Introduction
Neoadjuvant systemic treatment (NST) is a standard
approach of the early breast cancer (BC). Pathological
complete response (pCR) is a surrogate marker for the best prognosis in operable BC. Multiple markers
predict NST responses, including tumor intrinsic subtype
(Luminal A, Luminal B/Her2 positive, Her2 negative,
Her2 enriched, and triple negative), Ki-67 score,
tumor size, PD-L1 expression, and tumor-infiltrating lymphocytes (TILs).[] However, these factors are insufficient
to predict pCR, and the need for additional
predictive factors is a concerning issue.
The immune system of the host is crucial in BC.[]
A high neutrophile count has been linked to carcinogenesis
and enhanced angiogenesis.[] Although T
lymphocytes play a crucial role in inhibiting tumor formation,
neutrophils inhibit cytotoxic T lymphocytes
carrying CD8 antigen and promote the development
of metastasis.[,] In addition, a high neutrophile/lymphocyte
ratio (NLR) was found to be associated with
chemotherapy resistance.[,] This raised the question
of whether the NLR could be used to predict pCR
in clinical care. Numerous studies have investigated
whether NLR is predictive or prognostic, with contradictory
findings.[-]
In BC, the metabolic parameters of 18F-fluorodeoxyglucose
positron emission tomography (FDGPET)
can provide indirect information about the biology
of the tumor. One of the metabolic parameters of
FDG-PET, the maximum standardized uptake value
(SUVmax), was discovered to be associated with poor
prognostic tumor characteristics, including large tumor
size, axillary node involvement, high histological
grade, and TNBC.[<,r12>] Recent evidence demonstrated
that elevated SUV in early BC was indicative
of the overexpression of specific genes.[] Increased
SUVmax at baseline was also found to be associated with
pCR in the neoadjuvant setting.[,]
It is still unknown to what extent NLR reflects the
host immune system and whether SUVmax reflects the
aggressiveness of the tumor. Therefore, we conducted
a retrospective study to evaluate the role of NLR and
SUVmax as predictors of pCR.
Methods
Patients
We retrospectively analyzed of 99 patients with invasive
BC who were treated with NST at the Cerrahpaşa
Medical Faculty between 2016 and 2020. Bilateral
BCs, inflammatory BCs, and male BCs were all excluded.
Patients" characteristics age, menopausal status,
tumor characteristics (clinical T [cT] and clinical
N [cN] stage, histopathological characteristics), and
treatments all recorded.
All patients underwent FDG-PET/BT previous
to NST. SUVmax was calculated in the primary tumor.
The baseline NLR was calculated as the neutrophil
count divided by the lymphocyte count obtained from the blood count performed within 2 weeks before
starting NST. SUVmax and NLR were separated
into low and high categories based on their median
values. The median values for NLR and SUVmax were
1.9 and 12, respectively.
Surgical specimens' formalin-fixed, paraffin-embedded
tissues were immunohistochemically stained
for estrogen receptor (ER), progesterone receptor (PR),
Her2, and ki-67. ER and PR positivity were defined as a
cutoff value of ≥1%. Fluorescent or chromogenic in situ
hybridization was performed for intermediate Her2
scores (2+). According to the definition of Goldhirsch
et al.,[16] we used clinicopathological parameters to
classify the breast cancer subtypes as follows: Luminal
A (ER +, PR ±, Her2-, Ki-67 <20%), luminal B/Her2-
negative (ER + , PR ± , Her2-, Ki-67 ≥ 20%), luminal
B/Her2-positive (ER +, PR ±, Her2 +), Her2-enriched
(ER-, PR-, Her2 +), and TNBC (ER-, PR-, Her2-). pCR
was defined as no evidence of invasive tumor both
within the axilla and breast (ypT0/is, ypN0).
The study was approved by the Institutional Ethical
Review Board and the need for informed consent was
waived due to the retrospective nature of this study.
Statistical Analysis
Patients" characteristics, including pCR, baseline SUV
max, and baseline NLR, were compared using the
Chi-square test for categorical data and the t-test for
continuous data. For comparing ordinal variables,
Mann-Whitney U-tests were conducted. Using a binary
logistic regression model, univariable and multivariable
analyses of clinicopathological factors associated
with pCR were performed. Odds ratios (ORs)
and 95% confidence intervals (CIs) with two-sided p
values were given. The statistical analyses were conducted
using SPSS version 23 and statistical significance
was defined as p<0.05.
Results
A total of 99 patients were evaluated. Median age was
46 (range 24-73). The majority of patients (n=54,
54.5%) were found to be premenopausal, while
11.5% were perimenopausal and 34.3% were postmenopausal.
The majority of patients (n=50, 50.5%)
had cT2 at initial clinical staging, while 13 patients
(13.1%) had cT1, 15 patients (15.2%) had cT3, and 21
patients (21.2%) had cT4. Patients with cN2 were the
most common (n=46, 46.5%), followed by those with
cN1 (30.3%) and cN3 (23.25%). There were no cN0
tumors in our cohort. Twenty-seven patients (27.3%) were diagnosed with luminal A tumors, 25 patients
(25.3%) with luminal B/Her2-negative tumors, 17 patients
(17.2%) with luminal B/Her2-positive tumors,
14 patients (14.1%) with Her2-enriched tumors, and
16 patients (16.2%) with TNBC. Neoadjuvant chemotherapy
was administered to all patients, typically
including taxane+anthracycline and/or cyclophosphamide,
and trastuzumab and pertuzumab were administered
additionally to all Her2-positive patients.
The baseline characteristics of all patients are shown in Table 1. Overall, 36 patients (36.4% of the total)
achieved pCR, while 63 patients (63.6% of the total)
did not. 2 (5.6%) luminal A patients, 11 (30.6%) luminal
B/Her2-negative patients, 10 (27.8%) luminal
B/Her2-positive patients, 8 (22.2%) Her2 enriched
patients, and 5 (13.9%) TNBC patients achieved pCRp.
Table 1 Baseline characteristics of patients according to NLR
When we compared patients with low and high
NLR (with a cutoff of 1.9), we found that high NLR
was associated with higher SUVmax (p=0.021). There
were no another significant differences between groups according to NLR (Table 1). NLR was also
not related to pCR in our study (p=0.939). The median
NLR was 1.85 for patients with pCR and 1.90 for
those without pCR (p=0.392) (Fig. 1a).
Our study's coprimary endpoint was to examine
whether or not there is a correlation between SUVmax
at baseline and pCR. High SUVmax at baseline (cutoff
of 12) was associated with worse prognostic factors,
including larger tumor size, high grade, negative ER
and TNBC, and high NLR (Table 2). High SUVmax
was also significantly associated with pCR (p=0.003).
Patients with PCR had a higher median baseline
SUVmax than those with residual tumors (14.5 vs. 10,
p=0.023) (Fig. 1b).
Table 2 Baseline characteristics of patients according to SUVmax
Fig. 1. Comparison of patients as pCR and non-pCR. (a)
According to baseline median NLR and (b) according
to baseline median SUVmax.
NLR: Neutrophile/lymphocyte ratio.
We performed univariable and multivariable
analyses for clinicopathological factors that were associated
with pCR. Baseline SUVmax, histologic grade,
Ki-67, and tumor subtype were the factors that were
significantly associated with pCR in univariable analysis
(Table 3). High baseline SUVmax was significantly
associated with high pCR in univariable analysis (OR
3.70; 95% CIs 1.52-8.96; p=0.004) and it remained a
significant factor in a multivariable analysis adjusted
for other clinicopathological factors (OR 3.48; 95%
CIs 1.20-10.08; p=0.021). High histologic grade was
also associated with pCR in both univariable and multivariable
analyses; for univariable analysis (OR 2.80;
95% CIs 1.20-6.51; p=0.017) and multivariable analysis
(OR 3.05; 95% CIs 1.20-9.15; p=0.046). Among the
tumor subtypes, only the luminal B/Her2 (+) subtype
remained significant in multivariable analysis (OR =
9.89; 95% CI=1.21-80.70; p=0.032).
Table 3 ORs and 95% CIs for pCR
Discussion
The results of our study showed that baseline high
SUVmax was associated with poor prognostic features.
Patients with a high SUVmax at baseline had larger tumors,
more ER negativity, a higher tumor grade, and
more TNBC and Her2 enriched type. Similarly, these
findings corroborated with previous studies that increased
uptake show aggressive tumor features.[,]
Despite these unfavorable prognostic characteristics,
our results showed that tumors with a high SUVmax at
baseline had significantly more pCR both univariable
and multivariable analyses. In support of our findings,
baseline tumor metabolism as assessed by FDG PET/
CT has also been shown to be associated with the final
histopathologic status after neoadjuvant chemotherapy,
with higher SUVmax values for pCR.[]
Another study demonstrated a correlation between
baseline FDG uptake and TILs levels in patients with
TNBC and Her2 positive BC.[19] Although TNBC
(30%) and Her2+ (≈20%) BC patients have significantly
higher proportions of primary tumors with high
TILs than luminal-like carcinoma (13%), increased
TILs in the tumor have been found to predict NST responses
for all BC subtypes.[] In a systemic review of
15 studies, it has also been found that TNBC is filtrated
by the highest incidence of TILs, with a 20% prevalence
of lymphocyte-predominant breast cancer (LPBC), followed
by Her2+ (either hormone receptor positive or
negative) BC (LPBC: 16%), with the luminal-like BC
subgroup (HR+/Her2-) showing the lowest degree of
TIL infiltration as well as the lowest incidence of LPBC
(6%).[] Given that tumors with a high SUVmax are
more frequently Her2 positive and TNBC, it is possible
that a high SUVmax is associated with an inflammatory
response and that this is indicative of a pCR.
We found no correlation between baseline NLR
and pCR in this study. Although several previous reports
have suggested that high NLR associated with
low pCR,[,] some studies did not detect association
between NLR and pCR.[,] In contrast, a number
of studies have linked a high NLR to pCR.[] Some
studies found that NLR was only significantly associated with pCR in patients with TNBC, but not in those
who were HR+/Her2.[] We were unable to perform
subgroup analyses due to an insufficient number of patients.
However, although NLR is a reliable prognostic
factor in patients with localized BC receiving adjuvant
chemotherapy, the results are less conclusive for patients
with localized disease receiving NST.[]
When we compared patients based on their baseline
NLR, baseline characteristics were comparable with the
exception of baseline SUVmax. We found that patients with a greater SUVmax had a greater NLR. This may be
due to differences in inflammatory response. Although
there was a correlation between high SUVmax and high
NLR, there was no correlation between NLR ratio and
pCR. We attributed this to the fact that NLR is not a
reliable biomarker for pCR. Adjuvant and neoadjuvant
cohorts have investigated the prognostic value of various
T-cell subpopulations. Multiple retrospective series
of unselected BC patients receiving neoadjuvant chemotherapy
revealed an association between pCR rates and high levels of total T-cells (CD3+) as well as high
infiltration of T helper (CD4+) and cytotoxic (CD8+)
subsets.[] It led us to suppose that NLR in patients
receiving NST was unreliable and non-specific, as it was
unable to reflect the increasing subpopulation of T-cells
in the tumor. Obviously, all of these speculations need
to be clarified by further and comprehensive research.
Our study has several limitations: First, its retrospective
nature; and second, its small sample size. We were
unable to conduct subgroup analyses. Moreover, we were
unable to analyze the TILs. Although most patients received
anthracycline and taxane-based NST, Her2-positive
patients received Her2-targeted therapy. This may
have influenced the pCR rate. There is a need for prospective
studies with larger patient populations receiving the same NST and pathological analysis of TILs. At present,
the NLR and baseline SUVmax cutoff values have not been
established. Since there is no validated value, the median
value was used as the threshold for both. However, these
values should be supported by additional research.
Conclusion
Our study results that baseline SUVmax is a predictor of
pCR, patients with early BC who received NST. Our
study also showed that baseline SUVmax is corelated with
poor tumor characteristics. Although tumor aggressiveness
is associated with a poor prognosis, the high pCR
rate in tumors with increased SUVmax suggests that this
is associated with an increased inflammatory response rather than poor prognostic characteristics. To confirm
our findings, it is necessary to conduct additional research
with larger patient populations and to investigate
mechanisms that may have caused this condition, such
as TILs. Finally, our data showed that NLR is not a predictor
of pCR in patients treated with NST; however, due
to the population heterogeneity and/or small sample
size of our study, additional clinical trials are necessary.
Peer-review: Externally peer-reviewed.
Conflict of Interest: All authors declared no conflict of interest.
Ethics Committee Approval: The study was approved by
the İstanbul University-Cerrahpaşa Clinical Research Ethics
Committee (no: 691992, date: 22/05/2023).
Financial Support: The authors declare that no funds,
grants, or other support were received during the preparation
of this manuscript.
Authorship contributions: Concept - G.A.Ş., H.T.; Design
- G.A.Ş., H.T.; Supervision - G.A.Ş., H.T.; Funding - G.A.Ş.,
H.T.; Materials - G.A.Ş., H.T.; Data collection and/or processing
- G.A.Ş., H.T.; Data analysis and/or interpretation
- G.A.Ş., H.T.; Literature search - G.A.Ş., H.T.; Writing -
G.A.Ş., H.T.; Critical review - G.A.Ş., H.T.
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