The 126 patients included in this study were all from the Second Affiliated Hospital of Shandong Medical University (September 2012 - April 2019). Inclusion criteria: (1) Patients were over 18 years old; (2) Patients were diagnosed with NSCLC by histopathology; (3) Patients had a Karnofsky Performance Status (KPS) score of 80–100; (4) Patients had not received anti-tumor treatment before admission; (5) Peripheral blood tests had been completed one week before treatment, including albumin, cholesterol, neutrophils, monocytes, lymphocytes, and tumor markers; (6) Patients did not have any major internal medical conditions and must met the indications for chemotherapy and surgery as confirmed jointly by oncologists and thoracic surgeons; (7) The patients and their families agreed to the surgery and preoperative neoadjuvant chemotherapy, and already signed informed consent forms. Exclusion criteria: (1) Concurrent malignant tumors; (2) Previous use of antibiotics or nonsteroidal anti-inflammatory drugs; (3) Presence of chronic or active infectious diseases.

We have collected the following information: gender, age, smoking status, pathological type, tumor location, clinical stage, degree of differentiation, KPS score, CEA level, chemotherapy regimen, surgical procedure, postoperative complications, PFS, OS, as well as albumin, cholesterol, neutrophil, monocyte counts, and lymphocyte was measured one week before neoadjuvant chemotherapy. There were no missing data for any of the patients included in the analysis.

According to current lung Cancer treatment guidelines, treatment plans were developed for all patients receiving chemotherapy through multidisciplinary discussion and evaluation by senior oncologists. Specific chemotherapy regimens included: pemetrexed combined with platinum-based drugs, paclitaxel combined with platinum-based drugs, gemcitabine combined with platinum-based drugs, and pemetrexed or paclitaxel combined with platinum-based chemotherapy. Specific dosages were determined based on the patient’s tolerance, tumor status, and the dosage and duration of chemotherapy drugs.

Patients rested for two weeks after chemotherapy. If there were no contraindications, surgery could then proceed; if contraindications existed, the rest period was extended until surgical indications were met. The specific surgical approach depended on the patient’s lesion characteristics; thoracoscopic surgery or open thoracotomy was selected. The choice between the two surgical approaches was made after a comprehensive evaluation by at least three thoracic surgeons to ensure surgical safety and minimize patient injury.

All enrolled patients underwent regular follow-up. Follow-up was primarily conducted via telephone or outpatient examinations. Follow-up assessments were scheduled at three-month intervals during the initial three-year period, transitioning to six-month intervals for the subsequent six years. Scheduled follow-up included physical examinations, imaging studies, and laboratory tests.

OS was measured from the date of initial treatment to the date of all-cause death or the last known follow-up. PFS was assessed as the time from treatment initiation to the first evidence of disease progression, including local recurrence, metastatic spread, as well as death.

MNPS was calculated based on cholesterol, albumin, NLR, and LMR. Data analysis was conducted with X-tile 3.6.1 (Yale University, New Haven, CT, USA), aiming at establishing cohort-specific optimal cutoffs for cholesterol, albumin, NLR, and LMR. (Figure 1) The modified Naples prognostic score was constructed as follows: albumin concentration >41.8 g/L = 0 points, ≤41.8 g/L = 1 point; cholesterol concentration >137.5 mg/dL = 0 points, ≤137.5 mg/dL = 1 point; NLR ≤2.1 = 0 points, >2.1 = 1 point; LMR >4.8 = 0 points, ≤4.8 = 1 point. The total score of the four indicators was the mNPS. Group 0 had an mNPS score of 0, Group 1 had scores of either1 or 2, and Group 2 had scores of 3 or 4.

Statistical analysis was performed using IBM SPSS Statistics, Version 27.0 (SPSS Inc., Chicago, IL). The predictive accuracy of the mNPS, albumin, cholesterol, NLR, and LMR was evaluated using receiver operating characteristic (ROC) methodology. Survival outcomes across Groups were compared using the Kaplan-Meier method with comparison by the log-rank test. Univariate and multivariate Cox proportional hazards models were employed to identify candidate and delineate independent prognostic factors, respectively, with results expressed as hazard ratios (HR) and corresponding 95% confidence intervals (95% CI). Proportional hazards assumptions for all Cox regression models were verified using Schoenfeld residuals.

126 patients were included through strict inclusion and exclusion criteria. All patients received neoadjuvant chemotherapy prior to surgery and underwent regular follow-up (Figure 2). 66 patients (52.4%) were female, and 60 patients (47.6%) were male. 67 patients (53.2%) were aged <60 years, and 59 patients (46.8%) were aged ≥60 years. 52.4% of patients smoked. 82 patients (65.1%) were clinically stage IIIA, and 44 patients (34.9%) were stage IIIB. The majority of patients (98, 77.8%) recorded a KPS score of 100, with the remaining 28 (22.2%) scoring between 80 and 90. Of the 72 patients (57.1%), the pathological type was adenocarcinoma, and 54 patients (42.9%) were squamous cell carcinoma. 56 patients (44.4%) underwent open thoracotomy, and 70 patients (55.6%) underwent VAST surgery. 59 patients (46.8%) received neoadjuvant chemotherapy with paclitaxel+ platinum-based drugs, 30 patients (23.8%) received pemetrexed+ platinum-based drugs, and 37 patients (29.4%) received gemcitabine+ platinum-based drugs. 62 patients (49.2%) experienced postoperative complications.

Based on the mNPS criteria, Group 0 (0 points) comprised 20 patients (15.9%); Group 1 (1–2 points) comprised 85 patients (67.5%); and Group 2 (3–4 points) comprised 21 patients (16.7%). MNPS showed no statistically significant association with any clinicopathological characteristic (all P > 0.05) (Table 1).

The predictive performance of mNPS, albumin, cholesterol, LMR, and NLR was assessed via ROC curve analysis. Table 2 lists the area under the curve (AUC) for mNPS, albumin, cholesterol, NLR, and LMR. The results indicate that mNPS had greater predictive value for OS (AUC = 0.640, P = 0.007) and PFS (AUC = 0.623, P = 0.024) than albumin, cholesterol, NLR, and LMR. The ROC curves clearly demonstrated the predictive ability of mNPS (Figure 3). Figure 4 shows the OS and PFS survival curves for the three Groups. For all enrolled patients, the OS and PFS of Group 0 were superior to those of Groups 1 and 2 (OS: Group 1 vs Group 0, P = 0.038; Group 2 vs Group 0, P = 0.001; PFS: Group 1 vs Group 0, P = 0.005; Group 2 vs Group 0, P = 0.004).

Table 3 presented the results of the univariate Cox proportional hazards regression analysis for clinicopathological features, mNPS, and their association with OS and PFS. Univariate analysis showed that surgical method (P = 0.042), clinical stage (P = 0.004), and KPS score (P = 0.003) were significantly associated with OS. Conversely, smoking history (P = 0.744), gender (P = 0.506), age (P = 0.460), tumor location (P = 0.419), pathological type (P = 0.969), differentiation degree (P = 0.323), CEA level (P = 0.806), and mNPS (Group 1 vs Group 0, P = 0.051; Group 2 vs Group 0, P = 0.001) were not statistically associated with OS. KPS score (P = 0.002), clinical stage (P = 0.005), and mNPS (Group 1 vs Group 0, P = 0.010; Group 2 vs Group 0, P = 0.002) were significantly associated with PFS. Other clinicopathological factors were not statistically significant with PFS. Indicators significant in the univariate analysis of PFS were included in the multivariate analysis. The multivariate analysis results showed that mNPS score (Group 1 vs Group 0, P = 0.038; Group 2 vs Group 0, P = 0.008), clinical stage (P = 0.022), and KPS score (P = 0.017) were independent prognostic factors for PFS (Table 4).