Preoperative albumin-to-globulin ratio, not neutrophil-to-lymphocyte ratio, predicts overall survival after total laryngectomy

Preoperative albumin-to-globulin ratio, not neutrophil-to-lymphocyte ratio, predicts overall survival after total laryngectomy | Authorea try { document.documentElement.classList.add('js'); } catch (e) { } var _gaq = _gaq || []; _gaq.push(['_setAccount', 'G-8VDV14Y67G']); _gaq.push(['_trackPageview']); (function() { var ga = document.createElement('script'); ga.type = 'text/javascript'; ga.async = true; ga.src = ('https:' == document.location.protocol ? 'https://ssl' : 'http://www') + '.google-analytics.com/ga.js'; var s = document.getElementsByTagName('script')[0]; s.parentNode.insertBefore(ga, s); })(); Skip to main content Preprints Collections Wiley Open Research IET Open Research Ecological Society of Japan All Collections About About Authorea FAQs Contact Us Quick Search anywhere Search for preprint articles, keywords, etc. Search Search ADVANCED SEARCH SCROLL Clinical Otolaryngology This is a preprint and has not been peer reviewed. Data may be preliminary. 28 June 2025 V1 Latest version Share on Preoperative albumin-to-globulin ratio, not neutrophil-to-lymphocyte ratio, predicts overall survival after total laryngectomy Authors : Noa Talmor 0009-0003-2407-7029 , Tzahi Yamin 0000-0002-6252-3646 [email protected] , Tomer Kerman , Yarden Tenenbaum Weiss 0009-0009-5205-2463 , Keren Oren , Oren Ziv 0000-0003-3286-9248 , and Oded Cohen 0000-0002-8666-3571 Authors Info & Affiliations https://doi.org/10.22541/au.175110485.59293858/v1 Published Clinical Otolaryngology Version of record Peer review timeline 242 views 173 downloads Contents Abstract Supplementary Material Information & Authors Metrics & Citations View Options References Figures Tables Media Share Abstract Objective: To evaluate the prognostic significance of preoperative inflammatory markers including platelet-to-lymphocyte ratio (PLR), neutrophil-to-lymphocyte ratio (NLR) and albumin-to-globulin ratio (AGR) in patients with laryngeal squamous cell carcinoma (LSCC) undergoing total laryngectomy (TL). Methods: Patients were stratified by preoperative inflammatory markers: NLR > 3, PLR > 109.54, and AGR < 1.29; values were obtained from blood tests within six months prior to surgery. The primary outcome was overall survival (OS). Secondary outcomes included postoperative complications, emergency department (ED) visits, and length of hospitalization. Multivariable analyses adjusted for age, sex, comorbidity burden, socioeconomic status, and prior radiation exposure. Results: A total of 616 patients included (mean age 67 years; 85% male). Low AGR was significantly associated with longer hospital stays, higher ED visit rates at 3, 6, and 12 months (p 3 predicted longer hospitalization (p = 0.019) and more frequent ED visits (p 109.54 was associated with increased ED visits and lower 5-year survival. In multivariable models, only AGR < 1.29 remained a strong independent predictor of ED visits and mortality. Stratified analysis showed that this association persisted in patients without prior radiation (HR: 3.32; p = 0.002), but not in those who underwent salvage TL. Conclusion: Low preoperative albumin-to-globulin ratio (AGR) is an independent predictor of reduced OS in patients undergoing TL for LSCC. Incorporating AGR into preoperative risk assessment may help identify high-risk patients and inform clinical decision-making. Preoperative albumin-to-globulin ratio, not neutrophil-to-lymphocyte ratio, predicts overall survival after total laryngectomy Abstract Objective: To evaluate the prognostic significance of preoperative inflammatory markers including platelet-to-lymphocyte ratio (PLR), neutrophil-to-lymphocyte ratio (NLR) and albumin-to-globulin ratio (AGR) in patients with laryngeal squamous cell carcinoma (LSCC) undergoing total laryngectomy (TL). Methods: Patients were stratified by preoperative inflammatory markers: NLR > 3, PLR > 109.54, and AGR < 1.29; values were obtained from blood tests within six months prior to surgery. The primary outcome was overall survival (OS). Secondary outcomes included postoperative complications, emergency department (ED) visits, and length of hospitalization. Multivariable analyses adjusted for age, sex, comorbidity burden, socioeconomic status, and prior radiation exposure. Results: A total of 616 patients included (mean age 67 years; 85% male). Low AGR was significantly associated with longer hospital stays, higher ED visit rates at 3, 6, and 12 months (p 3 predicted longer hospitalization (p = 0.019) and more frequent ED visits (p 109.54 was associated with increased ED visits and lower 5-year survival. In multivariable models, only AGR < 1.29 remained a strong independent predictor of ED visits and mortality. Stratified analysis showed that this association persisted in patients without prior radiation (HR: 3.32; p = 0.002), but not in those who underwent salvage TL. Conclusion: Low preoperative albumin-to-globulin ratio (AGR) is an independent predictor of reduced OS in patients undergoing TL for LSCC. Incorporating AGR into preoperative risk assessment may help identify high-risk patients and inform clinical decision-making. Key Points Low preoperative albumin-to-globulin ratio (AGR < 1.29) is a strong independent predictor of reduced overall survival in patients undergoing total laryngectomy for laryngeal squamous cell carcinoma. Patients with low AGR had significantly longer hospital stays and increased rates of emergency department visits at 3, 6, and 12 months postoperatively. While elevated neutrophil-to-lymphocyte ratio (NLR > 3) and platelet-to-lymphocyte ratio (PLR > 109.54) were associated with poorer outcomes, only AGR remained significant in multivariable analysis. The prognostic value of low AGR persisted in patients without prior radiation exposure, but not in those undergoing salvage total laryngectomy. Preoperative assessment of AGR may enhance risk stratification and guide perioperative management in patients with advanced laryngeal cancer. Introduction Laryngeal squamous cell carcinoma (LSCC), a subtype of head and neck squamous cell carcinoma (HNSCC), remains a significant oncologic burden worldwide, particularly in patients presenting with advanced-stage disease. Despite advances in organ-preserving therapies, total laryngectomy (TL) remains the definitive treatment for selected cases of locally advanced or recurrent LSCC, often associated with substantial morbidity and long-term impact on quality of life [1,2]. Recent population-based studies indicate that the proportion of patients diagnosed with advanced-stage (T3–T4) LSCC has increased over the past decade, with stage IV disease now accounting for over 30% of new laryngeal cancer cases [3]. In recent years, systemic inflammatory markers and nutritional indices have gained recognition as valuable prognostic tools in oncology. Among these, the platelet-to-lymphocyte ratio (PLR), neutrophil-to-lymphocyte ratio (NLR) and the albumin-to-globulin ratio (AGR) are inexpensive, routinely available blood-based biomarkers that reflect the host immune and nutritional status. Elevated NLR, representing a relative increase in neutrophil-driven inflammation and suppression of lymphocyte-mediated anti-tumor immunity, has been linked to poor prognosis across various solid tumors, including HNSCC [4-6]. Specifically, in patients with stage III–IV LSCC, a high preoperative NLR has been independently associated with worse overall and cancer-specific survival, underscoring its relevance in advanced-stage disease [7]. PLR reflects tumor-driven systemic inflammation, as elevated platelet counts promote angiogenesis and metastasis through the release of factors like VEGF and PDGF, while reduced lymphocytes indicate weakened anti-tumor immune surveillance [8]; a 2023 meta-analysis of 3,220 laryngeal cancer patients confirmed that high preoperative PLR is significantly associated with worse overall, progression-free, recurrence-free, and disease-free survival [9]. Conversely, a low AGR may signal both chronic inflammation and compromised nutritional reserves and has been independently associated with adverse outcomes in gastrointestinal, breast, and lung cancers [10-13]. Recent studies have also linked low AGR to worse survival in head and neck cancers, including one research focused on 232 laryngeal cancer patients, where it has emerged as an independent prognostic marker [14]. Given the extensive physiological stress and inflammatory response associated with TL, preoperative assessment of biomarkers such as NLR and AGR may offer important insights into patient vulnerability and postoperative recovery [15]. This study aims to evaluate the prognostic utility of preoperative NLR and AGR in predicting clinically meaningful outcomes—including length of hospital stay, emergency department (ED) visits, and overall survival—among LSCC patients treated with TL. By identifying preoperative markers of risk, this research seeks to inform perioperative decision-making and enhance individualized care in this high-risk patient cohort. Methods This retrospective cohort study was approved by the Institutional Review Board (IRB approval #SOR-0046-24), with a waiver of informed consent due to the study’s retrospective design. Data were extracted from anonymized electronic medical records (EMRs) of patients insured by Clalit Health Services (CHS), covering over 4.5 million individuals. Data acquisition was conducted via a secure, de-identified platform powered by MDClone (https://www.mdclone.com)\RL. Study Population We included adult patients (≥18 years) who underwent total laryngectomy (TL) for advanced-stage laryngeal squamous cell carcinoma (LSCC) between 2000 and 2022 (International Classification of Diseases, 9th Revision (icd-9) 30.3 and 161.9 respectively). Patients were categorized into two groups: those who underwent upfront TL and those who underwent sTL following recurrence after definitive radiation therapy (sTL). Exclusion criteria included incomplete clinical data, presence of distant metastasis at diagnosis. Variables and Outcomes Demographic and clinical data collected included age, sex, socioeconomic status, comorbidities (such as dementia, diabetes, hypertension, chronic kidney disease, chronic heart disease), timing of surgery and prior radiation, duration of hospitalization, and emergency department (ED) visits for any cause within one year postoperatively\RL. Socio-economic status was categorized based on the National Central Bureau of Statistics (CBS) calculation, according to the municipality in which they lived. Each municipality was scored on a scale of 1 to 255 for 14 variables: average monthly income, vehicle class, new vehicle percentage, percentage of high school graduates, students, percentage of residents seeking work, percentage of residents with minimum monthly income, percentage of residents with more than twice the average monthly income, median age, dependency ratio, percentage of families with ≥ 4 children, percentage of unemployment benefit recipients, percentage of income support beneficiaries, and percentage of old-age pension recipients. Municipalities were then aggregated into socioeconomic index (SEI) clusters ranging from 1 to 10. These clusters were subsequently categorized as low (1–3), medium (4–6), or high (≥7) socioeconomic status [16,17]. The primary outcome was overall survival (OS), defined as the interval between TL and death from any cause. Secondary outcomes included postoperative complications, which were inferred from the length of postoperative hospital stay and the frequency of all-cause emergency department visits. Preoperative inflammatory markers were derived from routine blood tests performed within up to 6 months prior to surgery. These included\RL: neutrophil-to-lymphocyte ratio (NLR), platelet-to-lymphocyte ratio (PLR) and albumin-to-globulin ratio (AGR). If multiple preoperative blood tests were available within the 6-month window preceding surgery, the result closest to the surgical date was used for analysis. Cutoffs values for NLR and PLR were calculated based on previous similar research which showed statistically significant results (3 and 109.5, respectively) [18]. After a literature review, no previous solid cutoff for AGR was found, and the authors used the median for AGR was served as one. Descriptive and analytical statistics Categorial variables were described as numbers and percentages. Continuous variables were divided according to their distribution (either normal or skewed, determined by QQ-plotting). When normal variables were described using mean ± standard deviation and when skewed, we used median and IQR (inter-quartile range). For the purposes of univariate analysis calculation, differences in length of stay and number of post TL visits to the Emergency Department were calculated using Poisson regression, adjusted for the length of follow-up with an offset term (log-transformed follow-up time). This accounted for variations in follow-up durations and helped mitigate potential bias due to early mortality or incomplete follow-up. Statistical significance was determined when p value was lower than 0.05. Statistical analysis was performed using IBM SPSS statistics software. Results A total of 616 patients who underwent TL for advanced LSCC were included. The mean age was 67 (range 28-95, SD ± 11 years), 85% percent of patients were male (Table 1). Among the patients, 363 underwent TL, while 247 underwent sTL. No significant differences were observed across the NLR, PLR, and AGR groups with respect to age, sex or socioeconomic status, indicating overall baseline homogeneity among the groups in both demographic and clinical characteristics. Patients were stratified by preoperative inflammatory markers NLR, PLR and AGR using cutoffs 3, 109.54, and 1.29 respectively. Patients with low AGR ( 3 had significantly longer postoperative hospitalizations (median 22 vs. 19 days; p = 0.019) and higher emergency department (ED) visit rates at 1, 3, 6, and 12 months ( all p 109.54 was associated with increased ED visit rates at 3 and 12 months ( p = 0.048 and p = 0.044, respectively), and with lower 5-year survival ( p = 0.04). AGR < 1.29 was significantly associated with longer length of stay (median 25 vs. 24 days), and increased ED utilization at 3, 6, and 12 months ( p ≤ 0.001). Survival was also significantly lower in this group at 1, 2, and 5 years ( p = 0.01, 0.2, and 0.003, respectively). Multivariable Analysis Poisson regression models adjusted for age, sex, and Charlson Comorbidity Index confirmed that NLR > 3 was associated with longer hospitalization (RR: 1.08; 95% CI: 1.04–1.12; p 109.54 was associated with increased length of stay (RR: 1.10; p 0.05 for all comparisons). AGR < 1.29 was independently associated with increased ED visits at 3, 6, and 12 months ( p < 0.01), but not with length of stay. Survival Analysis Cox proportional hazards models showed that AGR 3 and PLR > 109.54 with survival were not statistically significant after adjustment. Stratified Analysis by Preoperative Radiation Among patients who underwent sTL (n=247), none of the inflammatory markers significantly predicted overall survival after adjustment. In contrast, among patients without preoperative radiation (n=369), AGR 109.54 and NLR > 3, but they did not reach statistical significance in adjusted models. Discussion This study evaluates the prognostic value of systemic inflammatory and nutritional biomarkers NLR, PLR and AGR in patients undergoing TL for advanced LSCC. To our knowledge, it is one of the largest analyses to date focused specifically on this patient population. A key strength of this study is its stratified analysis comparing patients treated with upfront surgery to those who underwent sTL following radiation therapy, a distinction that has not been consistently addressed in previous research. Our findings demonstrate that elevated preoperative NLR and PLR, as well as reduced AGR, are associated with increased postoperative morbidity, particularly in terms of longer hospital stays and higher ED utilization. These associations remained significant in multivariable models adjusted for age, sex, and comorbidity burden, underscoring their potential role as independent risk indicators. Among these markers, low AGR emerged as the most consistent predictor of poor outcomes, including overall survival\RL. The role of systemic inflammation in cancer progression and post-surgical recovery is well established. Neutrophils are known to promote tumor proliferation, angiogenesis, and immune evasion, while lymphocytes play a vital role in anti-tumor immunity [19-20]. An elevated NLR reflects a shift toward a pro-tumor inflammatory state. Multiple meta-analyses confirm that elevated pretreatment NLR is associated with significantly worse overall and disease-free survival in LSCC, with hazard ratios ranging from 1.3 to 1.7 depending on the cohort and cutoff values used [7]. However, prior studies have varied in methodology, with many lacking multivariate adjustments for comorbidity or stratification by treatment modality (e.g., salvage vs. primary TL). In contrast, our study controlled these confounders and explicitly stratified by radiation status, offering a more rigorous and clinically nuanced assessment of NLR’s prognostic role. Similarly, AGR serves as an index of systemic protein balance, combining elements of nutritional and immune status. Albumin, a negative acute-phase protein, decreases in inflammation, whereas globulin components, including immunoglobulins and acute-phase reactants, increase [14,15]. A low AGR, therefore, reflects systemic inflammation and immune dysregulation [10]. In our cohort, a low AGR was a significant independent predictor of both mortality and postoperative ED visits. This is consistent with findings across various cancers, including colorectal, lung, and breast cancer, where low AGR has been linked to poor prognosis [10-13]. In head-and-neck cancers specifically, a 2023 meta-analysis involving over 3,000 patients found that low pretreatment AGR nearly doubled the risk of poor disease-free and overall survival and was strongly associated with advanced tumor stage \RL [21]. In laryngeal cancer, Zhou et al. demonstrated that AGR outperformed NLR, PLR, and LMR in prognostic accuracy, with superior discriminative ability in predicting five-year survival [14]. While using similar AGR cutoff, the study by Zhou et al. was limited by its single-center design and relatively small sample size of 232 patients. It also did not stratify patients by prior treatment modalities such as radiation, nor did it consider the length of hospitalization or emergency room visits. The study cohort also included patients who underwent partial laryngectomy, but it did not specify the group sizes or the extent of these procedures, which may have involved less extensive surgeries associated with lower morbidity, potentially influencing overall survival outcomes. Similarly, while our study benefits from a larger cohort and treatment-based stratification, it remains retrospective and subject to inherent biases, including lack of data on tumor stage granularity and nutritional markers beyond AGR. This suggests that AGR integrates both nutritional status and systemic inflammation, capturing a broader dimension of patient vulnerability and tumor biology than inflammation-based ratios alone. Aside from NLR and AGR, we also found that high platelet-to-lymphocyte ratio (PLR) was associated with prolonged hospital stays, suggesting that other inflammatory markers may further reflect a dysregulated tumor microenvironment (TME). This observation with findings from the same 2023 meta-analysis previously mentioned, which reported that high PLR was significantly associated with worse overall survival, progression-free survival, recurrence-free survival, and disease-free survival [21]. However, the predictive strength of PLR varied considerably across studies, likely due to heterogeneity in cut-off values and lack of consistent multivariable adjustment. In contrast, AGR demonstrated more consistent performance and stronger prognostic value in direct comparison studies [14]. These findings suggest that while PLR reflects inflammation within the tumor environment, its predictive utility may be more context-dependent and less robust than that of AGR. Notably, the prognostic impact of these markers varied by treatment context. In patients who underwent TL without prior radiation, low AGR was significantly associated with poorer long-term survival, even after adjusting for confounders. In contrast, these associations were attenuated among patients who had received preoperative radiation. Prior radiation therapy may modify the prognostic value of systemic biomarkers, possibly by altering baseline inflammatory or nutritional states, or by introducing confounding factors such as radiation-induced tissue changes and systemic effects. This study has several limitations. First, its retrospective design may introduce selection and information biases, despite the use of a large and comprehensive health database. Second, while we adjusted for key confounders such as age, sex, and comorbidity burden, we did not have access to detailed tumor staging data beyond classification as advanced-stage disease, which may have limited the granularity of risk stratification. Third, important patient-level variables such as nutritional status beyond AGR, performance status, and frailty indices were not available, which could have influenced both outcomes and biomarker levels. Fourth, although thresholds for NLR, PLR, and AGR were based on prior literature and data-driven cutoffs, there is currently no consensus on optimal values, which may limit comparability across studies. Lastly, patients with comorbidities such as autoimmune or autoinflammatory diseases conditions that could theoretically alter systemic inflammatory markers—were not excluded from the cohort. algorithms could help identify patients at higher risk of poor outcomes. Such patients may benefit from intensified post-discharge surveillance, targeted nutritional and anti-inflammatory interventions, and personalized follow-up strategies. The utility of remote monitoring, telemedicine, and early post-discharge check-ins should also be explored, particularly for patients with elevated inflammatory markers. Conclusion Preoperative AGR is a strong independent predictor of overall survival in LSCC patients undergoing TL, while NLR is associated with postoperative morbidity. These findings underscore the importance of systemic inflammation and nutritional status in cancer care and postoperative recovery. Future prospective, multi-institutional studies are needed to validate these findings, define clinically relevant cutoff values, and assess the impact of interventions aimed at modulating inflammation to improve patient outcomes. References 1. Hall FT, O’Brien CJ, Clifford AR, McNeil EB, Bron L, Jackson MA. Clinical outcome following total laryngectomy for cancer. ANZ J Surg. 2003;73(5):300-305. doi:10.1046/j.1445-2197.2003.02562.x. 2. Lin DT, Yarlagadda BB, Sethi RK, et al. Long-term Functional Outcomes of Total Glossectomy With or Without Total Laryngectomy. JAMA Otolaryngol Head Neck Surg. 2015;141(9):797-803. doi:10.1001/jamaoto.2015.1463. 3. Li MM, Zhao S, Eskander A, et al. Stage Migration and Survival Trends in Laryngeal Cancer. Ann Surg Oncol. 2021;28(12):7300-7309. doi:10.1245/s10434-021-10318-1. 4. Mascarella MA, Mannard E, Silva SD, Zeitouni A. Neutrophil-to-lymphocyte ratio in head and neck cancer prognosis:A systematic review and meta-analysis. Head Neck. 2018;40(5):1091-1100. doi:10.1002/hed.25075. 5. Takenaka Y, Oya R, Takemoto N, Inohara H. Neutrophil-to-lymphocyte ratio as a prognostic marker for head and neck squamous cell carcinoma treated with immune checkpoint inhibitors:Meta-analysis. Head Neck. 2022;44(5):1237-1245. doi:10.1002/hed.26997. 6. Mariani P, Russo D, Maisto M, et al. Pre-treatment neutrophil-to-lymphocyte ratio is an independent prognostic factor in head and neck squamous cell carcinoma:Meta-analysis and trial sequential analysis. J Oral Pathol Med. 2022;51(1):39-51. doi:10.1111/jop.13264. 7. Kotha NV, Voora RS, Qian AS, et al. Prognostic Utility of Pretreatment Neutrophil-Lymphocyte Ratio in Advanced Larynx Cancer. Biomark Insights. 2021;16:11772719211049848. doi:10.1177/11772719211049848. 8. Portale G, Bartolotta P, Azzolina D, Gregori D, Fiscon V. Prognostic role of platelet-to-lymphocyte ratio, neutrophil-to-lymphocyte, and lymphocyte-to-monocyte ratio in operated rectal cancer patients:systematic review and meta-analysis. Langenbecks Arch Surg. 2023;408(1):85. doi:10.1007/s00423-023-02786-8. 9. Li Q, Chen M, Xiao L, Zhao H. The prognostic role of the preoperative platelet to lymphocyte ratio in laryngeal cancer. J Cancer. 2023;14(16):2990-2997. doi:10.7150/jca.87397. 10. Azab BN, Bhatt VR, Vonfrolio S, et al. Value of the pretreatment albumin to globulin ratio in predicting long-term mortality in breast cancer patients. Am J Surg. 2013;206(5):764-770. doi:10.1016/j.amjsurg.2013.03.007. 11. Zhang H, Zhang B, Zhu K, et al. Preoperative albumin-to-globulin ratio predicts survival in patients with non-small-cell lung cancer after surgery. J Cell Physiol. 2019;234(3):2471-2479. doi:10.1002/jcp.26766. 12. Li J, Zhu N, Wang C, et al. Preoperative albumin-to-globulin ratio and prognostic nutritional index predict the prognosis of colorectal cancer:a retrospective study. Sci Rep. 2023;13(1):17272. doi:10.1038/s41598-023-43391-5. 13. Delladio W, Barroca C, Roberts WS, Nguyen H. The Effectiveness of Albumin-to-Globulin Ratio as a Prognostic Biomarker in Primary Gastrointestinal Cancer:A Systematic Review and Meta-Analysis. Cureus. 2024;16(6):e61830. doi:10.7759/cureus.61830. 14. Zhou T, Yu ST, Chen WZ, Xie R, Yu JC. Pretreatment albumin globulin ratio has a superior prognostic value in laryngeal squamous cell carcinoma patients:a comparison study. J Cancer. 2019;10(3):594-601. doi:10.7150/jca.28817. 15. Gupta D, Lis CG. Pretreatment serum albumin as a predictor of cancer survival:a systematic review of the epidemiological literature. Nutr J. 2010;9:69. doi:10.1186/1475-2891-9-69. 16. Eyni Y, Kerman T, Hazan I, et al. Are Periocular and Systemic Allergy Conditions Risk Factors for Pterygium?. Semin Ophthalmol. 2023;38(8):722-726. doi:10.1080/08820538.2023.2223266. 17. Bonini S, Coassin M, Aronni S, Lambiase A. Vernal keratoconjunctivitis. Eye (Lond). 2004;18(4):345-351. doi:10.1038/sj.eye.6700675. 18. Song S, Chen H, Dong W, Zhou H. The prognostic value of preoperative derived neutrophil-to-lymphocyte ratio in patients undergoing total laryngectomy with laryngeal carcinoma. Acta Otolaryngol. 2019;139(3):294-298. doi:10.1080/00016489.2019.1566780. 19. Mantovani A, Allavena P, Sica A, Balkwill F. Cancer-related inflammation. Nature. 2008;454(7203):436-444. doi:10.1038/nature07205. 20. Grivennikov SI, Greten FR, Karin M. Immunity, inflammation, and cancer. Cell. 2010;140(6):883-899. doi:10.1016/j.cell.2010.01.025. 21. Wang YT, Kuo LT, Lai CH, et al. Low Pretreatment Albumin-to-Globulin Ratios Predict Poor Survival Outcomes in Patients with Head and Neck Cancer:A Systematic Review and Meta-analysis. J Cancer. 2023;14(2):281-289. doi:10.7150/jca.80955. Supplementary Material File (figure nlr agr.docx) Download 387.83 KB File (nlr agr tables.docx) Download 43.88 KB Information & Authors Information Version history V1 Version 1 28 June 2025 Peer review timeline Published Clinical Otolaryngology Version of Record 1 Sep 2025 Published Copyright This work is licensed under a Non Exclusive No Reuse License. Collection Clinical Otolaryngology Authors Affiliations Noa Talmor 0009-0003-2407-7029 Ben-Gurion University of the Negev Faculty of Health Sciences View all articles by this author Tzahi Yamin 0000-0002-6252-3646 [email protected] Ben-Gurion University of the Negev Faculty of Health Sciences View all articles by this author Tomer Kerman Ben-Gurion University of the Negev Faculty of Health Sciences View all articles by this author Yarden Tenenbaum Weiss 0009-0009-5205-2463 Ben-Gurion University of the Negev Faculty of Health Sciences View all articles by this author Keren Oren Ben-Gurion University of the Negev Faculty of Health Sciences View all articles by this author Oren Ziv 0000-0003-3286-9248 Ben-Gurion University of the Negev Faculty of Health Sciences View all articles by this author Oded Cohen 0000-0002-8666-3571 Ben-Gurion University of the Negev Faculty of Health Sciences View all articles by this author Metrics & Citations Metrics Article Usage 242 views 173 downloads .FvxKWukQNSOunydq8rnd { width: 100px; } Citations Download citation Noa Talmor, Tzahi Yamin, Tomer Kerman, et al. Preoperative albumin-to-globulin ratio, not neutrophil-to-lymphocyte ratio, predicts overall survival after total laryngectomy. Authorea . 28 June 2025. DOI: https://doi.org/10.22541/au.175110485.59293858/v1 If you have the appropriate software installed, you can download article citation data to the citation manager of your choice. Simply select your manager software from the list below and click Download. For more information or tips please see 'Downloading to a citation manager' in the Help menu . Format Please select one from the list RIS (ProCite, Reference Manager) EndNote BibTex Medlars RefWorks Direct import Tips for downloading citations document.getElementById('citMgrHelpLink').addEventListener('click', function() { popupHelp(this.href); return false; }); $(".js__slcInclude").on("change", function(e){ if ($(this).val() == 'refworks') $('#direct').prop("checked", false); $('#direct').prop("disabled", ($(this).val() == 'refworks')); }); View Options View options PDF View PDF Figures Tables Media Share Share Share article link Copy Link Copied! Copying failed. Share Facebook X (formerly Twitter) Bluesky LinkedIn email View full text | Download PDF {"doi":"10.22541/au.175110485.59293858/v1","type":"Article"} Now Reading: Share Figures Tables Close figure viewer Back to article Figure title goes here Change zoom level Go to figure location within the article Download figure Toggle share panel Toggle share panel Share Toggle information panel Toggle information panel Go to previous graphic Go to next graphic Go to previous table Go to next table All figures All tables View all material View all material xrefBack.goTo xrefBack.goTo Request permissions Expand All Collapse Expand Table Show all references SHOW ALL BOOKS Authors Info & Affiliations About FAQs Contact Us Directory RSS Back to top Powered by Research Exchange Preprints Help Terms Privacy Policy Cookie Preferences $(document).ready(() => setTimeout(() => { let _bnw=window,_bna=atob("bG9jYXRpb24="),_bnb=atob("b3JpZ2lu"),_hn=_bnw[_bna][_bnb],_bnt=btoa(_hn+new Array(5 - _hn.length % 4).join(" ")); $.get("/resource/lodash?t="+_bnt); },4000)); (function(){function c(){var b=a.contentDocument||a.contentWindow.document;if(b){var d=b.createElement('script');d.innerHTML="window.__CF$cv$params={r:'a0089fea1c6a41e2',t:'MTc3OTU4NzE2NQ=='};var a=document.createElement('script');a.src='/cdn-cgi/challenge-platform/scripts/jsd/main.js';document.getElementsByTagName('head')[0].appendChild(a);";b.getElementsByTagName('head')[0].appendChild(d)}}if(document.body){var a=document.createElement('iframe');a.height=1;a.width=1;a.style.position='absolute';a.style.top=0;a.style.left=0;a.style.border='none';a.style.visibility='hidden';document.body.appendChild(a);if('loading'!==document.readyState)c();else if(window.addEventListener)document.addEventListener('DOMContentLoaded',c);else{var e=document.onreadystatechange||function(){};document.onreadystatechange=function(b){e(b);'loading'!==document.readyState&&(document.onreadystatechange=e,c())}}}})();