Prognostic Significance of Pre-Treatment Neutrophil–Lymphocyte Ratio and Platelet-Lymphocyte Ratio in Head and Neck Malignancies

Abstract

Introduction

Carcinoma is the second most common cause of death worldwide. The neutrophil–lymphocyte ratio (NLR) and the platelet-lymphocyte ratio (PLR) are essential markers of inflammation and tumorigenesis in various cancers including head and neck cancers. Pretreatment platelet- lymphocytic ratio can be used as an independent predictor of mortality whereas neutrophil- lymphocytic ratio is an independent predictor of recurrence. The main aim of this study is to compare the pre-treatment neutrophil lymphocyte ratio and platelet-lymphocyte ratio in the patients of head and neck malignancies with those of the control group.

Material and Method

100 patients with histologically diagnosed cases of head and neck malignancies. Age and sex matched healthy subjects attending Otorhinolaryngology out-patient department for any other complaints (100 control subjects). Complete blood count had been done to calculate absolute neutrophil count and absolute lymphocyte count.

Results

The mean age of the subjects in the study group was 55.73 ± 11.56 years. In control group, the mean age group was 54.11 ± 10.46 years. NLR and PLR significantly increased in cases than controls. NLR associated with T stage, histological type and histological grade but not with site and nodal involvement. PLR associated with T stage, metastasis but not with the histological grade, histological type, site and nodal involvement.

Conclusion

From this study, we conclude that pre-treatment NLR and PLR were closely associated both with the size of primary tumor and also with the stage of malignant disease in patients of head and neck malignancies.

Introduction

Tumorigenesis is the process of the transformation of normal cell into malignant one which involves de-differentiation, proliferation, metastasis, evasion of apoptosis, dysregulated metabolism etc., which are the generalized hallmarks of neoplasm. Inflammation plays an important role in cancer physiology by promoting carcinogenesis, dedifferentiation and primary tumor growth and by stimulating tumor cell proliferation by inhibiting apoptosis and increasing mitotic rates [1]. Various inflammatory markers like IL-6, TNF-alpha, C-reactive protein, neutrophil–lymphocyte ratio have been investigated and have been found to be associated with high mortality trends. In cancers, other inflammatory markers like immune activating anti-CTLA4 Mab avoid immune destruction, EFGR inhibitors sustain proliferative signaling, proapoptotic BH3 mimetics resist cell death, VEGF inhibitors induce angiogenesis, cyclin-dependent kinase inhibitors evade growth suppressors [2]. Thus, it has been found that tumor host interactions can induce systemic inflammatory responses that affect number of circulating white blood cells and neutrophil–lymphocyte ratio in certain type of cancers.

Neutrophils have been shown to promote carcinogenesis, progression of tumor, metastasis of tumor and platelets also produce growth factors and cytokines that are also responsible for the same as that of neutrophils. On the contrary, lymphocytes are known to have reversible effect on tumor growth as lymphocytes cause cytotoxic cell death [3]. These suppress the activity of lymphocytes and thus, attenuate the antitumor immune responses and release genotoxic substances and prostaglandins E2 and elastases thus, damage the DNA of epithelial cells. They also produce pro-angiogenic factors like MMP9 and VEGF, which help in neovascularization [4]. Neutrophils inhibit the proliferation of T cells by exerting immunosuppressive action as well as interfere with the functioning of natural killer cells and thus, enhance tumor growth. By modulating the activity of macrophages, neutrophils cause metastasis [5]. Platelets facilitate the extravasation of cancer cells as they improve microvascular permeablility and activate tumor growth by promoting angiogenesis. The elevation of platelet counts results from megakaryopoiesis, thrombopoiesis and aggregation. Tumor cells bind to P-selectin and form aggregates with platelets to protect themselves from natural killer cells.

Recent studies have also shown that there is decrease in the number of lymphocytes in various malignancies whereas platelet and neutrophil counts increase. It has been seen that in head and neck squamous cell carcinoma patients, lymphocytes have higher rates of apoptosis as compared to patients without head neck squamous cell carcinoma [6]. Thus, the neutrophil–lymphocyte ratio (NLR) and the platelet-lymphocyte ratio (PLR) are essential markers of inflammation and tumorigenesis in various cancers including head and neck cancers. Neutrophil–lymphocyte ratio (NLR) has been studied in different cancers and was found to be associated with tumor aggressiveness, recurrence and progression. Platelet-lymphocyte ratio also has been found to have prognostic value in several other cancers such as esophageal squamous cell cancer, gastric cancer and lung cancer. On the contrary, Sumner et al. [7] reported that lymphocyte levels show no effect on tumor control as well as survival in head and neck cancer patients although pre-treatment neutrophil–lymphocyte ratio was suggestive of poor overall survival. Chen et al. [8] conducted a study which also showed that pre-operative platelet level and inflammatory markers like lymphocytes failed to be independent prognostic markers among laryngeal squamous cell carcinoma patients.

In view of such conflicting reports in the past regarding the correlation between pretreatment neutrophil–lymphocyte ratio and platelet-lymphocyte ratio and prognosis in head and neck malignancies, the present study was conducted to compare the pre-treatment neutrophil–lymphocyte ratio and platelet-lymphocyte ratio in patients of head and neck malignancies with that of the controls. We also tried to correlate the clinico-pathological features of the patients such as primary site of tumor, histological types and grading, TNM staging, with the pretreatment neutrophil–lymphocyte ratio and platelet-lymphocyte ratio. These inflammatory markers will give us an overview of aggressiveness of the tumor and risk stratification for survival prediction. Thus, the optimal therapeutic approaches in these patients could be re-evaluated depending upon neutrophil–lymphocyte ratio and platelet-lymphocytes ratio values.

Material and Methods

This study was an observational correlational study that was conducted in the Department of Otorhinolaryngology and Head and Neck Surgery June 2021 to December 2022 after the approval from institutional ethical committee GMC Jammu. This study included histologically diagnosed patients with head and neck malignancies, attending the Department of Otorhinolaryngology and Head and Neck Surgery.

The study included 100 histologically diagnosed head and neck cancer patients as study group and 100 healthy control group.

Study Group (n = 100)

Inclusion Criteria

Histologically diagnosed cases of head and neck malignancies.

Exclusion Criteria

1. Inflammatory conditions (fistula of neck, pneumonia, wound infections, abscess, urinary tract infection, cholecystitis).

2. Thromboembolic diseases (deep venous thrombosis, myocardial infarction).

3. Patients on corticosteroid therapy.

4. History of treatment with chemotherapy and/or radiotherapy.

5. Treatment with platelet aggregation inhibitors during the month before sampling.

6. Patients with autoimmune disorders.

Control Group (n = 100)

Age and sex matched healthy subjects attending Otorhinolaryngology out-patient department for any other complaints with

1. No history suggestive of systemic infection, active infection.

2. No significant drug history.

3. No history of any neoplasm.

Detailed clinical history was taken and general physical examination and complete head and neck examination was done. Investigations like X-ray chest, CT scan, MRI (if required), ultrasound abdomen, Fine Needle Aspiration Cytology (FNAC) of neck node were done for staging of the tumor. Site of tumor, histological type of tumor (World Health Organisation classification of tumor 4th edition) [Paul M. Speight et al. (2018)], degree of differentiation, and TNM staging were noted. AJCC and UICC 8th edition, 2017 was used for histological grading and clinical staging of the tumors [William M. Lydiatt et al. (2017)].

Routine investigations like blood grouping, complete blood count, bleeding time, clotting time, prothrombin index and INR, renal function tests, liver function tests, serology were taken atleast 6 weeks before initation of treatment. Pre-treatment absolute neutrophil count, absolute lymphocyte count, platelet count were calculated.

Absolute Neutrophil Count

$$\text{ANC}=\left(\text{total WBC X}\%\left[\text{PMNs}\right]\right)÷100$$

$$\text{The normal range for the absolute neutrophil count}=2500\text{to 6}000/\mu L.$$

Absolute Lymphocyte Count

$$\text{ALC}=\left(\text{total WBC X}\%\left[\text{lymphocyte}\right]\right)÷100.$$

$$\text{The normal range for the absolute lymphocyte count}=1000\text{to 48}00\backslash \mu \text{L}.$$

Neutrophil-lymphocytes ratio (NLR) was calculated as the absolute neutrophil count divided by the absolute lymphocyte count.

Platelet/Lymphocyte Ratio (PLR) was calculated as the absolute platelet count divided by the absolute lymphocyte count.

Statistical Analysis

Data regarding pre-treatment neutrophil–lymphocyte ratio, platelet- lymphocyte ratio, histological grading, histological type, site of tumor and TNM staging of tumor was entered in Microsoft excel spread sheet and compared using statistical package for social science (SPSS) software, IBM manufacturer, Chicago, USA, version 21.0. The mean, frequency distributions and normalcy of distribution between the groups were examined. The presentation of categorical variables was done in the form and percentage. Quantitative data was presented as mean ± SD. The comparison of variable were analyzed using chi square test. Appropriate analytical tests were applied as per advice of statistician. The p value of < 0.05 was considered significant.

Results

The study included 100 histologically proven cases of head and neck malignancies. The mean age of the subjects in the study group was 55.73 ± 11.56 years and in the control group, the mean age group was 54.11 ± 10.46 years. Thus, the study group and control group were comparable in terms of age with p value of 0.3. The Male: Female ratio in study group was 6:1 and in control group was 4.9:1.

Respiratory distress (98%) and hoarseness\voice change (64.7%) were the most common symptoms for laryngeal cancer, dysphagia (35.2%) was the most common symptoms for oropharyngeal cancer and non-healing ulcer (88.9%) was the most frequently symptom among patients of oral cavity cancers. Other clinical presentation included neck swelling (22%), thyroid swelling (6%), exophytic growth (19%) and trismus (21%). Cancer of larynx (51%) was the most prevalent followed by oral cavity (27%), oropharynx (12%) and thyroid (6%). 4% subjects had involvement of other sites i.e. maxilla, jaw, pinna, preauricular region. Majority of subjects (34%) presented at T3 stage, followed by T4 (28%), T2 (25%) and 13% patients presented in T1 stage of tumor. Most of the patient (54%) presented in N0 stage of tumor, followed by N1 stage (26%) and least presented in N3 stage of tumor (1%). It was seen that cancer patients predominantly reported at TNM stage III (40%), followed by stage III (34%), stage II (18%) and least presented in stage I (8%).

Squamous cell carcinoma was the predominant histological type in head and neck cancer patients accounting for 82% of the cases, followed by verrucous carcinoma (12%), papillary carcinoma (3%), medullary carcinoma (3%) and adenocarcinoma (1%). Out of 82 subjects of squamous cell carcinoma, 42.7% (35) were well differentiated SCC, 36.6% (30) were moderately differentiated SCC and 20.7% (17) were poorly differentiated squamous cell carcinoma.

Table 1 shows that the mean Absolute Lymphocyte Count ALC, APC and ANC in study group and control group. The differences between the study group and control group were statistically significant.

Table 1.

Mean absolute lymphocyte count (ALC), mean platelet count and mean absolute neutrophil count (ANC) in study and control groups

		Min. value (/µL)	Max. value (/µL)	Mean ± SD (/µL)	Significance
					T value	P value
Absolute lymphocyte count	Study group (n = 100)	840	3960	2046.32 ± 654.42	− 6.093	< 0.001
	Control group (n = 100)	1080	5000	2731.12 ± 913.77
Absolute platelet count	Study group (n = 100)	0.85	4	2.29 ± 0.50	5.140	< 0.001
	Control group (n = 100)	1	3.10	1.96 ± 0.39
Absolute neutrophil count	Study group (n = 100)	2720	12,201	6444.86 ± 1757	9.502	< 0.001

Table 2 shows the mean Neutrophil–Lymphocyte Ratio (NLR) and Platelet-Lymphocyte Ratio (PLR) in both study group and control group and the difference between them was statistically significant.

Table 3.

Relation of site of tumor with mean NLR and PLR in study group

Site	No. of patients (n = 100)	NLR (Mean ± SD)	PLR (Mean ± SD)
Oropharynx	12	2.91 ± 1.07	123.46 ± 56.67
Oral cavity	27	3.20 ± 1.12	121.29 ± 47.50
Larynx	51	3.72 ± 1.75	128.26 ± 58.78
Thyroid	6	3.31 ± 0.65	129.31 ± 45.53
Other head and neck cancer	4	2.90 ± 0.44	106.71 ± 48.08
P value		0.888	0.938

Mean NLR and PLR values were compared with the site of tumor. However, the difference was not statistically significant (Table 3)

Table 4.

NLR and PLR in different T category of cancer (n = 100)

T category of cancer	No. of patients (n = 100)	NLR (Mean ± SD)	PLR (Mean ± SD)
TI	13	3.15 ± 1.06	120.43 ± 35.32
T2	25	2.86 ± 0.78	98.45 ± 35.14
T3	34	12.52 ± 52.06	130.54 ± 55.36
T4	28	3.87 ± 1.32	144.1 ± 64.26
P value		0.034	0.016

The mean NLR and mean PLR values were compared with T stage of tumor and it was found that there was significant increase in both NLR and PLR with increasing tumor size (T stage of tumor) [p = 0.034 for NLR and p = 0.016 for PLR] (Table 4)

Table 5.

NLR and PLR in different N categories of cancer (n = 100)

N category of cancer	No. of patients (n = 100)	NLR Mean ± SD	PLR Mean ± SD
N0	54	3.42 ± 1.59	120.42 ± 60.33
N1	26	3.23 ± 1.12	127.63 ± 46.06
N2	19	3.78 ± 1.48	135.39 ± 45.17
N3	1	2.14	106.42
P value		0.506	0.739

However, we found out that there was no statistically significant increase in mean NLR and mean PLR with lymph node involvement (N category of cancer) (Table 5)

Table 6.

NLR and PLR in different histological types of tumors (n = 100)

Histological type	No. of patients (n = 100)	NLR (Mean ± SD)	PLR (Mean ± SD)
Squamous cell carcinoma	82	3.56 ± 1.56	127.58 ± 55.67
Other histological type of tumor	18	2.81 ± 0.57	113.22 ± 34.58
P value		0.047	0.307

On comparing the NLR and PLR values in squamous cell carcinoma and other histological types it was found that NLR was significantly increased in squamous cell carcinoma group (p = 0.047) whereas PLR was non-significantly increased in squamous cell carcinoma. (Table 6)

Table 7.

NLR and PLR in different histological grades in patients with squamous cell carcinoma (n = 82)

Histological grading	No. of patients	NLR	PLR
Well differentiated SCC	35	3.09 ± 1.09	117.13 ± 50.41
Moderately differentiated SSC	30	3.96 ± 1.47	127.50 ± 55.69
Poorly differentiated SCC	17	4.29 ± 2.05	149.27 ± 63.05
P Value	82	0.0025	0.149

The mean NLR and mean PLR values were compared with histological grades of tumor in 82 patients with squamous cell carcinoma. It was found that with the increase in the histological grade of tumor there was increase in the mean NLR and the difference was statistically significant. However, there was no statistically significant increase in mean PLR with increase in histological grade of tumor. (Table 7)

Table 2.

Mean neutrophil–lymphocyte ratio (NLR) and mean platelet lymphocyte ratio in study and control groups

		Min. value	Max. value	Mean ± SD	Significance
					T value	P value
Mean neutrophil–lymphocyte ratio	Study group (n = 100)	1.18	3.07	3.42 ± 1.46	9.773	< 0.001
	Control group (n = 100)	0.83	7.10	1.80 ± 0.80
Mean platelet lymphocyte ratio	Study group (n = 100)	30.90	352.38	125.0 ± 53.79	7.681	< 0.001
	Control group (n = 100)	34.00	166.60	78.84 ± 26.80

In our study, only 4% subjects had distant metastasis. The subjects who had distant metastasis had higher NLR values as compared to subjects with no distant metastasis (p = 0.047). However there was no statistically significant increase in mean PLR with presence of distant metastasis.

We found out that there was statistically significant increase in NLR and PLR with the increase TNM stage of cancer patients. (Fig. 1).

Fig. 1.

NLR & PLR in different TNM stages of cancer

Discussion

Inflammation is commonly recognized to play an important role in carcinogenesis and possibly affects the survival of cancer patients. Some studies suggest that persistent inflammation promotes cell proliferation which may lead to activation of oncogenic factors and inactivation of tumor suppressor genes. These inflammatory factors lead to the development of tumor-associated stroma which mediate angiogenesis, immune evasion and metastasis. Neutrophils inhibit cytolytic activity of immune cells such as lymphocytes, activated T cells and natural killer cells and thus, suppress immune system. Tumor associated neutrophils cause migration of endothelial cells and dissociation of tumor cells by releasing tumor promoting agents like matrix metallo-proteinases and fibroblast growth factors, thus lead to angiogenesis, tumor growth and development of metastasis [4]. In contrast, lymphocytes cause cytotoxic cell death and cytokine production thus, inhibiting proliferation and metastatic activity of tumor cells. Platelets increase tumor growth by increasing microvascular permeability and by increasing angiogenesis. With the help of P-selectin molecule, platelets directly bind to the tumor cells and encourage tumor metastasis and protect tumor cells from natural killer cells.

Biomarkers like NLR and PLR show interaction between systemic inflammation and tumor microenvironment and thus, help to identify patients with higher chances of cancer progression. Increased NLR has been shown to have prognostic significance in head and neck squamous cell carcinoma. Increased PLR has been shown to be an independent predictor of mortality whereas increased NLR has been used as an independent predictor of recurrence. Thus, increased pretreatment NLR and PLR can be significantly related with increased risk of mortality and cancer progression.

In the present study, the mean age group in study group was 55.73 ± 11.56 years and in control group was 54.11 ± 10.46 years. These findings are similar with the study conducted by Nakayama et al. [9]. Male:Female ratio in study group was 6:1 and in control group was 5.8:1. Our findings were similar with the studies conducted by Sheetohul et al. [10] and Mittal et al. [11] which also showed male preponderance. The study group and control group were comparable in terms of age and gender.

Larynx (51%) was the most prevalent site in our study, followed by oral cavity (27%), oropharynx (12%) and thyroid (6%). In the oral cavity, buccal mucosa (55.6%) was the most common subsite and in oropharynx, base of tongue (33.33%) was the most predominant subsite. In larynx, supraglottis (38.1%) was the most common subsite. Our findings were consistent with the study conducted by Nakayama et al. [9]. A study conducted by Tazeen et al. [12] suggested that the most common subsite in oral cavity was buccal mucosa (43.7%) followed by tongue.

Majority of subjects in our study (39%) presented at T3 stage, followed by T4 stage (28%), 25% patients were in T2, 13% patients were in T1 stage of cancer. In a study conducted by Chen et al. [13] most of the patients presented in T1-T2 category of cancer. However, another study by Lee et al. [14] suggested that most of the patients presented in T4 category (32%), followed by T2 (29.2%). Another study of Kuzuc et al. [15] suggested that 33.33% patients presented in T2 category, followed by T1 and T3 (26.1% both).

In the present study, 54% patients presented in N0 stage, followed by 26% and 19% in N2 and N3 stage of tumor, respectively. These findings are consistent with the studies conducted by Abelardo et al. [16]. A study conducted by Lee et al. [14] on 291 patients, 68.4% subjects presented in N0 stage of tumor, followed by N3 (12.4%) and least were in N1 stage of tumor (7.2%). In the present study 96% patients had no distant metastasis (M0) while only 4% had distant metastasis (M1) which is consistent with the study conducted by Abelardo et al. [16].

It was seen in our study that patients predominately reported in stage III (40%), followed by stage IV (34%), 18% patients were in stage II and 8% were in stage I according to TNM staging of tumor. Szilasi et al. [17] found that 16.7%, 15.4%, 28.2% and 39.7% presented in stage I, stage II, stage III and stage IV, respectively. Our study findings were also consistent with studies conducted by Nakayama et al. [9] and Mittal et al. [11].

The most common histological type was squamous cell carcinoma seen in 82% in the present study. Rest 12% patients had non-squamous cell carcinoma of head and neck including verrucous (12%), adeno-carcinoma (1%), medullary carcinoma (3%) and papillary carcinoma (3%). Our study findings were found consistent with the studies conducted by Seetohul et al. [10] and Ni et al. [18] which depicted that squamous cell carcinoma was the predominant histological type among all head and neck malignancies.

The mean absolute neutrophil count ANC and APC in study group were significantly increased (p value < 0.001). However, ALC was significantly decreased in cancer patients as compared to control. Our findings were consistent with the study conducted by Huesh et al. [19].

We compared the NLR and PLR of patients with malignant lesions with that of healthy control subjects. The mean neutrophil–lymphocyte ratio (NLR) in study group was 3.42 ± 1.46 and in control group was 1.80 ± 0.80 and the difference between these two was statistically significant with p value < 0.001. These findings were consistent with studies conducted by Acmaz et al. [20], Seetohul et al. [10] and Kuzucu et al. [15]. Another study conducted by Duzlu et al. [21] suggested that mean NLR in 65 cases of laryngeal cancer was 2.70 ± 1.25 and in 42 controls was 2.04 ± 0.90 and difference between them was statistically significant with p value of 0.004.

The platelet-lymphocyte ratio in study group was also statistically significantly increased as compared to control group with p value of < 0.001. The PLR value was also significantly decreased in study group as compared to control group and mean value in study group was 125 ± 53.79 and in control was 78.84 ± 26.80. Our study findings were consistent with the study conducted by Yilmaz et al. [22] and Kuzucu et al. [15]. Another study by Seetohul et al. [10] conducted on 170 histologically diagnosed cases of head and neck cancer and 80 control patients suggested that mean NLR and PLR was found to be higher in cases than in controls with p value of 0.005 and 0.030. The mean values of NLR in cases was 2.76 ± 1.82 and in control was 2.15 ± 0.90. The mean values of PLR in cases was 113.20 ± 60.36 and in control was 91.41 ± 38.62. Thus, these findings were consistent with the previous studies indicating relationship between NLR and PLR in head and neck cancer.

We found that there was no relation of site of tumor with mean Neutrophil–Lymphocyte ratio and mean PLR. However, studies conducted by Mittal et al. [11] on hypopharyngeal cancer patients and Kuzucu et al. [15] on parotid gland tumor suggested a significant increase in NLR in these tumor. Although, no association was found with mean PLR. Another study conducted by Zhou et al. [23] on laryngeal cancer patients showed statistically significant increase in PLR in these patients. Both mean NLR and PLR showed statistically significant increase with increasing T categories of cancer. These findings in accord to the studies conducted by Hsueh et al. [19], Seetohul et al. [10] which also showed that with increase in T categories of tumor the mean NLR values also increased. However, a study conducted by Duzlu et al. [21], did not show any such association.

NLR and PLR did not show statistically significant relation with increasing N categories of tumor which was in accord to the study conducted by Chen et al. [13] and Nakashima et al. [9]. However, Hsueh et al. [19], Seetohul et al. [10] which showed that with increase in nodal involvement of tumor there was increase in NLR and PLR values. We also found out mean NLR was significantly related to the presence of distant metastasis. However mean PLR did not show any significant relation.

Also, we found that there was significantly increase in NLR and PLR with increase in TNM stage of cancer. These findings were consistent with the study conducted by Park et al. [24] but contradictory to the studies conducted by Chen et al. [13] and Acharya et al. [25].

The present study suggested significant relation of NLR with histological type of tumor with mean value for squamous cell carcinoma to be 3.56 ± 1.56 and for other histological type of tumors to be 2.81 ± 0.57. This was consistent with the study conducted by Templeton et al. [26]. On the contrary, platelet-lymphocyte ratio did not show significant relation with histological type of tumor.

Our study also suggested significant increase in NLR with advancing degree of differentiation in squamous cell carcinoma with mean values of 3.09 ± 1.09, 3.96 ± 1.47, 4.29 ± 2.05 for well-differentiated squamous cell carcinoma, moderately differentiated squamous cell carcinoma and poorly differentiated squamous cell carcinoma, respectively. However, PLR showed no such relation. A study conducted by Seetohul et al. [10] showed non-significant increase in both NLR and PLR with advancing degree of differentiation. However, Yilmaz et al. [22] showed statistically significant difference in PLR values among different histological grades. Other study conducted by Hsuch et al. [19] showed no relation between these ratios and histological grades.

Conclusion

We can conclude that pre-treatment NLR and PLR significantly increased in head and neck squamous cell carcinoma patients as compared to controls. These were also closely associated both with the size of primary tumor and also with the stage of malignant disease in patients of squamous cell carcinoma of head and neck. Moreover, these tests can be performed easily, they are cost-effective and repeatable and yet, provide valuable information about aggressiveness of the tumor. Our results suggest that a classification system based on these pre-treatment hematological markers could identify patients with a high risk of recurrence and poor survival and thus be a useful complement to TNM staging. Thus, multicentric large scale prospective studies with evaluation of treatment responses are required in the near future to identify comprehensively the patients at high risk of poor outcome and to define precise cut off values of NLR and PLR as prognostic marker in head and neck squamous cell carcinoma. Thus, this inexpensive yet valuable information from routine pre-treatment hematological tests might be useful in survival prediction and tailored therapy.

Funding

None.

Declarations

Conflict of interest

None.