European Journal of Gynaecological Oncology,2026,47(1):50-55 DOI:10.22514/ejgo.2026.006
Original Research

Prognostic value of neutrophil-to-leukocyte ratio in surgical outcomes of endometrial cancer

Shai Ram1,2, Itamar Gilboa1,2, Maya Goldschmit1,2, Daniela Shapiro2, David Nadav Sabag2, Nadav Michaan1,2, Ido Laskov1,2, Michael Lavie1,2,*,

1Lis Hospital for Women, Tel Aviv Sourasky Medical Center, 6423906 Tel Aviv, Israel

2Gray Faculty of Medicine, Tel Aviv University, 6997801 Tel Aviv, Israel

*Corresponding Author(s):michaella@tlvmc.gov.il (Michael Lavie)

History Submitted: 08 September 2025 | Accepted: 16 October 2025 | Published: 15 January 2026
Copyright:  ©2026  The Author(s). Published by MRE Press.
This is an open access article under the CC BY 4.0 license (https://creativecommons.org/licenses/by/4.0/).

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Abstract

Background: Staging surgery for endometrial cancer poses significant risks of postoperative complications, impacting patient recovery and healthcare resources. Identifying reliable preoperative markers to predict these risks is crucial for optimizing patient care. The neutrophil-to-lymphocyte ratio (NLR), a simple inflammation marker derived from routine blood tests, has shown promise in various cancers but remains underexplored in gynecological oncology. This study investigates whether preoperative NLR and other blood parameters can predict short-term postoperative complications. Methods: A retrospective study was performed at a university-affiliated tertiary hospital, reviewing patients who underwent endometrial cancer staging surgery between 2016–2022. Short-term complications included blood transfusions, antibiotic use, intensive care unit (ICU) admissions, prolonged hospital stays, and hospital readmissions. Data collected encompassed demographics, comorbidities, surgical details, and preoperative complete blood count (CBC) results—specifically hemoglobin (Hb), platelet, and white blood cell (WBC) counts with differential, and NLR. Both univariable and multivariable analyses identified possible risk factors. Results: Out of 149 patients, 38 (25.5%) experienced at least one complication. Those with complications had significantly lower preoperative Hb levels (mean 11.8 vs. 13.3 g/dL, p < 0.001). An NLR >3 was significantly associated with complications (52.5% vs. 31.2%, p = 0.017) and was an independent risk factor (odds ratio (OR) 3.11, 95% confidence interval (CI) (1.01–9.52), p = 0.047). An additional risk was conversion to laparotomy (OR 13.7; 95% CI 1.77–106.38; p = 0.012). Conclusions: Preoperative CBC parameters, especially an NLR above 3, are significant independent predictors of short-term postoperative complications in endometrial cancer staging surgery. Incorporating routine NLR assessment could enhance preoperative risk stratification and targeted perioperative management. Further studies are necessary to validate these biomarkers and improve surgical outcomes.

Keywords:Short-term surgical complications;Staging for endometrial cancer;Neutrophils-tolymphocytes ratio
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Cite this article

Shai Ram, Itamar Gilboa, Maya Goldschmit, Daniela Shapiro, David Nadav Sabag, Nadav Michaan, et al.Prognostic value of neutrophil-to-leukocyte ratio in surgical outcomes of endometrial cancer.European Journal of Gynaecological Oncology,2026,47(1):50-55 DOI:10.22514/ejgo.2026.006

1. Introduction

Endometrial cancer is the most common gynecologic malignancy in developed countries, with its incidence rising globally [1]. The gold-standard treatment is total hysterectomy with bilateral salpingo-oophorectomy and sentinel lymph node biopsy for staging purposes [1]. Surgical treatment exposes patients to both short- and long-term complications [2, 3], with postoperative complications occurring in approximately 25% of cases [3]. These adverse events can significantly affect patients, influence treatment strategies, and burden healthcare systems. Therefore, identifying and evaluating potential risk factors for postoperative complications is essential to reduce their incidence where possible and to ensure appropriate management when prevention is not achievable.

Routine blood tests performed shortly before surgical procedures generally encompass a complete blood count (CBC), which includes hemoglobin (Hb) levels, a differential white blood cell (WBC) count, and platelet counts. Additionally, a metabolic panel is conducted to evaluate renal function, electrolyte levels, and other critical parameters.

Although several studies have examined hematologic parameters in relation to long-term oncologic outcomes [4], the influence of preoperative CBC values on short-term postoperative complications after endometrial cancer surgery remains underexplored. The neutrophil-to-lymphocyte ratio (NLR), a marker of systemic inflammation, has been shown to predict surgical outcomes across various procedures. Elevated preoperative NLR has been associated with an increased risk of postoperative complications, including mortality, acute kidney injury, and prolonged hospitalization [5, 6].

However, data regarding NLR in gynecologic oncology are limited. This study, therefore, aimed to assess the association between specific preoperative CBC parameters and short-term postoperative complications following surgery for endometrial cancer, to identify potential predictors of perioperative risk.

2. Methods

2.1 Study design and population

This retrospective cohort study evaluated the relationship between preoperative CBC components and short-term postoperative complications in patients who underwent surgery for endometrial cancer at a university-affiliated tertiary medical center between January 2016 and December 2022.

We included all patients who underwent staging surgery within this period, and excluded cases lacking complete data on preoperative, intraoperative, or postoperative outcomes. Staging surgeries for endometrial cancer were performed by three experienced gynecological oncologists, and included hysterectomy, bilateral salpingo-oophorectomy, and sentinel lymph node dissection.

The primary objective was to examine preoperative CBC indices as surrogate markers for the occurrence of composite short-term postoperative complications, defined as any of the following: (1) need for blood transfusion; (2) requirement for postoperative antibiotic therapy; (3) postoperative admission to the intensive care unit (ICU); (4) prolonged hospitalization (length of stay exceeding the 75th percentile); or (5) hospital readmission within 30 days of discharge, as previously described [7, 8].

Data were obtained from electronic medical records, including preoperative CBC results performed within three days before surgery (Hb, WBC, platelet count, and absolute neutrophil and lymphocyte counts, from which NLR was calculated). Additional preoperative variables included age, body mass index (BMI), comorbidities (diabetes mellitus, hypertension, ischemic heart disease, thyroid disorders), smoking status, previous abdominal surgery, and American Society of Anesthesiologists (ASA) classification score. Histological subtypes (endometrioid, serous, clear cell, carcinosarcoma) were documented; however, due to small subgroup sizes, only tumor grade was included in the statistical analysis.

At our institution, staging surgery for endometrial cancer is routinely performed via a minimally invasive approach (laparoscopic or robotic), comprising total hysterectomy, bilateral salpingo-oophorectomy, and sentinel lymph node dissection (SLND) using indocyanine green (ICG) mapping. Omentectomy was performed in cases of serous or clear cell histology.

Intraoperative data were collected, including the surgical approach (laparoscopy, laparotomy, or conversion from laparoscopy to laparotomy). Although minimally invasive surgery is the standard technique at our institution, laparotomy was performed in selected cases based on tumor characteristics (e.g., large uterine size or suspected extrauterine spread), patient comorbidities, or intraoperative findings.

Additional intraoperative variables included operative duration, performance of sentinel lymph node dissection (SLND), and occurrence of unplanned complications, such as significant bleeding or injury to the urinary or gastrointestinal tract. Estimated blood loss was obtained from surgical reports, as documented by the operating surgeon, together with total operative time. Cases with an operative time exceeding 180 minutes—corresponding to the 75th percentile—were classified as prolonged procedures. Performance of omentectomy was also recorded.

Cases with missing key data on preoperative, intraoperative, or primary outcome variables were excluded from the analysis.

The study protocol was approved by the Tel Aviv Sourasky Medical Center Institutional Review Board (TLVMC-0720-22). The Tel Aviv Sourasky Medical Center Institutional Review Board waived the requirement for informed consent due to the anonymized nature of the analysis.

2.2 Statistical analysis

Descriptive statistics were used to assess the distribution of variables among patients who underwent post operative complications and those who did not. Continuous variables were summarized as means with standard deviations, and categorical variables were summarized as counts and percentages. A simple logistic regression was performed to assess the associations of risk factors for post-operative complications. Variables with p-values of < 0.05 were chosen for multivariable logistic regression to calculate the odds ratios (OR) with 95% confidence intervals (CI). Finally, a multivariable model was built to delineate risk factors for the composite postoperative complications.

Cut-offs for laboratory values (e.g., NLR >3, Hb <10.5 g/dL) were predefined based on thresholds commonly reported in oncologic literature. All candidate variables were first assessed with univariable analysis, and those with p < 0.1 were included in a multivariable logistic regression model. No stepwise variable selection was used. Correction for multiple testing was not applied given the exploratory nature of this analysis.

The analyses were carried out using Python version 3.73. Significance in the final model was set at a p-value of < 0.05, presented with 95% CI.

3. Results

The study cohort comprised 149 patients who underwent staging surgery for endometrial cancer, of whom 38 (25.5%) experienced at least one of the five predefined postoperative complications. The most frequent complication was prolonged hospitalization, occurring in 31 patients (21%), followed by blood transfusion in 9 (6%), antibiotic treatment in 10 (7%), ICU admission in 4 (2.4%), and hospital readmission within 30 days in 11 patients (7.5%). Some patients experienced multiple complications; therefore, the total number of complications exceeded the number of affected patients (38 women, 25.5%).

Table 1 summarizes perioperative characteristics according to the presence or absence of postoperative complications. Most procedures were performed laparoscopically (n = 117, 78.5%), while 22 (14.7%) were open laparotomies and 10 (6.8%) required conversion from laparoscopy to laparotomy.

Table 1.Patient characteristics, surgical details, and laboratory findings in patients undergoing staging surgery for endometrial cancer, categorized by composite postoperative complications.
CharacteristicWithout complication
n = 111		Complication
n = 38		p-value
Preoperative details
Age >65 (yr)52 (46.8)26 (68.4)0.001
Diabetes mellitus28 (25.2)12 (31.5)0.109
Ischemic heart disease33 (30.3)14 (35.0)0.582
Thyroid disease16 (14.7)3 (7.5)0.244
Smoking16 (14.8)8 (20.0)0.447
Hypertension17 (15.6)6 (15.0)0.929
Previous abdominal surgeries57 (52.3)24 (60.0)0.403
BMI >3055 (50.5)17 (42.5)0.389
Pathologic Grade 320 (18.3)16 (40.0)0.006
Operative details
Upfront Laparotomy6 (5.5)16 (40.0)<0.001
Conversion to laparotomy3 (2.8)7 (17.5)<0.001
SLND71 (65.1)12 (30.0)<0.001
Mean Operation time (min), mean (minimum–maximum)136 (110–177)167 (122–216)0.016
Histological Type (non-endometrial)27 (25.5)21 (55.3)<0.001
Laboratory findings
Preop. Hb (g/dL)13.3 (12.2–13.9)11.8 (10.6–13.1)<0.001
Preop. Hb <10.55 (4.6)9.0 (22.5)<0.001
Preop. WBC mean (IQR 25%–75%)8.3 (6.5–9.7)8.0 (6.8–9.3)0.763
Preop. neutrophil count, mean (IQR 25%–75%)5.2 (3.6–6.6)5.4 (3.9–7.1)0.69
Preop. lymphocyte count, mean (IQR 25%–75%)2.0 (1.5–2.5)1.8 (1.4–2.1)0.101
NLR mean (IQR 25%–75%)2.5 (1.8–3.4)3.1 (1.9–4.0)0.067
NLR >334 (31.2)21 (52.5)0.017
Preop. plt mean (IQR 25%–75%)254 (214–301)246 (214–288)0.667

Values are given as number (%) unless indicated otherwise. BMI, body mass index; SLND, sentinel lymph node dissection; Preop., preoperative; Hb, hemoglobin; WBC, white blood cells; plt, platelets; NLR, neutrophil-to-lymphocyte ratio; IQR, Interquartile range.

Patients who developed postoperative complications had significantly lower preoperative hemoglobin levels than those without complications (mean Hb 11.8 g/dL vs. 13.3 g/dL, p < 0.001) and were more likely to have Hb <10.5 g/dL (22.5% vs. 4.6%, p < 0.001). The mean neutrophil-to-lymphocyte ratio (NLR) was also higher among patients with complications, although the difference reached statistical significance only when the NLR exceeded 3 (NLR >3: 52.5% vs. 31.2%, p = 0.017; Table 1). When specifically examining the association between an elevated NLR (>3) and postoperative complications, the complication rate was 38.2% (21/55) among women with NLR >3 compared with 18.1% (17/94) among women with NLR ≤3 (Risk Ratio (RR) = 2.11, 95% CI 1.22–3.64; Fisher’s exact p = 0.011), as seen on Table 2.

Table 2.Complication rates by neutrophil-to-lymphocyte ratio among patients undergoing staging surgery for endometrial cancer.
GroupComplications/Total patientsRate (95% CI)Risk Ratio (RR)p-value
NLR >321/5538.2% (26.5–51.4%)2.11 (1.22–3.64)0.011
NLR ≤317/9418.1% (11.6–27.1%)Reference—

Summary measures (unadjusted): Risk Ratio (RR) = 2.11 (95% CI 1.22–3.64). Odds Ratio (OR) = 2.80 (95% CI 1.31–5.96). Fisher’s exact: p = 0.011. Rates represent binomial proportions with 95% confidence intervals calculated using the Wilson method. CI, confidence intervals; NLR, neutrophil-to-lymphocyte ratio.

Additional factors associated with postoperative complications included age >65 years, high-grade (grade 3) tumors, non-endometrioid histology, and surgical approach (upfront laparotomy or conversion from laparoscopy). In multivariable analysis (Table 3), conversion to laparotomy remained a significant predictor of postoperative complications (OR 13.7; 95% CI 1.77–106.38; p = 0.012). Among hematologic parameters, NLR >3 was independently associated with postoperative complications (OR 3.11; 95% CI 1.01–9.52; p = 0.047).

Table 3.Multivariable analysis of risk factors for complications among patients undergoing staging surgery for endometrial cancer.
VariablesOdds Ratio95% CIp-value
Conversion to laparotomy13.7361.774–106.3800.012
NLR >33.1121.017–9.5260.047
Age >65 yr1.6060.501–5.1480.426
Operation time1.0060.995–1.0160.29
SLND0.8270.273–2.4680.468
Preoperative Hb <10.54.0950.836–20.0590.082

Hb, hemoglobin; NLR, neutrophil-to-lymphocyte ratio; SLND, sentinel lymph node dissection; CI, confidence intervals.

4. Discussion

In this study of patients undergoing staging surgery for endometrial cancer, a preoperative NLR greater than 3 emerged as the strongest predictor of short-term postoperative complications among all preoperative CBC parameters.

Previous research has linked hematologic abnormalities—such as anemia, leukocytosis, and thrombocytosis—to prognosis and survival in endometrial cancer [9, 10, 11]. A meta-analysis [9] demonstrated a strong association between anemia and reduced overall survival across multiple malignancies. Subsequent studies have confirmed that preoperative anemia is common among women with endometrial cancer and is correlated with adverse clinicopathologic features, including higher FIGO (International Federation of Gynaecology and Obstetrics) stage, deep myometrial invasion, lymph node metastasis, non-endometrioid histology, adnexal or cervical involvement, and high tumor grade.

Few studies, however, have investigated preoperative hematologic parameters in relation to short-term postoperative outcomes. Foley et al. [12] reported that preoperative anemia was associated with higher postoperative morbidity—including transfusions, infectious events, and thromboembolic complications—among gynecologic oncology patients. Although lower hemoglobin levels were also observed in our cohort among patients with complications, this association did not remain significant in multivariable analysis, possibly reflecting limited sample size.

Leukocytosis is a frequent finding in malignancy; however, in our cohort, absolute white blood cell counts did not differ significantly between groups. In contrast, an elevated NLR >3 was an independent predictor of postoperative complications. The clinical relevance of NLR has gained recognition, as it reflects systemic inflammation that may impair wound healing, immune function, and recovery. In breast cancer [13], an NLR >2.5 correlates with reduced disease-free survival, while NLR >3 predicts poorer overall survival. Similarly, Pergialiotis et al. [14] found that elevated preoperative NLR independently predicted postoperative infectious morbidity in gynecologic oncology patients.

Comparable findings have been reported in colorectal surgery [15], where an NLR ≥2.3 predicted major postoperative complications, such as wound infection, anastomotic leakage, and the need for transfusion. Several studies in gynecologic oncology [16, 17] further support the prognostic significance of NLR in endometrial cancer, associating elevated values with advanced stage, aggressive histology, and worse outcomes. Even among patients with early-stage disease, higher NLRs have been linked to lymph node involvement, higher FIGO stage, and poorer prognosis, likely reflecting the pro-tumorigenic role of systemic inflammation [18, 19].

Thrombocytosis, typically defined as a platelet count >400,000/μL, is another well-known paraneoplastic phenomenon associated with unfavorable outcomes in several solid malignancies, including colorectal and ovarian cancers [20, 21, 22]. However, findings in endometrial cancer remain inconsistent. Takahashi et al. [23] identified thrombocytosis as an independent predictor of decreased survival in advanced disease, whereas Kaloglu et al. [24] found no association between platelet count and tumor stage or grade. In our analysis, preoperative thrombocytosis was not significantly correlated with postoperative morbidity, possibly due to the relatively small cohort size.

Conversion to laparotomy and upfront open surgery were also independent predictors of postoperative complications, consistent with previous reports suggesting that minimally invasive approaches confer superior short-term outcomes and should remain the standard of care for low-risk endometrial cancer [25, 26, 27, 28].

This study has several limitations. Its retrospective design introduces potential selection and reporting biases. Some postoperative events may not have been captured if patients were managed at other institutions. Furthermore, because a composite endpoint was used, individual patients could have experienced multiple complications. Lastly, the study was exploratory and not powered to analyze individual complication subtypes.

Future prospective, multicenter investigations should validate NLR and other inflammatory markers as predictors of perioperative risk in gynecologic oncology. Incorporating automated NLR calculation into preoperative assessments may help identify high-risk patients, enabling personalized perioperative management and potentially improving surgical outcomes.

5. Conclusions

In conclusion, our study demonstrates that a preoperative NLR >3 is an independent risk factor for short-term postoperative complications in endometrial cancer surgery. Incorporating NLR into preoperative risk assessment may, therefore, help to identify patients at increased risk, thereby supporting tailored perioperative management and improved surgical outcomes. Future large, prospective, multicenter studies are warranted to validate these findings and refine predictive models integrating inflammatory markers.

Availability of data and materials

The datasets used and analyzed during the current study are available from the corresponding author on reasonable request.

Author contributions

SR—methodology, writing original draft, editing. IG—data curation, statistical analysis. MG, DS, DNS—data curation. NM, IL—supervision, methodology. ML—methodology, writing original and revised manuscript.

Ethics approval and consent to participate

The study protocol was approved by the Tel Aviv Sourasky Medical Center Institutional Review Board (TLVMC-0720-22). The Tel Aviv Sourasky Medical Center Institutional Review Board waived the requirement for informed consent due to the anonymized nature of the analysis.

Acknowledgment

Not applicable.

Funding

This research received no external funding.

Conflict of interest

The authors declare no conflict of interest.

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