LAUSR

Dear editor, We read with great interest the article by Wilson et al. [4] titled Pre-operative neutrophil count and neutrophillymphocyte count ratio (NLCR) in predicting the histological grade of paediatric brain tumours: a preliminary study. We commend the authors for undertaking this study to evaluate the feasibility of using a common laboratory parameter as a marker for grade of intra-axial brain tumor. In this study, the authors have systematically excluded those with recurrent tumor, metastasis, and bone marrow transplant recipients. These factors may act as confounders, and thus, their exclusion was warranted. However, with a marker such as differential leucocyte count, which is commonly perturbed by conditions much more prevalent than brain tumors, these conditions must have been excluded to realize the true value of this marker. Acute infectious conditions may alter these values randomly and result in dilution of the observed association. Also, other diseases like congenital heart disease, past history of infection and drugs may alter the NLR [2]. Use of steroids or a hypercortisolic state due to stress reaction may also significantly impact the NLR, and thus, cortisol levels must have been measured and those with abnormal levels must have been either excluded or results have been statistically adjusted. Similarly, the other probable confounders as discussed above were neither excluded nor systematically analyzed by the authors. Since, the proposed hypothesis for association of NLR with grade of tumor is systemic inflammatory activity, it seems plausible that other markers of inflammation like erythrocyte sedimentation rate (ESR), C reactive protein (CRP), or procalcitonin may also be related to the grade of pediatric brain tumors. It would have been interesting if these parameters were evaluated and compared as markers [1]. The authors have excluded patients of craniopharyngioma in this study as they considered it extra-axial tumor. However, Chen et al. [3] found that preoperative inflammatory markers including white blood cells (WBC), neutrophil, and NLR + platelet lymphocyte ratio (PLR) were to be related to the pathogenesis of craniopharyngioma. Thus, the reason for exclusion of craniopharyngioma seems unsatisfactory, and it would have been informative to know their findings regarding this subset as well. Also, authors have not separately analyzed their findings for different types of pediatric brain tumors. It would be of greater clinical significance if the role of NC, NLR, and other inflammatory markers is known for each type of tumor rather than a group as a whole. We would like to commend the authors for discussing an important topic; however, there were some shortcomings in the study as we have discussed. Thus, there is a need for a prospective study, which takes into account all the possible confounders, and with a greater sample size to detect the intended association with adequate power.