NLR as a prognostic marker in patients with HCC attracted more and more researchers’ attention [15], [16], [17] and [18]. As we know, the NLR is a marker of systemic inflammation that is easily measured,

easily calculated from routinely available data, highly repeatable, and inexpensive [21]. In this study, we authenticated that the optimal cutoff value of NLR was 2.31 according to the ROC curve (Figure 1). NLR appeared to be associated with tumor size, clinical TNM stage, PVTT, distant metastasis, and AST in HCC (Table 1). The NLR > 2.31 was identified as a factor for lower survival in patients with HCC. Patients with elevated BGB324 NLR (> 2.31) had a significantly shorter DFS and OS than those with Ku0059436 low NLR (≤ 2.31) (Figure 2, Table 2). Consistent with previous findings [16], [17] and [18], NLR > 3.0 (Figure 2, C and D) and 5.0 ( Figure 2, E and F) were also associated with a shorter DFS and OS, but there were 81 (31.64%) cases with NLR > 3.0 in 256 patients with HCC ( Figure 2, C and D) and only 29 (11.33%) cases with NLR > 5.0 in 256 patients with HCC ( Figure 2, E and F). That means that more patients

with HCC are excluded using NLR > 3.0 or 5.0; therefore, the cutoff value 2.31 of preoperative NLR had a higher sensitivity in patients with HCC than 3.0 or 5.0. It is noteworthy that 2.31 of preoperative NLR as an optimal cutoff value in patients with HCC is confirmed not only by this retrospective study but also by some prospective clinical trials [15] and [22]. The association between elevated NLR and poor prognosis is complex and remains Adenylyl cyclase to be elucidated. NLR is

derived from the value of neutrophils and lymphocytes, both of which are major parts of white blood cells. Neutrophils mediate inflammatory response by release of arachidonic acid metabolites and platelet-activating factors, whereas a relative lymphopenia reflects the cortisol-induced stress response [23]. On the one hand, relatively increased number of circulating neutrophils may increase the levels of circulating angiogenesis-regulating chemokines, growth factors, and proteases (for instance, CXCL8, also known as IL-8 [24], vascular endothelial growth factor, matrix metallopeptidase 9 [25], and intercellular adhesion molecule 1 [26], all of which contribute to cancer development and progression by regulating cell growth, angiogenesis, or inflammation [27] and could serve as a predictor for poor survival in patients with HCC [28]). However, the host’s immune response to tumor is lymphocyte dependent. Patients with elevated NLR usually have relative lymphocytopenia, and this may result in poorer lymphocyte-mediated immune response to tumor, leading to a worse prognosis and a greater chance of tumor recurrence and metastases.