Naples Prognostic Score as an Independent Predictor of Survival Outcomes for Resected Locally Advanced Non-Small Cell Lung Cancer Patients After Neoadjuvant Treatment

Figures & data

Figure 1 The flow chart of patient selection process.

Abbreviation: NSCLC, non-small cell lung cancer.

Table 1 Association of the NPS with LA-NSCLC Patient Clinicopathological Characteristics

Characteristics	NPS				P value
	Total (n=165)	Group 0 (n=35)	Group 1 (n=108)	Group 2 (n=22)
Age (years)					0.046
<60	83(50.3%)	24(68.6%)	50(46.3%)	9(40.9%)
≥60	82(49.7%)	11(30.4%)	58(53.7%)	13(59.1%)
Gender					0.533
Female	91(55.2%)	17(48.6%)	60(55.6%)	14(63.6%)
Male	74(44.8%)	18(51.4%)	48(44.4%)	8(36.4%)
Smoking history					0.004
No	85(51.5%)	22(62.9%)	53(49.1%)	10(45.5%)
Yes	80(48.5%)	13(37.1%)	55(50.9%)	12(54.5%)
ECOG score					0.005
0	70(42.4%)	23(65.7%)	41(38.0%)	6(27.3%)
1	95(57.6%)	12(34.3%)	67(62.0%)	16(72.7%)
BMI (kg/m2)					0.805
≥18.5	83(49.7%)	19(54.3%)	54(50.0%)	10(45.5%)
<18.5	82(50.3%)	16(45.7%)	54(50.0%)	12(54.5%)
Pathological type					0.451
AD	100(60.6%)	21(60.0%)	63(58.3%)	16(72.7%)
SCC	65(39.4%)	14(40.0%)	45(41.7%)	6(27.3%)
Differentiation					0.367
Well / Moderate	72(43.6%)	14(40.0%)	51(47.2%)	7(31.8%)
Poor	93(56.4%)	21(60.0%)	57(52.8%)	15(68.2%)
TNM stage					0.169
IIIA	130(78.8%)	31(88.6%)	84(77.8%)	15(68.2%)
IIIB	35(21.2%)	4(11.4%)	24(22.2%)	7(31.8%)
Surgery approach					0.788
Thoracotomy	86(52.1%)	19(54.3%)	57(52.8%)	10(45.5%)
VAST	79(47.9%)	16(45.7%)	51(47.2%)	12(54.5%)
Neoadjuvant treatment					0.017
Chemotherapy	109(66.1%)	30(85.7%)	67(62.0%)	12(54.5%)
Chemoradiotherapy	56(33.9%)	5(14.3%)	41(38.0%)	10(45.5%)
CEA Levels					0.844
≤5 ng/mL	57(34.5%)	11(31.4%)	39(36.1%)	7(28.0%)
>5 ng/mL	108(65.5%)	24(68.6%)	69(63.9%)	15(72.0%)
Postoperative complications					0.360
Yes	87(52.7%)	15(42.9%)	61(56.5%)	11(50.0%)
No	78(47.3%)	20(57.1%)	47(43.5%)	11(50.0%)

Abbreviations: NPS, Naples Prognostic Score; LA-NSCLC, locally advanced non-small cell lung cancer; Group 0, patients with a NPS score of 0; Group 1, patients with a NPS score of 1 or 2; Group 2, patients with a score of 3 or 4; ECOG, Eastern Cooperative Oncology Group; BMI, body mass index; SCC, squamous cell carcinoma; AD, adenocarcinoma; VATS, video-assisted thoracoscopic surgery; CEA, carcinoembryonic antigen.

Figure 2 Kaplan-Meier curves for OS in patients with LA-NSCLC according to Alb (A), TC (B), PNI (C), NLR (D), LMR (E) and SIS (F).

Abbreviations: OS, overall survival; LA-NSCLC, locally advanced non-small cell lung cancer; Alb, serum albumin concentration; TC, total blood cholesterol; PNI, prognostic nutritional index; NLR, neutrophil‐to‐lymphocyte ratio; LMR, lymphocyte‐to‐monocyte ratio; SIS, the systemic inflammation score.

Figure 3 Kaplan-Meier curves for PFS in patients with LA-NSCLC according to Alb (A), TC (B), PNI (C), NLR (D), LMR (E) and SIS (F).

Abbreviations: DFS, disease-free survival difference; LA-NSCLC, locally advanced non-small cell lung cancer; Alb, serum albumin concentration; TC, total blood cholesterol; PNI, prognostic nutritional index; NLR, neutrophil‐to‐lymphocyte ratio; LMR, lymphocyte‐to‐monocyte ratio; SIS, the systemic inflammation score.

Table 2 ROC Analysis of Inflammatory or Nutritional-Related Indicators

Variables	OS			PFS
	AUC	95% CI	P value	AUC	95% CI	P value
Alb	0.546	0.457–0.635	0.316	0.586	0.495–0.676	0.082
TC	0.637	0.552–0.722	0.003	0.625	0.536–0.714	0.011
NLR	0.530	0.440–0.620	0.516	0.558	0.465–0.651	0.241
LMR	0.582	0.493–0.672	0.075	0.586	0.490–0.682	0.082
BMI	0.510	0.420–0.601	0.824	0.505	0.408–0.602	0.918
PNI	0.551	0.463–0.640	0.267	0.547	0.453–0.640	0.346
SIS	0.604	0.516–0.692	0.024	0.639	0.549–0.730	0.005
NPS	0.704	0.621–0.787	<0.001	0.734	0.649–0.820	<0.001

Abbreviations: OS, overall survival; PFS, progression-free survival; Alb, albumin; TC, total cholesterol; NLR, neutrophil‐to‐lymphocyte ratio; LMR, lymphocyte‐to‐monocyte ratio; BMI, body mass index; PNI, prognostic nutritional index; SIS, the systemic inflammation score; NPS, Naples Prognostic Score.

Figure 4 Correlation analysis between Alb and NLR (A), Alb and LMR (B), TC and NLR (C), TC and LMR (D).

Abbreviations: Alb, serum albumin concentration; TC, total blood cholesterol; NLR, neutrophil‐to‐lymphocyte ratio; LMR, lymphocyte‐to‐monocyte ratio.

Figure 5 ROC curves of NPS for predicting OS (A) and DFS (B).

Abbreviations: ROC, receiver operator characteristic curve; OS, overall survival; DFS, disease-free survival.

Figure 6 Kaplan-Meier survival curves in patients with LA-NSCLC. (A) OS based on NPS groups; (B) DFS based on NPS groups.

Abbreviations: OS, overall survival; DFS, disease-free survival.

Figure 7 Kaplan-Meier survival curves in patients with LA-NSCLC according to the TNM stage. (A and B) OS and DFS based on NPS groups in stage IIIA; (C and D) OS and DFS based on NPS groups in stage IIIB.

Abbreviations: OS, overall survival; DFS, disease-free survival.

Table 3 Univariate and Multivariate Analyses of OS

Characteristics	Univariate Analysis		Multivariate Analysis
	HR (95% CI)	P value	HR (95% CI)	P value
Age (years)		0.033		0.004
<60	Reference		Reference
≥60	1.542(1.036–2.294)		2.007(1.256–3.208)
Gender		0.753
Female	Reference
Male	0.939(0.633–1.392)
Smoking history		0.161
No	Reference
Yes	1.323(0.894–1.958)
ECOG score		0.012		0.103
0	Reference		Reference
1	1.722(1.128–2.629)		1.457(0.927–2.291)
BMI (kg/m2)		0.283
≥18.5	Reference
<18.5	1.239(1.838–1.832)
Pathological type		0.982
AD	Reference
SCC	1.004(0.674–1.496)
Differentiation		0.308
Well/Moderate	Reference
Poor	1.228(0.828–1.821)
TNM stage		0.007		0.278
IIIA	Reference		Reference
IIIB	1.797(1.172–2.756)		1.276(0.821–1.986)
Surgery approach		0.044		0.001
Thoracotomy	Reference		Reference
VAST	0.668(0.451–0.989)		0.455(0.287–0.723)
Neoadjuvant treatment		0.086
Chemotherapy	Reference
Chemoradiotherapy	1.420(0.951–2.120)
CEA Levels		0.489
≤5 ng/mL	Reference
>5 ng/mL	0.866(0.577–1.300)
Postoperative complications		0.338
Yes	Reference
No	0.825(0.557–1.222)
PNI		0.238
>49	Reference
≤49	1.325(0.830–2.114)
SIS
0	Reference		Reference
1	1.420(0.909–2.219)	0.123	0.946(0.565–1.585)	0.834
2	2.051(1.081–3.891)	0.028	0.428(0.134–1.363)	0.151
NPS
Group 0	Reference		Reference
Group 1	2.771(1.335–5.749)	0.006	2.591(1.141–5.881)	0.023
Group 2	5.025(2.196–11.501)	<0.001	8.744(2.505–30.517)	0.001

Note: The variables in univariate analysis (P values <0.05) were entered into the multivariate analysis.

Abbreviations: OS, overall survival; ECOG, Eastern Cooperative Oncology Group; BMI, body mass index; SCC, squamous cell carcinoma; AD, adenocarcinoma; VATS, video-assisted thoracoscopic surgery; CEA, carcinoembryonic antigen; PNI, prognostic nutritional index; SIS, the systemic inflammation score; NPS, Naples Prognostic Score.

Table 4 Univariate and Multivariate Analyses of DFS

Characteristics	Univariate Analysis		Multivariate Analysis
	HR (95% CI)	P value	HR (95% CI)	P value
Age (years)		0.025		0.002
<60	Reference		Reference
≥60	1.523(1.053–2.201)		1.958(1.282–2.990)
Gender		0.999
Female	Reference
Male	1.000(0.693–1.442)
Smoking history		0.375
No	Reference
Yes	1.179(0.819–1.698)
ECOG score		0.001		0.028
0	Reference		Reference
1	1.875(1.274–2.759)		1.621(1.054–2.493)
BMI (kg/m2)		0.508
≥18.5	Reference
<18.5	1.131(10.785–1.629)
Pathological type		0.470
AD	Reference
SCC	1.146(0.791–1.660)
Differentiation		0.619
Well /Moderate	Reference
Poor	1.098(0.760–1.585)
TNM stage		0.002		0.150
IIIA	Reference		Reference
IIIB	1.878(1.249–2.825)		1.340(0.900–1.998)
Surgery approach		0.007		<0.001
Thoracotomy	Reference		Reference
VAST	0.607(0.421–0.875)		0.410(0.268–0.629)
Neoadjuvant treatment		0.258
Chemotherapy	Reference
Chemoradiotherapy	1.244(0.852–1.818)
CEA Levels		0.992
≤5 ng/mL	Reference
>5 ng/mL	1.002(0.682–1.470)
Postoperative complications		0.653
Yes	Reference
No	0.920(0.638–1.325)
PNI		0.146
>49	Reference
≤49	1.389(0.892–2.165)
SIS
0	Reference		Reference
1	1.519(1.000–2.308)	0.050	0.718(0.437–1.178)	0.189
2	2.992(1.639–5.462)	<0.001	0.617(0.200–1.900)	0.400
NPS
Group 0	Reference		Reference
Group 1	3.278(1.746–6.153)	<0.001	3.754(1.804–7.811)	<0.001
Group 2	6.819(3.270–14.222)	<0.001	9.673(2.973–31.474)	<0.001

Note: The variables in univariate analysis (P values <0.05) were entered into the multivariate analysis.

Abbreviations: DFS, disease-free survival; ECOG, Eastern Cooperative Oncology Group; BMI, body mass index; SCC, squamous cell carcinoma; AD, adenocarcinoma; VATS, video-assisted thoracoscopic surgery; CEA, carcinoembryonic antigen; PNI, prognostic nutritional index; SIS, the systemic inflammation score; NPS, Naples Prognostic Score.