≤ 4 vs >4
CI, 95% confidence interval
HR hazard ratio, NA not applicable, NLR neutrophil to lymphocyte ratio, OS overall survival, PFS progression-free survival
Italicized p-values are less than 0.05
0.64 (0.33-1.28), 0.67 (1.09-5.46), 0.56 (0.30-1.08), 0.45 (0.22-0.93), p
p = .20 p = .33 p = .08 = .03
2.20 (0.93-6.50), 4.13 (1.23-25.62), 2.02 (0.83-6.06), 4.02 (1.16-25.33), 1.91 (0.78-5.73), 3.42 (1.00-21.48),
p = .08 p = .02 p = .13 p = .03 p = .17 p = 0.05
4.46 (1.56-14.65), 10.43 (2.65-69.34), 3.38 (1.12-11.55), 7.00 (1.68-47.83), 3.23 (1.03-11.30), 5.41 (1.20-38.24),
p = .005 p = .0004 p = .03 p = .006 p = .04 p = .03
similar in those experiencing PR and SD, and were
significantly superior to those who did not experience objective
responses or SD . Although the use of HDIL-2
declined after the approval of targeted therapies starting in
2005, in the recent years with the resurgence of cancer
immunotherapy in general, the use of HDIL-2 has stabilized
and may have picked up . Identification of predictive
biomarkers in this setting is expected to further allow more
patients to experience benefits of HDIL-2 while limiting
toxicities and cost in others. No other therapy in the mRCC
setting has been shown to be associated with durable
longterm response, albeit in a small proportion of patients, in a
consistently reproducible fashion. Absolute number of
peripheral blood lymphocytes have been correlated with
objective response in patients treated with IL-2, interferon
alpha, and histamine. There was no difference in baseline
levels of lymphocytes of responding versus non-responding
patients . This further supports that NLR probably acts
as a better marker to predict response in patients with
mRCC treated with HD-IL2.
One of the main limitations of this study is the
retrospective nature of the study and the relatively small
In conclusion, these hypotheses generating data provides
initial evidence that low NLR may predict improved
survival outcomes in mRCC, and help better selection of
patients for HD-IL2 therapy. Low NLR was associated
with significantly improved PFS and OS with a trend for
improved objective responses with HD-IL2. Data need
further validation in a larger and an independent cohort.
ALC: Absolute lymphocyte count; ANC: Absolute neutrophil count; CI: Confidence
interval; HD-IL2: High-dose interleukin-2; HR: Hazard ratio; mRCC: Metastatic renal
cell carcinoma; NE: No effect; NLR: Neutrophil to lymphocyte ratio; OS: Overall
survival; PD: Progressive disease; PFS: Progression free survival; SD: Stable disease
No further individuals contributed to this manuscript.
This study was supported in whole or in part by funding from the Cancer
Clinical Investigator Team Leadership Award awarded by the National Cancer
Institute through a supplement to P30CA042014.
Availability of data and materials
The dataset supporting the conclusions of the article will be made available
as an additional manuscript file at time of acceptance. We are currently
working to blind the data prior to publication.
JAK and DDS contributed equally to the preparation of this manuscript. JAK,
DDS, and NA developed the hypothesis behind this research. JM, SBP, NA,
and AWH compiled the database used for this research. DDS performed all
statistical analyses. JAK, DMG, DDS, and NA wrote the original manuscript.
AMA performed pathology over reads. JAK, DDS, AMA, AWH, AA, DA, DMG,
and NA made revisions to the final manuscript. All authors read and
approved the final manuscript.
The authors declare that they have no competing interests.
Consent for publication
Ethics approval and consent to participate
The Institutional Review Board of the University of Utah approved the study
design, and informed consent was obtained from all patients.
1. Heng DY , Xie W , Regan MM , et al. Prognostic factors for overall survival in patients with metastatic renal cell carcinoma treated with vascular endothelial growth factor-targeted agents: results from a large, multicenter study . J Clin Oncol . 2009 ; 27 : 5794 - 9 .
2. Mekhail TM , Abou-Jawde RM , BouMerhi G , et al. Validation and extension of the Memorial Sloan-Kettering prognostic factors model for survival in patients with previously untreated metastatic renal cell carcinoma . J Clin Oncol . 2005 ; 23 : 832 - 41 .
3. Templeton AJ , Pezaro C , Omlin A , et al. Simple prognostic score for metastatic castration‐resistant prostate cancer with incorporation of neutrophil‐to‐lymphocyte ratio . Cancer . 2014 ; 120 : 3346 - 52 .
4. Motzer RJ , Jonasch E , Agarwal N , et al. Kidney cancer, version 3 . 2015 . J Natl Compr Canc Netw . 2015 ; 13 : 151 - 9 .
5. Hanahan D , Weinberg RA . Hallmarks of cancer: the next generation . Cell . 2011 ; 144 : 646 - 74 .
6. Guthrie GJ , Charles KA , Roxburgh CS , et al. The systemic inflammation-based neutrophil-lymphocyte ratio: experience in patients with cancer . Crit Rev Oncol Hematol . 2013 ; 88 : 218 - 30 .
7. Zahorec R. Ratio of neutrophil to lymphocyte counts-rapid and simple parameter of systemic inflammation and stress in critically ill . Bratisl Lek Listy . 2000 ; 102 : 5 - 14 .
8. Viers BR , Boorjian SA , Frank I , et al. Pretreatment neutrophil-to-lymphocyte ratio is associated with advanced pathologic tumor stage and increased cancer-specific mortality among patients with urothelial carcinoma of the bladder undergoing radical cystectomy . Eur Urol . 2014 ; 66 : 1157 - 64 .
9. de Martino M , Pantuck AJ , Hofbauer S , et al. Prognostic impact of preoperative neutrophil-to-lymphocyte ratio in localized nonclear cell renal cell carcinoma . J Urol . 2013 ; 190 : 1999 - 2004 .
10. Hu K , Lou L , Ye J , et al. Prognostic role of the neutrophil-lymphocyte ratio in renal cell carcinoma: a meta-analysis . BMJ Open . 2015 ; 5 : e006404 .
11. Soerensen AV , Geertsen PF , Christensen IJ , et al. A five-factor biomarker profile obtained week 4-12 of treatment for improved prognostication in metastatic renal cell carcinoma: Results from DARENCA study 2 . Acta Oncologica . 2016 ; 55 ( 3 ): 341 - 8 .
12. Ferrucci P , Gandini S , Battaglia A , et al. Baseline neutrophil-to-lymphocyte ratio is associated with outcome of ipilimumab-treated metastatic melanoma patients . Br J Cancer . 2015 ; 112 : 1904 - 10 .
13. Boyman O , Sprent J. The role of interleukin-2 during homeostasis and activation of the immune system . Nat Rev Immunol . 2012 ; 12 : 180 - 90 .
14. Stenehjem DD , Toole M , Merriman J , et al. Extension of overall survival beyond objective responses in patients with metastatic renal cell carcinoma treated with high-dose interleukin-2. Cancer Immunol Immunother . 2016 ; 65 : 941 - 9 .
15. Allard CB , Gelpi-Hammerschmidt F , Harshman LC , et al. Contemporary trends in high-dose interleukin-2 use for metastatic renal cell carcinoma in the United States . Urol Oncol . 2015 ; 33 :496.e11-6.
16. Donskov F , Bennedsgaard K , von der Maase H , et al. Intratumoural and peripheral blood lymphocyte subsets in patients with metastatic renal cell carcinoma undergoing interleukin-2 based immunotherapy: association to objective response and survival . Br J Cancer . 2002 ; 87 : 194 - 201 .