Predictive and Prognostic Role of the Neutrophil-To-Lymphocyte Ratio in Muscle Invasive Bladder Cancer Treated with Neoadjuvant Chemotherapy and Radical Cystectomy

Published:January 25, 2023DOI:



      There is a persistent lack of validated biomarkers that identify patients most likely to benefit from neoadjuvant chemotherapy (NAC) in urothelial carcinoma of the bladder (UCB). Therefore, the purpose of this study was to investigate the predictive and prognostic impact of the pretreatment neutrophil-to-lymphocyte ratio (NLR) in UCB patients treated with NAC and radical cystectomy (RC).

      Patients and Methods

      We conducted a retrospective analysis of an international-multicenter database comprising 404 UCB patients staged cT2-4N0-3M0. The cohort was split into low and high NLR using an optimal cutoff value determined by maximizing Youden's index. Logistic and Cox regression analyses were performed with respect to several clinical endpoints. The discriminatory ability of the models and the additive discriminatory value of NLR was assessed by calculating the area under receiver operating characteristics curves, C-Index, and decision curve analysis (DCA).


      169 patients (41.8%) had a high NLR, which was associated with a decreased probability of complete response (CR, OR: 0.24 [95%CI 0.13-0.42], p<0.001) and/or partial response (PR, OR: 0.33 [95%CI 0.21-0.49], p<0.001). Adding the NLR to predictive reference models significantly improved their accuracy for the prediction of both CR and PR. A high NLR was associated with poor survival outcomes in the pretreatment setting, however, it didn't meaningfully change the C-Index based on the model.


      We confirmed that an elevated NLR is an independent and clinically significant predictor of response to NAC and adverse pathological features in UCB treated with NAC plus RC. The accuracy of this biomarker in the age of immunotherapy warrants further evaluation.


      Validated biomarkers to predict response to preoperative chemotherapy in bladder cancer are lacking. We investigated the predictive/prognostic impact of the pretreatment neutrophil-lymphocyte ratio (NLR) in 404 bladder cancer patients treated with preoperative chemotherapy and radical surgery. A high NLR was associated with a decreased probability of complete and/or partial response to chemotherapy. NLR may risk-stratify patients prior to radical surgery.


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