{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,7,30]],"date-time":"2026-07-30T11:11:29Z","timestamp":1785409889473,"version":"3.56.0"},"reference-count":44,"publisher":"MDPI AG","issue":"15","license":[{"start":{"date-parts":[[2026,7,23]],"date-time":"2026-07-23T00:00:00Z","timestamp":1784764800000},"content-version":"vor","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/licenses\/by\/4.0\/"}],"funder":[{"DOI":"10.13039\/501100002474","name":"Dongyang University","doi-asserted-by":"crossref","id":[{"id":"10.13039\/501100002474","id-type":"DOI","asserted-by":"crossref"}]},{"id":[{"id":"https:\/\/ror.org\/05v1ekw79","id-type":"ROR","asserted-by":"publisher"}]}],"content-domain":{"domain":[],"crossmark-restriction":false},"short-container-title":["J. Clin. Med.","JCM"],"abstract":"<jats:p>Background: Anatomical staging is often insufficient for predicting outcomes in stage I-IIIA non-small cell lung cancer (NSCLC) patients after curative resection due to inherent prognostic variability. In this study, we evaluated the prognostic value of the C-reactive protein\u2013albumin\u2013lymphocyte\u2013monocyte (CALM) index as an integrative biomarker for overall survival (OS). Methods: This retrospective study included 533 patients with stage I-IIIA NSCLC. We assessed the association between the CALM index and OS using multivariable Cox proportional hazards models, adjusted for established clinicopathological factors. We employed LASSO-penalized regression to optimize variable selection and ensure model stability. Comprehensive performance metrics were calculated, including Harrell\u2019s C-index, integrated area under the curve (iAUC), integrated discrimination improvement (IDI), and decision-curve analysis (DCA). Results: The CALM index was identified as a stable, independent predictor of OS across both conventional and LASSO-penalized models. The final multivariable model incorporated the CALM index alongside age, pathological stage, American Society of Anesthesiologists status, pleural invasion, and the modified Shine\u2013Lal index. Incorporation of the CALM index significantly enhanced model discrimination and risk reclassification at 3 and 5 years, while consistently increasing net clinical benefit across a wide range of threshold probabilities. Conclusions: The CALM index is a biologically plausible, robust, and readily accessible prognostic biomarker that provides incremental prognostic information beyond established factors in patients with resected stage I-IIIA NSCLC. Its integration into postoperative assessment offers a framework for refined prognostic stratification and more individualized clinical decision-making.<\/jats:p>","DOI":"10.3390\/jcm15155772","type":"journal-article","created":{"date-parts":[[2026,7,23]],"date-time":"2026-07-23T17:13:17Z","timestamp":1784826797000},"page":"5772","update-policy":"https:\/\/doi.org\/10.3390\/mdpi_crossmark_policy","source":"Crossref","is-referenced-by-count":0,"title":["Prognostic Significance of the CALM Index in Surgically Resected Non-Small Cell Lung Cancer"],"prefix":"10.3390","volume":"15","author":[{"given":"Soomin","family":"An","sequence":"first","affiliation":[{"name":"Department of Nursing, Dongyang University, Yeongju 36040, Gyeongbuk, Republic of Korea"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-9289-371X","authenticated-orcid":false,"given":"Wankyu","family":"Eo","sequence":"additional","affiliation":[{"name":"College of Medicine, Kyung Hee University, Seoul 05278, Republic of Korea"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-8897-2124","authenticated-orcid":false,"given":"Sookyung","family":"Lee","sequence":"additional","affiliation":[{"name":"Department of Clinical Oncology, College of Korean Medicine, Kyung Hee University, Seoul 05278, Republic of Korea"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-8434-7380","authenticated-orcid":false,"given":"Dae Hyun","family":"Kim","sequence":"additional","affiliation":[{"name":"Department of Thoracic Surgery, Kyung Hee University Hospital at Gangdong, Seoul 05278, Republic of Korea"}],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"1968","published-online":{"date-parts":[[2026,7,23]]},"reference":[{"key":"ref_1","doi-asserted-by":"crossref","unstructured":"GBD 2023 Cancer Collaborators (2025). The global, regional, and national burden of cancer, 1990\u20132023, with forecasts to 2050: A systematic analysis for the Global Burden of Disease Study 2023. Lancet, 406, 1565\u20131586.","DOI":"10.2139\/ssrn.5533924"},{"key":"ref_2","doi-asserted-by":"crossref","first-page":"1623","DOI":"10.1016\/j.mayocp.2019.01.013","article-title":"Non-Small Cell Lung Cancer: Epidemiology, Screening, Diagnosis, and Treatment","volume":"94","author":"Duma","year":"2019","journal-title":"Mayo Clin. Proc."},{"key":"ref_3","doi-asserted-by":"crossref","first-page":"1408","DOI":"10.1093\/jnci\/djh293","article-title":"Outcome prediction and the future of the TNM staging system","volume":"96","author":"Burke","year":"2004","journal-title":"J. Natl. Cancer Inst."},{"key":"ref_4","doi-asserted-by":"crossref","first-page":"152","DOI":"10.1016\/j.clnesp.2021.12.026","article-title":"Associations between pretreatment nutritional assessments and treatment complications in patients with stage I-III non-small cell lung cancer: A systematic review","volume":"47","author":"Voorn","year":"2022","journal-title":"Clin. Nutr. ESPEN"},{"key":"ref_5","doi-asserted-by":"crossref","first-page":"29","DOI":"10.1016\/j.lungcan.2018.08.026","article-title":"Predicting survival following surgical resection of lung cancer using clinical and pathological variables: The development and validation of the LNC-PATH score","volume":"125","author":"Balata","year":"2018","journal-title":"Lung Cancer"},{"key":"ref_6","doi-asserted-by":"crossref","first-page":"1109","DOI":"10.1016\/j.jtho.2017.04.011","article-title":"The IASLC Lung Cancer Staging Project: External Validation of the Revision of the TNM Stage Groupings in the Eighth Edition of the TNM Classification of Lung Cancer","volume":"12","author":"Chansky","year":"2017","journal-title":"J. Thorac. Oncol."},{"key":"ref_7","first-page":"533","article-title":"The value of CRP-albumin-lymphocyte index (CALLY index) as a prognostic biomarker in patients with non-small cell lung cancer","volume":"31","author":"Liu","year":"2023","journal-title":"Support. Care Cancer"},{"key":"ref_8","doi-asserted-by":"crossref","first-page":"527","DOI":"10.1007\/s11748-023-02003-9","article-title":"Significance of preoperative evaluation of modified advanced lung cancer inflammation index for patients with resectable non-small cell lung cancer","volume":"72","author":"Sato","year":"2024","journal-title":"Gen. Thorac. Cardiovasc. Surg."},{"key":"ref_9","doi-asserted-by":"crossref","unstructured":"Takada, K., Takamori, S., Matsubara, T., Haratake, N., Akamine, T., Kinoshita, F., Ono, Y., Wakasu, S., Tanaka, K., and Oku, Y. (2020). Clinical significance of preoperative inflammatory markers in non-small cell lung cancer patients: A multicenter retrospective study. PLoS ONE, 15.","DOI":"10.1371\/journal.pone.0241580"},{"key":"ref_10","doi-asserted-by":"crossref","first-page":"460","DOI":"10.1016\/j.cllc.2024.04.018","article-title":"Pre-Operative Measures of Systemic Inflammation Predict Survival After Surgery for Primary Lung Cancer","volume":"25","author":"Taylor","year":"2024","journal-title":"Clin. Lung Cancer"},{"key":"ref_11","doi-asserted-by":"crossref","first-page":"567","DOI":"10.1200\/JCO.21.01929","article-title":"Circulating Tumor DNA Minimal Residual Disease Detection of Non-Small-Cell Lung Cancer Treated With Curative Intent","volume":"40","author":"Pellini","year":"2022","journal-title":"J. Clin. Oncol."},{"key":"ref_12","doi-asserted-by":"crossref","first-page":"309","DOI":"10.1016\/j.athoracsur.2017.06.071","article-title":"Prediction of Long-Term Survival After Lung Cancer Surgery for Elderly Patients in The Society of Thoracic Surgeons General Thoracic Surgery Database","volume":"105","author":"Onaitis","year":"2018","journal-title":"Ann. Thorac. Surg."},{"key":"ref_13","first-page":"3001","article-title":"Preoperative serum C-reactive protein level in non-small cell lung cancer","volume":"27","author":"Hara","year":"2007","journal-title":"Anticancer Res."},{"key":"ref_14","doi-asserted-by":"crossref","first-page":"603","DOI":"10.1007\/s00408-023-00649-z","article-title":"Prognostic Impact of Cancer Inflammation Prognostic Index for Non-small Cell Lung Cancer","volume":"201","author":"Motono","year":"2023","journal-title":"Lung"},{"key":"ref_15","first-page":"2687","article-title":"Preoperative leukocytosis, anemia and thrombocytosis are associated with poor survival in non-small cell lung cancer","volume":"29","author":"Tomita","year":"2009","journal-title":"Anticancer Res."},{"key":"ref_16","doi-asserted-by":"crossref","first-page":"223","DOI":"10.1016\/j.lungcan.2011.06.009","article-title":"Preoperative lymphocyte count is an independent prognostic factor in node-negative non-small cell lung cancer","volume":"75","author":"Kobayashi","year":"2012","journal-title":"Lung Cancer"},{"key":"ref_17","doi-asserted-by":"crossref","first-page":"88","DOI":"10.1016\/j.lungcan.2017.07.003","article-title":"Clinical significance of preoperative serum albumin level for prognosis in surgically resected patients with non-small cell lung cancer: Comparative study of normal lung, emphysema, and pulmonary fibrosis","volume":"111","author":"Miura","year":"2017","journal-title":"Lung Cancer"},{"key":"ref_18","doi-asserted-by":"crossref","unstructured":"Kiss, M., Caro, A.A., Raes, G., and Laoui, D. (2020). Systemic Reprogramming of Monocytes in Cancer. Front. Oncol., 10.","DOI":"10.3389\/fonc.2020.01399"},{"key":"ref_19","doi-asserted-by":"crossref","first-page":"86","DOI":"10.1016\/j.canlet.2006.12.012","article-title":"CCL2\/CCR2 pathway mediates recruitment of myeloid suppressor cells to cancers","volume":"252","author":"Huang","year":"2007","journal-title":"Cancer Lett."},{"key":"ref_20","doi-asserted-by":"crossref","first-page":"887","DOI":"10.1038\/nrd.2018.169","article-title":"Targeting macrophages: Therapeutic approaches in cancer","volume":"17","author":"Cassetta","year":"2018","journal-title":"Nat. Rev. Drug Discov."},{"key":"ref_21","doi-asserted-by":"crossref","first-page":"1046","DOI":"10.1053\/j.semtcvs.2020.03.019","article-title":"Prognostic Significance of Perioperative C-Reactive Protein in Resected Non-Small Cell Lung Cancer","volume":"32","author":"Okada","year":"2020","journal-title":"Semin. Thorac. Cardiovasc. Surg."},{"key":"ref_22","doi-asserted-by":"crossref","first-page":"457","DOI":"10.1016\/j.lungcan.2014.06.015","article-title":"Prognostic impact of preoperative monocyte counts in patients with resected lung adenocarcinoma","volume":"85","author":"Kumagai","year":"2014","journal-title":"Lung Cancer"},{"key":"ref_23","doi-asserted-by":"crossref","first-page":"93","DOI":"10.1146\/annurev-pathmechdis-012418-013058","article-title":"Monocytes in the Tumor Microenvironment","volume":"16","author":"Ugel","year":"2021","journal-title":"Annu. Rev. Pathol."},{"key":"ref_24","doi-asserted-by":"crossref","first-page":"1","DOI":"10.1038\/s41423-019-0306-1","article-title":"Myeloid immunosuppression and immune checkpoints in the tumor microenvironment","volume":"17","author":"Nakamura","year":"2020","journal-title":"Cell Mol. Immunol."},{"key":"ref_25","doi-asserted-by":"crossref","first-page":"137","DOI":"10.1056\/NEJMoa2304594","article-title":"Overall Survival with Osimertinib in Resected EGFR-Mutated NSCLC","volume":"389","author":"Tsuboi","year":"2023","journal-title":"N. Engl. J. Med."},{"key":"ref_26","doi-asserted-by":"crossref","first-page":"188","DOI":"10.1007\/s00292-014-1974-3","article-title":"The 2015 WHO classification of lung tumors","volume":"35","author":"Travis","year":"2014","journal-title":"Der Pathol."},{"key":"ref_27","doi-asserted-by":"crossref","first-page":"193","DOI":"10.1016\/j.chest.2016.10.010","article-title":"The Eighth Edition Lung Cancer Stage Classification","volume":"151","author":"Detterbeck","year":"2017","journal-title":"Chest"},{"key":"ref_28","doi-asserted-by":"crossref","first-page":"115","DOI":"10.1016\/S0344-0338(11)80700-4","article-title":"The pathologist and the residual tumor (R) classification","volume":"190","author":"Hermanek","year":"1994","journal-title":"Pathol. Res. Pract."},{"key":"ref_29","doi-asserted-by":"crossref","first-page":"562","DOI":"10.1093\/jjco\/hyac023","article-title":"The prognostic impact of preoperative mean corpuscular volume in colorectal cancer","volume":"52","author":"Nakamura","year":"2022","journal-title":"Jpn. J. Clin. Oncol."},{"key":"ref_30","doi-asserted-by":"crossref","first-page":"606","DOI":"10.1097\/JTO.0b013e31828632b8","article-title":"Visceral pleural invasion classification in non-small-cell lung cancer in the 7th edition of the tumor, node, metastasis classification for lung cancer: Validation analysis based on a large-scale nationwide database","volume":"8","author":"Kawase","year":"2013","journal-title":"J. Thorac. Oncol."},{"key":"ref_31","doi-asserted-by":"crossref","first-page":"605","DOI":"10.1080\/09537104.2016.1225467","article-title":"Studies on Mean Platelet Volume (MPV)\u2014New Editorial Policy","volume":"27","author":"Harrison","year":"2016","journal-title":"Platelets"},{"key":"ref_32","doi-asserted-by":"crossref","first-page":"607","DOI":"10.1080\/09537104.2016.1224828","article-title":"New roles for mean platelet volume measurement in the clinical practice?","volume":"27","author":"Noris","year":"2016","journal-title":"Platelets"},{"key":"ref_33","doi-asserted-by":"crossref","unstructured":"An, S., Eo, W., and Lee, S. (2025). Prognostic Significance of Modified Shine and Lal Index in Patients with Non-Small Cell Lung Cancer Undergoing Surgical Resection. Biomedicines, 13.","DOI":"10.3390\/biomedicines13040937"},{"key":"ref_34","doi-asserted-by":"crossref","first-page":"128","DOI":"10.1097\/EDE.0b013e3181c30fb2","article-title":"Assessing the performance of prediction models: A framework for traditional and novel measures","volume":"21","author":"Steyerberg","year":"2010","journal-title":"Epidemiology"},{"key":"ref_35","doi-asserted-by":"crossref","first-page":"E507","DOI":"10.1111\/ans.15480","article-title":"Novel systemic inflammation response index to predict prognosis after thoracoscopic lung cancer surgery: A propensity score-matching study","volume":"89","author":"Li","year":"2019","journal-title":"ANZ J. Surg."},{"key":"ref_36","doi-asserted-by":"crossref","unstructured":"Liu, Q., Xie, H., Cheng, W., Liu, T., Liu, C., Zhang, H., Lin, S., Liu, X., Tian, H., and Li, X. (2024). The preoperative hemoglobin, albumin, lymphocyte, and platelet score (HALP) as a prognostic indicator in patients with non-small cell lung cancer. Front. Nutr., 11.","DOI":"10.3389\/fnut.2024.1428950"},{"key":"ref_37","doi-asserted-by":"crossref","first-page":"1236","DOI":"10.1016\/j.clnu.2022.04.019","article-title":"Inflammatory burden as a prognostic biomarker for cancer","volume":"41","author":"Xie","year":"2022","journal-title":"Clin. Nutr."},{"key":"ref_38","doi-asserted-by":"crossref","first-page":"350","DOI":"10.1111\/1759-7714.12454","article-title":"Elevated pretreatment neutrophil\/white blood cell ratio and monocyte\/lymphocyte ratio predict poor survival in patients with curatively resected non-small cell lung cancer: Results from a large cohort","volume":"8","author":"Yuan","year":"2017","journal-title":"Thorac. Cancer"},{"key":"ref_39","doi-asserted-by":"crossref","first-page":"3348","DOI":"10.7150\/jca.77397","article-title":"Comparison of the Clinical Value of the Geriatric Nutritional Risk Index and Prognostic Nutritional Index as Determinants of Survival Outcome in Patients with Gastric Cancer","volume":"13","author":"An","year":"2022","journal-title":"J. Cancer"},{"key":"ref_40","doi-asserted-by":"crossref","first-page":"973","DOI":"10.1093\/ejcts\/ezx436","article-title":"American Society of Anesthesiologists physical status facilitates risk stratification of elderly patients undergoing thoracoscopic lobectomy","volume":"53","author":"Zhang","year":"2018","journal-title":"Eur. J. Cardio-Thorac. Surg."},{"key":"ref_41","doi-asserted-by":"crossref","first-page":"2149","DOI":"10.2217\/fon.14.121","article-title":"Lower mean corpuscular hemoglobin concentration is associated with unfavorable prognosis of resected lung cancer","volume":"10","author":"Qu","year":"2014","journal-title":"Future Oncol."},{"key":"ref_42","doi-asserted-by":"crossref","first-page":"4916","DOI":"10.21037\/jtd-22-1684","article-title":"Clinical significance of mean corpuscular volume as a prognostic indicator of radiotherapy for locally advanced lung cancer: A retrospective cohort study","volume":"14","author":"Wang","year":"2022","journal-title":"J. Thorac. Dis."},{"key":"ref_43","doi-asserted-by":"crossref","unstructured":"Zhou, L., Zhang, Y., Chen, W., Niu, N., Zhao, J., Qi, W., and Xu, Y. (2022). Development and validation of a prognostic nomogram for early stage non-small cell lung cancer: A study based on the SEER database and a Chinese cohort. BMC Cancer, 22.","DOI":"10.1186\/s12885-022-10067-8"},{"key":"ref_44","doi-asserted-by":"crossref","first-page":"205","DOI":"10.1007\/s00280-023-04558-z","article-title":"External validation of a tumor growth inhibition-overall survival model in non-small-cell lung cancer based on atezolizumab studies using alectinib data","volume":"92","author":"Kassir","year":"2023","journal-title":"Cancer Chemother. Pharmacol."}],"container-title":["Journal of Clinical Medicine"],"original-title":[],"language":"en","link":[{"URL":"https:\/\/www.mdpi.com\/2077-0383\/15\/15\/5772\/pdf","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2026,7,25]],"date-time":"2026-07-25T04:29:15Z","timestamp":1784953755000},"score":1,"resource":{"primary":{"URL":"https:\/\/www.mdpi.com\/2077-0383\/15\/15\/5772"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2026,7,23]]},"references-count":44,"journal-issue":{"issue":"15","published-online":{"date-parts":[[2026,8]]}},"alternative-id":["jcm15155772"],"URL":"https:\/\/doi.org\/10.3390\/jcm15155772","relation":{},"ISSN":["2077-0383"],"issn-type":[{"value":"2077-0383","type":"electronic"}],"subject":[],"published":{"date-parts":[[2026,7,23]]}}}