Platelet-to-Albumin Ratio and Clinical Outcomes in IDH-Wildtype Grade 4 Diffuse Glioma

Background: Clinical outcomes in isocitrate dehydrogenase (IDH)-wildtype grade 4 diffuse glioma remain highly heterogeneous despite standard multimodal therapy. We evaluated the prognostic significance of pretreatment platelet-to-albumin ratio (PAR) and compared its performance with established inflammatory biomarkers. Methods: This retrospective cohort study included 166 patients with histopathologically confirmed IDH-wildtype grade 4 diffuse glioma treated between 2017 and 2025. Pretreatment PAR, neutrophil-to-lymphocyte ratio (NLR), systemic immune-inflammation index (SII), systemic inflammation response index (SIRI), pan-immune inflammation value (PIV), C-reactive protein-to-albumin ratio (CAR), and lactate dehydrogenase-to-albumin ratio (LAR) were evaluated. Discriminative performance was assessed using classical and inverse probability of censoring weighting (IPCW)-adjusted time-dependent receiver operating characteristic (ROC) analyses. Survival outcomes were evaluated using Kaplan-Meier analyses and predefined baseline-adjusted multivariable Cox proportional hazards regression models. Internal validation was performed using 1000 bootstrap resampling iterations. Results: PAR demonstrated the highest discriminative performance for 12-month overall survival (OS), with an area under the curve of 0.853. Using an optimal cutoff value of 79.459, patients with elevated PAR experienced significantly shorter OS (median, 6.2 vs. 16.7 months; p < 0.001) and progression-free survival (PFS) (median, 5.9 vs. 12.3 months; p < 0.001). In baseline-adjusted multivariable analyses, elevated pretreatment PAR remained independently associated with inferior OS (hazard ratio [HR], 3.287; 95% confidence interval [CI], 2.196-4.921; p < 0.001) and PFS (HR, 3.791; 95% CI, 2.501-5.749; p < 0.001). These findings were supported by sensitivity analyses and bootstrap internal validation. Conclusions: Pretreatment PAR was independently associated with survival outcomes and demonstrated favorable discriminative performance relative to other inflammatory biomarkers. PAR may represent an accessible biomarker reflecting tumor-host interactions in IDH-wildtype grade 4 diffuse glioma. The proposed PAR cutoff should be considered exploratory and requires external validation before routine clinical application.