Post-operative radiation effects on lymphopenia, neutrophil to lymphocyte ratio, and clinical outcomes in palatine tonsil cancers

Alexander J. Lin, Yuan James Rao, Re I. Chin, Jian Campian, Daniel Mullen, Dinesh Thotala, Mackenzie Daly, Hiram Gay, Peter Oppelt, Dennis Hallahan, Douglas Adkins, Wade Thorstad

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27 Scopus citations


Objective: To evaluate radiation-induced lymphopenia associated with unilateral vs. bilateral neck radiation and to test post-treatment neutrophil to lymphocyte ratio (NLR) as a prognostic clinical biomarker. Methods: This was a single academic center retrospective review of palatine tonsil squamous cell cancer patients treated with post-operative intensity modulated radiation therapy (IMRT) from 1997 to 2013. Absolute lymphocyte count (ALC) and NLR were evaluated during and after radiation for up to a year. Correlations of lab values with loco-regional control (LRC), freedom from distant metastases (FFDM), and overall survival (OS) were assessed. Results: Ninety-nine patients with median follow up 5.8 years had ALC recorded at least at baseline and within one year of starting RT. Acute grade 3–4 lymphopenia (<10 weeks from RT start) occurred in 79% of bilateral neck RT patients (n = 70) and 58% of unilateral neck RT patients (n = 29), p = 0.03. There was no significant difference in late grade 3–4 (p = 0.12) lymphopenia. In a multivariable Cox regression model, acute NLR > 11.875 correlated with worse OS (HR = 4.4, 95% CI 1.2–16). Late NLR > 6.875 independently correlated with significantly worse FFDM (HR = 16, 95% CI 1.9–137) and OS (HR = 12, 95% CI 3.0–48). Conclusions: Unilateral neck radiation may prevent acute iatrogenic immunosuppression. In exploratory analyses, elevated post-treatment NLR was associated with risk for distant metastases and death.

Original languageEnglish
Pages (from-to)1-7
Number of pages7
JournalOral Oncology
StatePublished - Nov 2018


  • Head and neck
  • Immunosuppression
  • Lymphopenia
  • Neutrophil to lymphocyte ratio
  • Oropharynx
  • Squamous cell carcinoma (SCC)
  • Tonsil cancer
  • Unilateral radiation


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