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Integrating the Neutrophil-to-Lymphocyte Ratio into a Clinicopathological Nomogram for Event-Free Survival Prediction in Cisplatin-Treated Muscle-Invasive Bladder Cancer
by
, , , , and
Mariona Figols
1,2,3,*,
Andrea González
4,
Maria Fernandez-Saorín
5,6,
Ana Bautista
1,
Olatz Etxaniz
4,5,6,
Ester Ruz
7,
Jose Luis Gago
8,
Daniela Gómez-Díaz
1,
Juan Carlos Pardo
4,5,6,
Marta Galí
1,
Sergi Bernal
8,
Cristina Camps
4,
Lorena Rifa
1,
Montserrat Domenech
1,
Vicenç Ruiz de Porras
9,*
,
Anna Esteve
4 and
Albert Font
4,5,6 
1
Medical Oncology Department, Althaia Xarxa Assistencial Universitària de Manresa, C/Dr. Joan Soler, 1–3, 08243 Manresa, Spain
2
PhD Programme in Medicine and Biomedical Sciences, Doctoral School, University of Vic-Central University of Catalonia (UVic-UCC), C/Dr. Junyent, 1, 08500 Vic, Spain
3
Faculty of Medicine, University of Vic-Central University of Catalonia (UVicUCC), Can Baumann, Ctra de Roda, 70, 08500 Vic, Spain
4
Medical Oncology Department, Catalan Institute of Oncology, Camí de les Escoles, s/n, 08916 Badalona, Spain
5
CARE Program, Germans Trias i Pujol Research Institute (IGTP), Camí de les Escoles, s/n, 08916 Badalona, Spain
6
Badalona Applied Research Group in Oncology (B·ARGO), Catalan Institute of Oncology, Camí de les Escoles, s/n, 08916 Badalona, Spain
7
Urology Department, Althaia Xarxa Assistencial Universitària de Manresa, C/Dr. Joan Soler, 1–3, 08243 Manresa, Spain
8
Urology Department, University Hospital Germans Trias i Pujol, Camí de les Escoles, s/n, 08916 Badalona, Spain
9
GRET and Toxicology Unit, Department of Pharmacology, Toxicology and Therapeutic Chemistry, Faculty of Pharmacy and Food Sciences, University of Barcelona, 08028 Barcelona, Spain
*
Authors to whom correspondence should be addressed.
Cancers 2026, 18(13), 2054; https://doi.org/10.3390/cancers18132054 (registering DOI)
Submission received: 29 May 2026
/
Revised: 22 June 2026
/
Accepted: 23 June 2026
/
Published: 24 June 2026
(This article belongs to the Special Issue Diagnosis and Therapy in Urothelial Cancer)
Simple Summary
Patients with muscle-invasive bladder cancer who are fit for cisplatin usually receive chemotherapy before bladder-removal surgery. However, not all patients benefit from this approach, and some still relapse or die after treatment. In this study, we investigated whether information available before chemotherapy could help identify patients with a higher risk of poor outcomes. We analyzed 210 patients treated at two Spanish hospitals and developed a risk model based on age, sex, previous non-muscle-invasive bladder cancer, and a simple blood-test measure called the neutrophil-to-lymphocyte ratio, which reflects the balance between inflammation and immune cells. This model classified patients into low-, intermediate-, and high-risk groups. Patients in the high-risk group had a shorter time without relapse or death and were less likely to have no residual cancer in the bladder after treatment. The model is exploratory and should not yet be used to guide treatment decisions. However, after validation in other patient groups, it may help improve risk assessment and support more personalized treatment strategies.
Abstract
Background/Objectives: Neoadjuvant cisplatin-based chemotherapy (NAC) followed by radical cystectomy (RC) is a standard treatment for cisplatin-eligible patients with muscle-invasive bladder cancer (MIBC), yet baseline tools to refine prognostic stratification remain limited. We aimed to develop and internally validate a clinicopathological nomogram integrating the neutrophil-to-lymphocyte ratio (NLR) to estimate event-free survival (EFS) in patients with MIBC treated with NAC. Methods: We retrospectively analyzed 210 patients with cT2–T4aN0–1M0 MIBC treated with cisplatin-based NAC at two Spanish institutions between 2010 and 2021. Candidate predictors included demographic, clinicopathological, and routine laboratory variables. A multivariable Cox model with backward selection based on the Akaike information criterion (AIC) was used to derive the final model, and internal validation was performed using 1000 bootstrap resamples. Results: Sex, age, prior non–muscle-invasive bladder cancer (NMIBC), and NLR were retained in the final nomogram. The model showed moderate discrimination, with a Harrell’s c-index of 0.60 and an optimism-corrected c-index of 0.58. The nomogram stratified patients into low-, intermediate-, and high-risk groups, with median EFS not reached, 47.5 months, and 18.0 months, respectively. High-risk patients also showed lower pathological complete response (pCR) rates. Conclusions: This exploratory nomogram integrates an accessible systemic inflammatory marker with baseline clinical variables to identify patients with poorer outcomes despite NAC. External validation in contemporary cohorts is warranted before clinical implementation.
