Observational studyFrontiers in endocrinology2026
S-GRAS score and the complementary prognostic value of neutrophil-to-lymphocyte ratio in adrenocortical carcinoma: evidence for a synergistic interaction.
Observational study in Frontiers in endocrinology, 2026. The graph could read no effect estimate from its abstract, so it casts no vote on the map. Not yet cited in PubMed.
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Abstract
Introduction: This study aimed to assess the prognostic values of the S-GRAS model and two of the most frequently used inflammation-based scores - neutrophil-to-lymphocyte ratio (NLR) and platelet-to-lymphocyte ratio (PLR) - and to characterise the potential interaction between the two measures. Patients and methods: In this single-centre, retrospective, observational cohort analysis, 67 adult patients with histologically confirmed adrenocortical carcinoma (ACC) were analysed. The S-GRAS score and the inflammation-based markers were evaluated using Kaplan-Meier survival analysis with log-rank tests, univariate and multivariate Cox proportional hazards regressions. Discriminative ability was assessed using Harrell's C-index, later compared with likelihood ratio tests. An interaction analysis was conducted by constructing a multivariate regression with mean-centred variables and their interaction term. Results: External validation on the S-GRAS scoring system demonstrated the superior discriminative ability of the model (C-index=0.765) compared to its constituents. Our sub-analysis on 42 patients identified NLR as a significant predictor of mortality (HR = 3.1; p=0.008), whilst PLR failed to reach statistical significance. Our interaction analysis revealed a significant synergistic interaction between S-GRAS and NLR (HR = 1.177, p=0.009). While both S-GRAS (C-index=0.803) and NLR (C-index=0.722) was found to be a significant predictor of survival, their joint application demonstrated superior prognostic discrimination (C-index=0.822) over their individual use (p=0.006 and p<0.001). Conclusions: NLR provides independent and complementary predictive value to the well-established S-GRAS score, and their combination offers superior discrimination over each marker alone. A synergistic interaction between the two metrics is the most prominent in high-risk patient groups. External validation confirms the prognostic robustness of the S-GRAS score.
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