primary fallopian tube carcinoma ( pftc ) is a rare neoplasm , accounting for 0.14%-1.8% of all gynecological malignancies . however , recent data suggest that the true incidence of pftc has been substantially underestimated ; this conclusion is based on compelling evidence that papillary serous carcinoma , the most common subtype of epithelial ovarian carcinoma ( eoc ) , actually arises from the epithelial lining of the fallopian tube . the mean age at diagnosis of pftc is 64 years , and incidence peaks at 70 - 74 years . total abdominal hysterectomy with bilateral salpingooophorectomy and infracolic omentectomy , appendectomy , peritoneal washing , and peritoneal biopsy constitute the primary treatment of choice for pftc ; inclusion of pelvic and para - aortic lymphadenectomy has been controversial . klein et al .   reported that routine retroperitoneal sampling and node dissection are necessary for proper staging , whereas other authors have reported that systemic retroperitoneal lymphadenectomy is preferable due to the strong tendency of the tumor to spread in the lymphatic system . in addition , the therapeutic value of a systematic complete lymphadenectomy remains controversial , with a paucity of clinical data to support its use . stage , patient age , and residual tumor after initial surgery are consistently important prognostic factors . in addition , according to some reports , a closed fimbriated end of the fallopian tube , positive peritoneal cytology , lesion site within the tube ( fimbrial vs. non - fimbrial ) , human epidermal growth factor receptor 2/nu - positive expression , p53 alteration , elevated pretreatment cancer antigen 125 ( ca-125 ) , and lymphovascular space involvement are also important prognostic factors [ 2 - 6 ] . interest in elevated neutrophil to lymphocyte ratio ( nlr ) and platelet to lymphocyte ratio ( plr ) as markers of systemic inflammatory response ( sir ) in various clinical circumstances is increasing . in recent clinical studies , these ratios have been investigated as advanced - stage predictors or prognostic factors in different types of gynecologic cancer [ 7 - 14 ] . in addition , preoperative thrombocytosis has been associated with adverse outcomes from endometrial and ovarian cancers . however , no study investigating the predictive value of nlr , plr , or thrombocytosis in overall survival ( os ) and disease - free survival of patients with pftc has been reported . therefore , we retrospectively reviewed the clinical characteristics , management , and outcomes of 91 patients with pftc who were treated in six gynecological oncology departments . in addition , this study sought to determine whether 1 ) nlr , plr , or thrombocytosis plays a role in disease - free survival and os of pftc and 2 ) performance of para - aortic lymphadenectomy is essential for patients with pftc . the databases of six gynecological oncology departments from turkey , including izmir tepecik education and research hospital , izmir ege university school of medicine , eskisehir osmangazi university school of medicine , ankara university school of medicine , antalya akdeniz university school of medicine , and adana cukurova university school of medicine were reviewed for identification of patients with complete information and pathologically proven pftc who underwent surgical staging between january 1 , 1996 , and december 31 , 2011 . this study was conducted in accordance with the ethical standards of the declaration of helsinki and was approved by the local ethics committees of izmir tepecik education and research hospital . cases were identified according to the pftc diagnostic criteria established by hu et al .   and modified by sedlis . the following clinical data were collected from patient medical , surgical , pathological , and chemotherapy reports : demographic characteristics , presenting symptoms , serum ca-125 level , preoperative complete blood cell count ( cbc ) , date and type of surgical procedure , presence or absence of residual tumor after surgery , number of excised and positive lymph nodes , presence or absence of ascites , tumor pathological characteristics ( grade and size ) , type of first - line chemotherapy , date of recurrence , treatment after recurrence , date of last medical examination , and date of death . patients with any inflammatory signs or conditions , hematological disease , or other malignancies that might affect the cbc results , smokers , those who used corticosteroids or -agonists , and patients with missing data including preoperative cbc and surgico - pathological notes , were excluded . international federation of gynecology and obstetrics ( figo ) staging according to the 2009 revised classification system was used . cbc was measured within one month preoperatively using a coulter lh 750 device ( beckman coulter , brea , ca ) or a sysmex xe-2100 device ( toa medical electronics , kobe , japan ) at the six centers . when more than one cbc result was available , the result from the date closest to staging surgery was recorded for statistical analysis . the nlr was defined as the absolute neutrophil count divided by the absolute lymphocyte count , and the plr was defined as the absolute platelet count divided by the lymphocyte count . patients were classified as not having been staged if only a unilateral salpingo - oophorectomy , total hysterectomy with unilateral or bilateral salpingo - oophorectomy with or without omentectomy was performed . partial staging was defined as pelvic washing , peritoneal biopsy , omentectomy , bilateral pelvic lymph node dissection with a unilateral salpingo - oophorectomy , or total hysterectomy with unilateral or bilateral salpingo - oophorectomy . complete staging was defined as pelvic washing , peritoneal biopsy , omentectomy , bilateral pelvic and para - aortic lymph node dissection with a unilateral salpingo - oophorectomy , or total abdominal hysterectomy with unilateral or bilateral salpingo - oophorectomy . optimal debulking was defined as a procedure that left a maximum residual tumor < 1 cm in diameter . patients returned for a follow - up evaluation every three months for the first 2 years , every 6 months for the next 3 years , and annually thereafter . computed tomography or magnetic resonance imaging the survival analysis was based on the kaplan - meier method , and the results were compared using the log - rank test . progressionfree survival ( pfs ) was defined as the time from the date of primary surgery to detection of recurrence or the latest observation . os was defined as the time from the date of primary surgery to death or the latest observation . the chi - square test and student s t test for unpaired data were used for the statistical analysis . cox regression analysis was used to determine factors affecting survival , and results are presented as hazard ratios ( hrs ) with 95% confidence intervals ( cis ) . the two most common preoperative diagnoses were ovarian carcinoma ( 42.9% ) and adnexal mass of unknown nature ( 29.7% ) . the median follow - up period was 34 months ( range , 14 to 78 months ) . thirty - four patients ( 37.4% ) had figo stage i disease , 10 ( 10.9% ) had stage ii , 43 ( 47.3% ) had stage iii , and four ( 4.4% ) had stage iv disease . nine patients ( 9.9% ) had no surgical staging , 34 ( 37.4% ) had partial staging , and 48 ( 52.7% ) had complete staging . four unstaged patients who refused reoperation were treated based on high - risk features such as grade 3 disease or tumor rupture . we studied nlr and plr at different levels to determine the optimal cut - off point for prediction of disease stage ( early vs. advanced ) and primary surgical outcome ( optimal vs. suboptimal ) . the receiver operating characteristics ( roc ) curve indicated that nlr > 2.7 and plr > 233.3 was optimum for prediction of advanced stage ( stage iii / iv ) and suboptimal surgery ( table 3 ) . the mean and median pfs were 34.2 months and 32 months ( range , 9 to 76 months ) , respectively . results of univariate analysis indicated that advanced figo stages iii and iv , suboptimal surgery , and pretreatment nlr > 2.7 ( fig . 1a and c ) were adverse prognostic factors for pfs . results of multivariate analysis showed that advanced figo stage and suboptimal surgery were independent prognostic factors for pfs . the 5-year os rate was 63.7% , and the mean and median survival durations were 38.9 months and 35 months ( range , 14 to 78 months ) , respectively . results of univariate and multivariate analyses for os are shown in table 5 . in univariate analysis of survival rates , pretreatment ca-125 35 u / ml , presence of ascites , advanced figo stage , suboptimal surgery , pretreatment nlr > 2.7 ( fig . 1d ) , pretreatment platelet count  400,000 cells / mm , surgical staging type ( none vs. partial vs. complete ) , and histological subtype ( serous vs. non - serous ) showed significant association with poor os . in contrast , multivariate analysis of os showed significant association of advanced figo stage , suboptimal surgery , pretreatment nlr > 2.7 , and surgical staging type ( none vs. partial vs. complete ) with poor os . of of these , 48 ( 58.6% ) had complete staging , and 34 ( 41.4% ) had incomplete staging . the mean and median pfs tended to be better in the complete staging group ( 38.1 months and 34.0 months [ range , 9 to 76 months ] , respectively ) than in the partial staging group ( 27.8 months and 24.0 months [ range , 11 to 76 months ] ) , however , the difference was not significant ( hr , 1.7 ; 95% ci , 0.9 to 3.2 ; p=0.09 ) ( fig complete staging showed significant association with longer os , with mean and median os rates of 42.0 months and 35.5 months ( range , 22 to 78 months ) , respectively , vs. 33.5 months and 27.5 months ( range , 14 to 76 months ) , respectively , in the partial staging group ( hr , 3.1 ; 95% ci , 1.4 to 5.7 ; p=0.002 ) ( fig . the current study retrospectively analyzed patients with pftc who were treated at six gynecologic oncology centers in turkey . our aim was to describe the demographic and clinical characteristics of pftc and to identify variables affecting pfs and os in patients with this disease . it is not routinely suspected in women with a pelvic mass . in our study , none of the patients had a definitive preoperative diagnosis of pftc . in the literature , the mean age of patients with pftc is 55 years , similar to that in our patient population . reported that pftc is diagnosed at an earlier stage than ovarian cancer , possibly as a result of abdominal pain resulting from tubal distention and intermittent serosanguineous discharge . the 5-year os rate for all stages of pftc varies from 22% to 81.7% [ 20 - 22 ] . several studies have reported various prognostic factors for predicting the outcome of pftc , including age , stage , cell type , elevated ca-125 , and residual tumor after surgery . reported that in a univariate analysis , pretreatment serum ca-125 values were prognostic with respect to both pfs and os . they also showed that the side where the tumor was located was associated with pfs . however , multivariate analyses were not performed in these two studies . in the current study , advanced figo stage , presence of a residual tumor > 1 cm after surgery , and surgical staging type ( none vs. partial vs. complete ) showed significant association with poor os in both univariate and multivariate analyses . location and grade of tumor prognostic factors other than age and elevated ca-125 can only be assessed during or after surgery based on the pathological features of the cancer . do nlr , plr , and thrombocytosis play a role in disease - free and os in patients with pftc ? an increase in neutrophil count , a slight increase in platelet count , and a decline in lymphocytes are systemic alterations that are part of the inflammatory response to the growth , progression , and spread of tumors . in this respect , interest in nlr and plr has shown a recent increase , and they have been studied as sir markers in non - gynecologic and gynecologic cancers , with results suggesting that a preoperative increase in nlr and/or plr is significantly associated with nodal metastasis and advanced stage and is a significant prognostic factor [ 8 - 14 ] . indeed , it has been suggested that these ratios , which can be assessed using noninvasive , simple , and inexpensive methods and can be easily calculated from the cbc , should be included in the routine assessment of all patients with cancer . more recently , thrombocytosis was reported as an independent predictor of increased risk of recurrence in 587 women who underwent staging surgery for eoc . only four studies have analyzed pretreatment nlr and/or plr values in patients with eoc [ 11 - 14 ] , and the value of these ratios as prognostic factors in patients with pftc has not been validated . a preoperative nlr cut - off point > 2.6 distinguished ovarian cancer from benign conditions and predicted adverse outcomes , and a similar ratio was associated with advanced - stage disease or suboptimal ovarian surgery . plr was superior to nlr for prediction of poor survival in two ovarian cancer studies . first , asher et al .   showed that plr > 300 was superior to nlr > 4.0 for prediction of poor survival and was a novel independent prognostic marker for eoc . later , it was demonstrated that plr > 200 had the potential to predict advanced - stage disease or suboptimal surgery and was a better prognostic indicator for survival of patients with eoc than nlr of 2.6 . in our study , results of the roc curve analysis showed that the optimum cut - off value for prediction of advanced stage ( stage iii / iv ) and suboptimal surgery in patients with pftc was 2.7 for nlr , with 85.1% sensitivity and 75.0% specificity for advanced stage ; suboptimal surgery and a plr value of 233.3 showed 77.9% sensitivity and 84.3% specificity , with 87.2% sensitivity and 63.4% specificity for advanced stage and 81.3% sensitivity and 71.8% specificity for suboptimal surgery . in a univariate cox survival analysis , these ratios and a pretreatment platelet count  400,000 cells / mm showed significant association with poor os . however , in the multivariate cox survival analysis , nlr > 2.7 was also a significant prognostic marker , along with stage and postoperative residual disease . our results are consistent with those of previous studies and support the growing notion that the inflammatory process is linked to adverse outcomes in pelvic serous tumors . is performance of a para - aortic lymphadenectomy essential for pftc ? due to its rarity , optimal management for patients with pftc has not been well defined , and there is a tendency to treat this malignancy like ovarian cancer . the need for complete surgical staging , including lymph node sampling or dissection , is controversial . these procedures may be performed in different ways by different surgeons in many centers ; some highlight early extensive lymphadenectomy , some perform only pelvic lymphadenectomy , and others favor lymph node sampling or do not always perform lymphadenectomy . in our study , in univariate and multivariate analyses , type of staging surgery ( no staging , partial , or complete ) showed significant association with os . koo et al .   reported that para - aortic lymphadenectomy is an important procedure in patients with pftc and suggested that para - aortic nodes are the sentinel lymph nodes in these patients . in our analysis of patients treated with pelvic lymphadenectomy with or without para - aortic lymphadenectomy ( partial vs. complete staging ) , we found that the complete staging group showed significantly longer os compared with the partial staging group . the mean and median pfs tended to be better in the complete staging group than in the partial staging group , but the difference was not significant . potential limitations of this study include its retrospective nature , the use of two different devices for blood sample analysis for calculation of nlr , plr , and platelet counts , and the evaluation of data without preoperative c - reactive protein results because this test is not performed routinely at the six centers . despite these limitations , the availability of good follow - up data and one of the largest pftc cases series should increase the validity of results and mitigate the weaknesses . the following conclusions can be drawn from our data . first , in univariate analysis , only pretreatment nlr > 2.7 . however , in univariate analysis , pretreatment nlr > 2.7 , pretreatment plr > 233.3 , and pretreatment platelet count  400,000 cells / mm showed significant association with poor os . nlr and plr are inexpensive and easy tests to perform , and they provide useful prognostic information . finally , patients who underwent complete staging surgery for pftc had longer pfs and os .
purposethe purpose of this study is to evaluate the prognostic role of preoperative neutrophil to lymphocyte ratio ( nlr ) and platelet to lymphocyte ratio ( plr ) and the need for para - aortic lymphadectomy in patients with primary fallopian tube carcinoma ( pftc).materials and methodsninety - one patients with a diagnosis of pftc were identified through the gynecologic oncology service database of six academic centers . 
 clinicopathological , surgical , and complete blood count data were collected.resultsin univariate analysis , advanced stage , suboptimal surgery , and nlr > 2.7 were significant prognostic factors for progression - free survival , whereas in multivariate analysis , only advanced stage and suboptimal surgery were significant . 
 in addition , in univariate analysis , cancer antigen 125  35 u / ml , ascites , advanced stage , suboptimal surgery , nlr > 2.7 , plr > 233.3 , platelet count  400,000 cells / mm3 , staging type , and histological subtype were significant prognostic factors for overall survival ( os ) ; however , in multivariate analysis , only advanced stage , suboptimal surgery , nlr > 2.7 , and staging type were significant . 
 inclusion of pelvic and para - aortic lymphadenectomy in surgery showed significant association with longer os , with a mean and median os of 42.0 months and 35.5 months ( range , 22 to 78 months ) , respectively , vs. 33.5 months and 27.5 months ( range , 14 to 76 months ) , respectively , for patients who underwent surgery without para - aortic lymphadenectomy ( hazard ratio , 3.1 ; 95% confidence interval , 1.4 to 5.7 ; p=0.002).conclusionnlr ( in both univariate and multivariate analysis ) and plr ( only in univariate analysis ) were prognostic factors in pftc . 
 nlr and plr are inexpensive and easy tests to perform . 
 in addition , patients with pftc who underwent bilateral pelvic and para - aortic lymphadenectomy had longer os .