A predictive model for immunotherapy in extensive-stage small cell lung cancer based on peripheral blood

Extensive-stage small cell lung cancer (ES-SCLC) has a dismal prognosis, with first-line immunochemotherapy benefiting only a minority of patients. Existing inflammatory biomarkers show inconsistent predictive utility, and accessible tools for individualized survival estimation remain lacking. This study aimed to develop and validate a nomogram incorporating the serum lactate dehydrogenase to albumin ratio (LAR) to predict overall survival (OS) and progression-free survival (PFS) in ES-SCLC patients receiving first-line immunotherapy.

A retrospective cohort of 223 pathologically confirmed ES-SCLC patients treated at Yunnan Cancer Hospital (November 2021-August 2025) was analyzed. Ten inflammatory-metabolic markers [including LAR, systemic immune-inflammation index (SII), prognostic nutritional index (PNI)] and clinicopathological variables were extracted. Patients were randomly assigned in a 7:3 ratio to the training (n=156) and internal validation (n=67) cohorts. Optimal cutoff values for continuous variables were determined using the surv_cutpoint function. Independent prognostic factors were identified using univariate/multivariate Cox regression, and nomograms for OS and PFS were constructed. Model performance was evaluated via concordance index (C-index), calibration curves, time-dependent receiver operating characteristic (TimeROC), and decision curve analysis (DCA). Risk stratification was performed using median model-derived scores.

Median follow-up was 22 months. Multivariate analysis identified six independent OS predictors: LAR >6.27 [hazard ratio (HR) =2.794], adrenal metastasis (HR =3.725), PNI <50.5 (HR =0.622), smoking history (HR =1.596), white blood cell count (WBC) >8.30×10⁹/L (HR=1.692), and age >58 years (HR =1.97). Eight independent PFS predictors: tumor-node-metastasis (TNM) stage IV disease (HR =1.407) LAR >6.36 (HR =1.482), SII <342.25 (HR =0.574), albumin (ALB) <42.3 g/L (HR =0.684), neutrophil count (NEUT) <2.64×10⁹/L (HR =0.554), chlorine concentration <96 mmol/L (HR =0.613), male (HR =1.772) and liver metastasis (HR =1.762). The OS nomogram demonstrated superior discriminative ability compared with TNM staging (C-index: 0.728 vs. 0.519, P<0.001). The C-indices for the training and validation cohorts were 0.728 and 0.648 for OS, and 0.668 and 0.627 for PFS, respectively. Time-dependent area under the curve (AUC) for 12-month OS reached 0.793 (training) and 0.742 (validation). Calibration curves and DCA confirmed strong agreement and clinical utility. Low-risk patients (via median score) had significantly longer OS/PFS than high-risk patients (log-rank P<0.05).

We developed the first LAR-integrated nomogram for ES-SCLC immunotherapy outcomes, demonstrating robust predictive accuracy using routine peripheral blood parameters. This accessible tool enables individualized risk stratification and treatment optimization, particularly in resource-limited settings. Prospective multicenter validation is warranted to advance clinical adoption.