3.1 Patient characteristics
A total of 93 patients were included in this study. The age of 59 patients at the time of diagnosis was greater than or equal to 18 months, and the other 34 patients were less than 18 months. The tumor size was less than 5 cm in 20 cases and more than 5 cm in 73 cases.The end-point follow-up time of dead patients was the time of death. After a definite pathological diagnosis, there were 73 cases of NB and 20 cases of GNB.
3.2 ROC analysis
ROC analysis(Figure 1) was performed and the Youden Index was calculated to determine the best cut-off point with the highest sensitivity and specificity. Ferritin was 123.5, NLR was 0.84, PLR was 144.1, and SII was 488.9 ,while the results of LMR were not satisfactory: P=0.065. Thus LMR would not be considered in the following analysis.
According to the sensitivity and specificity(Figure 1), For each index, patients were divided into two groups for further analysis :[ Ferritin<123.5 (low) and Ferritin≥123.5 (high) NLR<0.84 (low) and NLR ≥0.84 (high); PLR< 144.1 (low) and PLR≥144.1 (high); SII≤ 488.9 (low) and SII≥488.9 (high)]. Due to the inspection standard of our hospital, We regard CRP ≥ 8 as the elevated group and CRP < 8 as the normal group.
3.3 Survival Analysis for Overall Neuroblastoma Patients
The mean follow-up time for this study was 54.2months. In this cohort, the median OS was 33months, while the 1, 3, and 5-years overall survival rate was 87.10%, 66.67%, and 64.52%, In addition to these inflammation biomarkers, clinical data such as the age of diagnosis, tumor size, and INSS stage were also included in the analysis(Figure2 A-J).
The median survival time of patients in the high NLR, PLR, and SII group was 29.5,27.5,and 29 months, and it in the low NLR, PLR, and SII group was 40,36,and 37 months respectively. Using the log-rank test, the low NLR, PLR, and SII group statistically had better long-term overall
survival outcome than the high NLR, PLR, and SII group respectively (Figure2 G, H, I).
The OS of patients with elevated CRP levels was significantly lower than that of patients with normal CRP levels (Figure 2A, P<0.001). Patients with higher NLR, PLR, SII, and ferritin values had significantly worse OS than those with lower NLR(Figure 2G, P=0.003), PLR(Figure 2H, P<0.001), SII(Figure 2I, P=0.002) and ferritin(Figure 2D, P<0.001) value.
Univariate survival analysis showed that Age (HR=4.271; 95% CI=1.638-11.137;p=0.003),INSS stage(HR=7.363; 95% CI=1.760-30.796;p=0.006), Tumor size(HR=4.876; 95% CI=1.165-20.402;p=0.03),Shimada(HR=17.681; 95% CI=4.166-75.048;p<0.001),N-MYC(HR=4.664; 95% CI=2.224-9.780;p<0.001),CRP(HR=5.902; 95% CI=2.839-12.269;p<0.001),Ferritin(HR=11.223; 95% CI=4.137-30.449;p 0.001),NLR(HR=3.783; 95% CI=1.458-9.817;p=0.006),PLR(HR=3.435; 95% CI=1.702-6.931;p=0.001) and SII(HR=2.871; 95% CI=1.425-5.783;p=0.003) were significantly associated with OS of the patients.
Then, multivariate survival analysis was performed on the all variables above, the results showed that ferritin(HR=7.184; 95% CI=2.005–25.748;p=0.002) and Shimada(HR=32.868; 95% CI=2.907–371.653;p=0.005) was significantly associated with OS of NB patients(Table 1).Next, we took the seven indicators of size, age, CRP, ferritin, NLR, PLR and SII as a group for multivariate analysis, which can be obtained at the initial diagnosis. We found that only ferritin (HR =8.532; 95%CI=2.412-30.179; p=0.001) was significantly associated with OS of NB patients.
Table 1
Univariate and Multivariate Cox Regression Analyses for OS of the patients with NB
Variables
|
Total No. (Death No.)
|
Univariate Analysis
|
Multivariate Analysis
|
HR(95% CI)
|
P value
|
HR(95% CI)
|
P value
|
Age
|
≥18 months
<18 months
|
59(28)
34(5)
|
4.271(1.638-11.137)
/
|
0.003
/
|
|
|
INSS stage
|
I and II
III and Ⅳ
|
27(2)
66(31)
|
/
7.363(1.760-30.796)
|
/
0.006
|
|
|
Tumor size
|
≥5cm
<5cm
|
73(31)
20(2)
|
4.876(1.165-20.402)
/
|
0.03
/
|
|
|
Shimada
|
FH
uFH
|
39 (2)
50 (29)
|
/
17.681(4.166-75.048)
|
/
<0.001
|
32.868(2.907-371.653)
|
0.005
|
N-MYC
|
amplification
non-amplified
|
15 (12)
75 (19)
|
4.664(2.224-9.780)
/
|
<0.001
/
|
|
|
CRP
|
≥8 mg/L
<8 mg/L
|
27(21)
66(12)
|
5.902(2.839-12.269)
/
|
<0.001
/
|
|
|
Ferritin
|
≥123.5ng/ml
<123.5ng/ml
|
35(24)
44(6)
|
11.223(4.137-30.449)
/
|
<0.001
/
|
5.678(1.521-21.200)
|
0.01
|
NLR
|
≥ 0.84
<0.84
|
58(28)
35(5)
|
3.783(1.458-9.817)
/
|
0.006
/
|
|
|
PLR
|
≥144.1
<144.1
|
32(20)
61(13)
|
3.435(1.702-6.931)
/
|
0.001
/
|
|
|
SII
|
≥488.9
<488.9
|
35(20)
58(13)
|
2.871(1.425-5.783)
/
|
0.003
/
|
|
|
Tumor size
Age
CRP
Ferritin
NLR
PLR
SII
|
≥5cm
<5cm
≥18 months
<18 months
≥8 mg/L
<8 mg/L
≥123.5ng/ml
<123.5ng/ml
≥ 0.84
<0.84
≥144.1
<144.1
≥488.9
<488.9
|
|
|
|
8.532(2.412-30.179)
|
0.001
|
Abbreviations: HR, hazard ratio; CI, confifidence interval; INSS, International Neuroblastoma Staging System; NLR, neutrophil to lymphocyte ratio; PLR, platelet to lymphocyte ratio;; SII, system inflflammation index; CRP, C-reactive protein.
3.4 Construction of the nomogram for 3、5‑year OS
Based on the results of COX regression analyses, all the predictors of OS in the whole study were integrated into the nomograms(Figure 3)illustrates the predictive nomograms for the 3、5‑year OS. By adding the score of each selected variable, the individual survival probability of the patient can be easily calculated. Each variable is projected upward to the value of the small scale (point) to obtain the score of each parameter. The lower the score, the worse the prognosis. The nomograms demonstrated good predictive performance for OS, with a C-index of 0.731. Because the expected nomogram was predicted based on the time point of the first diagnosis and the determination of INSS stage ,Shimada ,and NMYC amplification or not usually required pathological results, the nomogram was not included in these indicators. Under the guidance of a nomogram, we could judge the prognosis of patients at the first hospitalization according to the different characteristics of each patient.
In the prediction model, for the variable “Age ”,”1” meant the patient was 18 months or older at the time of diagnosis; for the variable “CRP”,”1” meant the patient's serum CRP level was greater than or equal to 8mg/L; for the variable “size”, ”1” meant the patient's tumor diameter was greater than or equal to 5cm.For the four metrics, Ferritin, NLR, PLR and SII, the scores can be calculated by matching the specific values to the scale.By simple numerical addition, we can predict the three-year and five-year survival probability of patients with neuroblastoma.
As shown in Figure 4,the calibration curves indicated good agreement between the predicted and observed probabilities.